The search and rescue response, crash recovery operation, and investigation by the Government of Canada took more than four years and cost CA$57 million.[2] The investigation carried out by the Transportation Safety Board of Canada (TSB) concluded that flammable material used in the aircraft's structure allowed a fire to spread beyond the control of the crew, resulting in the crash of the aircraft. Several wide-ranging recommendations were made which were incorporated into newer US Federal Aviation Administration standards.[3]: 253
Swissair Flight 111 was one of two ill-fated flights known as the "UN shuttle" (the other being Ethiopian Airlines Flight 302 in 2019) because of its popularity with United Nations officials traveling between the organization's two biggest centers.
Aircraft and crew
The aircraft, a seven-year-old McDonnell Douglas MD-11, serial number 48448, registration HB-IWF, was manufactured in 1991,[4] and Swissair was its only operator. It bore the title of Vaud, in honor of the Swiss canton of the same name. 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.[5] The aircraft was powered by three Pratt & WhitneyPW4462 turbofan engines and had logged over 36,000 hours before the crash.[3]: 9
The in-flight entertainment system was the first of its kind equipped on the plane. It allowed the first and business class passengers to browse the World Wide Web, select their own movies and games, and gamble. The system was installed in business class one year before the incident, between 21 August and 9 September 1997. It was installed in first class five months later, in February 1998, due to delivery delays.[3]: 45
The pilot-in-command was 49-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 from 1966 to 1970. Zimmermann was described as a friendly person with professional skills, who always worked with exactness and precision. Zimmermann was due to turn 50 the day after the accident.[6][3]: 5–7
The first officer, 36-year-old Stefan Löw, 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.[3]: 6
The cabin crew comprised a maître de cabine (purser) and eleven flight attendants. All crew members on board Swissair Flight 111 were qualified, certified, and trained in accordance with Swiss regulations under the Joint Aviation Authorities (JAA).[3]: 7
The flight took off from New York's John F. Kennedy International Airport at 20:18 EDT (00:18 UTC) on 2 September. From 20:33 – 20:47 EDT (00:33 to 00:47 UTC), the aircraft experienced a radio blackout for approximately thirteen minutes, which was later found to be caused by communication radio tuning errors.[7]
At 22:10 ADT (01:10 UTC, 52 minutes after takeoff), while flying over Yarmouth, the flight crew detected an odour in the cockpit and determined it to be smoke from the air conditioning system.[8] Four minutes later, the odour returned and smoke became visible, prompting the pilots to make a "pan-pan" radio call to Monctonair 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 Boston (234 nautical miles (433 km; 269 mi) away) before accepting Moncton ATC's offer of radar vectors to the closer Halifax International Airport in Enfield, Nova Scotia, 66 nautical miles (76 mi; 122 km) away.[3]: 1–2
At 22:18 ADT (01:18 UTC), 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 (35 mi; 55 km) from the airport, the crew requested more flight distance to allow the aircraft to descend safely from its altitude of 21,000 feet (6,400 m) 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[3]: 2–3 where it was safe for the aircraft to dump fuel while remaining within 40 nautical miles (45 mi; 75 km) of the airport.[3]: 3
Final flight path of Swissair Flight 111
In accordance with the Swissair checklist "Smoke/fumes of unknown origin", the crew shut off power to the cabin using the "CABIN BUS" switch, 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.[9] At 22:24:28 ADT (01:24:28 UTC), the crew informed Halifax that "we now must fly manually", followed by an emergency declaration. 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.[10]
The aircraft flight data recorder stopped operating at 22:25:40 ADT (01:25:40 UTC), 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 ADT (01:25:50 to 01:26:04 UTC), at which time the aircraft's altitude was 9,700 feet (3,000 m). After this, the aircraft could only be tracked through primary radar, which does not provide altitude information.[3]: 244
