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SGT Thomas (TOM) C JUBY RCMP RET

THOMAS C. JUBY FORENSIC PHYSICAL EVIDENCE CONSULTING

Swissair Flight 111 - ATC Recordings [FULL RECORDING]

SGT THOMAS C JUBY RCMP

This letter is presented in an effort to clear up some of the disinformation and answer questions that have arisen out of the recent disclosure to the public of events surrounding the Swissair 111 investigation. Due to space considerations, what is presented here is only a small portion of the details that were presented to the Commissioner, and later to the Fifth Estate. > MORE <6

Sgt Thomas Juby RCMP

'A Man Who Is A Man Will Go On Until He Can Do No More And Then He Will Go Twice As Far'

(An Old Norwegian Saying)

Background:

32 YEARS AS A MEMBER OF THE ROYAL CANADIAN MOUNTED POLICE

RETIRING AS THE SERGEANT IN CHARGE OF THE FORENSIC IDENTIFICATION SECTION, HALIFAX, N.S.
27 YEARS AS A QUALIFIED FORENSIC CRIME SCENE EXAMINER AT

DESIGNATED UNDER SEC 667 OF THE CRIMINAL CODE OF CANADA

LIFE TIME MEMBER OF THE CANADIAN IDENTIFICATION SOCIETY

CRIME SCENE EXAMINATION TRAINING & EXPERIENCE FOR

SUDDEN DEATH INVESTIGATIONS

FIRE / ARSON / EXPLOSIONS

MASS DISASTERS & MAJOR ACCIDENTS FOR AIRCRAFT, TRAINS, AND OTHER VEHICLES

DNA EVIDENCE LOCATION, RECORDING, & COLLECTION

MEMBER IN CHARGE OF THE RCMP's FINGERPRINT IDENTIFICATION TEAM

FOR THE SWISSAIR FLIGHT 111 AIRPLANE CRASH INVESTIGATION &

RESPONSIBLE FOR THE QUALITY & CONTROL AND THE LOGISTICAL SUPPORT

OF THE RCMP MORGUE TEAMS DURING THE 60 DAYS OF THE MORGUE OPERATION

4 YEARS AS THE MAIN RCMP FORENSIC IDENTIFICATION SECTION MEMBER FOR

THE SWISSAIR FLIGHT 111 AIRPLANE CRASH INVESTIGATION

PROVIDING SPECIALIZED DIGITAL & 35 MM PHOTOGRAPHIC & VIDEO-GRAPHIC SERVICES

AND PHYSICAL EVIDENCE TECHNICAL ASSISTANCE & SUPPORT

WHILE SECONDED TO THE TRANSPORTATION SAFETY BOARD OF CANADA

EXTENSIVE BACKGROUND, TRAINING, & EXPERIENCE IN

 

Thomas C. (Tom) JUBY
New Minas, N.S.

EMAIL
tom_juby@forensic-physical-evidence-consulting.ca

Posted 2/16/2003

 
 
 
   
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Doomed plane's gaming system exposes holes in FAA oversight

By Gary Stoller, USA TODAY

http://usatoday30.usatoday.com/money/biztravel/2003-02-16-swissair-investigation_x.htm

A small Las Vegas company with large ambitions and marquee investors sold U.S. regulators and Swissair on a video gaming system for airplanes. Until Flight 111 crashed, no one realized how many chances had been taken with passengers' safety.

 
   

Safety inspectors examine fragments of Swissair Flight 111.

 

By Andrew Vaughan, AP

Flight 111 was dubbed "the U.N. shuttle" for its popularity with United Nations officials, although passenger lists regularly carried the names of prominent scientists, researchers and business executives, too. Hours after the jumbo jet crashed into the Atlantic Ocean on Sept. 2, 1998, killing all 229 people aboard, Canadian and U.S. aviation authorities zeroed in on something else that was distinctive about Flight 111. (Aftermath: Changes since FAA review of Flight 111)

The McDonnell Douglas MD-11 was one of only a few jets in the world with a pioneering interactive entertainment system that let passengers select and watch movies on personal consoles, shop and, on various international flights, use credit cards to play computer casino games. Although the final accident report has not yet been released, the Canadian government has considered the system's electronics as a possible source of an electrical fire that may have caused the crash.

