The 54th Annual Safety and Security Week
Kathy Fox

Board Member
Transportation Safety Board of Canada
at the 54th Annual Safety and Security Week
Washington, D.C., United States
August 14, 2008


Good afternoon. Thank you for the kind introduction and for this opportunity to speak to one of the world's largest organizations representing airline pilots.


The second of September of this year will mark the tenth anniversary of the destruction of Swissair 111 off Peggy's Cove, Nova Scotia; with the tragic loss of all 229 souls on board.

As some of you might not be familiar with what happened that day, I will take a few minutes to provide you with a synopsis of the Swissair accident.

On September 2, 1998, Swissair Flight 111, a McDonnell-Douglas MD-11 departed New York City on a scheduled flight to Geneva, Switzerland, with 215 passengers and 14 crew on board.

About 53 minutes later, while cruising at flight level 3-3-0, the crew smelled an abnormal odour in the cockpit. Their attention was drawn to the area behind and above them and they began to investigate the source - the air conditioning system. After further troubleshooting, they assessed there was definitely smoke and decided to divert to Halifax.

While the flight crew was preparing to land, they were unaware that a fire was spreading above the cockpit ceiling. Soon thereafter, the aircraft's FDR logged a rapid succession of system failures. The crew declared an emergency and an immediate need to land.

About one minute later, radio communications and radar contact were lost, and the flight recorders stopped functioning. About five and a half minutes later, the aircraft crashed into the ocean with the loss of all 229  souls on board.

The crew did what made sense to them at the time. Knowing what they knew, and piecing together the sequence of events, we ran a number of detailed scenarios and concluded the crew could not have landed the plane.

Late last year, the Board decided to mark this tenth year by placing the investigation and its results in the context of what has been achieved and what remains outstanding.

Today I will speak to how TSB investigations and recommendations affect the aviation industry using the Swissair investigation as the example.

What you are going to hear is:

  • a quick recap on the TSB and its procedures;
  • some information on our recommendation process.
  • identification of the five main areas where recommendations were made; and

Then I will speak specifically to:

  • material flammability,
  • in-flight fire fighting, and
  • flight recorders.

And finally, I will issue a call for action.

About the TSB

First, I'd like to talk about the Transportation Safety Board of Canada, or TSB. Like our sister organization here in the US, the NTSB, we are an independent government organization with a mandate to advance transportation safety by conducting investigations into marine, rail, air and pipeline occurrences. That being said, we differ from the NTSB in some of our policies and procedures.

Approximately 1,900 aviation occurrences are reported to the TSB each year. We conduct full investigations when there is significant potential to reduce risks to people, property or the environment and to advance safety.

The TSB doesn't wait until an investigation is complete to make important safety information public. When we identify a safety deficiency, we act quickly by communicating it to those who can make transportation safer. This allows industry and regulators to take timely safety action. Swissair was no exception - 14 of the 23 recommendations on Swissair were made during the investigation, before the final report was completed.

The really big safety payoff occurs when everyone agrees and safety deficiencies are quickly addressed.

The Board issues recommendations where we find significant risks requiring immediate attention. Recommendations are typically used to handle more difficult, systemic issues. We try not to be prescriptive, since we recognize that the most difficult part in this whole process is not ours, but rather belongs to the regulator and industry -who have the responsibility to determine how best to mitigate identified risks.

Swissair 111 and the five themes

The Swissair investigation took four and a half years to complete. It was the biggest and most complex safety investigation that the TSB has ever undertaken.

As with all our investigations, the TSB took the time necessary to conduct a thorough investigation of the safety deficiencies, causes and contributing factors to the accident. We did not lay any fault or blame. We looked beyond the immediate causes to find underlying failures in the system in which aircraft and people operate to make recommendations to prevent a similar occurrence in the future.

The need for coordinated national and international effort was paramount, and the efforts of the many hardworking people from various countries, industries and regulatory authorities led to a world-class investigation, culminating in a comprehensive report that has helped to change the face of aviation safety.

The TSB made a total of 23 recommendations, grouped as follows:

  • on-board recorders
  • circuit breaker resetting procedures,
  • the supplemental type certification process,
  • material flammability, and
  • in-flight firefighting.

Our recommendations inevitably call for change. They may be implemented through amendments to regulations or changes to standards or organizational processes. Developing solutions and making changes can place significant demands on you - the pilots, the operators, manufacturers, and regulators.

