PBS NOVA: Crash of Flight 111

David Evans
Editor in Chief, Air Safety Week
Wednesday, February 18, 2004; 11:00 AM

On Sept. 2, 1998, Swissair Flight 111 crashed into the sea off of Nova Scotia while en route from New York to Geneva. All 229 people on board were killed. In March 2003, Canada's Transportation Safety Board published its final conclusions from an investigation that took more than four years and cost over $40 million. PBS NOVA's "Crash of Flight 111" tells the behind-the-scenes story on one of the most intricate investigations in aviation history.

David Evans, editor in chief of "Air Safety Week," PBI Media, was online Wednesday, Feb. 18 at 11 a.m. ET to discuss the documentary.

Evans, a former career officer in the U.S. Marine Corps, was a nationally syndicated military affairs correspondent for the Chicago Tribune newspaper (Washington, D.C., bureau) between 1987-1993. Since 1995, Evans has been the editor-in-chief of "Air Safety Week," PBI Media, the world's most recognized newsletter on air safety and security issues.

Editor's Note: moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.


David Evans: Hi. I'm David Evans. I was proably as curious as viewers about this NOVA documentary. We taped the parts on which I and Capt. Ken Adams appeared sme weeks ago, and we really did not know what else the producers had in the way of visual material to exlan the conduct of the investigation.


Akron, Ohio: Hi David--

How does the Canada's TSB compare to the US's NTSB? Anything the US NTSB can learn from Canada's TSB?



David Evans: Canada's TSB is set up pretty much like our NTSB, as an independent investigative body. There is one signbificant difference. Our NTSB uses public hearings to establish and flesh out facts, and a final hearng to hash out findings and recommendations. All that occurs behind closed doors at the TSB. They have the option of holding public hearings, but chose not to in the SR 111 case.


Herndon, Va.: The program was outstanding, as were your insights. I am left with the fear that another "111 crash," while not probable, certainly is still possible. Am I correct?

David Evans: Delta Air LInes had av ery similar case in one of its L-1011 trijets on a flight from Hawaii to the West Coast. I think it was just a couple months after the SR 111 crash. They had a fire in the flight engineer's console in the cockpit, could not extinguish it, and made an emergency landing at San Francisco. If they had been further out, the outcome could have been much worse.


Vienna, Va.: I did not see the documentary. Will it be rebroadcast? Also, in the investigation was there anything new found that was different from what officials thought had happened?

David Evans: I'm a big NOVA/Frontline fan, as most of what's on the tube strikes me as a wasteland of ignorance and superficiality. I've seen NOVA rebroadcasts, so would expect this show to appear again, as well. Having participated in its preparation, it turned out much better than I expected. It's a stunner.


Arlington, Va.: Am I the only one who is outraged that our government is so slow to respond to this documented threat? Why are planes still in service with the same materials that helped cause the crash of Flt 111?

David Evans: The FAA did order the removal and replacement of the metalized Mylar insulaiton blankets. It's a big deal, and a big burden on the airlines. Try removing it from the cockpit, for example, without damaging the masses of wiring behind the instruments. Believe me, I've seen it. So one problem we have here is that were removing the tinder but the the wiring "matches" are going to have to be dealt with. The FAA is developing a massive wiring inspeciton program that will hit the industry in the next year or so. Yes, a repeat of this tragedy is possible. We need to move faster. Swissaar did more than anybody, and didn't wait for the regulators to act.


Washington, D.C.: I have a question about the wiring and insulation that caused the fire about Flight 111. The program last night stated there were still quite a few aircraft in the US fleet, that have corrosive wiring and the old insulation(60%, I believe). Since we now know the fire danger, shouldn't all planes be fitted with the new insulation immediately, rather than waiting until 2005 when it becomes mandatory. Second, what about foreign airlines/aircraft? Are they at the same risk?

