SR 111 Investigation Report

Table of Contents

How This Report Is Organized
1.0 Factual Information

1.1 History of the Flight
1.2 Injuries to Persons
1.3 Damage to Aircraft
1.4 Other Damage
1.5 Personnel Information

1.5.1 General
1.5.2 Flight Crew
1.5.3 Cabin Crew
1.5.4 Seventy-Two-Hour History
1.5.5 Air Traffic Controllers

1.6 Aircraft Information

1.6.1 General
1.6.2 Environmental (Air) System
1.6.3 Ditching Mode
1.6.4 Auto Flight System
1.6.5 Electronic Instrument System
1.6.6 Flight Management System
1.6.7 Warnings and Alerts
1.6.8 Standby Flight Instruments
1.6.9 Communications Systems
1.6.10 Electrical System
1.6.11 In-Flight Entertainment Network
1.6.12 Aircraft Fire Protection System
1.6.13 Flight Control System
1.6.14 Fuel System
1.6.15 Hydraulic System
1.6.16 Cockpit Windows
1.6.17 Landing Gear
1.6.18 Aircraft Interior Lighting
1.6.19 Emergency Equipment
1.6.20 Powerplants
1.6.21 Landing Performance
1.6.22 Aircraft Maintenance Records and Inspection

1.7 Meteorological Information

1.7.1 General
1.7.2 Forecast Weather
1.7.3 Actual Reported Weather
1.7.4 Upper Level Wind
1.7.5 Weather Briefing
1.7.6 Weather Conditions on Departure from JFK
1.7.7 Weather Conditions during Descent

1.8 Aids to Navigation
1.9 Communications

1.9.1 General
1.9.2 Controller Training
1.9.3 Transition Procedures and Controller Communications
1.9.4 Emergency Communications
1.9.5 Air Traffic Services Communication Regarding Fuel Dumping

1.10 Aerodrome Information
1.11 Flight Recorders

1.11.1 General
1.11.2 Recorder Installation Power Requirements
1.11.3 Stoppage of Recorders
1.11.4 Lack of CVR Information
1.11.5 Quick Access Recorder
1.11.6 Lack of Image Recording

1.12 Wreckage and Impact Information

1.12.1 Wreckage Recovery
1.12.2 Aircraft Wreckage Examination
1.12.3 Examination of Recovered Electrical Wires and Components
1.12.4 Examination of Flight Crew Reading Lights (Map Lights)
1.12.5 Examination of Cabin Overhead Aisle and Emergency Light Assemblies
1.12.6 Examination of Standby Instruments
1.12.7 Examination of Flight Controls
1.12.8 Examination of Fuel System Components
1.12.9 Examination of the Engines
1.12.10 Examination of Aircraft Structural Components
1.12.11 Examination of Flight Crew and Passenger Seats
1.12.12 Aircraft Attitude and Airspeed at the Time of Impact

1.13 Medical Information

1.13.1 Recovery of Occupants
1.13.2 Identification of Individuals
1.13.3 Injury Patterns
1.13.4 Toxicological Information

1.14 Fire

1.14.1 Aircraft Certification Standards
1.14.2 Review of In-Flight Fire Accident Data
1.14.3 Designated Fire Zones and Smoke/Fire Detection and Suppression
1.14.4 Time Required to Troubleshoot in Odour/Smoke Situations
1.14.5 Risk of Remaining Airborne – Emergency Landing
1.14.6 Integrated Firefighting Measures
1.14.7 Airflow Patterns
1.14.8 Describing the SR 111 Fire-Damaged Area
1.14.9 Determination of Heat Damage
1.14.10 Assessment of Fire Damage
1.14.11 Potential Ignition Sources
1.14.12 Fire Propagating Materials
1.14.13 Potential Increased Fire Risk from Non-fire-hardened Aircraft Systems

1.15 Survival Aspects
1.16 Tests and Research

1.16.1 AES Examinations of the Recovered Arced Beads
1.16.2 Map Light Testing and Research
1.16.3 Airflow Flight Tests
1.16.4 Analysis of Cockpit Sounds Recorded on the CVR
1.16.5 Simulator Trials
1.16.6 Theoretical Emergency Descent Calculations
1.16.7 Statistics for Occurrences Involving Smoke or Fire
1.16.8 Electrical Ignition Tests of MPET-Covered Insulation Blankets
1.16.9 Computer Fire Modelling

1.17 Organizational and Management Information

1.17.1 SAirGroup/Swissair/SR Technics
1.17.2 Swissair Federal Office for Civil Aviation
1.17.3 Federal Aviation Administration
1.17.4 The Boeing Company

1.18 Other Relevant Information

1.18.1 Swissair Training
1.18.2 Swissair Checklists for In-Flight Firefighting
1.18.3 Availability of Published Approach Charts
1.18.4 Wire-Related Issues
1.18.5 Circut Protection Devices
1.18.6 High-Intensity Radiated Fields
1.18.7 In-Flight Entertainment Network
1.18.8 Chronological Sequence of Events
1.18.9 Witness Information
1.18.10 Reporting of Cabin Anomalies

