Original subtitles

3000.

We're not getting any oxygen.

We have the terrain alarm.

We are in an emergency.

In 1998, off Canada's east coast,

a modern passenger jet run by one of the world's best airlines,

catches fire at 33,000 feet.

Swiss Air 111. We are dumping fuel now

and we must land immediately.

In its final six minutes,

communications from the cockpit cease.

It's burning already!

Then the plane plummets into the ocean.

229 people are dead.

What caused the fire is a mystery.

Many of the vessels reported to the Canadian Navy

vessels standing by on scene, that they were finding bodies

and making repeated requests for more body bags...

Now, after one of the largest investigations in aviation history,

the complete story behind the loss of Swiss Air Flight 111 can finally be told.

It's a wake up call for the entire airline industry

to ensure that what happened aboard Swiss Air 111 would never happen again.

This accident investigation was a unique opportunity

to assess the materials in airplanes.

The problem is not only just the stuff that can burn,

but the fact you can't see it.

When you really have fire on board,

the clock is running against you.

September the 2nd, 1998,

Swiss Air Flight 111 prepares to depart New York's

JFK International Airport en route to Geneva, Switzerland.

The aircraft was a MacDonald Douglas 11 or MD11,

a model first developed in 1986

as a highly automated modern replacement

for the antiquated DC10.

It was considered one of the most reliable passenger jets

in the skies, and Swiss Air pilots

were among the world's best-trained.

Okay, I have to start checklist.

- Uh, Engine Anti Ice. - Not required.

Roger. Not required.

Auto brakes.

Swiss Air 111'S pilots were Captain Urs Zimmerman,

and First Officer Stephan Loew.

Swiss Air 111 hold short, 3-1 left.

Zimmerman encouraged an easy-going atmosphere in the cockpit,

but he was also known for his by-the-book precision.

When not flying, he was an instructor of new pilots

for Switzerland's national airline.

Flaps and slats.

Flaps set 15 degrees.

Set at 15.

On board were 215 passengers, 12 crew and two pilots.

Most were French, American, or Swiss.

23-year-old Stephanie Shaw was on her way home

to her parents in Geneva.

Stephanie, uh, was blessed in many ways.

She was physically very attractive.

She was an intelligent girl.

The reason she went to New York was that she had been invited

to become a member of the world economic forum

which is based in Geneva,

and she wanted to have this trip before she joined.

She was a darling. She was an absolute darling.

8:18 PM.

Swiss Air 111 heavy, clear for take-off.

Cleared for take-off.

Roger, Swiss Air 111.

For safety, the Swiss Air pilots push the throttles

forward together ensuring no single pilot can botch a takeoff.

VR.

V2.

Swiss Air Flight 111 lifted off and made her way Northeast,

toward the open Atlantic.

For the first 15 minutes after takeoff,

there was no communication from Swiss Air 111.

It was an unusual small detail

that would later baffle investigators.

Well, it does happen, occasionally.

They'd not yet reached what we call the North Atlantic Track System

where then you're not usually in radio contact.

So, I thought it was a little abnormal,

but it appears it was just nothing more than a mistake in radio frequency.

When the guy dialed it in and swapped over the radio,

he had put in the incorrect frequency, and evidently,

they didn't make another attempt at contacting someone.

It was strange.

And I agree with you. It was kind of like, well, that's interesting.

Atlantic air traffic is handled by a remote centre

in Moncton, New Brunswick, Canada.

Almost half an hour after takeoff,

Captain Zimmerman made his first communication with Moncton.

Moncton Centre, Swiss Air 111 heavy.

Good... evening, level 3-3-0.

Swiss Air 111 heavy, Moncton Centre. Good evening.

Reports of occasional light turbulence at all levels.

Moncton Swiss Air.

It was a perfectly normal transatlantic crossing.

In First Class, Swiss Air passengers were among the first

in the world to have a personalised in-flight entertainment network.

Though now common, the system was an innovation in 1998.

