Transportation Safety Board of Canada / Bureau de la sécurité des transports du Canada
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SR 111 Investigation Report

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2.0 Analysis

The investigation of the Swissair Flight 111 (SR 111) occurrence was complex, and involved prolonged wreckage recovery operations before the detailed examination and assessment of the technical issues could be completed. To permit an assessment of the fire-damaged area and to enable evaluation of the potential safety deficiencies, it was necessary to rebuild a portion of the front section of the aircraft. It was found that the extensive damage from the in-flight fire and impact with the water had either obscured or destroyed much of the information from many of the components in this area. However, through detailed examination, reconstruction, and analysis of the recovered components and material, potential fire scenarios were developed. The reconstruction mock-up—together with information from the evaluation of airflow, material properties, and timing of events—led to an understanding of how and where the flammable materials could have ignited and how the fire propagated.

The time interval between when an unusual smell was detected in the cockpit and when the aircraft struck the water was only about 20 minutes; therefore, considerable emphasis was placed on making determinations about the cues available to the crew and the factors affecting their assessment of the on board situation.

This part analyzes and validates many of the safety deficiencies regarding materials, equipment, and procedures that were highlighted during the investigation and discusses information that the Board considered in formulating the findings in Part 3, Conclusions, of this report.

2.1 General Information
2.2 On-Board Data Recording Capability
2.3 Material Susceptibility to Fire – Certification Standards
2.4 Aircraft Fire Detection and Suppression
2.5 In-Flight Firefighting Measures
2.6 Crew Preparation and Training
2.7 Checklist Issues
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
2.14 In-Flight Entertainment Network
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
2.18 Known Technical Failure Events
2.19 Remaining Few Minutes Following Stoppage of Recorders
2.20 Actual Versus Theoretical Emergency Descent Profile
2.21 Fire Initiation

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Updated: 2003-03-27

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