David Evans: It may not be realistic to ground the fleet and get this work done pronto. We've made a lot of progress since the SR 111 crash. My concern is that it was a preventable accident. The FAA was caught in it's too-typical Rip van Winkle mode, and it took the loss of 229 lives to galvanize the agency into action. The FAA cannot mandate action for foreign carriers, but Swissair has already set the example, removing and replacing the insulation, installing improved standby instruments, separating wire bundles in the cockpit overhead, and installing close circuit TV to help the pilots identiy fire in the overhead spaces and in the belly holds. It wasn't cheap. It shows what can be done when the spirit is willing.


Philadelphia, Pa.: Near the end of the NOVA program, it was mentioned that the FAA has not put into effect the changes that the Canadian TSB recommended. Any ideas as to why the FAA is dragging it's feet on those safety issues that, at least I thought, appeared to be justifiable?

David Evans: One of the most important recommendations dealt with the flight recorders. The TSB called for dual recorders, one set aft and one set forward, so that at least one flight data and cockpit voice recorder would survive a crash. The TSB wanted an independent battery supply to prevent another loss of that critical 6 minutes of data. The TSB also wanted a 2-hour recording capability. I think those are big three. Our own NTSB seconded the TSB recommendations. The FAA has not taken action, and that is unfortunate. If you're talking "data-driven" safety, the FAA's self-proclaimed mantra, we need better recorders for more reliable data capture.


Fairfax, Va.: Why was the investigation called the most intricate of all time and will the procedures for this investigation change standards for future cases?

David Evans: In my experience, high-prile cases like SR 111 involve detailed accident investigations that can take years to complete. With more avionics in today's new jets, tracing down the flow of evanescent electrons can make post-accident investigations even tougher. The SR 111 case was a real test of the TSB's mettle, and they rose to the challenge. They had a lot of issues to address, as evidenced by nearly two dozen recommendations. Some led directly to design standards, which can take a long time to change. Basically, the TSB has said that if flammable materials are not used in airliners, the danger of in-flight fire is reduced dramatically. I wholly endorse that position, especially for all newly manufactured airplanes.


Warren, Ohio: Was it absolutely necessary that 111 dump fuel before attempting to land? What would have happened had the pilot decided to head straight to Halifax Airport instead of heading back out to sea to dump fuel?

David Evans: Good question. Capt. Urs Zimmerman and First Officer Stefan Lowe could have made an overweight landing at Halifax. Problem is, they didn't know they had a raging fire overhead. Most of these in-flight smoke events involve some sort of rather benign contamination in the air conditioning system. That's probably what they thought, until the fire burst through the ceiling in a volcanic blast of hot gas and burning shards of material. That was what drove the captain out of his seat, as Capt. Ken Adams mentioned, in a desperate attemtp to fight the fire with a puny hand-held extinguisher. They didn't realize how dire the situation was until it was too late.


Columbia, S.C.: I thought the program was fascinating. It amazes me how investigators can pinpoint the cause of an airline crash with only shards of metal and wire to work with, especially since in this case the "black boxes" were of no help. Have steps been taken since the investigation to give a back-up power source to black boxes (since evidently the power was cut to these by the fire)?

David Evans: I give full credit to the determination of the TSB investigators. That was some impressive detective work! On the backup power for recorders, the regulators have done zilch. At least, that's my understanding.


Akron, Ohio: Like a lot of people, my wife has been reluctant to fly since the Sept. 11 attacks. Documentaries like this one scare her even more. Can you suggest some reassurance I can offer her about flying, or should we keep driving the minivan on vacations?

David Evans: Flying is pretty safe. The airplanes WANT to fly. They are inherently stable and the level of reliability that has been achieved is really remarkable. Deadly accidents like SR 111 occur rarely. But that's not the point. The issue is how many of these accidents were preventable! How many had known latent threats lurking in them? As I mentioned on the show, I haven't seen one of this cases yet where precursor incidents didn't provide a "heads up" or latent problems were not known beforehand. That's why I raised the issue of culpability at the show's closing.


Baltimore, Md.: Everyone is so quick to assign blame. No one gets a huge insurance settlement when faulty wiring causes fires in homes. Yet more children die in fires at home than die in airplane crashes. As an interim fix (while waiting for the other 60% of planes to revamp) why not install sprinklers/smoke detectors or other fire containment measures?