The system was made by Interactive Flight Technologies, a Las Vegas company that formed only four years before the crash. It hoped to make a fortune on in-flight gambling, a business that looked rich with opportunity in the early 1990s. Instead of a big payoff, however, the venture produced only failure and grief.

Less than two months after the crash, Flight 111's destruction prompted Swissair to disconnect IFT systems on its planes. A year after the crash, the Federal Aviation Administration banned their use on MD-11s. For the past year, USA TODAY has investigated how a piece of equipment that was so quickly discredited came to be installed on a major international airline — with the FAA's approval by proxy — in 1996.

It is a tale of a small, unknown company backed by politically connected investors who used a flawed regulatory system to its advantage. The investigation exposes a lack of FAA supervision and the agency's reliance on thousands of private companies to certify major airplane alterations. Among the findings:

IFT benefited from lax FAA oversight. After the crash, the FAA said the IFT system's design and installation were unsafe. The agency didn't catch the problems sooner because no one directly employed by the FAA reviewed the system's design or installation plans, supervised the installation or signed off on any work. All of that was done by a company that the FAA authorized to approve airplane modifications on its behalf. Yet the FAA had repeatedly criticized that company, Santa Barbara Aerospace (SBA), for violating regulations and even briefly revoked its operating authority as IFT systems were being installed on Swissair jets in 1996.

Swissair's entertainment systems were installed in Switzerland in a rushed process that violated FAA procedures. In many instances, SBA did not follow proper certification procedures, and inaccurate or inadequate design data were used. Much of SBA's paperwork required to prove the system was properly certified is missing or was never completed. The Swiss government said it allowed the Swissair jets to fly with the IFT system because it relied on forms completed by FAA designees attesting that the system met U.S. safety standards. One form that the Swiss relied upon was used in violation of the FAA's rules for certifying changes to foreign-registered aircraft.

After the Swissair crash, the FAA tightened oversight of private companies and individuals authorized to act on its behalf, but problems remain. Its post-crash review of other airliner entertainment systems turned up 18 installations that were improperly certified and unsafe. The FAA now demands more interaction between its officials and FAA designees during aircraft-modification projects and mandatory refresher training for engineers authorized to act on the agency's behalf. But, some designated engineers say, the FAA lacks the technical expertise and resources to oversee the projects.

USA TODAY pieced together the story of the IFT entertainment system from more than 100 interviews and a review of tens of thousands of pages of government documents, including more than 1,000 pages obtained under the Freedom of Information Act and court records. This is the story.

IFT struggles to develop interactive system

IFT was founded by Yuri Itkis, president of FortuNet, a Las Vegas-based manufacturer and distributor of electronic bingo and interactive video gambling games. Itkis, a Russian-born engineer and inventor, says he used his own $276,000 to start the company in February 1994 with his sons, Michail and Boris, and to build a prototype interactive system.

IFT promised airlines a revolutionary product — an interactive system that would generate revenue by allowing passengers to choose a pay-per-view movie or to gamble at their seats. At the whim of a passenger, a movie could be stopped or started, forwarded or reversed.

"We were ahead of our time," Itkis says. "We were the pioneers, and we started to preach this idea to the airlines."

In August 1994, IFT approached Edward Mlynarczyk, a private engineering representative designated to act on the FAA's behalf, to certify components and help bring the overall system to the FAA for a required supplemental type certificate (STC). An STC represents FAA approval for modifying an airplane from its original design and is granted after a rigorous process of sign-offs on design data, components and test results. An STC can be obtained from the FAA or from one of about 30 certified aviation repair shops.

   

By Andrew Vaughan, AP

Families of the victims gather in Nova Scotia, on Sept. 1, 1999, nearly a year after the crash.

 

Mlynarczyk is one of thousands of designees used by the FAA to help certify aircraft modifications. Under a decades-old program almost unknown to the public, the agency allows designees to be paid by the companies contracting them for certification work.

