FINAL REPORT SWISSAIR 111 - 02 September 1998

A98H0003 - In-Flight Fire Leading to Collision with Water
Peggy’s Cove, Nova Scotia - 2 September 1998

Safety Action Required

Other Thermal Acoustic Insulation Materials at Risk

Transport Canada Response A03-01

TC agrees with the intent of this recommendation, in that action needs to be taken to address unsafe materials.

TC is aware that testing by the FAA has identified some materials which do not meet the Radiant Panel Test (RPT) criteria.   This testing, which was neither exhaustive nor specifically controlled with regard to material specification, definition or condition (e.g., some materials may have been contaminated), was intended to provide baseline data to validate RPT performance against full-scale tests and, as such, does not (and was not intended to) definitively quantify the performance of existing materials tested.

TC has taken action to ensure that materials, which have been identified as unsafe – MPETs – are not used on Canadian-registered aeroplanes.  MPET was considered unsafe because it exhibited a propensity to both be ignited by a small ignition source and propagate flames; current information indicates that most of the materials identified in the FAA testing are more difficult to ignite, and therefore present a lower level of risk than MPET.

TC has contacted the FAA to request that this issue be considered by its International Aircraft Materials Fire Test Working Group (IAMFTWG).  The IAMFTWG, which involves CAAs (including TC) and industry from around the world, is the prime focus for the development of materials’ flammability test criteria and standards.

TC has developed proposed regulations to implement the RPT on new transport category aeroplane type designs as well as future production of existing designs.  Going beyond this recommendation, the subject proposed regulations as well as pertinent FAA proposed rules, incorporate criteria to require that thermal acoustic insulation also provide a barrier against the penetration of external fuel-fed fires into the fuselage (“burnthrough”).

TC has, and will continue to actively work with its ‘partner’ CAAs to identify unsafe and increased risk materials in service to either eliminate such materials or identify means to reduce or mitigate pertinent risks, as needed.

Proposed Certification Standard for Thermal Acoustic Insulation Materials

Transport Canada Response A03-02

TC agrees with the objective of this recommendation, and considers that the concerns raised by the TSB have already been or are being addressed.

The RPT is a very stringent test, which incorporates a realistic ignition source, as well as a radiant heat source.  It was developed with due consideration of the effects of the various installation factors that may influence its validity and the consistency of its results, as well as the need for it to be a ‘practical’ test.

Comparative testing conducted to validate the RPT has shown that its results closely correlate with those of full-scale tests, and that it provides an effective and realistic pass/fail criteria for a broad range of materials, configurations and conditions.

An advisory circular (AC) to address the testing of material/component variants and combinations is presently being developed by the FAA and is scheduled to be published concurrently with the issuance of its rules implementing the RPT.  TC intends to adopt the RPT and will be reviewing this AC, when available, for application to its own pertinent regulations.

Further, TC has contacted the FAA to request that this issue be further considered by its IAMFTWG.   The IAMFTWG, which involves CAAs (including TC) and industry from around the world, is the prime focus for the development of materials’ flammability test criteria and standards.

Interpretation of Material Flammability Test Requirements

Transport Canada Response A03-03

TC shares the TSB’s objective to achieve consistent and accurate application of flammability standards.

TC has been addressing various elements of this issue at regular meetings with its regional personnel, as well as with industry through its Delegates Conference held bi-annually.  In addition to putting increased emphasis on the subject within these activities, TC will continue to monitor the issue and will pursue efforts to improve this aspect of flammability certification.  TC will, as appropriate, develop advisory material to provide advice to regional personnel and delegates regarding the applicability and implementation of flammability standards.

Further, TC has contacted the FAA to request that this issue be considered by its IAMFTWG.  The IAMFTWG, which involves CAAs (including TC) and industry from around the world, is the prime focus for the development of materials’ flammability test criteria and standards.

In addition, going beyond this recommendation, a broad program of work is underway under the auspices of the IAMFTWG to ascertain the adequacy of present flammability criteria and standards for materials in hidden and isolated locations and, as needed, to develop improved test criteria and standards.  The objective of this work is to bring the level of performance of these materials to that provided by the RPT for thermal acoustic insulation.  The first task is the development of test criteria for wiring - this work is already underway and is expected to be completed this year.  Pertinent advisory material will be developed, as needed, to support the new standards as their formulation and implementation progress.

IFEN – Supplemental Type Certificate Process

Transport Canada Response A03-04

TC does not agree that a quantitative assessment is always required for every system installed through the STC process.  The regulatory requirements in place already require a systematic and comprehensive assessment for the approval of STCs including those for stand alone installations or those which may involve integration with the basic aircraft systems.  This structured and qualitative approach includes design and installation evaluation and may also include Failure Mode and Effects Analysis and/ or Fault Tree Analysis.  This is required to verify that the level of safety of the original aircraft design is not degraded by the modifications and that there is no hazard introduced by the STC.

TC will develop improved advisory  material to emphasize the need to verify that system integration requirements are adequately addressed when a new system is installed through the STC process.  In addition, TC will initiate awareness level sessions and training for industry delegates and TC certification engineers to highlight the need for thorough and rigorous analysis of system integration, associated requirements, potential pitfalls and lessons learned.   Particular emphasis will be placed on the safety impact of installations involving “non-essential, non- required” systems.

TC will continue to be involved in FAA/JAA Joint Aviation Authorities) harmonization activities related to FAR 25.1309 and other systems integration issues.

Circuit Breaker (CB) Reset Philosophy

Transport Canada Response A03-05

TC concurs with the TSB recommendation.  TC has recently requested that the Transport Aircraft and Engines Issues Group (TAEIG) initiate a task to establish the requirements and industry standards for circuit breaker resetting in order to produce harmonized standards for the regulatory authorities of the major aircraft manufacturing states (FAA, JAA and TC).

TC has adopted FAA guidance material concerning circuit breaker reset criteria.  Where TC is the prime design responsible authority, Transport Canada will conduct a review of Aircraft Flight Manuals (AFM) and Flight Crew Operating Manuals by January 2004, in order that the adopted criteria for circuit breaker resetting instructions are included.   TC will also conduct a review of existing guidance material regarding the inclusion of the circuit breaker reset criteria in the content of the AFM.

TC will publish advisory material in September 2003, which will, in part, require that inspectors responsible for the approval of company training programs re-evaluate air operator training programs by January 2004, in order that they contain clear and concise guidance materials on circuit breaker resetting procedures for appropriate crewmembers.  Similarly, advisory material will be published in order to raise the awareness of maintenance personnel.

TC will issue initial advisory material in September 2003, concerning the proper reset criteria of circuit breakers and this will be distributed to all commercial and private aircraft operators in Canada.  The advisory material will assist operators in the development of company policy.

TC has published information concerning the resetting of circuit breakers in a recent article (Issue 1/ 2001) in an Aviation Safety Letter and will publish another article in the Aviation Safety Maintainer.  Aeronautical Information Publication Canada also contains information to caution the flight crew against resetting tripped circuit breakers unless the associated equipment is essential for the continued safety of the flight and in that case, resetting is limited to only one attempt.

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