AIRCRASH INVESTIGATION

SWISSAIR FLIGHT 111

BSAET 3B | AMTA 329

Arcilla, John Mark
Ayran, Harold Russel
Castillo, Rhezee
Saquido, Sofia Kayla
GENERAL INFORMATION
• MANUFACTURER&MODEL: McDonnell Douglas MD-11
• OPERATOR: SWISSAIR
• REGISTRATION MARKS: HB-IWF
• FLIGHT NO: SWR111
• DATE: SEPTEMBER 2, 1998
• TIME: 10:31
• LOCATION: Atlantic Ocean, near St. Margarets Bay, Nova Scotia, Canada
• PILOT IN COMMAND: Urs Zimmermann
• FIRST OFFICER: Stefan Low
• PASSENGERS&CREW :229
The pilot-in-command was 50-year-old Urs Zimmermann At the time of the accident, he had
approximately 10,800 hours of total flying time, of which 900 hours were in an MD-11. He was
also an instructor pilot for the MD-11
Before his career with Swissair, he was a fighter pilot in the Swiss Air Force. Zimmermann
was described as a friendly person with professional skills, who always worked with exactness
and precision.
The first officer, 36-year-old Stefan Low, had approximately 4,800 hours of total flying time,
including 230 hours on the MD-11. He was an instructor on the MD-80 and A320. From 1982 to
1990, he had been a pilot in the Swiss Air Force
The aircraft, a seven-year-old McDonnell Douglas MD-11, serial number 48448, registration
HB-IWF, was manufactured in 1991 and Swissair was its only operator. The cabin was
configured with 241 passenger seats. First and business class seats were equipped with in-seat in-
flight entertainment (IFE) systems from Interactive Flight Technologies. The aircraft was
powered by three Pratt & Whitney 4462 turbofan engines and had logged over 36,000 hours
before the crash.