Passengers could choose their own movie,

browse the internet, and gamble.

They evaluated the market and they thought

that introducing modern in-flight entertainment system

combined with a gambling system

so that passengers actually can use their credit card

and gamble during long-range flights,

uh...

would make them more attractive.

This luxury would be the source of controversy to come.

Do you smell something?

Yeah. What is that?

Go have a look. I'll take the controls.

Roger. You have control.

1st Officer Loew investigates

the area near the air conditioner vent.

Harmless smoke traces from air conditioning systems

are common on commercial jets.

I don't see anything, Urs.

And there's nothing up there now.

You hailed for me, Captain?

Stephan and I were sure we smelled smoke a few seconds ago.

Can you smell anything?

I smell it too, yeah.

Could you smell it in the cabin before you came in?

No, definitely not.

They agree that the air conditioner was the likely culprit.

Can't see it or smell it anymore.

Air conditioning, is it? - Yes.

Please close it, thanks.

Behind the sealed panel, the pilots could not see

that the problem was getting worse.

Less than 45 seconds after smoke disappeared

in the cockpit of Swiss Air 111, it returned.

Zimmerman followed Swiss Air procedure.

There it is again.- He made plans to divert

to the nearest place to land.

Find the closest place to land, Stephan.

We'll need the Nav charts from the library.

Also, weather data for the area.

Boston is close.

It's not doing well at all up there.

Zimmerman radioed air traffic control in Moncton, New Brunswick.

Moncton Centre, Swiss Air 111 heavy. Good evening.

United 9-7-0 heavy, Moncton Centre, good evening.

The controller dealt with another aircraft

before responding to Swiss Air.

Other aircraft calling say again.

Swiss Air 111 heavy is declaring Pan Pan Pan.

We have smoke in the cockpit,

uh, request... immediate return

to a convenient place, I guess, Boston.

Pan Pan Pan is an international term

used to notify air traffic control of an urgent situation,

one step below declaring Mayday.

You say to Boston you want to go?

I guess Boston...

We need first the weather there,

we are starting a right turn here.

Swiss Air 111 heavy.

Swiss Air 111, roger.

And descend to flight level 3-1-0.

3-1-0, 3-1-0.

Swiss Air 1-1-1 heavy.

This is the first interview with one of the air traffic controllers in Moncton.

My name is Bill Pickrell and on September, 1998,

September 2nd, 1998, I was one of two Halifax

terminal controllers working the evening shift.

The "pan" in any kind of a special condition

is usually dealt with as an emergency

and this in fact was dealt with that way.

The aircraft was immediately given priority

and the high level supervisor initiated a call

to the rescue coordination centre.

Pickrell's colleague determined that Swiss Air 111

was just 66 nautical miles from Halifax, and 300 from Boston.

But Captain Zimmerman had chosen an airport he knew.

And a lot of times, when you're having a problem,

you'd rather be dealing with an issue

where you're much more familiar with the airport,

because that relieves a little stress on you.

That was his initial problem. He's looking up there

and he's trying to think, "I've got smoke here, what does it mean?

Let's see, where is the closest place I can go to

that I can talk to a Swiss Air mechanic?

Boston."

Swiss Air 111 Centre.

Swiss Air 111 heavy, go ahead.

Would you prefer to go into Halifax?

Urs, we better put the masks on.

Uh, standby.

Realizing their location,

Zimmerman decided Halifax was now the best option.

Affirmative, Swiss Air 111 heavy.

We prefer Halifax from our position.

Swiss Air 111, roger, proceed direct to Halifax,

descend now to flight level two-niner-zero.

Level two-niner-zero to Halifax, Swiss Air 111 heavy.

A British Airways pilot in the area offered the crew

what little help he could.

Swiss Air 111 heavy from Speedbird two-one-four,

I can give you the Halifax weather if you like?

Swiss Air 111 heavy,

we have the oxygen masks on, go ahead with the weather.

It's the 300 zulu weather...

