Thank you Jim. Ladies and gentlemen, good morning. With me is Vic Gerden, who, as most of you will know, has been heading the TSB investigation into the crash of Swissair Flight 111.
The investigation into this terrible accident has been going on for over two years now. We have been able to recover more than two million pieces of the MD-11 aircraft. Thousands of those recovered pieces have been painstakingly analysed, reconstructed and placed on the frame behind me.
The work here at Shearwater, though, is now coming to an end. As of December 15th, the remaining investigation operations will be moved to our facilities in Ottawa where the final analysis and the report writing will be carried out.
I would like to take this opportunity to express my gratitude to the RCMP, the Canadian Forces, the Canadian Coast Guard, the Province of Nova Scotia and many other organizations, for their generous support over the past two years of hard work. A successful investigation would not have been possible without their tremendous cooperation. I have a particular thought for the people of Nova Scotia.
Today, we are releasing a third set of interim safety recommendations stemming from this investigation. As you will see from the background material provided to you, the Board has made five recommendations dealing with the detection and management of in-flight fires within the fuselage of aircraft.
In a moment, I will be turning the microphone over to Mr. Gerden, who will explain some of the technical aspects of the recommendations. But first, if I may, I would like to give you some context.
It has now been 27 months since Flight 111 crashed into the sea near Peggy's Cove, taking the lives of all 229 people on board. We cannot, and will not, forget these people. And, though their fate was a tragedy that we cannot undo, we can, as part of an international community, try our best to learn from it.
To learn what we can about what went wrong, and what can be done to reduce the risk of this ever happening again.
And as you can see from the painstaking reconstruction effort behind me -- this is an investigation of great scope and complexity. We are using various kinds of expertise - scientific, engineering, technical, human behavioural and so on - to find out what happened and why. And, most important, what could be done to reduce the possibility of another tragedy like this.
It has been and continues to be a long, detailed investigation. The level of destruction and the lack of information on the flight recorders has meant that the investigation has had to use extraordinary measures in trying to find out what happened. We are using many traditional techniques and some that have not been used before in accident investigations.
There is still much work to do in analysing the information we have gathered. We want to make sure we have conducted a thorough investigation and have completed our analysis before producing a final report.
As in the majority of accidents, the investigation will likely show that this accident was not the result of a single cause. The experience from investigations around the world shows that in most cases accidents are not generally the result of single items. You can see from our previous recommendations, and those being released today, that a variety of safety issues are of concern.
Mission of TSB
I want to take this opportunity to explain that the mandate of the TSB is to advance transportation safety -- and NOT to find fault or to lay blame.
Some of the most important work that we do is to identify safety deficiencies and to make recommendations to address those deficiencies -- recommendations such as the ones we are releasing today.
It is part of our job to untangle those factors which might have contributed to the crash.
Moreover, I want to underline that, in the course of our investigation, we often encounter safety deficiencies that may have had nothing to do with that particular crash, but that could lead to an accident somewhere down the road.
Such problems are of immense interest to us and to the travelling public, because if they are present in one aircraft, there's a good chance you'll find them in others.
It is imperative that we bring risks that we identify to light as quickly as possible, so the appropriate authorities and the aviation industry can begin the process of remedying them. Remember that events that are as rare as one in several millions are unacceptable in aviation if they detract from the safe operation of an aircraft.
Clearly, it would make no sense, to keep knowledge of risks requiring early attention to ourselves, or until we issue our final report. Instead, when we have something to say that could enhance the safety of the travelling public, we say it -- typically in the form of interim recommendations. In fact, by the time the final report on this accident is completed, many of the safety actions coming from this investigation will have already been made public.
Some of you will recall that we have already done so twice in this investigation. In March of 1999, the Board issued four recommendations dealing with the recording capacity and power supply of flight recorders.
Then again in August of 1999, we brought forward another two recommendations on thermal acoustical insulation blankets and the related flammability test criteria. In addition, the TSB has issued two Safety Advisory Letters. One dealt with the condition of wiring in aircraft. The second dealt with overheating of flight crew reading lights, sometimes referred to as cockpit map lights. Both of these Safety Advisories have led to prompt actions by the FAA and follow-up by manufacturers and operators.
Which brings me to today, to the third set of interim safety recommendations stemming from our investigation into the Swissair Flight 111 accident.
During the course of the Swissair Flight 111 investigation, the TSB has necessarily looked beyond the specific circumstances of this occurrence to examine industry standards in the area of in-flight firefighting. The Board believes that industry efforts have fallen short in this area, that industry has not always looked at fire prevention, detection and suppression as being the components of an overall firefighting "system". An effective firefighting "system" would consider and include all aspects of firefighting, such as:
- aircraft design;
- certification of materials;
- accessibility to vulnerable areas of the aircraft for firefighting purposes;
- effective fire detection and suppression equipment;
- well-designed in-flight emergency procedures; and,
- fully trained and equipped aircraft crew.
