Swissair Flight 111


Swissair Flight 111 was a scheduled international passenger flight from John F. Kennedy International Airport in New York City, United States, to Cointrin International Airport in Geneva, Switzerland. This flight was also a codeshare flight with Delta Air Lines. On 2 September 1998, the McDonnell Douglas MD-11 performing this flight, registration HB-IWF, crashed into the Atlantic Ocean southwest of Halifax International Airport at the entrance to St. Margarets Bay, Nova Scotia. The crash site was from shore, roughly equidistant from the tiny fishing and tourist communities of Peggy's Cove and Bayswater. All 229 passengers and crew on board the MD-11 were killed, making the crash the deadliest McDonnell Douglas MD-11 accident in aviation history.
The search and rescue response, crash recovery operation, and investigation by the Government of Canada took more than four years and cost CAD$57 million. The investigation carried out by the Transportation Safety Board of Canada 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 have been incorporated into new US Federal Aviation Administration standards.
Swissair Flight 111 was known as the "UN shuttle" because of its popularity with United Nations officials; the flight also carried business executives, scientists, and researchers.

Aircraft and crew

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. 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 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.
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 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.
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 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.
The cabin crew comprised a maître de cabine 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.

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, 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 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 before accepting Moncton ATC's offer of radar vectors to the closer Halifax International Airport in Enfield, Nova Scotia, 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 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 – 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. The collision with the water decelerated the aircraft with approximately 350 g, causing it to disintegrate instantly. The location of the crash was approximately meters.

Victims

There were 132 American, 41 Swiss, 30 French, six British, three German, three Italian, three Canadian, two Greek, two Lebanese, one each from Afghanistan, China, India, Iran, Russia, Saudi Arabia, Spain, St. Kitts and Nevis, Mexico, Sweden, and Yugoslavia, and four other passengers on board.
Jonathan Mann, former head of the WHO's AIDS program, and his wife, AIDS researcher Mary Lou Clements-Mann, died in the crash.

Post-crash response

Search and rescue operation

The search and rescue operation was code-named Operation Persistence and was launched immediately by Joint Rescue Coordination Centre Halifax, which tasked the Air Command, Maritime Command and Land Force Command of the Canadian Forces, Canadian Coast Guard and Canadian Coast Guard Auxiliary resources.
The first rescue resources to approach the crash site were CCGA volunteer units, which were mostly privately owned fishing boats operating from Peggy's Cove and Bayswater, as well as other harbours on St. Margaret's Bay and the Aspotogan Peninsula. They were soon joined by the dedicated CCG SAR vessel, CCGS Sambro; CH-124 Sea King helicopters, flown from CFB Shearwater by Airforce crews from 423 Maritime Helicopter Squadron and 406 Maritime Operational Training Squadron ; and CH-113 Labrador SAR helicopters flown from CFB Greenwood by the 413 Transport and Rescue Squadron.
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.
The land-based 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.

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. The Royal Canadian Mounted Police were given overall command of the recovery operation, with remaining on-scene commander.
The aircraft broke up on impact with the water and most of the debris sank to the ocean floor. Some debris was found floating in the crash area and over the following weeks debris washed up on the nearby shorelines.
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", the aircraft was fragmented and the environmental conditions only allowed the recovery of human remains along with the aircraft wreckage.
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.
With CF 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. was tasked to the recovery effort, arriving from Philadelphia on 9 September. Among Grapples 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 Pacific.
The cockpit voice recorder and flight data recorder were found by the submarine using sonar to detect the underwater locator beacon signals and were quickly retrieved by Canadian Navy divers. Both had stopped recording when the aircraft lost electrical power at approximately, 5 minutes and 37 seconds before impact.
The recovery operation was guided by the TSB with resources from the CF, CCG, Royal Canadian Mounted Police, and other agencies. The area was surveyed using route survey sonar, laser line scanners, and remotely operated vehicles to locate items. After being located, the debris was then recovered.
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. 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.
The final phase of wreckage recovery employed the ship to dredge the remaining aircraft debris. It concluded in December 1999 with 98% of the aircraft retrieved: approximately of aircraft debris and of cargo.

