As a result of its findings in the Swissair tragedy, the TSB issued 23 recommendations, which may be grouped in five areas:

Only 5 of the 23 recommendations have been fully implemented, for a success rate of just 21%. Two recommendations have been classed “Unsatisfactory” because no action has been proposed. The remainder are classed either “Satisfactory Intent” or “Satisfactory in Part,” indicating that when implemented, the recommendation will either eliminate or reduce the safety deficiency. Acceptance or understanding of deficiencies is not a criterion for assessing accomplishment of a safety recommendation. The key is “when implemented,” and it appears doubtful the majority of the TSB’s recommendations will ever be implemented without considerable grass-roots activity to spur the FAA to action (for a detailed accounting of the TSB recommendations, see Aviation Safety & Security Digest, ‘A Decade of Minimal Action,’ homepage).

As a benchmark for comparison, the NTSB investigated the 1996 loss of TWA flight 800 and issued 15 recommendations, 6 of which have been fully implemented in the 12 years since the crash, for an implementation rate of about 40% (for a detailed accounting of the NTSB’s TWA 800-related recommendations, see Aviation Safety & Security Digest, ‘Twelve Years of Half Measures,’ homepage). That 40% is not much better than 21%, given that both accidents were the result of electrical arcing. Just as TWA 800 was destroyed by a tiny spark amidst flammable fuel/air vapors in the center wing tank, the TSB found that electrical arcing in the attic area over and behind the cockpit of Swissair flight 111 ignited flammable insulation materials. The fire grew, feeding on other flammable materials, some supposedly fire resistant but readily igniting nonetheless as the fire spread with the rapacious speed of a grassfire on the African savannah

To galvanize the FAA into action, TSB officials have made a conscious decision to go public with their frustration. Fox’s presentation to ALPA was just the latest.

At remarks before the Canadian Aviation Safety Seminar (CASS) last April in Calgary, TSB Member Jonathan Seymour said:

“We naturally have the most influence with Canadian regulators and operators, but most aircraft in airline service are manufactured and type-certified in the U.S. or Europe. For example, when it comes to making changes to aircraft made here, it is the FAA’s responsibility to require or oversee those changes.”

Because Member Seymour had more time in his presentation to articulate what still needs to be done, more of his presentation will be showcased below. However, Member Fox said virtually the same thing as the TSB endeavors to speak with one voice on unrequited recommendations.

Both members focused on three areas: material flammability, in-flight firefighting, and flight recorders.

Material flammability

As a result of the Swissair flight 111 tragedy, the FAA ordered the removal of metallized Mylar insulation blankets from about 700 Douglas-built airliners.

Here is Member Seymour’s take on the current situation:

“Although airworthiness directives were developed to mandate the removal of [metallized Mylar]-covered insulation from aircraft in service, substantive action has not been taken to comprehensively review the remaining types of insulation currently in use … Instead, regulators are relying on in-service performance to be the catalyst for further safety action.

“In other words, a material has to fail before action is taken …

“Another example: during the development of the Radiant Panel Test [a new test of blanket resistance to heat and flame], a number of thermal acoustic insulation materials failed the test. The Board subsequently recommended a review to quantify and mitigate the risks associated with all the types of materials that failed these tests … To date, no positive action has been taken by regulators to address this deficiency …”

“[A]ction has not yet been taken to address our recommendation to establish a test regime that evaluates aircraft electrical wire failure characteristics under realistic operating conditions … Testing a single [unpowered] wire does not necessarily predict what will happen when that wire is bundled and carries a load …

“The Board recommended that certification standards be established for all aircraft systems that could exacerbate a fire in progress. There were construction standards in place for electrical, vacuum, oxygen and other systems. But additional action has not been initiated to evaluate how these systems and their components could exacerbate an existing fire. In other words, certifying individual systems is not enough. It is the potential interplay between the systems that creates the additional risk …

“Probably our greatest concerns relate to (1) wire testing and (2) the continuation in service of materials that would fail the Radiant Panel Test.”

As Member Fox stressed, “We would like it if MPET [metallized Mylar] was removed from ALL aircraft and we would like to know HOW the FAA’s Alternative Means of Compliance will ensure insulation materials will not be flammable.”

In-flight firefighting

The TSB recommended that when smoke and fire of unknown origin exists, the aircraft should be landed immediately. The call to land without delay has been adopted by the FAA and other regulatory bodies. As a result, said Fox, “Crews routinely divert to land as soon as possible on the first hint of smoke in an aircraft.”

The TSB also recommended that odor and smoke checklists be designed for ease of reading and for quick troubleshooting. Investigators found that the smoke and fire checklist on the Swissair MD-11 could take as long as 30 minutes to completely execute.

In response, an International Air Transport Association (IATA) workshop developed generic industry-wide guidance material on smoke and fire cockpit checklist procedures. As a result of this effort, Bombardier Aerospace amended its Aircraft Flight Manual and emergency checklist procedures in January 2007. Manufacturer Boeing is also in the process of producing amendments to its manuals and checklists. However, these responses, however laudatory, have not been required by regulatory authorities.

As a result of a fire on a UPS DC-8, the NTSB issued a recommendation on 17 December 2007 that makes a direct reference to the adequacy of checklists, the delayed detection of the fire, and the delayed decision to land (see box below).

Note that the NTSB recommendation was issued nine years after the Swissair crash and, on the eve of the tenth anniversary of this fire-related disaster, the FAA has not seen fit to respond to the recommendation.

The TSB also recommended a review of the methodology by which designated fire zones are identified within the pressurized portion of the aircraft, and improved fire detection and suppression was called for in these zones. As TSB Member Seymour remarked, “TSB is not aware of any action taken or action planned that would specifically relate to this recommendation.”