Follow-up on recommendations

The TSB periodically assesses the progress made on our recommendations.

Our legislation requires that the Canadian Minister of Transport advise the Board in writing of any action taken or proposed on a recommendation within 90 days of the date it was issued. The Board's assessment of the response to our recommendations hinges on how much has been planned or completed to make the system safer.

However, I must admit that in some cases we see limited progress. We naturally have the most influence with Canadian regulators and operators, but most aircraft in airline service are manufactured and type-certified in the US or Europe. For example, when it comes to making changes to aircraft made here, it is the FAA's responsibility to require or oversee these changes.

Four categories are used to assess responses.

We publish our recommendations on this site which we update with the regulator's response and our assessment.

For every response that has been assessed as being less than fully satisfactory, the TSB follows-up by:

  • tracking the progress of actions being taken to mitigate the risks,
  • encouraging greater buy-in, and
  • exploring further options that could mitigate the residual risks
  • .

A recommendation is classified as inactive only when it can be proven there is no longer a risk to the transportation system.

Outstanding recommendations

For the purposes of today's presentation, I would like to highlight the Swissair recommendations in three specific safety areas: material flammability, in-flight firefighting, and on-board recordings.

Material flammability

Our investigation found that a fire aboard Swissair 111 started when an electrical arc ignited insulation material made of metalized polyethylene terephthalate or MPET. This material was tested and certified according to flammability standards and regulations in place at the time the aircraft was manufactured.

As such, the TSB issued eight recommendations associated with flammability during the Swissair investigation. These were mainly related to the adequacy of flammability testing standards and the flammability of the insulation materials themselves.

In response to our recommendations, regulators in Canada, the US and France almost immediately required the removal of MPET insulation from many aircraft, the first material to ignite in the Swissair accident.

Additionally, a more rigorous flammability test, the Radiant Panel Test, along with enhanced regulations and standards are now in place to validate insulation materials used in aircraft.

Notwithstanding these successes, we believe more needs to be done.

We would like it if MPET 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. We would also like to SEE more rigourous testing for ALL existing insulation materials.

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.

One such in-service failure did result in the detection of the flammability risk associated with the insulation material, AN-26. This material subsequently failed the new flammability test and was ordered removed from service.

A number of other insulation materials currently in service also failed the test, but no action was taken.

But is that approach really good enough?

The Board subsequently recommended a review to quantify and mitigate the risks associated with all the types of materials that failed to meet the new requirements. To date, no positive action has been taken by regulators to address this deficiency.

Regarding aircraft wiring, Transport Canada has been involved in a number of international initiatives related to wiring safety in aging aircraft. But action 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 wire does not necessarily predict what will happen when that wire is bundled and carries an electrical load.

While standards exist for individual systems, additional action is needed to address potential risks posed by the interplay between systems.

In summary, our greatest concerns with regards to material flammability relate to wire testing and the use of materials which would fail the new and more rigorous material flammability tests and standards.

In-flight firefighting

We issued five recommendations on in-flight firefighting. We found that procedures weren't in place to direct crews to rapidly locate and eliminate the source of smoke in the aircraft, and to expedite preparations for an emergency landing.

The regulatory agencies readily concurred with the thrust of these recommendations, and acknowledged that significant deficiencies existed and took action to address them.

Here is what's been done to date:

- Regulators now require that emergency procedures in aircraft flight manuals direct crews to prepare to land the aircraft without delay when smoke or fire is detected. As a result, crews routinely divert to land as soon as possible on the first hint of smoke in an aircraft.

We would like to take this opportunity to commend ALPA for presenting a paper at the Flight Safety Foundation's (FSF) International Air Safety Seminar in October 2007. It raised awareness of the risks posed by non-alerted smoke, fumes and fire events of unknown nature and intensity. This paper included proposals for improved checklists for these SFF events, and advocacy for improved fire detection and protection systems aboard aircraft.

- IATA, with ALPA's participation, developed generic, industry-wide guidance material on more effective smoke and fire cockpit checklist procedures. As a result, various aircraft manufacturers and operators are making improvements to their Aircraft Flight Manuals and procedures. For example, Bombardier Aerospace amended its Aircraft Flight Manuals and emergency checklist procedures in January 2007, and I understand that Boeing has adopted this guidance material as have many operators using Boeing equipment. Airbus and some operators using their aircraft have adopted the guidance material as well.