At 22:31:18 ADT (01:31:18 UTC), the aircraft struck the ocean at an estimated speed of 345 miles per hour (555 km/h; 154 m/s; 300 kn). The impact time also coincides with seismographic recorders at Halifax and Moncton which detected a seismic event at the time. The collision with the water decelerated the aircraft with approximately 350 g, causing it to disintegrate instantly.[3]: 116 The location of the crash was identified as approximately 44°24′33″N 63°58′25″W.[11]
There were 132 American (including one employee each from Delta Air Lines and United Airlines), 41 Swiss (including the 13 crew members), 30 French, three British, four Canadian, three Italian, two Greek, two Lebanese, one each from Afghanistan, China, Germany, India, Iran, Russia, Saudi Arabia, Spain, St. Kitts and Nevis,[12] Mexico, Sweden, and Yugoslavia, and four other passengers on board.[13][14] Epidemiologists Jonathan Mann and Mary Lou Clements-Mann, both prominent researchers of HIV/AIDS and a married couple, died in the crash.[15][16][17][18] Joseph LaMotta, son of boxing legend Jake LaMotta, also died. The LaMotta family later sued the airline for his death.[19][20]
The crash site's proximity to Halifax placed it within one hour's sailing time of ships docked at Canada's largest naval base, CFB Halifax, and one of the largest CCG bases in Canada, the CCG Regional Headquarters in Dartmouth. Calls went out immediately and ships sailed directly to St. Margaret's Bay.[21]
The provincial ambulance service, Emergency Health Services (EHS), received word of the crash at 22:39 AT, and ordered 21 emergency units from Halifax, the South Shore, and the Annapolis Valley to respond. An EHS helicopter was also sent to the crash site, and the Queen Elizabeth II Health Sciences Centre in Halifax was put on emergency alert. The emergency health services were stood down around 3:30 AT the next morning, as expectations of finding survivors diminished.[22]
The land search, including shoreline searching, was the responsibility of Halifax Regional Search and Rescue. The organization was responsible for all ground operations including military operations and other ground search and rescue teams.[23]
List of vessels involved in the search and rescue actions
The following are ships that took part in the search and rescue operation after the accident.
HMCS Preserver was assigned as the on-scene commander of Operation Persistence and had authority over all aircraft and vessels within the area surrounding the crash site.
Search and recovery operation
By the afternoon of 3 September, it was apparent that there were no survivors from the crash and JRCC Halifax de-tasked dedicated SAR assets (CCGS Sambro and the CH-113 Labrador helicopters). The Royal Canadian Mounted Police (RCMP) were given overall command of the recovery operation, with HMCS Preserver remaining on-scene commander.[citation needed]
The aircraft broke up on impact with the water and most of the debris sank to the ocean floor (a depth of 55 m, 180 ft). Some debris was found floating in the crash area and over the following weeks debris washed up on the nearby shorelines.[3]: 77
The initial focus of the recovery was on finding and identifying human remains and on recovering the flight recorders. As the force of impact was "in the order of at least 350 g",[3]: 104 the aircraft was fragmented and the environmental conditions only allowed the recovery of human remains along with the aircraft wreckage.[3]: 103–105
Only one of the victims was visually identifiable. Eventually, 147 were identified by fingerprint, dental records, and X-ray comparisons. The remaining 81 were identified through DNA tests.[25]: 264
With CAF divers (navy clearance divers, port inspection divers, ship's team divers, and Army combat divers) working on the recovery, a request was made by the Government of Canada to the Government of the United States for a larger dedicated salvage recovery vessel. USS Grapple was tasked to the recovery effort, arriving from Philadelphia on 9 September. Among Grapple's crew were 32 salvage divers. Additionally, the USS Grapple welcomed two teams of Canadian Navy Clearance Divers that flew across Canada from Fleet Diving Unit (FDU) Pacific.[26][27]
The cockpit voice recorder (CVR) and flight data recorder (FDR) were found by the submarine HMCS Okanagan using sonar to detect the underwater locator beacon signals and were quickly retrieved by Canadian Navy divers (the FDR on 6 September and the CVR on 11 September 1998). Both had stopped recording when the aircraft lost electrical power at approximately 10,000 ft (3,000 m), 5 minutes and 37 seconds before impact.[3]: 74
