SR111 report released

[wes_wall]

The report was released today. Details at:


http://www.bst.gc.ca/en/reports/air/1998/a98h0003/a98h0003.asp

[OVERTALK]

You will find it here:

LINK (http://www.iasa-intl.com/davidevans/SR111 REPORT.zip)

[Few Cloudy]

There was a fantastic programme on Swiss TV about this last night - very well reported - (seemed to be originally in English with German overdubs) going through the whole investigation take by take - showing the reconstruction of the ship in the hangar - the false clues and the patience and dedication of the team.

A tremendous story - worthy of the best investigative authors. Amongst other things it showed: how the aluminium covered insulation (guarranteed burn proof) actually did burn - and keep burning; how the silicone air conditioning blanks used on non operator-required ducts would glow - then burn too, allowing a non-configured airflow in the affected region; how Velcro - being used to hold up a fire-proof barrier actually burned (seem to remember it did on a deadly NASA mission too once) - spread the fire and then let go, causing the barrier to drop out of place; how the checklist item powering down cabin items (including fans) actually aggravated the situation in combination with the altered airflow and allowed smoke and heat forward into the cockpit.

It showed that top pilots, with pre-knowledge and training could have got an MD-11 in good condition onto the ground in Halifax in (I think) 15 minutes but that this aircraft (great sim reconstuction) lost display after display, system after system and finally left only standby instruments and manual flight (but ATS giving full chat at one point) and smoke and possibly flames in cockpit at the end, so that they had no chance - with the loss of control coming two minutes before the estimated best possible landing time mentioned above. Much more info as well - too much to mention.

A devilish situation and a commited team of investigators. I hope this cassette can be made available to all - and to all airlines.

[rapide89]

Have read the report for most of the day.
Mind-boggling, phantastic work !!
Thank you, Canadians.

Few Cloudy, you have hit the nail on the head about the TV program. Well balanced, un-emotional, the pictures speak for themselves.There are still journalists who deserve our deepest respect. Thank you Kurt Schaad and Howard Green.

Deep emotions revisited at a time like this.

[Few Cloudy]

Saturday Morning - the programme has just been reshown. It was 13 minutes (not 15 as I wrote above) which a top crew with a fully functioning machine would have required to land at Halifax -and two minutes before this, due to the change in airflow in the ceiling allowing fire gases to flow forward, a piece of cockpit ceiling either collapsed or melted and the gases entered the cockpit.

At this point, both pilots simultaneously made a Mayday call, showing how dramatically the situation had degenerated. Forty seconds after that the ship was in an uncontrolled right banked descent. The pilots were for whatever reason no longer controlling the aircraft at this point ( purely speculation if incapacitated or attempting shelter from the heat) and as one team member said, "they had no chance."

Of the many recommendations made, most have now been incorporated into the MD-11 fleet - which in the meantime belongs to Swiss - but many other lines are flying ships with metallised Mylar insulation, Velcro and other hazards still in place.
One useful item is a smoke detector behind the panelling, which would have alerted the crew much earlier in the sequence to the hidden fire just behind their heads.

All this safety costs money - is that why only so few unaffected fleet operators have made these changes? "Once bitten, twice shy", springs to mind.

[B767300ER]

SR 111 was absolutely a tragedy.

But, showing 'top' pilots in simulators with the same scenario is monday-morning quarterbacking or second-guessing the SR111 flight crew, who did what they thought prudent and were running SR-approved somke-removal procedures when the accident occured. The thing to remember is pilots in simulators always walk away safely; I have every reason to believe SR111's crew were fighting to save the aircraft, but ran out of time.

Hard lessons learned, indeed.

[Few Cloudy]

767ER,

You might have mis interpreted the point there. This was no second guessing. It was an attempt by the very professional investigation team (at hard work for three years and more - no Monday morning quarterbacks) to find out whether the situation was surviveable.

What they discovered is that it was not - the point being that the aircraft became unflyable 2 minutes before a completely serviceable one could possibly have landed.

So the attempt and the evidence vindicates the crew - rather than incriminates them. There is no suggestion that the crew (and I knew them too) were anything other than top pilots.

[gofer]

Only had time for the conclusions so far, but must congratulate all concerned on what looks like a most professional and thorough analysis that has come up with a most iteresting series of comments and logical recommendations that would otherwise probably never have been made.

