Aviation Investigation Report A98H0003

Table of Contents

  1. How This Report Is Organized
  2. 1.0 Factual Information
  3. 2.0 Analysis
  4. 3.0 Conclusions
  5. 4.0 Safety Action
  6. 5.0 Appendices
  7. List of Figures

How This Report Is Organized

  1. How This Report Is Organized

1.0 Factual Information

  1. 1.0 Factual Information
  2. 1.1 History of the Flight
  3. 1.2 Injuries to Persons
  4. 1.3 Damage to Aircraft
  5. 1.4 Other Damage
  6. 1.5 Personnel Information
  7. 1.5.1 General
  8. 1.5.2 Flight Crew
  9. 1.5.3 Cabin Crew
  10. 1.5.4 Seventy-Two-Hour History
  11. 1.5.5 Air Traffic Controllers
  12. 1.6 Aircraft Information
    1. 1.6.1 General
    2. 1.6.2 Environmental (Air) System
    3. 1.6.3 Ditching Mode
    4. 1.6.4 Auto Flight System
    5. 1.6.5 Electronic Instrument System
    6. 1.6.6 Flight Management System
    7. 1.6.7 Warnings and Alerts
    8. 1.6.8 Standby Flight Instruments
    9. 1.6.9 Communications Systems
    10. 1.6.10 Electrical System
    11. 1.6.11 In-Flight Entertainment Network
    12. 1.6.12 Aircraft Fire Protection System
    13. 1.6.13 Flight Control System
    14. 1.6.14 Fuel System
    15. 1.6.15 Hydraulic System
    16. 1.6.16 Cockpit Windows
    17. 1.6.17 Landing Gear
    18. 1.6.18 Aircraft Interior Lighting
    19. 1.6.19 Emergency Equipment
    20. 1.6.20 Powerplants
    21. 1.6.21 Landing Performance
    22. 1.6.22 Aircraft Maintenance Records and Inspection
  13. 1.7 Meteorological Information
    1. 1.7.1 General
    2. 1.7.2 Forecast Weather
    3. 1.7.3 Actual Reported Weather
    4. 1.7.4 Upper Level Wind
    5. 1.7.5 Weather Briefing
    6. 1.7.6 Weather Conditions on Departure from JFK
    7. 1.7.7 Weather Conditions during Descent
  14. 1.8 Aids to Navigation
  15. 1.9 Communications
    1. 1.9.1 General
    2. 1.9.2 Controller Training
    3. 1.9.3 Transition Procedures and Controller Communications
    4. 1.9.4 Emergency Communications
    5. 1.9.5 Air Traffic Services Communication Regarding Fuel Dumping
  16. 1.10 Aerodrome Information
  17. 1.11 Flight Recorders
    1. 1.11.1 General
    2. 1.11.2 Recorder Installation Power Requirements
    3. 1.11.3 Stoppage of Recorders
    4. 1.11.4 Lack of CVR Information
    5. 1.11.5 Quick Access Recorder
    6. 1.11.6 Lack of Image Recording
  18. 1.12 Wreckage and Impact Information
    1. 1.12.1 Wreckage Recovery
    2. 1.12.2 Aircraft Wreckage Examination
    3. 1.12.3 Examination of Recovered Electrical Wires and Components
    4. 1.12.4 Examination of Flight Crew Reading Lights (Map Lights)
    5. 1.12.5 Examination of Cabin Overhead Aisle and Emergency Light
    6. Assemblies
    7. 1.12.6 Examination of Standby Instruments
    8. 1.12.7 Examination of Flight Controls
    9. 1.12.8 Examination of Fuel System Components
    10. 1.12.9 Examination of the Engines
