SR 111 Investigation Report How This Report Is Organized This report was prepared in accordance with International Civil Aviation Organization standards and recommended practices,[*] and with Transportation Safety Board (TSB) standards for investigation reports. In keeping with these standards, the report is organized into the following main parts: § Part 1, Factual Information: Provides objective information that is pertinent to the understanding of the circumstances surrounding the occurrence. § Part 2, Analysis: Discusses and evaluates the factual information presented in Part 1 that the Board considered when formulating its conclusions and safety actions. § Part 3, Conclusions: Based on the analyses of the factual information, presents three categories of findings: findings as to causes and contributing factors to the occurrence; findings that expose risks that have the potential to degrade aviation safety, but that could not be shown to have played a direct role in the occurrence; and "other" findings that have the potential to enhance safety, or clarify issues of unresolved ambiguity or controversy. § Part 4, Safety Action: Based on the findings of the investigation, recommends safety actions required to be taken to eliminate or mitigate safety deficiencies, and records the main actions already taken or being taken by the stakeholders involved. Note: Owing to the scope of the Swissair 111 investigation, various supporting technical information (STI) materials are referenced throughout the report. STI materials are peripheral to the report and are not required to develop a complete understanding of the facts, analyses, conclusions, or recommended safety actions. Rather, the STI materials expand, in technical detail, on the information provided in the report. A superscript "STIx-yyy" is inserted into the report wherever such a reference exists. In the hard-copy version, the number "x" identifies the part of the report, and "yyy" identifies the reference within the part, as indicated in Appendix E – List of Supporting Technical Information References. In the electronic version of the report, such references are hyperlinked directly to the applicable location in the electronic version of the STI. Appendix E is not included in the electronic version. The report also consists of the following appendices and background material, which are referenced in the report: § Appendix A – Flight Profile: Selected Events: A chronological depiction of the intended itinerary, actual flight profile, and selected events during the occurrence, presented in Coordinated Universal Time (UTC). § Appendix B – Swissair Air Conditioning Smoke Checklist: The checklist used by Swissair to isolate a source of smoke originating from an aircraft air conditioning system. § Appendix C – Swissair Smoke/Fumes of Unknown Origin Checklist: The checklist used by Swissair to isolate a source of smoke or fumes originating from an unknown source. § Appendix D – Timeline: A chronological list of events for the duration of the occurrence, presented in UTC. § Glossary: An alphabetical list of abbreviations, acronyms, and initialisms used throughout the report. Available Formats The report can be viewed in the following formats: § Paper. § Compact Disc (CD-ROM) attached to the back cover of the paper report (compatible with Microsoft® Windows 95® or higher). § On the TSB web site at http://www.tsb.gc.ca. The STI materials can be viewed: § On the TSB web site at http://www.tsb.gc.ca. § On Compact Disc (CD-ROM) along with the investigation report (compatible with Microsoft® Windows 95® or higher). Readers can print copies of the report and STI materials from the CD-ROM or TSB web site. To obtain additional copies of the report, please contact TSB Communications Division Place du Centre 200 Promenade du Portage 4th Floor Gatineau, Quebec K1A 1K8 Canada Telephone: (819) 994-3741 Fax: (819) 997-2239 E-mail: [email protected] [*] For more detailed information on International Civil Aviation Organization standards, refer to International Standards and Recommended Practices, Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, Ninth Edition, July 2001. Table of Contents Expand all || Collapse all How This Report Is Organized 1.0 Factual Information 1.1 History of the Flight 1.2 Injuries to Persons 1.3 Damage to Aircraft 1.4 Other Damage 1.5 Personnel Information 1.5.1 General 1.5.2 Flight Crew 1.5.3 Cabin Crew 1.5.4 Seventy-Two-Hour History 1.5.5 Air Traffic Controllers 1.6 Aircraft Information 1.6.1 General 1.6.2 Environmental (Air) System 1.6.3 Ditching Mode 1.6.4 Auto Flight System 1.6.5 Electronic Instrument System 1.6.6 Flight Management System 1.6.7 Warnings and Alerts 1.6.8 Standby Flight Instruments 1.6.9 Communications