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SR 111 Investigation Report

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1.17.1  SAirGroup/Swissair/SR Technics Swissair Flight Safety Program Swissair Postholder – Maintenance SR Technics Quality Assurance Program SR Technics Reliability Program

The original Swissair company was founded in 1931 as Swissair Swiss Air Transport Company Limited. This organization evolved into a multi-faceted company, which included several diverse enterprises, such as the airline, aircraft maintenance, airport ground handling, software development, and real estate. In March 1996, a new management structure was introduced, creating a holding company structure organized to provide improvements in management responsibility and accountability. By 1997, the Swissair Swiss Air Transport Company Limited was reorganized into a group of holding companies named SAirGroup.

At the time of the SR 111 occurrence, SAirGroup functioned as the parent company for an aircraft leasing company (Flightlease AG) and the following four subsidiary holding companies: SAirLines, SAirServices, SAirLogistics, and SAirRelations. The former airline business unit became an operational subsidiary of SAirLines, but retained the name of Swissair Swiss Air Transport Company Limited (referred to as Swissair in this report). Likewise, the former aircraft maintenance business unit became a fully owned subsidiary of SAirServices and was named Swissair Technical Services Limited. Swissair Technical Services Limited became an autonomous company on 1 January 1997 known as SR Technics Group AG (referred to as SR Technics in this report).

At the time of the SR 111 occurrence, SR Technics had more than 3 000 employees and was responsible for aircraft maintenance for Swissair, which was its primary customer. SR Technics also performed maintenance for other SAirLines carriers and for third-party customers. Approximately 50 per cent of the total SR Technics work capacity was devoted to non-SAirGroup customers.

In April 2001, the parent holding company, SAirGroup, was renamed The Swissair Group. On 31 March 2002, Swissair ceased operations.

Back to the top  Swissair Flight Safety Program

Swissair initiated a confidential reporting system in 1983; however, it was seldom used by the flight crews as a result of the establishment of a flight data analysis system that enabled the analysis of aircraft performance data. The information retrieved from the auxiliary data acquisition system (ADAS) was confidential and the analysis of this information was carried out by three selected Swissair pilots.

In each case, the Swissair analysts examined the data to determine how the aircraft was being flown, and to monitor any developing performance trends, such as out-of-tolerance flight parameters or deviations from standard operating procedures. As an example, they would monitor airspeeds to determine whether the speeds flown were within tolerances. The names of the pilots conducting the flights being analyzed were kept confidential. Only the relevant analysis was passed on to the Flight Safety department so that trends could be analyzed and addressed in newsletters or in simulator training. Each month a bulletin, entitled Incidents and Non-routine Occurrences, was published and distributed to the Swissair pilot community and also shared with other companies in the SAir Group. A quarterly safety letter, entitled Information Bulletin, was also distributed.

Pilot trust in this program was high. Each pilot at the company could request an analysis of the flights they had flown. It is estimated that at least 60 per cent of the case evaluations were pilot-requested.

Back to the top  Swissair Postholder – Maintenance

Swissair was a scheduled airline operating under JAR-OPS 1 (see Section 1.17.2). As of 1 April 1998, Swissair was required, under JAR-OPS 1.175, to have nominated postholders[84] to be responsible for the management and supervision of the following areas:

  • Flight operations;
  • Maintenance system;
  • Crew training; and
  • Ground operations.

JAR-OPS 1.895 required an operator to employ a person, or group of persons, to ensure that all maintenance was carried out on time, and to an approved standard. The individual, or senior person in the group as appropriate, was the nominated postholder.

Swissair nominated the head of Flight Operations Engineering and Support to be responsible for its Postholder-Maintenance System. This position was responsible for protecting the interests of the airline regarding all maintenance, manufacturing, and service provider issues, and for being the primary point-of-contact within Swissair for all its maintenance providers. Other responsibilities included ensuring that the aircraft were airworthy and that the operational and emergency equipment was serviceable.

The Swissair Postholder-Maintenance System was also responsible for conducting routine monitoring of the maintenance activities performed by SR Technics. Some of the areas that required monitoring responsibilities in the Swissair Maintenance Management Exposition included

  • performing audits with qualified auditors;
  • submitting a written report, indicating the findings, required actions, responsibilities and deadlines for actions;
  • submitting a copy of the report to the Quality Manager;
  • storing the report for five years; and
  • monitoring the implementation of the actions taken, and their effectiveness.

Back to the top  SR Technics Quality Assurance Program

At the time of the accident, SR Technics had a valid JAR-145 Maintenance Organization Approval issued by the FOCA. The Quality Assurance (QA) program was established in accordance with JAR 145.65 and was based on the requirements of the Euro/International Standard EN 29001/ISO 9001. The QA program covered all organizational requirements and activities related to quality. The QA program was designed to ensure that all work performed, and services rendered, were done in accordance with SR Technics policies, procedures, and instructions, and with standard industry maintenance practices.

The QA program also ensured compliance with applicable regulatory requirements. QA within SR Technics, particularly the airworthiness of the aircraft and the use of aircraft parts, was the responsibility of the individual production units, in accordance with relevant job descriptions and procedures. SR Technics took a "Total Quality Management" approach to QA; that is, individual employees were expected to be responsible for the quality of their own work, and were required to perform a self-inspection after each "work step." Depending on the nature of the maintenance procedure, additional inspections were required in accordance with the SR Technics Maintenance Organization Exposition. Unit supervisors were responsible for ensuring that their personnel were sufficiently trained and equipped to perform the task at hand, and for inspecting the quality of their employees' work. Random quality inspections were also performed by members of the SR Technics quality department.

Back to the top  SR Technics Reliability Program

At the time of the occurrence, a reliability program was in place at SR Technics to ensure airworthiness and a high level of reliability to optimize economic operations. The program existed under the umbrella of a joint reliability program. The program was known as KSSU because it included the following operators: KLM, SAS, Swissair, Union de Transport Aeriens, and later Air France. The program was designed for use when performing maintenance on aircraft from the Swissair fleet or other customer airlines. The total maintenance program was based on the FAA Advisory Circular (AC) 120-17A. The KSSU reliability program was published in the SR Technics Engineering Handbook, Technik, and was valid for all aircraft types operated by Swissair.

Overall, reliability of the airframe, engines, and aircraft systems was subject to continuous monitoring and analysis, as required by JAR-OPS 1 Subpart M.

[84]    Postholder describes the person who has the position or is the incumbent of the post.

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Updated: 2003-03-27

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