- Swiss Air 111 commenced its descent to below 30,000 feet,

the pilots calm and in control.

It would take about 20 minutes to reach Halifax.

...over.

Roger, Swiss Air 111 heavy.

We copy. Two-niner-eight-zero.

Swiss Air 111, you're cleared to 10 000 feet

and the Halifax altimeter is two-niner-eight-zero.

Swiss Air 111 heavy, two-niner-eight-zero at 10 000 feet.

And Swiss Air 111, can you tell me what your fuel on board is?

Stand by for this.

Speedbird one-five-zero-six

is at Tusky listening out.

Speedbird one-five-zero-six, roger.

The controller signed off with another aircraft.

His jurisdiction was high-altitude flights.

As Swiss Air was on descent to Halifax,

he hands over responsibility to Bill Pickrell.

At that point, everything was normal.

I gave the pilot an initial descent

and he requested to level off at an intermediate altitude

to get the cabin in order for the landing

which I took to mean that they needed to pack away

dinner trays and things like that.

It was an indication to me that while his situation was unusual,

that they weren't considering it as an emergency at that time.

Watch your speed, Stephan, don't descend too fast.

Roger.

Yes, Captain.

We have got smoke in the cockpit here.

Have the cabin crew prepare for landing,

we'll be setting down in Halifax in about 20 minutes.

I'm about to start the checklist here.

Yes, Captain Zimmerman.

Zimmerman had two checklists for smoke in the cockpit.

To complete both will take 20 minutes.

This was Swiss Air company policy.

In the meantime, Loew continued the descent into Halifax.

Stephan, I'll need you to handle the radio

while I go do this checklist.

One-one-niner, point-two for the Swiss Air 1-1-1 heavy.

Swiss Air 111 was now at about 25,000 feet.

Pickrell advises them to descend to 3000.

But First Officer Loew says he'd rather fly at 8000,

until the passenger cabin was cleared.

Their attitude underscored the sense of control in the cockpit.

From my point of view, it gave all initial appearances

that it should be a fairly straight forward operation,

assuming that everything happened normally,

the aircraft would require a minimum of handling

to lead them into Halifax.

Swiss Air 111, you can descend to 3,

level off at an intermediate altitude, if you wish, just advise...

But Pickrell was concerned the plane

was not coming down fast enough.

It appeared that the aircraft might've been a little bit high

and I wanted to ensure that the pilots were aware

of how far they were from the airport,

how many miles they had to fly.

So that they could judge their own descent

and make their decision about what they wanted to do.

Roger. At the time we descend to 8000 feet.

And we are clear anytime to 3000 feet.

I keep you advised.

Okay. Can I vector you

to set up for runway zero-six at Halifax?

Roger, vector for 6 will be fine.

Swiss Air 111 heavy.

Swiss Air 111 roger, turn left heading 0-3-0.

Left heading 0-3-0 for Swiss Air 111 heavy.

Captain Zimmerman needed information

for the unfamiliar airfield,

but his flight bag was out of reach.

He summoned the flight attendant to help.

- You hailed me, Captain? - For two minutes now.

I need the flight bag there,

it's got the approach charts for Halifax.

Get back to your crew. - Yes, Captain.

This is your Maitre de Cabin speaking.

The chief flight attendant notified passengers that

the flight was being diverted.

There was no panic, the plane was flying normally,

and there was no sign of smoke in the cabin.

Swiss Air 111, the localizer frequency

is one-zero-niner decimal niner.

You've got 30 miles to fly to the threshold.

We're gonna need more than 30 miles...

But still at more than 20,000 feet,

Swiss Air 111 was too high to make a landing

in just 30 miles.

The frequency is one-zero-niner decimal niner for the localizer.

Okay, roger. One-zero-niner point niner,

and we are turning left heading, uh... north.

Swiss Air 111 heavy.

We've got to dump fuel.

Agreed.

So far, communications from Swiss Air have been calm.