Systems 1.6.10 Electrical System 1.6.11 In-Flight Entertainment Network 1.6.12 Aircraft Fire Protection System 1.6.13 Flight Control System 1.6.14 Fuel System 1.6.15 Hydraulic System 1.6.16 Cockpit Windows 1.6.17 Landing Gear 1.6.18 Aircraft Interior Lighting 1.6.19 Emergency Equipment 1.6.20 Powerplants 1.6.21 Landing Performance 1.6.22 Aircraft Maintenance Records and Inspection 1.7 Meteorological Information 1.7.1 General 1.7.2 Forecast Weather 1.7.3 Actual Reported Weather 1.7.4 Upper Level Wind 1.7.5 Weather Briefing 1.7.6 Weather Conditions on Departure from JFK 1.7.7 Weather Conditions during Descent 1.8 Aids to Navigation 1.9 Communications 1.9.1 General 1.9.2 Controller Training 1.9.3 Transition Procedures and Controller Communications 1.9.4 Emergency Communications 1.9.5 Air Traffic Services Communication Regarding Fuel Dumping 1.10 Aerodrome Information 1.11 Flight Recorders 1.11.1 General 1.11.2 Recorder Installation Power Requirements 1.11.3 Stoppage of Recorders 1.11.4 Lack of CVR Information 1.11.5 Quick Access Recorder 1.11.6 Lack of Image Recording 1.12 Wreckage and Impact Information 1.12.1 Wreckage Recovery 1.12.2 Aircraft Wreckage Examination 1.12.3 Examination of Recovered Electrical Wires and Components 1.12.4 Examination of Flight Crew Reading Lights (Map Lights) 1.12.5 Examination of Cabin Overhead Aisle and Emergency Light Assemblies 1.12.6 Examination of Standby Instruments 1.12.7 Examination of Flight Controls 1.12.8 Examination of Fuel System Components 1.12.9 Examination of the Engines 1.12.10 Examination of Aircraft Structural Components 1.12.11 Examination of Flight Crew and Passenger Seats 1.12.12 Aircraft Attitude and Airspeed at the Time of Impact 1.13 Medical Information 1.13.1 Recovery of Occupants 1.13.2 Identification of Individuals 1.13.3 Injury Patterns 1.13.4 Toxicological Information 1.14 Fire 1.14.1 Aircraft Certification Standards 1.14.2 Review of In-Flight Fire Accident Data 1.14.3 Designated Fire Zones and Smoke/Fire Detection and Suppression 1.14.4 Time Required to Troubleshoot in Odour/Smoke Situations 1.14.5 Risk of Remaining Airborne – Emergency Landing 1.14.6 Integrated Firefighting Measures 1.14.7 Airflow Patterns 1.14.8 Describing the SR 111 Fire-Damaged Area 1.14.9 Determination of Heat Damage 1.14.10 Assessment of Fire Damage 1.14.11 Potential Ignition Sources 1.14.12 Fire Propagating Materials 1.14.13 Potential Increased Fire Risk from Non-fire-hardened Aircraft Systems 1.15 Survival Aspects 1.16 Tests and Research 1.16.1 AES Examinations of the Recovered Arced Beads 1.16.2 Map Light Testing and Research 1.16.3 Airflow Flight Tests 1.16.4 Analysis of Cockpit Sounds Recorded on the CVR 1.16.5 Simulator Trials 1.16.6 Theoretical Emergency Descent Calculations 1.16.7 Statistics for Occurrences Involving Smoke or Fire 1.16.8 Electrical Ignition Tests of MPET-Covered Insulation Blankets 1.16.9 Computer Fire Modelling 1.17 Organizational and Management Information 1.17.1 SAirGroup/Swissair/SR Technics 1.17.2 Swissair Federal Office for Civil Aviation 1.17.3 Federal Aviation Administration 1.17.4 The Boeing Company 1.18 Other Relevant Information 1.18.1 Swissair Training 1.18.2 Swissair Checklists for In-Flight Firefighting 1.18.3 Availability of Published Approach Charts 1.18.4 Wire-Related Issues 1.18.5 Circut Protection Devices 1.18.6 High-Intensity Radiated Fields 1.18.7 In-Flight Entertainment Network 1.18.8 Chronological Sequence of Events 1.18.9 Witness Information 1.18.10 Reporting of Cabin Anomalies 1.19 Useful or Effective Investigation Techniques 1.19.1 Exhibit Tracking Process 1.19.2 Data Analysis Tools 1.19.3 Partial Aircraft Reconstruction 1.19.4 Electrical Wire Arc Sites Analysis 1.19.5 Temperature Reference Coupons 1.19.6 Speech Micro-coding Analysis 1.19.7 Fuel Detection by Laser Environmental Airborne Fluorosensor 1.19.8 Aircraft Engine Analysis 1.19.9 Restoration and Extraction of Non-volatile-memory information 1.19.10 Use of Computer Fire Modelling 2.0 Analysis 2.1 General Information 2.2 On-Board Data Recording Capability 2.2.1 General 2.2.2 Cockpit Voice Recorder 2.2.3 Survivability of Quick Access Recorder Information 2.2.4 Image Recording 2.2.5 Underwater Locator Beacons – Bracket Attachments 2.3 Material Susceptibility to Fire – Certification Standards 2.3.1 Flammability of Materials 2.3.2 Contamination Issuess 2.3.3 Non-fire-bardened Aircraft Systems 2.4 Aircraft Fire Detection and Suppression 2.5 In-Flight Firefighting Measures 2.6 Crew Preparation and Training 2.6.1 In-Flight Firefighting 2.6.2 In-Flight Emergency Diversions 2.7 Checklist Issues 2.7.1 Swissair Checklist Options for Smoke Isolation 2.7.2 Emergency Electrical Load-Shedding 2.7.3 Additional Checklist Issues 2.7.4 Checklist Revisions and Approvals