1 / 22

Swissair 111: Where Do We Go From Here ?

Swissair 111: Where Do We Go From Here ?. Henry Wright, Board Member Transportation Safety Board of Canada. Royal Aeronautical Society Flight Operations Group Meeting London, England October 22, 2008. Presentation Outline. About the TSB Recommendation process

trella
Download Presentation

Swissair 111: Where Do We Go From Here ?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Swissair 111: Where Do We Go From Here? Henry Wright, Board MemberTransportation Safety Board of Canada Royal Aeronautical Society Flight Operations Group Meeting London, England October 22, 2008

  2. Presentation Outline • About the TSB • Recommendation process • Swissair accident, TSB investigation and recommendations themes • Call for action

  3. About the TSB Independent organization investigating marine, pipeline, rail and air occurrences Finds out what happened and why Makes recommendations to address safety deficiencies Not a regulator or a court

  4. TSB’s Methodology • 1900 aviation occurrences reported each year • Decision to investigate hinges on potential to reduce risks and/or increase safety • SYSTEMATIC, THOROUGH, and UNBIASED investigations • Important safety information made public immediately • Recommendations for safety deficiencies involving significant risk and requiring immediate action

  5. Follow-up to Recommendations • Regulator and industry take action to mitigate risks • TSB tracks action taken and evaluates progress on recommendations • Canadian Minister of Transport has 90 days to respond to a recommendation • Assessment based on extent to which action completed or planned will mitigate risks

  6. Swissair Flight 111 Halifax International Airport Pilots declare an emergency 1024PM ADT Comm and Nav radios and other systems lost 1025 PM ADT Water impact 1031 PM ADT Pilots decided to divert to Halifax 1015PM ADT 1011PM ADT Pilots smell an abnormal odour in the cockpit

  7. Swissair Flight 111 (cont.)

  8. TSB’s Investigation –1998 Swissair Accident

  9. Swissair 111 Recommendations • 23 recommendations in regards to: • on-board recorders • circuit breaker resetting procedures • supplemental type certification process • material flammability • in-flight firefighting

  10. 8 Flammability Recommendations

  11. Flammability – Action Taken • Directives mandated removal of MPET insulation • New flammability test criteria established • Guidance material developed for more accurate and consistent interpretation of test standards

  12. Flammability – Outstanding Action Materials • Removal of MPET from all aircraft • Comprehensive review of remaining types of insulation • Quantification and mitigation of risks associated with all materials that failed the Radiant Panel Test

  13. Flammability – Outstanding Action Electrical issues • Establishment of test regime to evaluate aircraft electrical wire failure characteristics • Evaluation of how aircraft systems and their components could exacerbate existing fire In-flight entertainment network power supply unit cable segments

  14. Recorders • Aviation leads the way with requirements for FDRs and CVRs • The FAA published its final rule on FDR/CVR: • CVR two-hour recording capacity and independent power supply providing 10 minutes of electrical power • power redundancy in that any single electrical failure must not result in disabling both the CVR and the FDR (flight data recorder)

  15. Recorders – Outstanding Action • Independent power supply for 2-hr CVRs • Separate buses for CVRs and FDRs • Protecting confidentiality of CVR or image recording systems for accident investigation purposes • Harmonization with new FAA flight data recorder regulations

  16. In-Flight Firefighting Area where fire originated – occurrence aircraft

  17. In-flight Firefighting – Action Taken • Emergency procedures direct crews to prepare to land the aircraft without delay • International Air Transport Association (IATA) workshop developed guidance material on smoke and fire cockpit checklist procedures • Aircraft manufacturers improved their aircraft flight manuals • Action plan established to improve current in-flight firefighting standards

  18. In-flight Firefighting – Outstanding Action • Review of methodology for establishing designated fire zones • Provision of improved fire-detection and fire suppression capabilities • Continued adoption of emergency checklist by manufacturers and operators • Assessment of inter-relationships between individual firefighting measures

  19. Conclusion • We rely on collaboration with operators and regulators when conducting investigations • While improvements have been made since Swissair, more action still required on 18/23 recommendations • Change for the better can be made over and above regulatory requirements by operators and manufacturers

  20. In Memory Of

  21. Call for Action • Mandatory international adoption of checklist templates • Adoption of a more systematic approach to in-flight firefighting • International harmonization of the protection afforded to cockpit voice and image recordings

  22. www.tsb.gc.ca Swissair 111 1998 - 2008

More Related