    11. 1.12.10 Examination of Aircraft Structural Components
    12. 1.12.11 Examination of Flight Crew and Passenger Seats
    13. 1.12.12 Aircraft Attitude and Airspeed at the Time of Impact
  19. 1.13 Medical Information
    1. 1.13.1 Recovery of Occupants
    2. 1.13.2 Identification of Individuals
    3. 1.13.3 Injury Patterns
    4. 1.13.4 Toxicological Information
  20. 1.14 Fire
    1. 1.14.1 Aircraft Certification Standards
    2. 1.14.2 Review of In-Flight Fire Accident Data
    3. 1.14.3 Designated Fire Zones and Smoke/Fire Detection and Suppression
    4. 1.14.4 Time Required to Troubleshoot in Odour/Smoke Situations
    5. 1.14.5 Risk of Remaining Airborne – Emergency Landing
    6. 1.14.6 Integrated Firefighting Measures
    7. 1.14.7 Airflow Patterns
    8. 1.14.8 Describing the SR 111 Fire-Damaged Area
    9. 1.14.9 Determination of Heat Damage
    10. 1.14.10 Assessment of Fire Damage
    11. 1.14.11 Potential Ignition Sources
    12. 1.14.12 Fire Propagating Materials
    13. 1.14.13 Potential Increased Fire Risk from Non-fire-hardened AircraftSystems
  21. 1.15 Survival Aspects
  22. 1.16 Tests and Research
    1. 1.16.1 AES Examinations of the Recovered Arced Beads
    2. 1.16.2 Map Light Testing and Research
    3. 1.16.3 Airflow Flight Tests
    4. 1.16.4 Analysis of Cockpit Sounds Recorded on the CVR
    5. 1.16.5 Simulator Trials
    6. 1.16.6 Theoretical Emergency Descent Calculations
    7. 1.16.7 Statistics for Occurrences Involving Smoke or Fire
    8. 1.16.8 Electrical Ignition Tests of MPET-Covered Insulation Blankets
    9. 1.16.9 Computer Fire Modelling
  23. 1.17 Organizational and Management Information
    1. 1.17.1 SAirGroup/Swissair/SR Technics
    2. 1.17.2 Swissair Federal Office for Civil Aviation
    3. 1.17.3 Federal Aviation Administration
    4. 1.17.4 The Boeing Company
  24. 1.18 Other Relevant Information
    1. 1.18.1 Swissair Training
    2. 1.18.2 Swissair Checklists for In-Flight Firefighting
    3. 1.18.3 Availability of Published Approach Charts
    4. 1.18.4 Wire-Related Issues
    5. 1.18.5 Circut Protection Devices
    6. 1.18.6 High-Intensity Radiated Fields
    7. 1.18.7 In-Flight Entertainment Network
    8. 1.18.8 Chronological Sequence of Events
    9. 1.18.9 Witness Information
    10. 1.18.10 Reporting of Cabin Anomalies
  25. 1.19 Useful or Effective Investigation Techniques
    1. 1.19.1 Exhibit Tracking Process
    2. 1.19.2 Data Analysis Tools
    3. 1.19.3 Partial Aircraft Reconstruction
    4. 1.19.4 Electrical Wire Arc Sites Analysis
    5. 1.19.5 Temperature Reference Coupons
    6. 1.19.6 Speech Micro-coding Analysis
    7. 1.19.7 Fuel Detection by Laser Environmental Airborne Fluorosensor
    8. 1.19.8 Aircraft Engine Analysis
    9. 1.19.9 Restoration and Extraction of Non-volatile-memory information
    10. 1.19.10 Use of Computer Fire Modelling