David Evans: New low-pressure water mist extinguisher technology is in development that could really improve fire suppression on airplanes. Deployment is about 3-5 years away, assuming that the FAA requires it. The system would use the potable water supply, thereby saving weight. Some in the industry have argued that the potable water supply ought not be used for firefighting. Who's going to want a drink when the airplane's on fire? Gimme a break. I note that electrical power us used to supply critical flight systems as well as the in-flight entertainment system. No one has said we can't use electrons for two purposes. I say apply the same standard to the on-board water supply.


Rockville, Md.: Airlines are starting to provide passengers with more passenger electronic entertainment, whether it's personal TV screens or some kind of entertainment unit. The wiring system already looks as complex as a human circulatory system. Even if they swap out the insulation blankets, is the amount of wiring simply overstuffed? How much testing and approval goes into an airline's decision to include new features like electronic entertainment?

David Evans: You are onto an extremely important issue. For some entertainment system installations, the amount of associated wiring equals that in the rest of the airplane. The FAA approves the installations, and now wants to see the routing of every wire on the plans, from point of origin to destination. Nonetheless, we have a problem here. There is a move within the industry to now consider wiring as a seprate system, co-equal in importance to powerplants, hydraulics, etc. The FAA supports this approach, and the agency should be commended for it. Yes, swapping out the blankets isn't enough. Some selective wiring replacement may be in order, particularly in the so-called SWAMP areas -- severe wear and moisture prone.


Maryland: What is the latest in aviation technology. I hear that the material that planes are made of stretch to be flexible with air pressure and motion. Will we ever see techonological advances towards indestructable materials to create a plane (like say, the black box that always survives)?

David Evans: If the whole plane is built to the toughness of the black boxes, the weight would be prohibitive. However, I believe with negligible or nil weight gain airliners could be built to be more crashworthy. Most accidents are survivable. SR 111 wasn't, but with better smoke/fire detection in inaccessible spaces, it could have been.


Jacksonville, Fla.: Preliminary reports indicated that both the FDR and CVR had stopped working approximately 6 minutes prior to the crash. Is there any explanation why?

David Evans: They lost electrical power. The Canadian investigators called for independent (battery) back up power supplies for the recorders. A very important recommendation, on which regulators have yet to act.


Washington, D.C.: The scenario of the fire isn't plausible. For example, in some places the fire was more than 1000 degrees, but the lab test of the metalized mylar insulation shows a lot of melting but comparatively few flames. Certainly, the plastic coatings on the wires could have provided the fuel to the fire, but those coverings take more than a spark or weak mylar flames to ignite. For the longest time, investigators could only identify the source of the fire as a 24" by 24" area over the back of the cockpit, and there were many examples of melted copper shown.

The most logical explanation given all the facts, including the fact of national security at the millennium, is that the fire was caused by an everyday road flare with an ignition timer placed by an al Qaeda ground crew service employee. That would explain the continued, high-intensity heat necessary to burn copper, wire insulation, mylar insulation, and plastic. It would explain why the fire burned at 1000 degrees. The road flare provided a contining source of heat to materials that otherwise cannot sustain a fire on their own.

It would also explain why it took three years to announce an explanation.

I'm looking forward to NOVA's piece on EgyptAir Flight 990, which crashed just two months shy of SwissAir 111, on October 31, 1999.

In that investigation, it's claimed the prayer of co-pilot was a suicide act, not a reaction to al Qaeda entering the cockpit. The repeated power dives recorded on internaitonal radar are said to have been the pilot and co-pilot fighting over the controls, not the co-pilot following a known proceedure for disrupting hijackers. The family of the co-pilot insists he would never endanger the passengers or kill himself, and the government of Egypt did not agree with the suicide scenario almost immediately.

Do the back-up controls on an MD-11 include an artificial horizon?