Bravo Canada ! Sad that people have to lose their lives for us to have to possibility to learn.; and probably even sadder that the lessons will, for the most only be followed by a very very few, as safety is too expensive for most people.

Monsieur/Herr Airbus and Mr. Boeing - good reading that could help you avoid some problems in the future.

[Azure]

As a Canadian, I wish I would have seen the show, however I don't think it aired here in Canada. With the war on, I avoid the TV, but I never heard any mention on any Canadian aviation forum about the program either, so I guess the war took presedence over a sad part in Canadian/Swiss history.

[aardvark2zz]

I may be wrong but I believe that they're implying that if the pilots flew the plane without breaking ANY aeronautical laws then they would have never had enough time. Laws such as speed limits below 10000ft.

But I believe that a pilot like Chuck Yeager (assuming trained on the MD11) or other could have safely landed the plane by going into an emergency dive (with spoilers out for e.g.) and near Vne to lose potential energy and gone super direct to Halifax. Of course this would of implied flying near Vne below 10000 and way above 200 knots. But hey it's an emergency. Or he could of dumped it in the water (or field) with possibly at least some survivors.

I'd like to hear opinions from those who read this part of the report about why the investigators claim that the plane couldn't have landed at all. What about the water ditching scenario. Or the "kamakazi" direct approach to Halifax.

I just did calculations based on the data presented in the crash report. Of course I can't completely second guess the pilot's decisions but it's an interesting bit of analysing.

There was a lapse of 21 minutes between the detection of the first odour and the crash.

A maximum of 9 minutes was required to lose 33000 ft and an extra 5 minutes to get to Halifax for a total of 14 minutes.

This leaves 7 to 12 minutes spare time to diagnose and prepare for the emergency landing at the airport, field, or water.

I don't know how the investigators came to conclude that it was impossible to land somewhere. I'd like to read about other's opinions.

Here is a plot of altitude, speed, climb rate, and distance to halifax vs minutes after the hour. This covers the time when the first odour is smelled till the crash some 21 minutes latter. I'm currious to find out if they could of ditched somewhere with some survivors. I have my suspicions that they could of if they would of done a "Chuck Yeager" landing.

I believe that the canadian board didn't want to hint that they could of survived had the pilot bypassed some check lists and laws and done a direct approach at very high speeds.

Keep the blue side up; wherever UP is

From the report:
From any point along the Swissair Flight 111 flight path after the initial odour in the cockpit, the time required to complete an approach and landing to the Halifax International Airport would have exceeded the time available before the fire-related conditions in the aircraft cockpit would have precluded a safe landing.

Quote:
Schatzkiste: Some people had been wondering if going straight for Halifax would have saved the day. Apparently it wouldn't have:
A theoretical descent profile calculation, conducted by the TSB during the investigation, confirmed that, because of the rapid progression of the fire and its adverse effects on various aircraft systems and the cockpit environment, they would not have been able to complete a safe landing in Halifax, even if they had undertaken to do so at the time of the PAN PAN urgency radio communication at 10:14 p.m. ADT.

http://www.airdisaster.com/user-uploads/000dd.gif

[Jabewar]

Azure,

It was on the CBC. I believe it was 'The Nature of Things' hosted by David Suzuki. Keep an eye for a re-run.

Cheers :D :D

[Ignition Override]

What a nightmare. Our emergency checklists for smoke/fire in the airplane is to put on smoke goggles+oxygen masks and then land immediately, whether the emergency checklist is finished or not.

Is most of the same insulation etc built into the cargo MD-11s? Without the entertainment systems, which was apparently not up to normal electrical specs as required by McDonnell Douglas, would the fire have started?

A show about the terrible ship explosion in Halifax harbor came on here the other night. Such a series of disasters for the area up there.

[Azure]

Thanks Jabewar, I did catch that special about a week after I posted that remark. I skipped the Suzuki round table discussion afterwards though ;)

[N380UA]

aardvark2zz,

Interesting thinking. Yes, perhaps such radical approach to the situation may have resulted in a different outcome.

But how realistic or professional is it of a crew to go into an insane dive at or near Vne, with an MD11 at that, scud running to the nearest airport or even contemplating ditching or crash landing at the first, ever so slightly and temporary strange smell?

Aviate, Navigate, Communicate I once learned. Meaning fly your ship firstly before you do anything else while analysing your situation. Let me point out that Capt. Al Haynes on United 232 did just that.

