Notes for an Address by
Mr. Camille Thériault
Chairman of the Transportation Safety Board of Canada
For the release of the Final Report
Of the Investigation into the crash of Swissair Flight 111
World Trade and Convention Centre
Halifax, Nova Scotia
27 March 2003
Good morning and thank you for coming.
Today marks the conclusion of the Swissair Flight 111 investigation - the most exhaustive investigation conducted by the Transportation Safety Board of Canada.
During this investigation, the TSB has made a total of 23 Aviation Safety Recommendations to enhance aviation safety. We are releasing the final nine recommendations today.
We continue to mourn the loss of the 229 passengers and crew members who died in this terrible accident. Our sympathy goes out to all the families and friends that have been affected.
Yet we can take some consolation in knowing that much has been learned from this investigation -- and that many measures have already been taken to enhance aviation safety -- today and well into the future.
We're also heartened by the way in which so many people -- from so many places -- helped provide this investigation with its strength and purpose:
- The men and women of the Royal Canadian Mounted Police, the Department of National Defense; and the Department of Fisheries and Oceans; and provincial government agencies;
- International regulators, manufacturers, airline operators;
- Our investigators and, of course, the people of Nova Scotia.
Their acts of courage and compassion, determination and devotion, have served this investigation well. Their devotion and compassion were a source of strength to the families of the 229 passengers and crew.
I'm joined today by Vic Gerden, the Investigator-in-Charge, and Daniel Verreault, Director of Air Investigations. They'll provide you with a technical summary of this investigation in a few minutes.
But first let me put this investigation into context.
The final report, which we publish today, provides the world with one of the most detailed accounts of an aviation disaster. This exhaustive investigation reflects the unique mandate of the Transportation Safety Board of Canada.
We're an independent body that examines all factors that may have played a role in an accident, whether it's an aviation or marine accident, or an accident along Canada's railways and pipelines.
Our focus is on what happened, why it happened, and how we can avoid a similar accident from ever happening again.
It is not our role to cast blame. That's because safety experts in Canada -- and around the world -- recognize it takes a wide range of causes and contributing factors for an accident of this nature and magnitude to occur. And when it does occur, we must focus our attention on all of the safety issues that can prevent a similar accident.
The Swissair 111 investigation is no exception.
Therefore our approach is systemic. We examine as many individual parts of the aviation system as the investigation requires, and we look at how all elements and events inter-relate with each other to determine what happened and what the safety deficiencies are.
As such, our job is to identify all causes and contributing factors leading to the accident.
A complex and exhaustive investigation
It's for this reason that our investigation took more than four years to complete.
Consider its complexity:
- millions of pieces of shattered aircraft needed to be recovered from the sea;
- of the more than 250 kilometers of electrical wire, much was recovered and it all needed to be identified and examined;
- extensive series of flight and laboratory tests had to be conducted; and,
- exhaustive analysis of events -- even when little information existed -- needed to be carried out.
This accident tested the investigation team in many different ways. But all challenges were overcome by their ingenuity. For example, we were able to retrieve 98 percent of the airplane, in terms of weight, despite the wreckage resting 55 metres down on the ocean floor. An amazing technical feat.
The sheer complexity of this type of investigation has demanded significant resources. The recovery and investigation cost approximately $57 million dollars.
This has been the largest, most complex safety investigation the Transportation Safety Board of Canada has ever undertaken, and required a significant investment of people, resources and time. The efforts of thousands of hardworking people from many countries, industries, and regulatory authorities have culminated in a comprehensive report that has changed the face of aviation safety.
And that means it's also the greatest contribution ever made by Canadians to aviation safety, here and around the world.
We've already seen profound results stemming from this investigation. That's because we acted immediately to inform the aviation community about any safety deficiencies as soon as they were identified.
Let me be clear: our focus is -- and always has been -- to put our key findings to use as soon as they became known to us, in order to improve aviation safety.
Before I release the final nine recommendations contained in this report, it is important to summarize the 14 Aviation Safety Recommendations the TSB has already released:
- four regarding flight recorder duration and power supply;
- two regarding thermal acoustical insulation materials and -- flammability test criteria;
- five regarding in-flight firefighting measures; and
- three regarding aircraft material flammability standards, including wire testing standards.
Several of these recommendations have already been adopted by regulatory authorities, airlines and aircraft manufacturers. The adoption of these recommendations has improved the safety of aviation worldwide.