Mlynarczyk says IFT's system was very rudimentary and unsuitable for aircraft use, but the company pressured him to accelerate the certification process. He says much work was needed before the equipment could pass FAA tests, including environmental and electromagnetic interference tests.

"They had no clue what it would take to get an STC," says Mlynarczyk. "They would send some information about the system, and when we'd say, 'That's not good enough,' they'd say, 'You're trying to gouge us for more money.' They were running out of funds and trying to shortcut so many things."

Mlynarczyk says he received a phone call from a representative of stockbroker D.H. Blair & Co., who asked him whether certification was near and whether he'd like to get in on the ground floor of IFT's initial public stock offering. IFT went public in March 1995.

Such an offer could violate a federal bribery law, which applies to anyone, like Mlynarczyk, acting on behalf of the government. The law, which imposes a fine and up to 15 years imprisonment, is violated by offers of "anything of value to any public official" with intent "to influence any official act."

Mlynarczyk says he turned the offer down. Several years later, D.H. Blair and 13 former employees were found guilty of defrauding investors in 15 IPOs — including IFT's — through stock-price manipulation. Four of those employees — including the vice chairman — received prison sentences. The company is now defunct.

A month after the stock offering, Mlynarczyk says he canceled his contract with IFT because the company kept changing its entertainment system specifications and pressuring him to speed up the certification process. Two days later, while he was away, two men arrived at his Florida office in a limousine with New York state license plates and demanded that his wife hand over the prototype and related data, Mlynarczyk says.

His wife refused their demands because IFT still owed $30,000. The two men handed over $30,000 in cash and then cut the prototype system into parts when it didn't fit into the limo, Mlynarczyk says.

Itkis says he can't recall Mlynarczyk, but he laughed when he was told about Mlynarczyk's account. "He has a very vivid imagination," Itkis says. "It sounds like a movie scenario. Can I get rights to it?"

First customer finds flaws

About the same time IFT parted ways with Mlynarczyk, it also landed its first customer. Alitalia agreed to pay $2.7 million for the hardware components for five IFT entertainment systems. William Ashworth, an FAA designee and former FAA aircraft-certification official, was hired by IFT to certify that the systems installed on Alitalia met FAA standards.

In August, 1995, Ashworth operated the IFT system on a test flight, made sure it didn't affect other onboard electronics and approved it. He says the FAA closely monitored the certification process as well, often talking daily with engineers at his company — Elsinore Aerospace — and eventually signing off on the STC he issued. In December, the first passenger flight equipped with the system, installed only in business- and first-class, flew round trip between Rome and Chicago. Alitalia officials say they encountered myriad problems. The airline bought the system because, "It was the only one that could provide video on demand," says Alfredo Gennari, Alitalia's project manager, but soon noticed design and engineering flaws. It was a difficult system to control and maintain, he says.

   

1999 file by Andrew Vaughan, AP

Transport Safety Board investigator Don Enns displays debris from Swissair Flight 111.

 

An average of three to five computer processing units under passenger seats failed each flight and had to be replaced, Gennari said in an interview from his office in Rome. "We removed the system (in 1998), because it had very low reliability, and the under-the-seat boxes were very poor," he says. "Everything was terrible about the system, and we were very upset about it."

The system, Gennari says, raised cabin temperatures, making it uncomfortable for passengers and causing hard drives in the seat boxes to fail.

Ashworth says he does not know why the system met certification requirements but later performed as poorly as Alitalia officials say it did. "FAA requirements don't look at a system's longevity and a customer's satisfaction. FAA rules look at safety," he says.

IFT lands prominent investors and contract

IFT began wooing other airlines with a second-generation system that included gambling games that could generate additional revenue.

The company also attracted many prominent investors and board members. Alexander Haig, the former secretary of state, was a consultant and a director. John Pritzker, a member of the family that owns the Hyatt hotel chain, was on the board. James Wolfensohn, the head of the World Bank, bought shares for his children. Another shareholder was Orin Kramer, a leading Democratic Party fundraiser and a friend of then-president Bill Clinton. IFT's initial public offering of stock was underwritten by D. H. Blair Investment Banking, which was led by J. Morton Davis, a well-connected executive who donated to both political parties and introduced prominent people like Haig and Wolfensohn to IFT.

