A Decade of Minimal Action

Wed, Aug 27, 2008 — David Evans


The Faces May Change – But The Maladies Linger On

Canadian safety officials say some limited progress has been made on recommendations coming out of the Swissair flight 111 disaster. Cut through the positive-sounding rhetoric, though, and it is apparent that only 21% of the recommendations have been fully implemented.


Moreover, the characterization that other recommendations have a “Satisfactory Intent” or a “Satisfactory in Part” implementation is belied by a close reading of the documentation, which reveals a pattern of bureaucratic “business as usual,” tokenism, obfuscation and half-measures.

While the Transportation Safety Board (TSB) of Canada categorizes only two responses to its recommendations as “Unsatisfactory,” it could be argued at this juncture, the 10th anniversary of the Swissair crash in Halifax, that up to 14 of the responses to the 23 recommendations could be classified as “Unsatisfactory.”

The record of accomplishment on the deficiencies identified in the Swissair investigation is worse than for the U.S. National Transportation Safety Board’s (NTSB) recommendations issued in the wake of the TWA flight 800 disaster. The NTSB issued 15 recommendations, of which some 40% have been fully implemented (see Aviation Safety & Security Digest, ‘’Twelve Years of Half Measures,’ homepage). In other words, taking the TSB’s most generous characterization, a greater percentage of the TWA 800 recommendations have been adopted. To be sure, a 40% acceptance rate is less than half, and it is far less than the overall 90% rate NTSB officials say prevails for all safety recommendations.

Superb, detailed detective work on the part of the TSB found the source of electrical arcing that started the conflagration. Would that the responses to the TSB’s work were equal in their attention to detail and their aggressive fixes to the problems uncovered. Source: TSB, Swissair 111 accident report

TSB Member Jonathan Seymour explained the difference as being his agency’s characterization of responses to recommendations and that of the NTSB:

“Our approach is similar in some respects to that of the NTSB. But what you will not see is an equivalent to the NTSB’s closed – unacceptable action.

“Our view is that the only justification for placing a recommendation in the inactive file is that the safety deficiency has been dealt with, and the residual risk either eliminated or significantly reduced.”


The arcing occurred in the small oval area marked directly above the cockpit door. Note the presence of wiring in very close proximity to thermal/acoustic insulation blankets. These spaces, concealed from direct access by the flight crew, are still not required to have built-in smoke detection or fire suppression. Source: TSB, Swissair 111 accident report

The TSB uses four categories to assess responses:

(1) Fully Satisfactory: This rating is assigned if the action taken will substantially reduce or eliminate the safety deficiency.

(2) Satisfactory Intent: If action has not yet been taken to substantially reduce the risk, but the planned action when fully implemented will accomplish this goal, this rating is assigned.

(3) Satisfactory in Part: This rating is assigned if the action planned or taken will reduce but not eliminate or largely mitigate the identified safety deficiency.

(4) Unsatisfactory: This rating is given if no action is taken or proposed that will reduce or eliminate the safety deficiency.

To be sure, the ratings are based on qualitative (as opposed to quantitative) judgments, and they appear to put the best face on inevitable delays in implementation. On the other hand, a close reading of the documentation reveals that the TSB is generous with its characterizations. The really important work of reducing the vulnerability to in-flight fire is yet to be done.

The recommendations stop short of calling for three initiatives that would really make a difference:

  • Elimination of all materials in transport category aircraft that are not fireproof. As TSB officials have rightly said, if there is nothing in the airplane’s construction that can burn, the danger of in-flight fire is nil.

  • No area of the airplane can be left unprotected by fire detection and suppression. The cabin, the attic space, the dry bays below the cabin are presently naked, with neither smoke detectors nor fire extinguishers. Certain discrete areas of the airplane are covered, such as engines, cargo holds and lavatories, but inaccessible areas are unprotected.