The recovery operation was guided by the TSB with resources from the Canadian Forces, Canadian Coast Guard, Royal Canadian Mounted Police, and other agencies. The area was surveyed using route survey sonar, laser line scanners, and remotely operated vehicles (ROVs) to locate items. After being located, the debris was then recovered (initially by divers and ROVs, later by dredging and trawling).[28]
On 2 October 1998, the TSB initiated a heavy lift operation to retrieve the major portion of the wreckage from the deep water before the expected winter storms began. By 21 October, an estimated 27% of the wreckage was recovered.[29] At that point in the investigation, the crash was generally believed to have been caused by faulty wiring in the cockpit after the IFE system started to overheat. The TSB released its preliminary report on 30 August 2000 and the final report in 2003.[3]: 298
The final phase of wreckage recovery employed the ship Queen of the Netherlands to dredge the remaining aircraft debris. It concluded in December 1999 with 98% of the aircraft retrieved: approximately 279,000 lb (127,000 kg) of aircraft debris and 40,000 lb (18,000 kg) of cargo.[3]: 77
Response to victims' families and friends
JFK Airport used the JFK Ramada Plaza Hotel to house relatives and friends of the victims of the crash, due to the hotel's central location relative to the airport.[30]Jerome Hauer, the head of the emergency management task force of New York City, praised the swift actions of Swissair and codeshare partner Delta Air Lines in responding to the accident; he had criticized Trans World Airlines in its response to the TWA Flight 800 crash in 1996.[31]
Investigation
Identification of victims
The RCMP medical examiners positively identified most of the bodies within ten weeks of the accident. Due to extreme impact forces, only one body was identifiable by sight. DNA profiling was used to identify approximately one hundred bodies, in what has been referred to as "the largest DNA identification project ever undertaken in Canada".[32] The RCMP contacted relatives of victims to request medical histories and dental records. They were also asked to provide blood samples for genetic matching in the DNA identification of the victims. About 90 bodies were identified by the medical examiners using dental records; owing to the large number of ante-mortem (before death) dental X-rays available to the examiners, these bodies were identified by late October 1998. Fingerprints and ante-mortem X-rays were used to identify around 30 bodies.[32]
As each piece of wreckage was brought in, it was carefully cleaned with fresh water, sorted, and weighed. The item was then placed in a specific area of a hangar at CFB Shearwater, based on a grid system representing the various sections of the plane. All items not considered significant to the crash were stored with similar items in large boxes. When a box was full, it was weighed and moved to a custom-built temporary structure (J-Hangar) on a discontinued runway for long-term storage. If deemed significant to the investigation, the item was documented, photographed, and kept in the active examination hangar.[3]: 197–198 Particular attention was paid to any item showing heat damage, burns, or other unusual marks. The front 33 ft (10 m) of the aircraft, from the front of the cockpit to near the front of the first-class passenger cabin, was reconstructed. Information gained by this allowed investigators to determine the severity and limits of the fire damage, its possible origins, and progression.[3]: 199
The lack of flight recorder data for the last six minutes of the flight added significant complexity to the investigation and was a major factor in its lengthy duration. The TSB team had to reconstruct the final six minutes entirely from the physical evidence. The investigation became the largest and most expensive transport accident investigation in Canadian history, costing CA$57 million (US$48.5 million) over five years.[34]
Cockpit recordings
The cockpit voice recorder used a 1⁄4-inch (6 mm) recording tape that operated on a 30-minute loop. It therefore retained only that half-hour of the flight before the recorders failed, six minutes before the crash.[3]: 73–74 The CVR recording and transcript were covered by a strict privilege under section 28 of the Canadian Transportation Accident Investigation and Safety Board Act[35] and thus were not publicly disclosed, although the air traffic control recordings are less strictly privileged: section 29 of the same act provides only that they may not be used in certain legal proceedings.[36] The air traffic control transcripts were released within days of the crash in 1998[37] and the air traffic control audio was released in May 2007,[38][39][40] following a ruling by the Federal Court of Appeal.[41][42] Several key minutes of the air traffic control audio can be found on the Toronto Star web site.[43]
