Swissair Flight 111

Swissair Flight 111 (SR-111, SWR-111) was a Swissair McDonnell Douglas MD-11 on a scheduled airline flight from John F. Kennedy International Airport in New York City, United States to Cointrin International Airport in Geneva, Switzerland. This flight was also a codeshare flight with Delta Air Lines.

On Monday, 2 September 1998 the aircraft used for the flight, registered HB-IWF, crashed into the Atlantic Ocean southwest of Halifax International Airport at the entrance to St. Margarets Bay, Nova Scotia. The crash site was 8 kilometres (5.0 mi) from shore, roughly equidistant from the tiny fishing and tourist communities of Peggys Cove and Bayswater. All 229 people on board died. It was the highest-ever death toll of any aviation accident involving a McDonnell Douglas MD-11.

The initial search and rescue response, crash recovery operation, and resulting investigation by the Government of Canada took over four years and cost CAD 57 million (at that time approximately USD 38 million). The Transportation Safety Board of Canada's (TSB) official report of their investigation stated that flammable material used in the aircraft's structure allowed a fire to spread beyond the control of the crew, resulting in the loss of control and crash of the aircraft.

Swissair Flight 111 was known as the "U.N. shuttle" due to its popularity with United Nations officials; the flight often carried business executives, scientists, and researchers.

Aircraft
The aircraft, a McDonnell Douglas MD-11, serial number 48448 registered HB-IWF, was manufactured in 1991 and Swissair was its only operator. It bore the title of Vaud, in honor of the Swiss canton of the same name. The airframe had a total of 36,041 hours. The three engines were Pratt & Whitney 4462s. The cabin was configured with 241 seats (12 first-, 49 business-, and 180 economy-class). First- and business-class seats were equipped with an in seat in-flight entertainment system, installed at some point after initial entry into service.

Crew
An MD-11 has a standard flight crew consisting of a captain and a first officer, and a cabin crew made up of a maître de cabine (M/C - purser) supervising the work of 11 flight attendants. All personnel on board Swissair Flight 111 were qualified, certified and trained in accordance with Swiss regulations, under the Joint Aviation Authorities (JAA).

Flight and crash
The flight took off from New York's John F. Kennedy Airport at 20:18 Eastern Standard Time (00:18 UTC). Beginning at 20:33 EST (00:33 UTC) and lasting until 20:47 (00:47 UTC), the aircraft experienced an unexplained thirteen-minute radio blackout. The cause of the blackout, or if it was related to the crash is unknown.

At 22:10 Atlantic Time (01:10 UTC), cruising at FL330 (approximately 33,000 feet or 10,100 metres), the flight crew—Captain Urs Zimmermann and First Officer Stephan Loew—detected an odor in the cockpit and determined it to be smoke from the air conditioning system, a situation easily remedied by closing the air conditioning vent, which a flight attendant did on Zimmermann's request. Four minutes later, the odor returned and now smoke was visible, and the pilots began to consider diverting to a nearby airport for the purpose of a quick landing. At 22:14 AT (01:14 UTC) the flight crew made a "pan-pan" radio call to ATC Moncton (which handles trans-atlantic air traffic approaching or departing North American air space), indicating that there was an urgent problem with the flight, but not an emergency (denoted by a "Mayday" call) which would imply immediate danger to the aircraft, and requested a diversion to Boston's Logan International Airport, which at that time was 300 nautical miles (560 km) away. ATC Moncton offered the crew a vector to the closer Halifax International Airport in Enfield, Nova Scotia, 66 nm (104 km) away, which Loew accepted. The crew then put on their oxygen masks and the aircraft began its descent. Zimmermann put Loew in charge of the descent while he personally ran through the two Swissair standard checklists for smoke in the cockpit, a process that would take approximately 20 minutes and become a later source of controversy.