  • Crew training for combating in-flight fires remains inadequate. Flight simulators could present the pilots with continuous smoke, and training to integrate the efforts of flight attendants and pilots should be adopted.

Having said this, the TSB recommendations make a significant dent in the hazard posed by in-flight fire. That so few recommendations have been implemented shows that the vulnerability still exists.

Recommendations issued in 1999

– Recommendation: A-99-01

That, as of 1 January 2003 any CVR installed on an aircraft as a condition of original certification be required to have a 2-hour recording capability.

Rating: Fully Satisfactory

(Comment: Transport Canada amended its regulations to incorporate this recommendation.)

– Recommendation: A-99-02

That, as of 1 January 2005, all aircraft requiring both an FDR [flight data recorder] and a CVR [cockpit voice recorder] be required to be fitted with a CVR having a recording capacity of at least two hours.

Rating: Satisfactory Intent

(Comment: The FAA issued its final recorder rule on 7 March 2008, more than three years after the deadline contained in the TSB recommendation; additional years will pass before a significant number of airplanes have the expanded capability, as the rule indicates the upgrade work can extend to 2017, some 12 years beyond the 2005 deadline recommended by the TSB. However, we feel compelled to point out the quintessential difference between prioritizing hazard resolution and investigability. Logically, any priority for the latter undershoots the former by many degrees of vitality. Nevertheless, it’s still important to understand the genesis of an accident as a basis for instituting fixes.)

– Recommendation: A-99-03

That, as of 1 January 2005, for all aircraft equipped with CVRs having a recording capacity of at least two hours, a dedicated independent power supply be required to be installed adjacent or integral to the CVR, to power the CVR and the cockpit area microphone for a period of 10 minutes whenever normal aircraft power sources to the CVR are interrupted.

Rating: Satisfactory Intent

(Comment: Same comment as above.)

– Recommendation: A-99-04

That aircraft required to have two flight recorders [FDR/CVR] be required to have those recorders powered from separate generator busses.

Rating: Satisfactory Intent

(Comment: The FAA issued its final rule 7 March 2008 on flight recorders requiring a Recorder Independent Power Supply [RIPS], but only for newly manufactured aircraft. In-service aircraft will not be retrofitted.)

– Recommendation: A-99-07

That regulatory authorities confirm that sufficient action is being taken, on an urgent basis, to reduce or eliminate the risk associated with the use of metallized PET-covered [poly ethylene terephthalate] insulation blankets in aircraft.

Rating: Satisfactory in Part

(Comment: The rules to address newly manufactured aircraft and for the routine replacement of existing insulation blanket cover materials are still in progress. The TSB is concerned that the risks associated with the use of MPET will not be substantially reduced because the FAA-approved alternate means of compliance allows substantial quantities of MPET-type cover material to remain in affected aircraft. On the other hand, the FAA released its notice of proposed rulemaking [NPRM] calling for the wholesale removal on Douglas-built jets 11 August 1999, the same day as A-99-07 was issued. The final rule was issued in the first half of 2000. However, flammable insulation material remains on other jets. For these other aircraft, the word “urgent” remains inoperative.)

– Recommendation: A-99-08

That, on an urgent basis, regulatory authorities validate all thermal acoustic insulation materials in use, or intended for use, in applicable aircraft, against test criteria that are more rigorous than those in Appendix F of FAR [Federal Aviation Regulations] 25.853, and similar regulations, and that are representative of actual in-service system performance.

Rating: Satisfactory in Part

(Comment: A-99-08 sought to have all thermal acoustic insulation materials held to a higher certification standard, and the Radiant Panel Test (RPT) is that higher standard, and MPET and AN-26 insulation have been measured against it and found to be deficient. What has not happened is the validation of all thermal acoustic insulation material against the RPT. It is for this reason that the TSB said the response is “Satisfactory in Part.” However, a rating of “Unsatisfactory” seems more appropriate, in light of the TSB’s call for “urgent” action, which has been anything but in this case.)