In 1999, an article[44] in The Wall Street Journal alleged that the pilots disagreed about whether to dump fuel or descend straight to Halifax. Based on internal TSB summaries of the CVR recording, the Journal claimed that co-pilot Löw suggested steps aimed at a quick landing, which were ignored or rejected by Captain Zimmermann. Swissair and Canadian investigators would not comment on the accuracy of the reporting, with a TSB spokesman deeming it "a reporter's interpretation of a summary document of what might have been" on the CVR.[45]
Probable cause
The Transportation Safety Board of Canada investigation identified eleven causes and contributing factors of the crash in its final report. The first and most prominent was:
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.[3]: 253
Investigators identified evidence of arcing in wiring of the in-flight entertainment network (IFEN), but this did not trip the circuit breakers, which were not designed to trip on arcing. The investigation was unable to determine whether this arc was the "lead event" that was assumed to have ignited the flammable covering on MPET insulation blankets that quickly spread across other flammable materials.[3]: 253 After the crew cut power to "non-essential" cabin systems, a reverse flow in the cockpit ventilation ducts increased the amount of smoke reaching the flight deck.[3]: 240 By the time the crew became aware of the severity of the fire, it had become so extensive that it was impossible to address as it happened.[3]: 254
The rapid spread of electrical power failures led to the breakdown of key avionics systems, and the crew was soon rendered unable to control the aircraft. The pilot-in-command was forced to fly manually because he had no light by which to see his controls after the instrument lighting failed. The fuel-laden plane was above maximum landing weight so the flight crew activated dumping of fuel. The pilots lost all control and the doomed plane flew into the ocean uncommanded. Recovered fragments of the plane show that the temperature inside the cockpit became so great that aluminium parts in the flight deck ceiling had melted. The recovered standby attitude indicator and airspeed indicators showed that the aircraft struck the water at 300 knots (560 km/h; 350 mph) in a 20 degrees nose down and 110-degree bank attitude; the impact force of the aircraft crashing into the Atlantic Ocean was calculated to be 350 times the force of gravity (G-force).[3]: 103 Death was instantaneous for all passengers and crew due to the impact forces and deceleration.[3]: 104
Touchscreen In-flight entertainment system aboard Swissair MD-11 in 1997
In-flight entertainment network
Video system aboard Swissair MD-11
Both first and business class seats were equipped with a Windows NT 4.0 based In-Flight Entertainment Network (IFEN) system with touchscreen in-seat video displays and magnetic card readers.[46] In galley, a cabin file server served as a central hub for managing content, which facilitated movie downloads, stored flight and casino information, and collected credit card data transmitted from each seat.[47]
The original system design provided IFEN to all 257 seats. Originally, the IFEN was to be powered from the cabin power distribution, but it couldn't deliver enough power for the complete IFEN setup intended for the 257-seat configuration. As a result, 115-volt three-phase 400 Hz AC Bus 2, located in the cockpit area (the origin of the fire), was used to provide most of the IFEN power requirements. In April 1997 IFEN configuration was reduced only to 61 first and business class seats.[47]
By design, AC Bus 2 remained active even when the "CABIN BUS" switch was turned off. The purpose of using the "CABIN BUS" switch, which was the first step in Swissair's "Smoke/Fumes of Unknown Origin" checklist during the incident, was to cut off most electrical power to the aircraft cabin, which was not helpful in the system design where IFEN was connected to AC Bus 2.[47]
