Aviation industry slow to act on Swissair safety issues, investigators say

A decade after the Swissair Flight 111 crash off Nova Scotia that claimed 229 lives, the aviation industry has yet to act on recommendations stemming from one of lengthiest and most expensive air investigations in Canadian history.

10 years after Swissair crash, TSB investigators still pushing for changes to regulations

Jim Harris of the Transportation Safety Board examines a recovered piece of the fuselage from Swissair Flight 111 at CFB Shearwater in Dartmouth, N.S., in Dec. 1998. ((Andrew Vaughan/CP))
Ten years after Swissair Flight 111 crashed into the Atlantic Ocean off the coast of Nova Scotia, airlines have yet to act on many of the recommendations stemming from one of lengthiest and most expensive air investigations in Canadian history. While aviation officials continue to disagree over the level of risk involved, crash experts worry that the industry is flirting with disaster.

At the heart of the matter are "unsatisfactory" ratings the Canadian Transportation Safety Board (TSB) has given the industry regarding action on two of its recommendations — one dealing with the information gathered by the black boxes on planes and the other addressing the safety testing of insulation materials. Transport Canada says all high-risk insulation has been removed from domestic aircraft, but some safety experts maintain that the safety of some material still in use needs to be reassessed. The airlines, meanwhile, say they are waiting for regulatory changes to guide them.

The revelation that there are still outstanding recommendations is a surprise to people who lost loved ones on the flight, and who thought the investigation would lead to safer skies. 

Role of the Transportation Safety Board
  • Conduct marine, pipeline, rail and air investigations; inform the public about what happened and what caused an accident/incident to occur.
  • Identify safety deficiencies and make recommendations to government and respective industries about how to address them, but does not have the power to enforce those recommendations.
  • Make recommendations public by publishing them on its website,
  • Communicate with industry officials and regulators when action on its recommendations is anything less than "fully satisfactory"; follow up regarding progress made, encourage those responsible to take further action, and work with the airline, regulator, and/or manufacturer involved to explore other possibilities that could eliminate the risk identified in a recommendation. 



"It actually makes you wonder why the Canadian Transportation Safety Board went through all that work to make the recommendations and no one seems to listen to it," said Myron Ratnavale. "You're talking about a fire that took a plane down in 20 minutes."

Ratnavale lost his parents on Sept. 2, 1998, when Swissair Flight 111, en route to Geneva, Switzerland, from New York, crashed near Peggy's Cove, N.S., killing all 229 aboard. Ratnavale's parents were returning home to Geneva following his father Victor's heart bypass surgery.

"At the time you're thinking Swissair didn't crash, this didn't happen," he said, recalling the hours after the disaster. "You're totally lost — totally lost — and your mind is just not there. I mean, a couple hours before you knew you had to get up early and go collect someone at the airport, and suddenly you've gone 180 degrees."

It was only when Ratnavale went to the Halifax warehouse where the investigators were painstakingly examining pieces of the shattered plane that he understood why there were no survivors for rescuers to find.

"You don't imagine that such a huge piece of metal like that can be chopped up into pieces no bigger than three centimetres square with the exceptions of landing gears or something."

Flight 111 investigation

It took the TSB 4 ½ years and approximately $57 million to complete its investigation into the cause of the crash. According to the TSB, more than 3,000 people were involved in the recovery efforts and a core group of 15 investigators took part in the probe from start to finish.


TSB ratings

Recommendations are giving a rating based on the following criteria:

  • Fully Satisfactory: The deficiency has been acknowledged, and substantial action has been taken to reduce or eliminate the risk.
  • Satisfactory Intent: Sufficient action is not being taken to reduce the risks identified in the recommendation, but there is planned action that will, if fully implemented, reduce or eliminate the concern.
  • Satisfactory in Part: The planned action will reduce, but not significantly reduce or eliminate, the deficiency identified by the TSB.
  • Unsatisfactory: No action has been proposed or taken that will reduce or eliminate the risk. The TSB maintains this rating if it has not received a suitable explanation to convince it that the risks do not require tracking, and: "In the board's view, the safety deficiency will continue to put persons, property or the environment at risk."

"Inactive" status: The safety concern has been addressed and resolved and the "residual risk" associated with the deficiency is considered to be relatively low.

"Active" status: The risk associated with the deficiency still calls for TSB involvement.


In its final report  released on March 27, 2003, the board attributed the crash to an in-flight fire caused by faulty wiring. In a matter of minutes after a problem was detected, the cockpit was full of smoke. Investigators concluded that the flames fed off the surrounding flammable thermal acoustic insulation materials called metallized polyethylene terephthalate (MPET).  