Still, Moncton Center initiated emergency efforts at Halifax airport.

Preparing ground crews for an emergency,

Pickrell sought information from the pilots.

Swiss Air 111, when you have time,

could I have the number of souls on board

and your fuel on board please for emergency services.

Roger, at this time, fuel on board is two-three-zero tons.

We have to dump some fuel.

May we do that in this area during descent?

Pickrell was surprised to learn so late

that Swiss Air 111 needed to dump fuel.

At that point, it became more of a complicated situation.

In fact, with every transmission after that,

it became more and more complicated.

Pickrell considered his options for a safe place,

that wouldn't take the aircraft too far from Halifax.

He decided to direct the plane over St. Margaret's Bay,

about 30 miles from the airport.

The other choice, if he had said he needed to stay close,

was to start the aircraft in a right-hand turn

to set them up for any of the other runways.

I had to keep them flying in a circle or a constant track

so that he wouldn't fly back into his own fuel

which would have been not good.

Dumping fuel is standard procedure.

A fully fuelled passenger jet is too heavy,

and could break up on landing.

But Co-Pilot Loew wondered if, given their situation,

they might forgo the regulations.

They want us to turn to the south.

Should we just forget about dumping and just land?

No, dump it.

Okay, we are able for a left or right turn

to the south in order to dump.

I initiated the vector back toward St. Margaret's Bay

to start him in that direction.

It indicated to me that again

it wasn't a critical situation on board

and in fact he did have time to be able to go back

and dump his fuel over the water.

Swiss Air 111, roger.

Turn left heading of two-zero-zero degrees

and advise me when you're ready to dump.

It will be about ten miles before you are off the coast.

You will still be within about 25 miles of the airport.

Roger, we are turning left 2-0-0.

In that case, we're going to descend

to only 10 000 feet in order to dump the fuel.

Roger, maintain one-zero-thousand.

I'll advise you when you are over the water.

It will be very shortly.

Roger.

While Zimmerman continued with his checklist,

Loew accidentally transmitted to Bill Pickrell in Moncton.

Are you in the emergency checklist

for air conditioning smoke? - Yes.

Uh, Swiss Air 111, say again please.

Sorry, that was not for you.

Swiss Air 111 was asking internally.

Okay.

Airspeed is decreasing below 306, level off speed here?

Just fly the plane as you see fit.

Swiss Air 111, continue left heading 1-8-0,

you'll be off the coast in about 15 miles.

Left heading one-eight-zero, roger.

Swiss Air 111 and maintaining at 10 000 feet.

Roger.

Cabin Bus off?

Cabin Bus off, roger.

The cabin bus switch knocked out all the lighting in the cabin.

It was an indication for the passengers

that something was wrong, but hardly alarming.

Ladies and gentlemen, we have temporarily lost the lights in the cabin.

Please, remain calm, the crew will be coming around

with flashlights to assist in landing.

Despite a cockpit filled with smoke,

there was still no trace in the passenger cabin.

You will be staying within about 35, 40 miles of the airport

if you have to get back to the airport in a hurry.

Okay, that's fine with us.

Please tell us when we can start to dump the fuel.

Suddenly, the aircraft sent out a warning

that the smoke was a sign of a more serious problem.

Autopilot disconnect.

Copy that, autopilot disconnect.

Swiss Air 111...

The autopilot disconnected

because the plane's computers sensed erratic readings.

In the next 90 seconds, those readings went haywire.

11 000 and 9 000 feet!

Swiss Air 111, you can block

between 5 000 and 12 000 if you wish.

Once by one, the instruments failed.

The calm in the cockpit dissolved.

Copy that! We are between 12 and 5 000 feet.

We are declaring emergency now,

Swiss Air 111, at time zero-one-two-four.

Then the two pilots spoke simultaneously.

Combined with other distractions in the control room,

Pickrell was unable to hear a critical transmission:

Loew's declaration that they must land immediately.

We are dumping fuel now. We must land immediately!