In May 1996, Swissair agreed to pay about $72 million, plus the cost of installation, upgrades and design modification, for entertainment systems on 16 McDonnell Douglas MD-11s and five Boeing 747 jets. Swissair planned on offering lotto, keno and video slots to passengers on non-U.S. routes, and revenue would be shared by the airline, IFT and the Swiss international lottery system.

Three weeks before IFT announced its original Swissair deal, the company signed a consulting agreement with Haig, White House chief of staff under President Nixon and President Reagan's secretary of state. IFT named Haig to its board of directors and agreed to pay the influential Republican $50,000 annually, plus 1% of gross revenue.

Haig says he called on airlines to buy IFT's entertainment system but wasn't involved in the Swissair deal. After the deal was finalized, he says he discussed it with Thomas Schmidheiny, a close friend and former member of Swissair's board of directors.

Schmidheiny, one of the world's wealthiest individuals, says that the IFT deal was brought before the Swissair board, and it agreed to go ahead with the project.

Karl Laasner, Swissair's head of in-flight systems, says he recommended IFT's entertainment system to the airline's top management. When Swissair closed the deal, he bought 2,700 shares of IFT for $30,000, reported FACTS, a major Swiss magazine. Three or four other Swissair employees also bought IFT shares, the magazine reported.

IFT contracted Hollingsead International to install the entertainment systems and oversee FAA certification. Hollingsead, which manufactured and installed racks for avionics equipment, specialized in installing passenger telephone equipment and lacked FAA authority to approve major modification work on airplanes.

The business agreement between the companies stipulated that Hollingsead would prepare an FAA-required "electrical load analysis," a spreadsheet calculation that would determine the entertainment system's additional electrical load on the aircraft. The agreement also stated that the system wiring's interface with the plane's power and existing systems would be determined by Swissair.

Swissair required IFT to pay nearly $600,000 to SR Technics, a related company that maintained its jets, to ensure the entertainment system "was properly interfaced with the Swissair aircraft" and that the system conformed to U.S. and European government standards.

Bill Weaver, who was appointed Hollingsead president years after the Swissair project, says he cannot comment about anything because his company and others are involved in lawsuits brought by families of Flight 111 victims.

Subcontractor hired to certify product

Hollingsead hired a subcontractor that did have the authority to issue STCs — Santa Barbara Aerospace, an FAA-approved "designated alteration station."

SBA, a subsidiary of Quaker Holding Co., the world's largest privately held coal company, was founded in 1994, and, within "three short years," the company claimed, it had become "one of the 10 largest providers of heavy jet aircraft maintenance in the U.S."

In August 1996, SBA sent the FAA's Los Angeles certification office, which oversees STC projects and designated alteration stations, a letter of intent, notifying the agency about Swissair's entertainment system project. Another FAA office, the flight standards district office in Van Nuys, Calif., was responsible for overseeing SBA's repair station activities.

The letter to the Los Angeles office omitted critical information. It said the system would be installed on one MD-11 jet and made no reference to Swissair's order for 16. The letter didn't specify that Hollingsead would be involved in the project and that installation would be done outside the USA. Had the letter described the full scope of the Swissair project, the project might have drawn more FAA attention. The FAA has more elaborate procedures for STCs covering multiple aircraft.

The FAA's Los Angeles office wrote back to SBA, specifying two additional tests that would be needed to certify the system. The FAA's response to a Freedom of Information request shows no further record that FAA and SBA officials discussed the Swissair's MD-11 entertainment system project, which continued for more than a year. Much more documentation would have been expected because no system like it had ever been used on an airplane. Test plans and reports, and inspection reports are typically generated for STC projects, according to a 1996 FAA application guide.

The Swissair project required major aircraft modifications — adding at least 2,300 pounds of entertainment equipment to each plane — and the FAA was aware of repeated problems at SBA. According to government documents, an FAA inspector at the agency's Van Nuys office cited SBA in March 1995 for performing, supervising and inspecting work with inadequate personnel. In September 1995, another FAA inspector in Van Nuys said SBA didn't provide requested documents and was still "without the proper staffing." In addition, the FAA said, some SBA equipment violated federal regulations because it was not tested for "correct calibration."