Recommendations issued in 2000

– Recommendation A-00-16

That regulatory authorities review the adequacy of in-flight firefighting to ensure that aircrews are provided with a system optimized to provide the maximum probability of detecting and suppressing any in-flight fire.

Rating: Satisfactory in Part

(Comment: Transport Canada’s response is that it is participating with other regulatory authorities within the International Aircraft Systems Fire Protection Working Group. The uses of hand-held firefighting equipment in hidden areas as well as infrared detection devices are being evaluated. The working group is also producing a video to “educate” flight/cabin crew about dealing with in-flight fires. A couple items bear comment. First, to apply a hand-held extinguisher to a fire in a hidden space, say behind a cabin sidewall, the sidewall must either feature a port for the fire extinguisher or the crew must have a knife or similar tool to cut open the sidewall. Neither access ports nor cutting tools have been provided. Second, Swissair demonstrated that infrared cameras in hidden spaces work and can be installed in new and existing airliners, yet regulatory authorities have not mandated such equipment to provide the flight crew with unambiguous evidence of a fire.  It shouldn’t take ten years for this kind of tepid response; a rating of “Unsatisfactory” seems highly applicable.)

– Recommendation: A-00-17

That appropriate regulatory authorities, together with the aviation community, review the methodology for establishing designated fire zones within the pressurized portion of the aircraft, with a view to providing improved detection and suppression capability.

Rating: Satisfactory Intent

(Comment: The TSB is concerned that no action has been taken or proposed that will eliminate or reduce the deficiency. The Board believe that Transport Canada remains committed to its original action plan which will, if fully implemented, reduce he safety deficiency described in the recommendation. The original action plan does not appear to be responsive to the recommendation. An “Unsatisfactory” rating would seem more appropriate.)

– Recommendation A-00-18

That regulatory authorities ensure industry standards reflect a philosophy that when odor/smoke from an unknown source appears, the most appropriate course of action is to land expeditiously.

Rating: Fully Satisfactory

(Comment: In December 2004 Transport Canada issued Advisory Circular 500-014 which indicates that an aircraft’s flight manual must contain a statement to the effect that: “In the event of smoke or fire, prepare to land the aircraft without delay while completing the suppression and/or smoke evacuation procedures.” The problem with this response is fourfold: (1) an advisory circular does not have the force of a regulation, so if the airline and/or crew does not follow this guidance, they have not busted a regulation, (2) many areas of the airplane utterly lack any means of fire suppression, and (3) smoke evacuation procedures may not work, and in truth probably won’t, and (4) long-haul ETOPS [extended range operations] aircraft may not have the ability to land immediately. It can b e hours from any expedited landing. Experience has shown that escalation of a hidden fire to a “burn-through” and/or crew incapacitation may take as little as 15-20 minutes. The response characterization of “Fully Satisfactory” seems an elasticized stretch toward fantasy, if not toward prevarication and mendacity.)

– Recommendation: A-00-19

That appropriate regulatory authorities ensure that emergency checklist procedures for the condition of odor/smoke of unknown origin be designed so as to be completed in a time frame that will minimize the possibility of an in-flight fire being ignited or sustained.

Rating: Satisfactory in Part

(Comment: Internationally, there is no indication as to whether manufacturers have adopted the use of the Flight Safety Foundation emergency checklist template or that regulatory authorities have mandated its use. Therefore, as the use of the template is voluntary, emergency checklists can continue to be designed without regard for the timeliness of their completion [or, for that matter, their effectiveness]. Characterizing the response as “Satisfactory in Part” seems to come under the heading of a duplicitous gilding the lily.)

– Recommendation: A-00-20

That appropriate regulatory authorities review current in-flight firefighting standards – including procedures, training, equipment, and accessibility to spaces such as attic areas – to ensure that aircraft  crews are prepared to respond immediately, effectively and in a coordinated manner to any in-flight fire.

