99-12-04          0800    Supposed to be a RTO today, but John GARSTANG wants to go through the final human remains with his doctors from TSB & FAA.  He wants some of the material photographed.  As well, nothing from this sort has been photographed as new exhibits.

….

Then started photographing the H.R. exhibits.  They were locked in the cooler and had received the keys yesterday from Andy KERR.  Mike WETZELL assisted me.  Photos taken 35 mm & digital of following Exh #’s: 8301, 9001, 9002, 9003, 9004,9005, 9006, 9007, 9008, 9009, 9010, 9011, 9012, 9013, 9014, 9015, 9016, 9017, 9019, 9020, 9021, 9022, 9023, 9024, 9025, 9026, 9027, 9028, 9029, 9030, 9031, 9032, 9033, 9034, 9036.

While doing that, John GARSTANG, Dr Vern DAVIES of the TSB, and the other three doctors attended at the morgue and examined the bone fragments.  Dr. Steve VERONNEAU of the FAA, Dr. Craig WINSOR of the TSB, Dr. John SHAW of IFALPA, and Dr. CHATURVEDI of the FAA along with Dr. Vern DAVIES went over the pieces picking out several for further photos.  Each bag number was photographed and then the contents were photographed with a colour scale present.  The pieces that were selected for specific photos were only photographed in 35 mm, not digital, but with a scale.  These included unusual fractures and dental pieces or teeth.  From the number of teeth present, the vacuum method would seem to be a very suitable method to recover identifiable human remains if we had been unable to do so at the initial stage of the investigation (now as is the case of Egyptair 990).  From the teeth, there is not only the dental record comparison, but also the chance to perform DNA identification.  The H.R. was completed about 1530 hrs and everything was locked up.

On completion, John GARSTANG held an informal meeting with the doctors to discuss toxicology and other subjects, and I was invited to sit in on it.  The following notes are of the discussions & observations/comments of the four doctors and John GARSTANG during the meeting except where noted. 

Dr. CHATURVEDI has done much work on the toxicology of the aircraft pieces.  To sum up his discussions, he felt that there would have been high amounts of carbon monoxide and carbon dioxide within the aircraft’s atmosphere once the fire started.  In addition, the nylon and plastic material would produce cyanide compounds.  The Metallized Mylar would produce a large amount of smoke, as would other materials.  While the re-circulation system’s filters would remove all or most of the smoke and materials, the ceiling is porous enough with large enough voids to allow for this smoke to enter the passenger compartment.  General discussion indicated that with the ‘Econ’ button on, the re-circulation fans in economy mode would re-circulate as much as 70% of the cabin air allowing only 30% to be new air.  So any carbon monoxide and cyanide compounds already in the air would not be filtered out and much of it would be re-circulated. 

The FAA burn tests were discussed, along with the need to take further accurate air samples during the burn.  Dr. CHATURVEDI advised that the FAA were set up on site to provide cyanide test results almost immediately.  They have to be done as soon as possible before the compounds break down.  The set-up was discussed along with the need to accurately represent the atmospheric conditions within an enclosed aircraft.

From the discussions, I developed the opinion that there was a need for this to be fully and carefully conducted and documented.  These burn tests will be important for later court concerns, and the manner and positions from which the samples are taken will be very important.  This will not be something that will be passed over lightly in future hearings.  It is another test that will have to be shown at a later date to have been performed accurately as the results will have impact on future court decisions.

The discussions then centred on the actual flight and John brought out the latest timeline.  We went over it item by item.  Of interest is the fact that the flight crew were served their supper and in doing so, the overhead light was turned on (a normal action so that they can see what they are eating).  During that time, it was that smoke was smelled and then seen high in the cockpit.  The first officer got up and eventually indicated that the smoke/smell was coming from the air conditioning.  He would not be able to say anything more than that because the airflow from above G1 likely travels through the tubing and holes in the smoke barrier and wall and would enter into the cockpit close to the air conditioning vent.  The airflow tests are designed to show if this is in fact the case.  When they called in the flight attendant to ask her if there was smoke/smell in the galley, she expressed surprise when she entered and saw the smoke.  It is new to us that she was ‘surprised’.  There are indications that she remained in the cockpit for several minutes as someone handed the Halifax maps to the pilot and verbally indicated doing so (a female voice).

I brought up to the group that two things here are important.  First, in June Swissair and Boeing tried to decrease her value by saying that because she was so involved in the food preparation, she would not notice anything around her.  Yet she readily noticed the difference in the cockpit atmosphere and was surprised by it – so the volume in the cockpit was very noticeable.  Remember that she had already been in to serve the crew their supper.  Second, because she noticed the difference, it would tend to separate this incident from that of the BORN incident on 98AUG10 when the captain had to come out of his cockpit to smell the “smoke” or burning smell at the 1.1 door.  At that time, BORN had actually smelled it in the galley at the 1.2 door first and then at the 1.1 door (the strongest).  But on the 2nd they smelled it in the cockpit first.  This could imply that the two incidents were from totally different sources.  Nowhere on the CVR record does it indicate any mention of smoke or fire in the cabin area during the initial minutes of the incident. 

The timeline showed that from the time the smoke was smelled and then seen until the crash, approx. fourteen minutes elapsed.  Dr. DAVIES advised that the injuries of the Prince were different from those of the other first-class passengers, more in keeping with those far to the aft, indicating that he was likely moved far to the rear of the aircraft.  The injury patterns overall show a difference between the forward area and the aft area.  This had only been hinted at previously.