Former employees of Interactive Flight Technologies, the company that manufactured the IFEN, conceded that each entertainment system box which processed all information for the passenger interface was positioned beneath each passenger seat and emitted excessive heat. Others raised concerns that extended to the high power consumption and overall heat generation of the system.[48][49][50]
Installation of IFEN at Swissair was rushed and violated various FAA certification procedures.[50][51] According to Swissair Operational Engineering, IFEN added more than 1000 kg of weight to the plane.[52]
Safety recommendations
The TSB made nine recommendations relating to changes in aircraft materials (testing, certification, inspection, and maintenance), electrical systems, and flight data capture, as both flight recorders had stopped when they lost power six minutes before impact. General recommendations were also made regarding improvements in checklists and in fire-detection and fire-fighting equipment and training. These recommendations have led to widespread changes in Federal Aviation Administration standards, principally affecting wiring and fire hardening.[citation needed]
Conspiracy and alternative theories
On October 16, 1998, the involvement of British intelligence, through the planting of a magnesium sulfate-based incendiary device in the cockpit, was posited in an article by Executive Intelligence Review in Volume 25 of the magazine. The author, Dean Andromidas, based his assertion on the fact that former MI6 agent Richard Tomlinson had been scheduled to fly on Swissair 111, which was also reported in the British tabloid News of the World and confirmed by Tomlinson himself.[53] However, Tomlinson was detained on arrival at JFK after disembarking Swissair Flight 110 from Geneva, thereby preventing him from flying back days later on the ill-fated flight.[54] Tomlinson had revealed British state secrets and in the months preceding the crash had threatened to reveal more. Andromidas further alleged that a key Swissair safety official involved in the investigation, upon returning to Switzerland, was banned from speaking to the press and even his superiors.
Unrelated to Andromidas, former RCMP sergeant Tom Juby, who had been part of the Swissair 111 investigation, published a book in 2017 titled "Twice as Far" where he alleged that the TSB suppressed strong evidence for the existence of an incendiary device aboard Swissair 111, such as high levels of magnesium, iron and other elements in the part of the cockpit that burned the strongest. Juby also states that a mechanic who serviced the airplane before the flight had provided fake credentials and had disappeared. Further, Juby claims he was asked by senior RCMP officials to retroactively edit his notes for the public record of the investigation so as to omit any mention of his views on the plausibility of an incendiary device having brought down the flight. Reaction to Juby's book was mostly negative.[55][56] The TSB would not comment explicitly on Juby's claims, saying that it stood by the findings of its investigation. Juby's allegations were initially featured in an episode of the CBC'sThe Fifth Estate on September 16, 2011. Swiss television co-produced the episode, but withdrew it from being broadcast in Switzerland citing the speculative nature of Juby's conclusions.[57]
Other alternative theories pertain to whether the pilots could have landed at Halifax had they not attempted a fuel dump procedure.[58][59] It has emerged that the Swiss Federal Archives holds records, still in the 50-year statutory protection period, dating from 1998 to 1999 suggesting Swiss Federal Prosecutors had pursued a criminal investigation of possible involuntary homicide (manslaughter) related to the Swissair 111 crash, though it remains unclear who the exact target of the probe was.[60]
Legacy
Valuables
The plane's manifest indicated the presence of significant amount of valuables, including 2 pounds of diamonds from ''Nature of Diamonds'' exhibition[61] at the American Museum of Natural History, 4 pounds of watches, 10 pounds of jewelry, 49 kilograms of cash intended for a U.S. bank in Geneva.[62][63][64]
Insurer Lloyd's of London reportedly paid out an estimated $300 million for the lost diamonds and jewels. The company applied for a treasure-trove license from the Nova Scotia government to search the crash site but faced opposition from victims' relatives, leading to the withdrawal of the application.[62][65][64]