At 22:18 AT (01:18 UTC), ATC Moncton handed over traffic control of Swissair 111 to ATC Halifax, since the plane was now going to land in Halifax rather than leave North American air space. At 22:19 AT (01:19 UTC) the plane was 30 nautical miles (56 km) away from Halifax International Airport, but Loew requested more time to descend the plane from its altitude of 21,000 feet (6,400 m). At 22:20 AT (01:20 UTC), Loew informed ATC Halifax that he needed to dump fuel, which ATC Halifax controllers would say later was a surprise considering that the request came so late; dumping fuel is a fairly standard procedure early on in nearly any "heavy" aircraft urgent landing scenario. ATC Halifax subsequently diverted Swissair 111 toward St. Margaret's Bay, where they could more safely dump fuel but still be only around 30 nautical miles (56 km) from Halifax.

In accordance with the Swissair checklist entitled "In case of smoke of unknown origin", the crew shut off the power supply in the cabin, which caused the recirculating fans to shut off. This caused a vacuum which induced the fire to spread back into the cockpit. This also caused the autopilot to shut down; at 22:24:28 AT (01:24:28 UTC), Loew informed ATC Halifax that "we now must fly[...]manually." Seventeen seconds later, at 22:24:45 AT (01:24:45 UTC), Loew informed ATC Halifax that "Swissair 111 heavy is declaring emergency", repeated the emergency declaration one second later, and over the next 10 seconds stated that they had descended to "between 12,000 and 5,000 feet" and once more declared an emergency. The flight data recorder stopped recording at 22:25:40 AT (01:25:40 AT), followed one second later by the cockpit voice recorder. The doomed plane briefly showed up again on radar screens from 22:25:50 AT (01:25:50 UTC) until 22:26:04 AT (01:26:04 UTC). Its last recorded altitude was 9,700 feet. Shortly after the first emergency declaration, the captain can be heard leaving his seat to fight the fire, which was now spreading to the rear of the cockpit; the Swissair volume of checklists was later found fused together, as if someone had been trying to use them to fan back flames. The captain did not return to his seat, and whether he was killed from the fire or asphyxiated by the smoke is not known. However, physical evidence provides a strong indication that First Officer Loew may have survived the inferno only to die in the eventual crash; instruments show that Loew continued trying to fly the now-crippled aircraft, and gauges later indicated that he shut down engine two approximately one minute before impact, implying he was still alive and at the controls until the aircraft struck the ocean at 22:31 AT (01:31 UTC). The aircraft disintegrated on impact, killing all on board instantly. The crash location was approximately 44.40917°N, -63.97361°W, with 300 metres' uncertainty.

Search and rescue operation
The search and rescue operation was code-named OPERATION PERSISTANCE and was launched immediately by Joint Rescue Coordination Centre Halifax (JRCC Halifax) which tasked the Canadian Forces Air Command, Maritime Command and Land Force Command, as well as Canadian Coast Guard (CCG) and Canadian Coast Guard Auxiliary (CCGA) resources.

The first rescue resources to approach the crash site were Canadian Coast Guard Auxiliary volunteer units - mostly privately owned fishing boats - sailing from Peggys Cove, Bayswater and other harbours on St. Margarets Bay and the Aspotogan Peninsula. They were soon joined by the dedicated Canadian Coast Guard SAR vessel CCGS Sambro and CH-113 Labrador SAR helicopters flown by 413 Squadron from CFB Greenwood.

The crash site's proximity to Halifax meant that ships docked at Canada's largest naval base, CFB Halifax, as well as one of the largest Canadian Coast Guard bases, CCG Base Dartmouth, were within 1 hour's sailing time. Calls immediately went out to crewmembers of the following ships which sailed as soon as possible for St. Margarets Bay:

CCGS Hudson, CCGS Mary Hichens, CCGS Simon Fraser, CCGS Earl Grey, CCGS Matthew, and CCGS Sambro (initial tasking - first government vessel on scene)
 * Canadian Coast Guard ships

There were also several CCG helicopters (model MBB Bo 105), RHIBs and auxiliary vessels which assisted.

HMCS Kingston (MM 700), HMCS Preserver (AOR 510), HMCS Ville de Québec (FFH 332), HMCS Halifax (FFH 330), HMCS Glace Bay (MM 701), HMCS Goose Bay (MM 707), HMCS Moncton (MM 708), HMCS Anticosti (MSA 110)
 * Canadian Forces warships

There were also several RCAF CH-124 Sea King anti-submarine warfare helicopters as well as RCN RHIBs which assisted.