Swiss Air 111, just a couple more miles. I'll be right with you.

Roger that.

We are declaring emergency now, Swiss Air 111.

Missing this transmission is a moment Bill Pickrell relives today.

I'm not sure that it's a feeling

that you can adequately describe.

I recall reviewing the events of that night

a thousand times to determine

if there was something additionally

that I could have done or if there was some mistake

that I might have made or was there any way that I contributed to this.

And eventually, I was able to come to the point of realization

that there wasn't anything that I could have done.

That... everything that could have was done.

Now, there was nothing to do but wait.

30 seconds after declaring an emergency,

the pilots of Swiss Air 111 faced an inferno.

All my screens are down!

I'm flying on standby instruments, maintaining 300.

Swiss Air 111, you are cleared to commence your fuel dump

on that track and advise me when your dump is complete.

Soon after I gave him authorization

to commence the fuel dump, there was no acknowledgement.

Initially, I wasn't concerned by that because I considered

that he was probably doing the fuel dump.

He was reviewing a checklist.

He was busy doing things, and as per our training,

we're told not to bother the pilots

in those kinds of situations.

Swiss Air 111, check. You're cleared to start the fuel dump.

There was no further communication from the aircraft.

Six minutes later, residents of Peggy's Cove

heard a devastating explosion.

No one knew what had happened to 229 people

after six minutes of silence.

It was probably one of the most helpless feelings

that any individual can have,

not being able to do anything,

but just sit and watch the target

and hope that it would turn back toward the airport.

And of course, it didn't.

The following morning, would-be rescuers

glimpsed the terrible remains of Swiss Air 111.

Only one body was discovered intact.

In Geneva, Ian Shaw had a premonition

about his 23-year-old daughter Stephanie.

That night, the night on which she was due to return,

for reasons I can't explain even now,

I was restless and I was disturbed

and I slept early and woke

while my wife was still awake

and asked her if she had had news of Stephanie.

No, she had not, but she didn't expect to have news of Stephanie,

we knew she was coming on that flight

and that she would certainly expect me to be at the airport

to fetch her in the morning.

I awoke around 6:00, Geneva time,

and on television, there was a report

of the crash of Swiss Air 111.

And I knew instantaneously that we had lost our daughter.

Air traffic controller Bill Pickrell was in shock.

It's a strange experience.

I'm not sure that I can adequately express the feelings. But it's...

You work to provide a service

and you read about aircraft flying into a mountain

or ending up in a swamp in some distant country,

but you never expect that it's going to happen in your backyard.

And when it does, it's...

...it's kind of a lonely experience, I guess, in one sense.

The Transportation Safety Board of Canada

launched what would become the largest disaster investigation

in the nation's history.

They only knew Swiss Air 111 experienced a cockpit fire,

but what caused it remained a mystery.

Well, this accident was a challenging one

to investigate in that initially, of course,

we had to recover the aircraft from about 55 metres of water,

around 185 feet.

Of course, it was also in many pieces,

as it turns out, it was in a couple of million pieces.

So that was the initial challenge.

And then after that, of course,

when you have so many pieces, you need to determine

which are the relevant ones

and what are these pieces telling you,

about what happened and why.

The TSB embarked on a five-stage plan.

First, divers were deployed to survey the wreckage.

They discover that the plane

was smashed into millions of pieces.

But as the autumn weather worsened,

the risks to divers increased.

At this rate, the salvage would take years to complete.

Stage two.

With help from the United States Navy,

Remote Operated Vehicles began a more detailed search.

The ROV's helped investigators survey the site.

But the question remained:

how to recover tiny pieces of twisted metal

from the bottom of the sea.

We have to go through little bits of airplane, pieces.

In Swiss Air, we had about two million pieces of airplane

and we pretty much almost had to look at them all,

because we had to discredit certain things:

terrorists, bombs, various other types of faults.

The TSB's investigators finally got the breakthrough

they'd been seeking, the black boxes.