1.19 Useful or Effective Investigation Techniques

1.19.1 Exhibit Tracking Process
1.19.2 Data Analysis Tools
1.19.3 Partial Aircraft Reconstruction
1.19.4 Electrical Wire Arc Sites Analysis
1.19.5 Temperature Reference Coupons
1.19.6 Speech Micro-coding Analysis
1.19.7 Fuel Detection by Laser Environmental Airborne Fluorosensor
1.19.8 Aircraft Engine Analysis
1.19.9 Restoration and Extraction of Non-volatile-memory information
1.19.10 Use of Computer Fire Modelling

2.0 Analysis

2.1 General Information
2.2 On-Board Data Recording Capability

2.2.1 General
2.2.2 Cockpit Voice Recorder
2.2.3 Survivability of Quick Access Recorder Information
2.2.4 Image Recording
2.2.5 Underwater Locator Beacons – Bracket Attachments

2.3 Material Susceptibility to Fire – Certification Standards

2.3.1 Flammability of Materials
2.3.2 Contamination Issuess
2.3.3 Non-fire-bardened Aircraft Systems

2.4 Aircraft Fire Detection and Suppression
2.5 In-Flight Firefighting Measures
2.6 Crew Preparation and Training

2.6.1 In-Flight Firefighting
2.6.2 In-Flight Emergency Diversions

2.7 Checklist Issues

2.7.1 Swissair Checklist Options for Smoke Isolation
2.7.2 Emergency Electrical Load-Shedding
2.7.3 Additional Checklist Issues
2.7.4 Checklist Revisions and Approvals

2.8 Maintenance and Quality Assurance Aspects
2.9 Potential Effect of High-Intensity Radiated Fields
2.10 Air Traffic Services Issues
2.11 ACARS and VHF Communications Gap Anomalies
2.12 Flight Crew Reading Light (Map Light) Installation
2.13 Circuit Breaker and Electrical Wire Issues

2.13.1 Circuit Breaker Technology
2.13.2 Circuit Breaker Reset Philosophy
2.13.3 Circuit Breaker Maintenance
2.13.4 Electrical Wire Separation Issues

2.14 In-Flight Entertainment Network

2.14.1 Operational Impact of the IFEN Integration
2.14.2 FAA Oversight (Surveillance) of the IFEN STC Project
2.14.3 IFEN System Design and Analysis Requirements
2.14.4 FAA Aircraft Evaluation Group Role/STC Involvement
2.14.5 IFEN STC Project Management

2.15 Factors Influencing Pilot Decision Making Regarding Initial Odour and Smoke
2.16 Factors Influencing Pilot Decision Making during Diversion
2.17 Fire Development

2.17.1 Potential Ignition Sources – General
2.17.2 Arc-Damaged Cables and Wires
2.17.3 Airflow, Fire Propagation, and Potential Ignitioin Locations
2.17.4 Fire Propagation from an Arc Fault Near STA 383

2.18 Known Technical Failure Events
2.19 Remaining Few Minutes Following Stoppage of Recorders
2.20 Actual Versus Theoretical Emergency Descent Profile

2.20.1 General
2.20.2 Earliest Possible Landing Time
2.20.3 Effect of Fire-Related Failures on Landing
2.20.4 Theoretical Emergency Descent Calculations

2.21 Fire Initiation

3.0 Conclusions

3.1 Findings as to Causes and Contributing Factors
3.2 Findings as to Risk
3.3 Other Findings

4.0 Safety Action

4.1 Action Taken

4.1.1 MD-11 Wiring
4.1.2 Flight Recorder Duration and Power Supply
4.1.3 Thermal Acoustic Insulation Materials
4.1.4 MD-11 Flight Crew Reading Light (Map Light)
4.1.5 In-Flight Firefighting
4.1.6 Overhead Aisle and Emergency Lights
4.1.7 In-Flight Entertainment Network/Supplemental Type Certificate
4.1.8 Circuit Breaker Reset Philosophy
4.1.9 Standby Instrumentation
4.1.10 Material Flammability Standards
4.1.11 Air Traffic Controller Training

4.2 Action Required

4.2.1 Thermal Acoustic Insulation Materials
4.2.2 Interpretation of Material Flammability Test Requirements
4.2.3 IFEN – Supplemental Type Certificate Process
4.2.4 Circuit Breaker Reset Philosophy
4.2.5 Accident Investigation Issues

4.3 Safety Concern

4.3.1 In-Flight Firefighting Measures
4.3.2 Aircraft System Evaluation: Fire-Hardening Consideration
4.3.3 Aircraft Wiring Issues
4.3.4 Flight Crew Reading Light (Map Light)
4.3.5 Standby Instrumentation
4.3.6 Contamination Effects
4.3.7 Arc-Fault Circuit Breaker Certification
4.3.8 Role of the FAA's Aircraft Evaluation Group
4.3.9 Checklist Modifications
4.3.10 Accident Investigation Issues

5.0 Appendices

Appendix A – Flight Profile: Selected Events
Appendix B – Swissair Air Conditioning Smoke Checklist
Appendix C – Swissair Smoke/Fumes of Unknown Origin Checklist
Appendix D – Timeline

List of Figures

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