Of course, in hind sight we’re always smarter. But to “would of, could of, should of” is of no help now. The crew had no way of knowing the extent of the fire between to cockpit and the galley.

Due to the inaccessibility of taking a look behind the panels, Swissair has now installed cameras on all MD11 in their fleet to cover those locations. Which by the way was an expansive proposition?

So again yes, IF at first suspicion the crew were to do a “Chuck Yeager” the out come just may have been different. But then again, not even Chuck Yeager would have done a “Chuck Yeager” IMO. Hence the conclusion of the CSB was correct in saying that the flight had no chance of making it safely to anywhere.


p.s.
Very excellent job on the report and the TV show. Thanks Canada!
:ok:

[aardvark2zz]

Altitude vs time for different dive scenarios i.e.: as is, immediate, and delayed. Distance to Halifax. Depending on the descision there are 8 to 12 minutes of extra time to decide once low and near.

http://www.airdisaster.com/user-uploads/000rr.gif

[DouglasFlyer]

Quote:

"On Dec. 10, 1963, while testing an NF-104A rocket-augmented aerospace trainer, he narrowly escaped death when his aircraft went out of control at 108,700 feet (nearly 21 miles up) and crashed. He parachuted to safety at 8,500 feet after vainly battling to gain control of the powerless, rapidly falling craft. In this incident he became the first pilot to make an emergency ejection in the full pressure suit needed for high altitude flights.” (from the biography of Gen. Yeager look here:http://www.check-six.com/lib/bios/Charles%20E_%20Yeager%20Biography.htm)."

end quote

... he did it to the ground ...

[Huck]

It's worth remembering that the entire philosophy of smoke response changed after 111.

I, too, was taught the byzantine MD11 smoke checklist but was also taught that priority one was getting on the ground. Diagnosing smoke is something you do if you don't have a runway to dive onto.

Valujet also taught us about this. There was a sea change in philosophy in the late nineties.

[Belgique]

Seven pages illustrating the Swissair MD-11 improvements designed to enhance fire-safety and make SR-111 non repeatable (at least in those few aircraft that were modified). Neither Boeing nor the FAA would have a bar of this modification - as to have officially recognized it would have been to admit that the original MD-11 design -as certificated- was flawed. link (http://www.iasa.com.au/folders/images/srimages/newstandbyfltinst.html)

Some SR-111 Report Analysis

Link ONE (http://www.iasa-intl.com/pdf/AFJVOL5-3.pdf)

Link TWO (http://www.iasa.com.au/folders/sr111/MurphySRreport.htm)

[eng123]

Having flicked through the report for the last hour or so,I felt the need to comment on one of the most proffesional and complete accident reports I have read.What a fantastic job the Canadian's have done.
I'm not a pilot but a ground engineer but I can only imagine what a nightmare situation those poor pilots were in.I only hope their tragic end was painless.
The part about the pilot who was flying as a pax,the only one found to have donned a lifejacket,I felt was telling.He must have had a grasp of what was approaching.Poor people.It's enough to bring a tear to the eye.

[aardvark2zz]

Does anyone know where I can get the cockpit transcript, and not the ATC transcript. It seems surprising that they didn't include it in the official final report. When someone hides something, that is to me a clear warning sign of a conspiracy.

Where can I get on the web the summary of the FDR data ?

One of the first things I was told while training was to land immediately once a fire is detected.

Also, since there have been fires in several planes whereby most have turned up disastrous I still find it hard in this day and age in this 3rd millennium that so much time is spent diagnosing fires. It seems to me that once you've spent 5 minutes unsuccessfully diagnosing smoke that you have to land within 15 minutes max. F*&? the extra time for a fuel dump. I'm sure planes can still land with a lot of fuel. But of course the brakes are going to be shot, but hey it's relatively minor maintenance as compared to a lost plane.

I find it frustrating that pilots reading this report will believe that it is almost impossible to land a plane with smoke when in fact a precautionary descent while simultaneously diagnosing the problem could of been done. If the problem is minor then the plane can climb back out again with a minor fuel expense (remember very little fuel is consumed on descent). I'm sure a balance can be attained between spending time diagnosing and doing an immediate precautionary descent towards the closest airport or water.

From the report the weather was not CAVOK but it wasn't the end of the world.

[InitRef]

Can someone with ETOPS or B777 knowledge help me - As I understand ETOPS has more stringent fire detection and fire suppression standards.