HMCS Okanagan (S74)
 * Canadian Forces submarines

CFAV Sechelt (YDT 610), CFAV Granby (YDT 12), CFAV Glenevis (YTB 642)
 * Canadian Forces auxiliary vessels

HMCS Preserver was assigned on-scene commander of OPERATION PERSISTENCE and had authority over all aircraft and vessels within the area surrounding the crash site.

Search and recovery operation
By the afternoon of September 3 it was apparent that there were no survivors from the crash and JRCC Halifax de-tasked dedicated SAR assets (CCGS Sambro and the CH-113 Labrador helicopters). The Royal Canadian Mounted Police were given overall command of the recovery operation with HMCS Preserver remaining on-scene commander.

The aircraft broke up on impact with the water, and most of the debris sank to the ocean floor (a depth of 55 m or 180 ft). Some debris was found floating in the crash area, and over the following weeks debris washed up on the nearby shorelines.

The initial focus of the recovery was on finding and identifying human remains, and on recovering the flight recorders, but this proved difficult as the force of impact was "in the order of at least 350 g", and the environmental conditions only allowed recovery along with wreckage. Only one of the victims was visually identifiable. 147 were identified by fingerprint, dental records, and X-ray comparisons. The remaining 81 were identified through DNA tests.

A request was made by the Government of Canada to the Government of the United States for a dedicated salvage ship. USS Grapple (ARS-53) was tasked to the recovery effort, arriving on Wednesday, September 9, 1998 from Philadelphia. Among Grapple's crew were 32 salvage divers.

The cockpit voice recorder (CVR) and flight data recorder (FDR) were found by the submarine HMCS Okanagan (S74) using sonar to detect the underwater locator beacon signals, and quickly retrieved by Navy divers (the FDR on 6 September and the CVR on 11 September 1998). However, both had stopped recording when the aircraft lost electrical power at approximately 10,000 ft (3,000 m), 5 minutes and 37 seconds before impact.

The recovery operation was guided by the Transportation Safety Board of Canada (TSB) with resources from the Canadian Forces, Canadian Coast Guard, RCMP, and other agencies. The area was surveyed using route survey sonar, laser line scanners, and remotely operated vehicles to locate items, then recovered (initially by divers and ROV's, later by dredging and trawling).

On 2 October 1998 the TSB initiated a heavy lift operation to retrieve the major portion of the wreckage from the deep water before the expected winter storms began. By 21 October, an estimated 27% of the wreckage was recovered.

At that point in the investigation, the crash was generally believed to have been caused by faulty wiring in the cockpit, after the entertainment system in the plane started to overheat. Certain groups issued Aviation Safety Recommendations. The TSB released its preliminary report on 30 August 2000, but the final report was not completed until 2003.

The final phase of wreckage recovery employed the ship Queen of the Netherlands to dredge the remaining aircraft debris. It concluded in December 1999 with 98% of the aircraft retrieved: approximately 126,554 kg (279,000 lb) of aircraft debris and 18,144 kg (40,000 lb) of cargo.

Victims
Most of the passengers were American, French, and Swiss.

132 Americans (including one Delta Air Lines flight attendant), 41 Swiss (including 13 crew members), 30 French, 6 Britons, 3 Germans,3 Italians, 3 Canadians, 2 Greeks, 2 Lebanese, 1 each from Afghanistan, China, India, Iran, Russia, Saudi Arabia, Spain, St. Kitts and Nevis, Sweden, and Yugoslavia, and 4 others were on board.

A number of notable individuals died in this accident, including Jonathan Mann, former head of the WHO's AIDS program; Mann's wife, AIDS researcher Mary Lou Clements-Mann; Pierce J. Gerety Jr., UNHCR Director of  Operations for the Great Lakes Region of Africa, who was on a special mission for U.N. Secretary General Kofi Annan to the Democratic Republic of the Congo to attempt to negotiate a peace accord with Laurent Kabila in an erupting regional war; and Joseph LaMotta, son of former boxing world champion Jake LaMotta. Also among the passengers were Mahmood Diba, the cousin of former Iranian Queen Farah Diba, Saudi royalty Prince Bandar Bin Saud bin Saad Abdul Rahman al-Saud, former New York Times executive John Mortimer and his wife Hilda, and Dr. Roger Williams, a top cardiovascular genetics expert and professor of internal medicine at the University of Utah Tennis player Marc Rosset, originally scheduled to take the flight, had changed his plans to a different flight.