Other FAA documents show that eight officials from the FAA's Los Angeles office reviewed SBA's status as a designated alteration station in March 1996 and found at least one problem in each of 11 STCs the company issued. Two certificates with problems involved SBA work on entertainment systems unrelated to the Swissair project.

The officials found that SBA was not completing inspection reports as required by FAA safety rules and the company's designated alteration station manual. They also said SBA was violating FAA rules by circumventing a parts-approval process and instructed the company to store its STCs in locked cabinets to restrict access to them.

Swiss authorities rely on FAA approval

In the Swissair project, Santa Barbara Aerospace issued its first STC in November 1996 for one entertainment system on one MD-11. The certificate was issued even though the system wasn't functional, FAA documents show. Only part of the equipment was installed, and the jet had to return to Swissair's hangar for the rest of the installation more than a year later.

The MD-11s being modified also awaited installation of new seats equipped with entertainment components and lacked another required STC certifying the seats. So Swissair obtained temporary authorization from the Swiss Federal Office for Civil Aviation to permit the planes to fly until the seat certificate was granted.

Swissair was given permission to operate the planes, although one of the Swiss aviation agency's inspectors told Swiss newspaper SonntagsZeitung after Flight 111's crash that his agency had to hurry its inspection to meet Swissair's flight schedules and that much of the entertainment system work was not visible. The installations were hidden, and the inspections were "a pure alibi exercise," inspector Leon Vonlanthen was quoted as saying.

Vonlanthen, now president of a small Swiss airline, refuses to discuss the entertainment system inspection.

The Swiss aviation agency refused to answer any questions about its oversight role. After the crash, the agency said it granted Swissair temporary authorization, because Hollingsead gave SR Technics, Swissair's maintenance arm, an FAA document, Form 337, that stated the systems met certification requirements.

A special FAA review team formed after the crash said the use of Form 337 did not violate FAA regulations, but an FAA advisory explicitly says the form cannot be used for foreign-registered jets, as Swissair's were. Form 337 is only authorized for use on U.S.-registered aircraft and is usually used for major repairs — not for major aircraft modifications.

A month after SBA began certifying the entertainment systems on Swissair jets, the FAA's Western Pacific region office finally acted on its Van Nuys inspectors' findings and ongoing concerns about SBA. The office suspended SBA's operating certificate, according to FAA documents.

The suspension should have halted SBA's operations, but the company continued to work on the Swissair project. On Dec. 16, 1996, four days after SBA's operating certificate was suspended, an SBA official wrote a letter to Hollingsead's quality-assurance director and authorized him to sign an FAA form stating that part of the project met federal regulations.

The following day, the FAA's regional legal office abruptly reversed itself, saying it had suspended SBA "by mistake" and restored its certificate, according to a Dec. 31 letter. FAA attorney Sam Frazer, who signed the letter, said the case against SBA was dropped because the inspector involved in the case had retired.

Keith Thompson, the now-retired inspector, says the case should not have been dropped because he left the agency. A suspension of an operating certificate and an immediate reversal is suspicious, he says, but he doesn't know why the FAA legal office acted as it did.

SBA's Mark Ostendorf, a designated engineering representative, approved much of the IFT electrical work and did the entertainment system's electrical load analysis, documents show. The analysis was a critical piece of work and, according to the Swissair-IFT agreement, Hollingsead was responsible for doing it.

Ostendorf said he is now a paid consultant for the Rose-Walker law firm that represents SBA's insurance company and is handling lawsuits related to the Swissair 111 accident. He refused to discuss the entertainment system project.

In 1995, the state of California ordered Ostendorf to stop advertising his services as an electrical engineer. Ostendorf was not violating federal regulations, however, because an FAA designated engineering representative does not have to be an electrical engineer.

IFT, SBA woes precede Swissair crash

As 1997 unfolded, difficulties mounted for IFT and SBA.