David Evans: Given what I've seen of electrically-stoked in-flight fires, I agree with the TSB scenario. Yes, back up instruments include an artificial horizon. What they showed on the NOVA show was the backup compass (remember, right above the windshield?). The standby artificial horizon was located at the bottom center of the instrument panel, and it appears that the pilots lost it, too, along with their primary instruments. Swissair has since installed a much improved, easier to view, standby horizon, with an independent power supply. No one else seems to have taken similar initiative.


Washington, D.C.: Why leave so tantalizing a piece of evidence hanging at the end of the program, i.e., that in China, an MD-80 had previously caught fire due to the same cause as SR 111, after which China notified the FAA? As an engineer who conducts safety and technological feasibility studies, I believe this was the REAL story. Did you find out too late to follow up?

David Evans: Actually, the NOVA producers found out more than I had known. I was familiar with the letter Chinese authorities sent to the FAA. Given the time constraints of the show, I think the point came across -- that this insulation blanket material burns, and that the FAA was warned years before the SR 111 accident. But the material met the baloney flammability standard and the FAA did nothing, until embarrassed into action by the SR 111 crash.


Philadelphia, Pa. Dear Mr. Evans,
In the NOVA program, I observed the testing of the silver colored insulation blankets and other items at the FAA Center in Pomona. And like the FAA engineer in the program, I was amazed at the materials igniting like they did. The program mentioned that the insulating materials was originally certified by the FAA back in the early 1970's. This prompts me to inquire if there is any program (s) by the FAA or by any other Saftety Board in other countries to require recertification for flight after, for example, a ten year period? I realize that there are numerous inspection programs in place for Mean Time Between Overhauls, etc. However, what got my attention at that point in the program was that the testing method (s) for certification of that material back in the early '70's is not the same as today. Since advances in R&D lead to new materials, etc., methods for testing also evolve and are updated. Would I be correct to assume that no country requires flight hardware and materials that were developed in the past to be tested to new and current testing specifications?

David Evans: I think you are eminently correct -- installed materials are not held to tougher standards developed later. One could argue that the overhauls occuring for a jetliner every 4-5 years are a good time to replace and upgrade materials. Even the new standard for blanket flammability may not be adequate. TSB investigators noted (1) that the test sample is oriented horizontally, not vertically, (2) the test sample is not pre-heated, (3) does not test the flammability of tape, scrim, attachment fittings, and such, and (4) uses a flame, not the much higher heat of an electrical arc.


Piscataway, N.J.: Is there any evidance to suggest that this airplane was brought down by terrorism?

David Evans: Terrorism? NOt to my knowledge. Actually, the probable cause is worse, because it represents a failure of design, certification and oversight, rather than a one-off breakdown of security.


College Park, Md.: Was the first-class electronics to blame, or not?

David Evans: The interactive in-flight entertainment system was installed in the first class and business sections. TSB investigators found heat-damaged IFEN wiring, as you saw on the show, but they were not able to resolve the "chicken and egg" condundrum: did the IFEN wiring arc first, or did other wiring in close proximity arc first and the IFEN wiring was damaged in the cascading sequence of catastrophe? What I can say is that a Swissair technician who witessed the IFEN installaliton described the wiring practices to me as "barbaric." His words. Not mine. An FAA-approved system, mind.


Boston, Mass.: Since pilots may not be able, today, to evaluate the true degree of hazard in smoke in cockpit situations, would a flying rule of the type -land
as soon as possible without fuel dump if smoke in cockpit- be practible or safety enhancing? Of course,one is not second guessing the Swiss Air crew here.

David Evans: Land immediately is the operative term. Sort out the problem after you're on the ground. Would you prefer having to explain an overweight landing rather than die from lack af alacrity to land?


Salt Lake City, Utah: The program showed that discoloration of the paint caused by heat can be used as a clue to determining the origin of a fire. Is the paint or material used specifically designed to provide such a "heat index" or was this merely determined after the fact?

David Evans: Determined after the fact. But, you know, this could be a design feature of the paint -- an idea the industry could pursue.


David Evans: Time's out. The questions were extremly well-informed and I thank all concerned for the opportunity to participate in this thought-provoking exchange.


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