The TSB made 23 recommendations based on its findings, and yet 10 years after the crash, 18 have an "active" status (see sidebar). This means the board is still trying to solve a particular safety issue, and tracking regulators and manufacturers that haven't followed its recommendation.

Two of those active recommendations have been given an "unsatisfactory" rating by the TSB, which means little has been done to eliminate the risk.

The first involves increasing the amount of information collected by a plane's flight data recorder — the so-called "black box" — to help crash investigators pinpoint the cause of accidents (see sidebar "Bolstering the black box").

More worrying, the second recommendation is aimed specifically at averting a repeat of the type of fire that brought down Flight 111.

That second recommendation, which the TSB is still trying to get the airline industry to act on, involves new tests done by regulators in Canada and the United States to measure the flammability of insulation materials.

"When we come across something that is as significant as a safety issue, we make it into a recommendation so we can track it, because these are issues which have a significant impact on the aviation industry and for the public as they are flying from point 'A' to point 'B,'" said Don Enns, a TSB investigator. "So with recommendations like the replacement of metallized Mylar insulation, we do in fact treat that very seriously and we want people to take action to make the industry safer."

Transportation Safety Board senior investigator Don Enns displays metalized Mylar insulation material in front of the partially reconstructed cockpit of Swissair Flight 111 at a news conference in Halifax on Dec. 4, 2000. ((Andrew Vaughan/CP))
Regulators issued an order in 1999 that metallized polyethylene terephthalate insulation material be removed from all Canadian and U.S. registered aircraft. The airline industry completed the MPET replacement work in June 2005. 

As a result of the board's conclusion that MPET insulation blankets were a key factor that allowed the fire on the Swissair jet to spread so quickly, the FAA also designed the Radiant Panel Test  to identify what types of insulation materials are flammable and how quickly they burn. In the United States, the Federal Aviation Administration (FAA) now requires material used in all new planes to pass this rigorous test to ensure they are safe.

However, some older planes currently in operation around the world were built using materials that have failed the new test, and they are still flying. Those materials were examined and approved under the older, less stringent testing methods.

Swissair Flight 111 investigators recommended that planes containing insulating materials that have failed the newer, tougher flammability standards should be looked at closely to determine whether those materials pose a safety risk to passengers. But regulatory authorities are not ready to take further action and assess these materials — in fact, Transport Canada says it considers the potentially flammable insulation material to be a low-risk matter.

"All that high-risk material has been removed from Canadian aircraft … and we've identified some low-risk material," said Merlin Preuss, Transport Canada's director general of civil aviation. "And in some of those cases, while some of it is still on aircraft, we've ensured that it's not in any kind of a safety-sensitive area that would lead to the same type of problems that we saw with Swissair." 

John Britten, an accident investigator for the TSB, disagrees.

"If you took all the in-service thermal acoustic insulation materials that were tested during the development of the Radiant Panel Test, you would find that some of them have failed and they are still in service across the world," Britten said. "What we have discovered is that these materials will feed a fire once it gets started, which they aren't supposed to do. If the source of ignition goes out, like in a spark, and they catch fire, they are supposed to self-extinguish — and the material does not do that."

Level of risk

The issue of how to deal with material that has failed the Radiant Panel Test remains controversial due to the difference of opinion between the regulatory authorities over the level of risk. The role of the TSB is to conduct investigations, identify safety deficiencies and make recommendations to the industry to address the concerns and ensure safety. Transport Canada is a regulatory body responsible for implementing recommendations and developing programs and policies.

Bolstering the black box

One of the recommendations from the Swissair Flight 111 investigation that has yet to be acted on proposes allowing the so-called "black box" or flight data recorder (FDR) aboard all aircraft manufactured from 2007 onwards to retrieve information recorded on quick access recorders (QARs). A plane's QAR is primarily used as a maintenance tool — it collects more information about the aircraft than FDRs are currently required to record, but the device itself isn't built to withstand a crash.

"They [QARs] are not designed for any accident investigation," said John Britten, accident investigator for the TSB. "It's just that you can look at this equipment if it survived or if the memory survived, and you might try to recover what it's telling you, the zeros and ones [data]. And then it might be able to help you confirm other information that you have."

Backing up the additional information collected by the QARs to a plane's black box wouldn't necessarily make the aircraft itself any safer, Britten says, but it would provide investigators with additional data when trying to determine the cause of an accident, which could in turn help prevent similar accidents and make air travel safer over time.  

The airlines are waiting for official direction from regulators, according to Les Aalders, vice-president of operations at the Air Transport Association of Canada, the group that represents the interests of commercial aviation in Canada.

"As an industry, we support the research going into the new flammability test and on an ongoing basis, incorporating them into the new production aircraft. We need to make sure that the recommendations that are going through regulatory change in Canada do get through the system and don't get bogged down," Aalders told CBC News.