We have known virtually from the beginning that the accident involving Swissair Flight 111 was somehow related to a fire in a portion of the so-called "attic" of the aircraft. That is, in the front section of the aircraft, above the ceiling, extending about 1.5 metres forward and 5 metres back of the cockpit bulkhead.
We also know that the fire spread along flammable material, and that, because it was in an inaccessible space, the crew would have had trouble identifying, locating, and containing the fire.
We do not know yet what started the fire and our investigation of that aspect continues.
But, in the course of our work so far, we have made a number of troubling observations that warrant safety follow-up. These include industry-wide shortcomings in design, equipment, crew training and awareness, and procedures. In the case of Swissair Flight 111, these shortcomings may have made it difficult to quickly detect and suppress this in-flight fire.
For example, there are many areas within the fuselage - such as the attic area above the ceiling - that are not "designated fire zones." That means they contain neither detectors nor firefighting equipment, even in places where they contain materials such as wiring and insulation that can sustain smoke or flames.
In reality, these spaces can be highly inaccessible, which means the crew cannot get there to put out the fire. In those circumstances, an otherwise controllable situation could rapidly deteriorate into a situation that has disastrous consequences.
It seems strange to us that in order to ensure public safety, in a time of rapid technological advances, we rely so much on the human sense organs to detect smoke or fire.
We also found that the step-by-step protocols and procedures developed under industry standards to locate and control in-flight fires are inadequate. They can be too slow. As a result, the pilot may delay crucial decisions, such as whether to initiate a diversion and to set up for an emergency landing.
In-flight Fire Recommendations
And so, the Transportation Safety Board has made another five safety recommendations, aimed at the appropriate authorities.
- Our first recommendation is intended to ensure that the aviation community considers all in-flight firefighting measures using a more thoroughly coordinated and comprehensive approach. This is not always the case today. The TSB is concerned that unless there is full coordination in the approach to in-flight firefighting, solutions could miss elements of the problem. The TSB wants aircraft crews to be provided with a comprehensive and integrated firefighting plan, that encompasses policies, procedures, equipment, training, and other appropriate measures that minimize the probability of an in-flight fire and provide maximum probability of dealing effectively with it, should one occur.
- Second, we are calling for a thorough review of what areas in aircraft should be designated as "fire zones". We would expect that this review will conclude that there are additional areas in aircraft, in which fires may start, that are not easily accessible in flight, and must be equipped with built-in fire detection and suppression systems.
- Third, we are asking that industry standards reflect a philosophy that all flight crews expeditiously prepare the aircraft for a landing when odour or smoke from an unknown source appears in an aircraft. Some airlines have already adopted this procedure. The Board is concerned that this is not always the case.
- Fourth, we are concerned about the emergency checklists that flight crews now use when confronted with smoke or fire. Our concern is that it can take too long for flight crews to complete these checklists as they are presently designed. Therefore we are recommending that they be redesigned to be more effective in minimizing the possibility of igniting or sustaining an in-flight fire by dealing with key items as soon as possible.
- Fifth, we are calling for a review of in-flight firefighting standards in the industry, including procedures, training, design, and equipment, to ensure that aircraft crews are prepared to respond quickly and effectively to any indication of smoke or fire in an area not protected by automatic detection and suppression features.
And, now I would like to call on Vic Gerden to give you some details on how these recommendations came about, and to give you a brief Update on how the overall investigation is progressing -- Vic.
********** (Vic Gerden) **********
Thank you Vic.
The Board believes that the five recommendations we are releasing today describe initiatives that could be taken to reduce the risks of fire in the aircraft fuselage.
Of course, it will be up to authorities in Canada, the United States, and elsewhere to ensure that the proposed changes are actually put into effect. As an independent investigative agency, we can only put forward the information we find about safety deficiencies, and how we believe these deficiencies ought to be addressed. We do not dictate specific solutions; that we leave to the regulators and the industry.
The safety deficiencies identified so far by the Board are being aggressively addressed by government and industry. There is an excellent climate of co-operation among ourselves, the National Transportation Safety Board and the Federal Aviation Administration in the United States, Transport Canada and the Joint Aviation Authorities in Europe. We trust that this longstanding cooperation will lead the international aviation community to take early safety action on these issues.
Even so, the TSB will monitor the response of regulators, manufacturers and operators to this latest set of recommendations, just as we follow up on any safety issues we identify, so actions that have been taken can be included in the Board's final report.
And, again, I want to underline that an investigation of this magnitude really is a lengthy process. Considerable work remains to be done to ensure that we extract the important safety lessons to be learned.
Whenever we identify further safety deficiencies in need of urgent attention, we will certainly make public announcements of this kind again.
Now, I understand Vic and I have about 30 minutes to take your questions.
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