Regarding a comprehensive approach to in-flight firefighting (i.e., not only improved checklists but also implementing fire detection and suppression, and improved crew training in dealing with in-flight fire), Seymour noted, “Both the FAA and Transport Canada agreed with the recommendation but, to date, these regulators have only implemented single facetted initiatives.”

Presently, vast areas of the aircraft are not covered by fire detection or suppression. For example, the attic space above the main cabin, where critical flight controls and electrical circuits are frequently routed, remains unprotected by fire detection and suppression. It should be noted that after the crash at Halifax, Swissair modified its remaining MD-11s such that infra-red closed circuit television cameras were positioned in areas above and below the main deck, with their imagery fed to the cockpit, so crews had visual confirmation of a fire. While Swissair did not install fire extinguishers in these areas, it did provide its crews with a significant advance in early detection. Swissair also changed the routing of electrical bundles, increasing the separation of vital circuits.

Such improvements have yet to be mandated by any regulatory authority. As Fox said, with commendable restraint, “There is still work outstanding in this area.”

Flight recorders

Fox captured the essence of the role flight recorders play:

“There is no doubt that flight recorders make the investigator’s job substantially easier. Within the aviation community, there is a long-established recognition that access to good data leads to better investigation results, which in turn leads to enhanced safety.

“Both the CVR [cockpit voice recorder] and the FDR [flight data recorder] on Swissair 111 ceased to function some five and a half minutes before impact. Consequently, in this investigation, as with many others, the lack of quality data severely hampered our efforts to validate some of the primary safety deficiencies.”

The TSB issued several recommendations for improved recorders, and on 7 March 2008 the FAA issued its final rule on recorder regulations, stating that by April 2012, CVRs and FDRs on turbine engine-powered airplanes must be upgraded (see Aviation Safety & Security Digest, ‘Significant Regulatory & Related Activity,’ archive, May 2008).

Basically, the FAA is correcting deficiencies identified in the recorder arrangement on Swissair 111, mandating that fixes be implemented some 14 years after the crash, specifically:

• That the CVR must have a 2-hour recording capacity, up from 30 minutes.

• That the CVR must have an independent power supply capable of providing 10 minutes of electrical power.

• That any single electrical failure must not result in disabling both the CVR and the FDR.

Note that the ordered upgrades focus primarily on the CVR, not the FDR. And one would wish for a two-word change to the third bullet above: a single electrical failure must not knock out either the CVR or the FDR. It should also be mentioned that this provision for better reliability in the face of electrical failure only applies to newly-manufactured aircraft; there is no requirement to retrofit the existing fleet.

And the FAA flatly rejected the call from the TSB and the NTSB for image recorders in the cockpit, although the technology exists to do so. In its final ruling, the FAA simply said, “The issue of cockpit video is unsettled and would dramatically delay the implementation of DLC [data link communication] standards that are already being developed internationally.”

To this FAA comment, a number of observations are due. First, image recorders weren’t proposed solely to capture data link messages displayed on the instrument panel. Rather, that was but one of many benefits foreseen, to include recording the presence of smoke in the cockpit (and whether or not the crew donned smoke goggles and oxygen masks), to record switch and toggle positions, to record crew manipulation of throttles and flight controls, and to record key information shown on the primary flight displays (or loss of such displays, as occurred on Swissair flight 111 as a consequence of the cascading electrical failures that occurred as wiring was burnt through).

Moreover, the International Civil Aviation Organization (ICAO) has recommended the use of image recorders.

“There are notable outstandings within the recorder recommendation group,” said the

TSB’s Seymour.

“Dare I say image recorders?” he asked, going on to say:

“If you were to go back to the Swissair investigation report, you would note that our recommendation on image recorders is explicitly paired with our recommendation on harmonizing the international treatment of cockpit voice recorders and image recorders. We continue to believe that image recorders are highly desirable …

“As you have heard, 10 years after the devastating Swissair accident, further action is still needed to mitigate the significant risks identified in 18 of the 23 recommendations.”

In other words, 80% of the TSB’s recommendations await implementation.

Member Fox put the importance of the unfinished business in context:

“Sometimes when we are discussing the minutia of technical details, it is easy to lose sight of what this is all about. We must remember, in the end, it’s about preserving lives of crews and passengers. And, in this case, it is about the 229 men, women and children who lost their lives on September 2, 1998.

“A fire initiated by an electrical arc, that set alight materials believed to be non-flammable, and exacerbated by the failure of other material and systems.  A fire that went undetected during those first few minutes, and that could not have been controlled by the firefighting capabilities of the aircraft and its crew.”

Let us recall the desperate circumstances faced by Captain Urs Zimmermann and First Officer Stefan Loew on Swissair flight 111. They were in a dark cockpit, filling with smoke and hot gas; they were soon gasping futilely for breath when the line supplying emergency oxygen to them was melted by (and the liberated oxygen then accelerating) the intense heat of the inferno in the “attic” space above the flight-deck’s overhead panels. Large red X’s appeared on five of their six “glass cockpit” displays showing they were no longer functional. Their sole analog backup attitude instrument, essential for avoiding disorientation and loss of control in the absence of a visual horizon, was also disabled. The master caution alarm was sounding insistently, and the Halifax runway, just 30 miles distant, was so close yet so far away.

The aircraft hit the water nose-down, in a steep bank, at a speed of some 300 knots. Broken bodies and broken aluminum were “commingled,” in the delicate euphemism employed by investigators.

They completed the longest and most expensive air accident investigation in Canada’s history, and it is not too much to say that the resulting 23 recommendations have a price written in blood. Sadly, that price could go higher, with so many recommendations languishing in the limbo of regulatory complacency.