Identification
The Royal Canadian Mounted Police (RCMP) medical examiners identified most of the bodies within 10 weeks of the accident flight. One body was identifiable by sight. For around 100 bodies the examiners used DNA; the DNA analysis has been referred to as the largest DNA identification project in Canadian history. For around 90 bodies Canadian medical examiners used dental records. For around 30 bodies examiners used fingerprints and antemortem (before death) x-rays. The large number of antemortem dental x-rays meant that around 90 bodies had been identified by the end of October. The RCMP contacted relatives of victims to ask for medical histories and dental records. Blood samples from relatives were used in the DNA identification of victims.

Examination and investigation
An estimated 2 million pieces of debris were recovered and brought ashore for inspection at a secure handling facility in a marine industrial park at Sheet Harbour, where small material was hand inspected by teams of RCMP officers looking for human remains, personal effects and valuables from the aircraft's cargo hold. The material was then transported to CFB Shearwater where it was assembled and inspected by over 350 investigators from multiple organizations such as TSB, NTSB, FAA, AAIB, Boeing, and Pratt & Whitney.

As each piece of wreckage was brought in, it was carefully cleaned with fresh water, sorted, and weighed. The item was then placed in a specific area of a Hangar at CFB Shearwater, based on a grid system representing the various sections of the plane. All items not considered significant to the crash were stored with similar items in large boxes. When a box was full, it was then weighed and moved to a custom-built temporary structure (J-Hangar) on a discontinued runway for long-term storage. If deemed significant to the investigation, the item was documented, photographed, and kept in the active examination hangar. Particular attention was paid to any item showing heat damage, burns, or other unusual marks.

Cockpit and recordings
The front 10 m (33 ft) of the aircraft, from the front of the cockpit to near the front of the first-class passenger cabin, was reconstructed. Information gained by this allowed investigators to determine the severity and limits of the fire damage, its possible origins and progression. The cockpit voice recorder used a 1/4 inch recording tape, operating on a 30 minute loop. It therefore only retained the last half hour of the flight. The CVR recording and transcript are protected by a strict privilege under section 28 of the Canadian Transportation Accident Investigation and Safety Board Act, and thus have not been publicly disclosed. The air traffic control recordings are less strictly privileged: section 29 of the same act provides only that they may not be used in certain legal proceedings. The air traffic control transcripts were released within days of the crash in 1998. The air traffic control audio was released in May 2007.

TSB findings
The investigation identified eleven causes and contributing factors of the crash in its final report. The first and most important was:

Aircraft certification standards for material flammability were inadequate in that they allowed the use of materials that could be ignited and sustain or propagate fire. Consequently, flammable material propagated a fire that started above the ceiling on the right side of the cockpit near the cockpit rear wall. The fire spread and intensified rapidly to the extent that it degraded aircraft systems and the cockpit environment, and ultimately led to the loss of control of the aircraft.

Arcing from wiring of the in-flight entertainment system network did not trip the circuit breakers. While suggestive, the investigation was unable to confirm if this arc was the "lead event" that ignited the flammable covering on MPET insulation blankets that quickly spread across other flammable materials. The crew did not recognize that a fire had started and were not warned by instruments. Once they became aware of the fire, the uncertainty of the problem made it difficult to address. The rapid spread of the fire led to the failure of key display systems, and the crew were soon rendered unable to control the aircraft. Because he had no light by which to see his controls after the displays failed, the pilot was forced to steer the plane blindly; intentionally or not, the plane swerved off course and headed back out into the Atlantic. Recovered fragments of the plane show that the heat inside the cockpit became so great that the ceiling started to melt.