For example, the In-Flight Entertainment Network system was removed voluntarily from Swissair aircraft MPET covered insulation used on thermal acoustical insulation blankets has been ordered removed from all aircraft.
Flammability standards for materials used in aircraft are being upgraded, and in-flight firefighting procedures have been subjected to intense review and changes have been made. Other recommendations are also being implemented.
The final nine recommendations: the last part of the puzzle
As I mentioned earlier, The Board is issuing nine additional recommendations today. These final recommendations continue to identify systemic safety deficiencies related to material and flammability standards and wiring. They also address ways to enhance future investigations.
Two recommendations relate to the testing and flammability standards of in-service thermal acoustical insulation materials, and one relates to the application of existing standards for the certification of other materials.
Specifically, we recommend that regulatory authorities:
- Quantify and mitigate the risks associated with in-service thermal acoustic insulation materials that have failed the proposed Radiant Panel Test;
- Develop a test regime that will effectively prevent the certification of any thermal acoustic insulation materials that, based on realistic ignition scenarios, would sustain or propagate a fire; and
- Take action to ensure the accurate and consistent interpretation of regulations governing material flammability requirements for aircraft materials so as to prevent the use of any material with inappropriate flammability characteristics.
Two other recommendations relate to aircraft electrical systems. We urge that regulatory authorities:
- Require that every system installed through the supplemental type certificate process undergo a level of quantitative analysis to ensure that it is properly integrated with aircraft type-certified procedures, such as emergency load-shedding; and
- Establish requirements and an industry standard for circuit breaker resetting.
And finally, four recommendations relate to proposed improvements to the capture and storage of flight data. Specifically, we ask regulatory authorities to:
- In concert with the aviation industry, take measures to enhance the quality and intelligibility of Cockpit Voice Recorder recordings;
- Require, for all aircraft manufactured after 1 January 2007 which require an Flight Data Recorder, or FDR, that in addition to the existing minimum mandatory parameter lists for FDRs, all optional flight data collected for non-mandatory programs be recorded on the FDR;
- We also recommend that regulatory authorities develop harmonized requirements to fit aircraft with image recording systems that would include imaging within the cockpit; and
- And harmonize international rules and processes for the protection of cockpit voice and image recordings used for safety investigations.
I will now call upon Vic Gerden and Daniel Verreault to provide you with a technical overview of what happened during Swissair Flight 111 and how our key recommendations came about.
Thank you Vic and Daniel.
We've spent much of today discussing the technical aspects of this investigation. But all successful investigations are first and foremost an act of compassion for those who have endured the sorrow of human loss.
Let it be known that thousands of people have worked together on behalf of all those touched by this tragedy… to understand this crash … and ensure it never happens again. There have also been many people who've put their own lives on hold to serve those suffering and in need. I would like to personally thank them.
To the regulators, manufacturers and airlines: You've acted responsibly and moved quickly to address a wide range of safety deficiencies stemming from this accident. We thank you for your cooperation throughout the entire investigation.
To the people of Nova Scotia, and in particular the people of Peggy's Cove, and communities surrounding St. Margaret's Bay: In the darkest days, you provided comfort where there was only pain; compassion where there was only suffering; hope where there was only despair. Thank you for showing the world the very best of our national character.
And to the people of the TSB, and in particular Vic Gerden and his entire team: You've sacrificed so much and served so many in your unwavering pursuit to untangle this tragic event. You've turned the final page of this investigation, but its impact will benefit the traveling public for decades to come. Thank you for your perseverance, focus and commitment.
Enhancing travel safety
The efforts of thousands of hardworking people from various countries, industries and regulatory authorities have culminated in a comprehensive report that has changed the face of aviation safety.
We are pleased with the way in which the industry has cooperated throughout the investigation. We understand that many of the issues are complex, international in scope and take time to implement and resolve.
But it's our belief that all 23 recommendations will have a meaningful impact on aviation safety and future investigations.
This investigation concludes -- but our work at the TSB continues.
The TSB will monitor the progress industry and the regulators are making on implementing the Board's recommendations. We'll call on them, and offer our help in advancing aviation safety.
We are a world on the move, and we rely on aviation travel to get there. It has long been a safe mode of transportation. It's now safer, with the completion of this exhaustive investigation.
I now would like to open the floor up for questions.
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