TSB recommended that aircraft crews be prepared to respond immediately, effectively and in a coordinated manner to any in-flight fire, including inaccessible spaces such as attic areas.

Transport Canada and international regulators are working on improvements to current in-flight firefighting training and standards for crews.

We applaud the international community for taking these steps to improve safety in the event of in-flight fires. However, there is still work outstanding in this area. Overall, the Board's position is that a systematic approach towards in-flight fires must be developed to reduce residual risk.

This approach must:

  • comprehensively identify fire zones,
  • implement fire detection systems,
  • provide fire-suppression equipment and systems,
  • mandate checklist design criteria, and
  • require appropriate training.

FDRs/CVRs/image recorders

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 and the FDR 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.

As such, the TSB issued eight recommendations dealing with on-board recorders. These recommendations included increasing recording capacity, increasing the quality and readability of data, making sure they continue recording in the event of electrical failures, requiring image-recording systems and protecting the confidentiality of cockpit voice and image recordings.

So what has been done to address data recorder deficiencies?

In March 2008, the FAA issued new regulations stating that by April 2012, CVRs on all turbine engine-powered airplanes:

  • must have a 2 hour recording capacity;

  • must have an independent power supply that provides 10 minutes of electrical power; and

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

This is real progress, and addresses three of our Swissair recommendations.

But there are some notable outstanding issues within the recorder recommendation group.

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 and image recorders. We continue to believe that image recorders are highly desirable. But we fully understand the concerns that have been expressed by ALPA.

On board recordings are investigative tools. In Canada, the contents of on board voice recordings can be used in an investigative report if - and only if - they are necessary for advancing transportation safety.

The Board interprets this very strictly. Their use must go directly to a finding. In applying our legislation (which is actually very clear) we, as Board Members, don't care if the inclusion of information obtained from a voice recorder makes for a better story. If it doesn't go to a finding, it isn't in.

We believe that international harmonization at the level applied in Canada to protect voice and image recordings is the way to go. Is that achievable? ICAO is undoubtedly the appropriate forum. Is this not something that the aviation community, including ALPA, could put its weight behind?


During an investigation, the TSB works with regulators, transportation companies, equipment manufacturers and service providers, to help us conduct a thorough investigation.

The Board makes recommendations to draw immediate attention to safety deficiencies that involve significant risk and that require immediate action.

The TSB recognizes the challenges regulators and industry face. We know that some recommendations can be addressed promptly, while others require more time and resources to completely mitigate the deficiency.

Ten years after the devastating Swissair accident, further action is still needed to mitigate the significant risks identified in 18 of 23 recommendations.

While TSB recommendations, for the most part, are addressed to the regulators, the responsibility for mitigating the safety risks belongs with some of you in this room today.

Therefore, I encourage you to follow TSB air investigations closely. When safety concerns are identified, ask: "What can I as a pilot, manufacturer, airline, or association do to lessen the identified risk?" You can make changes yourself - you don't need to wait for the regulator to take action. Safety is good for business.

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 vital first few minutes, and that could not have been controlled by the firefighting capabilities of the aircraft and its crew. A fire that only extinguished when the aircraft plunged into the sea off Peggy's Cove.

A call for action seems appropriate at this point. In our view, the highest priorities are

  • mandatory international adoption of the improved smoke, fire and fumes checklist templates;

  • adoption of a more systematic (or holistic) approach to in-flight fire fighting; and

  • international harmonization of the protection Canada extends to cockpit voice and image recordings for accident investigation purposes.

The action taken by the aviation community in response to the Swissair recommendations has been substantial. We do acknowledge what Transport Canada, the FAA, the Flight Safety Foundation, the NTSB, Boeing, Swissair International Air Lines Limited, ALPA and everyone else involved has achieved to date. We recognize that the process can be slow and tortuous. It involves changes in how you operate; it affects your personnel, your management, and your organization and systems.

But let us not stop there or overlook the remaining safety deficiencies. They need to be addressed. And this must be an international effort.

I hope that you leave here today with a greater understanding of what has been accomplished since this tragedy 10 years ago, but also the importance of finishing the job to make aviation even safer.

I invite you to visit our website to look at the specific information on the Swissair accident. Everything the TSB issued on this investigation is accessible through one web page, as seen on the screen.

Thank you for your attention.