Rating: Satisfactory Intent

(Comment: Transport Canada indicates that the Flight Attendant Training Standard addresses the issues raised by this recommendation. However, the TSB says this response is selective. It does not address any categorization or training standard for the flight crew, nor does it address the adequacy of existing firefighting equipment or the accessibility to spaces such as the attic areas. As the TSB says, “The actions taken have not substantially reduced or eliminated the safety deficiency.” This trenchant statement does not square with the characterization of “Satisfactory Intent.” The response has really been “Unsatisfactory.”)

Recommendations issued in 2001

– Recommendation A-01-02

That, for the pressurized portion of the aircraft, material flammability standards be revised to prevent the use of any material that propagates or sustains a fire, based on realistic ignition scenarios.

Rating: Fully Satisfactory

(Comment: Transport Canada indicates it has worked with other regulatory authorities to improve material flammability standards, to include certification test criteria that are based on realistic ignition scenarios and is monitoring the FAA’s work in developing “advanced fire-resistant materials” for use in aircraft. The question here is how this recommendation yielded a “Fully Satisfactory” rating while the response to Recommendation A-03-02 is so clearly shot full of loop-holes.)

– Recommendation A-01-03

That a certification test regime be mandated that evaluates electrical wire failure characteristics under realistic operating conditions and against specified performance criteria, with the goal of mitigating the risk of ignition.

Rating: Satisfactory in Part

(Comment: Transport Canada indicates that its requirements for type certification will reference technical standards to ensure that an acceptable level of safety is maintained. However, Transport Canada’s response does not reference any initiative that would mandate a certification test regime for electrical wire generically – or by types.)

– Recommendation A-01-04

That, as a prerequisite to certification, all aircraft systems in the pressurized portion of an aircraft, including their sub-systems, components, and connections, be evaluated to ensure that those systems whose failure could exacerbate a fire in progress are designed to mitigate the risk of fire-induced failures.

Rating: Satisfactory in Part

(Comment: Transport Canada has provided little in the way of clarity as to whether international standards are being amended to mitigate the risks identified in the recommendation. How this response could be assessed “Satisfactory in Part” is a mystery.)

Recommendations issued in 2003

– Recommendation A-03-01

That regulatory authorities quantify and mitigate the risks associated with in-service thermal acoustic insulation materials that have failed the Radiant Panel Test.

Rating: Unsatisfactory

(Comment: Transport Canada’s response does not provide any new information that would suggest the development of strategies to address the safety deficiency identified in the recommendation. As TSB Member Jonathan Seymour has said, “Regulators are relying on in-service performance to be the catalyst for further safety action. In other words, the material has to fail before action is taken.” Not for nothing is the FAA occasionally referred to as the “tombstone agency,” for its reactive approach to safety, as opposed to the proactive approach suggested in the recommendation.)

– Recommendation A-03-02

That regulatory authorities 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.

Rating: Satisfactory in Part

(Comment: Transport Canada has yet to state its position on FAA Advisory Circular 25.856-1, “Thermal/Acoustic Insulation Flame Propagation Test Method Details,” which was published 24 June 2005 to address some, if not all, the risks highlighted by the recommendation. For example, this AC spells out how attachment tape should be tested:


As shown, the tape should be arranged so that the centerline of the pilot burner flame contacts the seam of the first overlap. However, even the FAA concedes that this AC, which is guidance material and not regulatory in nature, may not represent the reality of an aircraft fire, saying, “If we become aware of circumstances that convince us that following this AC would not result in compliance with the applicable regulations, we will not be bound by terms of this AC, and we may require additional substantiation or design changes as a basis for finding compliance.” As the saying goes, “Over to you, Transport Canada.” How is this AC “Satisfactory in Part” when the FAA says it may be thrown out entirely?)