The entertainment installation and certification on Swissair were very rushed. The installations had to be done when an MD-11 was due for a major maintenance overhaul, and the work had to be done expeditiously, so the plane could be promptly returned to passenger service. Any time lost would mean lost revenue for IFT and Swissair. In a January 1997 internal Swissair newsletter, the company's heavy maintenance project manager said the "time pressure was enormous" for the IFT project.

On Jan. 21, 1997, Swissair advised its pilots that if problems occurred with the entertainment system, they should pull a circuit breaker on an avionics panel to kill power to the whole system. Five days later, the first passenger flight with an operating entertainment system flew between Switzerland and Singapore.

The system was an immediate financial disappointment. IFT said in a March 1997 filing with the Securities and Exchange Commission that gaming revenue on the two MD-11s so far equipped with the entertainment systems was "significantly less" than expected. In an airline trade publication, Swissair's Laasner said first-class passengers rebelled over paying for movies, and only 50 passengers had gambled the limit of $200.

During the fiscal 1997 third quarter, IFT announced that it had lost $18.2 million. Technical problems also were apparently emerging.

Swissair began complaining that the entertainment electronics boxes under passenger seats were getting too hot and causing the hard disk drives to fail. IFT charged that the hard drives were defective and sued its supplier, Avnet. In court, Frank Talke, an expert witness for Avnet, testified that his tests showed that within an hour after IFT's entertainment system was turned on, heat generated by the system made the hard drives hot enough to fail. Aboard an airplane, the hard drives would probably get 10-20 degrees Celsius (50 to 68 degrees Fahrenheit) hotter than in a laboratory, he said.

Talke and others say malfunctioning hard drives wouldn't start a fire, but Talke's testimony may add to the FAA's criticism, made after the crash, that the IFT system had design shortcomings.

It "was extremely heavy and used an inordinate amount of power," says John White of the World Airline Entertainment Association, a trade group of airlines and in-flight entertainment suppliers. "IFT offered very large video screens with a lot of capability. The systems were tremendous power draws that created a lot of heat."

In June 1997, Qantas engineers spent nearly three weeks at IFT facilities evaluating the entertainment system. After reviewing IFT's "failure data," the engineers said they had serious concerns about the poor reliability of hard disk drives. A month later, according to a Qantas letter to IFT that was included in court documents, Qantas rejected the system, stating that it had a "number of issues" related to the product. IFT approached other major airlines with direct sales pitches and at trade conferences, but none bought the system.

In August 1997, the MD-11 jet that would later crash as Swissair Flight 111 entered a hangar for a maintenance overhaul by Swissair mechanics and an entertainment system installation by Hollingsead.

IFT directors began leaving the company in the fall, a year before the crash. Haig, Hyatt executives Pritzker and Adam Aron, and Brian Barents, former chief executive of Cessna and Learjet, resigned from the board. Hyatt also severed its $120 million alliance agreement with IFT.

The FAA conducted another audit of SBA in May 1998 and found missing information and a lack of appropriate approvals in STC data files. The agency also said SBA had certified an aircraft that was not eligible for such certification. The plane's owner was not identified.

The same month, IFT said it was ending nearly all its sales and marketing efforts because of its lack of prospects and need to cut costs. The company soon announced that it was entering the dry cleaning business.

That fall, a Canadian airline, WestJet, decided to repossess a plane that SBA was four months behind in repairing. The plane left Santa Barbara with three SBA officials onboard and landed at a California airport where the SBA officials were told to get off and given $200 for cab fare. The 737 then departed for Canada.

Gregory Long, a lawyer who represented WestJet, says that SBA had unskilled and untrained workers who didn't know how to repair the frame of an airplane. He says a special Boeing team had to be brought in to repair it. "It's frightening," he says. "We trust these repair stations to do work that could be a matter of life and death. It's a shame that they don't do the work properly."

On Sept. 2, 1998, Swissair Flight 111 took off from New York to Geneva. The Canadian Transportation Safety Board says about 53 minutes after takeoff, the pilots detected smoke in the cockpit. About 15 minutes later, electrical systems malfunctioned, and 61/2 minutes later, the MD-11 plunged into the Atlantic Ocean.