FLIGHT TIMELINE
The flight took off from New York's John F. Kennedy International Airport at 20:18 EDT on
2 September.
From 20:33 – 20:47 EDT ,the aircraft experienced a radio blackout for approximately
thirteen minutes, which was later found to be caused by communication radio tuning errors
 At 22:10 AT, 52 minutes after takeoff, the flight crew detected an odor in the cockpit and
determined it to be smoke from the air conditioning system. Four minutes later, the odor returned
and smoke became visible, prompting the pilots to make a "pan-pan" radio call to Moncton air
traffic control, the area control center (ACC) station in charge of air traffic over the Canadian
province of Nova Scotia
The pan-pan call indicated that there was an urgency due to smoke in the cockpit but did not
declare an emergency as denoted by a "mayday" call.
The crew requested a diversion to Logan International Airport in Boston 234 nautical miles
away before accepting Moncton ATC's offer of radar vectors to the closer Halifax International
Airport in Enfield, Nova Scotia, 66 nautical miles away.
At 22:18 AT , Moncton Centre handed over traffic control of the plane to Halifax terminal air
traffic control, the ATC station in charge of controlling traffic in and out of Halifax International
Airport.
Upon being advised by Halifax ATC that they were 30 nautical miles from the airport, the
crew requested more flight distance to allow the aircraft to descend safely from its altitude of
21,000 feet at the time.
The crew then requested to dump fuel to reduce their weight for landing.
Halifax thus vectored the plane south toward St. Margaret's Bay where it was safe for the
aircraft to dump fuel while remaining within 40 nautical miles of the airport.
In accordance with the Swissair checklist 'In case of smoke of unknown origin', the crew shut
off power to the cabin, which also turned off the recirculating fans in the cabin's ceiling.
This allowed the fire to spread to the cockpit, eventually shutting off power to the aircraft's
autopilot.
At 22:24:28 AT , the crew informed Halifax that "we now must fly manually", followed by
declaring an emergency.
Ten seconds later, the crew declared an emergency again, saying "...and we are declaring
emergency now, Swissair one eleven"; this was the last transmission received from Flight 111.
The aircraft flight data recorder stopped operating at 22:25:40 AT ,followed one second later
by the cockpit voice recorder.
The aircraft's transponder briefly resumed transmission of secondary radar returns from
22:25:50 to 22:26:04 AT, at which time the aircraft's altitude was 9,700 feet. After this, the
aircraft could only be tracked through primary radar, which does not provide altitude
information.
At 22:31:18 AT. the aircraft struck the ocean at an estimated speed of 300 knt. The collision
with the water decelerated the aircraft with approximately 350 g, causing it to disintegrate
instantly.
INVESTIGATION
Reconstruction of the wreckage disclosed significant heat damage on portions of the
airframe structure and air conditioning system ducts. Most of the heat damage in the cockpit was
concentrated above the level of the bottom of the upper avionics CB panel and in the area of the
forward cabin drop-ceiling. The farthest forward deposits of significant soot in the cockpit were
found on the standby compass. The farthest aft soot deposits were found on an overhead stowage
bin.
Thermal acoustic insulation materials are used extensively throughout the aircraft
fuselage to maintain comfortable cabin temperatures, and to reduce the noise entering the
passenger cabin and cockpit. While material, such as fluoropolymer composite or polyethylene
foams have been used for this purpose, the most popular choice is the insulation blanket. These
insulation blankets are typically installed immediately adjacent to the inside of the fuselage skin,
over the frames and around the outside of air conditioning ducts.
Douglas used MPET-covered insulation blankets in various models of production aircraft
between 1981 and 1994. The use of MPET-covered insulation blankets was superseded bynon-
metallized PET-covered insulation blankets. In the occurrence aircraft, which was built in 1991,
MPET-covered insulation blankets were used to insulate the fuselage. They were also used to
insulate some of the air conditioning ducts.
Metallized polyethylene terephthalate (MPET)–type cover material on the thermal
acoustic insulation blankets used in the aircraft was flammable. The cover material was most
likely the first material to ignite, and constituted the largest portion of the combustible materials
that contributed to the propagation and intensity of the fire.
Once ignited, other types of thermal acoustic insulation cover materials exhibit flame
propagation characteristics similar to MPET-covered insulation blankets and do not meet the
proposed revised flammability test criteria. Metallized polyvinyl fluoride–type cover material
was installed in HB-IWF and was involved in the in-flight fire.
Silicone elastomeric end caps, hook-and-loop fasteners, foams, adhesives, and thermal
acoustic insulation splicing tapes contributed to the propagation and intensity of the fire.
Aircraft certification standards for material flammability were inadequate in that they
allowed the use of materials that could be ignited and sustain or propagate fire. Consequently,
flammable material propagated a fire that started above the ceiling on the right side of the
cockpit near the cockpit rear wall. The fire spread and intensified rapidly to the extent that it
degraded aircraft systems and the cockpit environment, and ultimately led to the loss of control
of the aircraft.
The type of circuit breakers (CB) used in the aircraft were similar to those in general
aircraft use, and were not capable of protecting against all types of wire arcing events. The fire
most likely started from a wire arcing event.
 There were no built-in smoke and fire detection and suppression devices in the area
where the fire started and propagated, nor were they required by regulation. The lack of such
devices delayed the identification of the existence of the fire, and allowed the fire to propagate
unchecked until it became uncontrollable.
There was a reliance on sight and smell to detect and differentiate between odor or smoke
from different potential sources. This reliance resulted in the misidentification of the initial odor
and smoke as originating from an air conditioning source.
There was no integrated in-flight firefighting plan in place for the accident aircraft.
Therefore, the aircraft crew did not have procedures or training directing them to aggressively
attempt to locate and eliminate the source of the smoke, and to expedite their preparations for a
possible emergency landing. They concentrated more on preparing the aircraft for the diversion
and landing.
There is no requirement that a fire-induced failure be considered when completing the
system safety analysis required for certification. The fire-related failure of silicone elastomeric
end caps installed on air conditioning ducts resulted in the addition of a continuous supply of
conditioned air that contributed to the propagation and intensity of the fire.

SAFETY ACTION AND MODIFICATIONS

• Miscellaneous Smoke Detector System: This modification installs smoke detectors int
he avionics compartment, the cockpit overhead area, and the first-class galley overhead
zone of the MD-11. The system consists of a dual-loop smoke detector system, which
illuminates an amber MISC SMOKE warning light on the glareshield control panel,
together with an aural warning.
• Video Camera Monitoring System: This system installs cameras in the avionics
compartment, the cockpit overhead area, and the first-class galley overhead zone to
provide a visual confirmation of the presence of smoke. The camera installation includes
a dedicated display screen, located on the centre pedestal, to allow the pilots to view the
area of interest.
• Halon Distribution System: This system consists of three fixed Halon bottles connected
to a distribution system. The HDS can direct a fire-suppressing agent to the cockpit
overhead area, and the first-class galley overhead zone. As these areas are not readily
accessible, this modification optimizes the aircraft crew’s fire-suppression capabilities.
• Wire Routing: This part of the program includes a wiring modification designed to
enhance separation and increase survivability of flight-critical systems. The modification
physically separates the left and right power wires to opposite sides of the cockpit.
• Oxygen System/Air Conditioning System Improvements: As a fire-hardening measure
for its crew oxygen system, Swissair incorporated Boeing’s SB MD11-35-021, which
replaces aluminum components with steel. Additionally, Swissair has replaced the end
caps used in the air conditioning system ducting with a more fire-resistant version.