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SR 111 Investigation Report

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How This Report Is Organized

This report was prepared in accordance with International Civil Aviation Organization standards and recommended practices,[*] and with Transportation Safety Board (TSB) standards for investigation reports. In keeping with these standards, the report is organized into the following main parts:

  • Part 1, Factual Information: Provides objective information that is pertinent to the understanding of the circumstances surrounding the occurrence.

  • Part 2, Analysis: Discusses and evaluates the factual information presented in Part 1 that the Board considered when formulating its conclusions and safety actions.

  • Part 3, Conclusions: Based on the analyses of the factual information, presents three categories of findings: findings as to causes and contributing factors to the occurrence; findings that expose risks that have the potential to degrade aviation safety, but that could not be shown to have played a direct role in the occurrence; and "other" findings that have the potential to enhance safety, or clarify issues of unresolved ambiguity or controversy.

  • Part 4, Safety Action: Based on the findings of the investigation, recommends safety actions required to be taken to eliminate or mitigate safety deficiencies, and records the main actions already taken or being taken by the stakeholders involved.

Note: Owing to the scope of the Swissair 111 investigation, various supporting technical information (STI) materials are referenced throughout the report. STI materials are peripheral to the report and are not required to develop a complete understanding of the facts, analyses, conclusions, or recommended safety actions. Rather, the STI materials expand, in technical detail, on the information provided in the report. A superscript "STIx-yyy" is inserted into the report wherever such a reference exists. In the hard-copy version, the number "x" identifies the part of the report, and "yyy" identifies the reference within the part, as indicated in Appendix E – List of Supporting Technical Information References. In the electronic version of the report, such references are hyperlinked directly to the applicable location in the electronic version of the STI. Appendix E is not included in the electronic version.

The report also consists of the following appendices and background material, which are referenced in the report:

  • Appendix A – Flight Profile: Selected Events: A chronological depiction of the intended itinerary, actual flight profile, and selected events during the occurrence, presented in Coordinated Universal Time (UTC).

  • Appendix B – Swissair Air Conditioning Smoke Checklist: The checklist used by Swissair to isolate a source of smoke originating from an aircraft air conditioning system.

  • Appendix C – Swissair Smoke/Fumes of Unknown Origin Checklist: The checklist used by Swissair to isolate a source of smoke or fumes originating from an unknown source.

  • Appendix D – Timeline: A chronological list of events for the duration of the occurrence, presented in UTC.

  • Glossary: An alphabetical list of abbreviations, acronyms, and initialisms used throughout the report.

Available Formats

The report can be viewed in the following formats:

  • Paper.
  • Compact Disc (CD-ROM) attached to the back cover of the paper report (compatible with Microsoft® Windows 95® or higher).
  • On the TSB web site at

The STI materials can be viewed:

  • On the TSB web site at
  • On Compact Disc (CD-ROM) along with the investigation report (compatible with Microsoft® Windows 95® or higher).

Readers can print copies of the report and STI materials from the CD-ROM or TSB web site.

To obtain additional copies of the report, please contact

TSB Communications Division
Place du Centre
200 Promenade du Portage
4th Floor
Gatineau, Quebec K1A 1K8

(819) 994-3741
(819) 997-2239

[*]  For more detailed information on International Civil Aviation Organization standards, refer to International Standards and Recommended Practices, Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, Ninth Edition, July 2001.

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Updated: 2003-03-27

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