Would a fire starting in the same place as SR111 have the same devastating effect on say - a B777 under today's ETOPS 120/180 regulations? Should all aircraft have ETOPS-like fire detection/suppression? Or would it not have made a difference here?

[PPRuNe Radar]

aardvark2zz

I find it frustrating that pilots reading this report will believe that it is almost impossible to land a plane with smoke when in fact a precautionary descent while simultaneously diagnosing the problem could of been done.

As a generic statement you have a valid concern. However in this incident the investigation determined that the aircraft could not have been landed safely in the time available.

# From any point along the Swissair Flight 111 flight path after the initial odour in the cockpit, the time required to complete an approach and landing to the Halifax International Airport would have exceeded the time available before the fire-related conditions in the aircraft cockpit would have precluded a safe landing.

This shouldn't stop pilots from trying to land without undue delay in similar incidents though. The memories of SR111 will ensure that no one forgets what could happen.

[A310GUY]

aadrvark2zz,

Chuck Yeager? What does that mean? I assume you mean - throw out the checklists, knee jerk react, improvise and 'go for it'. I don't think that Chuck Yeager ever did a 'Chuck Yeager'. He was a well trained test pilot dealing with risky situations and for all of his swagger I am sure that he was well briefed, studied and professional in his approach.
As for the Swiss Air situation: Yes if they proceded to YHZ at 100% at first sign they may have made it. Or they may have crashed in the communities of Dartmouth or Bedford in the latter stages of the approach when the flight deck environment was unbareable.
As a commercial airline pilot I do not assume the first hint of smoke or a tripped circuit breaker is the genesis of a catastrophic situation. I analyse. I have smelled smoke on numerous occasions that turned out to be some paper in the oven. Should I have made an emergency landing at the nearest airport? I have had an inverter burn out with smoke in the flight deck - donned masks, proceded towards an airport and completed checklists. I have had a circuit breaker trip in flight. Should I have made and emergency landing assuming this was the start of something really bad? No I assumed the breaker was functioning normally and protecting a circuit from a short. I don't reset the breaker and I follow a checklist. The Swiss pilots did the same. They reacted in an analytical way and did what most professional commercial airline pilots would do.
As for ditching in the ocean. At night, strangers to the area, over the coast with not many lights for perspective in a hostile cockpit environment - poor chance. This was pointed out.
There are no fields of opportunity to land in the Halifax area. It is rough rocky shore with dense wooded inland areas.
These are points the investigators highlighted. Given the situation and circumstances the crew did their best.
It is always easy to armchair quarter back.
A310

[19F]

There's an excellent audio-video feature of the Swisair 111 investigation at the CBC website: http://www.cbc.ca/natureofthings/swissair_feature.html#

[Bubbette]

Thank you for that info.

[Stumpie]

Aardvark2zz. It seems regardless of what the TSB of Canada concluded from months of investigation, you have a VERY considered opinion to state. It is always easy to be critical after the fact and about people who are not around anymore to defend their decisions made under it appears very difficult circumstances. Hopefully you will never be put in the situation to prove what a Hot Shot "Chuck Yaeger" you actually are!

[Few Cloudy]

19 F,

If that is the same thing shown a few times on various Swiss TV stations, then it answers all the questions and accusations made here. The situation was hopeless and the runway could not have been reached before the ship became unflyable.

By the way, this was not Swissair's first experience of smoke;

Coronado lost after terrorist device caused smoke after takeoff from cargo hold - last words - we cannot see the instruments - we are crashing - goodbye everyone. This particular case MAY have been rescuable with quicker action.

MD-80 with heavy smoke in cockpit and subsequent landing in MUC in almost blind conditions. This was caused by a short to the emergency power switch which could have only been disconnected by a crewmember descending through the small hatch to the EE compartment and pulling th 80A CB by the battery - if they had known. Try that by the way with the other pilot flying on minimum panel and fixed stabilizer, with your smoke mask and goggles on!

As a result of that incident the checklist philosophy was changed from the FAA approved "try this and wait""try that and wait" version, to the MDC "switch off everything and build up again as smoke clears" philosophy. It was printed in thick letters at the very back of the checklist (QRH) where it could be easily found and began with the words "consider immediate diversion" or similar.

The MD-80 fleet got sold and the lessons learned were rather filtered as they reached the rest of the fleet.