The recovered standby attitude indicator and airspeed indicator showed that the aircraft struck the water at 300 knots (560 km/h, 348 mph) in a 20 degrees nose down and 110 degree bank turn, or almost upside down. Less than a second after impact the plane would have been totally crushed, killing all aboard almost instantly. The TSB concluded that even if the crew had been aware of the nature of the problem, the rate at which the fire spread would have precluded a safe landing at Halifax even if an approach had begun as soon as the "pan-pan-pan" was declared.

TSB recommendations
The TSB made nine recommendations relating to changes in aircraft materials (testing, certification, inspection and maintenance), electrical systems, and flight data capture. (Both flight recorders stopped when they lost power six minutes before impact.) General recommendations were also made regarding improvements in checklists and in fire-detection and fire-fighting equipment and training. These recommendations have led to widespread changes in FAA standards, principally impacting wiring and fire hardening.

The lack of flight recorder data for the last six minutes of the flight added significant complexity to the investigation and was a major factor in its duration. The Transportation Safety Board team had to reconstruct the last six minutes of flight entirely from the physical evidence. The plane was broken into millions of small pieces by the impact, making this process time-consuming and tedious. The investigation became the longest and most expensive transport accident investigation in Canadian history, costing C$57 million (US$48.5 million) over five years.

2011 speculation
In September 2011, the CBC program The Fifth Estate reported allegations suggesting that an incendiary device might have been the cause of the crash. These claims came from a former RCMP officer who claims that suspicious levels of magnesium and other elements associated with arson were discovered in the wiring, and that he was ordered to remove references to magnesium or a suspected bomb from his investigative notes. The CBC later reported that the magnesium was explained by the long exposure of the wires to seawater.

Legacy
A memorial service was held in Zürich. The following year a memorial service was held in Nova Scotia.

Two memorials to those who died in the crash have been established by the Government of Nova Scotia. One is to the east of the crash site at The Whalesback, a promontory one kilometre (0.6 mile) north of Peggys Cove. The second memorial is a more private but much larger commemoration located west of the crash site near Bayswater Beach Provincial Park on the Aspotogan Peninsula in Bayswater. Here, the unidentified remains of the victims are interred. A fund was established to fund maintenance of the memorials and the government passed an act to recognize them. Various other charitable funds were also created, including one in the name of a young victim from Louisiana, Robert Martin Maillet, which provides money for children in need.

In September 1999 Swissair, Delta and Boeing (who had acquired McDonnell Douglas through a merger in 1997) agreed to share liability for the accident and offered the families of the passengers financial compensation. The offer was rejected in favour of a $19.8 billion suit against Swissair and DuPont, the supplier of Mylar insulation sheathing. A US federal court dismissed the claim in February 2002.

Two paintings, including the "Le Peintre" (the Painter) by Pablo Picasso, were on board the aircraft and were destroyed in the accident.

After the crash, the flight route designator for Swissair's New York-Geneva route was changed to Flight 139. After Swissair's bankruptcy in 2002, the flight designator was changed again to Flight LX 23, currently using an Airbus A330-300.

Since the crash, there have been many television documentaries on Flight 111, including the CBC's The Fifth Estate, "The Investigation of Swissair 111", PBS's NOVA "Aircrash", and episodes of disaster shows like History Channel's Disasters of the Century and Discovery Channel's Mayday. NOVA created a classroom activity kit for school teachers using the crash as an example of an aircraft crash investigation.

In May 2007 the TSB released copies of the audio recordings of the air traffic control transmissions associated with the flight. The transcripts of these recordings had been released in 1998 (within days of the crash), but the TSB had refused to release the audio on privacy grounds. The TSB argued that under Canada's Access to Information Act and Privacy Act, the audio recordings constituted personal information and were thus not disclosable. Canada's Federal Court of Appeal rejected this argument in 2006, in a legal proceeding concerned with air traffic control recordings in four other air accidents. The Supreme Court of Canada did not grant leave to appeal that decision, and consequently the TSB released a copy of the Swissair 111 air traffic control audio recordings to Canadian Press, which had requested them under the Access to Information Act. Several key minutes of the air traffic control audio can be found on the Toronto Star web site.