"action still needed" in 18 of 23 says TSB

[Mitch Cronin]

http://www.canada.com/ottawacitizen/news/s...ab-123048514196

Skies still unsafe 10 years after Swissair crash: Experts

Charles Mandel, Canwest News Service

Published: Friday, August 29, 2008

HALIFAX - A decade after Swissair Flight 111 crashed off the coast of Nova Scotia, the Transportation Safety Board of Canada said more work needs to be done to satisfy the safety deficiencies identified in the 4 1/2 year investigation into the accident.

The McDonnell Douglas MD-11, en route to Geneva from New York City, plummeted into the ocean off Peggy's Cove on Sept. 2, 1998. All 215 passengers and 14 crew members died in the crash.

Since the TSB released its report into the investigation, action is still needed in 18 of the 23 recommendations, said Jonathan Seymour, a TSB board member. Seymour made his remarks at an industry safety seminar last April, but the TSB only recently made those comments available on its website.

"It's sad that Canada spent so much on this investigation and did such a tremendous job and then to have what it recommended only be implemented at glacial speed," Miles Gerety said Friday. Gerety, a public defender in Connecticut, lost his brother in the crash.

Gerety praised the TSB for its work investigating the accident, but added airline manufacturers needed to embrace all the recommendations. "I'm not at all surprised that everything they recommended hasn't been put in place."

The TSB said since the accident, substantive action has not been taken to comprehensively review the remaining types of insulation currently in use on aircraft. "Instead, regulators are relying on in-service performance to (be) the catalyst for further action," Seymour said.

"In other words, a material has to fail before action is taken."

Worn or faulty entertainment-system wiring surrounding highly flammable material led to a fire which is believed to have downed the doomed jetliner. The TSB spent $57 million on the agency's largest ever investigation and its 338-page final report came out in the spring of 2003.

Seymour criticized the failure of regulators to develop a "test regime that evaluates aircraft electrical wire failure characteristics under realistic operating conditions."

Seymour also called for a systematic approach to preventing fires during flights; one that would comprehensively identify fire zones, implement fire detection systems, provide fire-suppression equipment and systems, and require appropriate training.

Wendy Tadros, chair of the TSB, said actions have been taken in a number of areas, including raising awareness among flight crew to land immediately when there's smoke of an unknown origin. As well, all new aircraft now come with two-hour cockpit voice recorders, Tadros said Friday.

"There are still some areas where we'd like to see further improvements," she said.

Tadros acknowledged that as the 10th anniversary of the crash approached, distraught families who had lost members would once again be questioning what actions had been taken since the tragedy. "I think as a result of this thorough investigation, aviation safety has certainly been advanced," she said. "There's still more work to be done, but it's certainly been advanced."

Greg Phillips, an aviation safety consultant with insurance firm Willis Global Aviation in Washington, D.C., said anytime a large-scale investigation such as the Swissair review is carried out, regulatory authorities should carefully consider its conclusions and proposals.

"The recommendations from accident investigations are well thought-out and should be looked at with seriousness," he said.

© Canwest News Service 2008

[Mitch Cronin]

Not sure which one of those folks interviewed said the skies were "unsafe"...

...

But I wanted to point to this part:

"Instead, regulators are relying on in-service performance to (be) the catalyst for further action," Seymour said.

"In other words, a material has to fail before action is taken."

That's what I meant by saying the 380 reminds me of American cars built in the late 70's and early 80's. We'll just build it and let the consumers tell us what's wrong with it.

[J.O.]

We'll just build it and let the consumers tell us what's wrong with it.

Hey Mitch,

I know you're not a big fan of the European behemoth, but do you not think that all those production delays were largely because they were trying to ensure they were releasing a safe and reliable product? It may not be pretty, but it's a little unfair to equate a lack of good looks with a lack of quality or reliability. After all, you're the guy who's still in love with an airplane that had an extra engine pasted into the centre of the tail!

Just my two cents.

Jeff

[Mitch Cronin]

Hiya Jeff... I'm not so sure it's the airplane I don't like so much as the process that got it to the passenger. Which results in my not trusting the airplane.

I don't trust that all the right decisions would have been made in the event of those right decisions being the cause of even further delays. At some point, I have the impression, they considered it to have swallowed enough money, and come hell or high water, it was going to production. ...something like the push to fly the shuttle even if those o-rings might not like icy weather.

It bacame a sink or swim issue for Airbus, and that's not the right environment to produce a decent flying machine. IMO.

Now, that dear old devil the diesel dixie.... I appreciate her for her stout, reliable machinery. ...and I think she's a beautiful bird!

[deicer]

Now, that dear old devil the diesel dixie.... I appreciate her for her stout, reliable machinery. ...and I think she's a beautiful bird!

Now Mitch....

Wasn't your beloved Diesel 10 a rushed answer to the long thought out Tritanic that also had a few 'fatal' flaws before they got it right?