Internal FAA report finds mistakes

Within hours after the crash, the FAA began reviewing the performance of designees who signed off on the entertainment system, according to an Air Safety Week interview with the FAA's Ronald Wojnar.

But Laasner and other Swissair officials continued to negotiate with IFT for more entertainment systems, according to Swissair court documents. In a fax to IFT that is part of court documents, Laasner said another entertainment system would be needed for LTU, Swissair's charter airline.

Three weeks later, on Oct. 29, Swissair announced that it had voluntarily disconnected the entertainment systems in its jets as a "precautionary measure." The Swiss Federal Office for Civil Aviation withdrew a certificate of validity for the systems.

The FAA soon launched a "special review" that found numerous problems with the entertainment systems and their certification but said the agency's oversight was proper.

The team found that:

• "In many instances," SBA did not follow proper certification procedures. It failed to complete various forms that were required, so there was no proof that an authorized expert had reviewed and approved data for flight test reports and tests for flammability and weight and balance.

• SBA issued an amendment approving an entertainment system, although a required flight test hadn't been done. It "failed to complete" FAA maintenance requirements and issued parts approval to IFT for entertainment system components that were not approved.

• Design data for the Swissair jets "revealed numerous instances" in which the data for the entertainment system was inadequate or inaccurate.

• SBA didn't correct problems identified by FAA audits before the crash, and the FAA did not follow up to ensure corrections were made.

The FAA team concluded that SBA's designated alteration staff was knowledgeable, qualified and in good standing. But "in some instances," the staff "didn't demonstrate a thorough knowledge of the MD-11 type design, design philosophy, design standards, airplane manufacturer's operational assumptions and Swissair operational procedures."

It also wasn't good at keeping required records. Many of SBA's documents certifying the entertainment systems are missing, the FAA says. Various other documents, obtained from the FAA under the Freedom of Information Act, are incompletely filled out. Others are meaningless because they lack supporting documents, says Chuck Cupani, one of the FAA designees who approved components of Swissair's entertainment systems.

The Swissair accident isn't the first time that the FAA's oversight of companies that do aircraft work has been questioned. In May 1996, the same month that IFT made its deal with Swissair, a ValuJet DC-9 crashed in the Florida Everglades, killing all 110 people aboard. The National Transportation Safety Board said the FAA's inadequate oversight of ValuJet, which hired contractors to do its maintenance, contributed to the accident. It also faulted the FAA for not overseeing aircraft repair stations, like those used by ValuJet closely enough.

Maybe even more pertinent is a 1993 General Accounting Office report probing the oversight provided by the FAA and its designees. The report says that the use of designees rose dramatically, from 299 designees in 1980 to 1,287 in 1992, as aircraft became more complex and the FAA's workload increased. The FAA "has not ensured that its staff are effectively involved in the certification process," the report says.

Three days after the FAA team's report on Swissair was completed, the agency's headquarters in Washington proposed new rules to "ensure that certificated repair stations are held responsible for all maintenance work that is outsourced to contractors."

In a September 1999 interview, FAA official John Hickey told the Seattle Times that the agency's Los Angeles office "probably needed a closer relationship" with SBA. "There's no information or data that suggest that this problem exists outside that one case," he said.

Entertainment system draws scrutiny in accident investigation

Aviation authorities in Canada haven't said officially whether IFT's system caused or contributed to the Swissair crash. The entertainment system drew suspicion after investigators recovered 21 short-circuited electrical wires, including at least seven that came from the system. A wire that short circuits can cause a spark or fire that could ignite other materials on an airplane.

A final report on the accident is expected to be released in the next few months. A draft report is said to devote several pages to the entertainment system and holds the system partly responsible for the tragedy, SonntagsZeitung reported in September. The final report could contain different information from the draft.

In the aftermath of the crash, however, aviation safety experts have pointed to shortcomings in both the system's design and its installation.

