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Swissair Flight 111 Abbreviated Investigation Chronology

September 2, 1998: At 21:18 Atlantic daylight time (ADT), Swissair Flight 111 (SR 111), a McDonnell Douglas MD-11 aircraft, departs John F. Kennedy Airport, New York, en route to Geneva, Switzerland, with 215 passengers and 14 crew members on board. Approximately 53 minutes after take-off, while cruising at 33 000 feet, the crew notices an unusual smell in the cockpit. Within approximately three and a half minutes the flight crew notes visible smoke and declares the international urgency signal "Pan Pan" to Moncton Area Control Centre, advising the air traffic services (ATS) controller of smoke in the cockpit. SR 111 is cleared to proceed direct to Halifax International Airport, Nova Scotia, from its position 56 nautical miles southwest of the airport. While the aircraft is manoeuvring in preparation for landing, the crew advises ATS that they must land immediately and that they are declaring an emergency. At approximately 22:31 ADT, the aircraft strikes the water near Peggy's Cove, Nova Scotia, fatally injuring all on board.

An Exclusion Zone at the SR 111 crash site is implemented and rescue/recovery operations begin immediately, around the clock, seven days a week, with extensive initial rescue and recovery efforts voluntarily undertaken immediately by local residents. The wreckage field comprises an area of approximately 70 metres by 30 metres, littered with pieces of the aircraft.

September 6, 1998: SR 111 Flight Data Recorder (FDR) is recovered and transferred to TSB Engineering Branch Flight Recorder Laboratory in Ottawa, Ontario.

September 11, 1998: SR 111 Cockpit Voice Recorder (CVR) recovered and transferred to TSB Engineering Branch Flight Recorder Laboratory in Ottawa, Ontario.

September 15, 1998: The TSB investigation team determines that both the FDR and CVR stopped recording while the aircraft was at an altitude of approximately 10 000 feet, approximately six minutes before the aircraft struck the water.

October 2, 1998: TSB announces initiation of heavy lift operations to retrieve the major portion of the wreckage in the debris field from the deep-water site (approximately 55 metres) before winter storms complicate the recovery effort. By now, more than 3000 people from the Canadian Forces, the Canadian Coast Guard, the RCMP, the United States Navy, the Transportation Safety Board of Canada, the Department of Fisheries and Oceans, the Nova Scotia Chief Medical Examiner and other provincial departments, the U.S. National Transportation Safety Board (NTSB), volunteers with the federal and provincial Emergency Measures Organizations (EMO), and many local volunteers have been involved in the recovery effort.

October 21, 1998: A TSB Investigation Update reports that approximately 27 per cent of the aircraft, by weight, has been recovered. Recovered material is brought to the Canadian Forces Base (CFB) Shearwater jetty, where it is washed and readied for the sorting operation at the Shearwater operations hangar.

October 29, 1998: A TSB Investigation Update reports that technical examination of recovered materials from SR 111 has revealed that some of the wiring and structure, located in the ceiling in the vicinity of the cockpit, shows signs of heat damage. Some of this wiring is associated with the aircraft's in flight entertainment network (IFEN) system. After discussions with TSB, U.S. NTSB and Swiss Federal Aircraft Accident Investigation Bureau, Swissair voluntarily disables the IFEN system on MD-11 and Boeing 747 fleets.

November 4, 1998: A nine-metre-long reconstruction frame is built to allow investigators to systematically reconstruct the forward portion of the aircraft.

December 21, 1998: TSB reports that 85 per cent of aircraft by weight has been recovered, including about 60 per cent of the forward fuselage. TSB signifies intent to pass on to regulators, manufacturers, and operators, information about safety deficiencies as they come to light.

December 22, 1998: TSB issues Aviation Safety Advisory (ASA) (980031-1) to U.S. NTSB, noting anomalies in cockpit wiring.

March 5, 1999: Work continues at CFB Shearwater on identifying, examining, analyzing, documenting, and matching aircraft nose section pieces; as well, examination, identification, heat damage analysis, documentation, and matching of wire from the aircraft continues. Approximately 88 per cent of the aircraft structure, by weight, reported recovered.