Iceman

[Don Hudson]

Mitch;

We'll just build it and let the consumers tell us what's wrong with it.

Like the Pinto...like the side fuel-tanks on Ford trucks...

Re the quote you posted from the story,

The TSB said since the accident, substantive action has not been taken to comprehensively review the remaining types of insulation currently in use on aircraft. "Instead, regulators are relying on in-service performance to (be) the catalyst for further action," Seymour said.

Now, we all know that such issues are both complicated and complex. But with this quality of "leadership" from Transport Canada, who is, after all the regulator here, and from who airlines take their "cue" on "what's important" from a regulatory standpoint, why would airlines adopt a different, perhaps slightly more "aggressive" view on recommendations which came at an extremely high price? What justification is there for airlines to change their safety thinking when the regulator itself says that "in-service performance" will be "the catalyst for further action"?

Doesn't that mean that another accident (catalyst) has to happen before change, (further action) will occur? Doesn't this play right into the de-regulation of safety in terms of SMS and the "self-regulation" of safety which airlines are now supposed to be doing?

While such events may no longer be in the public's, the airlines' or the regulators' mind, US carriers were severely taken to task a few months ago for "lax" procedures...issues which which themselves obviously had to have long germination periods, (like Alaska 261...). "Failure" is a complexity all it's own, but the signal being broadcast by this article is certainly salient against the background of regulatory white noise.

[J.O.]

You beat me to it deicer. Mitch, it's not all that long ago that people were afraid of the DC-10 for some pretty good reasons. But as I am sure you would attest, it was "fixed" for the most part and became a pretty reliable performer in its later years. But out of the problems of the early DC-10 and others came far more stringent build and certification requirements that have led to the prevention of similar problems on newer types like the A380. I am not here saying that the A380 won't have issues, but the folks in Toulouse put out some pretty reliable stuff these days.

[CD]

Hi Don...

I know you realize that Transport Canada is only one regulator in an industry where the certification standards are harmonized internationally. It is highly unlikely that anything done by Canada alone would effect any manufacturers except Bombardier (and Diamond, of course). Even then, exemptions to conform with "international" standards have been granted in the past in order to remain competitive (mid-cabin doors and side-facing seats are a few that come to mind).

Work is being done internationally to develop new test methods and to identify new materials -- but that all takes time and money as well. Some of the work underway is documented on the FAA Fire Safety Branch website. As you likely know, the Cabin Safety Research Technical Group currently consists of the FAA, JAA (EASA), TCCA, DGAC, UK CAA, ENAC, JCAB, ANAC, MAK and CASA. So it truly is an international effort...

Then again, there is the length of time that it takes to get a regulatory change through the system in Canada. On the issue of flammability requirements for in-service aircraft, here is one that started life in 1989 and still has not been published in Gazette I: NPA 2001-070 - Flammability Standards for Aircraft Cabin Interiors (RU 10000-614)

[Mitch Cronin]

Yes, Iceman and Jeff... The DC10 was rushed into production, and it had flaws... flaws that weren't even fixed after they first surfaced! They had to cause at least two disasters before they were fixed... (and still there remained flaws for a future disaster to illuminate)

All of which underlines my point!

Those mistakes shouldn't be repeated.

[Mitch Cronin]

Like the Pinto...like the side fuel-tanks on Ford trucks...

...and like the DC10.

I'm not as cynical as I sound, I think ( ) , but I do have a hard time accepting the sort of risk management that's rooted in an accountant's look at past events, and costs, and non-events, and statistics of same.

[Don Hudson]

CD;

A thoughtful response, thank you. Yes, I am aware of the nuances as you suggest and know the "pace" at which change occurs. Pointing out inconsistencies and hypocrisies in human enterprises is among the easiest work in the world. I appreciate you raising the point regarding international work on certification (upon which there is another post here re TC certification and FAA certification processes - can't recall where at the moment). Replacing both insulation and kapton-covered wiring is one of the recommendations and such standards must be the result of new solutions which in turn require research, testing, validation over time and appropriate regulatory support.

As you likely perceive, the post may be more of a "poke" than a lament on the state of affairs which is as heavily politicized as any we might encounter in non-safety areas.

Again, thank you for a thoughtful response. Continued observing and comment is the order of the day I think.

Mitch,

but I do have a hard time accepting the sort of risk management that's rooted in an accountant's look at past events, and costs, and non-events, and statistics of same.

I do too as you know. But as the above may indicate, such may not be the "linked" relationship that I and many safety people may assume to be the case. Beyond very good works on safety processes which involved balancing economic, political and "safety" goals/processes there are indications that profitable co-existence is possible and so one must find a new set of glasses I think. We know very well the phrases which traditionally describe the costs of focussing solely on costs. I sense that it must go beyond that now that de-regulation, "lo-cost", SMS models are establishing the new "normal". I have some words to look up!...

D.