• Though no U.S. airlines used IFT's system, the FAA zeroed in on the design concerns when it banned the system for future use. One problem, it pointed out, was the system could only be shut off by pulling a circuit breaker in the cockpit, an action that was far down the list of emergency responses for pilots dealing with an electrical problem. A quick response can often be critical in an emergency. The system was supposed to have an on-off switch accessible to flight attendants in each MD-11 passenger cabin, according to the IFT-Swissair business agreement filed with the SEC. The FAA and Canadian authorities refused to comment.

• Inspections of other Swissair MD-11s also uncovered problems with the entertainment system's wiring installation, an FAA official told Air Safety Week after the crash. "We've seen instances in those airplanes where they didn't use good industry practices for the installation of the wiring," the FAA's Wojnar was quoted as saying.

Mlynarczyk, the FAA-designee who IFT first approached to certify its entertainment system, also faults the wiring installation. He saw a journalist's photos of wire bundles on other Swissair jets.

"The installation was pretty bad," Mlynarczyk says. "They did everything that Installation 101 would tell them not to do. They mixed wire types, installed wires under metal clamps not designed to hold wire and installed coaxial cables with right angles. It didn't look like a professional job. It surprised me because the work was accomplished at Swissair's facilities, and Swissair doesn't do work like that."

• The entertainment system, as designed, was connected to the wrong electrical power source, the FAA's review team said. Airplanes are wired with separate electrical power buses that control essential functions needed to fly the plane and for non-essential uses, such as entertainment systems. On the Swissair jet, the IFT system was wired to the essential power system. That might have prevented Flight 111's pilots from quickly shutting down the entertainment system when the emergency started. "The entertainment installation was a very rushed process," says Peter Eggler, a Swissair pilot who's participated in the Canadian accident investigation. "I'm sure that led to the hookup problem."

Not all theories about the accident point solely to the entertainment system.

Edward Block, a private expert on aircraft wiring who was hired by lawyers for families of Swissair victims, says the main wiring on the MD-11 could have been responsible. He examined IFT systems on four Swissair jets after the crash and found the main wiring and the entertainment system wiring mixed together in some bundles. That was contrary to an FAA advisory and could have led to chafing and short-circuiting, he says.

The FAA also says its post-crash tests of the entertainment system — on a Swissair MD-11 and on an MD-11 mockup — did not produce conditions that could be considered unsafe.

IFT's Itkis maintains that the entertainment system "had nothing to do with the crash." The entertainment system, he says, "was a victim of whatever was the cause of the fire and not the source," he says.

Epilogue

Some of the companies involved in the IFT project are out of business, while others continue to operate and even prosper.

Swissair went bankrupt and stopped flying under its own name. Last month, a Swiss government-sanctioned report by consultant Ernst & Young said the airline was put out of business by management incompetence and a lack of aviation expertise. Its corporate successor, Swiss, flies between the USA and Switzerland, including the New York-Geneva route.

Hollingsead continues its aircraft-modification work, including installing and now certifying entertainment systems. It says it has been chosen to install and certify the first cabin video surveillance system that will allow pilots to monitor passenger activities on U.S. airliners.

SBA filed for bankruptcy and stopped operating in 1999. But it continued repairing and modifying jets for months after the Swissair crash. Jay Akely, a former mechanic who joined the company after the accident, says that he and other inexperienced mechanics were instructed to do jobs they weren't qualified to do and did poor repair work. After one repair, a jet popped a hole in its fuselage during its return flight from SBA's maintenance facility, he says.

New owners acquired IFT and changed its name to Global Technologies. The company is in a "tenuous financial condition," according to a March 2002 document it filed with the SEC. Last year, Global delisted its stock and discontinued public reporting of its financial condition.

Despite all that has transpired, the company still hasn't veered far from IFT's original vision. The March SEC filing said Global hopes to be the first company to sell an interactive entertainment system that will allow rail passengers in the United Kingdom to play video games and movies at their seats.

"We believe there is an opportunity to be one of, if not the, first in making available to train operators a customized, at-seat multimedia and entertainment system solution," the company said.

Contributing: Chris Woodyard in Phoenix

 

 

 


 

Fifth Estate: Swissair 111 The Untold Story 1998


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