TWICE AS FAR

 

SWISSAIR 111

CRASH INVESTIGATION

 

 

 

- EXTRACT FROM FILE NOTES -

 

 

FOR

- 2000 SEP 17 -

 

From Wikipedia, the free encyclopedia

00-09-17          0700    Routine weekend.  Worked on notes, then turned exhibits.

            John GARSTANG advised that he has received results from Skip PALENIK about the cockpit carpets.  Wendy NORMAN from Ottawa CDL Chemistry had cut samples of suspected burn areas when she was down here working, early in the investigation.  John finally heard back on them, and they definitely are burn areas in the carpet.  It would appear that the cockpit liner had melted and dropped to the floor, burning the carpet surface.  These sample locations can be seen in my overhead photos as a cut out triangle & rectangle.  It seems that the areas of short carpet are actual burn areas where the object that was on it burning has suddenly been shifted or torn away, as if on impact.

            Lee and John GARSTANG also confirmed that the reason for TSB wanting to shut down the file so soon is because Ken JOHNSON wants to retire but wants to present the report to the board before his retirement.  Lee apparently had a conversation with Vic GERDEN a week ago Friday (00-09-08), on returning from their financial meeting over at RCMP HQ.  Vic confirmed then the rumour for Lee.  At the same time, he complained that they were working their people too hard with too many long hours.  Johnís comment was to the effect that how else does he expect the work to be completed by their deadline.

Ö..

            John GARSTANG came in to the studio to see me this afternoon to ask about further filming of more end cap burn tests.  He plans to do further samples this week.  I then asked him about the oxygen line tests.  He said that they had conducted several tests last week with significant results.  They had received only one O2 line from Boeing, so they worked with what they had.  Paul FIOCCA and Larry FOGG were present for Boeing, and they audio taped the test (did not videotape it as it was in an enclosed furnace).  The first test involved dialling in a temperature of 800 deg F with the O2 line in the furnace.  It took nearly half an hour to come to temperature.  The line had 70 lbs of pressure on it, and it did slow a leak around the threads of about 10 lbs pressure in ten minutes.  This test was completed, and John then went on to the next test, this one having the furnace at 800 deg F and inserting the line with it under 70 lbs pressure.  The unit was in the furnace for about 3.5 minutes when they heard a definite pop sound.  The line was connected to a regulator that could only maintain 64 lbs pressure, a reduction of 6 lbs of pressure.  So, the leak did not result in a complete loss of pressure. The pilotís system allows for a loss of up to 8 lbs, or down to 62 lbs pressure.  Therefore, they would still maintain an oxygen feed, and the tank should have been sufficient to last through the suspected fire duration.  John indicated that he could feel the air blowing from the popped cap, but they could not visually see the difference in the cap.  They had placed witness marks on the cap and line, and the cap had not turned.  However, it could now be hand twisted off, even though it had been torqued into position with 120 inch/pounds of torque.  It is also interesting to note that the Boeing reps did not want this test performed as they advised that because the lines had been previously baked, they were no longer pristine lines, and the anodising had been removed.  This was ignored, because the line was shown to hold pressure before being placed in the furnace.  On losing pressure, it was argued that the loss could be due to a break in the line rather than the aluminium cap separating from the stainless-steel line.  So, a stainless-steel cap was used to replace the aluminium cap, and there no longer was a loss of pressure. 

            The test was then repeated with the temperature at 1200 deg F., and the cap popped again at about 3.5 minutes.  It may be noted that Metallized Mylar burns with a flame of about 1200 deg F. 

            Because only one length of tubing was supplied, further tests could not be run.  However, it was determined that the tubing is a standard stainless-steel tube, with a standard stainless steel cap applied to it by a standard method for this type of air line tubing.  So CANMET is to create further lines to the Boeing specs (to be supplied to them by TSB), and they will conduct further tests.  It is expected that sufficient tests will be conducted using the same standards to create a statistical record of events, so it cannot be argued that it was an unusual event that occurred at CANMET.

            The final analysis of the leak will depend greatly on the fire patterns being generated on the computer from the debris and will involve someone like QUINTIERE.  The shut down of the re-circulation fans (indicated on the FDR) would cause a change of the airflow towards the forward area of the aircraft.  This would likely cause the Velcro tabs on the smoke curtain to melt or burn, allowing it to fall down and provide a routing for the smoke and flame into the overhead cockpit area, being sucked in by the airflow system below the cockpit in the forward avionics bay.  At the same time, the Metallized Mylar around the oxygen line would burn, causing sufficient heat to cause the lineís cap to leak, providing pure oxygen to the fire.  Even if only a small leak, it would have an effect.  The FDR indicates a significant change in events (numerous items being shut down due to blown fuses) shortly after the shutdown of the re-circulation fans.  Since we now have evidence of burning on the cockpit carpet, it would appear that there was sufficient heat to melt the cockpit liner and cause it to burn.  This is the same environment in which the co-pilot is trying to fly, and the captain is trying to follow his checklist.

            Boeing has already put out a recall notice to all the airlines with MD-11ís to change the cap to stainless steel.  The FAA has been asked by the TSB to issue an AD on the subject, but they have declined at this time, stating that they need to allow time for the airlines to make the change on their own.  I donít understand this line of thinking.  Johnís concern is that if there is another similar fire situation, they donít need this line as an oxygen source to keep the fire going.

            It is interesting to note Larry FOGGís description of the test when he spoke to me on Friday, 00-09-15 when he said: (my notes for the subject written on that day)

. . that at high heat (800 deg F), there was a slight leak around the threads, but nothing that amounts to very much, and no weakening of the capís structure.

            It is also interesting to note that Paul FIOCCA mentioned the magnesium problem to John GARSTANG and indicated to him that I was very interested in the matter, as were they.  It is even more interesting to note that John is of the opinion that Vic GERDEN is also very interested in the magnesium matter, having mentioned it several times.

Ö..

            John GARSTANG also advised that the IFEN report is presently being written.  They have completed the latest interviews of people in Long Beach.  The report will be over 80 pages in length.  This fact has generated some comments from the TSB management.  The person whom Vic GERDEN reports to has expressed his opinion that if the IFEN report is this long, then they cannot be writing it correctly, as it should only be a few pages in length.  John also noted that there are fifteen or so aircraft flying with the IFEN system still in tact the way it was on HB-IWF at the time of the crash.  He expressed concern over this.

            I expressed concern to John that the tests had not been videotaped.   Even if the test is in an enclosed furnace, the set up, the equipment going in, the time involved, and the equipment coming out, plus viewing the regulator dial is of significance.  This is something that Boeing is going to argue heavily, and a jury should be able to witness for themselves.

(Clarification:)    Much later I will receive a copy of GORMAN's version of this matter dated 2002 JAN 14.  This shows that Gorman, Fraser, and Lathem were totally ignorant of the materials and the equipment in the aircraft, and could not understand events as they had occurred during the fire.  See:   Gorman's report - 02JAN14





 

 

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