Recordings of cockpit and computer data

told investigators that everything on the plane

was working perfectly until the last few minutes.

When the crew declared the Pan Pan Pan,

that they had smoke in the cockpit,

after going through all of these parameters,

we found no anomalies, no problems in any of the flight data

that suggested there was a problem with the aircraft.

So this led us to believe

that the crew had a relatively operational aircraft.

Aside from the smoke in the cockpit that they noted,

everything else appeared to be working fine.

And as they were making their plan to descend the aircraft,

they experienced a series of systems failures

that were in rapid succession and exponential.

Copy that. Autopilot disconnect.

Swiss Air 111, we must fly manually now.

Mike Poole's CVR team then faced a serious setback.

The last six minutes on both flight recorders were missing.

You're losing systems rapidly on the airplane

in that 90-second period when things are happening very fast.

And one of the last things we knew about

was the two recorders went off-line.

So the fire has presumably breached the lines,

breached the sources to these recorders and has stopped them.

With the failure of the black boxes,

investigators were no closer to learning how, or where,

the fire started on Swiss Air 111.

Stage Three.

Barges were deployed to scour the seabed for evidence.

One by one, sad remnants of the airplane reach the surface.

Her engines were recovered.

Then the landing gear.

These were among the largest pieces

of Swiss Air 111 to be recovered.

The rest were mere fragments,

dredged up in a painfully slow process.

Stage Four.

A nearby military hangar provided a makeshift lab

for the growing team of forensic investigators.

Representatives from the American NTSB, Boeing,

Swiss Air, and the Royal Canadian Mounted Police

joined in the search for answers.

Pieces of Swiss Air 111 arrive by the truckload,

organised into various categories for analysis.

Soon, the hangar was stacked to capacity

with the biggest jigsaw puzzle in aviation history.

All the investigators knew for sure

was that an initially small cockpit fire

suddenly turned to catastrophe.

The team sorted through nearly 155 miles of wiring

retrieved from the wreckage of Swiss Air 111.

Here, the first real clue.

Evidence of electrical arcing.

Scorch marks on metal reveal that the source of the fire

was in the back of the cockpit directly behind the first officer.

By examining the aircraft's wiring plans,

investigators found a likely suspect:

the entertainment system in first-class.

The system had some major deficiencies.

It was getting very hot,

it drew a lot of power.

And thereby, for example, raising the cabin temperature

considerably, because it was always running.

They did not install a simple off switch.

Nor did they install appropriate cooling systems

to cool the system down.

The TSB's investigators finally thought

they had the breakthrough they'd been seeking.

Our report indicates that there was a design flaw

in the way the in-flight entertainment network installed

in the first-class and business-class sections

of the aircraft were installed,

integrated into the electrical system of the airplane.

When Captain Zimmerman threw the cabin bus switch,

all power to the cabin should have been switched off.

But the entertainment system remained on, over-heating.

If you'd ask most pilots, they would say,

"Well, if I pushed the cabin bus switch,

it's going to turn off the things behind the cockpit.

It's going to isolate that electrically for me,

so that I don't have to worry about that,

and then I can just concentrate on those things

that might affect me flying the airplane."

Well, it turns out that this switch

was kind of bypassed, in this case,

for this IFE or entertainment system.

Swiss Air immediately disabled the entertainment systems

on the rest of its fleet.

And the US National Transportation Safety Board

ordered an inspection of cockpit wiring on all MD-11s.

Unfortunately, this simple solution proved insufficient.

By the time that cabin switch was turned off,

the fire was well under way,

so that had no real bearing on the initiation

or propagation of the fire on the Swiss Air 111 aircraft.

But investigators determined that the problem

with the entertainment system alone

could not have brought down Swiss Air 111.

The search for answers continued.

Stage Five.

Undaunted, the TSB reconstructed the MD-11 from the wreckage.

A wire-frame mock-up they call "the jig" provided a spine

for placing tiny pieces back where they once belonged.