It was also learned that Swissair does not train their pilots to fly the MD-11 on manual instruments only.  They always rely on the EDT’s being operational.  Tests have shown that because of the nature of the manual instruments, some pilots have a problem with correct orientation when forced suddenly from the electronic to the manual.  To turn on a compass bearing, they sometimes turn the wrong way because of the manner in which the numbers are orientated on the compass in relation to the turning of the dial.  The same goes for the artificial horizon.  This could account for the right turn at the end of the flight versus a left and more direct turn to return to an airport heading.  In addition, John feels that the #3 engine, the right engine, was not at full power, although Elaine SUMMERS has written it up as likely being in full power.  The FADEC for this engine was not recovered intact.  But the bend in the shaft should have caused every blade to be destroyed if it was turning at full power.  Instead, only half the blades were destroyed.  The #2 engine in the tail was in windmill mode having been shutdown likely due to a malfunctioning warning of an engine fire.  The #1 engine, Captain’s left side, was in full power.  This would tend to cause a right-hand turn unless the pilot heavily compensated for it.  Being on manual and having difficulty maintaining a level altitude, the pilot might not have noticed his turn, especially when flying towards the dark ocean at night on manual.  In addition, the last ground lights to have been seen would have been Blandford, which was on the right.  So he might have intentionally turned right to get close to what he knew was land.  That is if he could see out the windows through the smoke.  The cockpit might have been so full of smoke that he may not have been able to see his instruments.  As well, the panel above and behind his head indicates heavy fire and high heat.  He would have had a very difficult time to remain in his seat.

It is also interesting to note that two minutes elapsed from the time the Maître d’cabin was advised to cease supper and prepare for a Halifax landing until he actually made the announcement over the PA – picked up by the CVR.  There is nothing to indicate that he even knew a serious problem was occurring, and he advised the passengers that the landing would take place in 20 to 25 minutes.  While he was not advised of an ETA, it certainly seems he had no knowledge of how serious the matter was or where they were.

When the autopilot shut down, a very loud warble alarm goes off.  This is always shut off by the crewmembers, as it is so loud.  The pilots wear an open style earphone with the button type earpieces that would not muffle the cabin sound.  Additionally, the warble sounds in the earpieces and is very disconcerting if not shut off.  But it seems that they could not shut off the alarm and it remained on until the end of the tape, only twice shutting off momentarily.

There is considerable question about the ‘fire of unknown origin’ switch.  One of the settings actually shuts down the CVR/FDR.  The units did shut down, but only momentarily.  So he may have cycled through the switch, but it is a switch that turns only one way.  When he enters the first position, he must continue to the second and then to the third position to put all the systems back on.  By entering one particular position, the systems are not immediately shut down.  They are rerouted electronically so that some essential systems can be moved to an active bus without being shut down.

In addition, when total power to the systems was lost, they would have had a maximum of fifteen minutes of backup battery power, if the batteries were at peak charge and efficiency.  They only flew for a further six minutes.

Swissair has expressed concern that because of the location of the oxygen line in relation to the fire location, it may have heated the oxygen within the tubing to a temperature too high to breath.  The doctors felt that once it passes through the regulator, the pressure reduces from 65 psi to 15 psi and it would cool.  As well, it is normally mixed with cabin air picked up by the regulator.  This is located at floor level at the feet of the pilots.  This raised a concern.  It was noted that above 10000 feet, the regulator supplies oxygen in proportions pre-set according to the air pressure of the cockpit (altitude).  Below that level, it adds no oxygen to the air, as it normally is suitable to sustain normal functions.  However, there is a switch on the mask that allows the pilot to go to full oxygen.  The air intake is filtered, likely to a very high standard.  This might remove all indications of smoke from the air being breathed but would not remove poisonous gas levels.  Because of the high stress and volume of work being performed, the pilots might have forgotten to switch to pure oxygen.  One thing that indicates that they may have switched is the fact that during the eight minutes of CVR, there are no sounds (except possibly one) of coughing or throat clearing.  Mind you, the filters may have been working well up until the last couple of minutes.  None of this material has yet been recovered.

One thing that I was not aware of is the fact that one passenger was found to have donned his life jacket.  A second thing is that one upper body had an oxygen cup and tube around its neck.  Dr. DAVIES was disappointed that this had not been photographed before its removal, contrary to protocol (see notes of meeting for 99-12-06).  It may have been present just as a result of the crash.  I did not know of this until now.  However, John advised that the latches on the oxygen mask compartments found so far all seem to indicate that the hatches were in their closed position.  There is nothing to indicate that they had been dropped for the passengers.  Indeed, most pilots would hesitate to do this as they might actually be supplying oxygen to a fire.  It seems to be an odd situation to be in as you might starve the fire and at the same time kill the passengers.

The airflow tests are still potentially on.  However, any correspondence in the matter will no longer be via email (which I have been receiving and stored in the airflow directory).  It will be in a more secure format via faxed memo.  A hard copy will be created for record purposes for TSB.

On a different subject, I had a conversation at noon with John GARSTANG over the FDR/CVR examination.  It led to John telling me about an incident that had occurred prior to the Swissair accident.  He advised that XXXX, the TSB member responsible for the CVR/FDR examination, had told him that on a previous accident he had found evidence of an impaired pilot.  The pilot’s voice was slurred, incoherent at times, and the FDR had shown every indication of impaired actions on the part of the pilot.  They had found evidence of liquor/beer bottles in the flight bag of the pilot.  When John asked him if he had advised the RCMP, he told him that he had not, that it was not his responsibility to do so, that they were not there to investigate criminal matters.  John didn’t want to get into further details. 

What this tells me for this accident is that we need to keep a very close eye on everything because we cannot count on the TSB to advise us of anything that may indicate a criminal act.

Finished up at 2000 hrs.