Following the crash, a two-kilometer-square exclusion zone was established around the site and maintained for over a year to secure the scene. Despite restrictions, concerns arose regarding potential unauthorized attempts to search for valuables. Halifax-based TV documentary producer John Wesley Chisholm suggested that treasure hunters might have covertly explored the area in the years following the crash.[62]
Lost works
Two paintings, including Le Peintre (The Painter) by Pablo Picasso, were on board the aircraft and were destroyed in the accident.[66] At the time, The Painter painting's value was estimated at $1.5 million.[67]
Lawsuit
In September 1999, Swissair, Delta Air Lines, and Boeing (who had acquired McDonnell Douglas through a merger in 1997) agreed to share liability for the accident and offered the families of the passengers financial compensation.[68] The offer was rejected in favour of a $19.8 billion suit against Swissair and DuPont, the supplier of the Mylar insulation sheathing. A US federal court ruled against punitive damages in February 2002. The resulting compensations for one group of plaintiffs totaled over $13 million.[69]
A non-denominational memorial service was held on the grounds of East St. Margaret's Elementary School in Indian Harbour on 9 September 1998. Among those in attendance were 175 relatives of the crash victims, Swiss president Flavio Cotti, Canadian prime minister Jean Chrétien, and Nova Scotia premier Russell MacLellan.[70][71][72] A memorial service was also held in Zürich on 11 September 1998.[73] The following year, another memorial was held in Nova Scotia.[74]
Two memorials to those who died in the crash were established by the Government of Nova Scotia. One is to the east of the crash site at The Whalesback, a promontory 1 kilometre (0.62 mi; 0.54 nmi) north of Peggy's Cove.[75] The second is a more private, but much larger commemoration located west of the crash site near Bayswater Beach Provincial Park on the Aspotogan Peninsula in Bayswater.[76] Here, the unidentified remains of the victims are interred. A fund was established to maintain the memorials and the government passed an act to recognize the memorials.[77][78] Various other charitable funds were also created, including one in the name of a young victim from Louisiana, Robert Martin Maillet, which provided money for children in need,[79][80] and one in the name of Robert's mother, Karen E. Maillet-Domingue (also a victim), which granted scholarships.[81]
A further permanent memorial, albeit not publicly accessible, was created inside the operations centre at Zürich Airport where a simple plaque on the ground floor in the centre opening of a spiral staircase pays tribute to the victims.[citation needed]
Aftermath and effects on the industry
The crash of Flight 111 was a severe blow to Swissair and the airline suffered even more loss following the crash, particularly as the in-flight entertainment system that was blamed for causing the accident had been installed on the aircraft to attract more passengers. It was disconnected following the Transportation Safety Board discovery on 29 October 1998 and eventually removed on both Swissair fleets of 15 MD-11 and 3 Boeing 747.[82][83][47][84][85] Swissair later went bankrupt shortly after the September 11 attacks in 2001, an event that caused a significant and widespread disruption to the aviation transportation industry.[86]
After the crash of Flight 111, the flight designator for Swissair's New York–Geneva route was changed to SR139, although the route was still operated by MD-11 aircraft. Following the bankruptcy of Swissair in 2002, their international traffic rights were passed to Crossair who began operating flights as Swiss International Air Lines, changing the flight designator for the New York–Geneva route to LX023. The MD-11 was retired from the Swiss fleet in 2004, and the flight today is operated by an Airbus A330-300.[87]
^St. Kitts and Nevis nationality was estimated by Swiss Air on 4 September 1998 based on passports of ticketholders, but was not listed as a nationality of any of the passengers in the list of names published 7 September 1998. See CNN citations at end of this section.
^Butler, John Marshall (2001). Forensic DNA Typing: biology & technology behind STR markers. Academic Press, San Diego. ISBN0-12-147951-X.
^Kettenhofen, Suzette; Digital Information Specialist, Technology Integration, Navy Office of Information (10 September 1998). "U.S. Navy Assists With Recovery of Swissair Flight 111". Navy.mil. Archived from the original on 1 October 2012. Retrieved 29 July 2013.((cite web)): CS1 maint: multiple names: authors list (link)
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