Response to victims' families and friends

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. 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.

Investigation

Identification of victims

The Royal Canadian Mounted Police 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". 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; due to the large number of dental X-rays available to the examiners, these bodies were able to be identified by late-October 1998. Fingerprints and ante-mortem X-rays were used to identify around 30 bodies.

Examination of wreckage

An estimated 2 million pieces of debris were recovered and brought ashore for inspection at a secure handling facility in a marine industrial park at Sheet Harbour, where small material was hand inspected by teams of RCMP officers looking for human remains, personal effects, and valuables from the aircraft's cargo hold. The material was then transported to CFB Shearwater, where it was sorted and inspected by over 350 investigators from multiple organizations and companies, including the Transportation Safety Board of Canada, the US National Transportation Safety Board, the US Federal Aviation Administration, the Swiss Aircraft Accident Investigation Bureau, Boeing, Pratt & Whitney, Air Line Pilots Association, and Swissair.
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 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. Particular attention was paid to any item showing heat damage, burns, or other unusual marks. The front 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.
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 last six minutes of flight entirely from the physical evidence. The investigation became the largest and most expensive transport accident investigation in Canadian history, costing CAD$57 million over five years.

Cockpit recordings

The cockpit voice recorder used a 1/4 inch 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. The CVR recording and transcript were covered by a strict privilege under section 28 of the Canadian Transportation Accident Investigation and Safety Board Act 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. The air traffic control transcripts were released within days of the crash in 1998 and the air traffic control audio was released in May 2007, following a ruling by the Federal Court of Appeal. Several key minutes of the air traffic control audio can be found on the Toronto Star web site.
In 1999, a The Wall Street Journal article 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 WSJ claimed that co-pilot Loew 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.

Probable cause

The TSB investigation identified eleven causes and contributing factors of the crash in its final report. The first and most prominent was:
Investigators identified evidence of arcing in wiring of the in-flight entertainment network, 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. 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. 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.
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; as the flight crew dumped fuel as per procedure, they lost all control, and the doomed plane flew into the ocean uncommanded. Recovered fragments of the plane show that the heat 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 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. Death was instantaneous for all passengers and crew due to the impact forces and deceleration.

Safety recommendations

The TSB made nine recommendations relating to changes in aircraft materials, 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 Authority standards, principally impacting wiring and fire hardening.

Legacy

Lost works

Two paintings, including Le Peintre by Pablo Picasso, were on board the aircraft and were destroyed in the accident.

Lawsuit

In September 1999 Swissair, Delta, and Boeing agreed to share liability for the accident and offered the families of the passengers financial compensation. 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 totaled over $13 million.

Memorials and tributes

A memorial service was held in Zürich. The following year a memorial service was held in Nova Scotia.
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 north of Peggy's Cove. 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. 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. Various other charitable funds were also created, including one in the name of a young victim from Louisiana, Robert Martin Maillet, which provides money for children in need.
A further permanent memorial, albeit not publicly accessible, was created inside the Operations Center at Zürich Airport where a simple plaque on the ground floor in the centre opening of a spiral staircase pays tribute to the victims.

Impacts on the industry

In the late 1990s, the McDonnell Douglas MD-11 was the only and last tri-jet airliner in production. At the time of the accident, Boeing was still producing the freighter version, but had ceased production of the passenger version, the last of these being delivered to Sabena in 1998. The last MD-11 freighter was delivered to Lufthansa Cargo in 2001.
The crash of Flight 111 was a severe blow to Swissair, particularly as the in-flight entertainment system that was blamed for causing the accident had been installed on the aircraft to attract more passengers, in order to ease the airline's financial difficulties. Swissair went bankrupt shortly after the September 11 attacks in 2001, an event that caused a significant and widespread disruption to the aviation transportation industry.
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. As of April 2018, this flight continues to operate between New York's JFK airport and Geneva Airport using the Airbus A330-300.

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