March 9, 1999: TSB reports that investigation has revealed heat damage consistent with a fire in the ceiling area forward and aft of the cockpit bulkhead.

March 9, 1999: TSB issues four Aviation Safety Recommendations (ASRs) with respect to the recording capacity and power source requirements of CVRs and FDRs:

August 11, 1999: TSB issues two ASRs dealing with the risks associated with flammability of metallized polyethylene terephthalate (MPET)-covered insulation blankets and test criteria that certified this material for use:

August 27, 1999: Tests begin to assess the significance of arcing found on 14 wire segments. TSB works in conjunction with a number of engineering laboratories to develop a method to test whether wires arced as a result of a short circuit in a normal environment or whether the arcing was a secondary outcome of a fire that damaged wire insulation.

September 1-3, 1999: Memorial services held near Peggy's Cove to mark the first anniversary of the accident. Family visits to investigation site organized as part of services. Many families visit the SR 111 reconstruction in CFB Shearwater Hangar.

November 1, 1999: Exclusion zone at SR 111 crash site is lifted.

December 15, 1999: Recovery operations are completed. Ninety-eight per cent of aircraft, by weight, has been recovered. Dredged material yielded estimated additional one million pieces of aircraft structure, components and cargo. An estimated two million pieces of wreckage are recovered.

March 2, 2000: TSB reports that, although the flight crew reading light (map light) was not involved in the origin of the SR 111 fire, deficiencies in its design had the potential for electrical arcing. Map light installations were located in confined areas near, or in direct contact with, combustible materials that could exacerbate the consequences of potential arcing. TSB issues ASA A000008-1 to U.S. NTSB.

December 4, 2000: TSB issues five ASRs related to in-flight

firefighting measures:

December 29, 2000: TSB issues Aviation Safety Information Letter (ASIL) (A000061-1) with respect to the flight crew reading light, identifying more failure modes and aircraft to which they apply.

August 14, 2001: TSB issues ASA (A010020-1) to Transport Canada, suggesting it review controller training requirements, particularly with respect to emergency procedures.

August 28, 2001: TSB issues three ASRs, detailing concerns over flammability standards for certain materials, testing, and certification of aircraft wiring, and requirements when conducting system safety analyses:

September 28, 2001: TSB issues ASA (A010042-1, A010042-2) with respect to standby (secondary) instruments on MD-11 aircraft, suggesting that requirements for standby instrumentation, including communications and navigation capabilities, flight crew training and design standards, be reviewed.

August 3, 2002: TSB distributes Confidential Draft Report to Designated Reviewers for review and comment. Designated reviewers are selected by the Board, and consist of the operators, representatives of the crew, regulators, agencies, companies and manufacturers whose performance, behaviour or products may be commented on in the final report, as well as those who may contribute to the completeness and accuracy of the report.

September 20, 2002: Designated reviewers submit comments on the Confidential Draft Report to the TSB. Preparation of the final report begins.

March 27, 2003: TSB issues final report on the investigation into the Swissair Flight 111 occurrence. Nine additional ASRs are included in the report:

March 27, 2003: TSB Investigation into Swissair Flight SR 111 is officially closed.

Glossary of Terms

AD airworthiness directive
ADT Atlantic daylight time
ASA aviation safety advisory
ASIL Aviation Safety Information Letter
ASR Aviation Safety Recommendation
ATS air traffic services
CVR cockpit voice recorder
FDR flight data recorder
FOCA Federal Office of Civil Aviation (Switzerland)
IFEN In-flight Entertainment Network (System)
MPET metallized polyethylene terephthalate
NRPM Notice of Proposed Rule-Making (FAA)
NTSB National Transportation Safety Board (U.S.)
PVF polyvinyl fluoride
RCMP Royal Canadian Mounted Police
ROV remotely operated vehicle
STC supplemental type certificate
SR 111 Swissair Flight 111
TSB Transportation Safety Board (of Canada)