2.0 Analysis

  1. 2.0 Analysis
  2. 2.1 General Information
  3. 2.2 On-Board Data Recording Capability
    1. 2.2.1 General
    2. 2.2.2 Cockpit Voice Recorder
    3. 2.2.3 Survivability of Quick Access Recorder Information
    4. 2.2.4 Image Recording
    5. 2.2.5 Underwater Locator Beacons – Bracket Attachments
  4. 2.3 Material Susceptibility to Fire – Certification Standards
    1. 2.3.1 Flammability of Materials
    2. 2.3.2 Contamination Issuess
    3. 2.3.3 Non-fire-bardened Aircraft Systems
  5. 2.4 Aircraft Fire Detection and Suppression
  6. 2.5 In-Flight Firefighting Measures
  7. 2.6 Crew Preparation and Training
    1. 2.6.1 In-Flight Firefighting
    2. 2.6.2 In-Flight Emergency Diversions
  8. 2.7 Checklist Issues
    1. 2.7.1 Swissair Checklist Options for Smoke Isolation
    2. 2.7.2 Emergency Electrical Load-Shedding
    3. 2.7.3 Additional Checklist Issues
    4. 2.7.4 Checklist Revisions and Approvals
  9. 2.8 Maintenance and Quality Assurance Aspects
  10. 2.9 Potential Effect of High-Intensity Radiated Fields
  11. 2.10 Air Traffic Services Issues
  12. 2.11 ACARS and VHF Communications Gap Anomalies
  13. 2.12 Flight Crew Reading Light (Map Light) Installation
  14. 2.13 Circuit Breaker and Electrical Wire Issues
    1. 2.13.1 Circuit Breaker Technology
    2. 2.13.2 Circuit Breaker Reset Philosophy
    3. 2.13.3 Circuit Breaker Maintenance
      2.13.4 Electrical Wire Separation Issues
  15. 2.14 In-Flight Entertainment Network
    1. 2.14.1 Operational Impact of the IFEN Integration
    2. 2.14.2 FAA Oversight (Surveillance) of the IFEN STC Project
    3. 2.14.3 IFEN System Design and Analysis Requirements
    4. 2.14.4 FAA Aircraft Evaluation Group Role/STC Involvement
    5. 2.14.5 IFEN STC Project Management
  16. 2.15 Factors Influencing Pilot Decision Making Regarding Initial Odour and Smoke
  17. 2.16 Factors Influencing Pilot Decision Making during Diversion
  18. 2.17 Fire Development
    1. 2.17.1 Potential Ignition Sources – General
    2. 2.17.2 Arc-Damaged Cables and Wires
    3. 2.17.3 Airflow, Fire Propagation, and Potential Ignitioin Locations
    4. 2.17.4 Fire Propagation from an Arc Fault Near STA 383
  19. 2.18 Known Technical Failure Events
  20. 2.19 Remaining Few Minutes Following Stoppage of Recorders
  21. 2.20 Actual Versus Theoretical Emergency Descent Profile
    1. 2.20.1 General
    2. 2.20.2 Earliest Possible Landing Time
    3. 2.20.3 Effect of Fire-Related Failures on Landing
    4. 2.20.4 Theoretical Emergency Descent Calculations
  22. 2.21 Fire Initiation

3.0 Conclusions

  1. 3.0 Conclusions
  2. 3.1 Findings as to Causes and Contributing Factors
  3. 3.2 Findings as to Risk
  4. 3.3 Other Findings

4.0 Safety Action

  1. 4.0 Safety Action
  2. 4.1 Action Taken
    1. 4.1.1 MD-11 Wiring
    2. 4.1.2 Flight Recorder Duration and Power Supply
    3. 4.1.3 Thermal Acoustic Insulation Materials
    4. 4.1.4 MD-11 Flight Crew Reading Light (Map Light)
    5. 4.1.5 In-Flight Firefighting
    6. 4.1.6 Overhead Aisle and Emergency Lights
    7. 4.1.7 In-Flight Entertainment Network/Supplemental Type Certificate
    8. 4.1.8 Circuit Breaker Reset Philosophy
    9. 4.1.9 Standby Instrumentation
    10. 4.1.10 Material Flammability Standards
    11. 4.1.11 Air Traffic Controller Training
  3. 4.2 Action Required
    1. 4.2.1 Thermal Acoustic Insulation Materials
    2. 4.2.2 Interpretation of Material Flammability Test Requirements
    3. 4.2.3 IFEN – Supplemental Type Certificate Process
    4. 4.2.4 Circuit Breaker Reset Philosophy
    5. 4.2.5 Accident Investigation Issues
  4. 4.3 Safety Concern
    1. 4.3.1 In-Flight Firefighting Measures
    2. 4.3.2 Aircraft System Evaluation: Fire-Hardening Consideration
    3. 4.3.3 Aircraft Wiring Issues
    4. 4.3.4 Flight Crew Reading Light (Map Light)
    5. 4.3.5 Standby Instrumentation
    6. 4.3.6 Contamination Effects
    7. 4.3.7 Arc-Fault Circuit Breaker Certification
    8. 4.3.8 Role of the FAA's Aircraft Evaluation Group
    9. 4.3.9 Checklist Modifications
    10. 4.3.10 Accident Investigation Issues

5.0 Appendices

  1. 5.0 Appendices
  2. Appendix A – Flight Profile: Selected Events
  3. Appendix B – Swissair Air Conditioning Smoke Checklist
  4. Appendix C – Swissair Smoke/Fumes of Unknown Origin Checklist
  5. Appendix D – Timeline

List of Figures

  1. List of Figures
Date de modification :
2012-07-27