The reconstruction revealed that the fire spread

with alarming speed, from the cockpit,

back into the first-class galleys.

Some metal showed heat damage from temperatures

as high as 600 degrees centigrade.

As the investigation continued,

some argued that the actions of the pilots

may have contributed to the disaster.

Some experts charged that Zimmerman and Loew's by-the-book approach,

may have cost them their lives.

...Swiss Air 111 was asking internally.

Some operators emphasize, in the very early stage,

land as soon as possible,

and then if you have time, go into the checklist.

Others say: use the checklist,

and at the end of the checklist,

if that doesn't help, then land as soon as possible.

Pretty contradictory to basic flying instructions

where student pilots

learn at a very early stage that whenever you have smoke,

you have a fire and fire means land as soon as possible.

Emergency light switch on.

Emergency light switch on.

Unfortunately, in this case,

the way the checklist was written,

it didn't identify that, "Now, start towards a divert."

It started more on, "Let's try to see if we can solve the problem."

And...

So now all of a sudden,

you're taking on a problem that just kind of crept up on you.

You weren't expecting it.

We're gonna need more than 30 miles...

But the TSB considered the timeline.

Investigators determine that Swiss Air 111

would not have made Halifax airport under any circumstances.

There just wasn't enough time.

In our calculation...

we showed that starting at the ideal decent point,

from 33,000 feet, which was

at about 10:14 PM that night,

it would take some 13 minutes

to get the airplane onto the ground.

Which would take us to 10:27 PM.

By 10:24, the systems in the aircraft

were starting to deteriorate.

So we believe that under these circumstances,

the crew would not have been able to successfully

land the airplane under those conditions

with the amount of time that they had.

Whatever caused the fire on Swiss Air,

it happened at a lethal speed.

The mystery remained.

A year passed, then another ambitious operation began.

The TSB hired a sophisticated Dutch salvage ship,

Queen of the Netherlands.

The vessel has a gigantic vacuum system,

capable of dredging even the tiniest pieces

of Swiss Air 111 from the ocean floor.

A mixture of sea water, silt and aircraft

were pumped into the ship's hold.

This cargo was then pumped into a specially-constructed reservoir on shore.

When the water drained away,

investigators found another million pieces of the aircraft.

Any one of them may have held the clue to what caused the catastrophic fire.

The pain-staking sorting once again resumed.

Finally, after 15 months,

they found what they'd been seeking:

A single faulty wire.

We looked at all of the possible sources of heat

that might start a fire in that area.

And in this instance, we did discover a wire

that arced in that way and right next to it

was some very flammable material

called Metalized Polyethylene Terrathalate,

covering material, that covers the insulation blankets.

This polyethylene insulate which lined the MD-11

is common on commercial airlines worldwide.

It has passed the industry's flammability tests

that require materials to self-extinguish

after a reasonable period of time.

The investigation now took an abrupt turn.

Instead of seeking the cause of the fire,

the TSB now focussed on the flammable materials that fuelled it.

The thermo-acoustical material that was

in this aircraft was very flammable.

Even though it passed a test,

it does sustain and it does propagate flame.

So this investigation did focus on the flammability of materials

and the requirement to reassess the criteria

that is used to certify materials.

Not just thermal acoustical insulation blanket materials,

but also other materials that goes into aircraft,

much of it in hidden areas.

Investigators now had their answer.

A wire arced in a closed space behind the cockpit.

The arc ignited the insulation

which in turn lit other materials,

such as foams and plastics.

The pilots could not sense how quickly the fire intensified.

But 14 minutes after they declared "pan pan pan",

the fire disabled all electronics in the cockpit.

The black boxes went dead.

A forensic examination also shed light

on the desperate final minutes in the cockpit.

Loew was in his seat. Captain Zimmerman was not.

Likely fighting the fire and probably dead before impact.

The first officer was probably trying to find a place

where he could put this big airplane.

He just didn't have a lot going for him.