"As an industry that's very focused on safety, we're very keen to see it through. It can be frustrating to see how long it takes to get through the whole documentation system. So we're very supportive, working with the TSB and Transport Canada in getting the right changes to our regulations as quick as possible."

As Preuss points out, Transport Canada's position is that material it considers high-risk has been removed from commercial aircraft and only low-risk material remains. But during the Swissair investigation, the TSB concluded there are insulating materials on aircraft in operation that show signs of similar flammability characteristics to the MPET-covered blankets present on Flight 111. As a result, the TSB is still pushing for a higher standard to assess the insulation materials in older planes and better identify the risks.

"We're concerned," said Mark Clitsome, director of air investigations for the TSB. "We've given them [Transport Canada] an unsatisfactory rating, or satisfactory with intent until all that testing is done and the insulation as a system is tested — then we'll be satisfied."

The dispute comes down to the level of risk that's considered acceptable, Clitsome adds.

"There are some types of insulation that still have the potential to be ignited, even though that potential is very small," he said. "Because there are areas where there are no wires — heating ducts, just insulation to keep the plane warm, and thermal acoustic insulation — the chances of that igniting are very low, but there are still some out there."

TSB investigators say flammable insulation has already played a part in a major crash, and they're just trying to be proactive.

This B767 cargo jet operated by Airborne Express caught fire in late June 2008 on the runway at San Francisco International Airport. The burned fuselage is a stark reminder of the fire that brought down Swissair Flight 111. ((Courtesy NTSB))
"What we've been told by the FAA and Transport Canada is that they are relying on in-service flammability performance," crash investigator Britten said.

"When an occurrence happens and the material is deemed to be a player, then they will react depending on whatever their criteria are for taking mitigating action. What we were looking for in the recommendation was [for regulators to take] a proactive approach and say, 'Look, identify the materials that have failed the Radiant Panel Test and then develop a mitigation strategy for each one of them.'"

"The threat of fire remains as serious as a decade ago," added David Evans, the editor of Aviation Safety and Security Digest.

He said that all the back and forth between the safety agencies and the regulators adds up to one simple truth.  "I think people would be shocked to discover that the risk has probably gone up because of the density of the wiring and electronics in the cabin, but [also] by the fact that the cabin itself is not protected by smoke detection or fire suppression. The flight attendants, depending on the size of the airplane, have between two and four handheld fire extinguishers, that's it. It's not only amazing, it's appalling."

Smoke in the cockpit forced emergency landings in at least three incidents in a three-day period in August: 

  • An American Airlines Boeing 757 en route from Los Angeles to Honolulu made an emergency landing at Los Angeles International on Aug. 5 due to smoke in the cockpit. The flight landed without incident and passengers left the plane by the emergency chutes.
  • On Aug. 6, an Air Canada Airbus flying from Montreal to Edmonton developed smoke in the cockpit as the plane was making its final approach into Edmonton.  The pilot declared an emergency and a fire alert, and the plane landed safely with no injuries among the 138 passengers.
  • On Aug. 7, a Continental Airlines Boeing 737 flying from Orange County, Calif., to Newark was forced to return to Orange County after the pilot smelled smoke in the cockpit. There were no injuries among the 118 people onboard.

The U.S. National Transportation Safety Board and Canada's TSB are still investigating the precise causes of these recent incidents.

"We're going to have another crash that's caused by an electrical problem, it's a matter of time," said Ladd Sanger, an attorney with Slack and Davis in Dallas, specializing in aviation litigation. "You can't have all the emergency landings we're having, and not have one of those lead to a crash in the not too distant future. It could be in a matter of just a few minutes that some of these emergency landings ended up like Swissair."

Call for action

Ten years after the Swissair crash, with experts still at odds over the investigation's recommendations, the families of Flight 111's passengers just want to ensure the type of disaster that befell their loved ones isn't repeated.

Haunted by the image of the plane hitting the water, Ratnavale said it took him several sessions with a psychologist to shake the vision and start functioning again. The fact that the TSB found flammable materials on the aircraft that were once thought to be safe and which helped the fire spread was a "wake-up call to the industry" to stop ignoring key issues and start taking action, he said. 

"I guess it is big bucks and there's a money story behind it in order to revamp their planes," Ratnavale said.

Accident investigator Britten said more needs to be done to ensure history doesn't repeat itself.

"If nothing has been done to mitigate the risks, then you're in the situation where it can happen again," Britten said. "Now we are looking into a room that is pitch dark and you haven't turned on the light yet so you don't know what's there waiting for you. It's a mystery to us right now as to what exactly is out there. The risk is unknown."