– Recommendation A-03-03

That regulatory authorities take action to ensure consistent interpretation of the regulations governing material flammability requirements so as to prevent the use in aircraft of any material with inappropriate flammability characteristics.

Rating: Fully Satisfactory

(Comment: The publication in July 2003 of Policy Letter 525-002, “Use of the FAA Materials Fire Test Handbook,” should provide more accurate and consistent interpretation of the applicable flammability regulations.)

– Recommendation A-03-04

That regulatory authorities require that every system installed through an STC [Supplemental Type Certification] process undergo a level of quantitative analysis to ensure that it is properly integrated with aircraft type-certification procedures, such as emergency load-shedding.

Rating: Satisfactory in Part

(Comment: Transport Canada’s position is that the risk articulated in the recommendation can be dealt with through a proactive approach to managing the STC process, and though a change in the regulations [CAR 525.1309, which mirrors FAR 25.1309 but differentiates between the level of scrutiny required for avionics equipment in the cockpit and cabin equipment installed for the convenience of the passengers].  TSB maintains that while these initiatives may reduce the deficiency, a qualitative analysis is still permitted in some cases, implying that a level of undefended risk will remain.)

– Recommendation A-03-05

That regulatory authorities establish the requirements and the industry standard for circuit breaker resetting.

Rating: Fully Satisfactory

(Comment: Transport Canada issued Policy Letter 161, titled Resetting Tripped Circuit Breakers, in March 2004, adopting FAA guidance material that provides policy and procedures to reduce or eliminate the threat of resetting a tripped circuit breaker)

– Recommendation A-03-06

That regulatory authorities, in concert with the aviation industry, take measures to enhance the quality and intelligibility of CVR recordings.

Rating: Satisfactory in Part

(Comment: Transport Canada to assess the need for advisory material and standardization with other civil air agencies.)

– Recommendation A-03-07

That regulatory authorities require, for all aircraft manufactured after 1 January 2007 which require an FDR, that in addition to the existing minimum mandatory parameter lists for FDRs, all optional flight data collected for non-mandatory programs such as FOQA/FDM [Flight Operations Quality Assurance/Flight Data Management] be recorded on the FDR.

Rating: Unsatisfactory upgraded in 2005 to Satisfactory Intent

(Comment: Transport Canada indicates now that future rulemaking will be contingent on internationally harmonized requirements, but such requirements for FOQA/FDM are understood not to be developed.)

– Recommendation A-03-08

That regulatory authorities develop harmonized requirements to fit aircraft with image recording systems that would include imaging within the cockpit.

Rating: Satisfactory Intent

(Comment: Transport Canada indicates its intent to carry out a harmonized program with other regulatory bodies, and to initiate rulemaking once harmonization is achieved. However, the FAA’s final rule on recorders, issued 7 March 2008, indicates that the issue of image recorders is “unsettled” and is therefore dead in the water. The “unsettled” situation averred to by the FAA results in large measure because of its failure to press the issue with industry. The technology to provide image recorders now exists, and in fact the cameras have been successfully tested in both day and night conditions in the cockpit. Characterizing the response to this recommendation as “Unsatisfactory” seems a more accurate description than “Satisfactory Intent.” Harmonization appears to be alternately a horse with two heads [artifice] and a horse with two hindquarters [guile]. It can assist policy-making in generalized industry acceptance of in situ practices, but it can also become a pretext for shelving unpopular change – due to alleged dissonance within the domestic industry, or beyond U.S. borders and outside the FAA’s regulatory control,)

– Recommendation A-03-09

That regulatory authorities harmonize international rules and processes for the protection of cockpit voice and image recordings used for safety investigations.

Rating: Satisfactory Intent

(Comment: Transport Canada has never provided confirmation that it has raised the deficiency identified in the recommendation with Canada’s representative at the International Civil Aviation Organization [ICAO]. With no apparent action five years after the recommendation was issued, the response could easily be classified “Unsatisfactory.”)

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