He didn't have a lot of instrumentation left.

And I'm sure he was looking for something,

some indication that would give him an idea

where he could put the airplane down,

maybe even ditch the airplane.

What is known is that the first officer was in his seat.

Whether he was unconscious,

conscious, maybe had severe degree burns on his skin.

It's not known.

We know the captain was not in his seat,

so very likely, he was trying to fight the fire.

The checklists were found, uh...

...molten together, the pages.

It indicates they were used to fight a fire.

At 10:30, Halifax time, Loew shut down engine 2.

Investigators determined that he probably received a warning

the engine was on fire.

Chillingly, it proved that Loew

was alive a minute before impact.

They could not determine whether the passengers

were aware of the fire, at least until the very final moments.

There were traces found of soot and smoke,

extending as far as the business class, overhead area.

Whether... the passengers

had smelled the smoke, it is not known.

DNA analysis showed that they had no residue in their body.

The aircraft hit the water with a force of 350 Gs.

The TSB spent four and a half years

and 40 million US dollars

analyzing the wreckage of Swiss Air 111,

the largest air disaster investigation in Canada's history.

Their conclusion: Flammable materials

do not belong on commercial aircraft.

The rate of progression in this airplane, I think,

surprised us and surprised others

and that's why we emphasize again

the importance of raising the bar

on the flammability standards

for materials used in airplanes.

Ian Shaw waited four years for the report to reveal

the fatal flaw that took the life of his daughter.

The truth has not diminished his anger at Swiss Air.

There has to be accountability.

If you are involved in wrongdoing,

you must be held accountable.

And you must declare your sense of responsibility.

Otherwise, you are hiding.

And you are hiding, in this case,

behind the flag of Switzerland. I think it's unbelievable.

In the aftermath, Swiss Air decided to remove

the flammable insulate from its entire fleet.

They also made changes to checklist procedure,

reducing response time in a cockpit smoke emergency.

Swiss Air did something very interesting,

they modified their entire Swiss Air 11 fleet

according to all these findings.

They built in cameras and smoke detectors

even into hidden areas...

where pilots have a little TV monitor

and they can see whenever there is a smoke warning,

which makes them all help gain time,

and that's most important when you have a case of...

when you have a fire.

Plagued with financial problems,

the mighty Swiss Air shocked the industry

when it declared bankruptcy in October, 2001.

The flammable insulation that set Swiss Air ablaze

remains in two-thirds of commercial airplanes today.

But not for very much longer.

The Metalized Polyethylene Terrethalate material

has been essentially banned from aircraft

and the criteria to certify that kind of material

for use in airplanes has been worked on.

It has not been put into law as yet,

but we look forward to that being done.

So the criteria is more stringent.

The US Federal Aviation Administration

has given a deadline of 2005

to remove the material from all commercial aircraft.

This major overhaul is designed to ensure

that what took place on Swiss Air 111 will never happen again.

The industry is trying to remove it,

but I don't think they're removing it as quickly,

necessarily, as they could.

There's always that battle.

How expensive is it to do something that's a replacement,

or are you going to replace it in an airplane

that you're going to throw away in another couple years.

We have to live within certain economic realities.

For Ian Shaw, losing his daughter

so suddenly and violently has left a permanent emotional scar.

He left his wife and his wealth behind in Geneva,

and now runs a modest restaurant in Nova Scotia,

in view of the sea, where his daughter died.

Why would I come here to this particular point in Nova Scotia?

A lot of people have said, "Oh yes, we fully understand,

you want to be close...

to your daughter and the point where the plane crashed."

That is no part of my being here.

Swiss Air ripped out of me

any possibility of proximity to my daughter.

I found a comfort in the awareness

of the presence of the eternal ocean,

the ocean which has been going backwards and forwards

for many, many, many thousands and millions of years.

I came here because I had to.

Um, I...

I can't give a fully rational declaration

to you of why I came here.

I can only say to you

I am in the right place for the wrong reasons.

difuze