Features Safety
The TSB After SW111

The Nova Scotia village of Peggy's Cove has long been a Canadian icon,
its picturesque headlands and lighthouse recognized worldwide. It
became a landmark of a grimmer sort on the night of September 2, 1998,
when Swissair Flight 111 out of New York for Geneva slammed into the
Atlantic, killing the 215 passengers and 14 crewmembers. Four and a
half years later, after one of the most exhaustive – and probably most
expensive – investigations of its kind, the Transportation Safety Board
(TSB) confirmed that the accident was the result of a catastrophic
chain of events that began with an electrical arc in a wiring harness.

"Swissair
is the most elaborate investigation that this organization has ever
undertaken but also is one of the more comprehensive that the world has
ever seen," TSB Chairman Camille Thériault told WINGS as the
independent agency was preparing to make its report public. He noted
that it took nearly two years, with the help of other agencies, to
recover a staggering 98% (by gross weight) of the aircraft. "It was
not a 'normal' investigation."

That said the former premier of
New Brunswick, who was appointed to the TSB board in December 2001 and
became chairman the following July, is sensitive to the time issue. (It
should be noted, however, that the NTSB took as long on its TWA
investigation.) He's more concerned with the length of time it has
taken to complete investigations and issue final reports on relatively
minor accidents. "A small Cessna that clipped some trees and crashed
in a field? It shouldn't take us four years to do that investigation.''
While those have been the exception rather than the rule — as
investigators have had to deal with several accidents almost
simultaneously — Thériault did ask for a review of how investigations
are conducted.

"We took some reports that were already done and
I wanted to know what happened in the first 60 days? The next 60 days?
Why was there a delay of six months? What happened? A lot of our
experts were working full time on Swissair, so there was less time for
them to do other reports.” The result of that review was reflected in
three as yet unpublished reports "All three were done and brought to
the board within six months,'' he said, calling it an "impressive''
performance by TSB staff. He suggested he would be happy with a
one-year turnover, but added that there are circumstances — such as
the complexity of the Swissair investigation — that make that goal
impossible.  "If we can't do it, we can't do it! Don't create
expectations.''