Swissair Flight 111 Disaster: Analysis of Causes and Safety Report

This report analyzes the Swissair Flight 111 crash, which occurred on September 2, 1998, claiming the lives of all 229 passengers. The investigation by the Transportation Safety Board (TSB) revealed that an inflight fire, likely caused by faulty wiring and flammable insulation, disabled critical electrical systems and led to the aircraft's loss. The report details the application of Fault Tree Analysis and Failure Mode and Effects Analysis (FMEA) to understand the incident's causes and potential risks. It highlights the failure of safety protocols, including inadequate fire detection and the lack of independent power supplies for the flight data recorder and voice recorder. The analysis underscores the importance of aviation safety regulations and the implementation of TSB's safety recommendations to prevent similar disasters. The report emphasizes the significant financial and time investment in the investigation and its impact on aviation safety improvements.

Incident
Tikkanen stated that the Swissair Flight 111 had crashed on the 2nd of September, 1998.
This crash had claimed the lives of all the 229 passengers who had been present in the flight. The
aircraft was a tri-engine McDonnell Douglas MD-11 that was bound towards Geneva. It was a
scheduled plane that was supposed to start its journey from the John F. Kennedy international
airport. The plane had crashed into the sea at Peggy’s Cove in Nova Scotia, Canada in just 53
minutes after the take-off. The Transportation Safety Board (TSB) based in Canada had
investigated the case. The investigation revealed the fact that the mishap had occurred from an
inflight fire that had broken thereby leading to the disabling of the various major electrical
devices that were present within the cockpit. The investigation revealed that the pilots were
manually6 controlling the aircraft when the smoke filled inside the cockpit. It was a cloudy night
and the pilots had reportedly asked for a diversion to the nearest airport and had sent in a “pan-
pan” signal.
However, the smoke and the fire had increased uncontrollably thereby leading to the loss
of the control of the pilots. The pilots declared an emergency situation and the plane crashed into
the water and shattered into pieces within a few minutes.
Risks
The investigation by the TSB revealed that the disaster had resulted from the breaking of
a fire in the cockpit during the flight. The fire had spread in a deadly manner and thus led to the
fatal condition within the flight and eventually the death of all the person aboard. Russell stated
that the fire had been “spreading rapidly through the walls of the doomed jet.” The tragedy was
over in a small span of twenty minutes however, the investigation reports state that the data was

lost due to the loss of the electric supply to the flight data recorder and the voice recorder
was snapped in just 6 minutes before the crash.
There was no criminal activity that was undertaken by the crew that was onboard. The
flammable insulation had caught fire due to the fault in the wiring system. This had led to the
failure of the key electrical systems that were present inside the aircraft. The investigation
revealed the fact that the installation of the new entertainment system within the aircraft might
have led to the spreading of the fire. The investigation report further revealed the absence of the
mechanism for the fire detection just above the cockpit. This barred the crew from realizing that
the fire had spread in the frontal part of the jet which was flying at a high speed of 7 nautical
miles per minute. The key electrical systems had begun to fail and shutdown in a very fast
succession after the detection of the foul smell in the cockpit for about a span of 13 minutes.
Fault Tree Analysis
The Fault Tree Analysis is generally used to deal with the revelation of the cause of the
failure of the control systems that have been present within the aircraft. The analysis attempts to
discuss the various factors that had been a reason for the development of the issues that are
responsible for the development of the disaster situation. The analysis is majorly dependent on
the deductive approaches towards the top-down understanding of the incident. The analysis
considers the various minor events that could result in a huge disaster. The concerned incident
had been caused due to the flawed wiring, the absence of the fire detection, the cloudy weather,
the use of the flammable substances as a part of the entertainment system which was present
within the organization. The absence of the proper fire detection system had resulted in the
conditions wherein the pilots could not take proper action due to the non-detection of the fire
within the aircraft.

The incident could also have resulted from the conditions wherein the crew had
sabotaged the aircraft but no such incident was reported through the investigation. The airlines
had not paid heed to the safety guidelines that should have been followed by the organization in
the installation of the entertainment system. A separate electrical supply should have been
provided to the voice recorder and the flight data recorder in order to collect the data till the last
possible moment of communication within the cockpit. Stephen stated that “communication with
Halifax ended six minutes before impact with the Atlantic, around eight kilometers from Peggy’s
Cove”. The analysis revealed that the flight crew was unable to take care of the fire that had
erupted.
The Failure Mode and Effects Analysis (FMEA) refers to a failure analysis method that is
extremely structured and systematic in nature. The technique uses the thorough analysis of all the
subsystems and the components that are related to the incident. The FMEA is observed to have
been relying on the inductive reasoning for the prediction of the issues that might take place in
the future. The FMEA helps in the development of an entire list of the possibilities that refer to
the different types of failures. This list in turn is found to be extremely helpful in the
development of the proper assessment of the risks. The analysis is considered to be helpful in the
assessment of the risks that might be faced by the organization in the future days. The analysis is
further used to deal with the reduction of the risks after the successful identification of the risks
in the area. The reports revealed that a plethora of risks could be avoided with the help of a
systematic solution that would help in the resolution of the risks.
The Transportation Safety Board (TSB) based in Canada had arrived at the best
conclusion with the help of the available data. Dubreuil revealed that “TSB issued 23 safety
recommendations”. The investigation stated that only three of the safety recommendations were

followed. The airline crew were provided with the training for dealing with fire outbreaks, the
material that was used for the insulation were certified and stringent. The power supply
dedicated to the voice recorder and the flight data recorder were considered to be mandatory for
the flight.
Conclusion
The analyses revealed the risks that could have resulted in the situation. Stephens state
that the accident impact was too huge resulting in the shattering of the aircraft into very small
pieces. The evaluation of the causes had led to the expenditure of above 57 million dollars and
took almost 5 years to complete. The incident led to the changes in the aviation safety
regulations as well. The flight operators who had been present within the area tend to express a
great a great amount of thanks and regards to the entire team of experts who have contributed
their best to the study of the incident and thereby helped in avoiding the similar situations in the
future days.