A Report on Failures Causing the Swiss Air 111 Accident and Possible Design Improvements That Would Have Prevented Such Failures

The Swiss air 111 accident was caused due to a fire that spread beyond the control of the crew

and resulted in loss of control of the plane.

The following failures occurred which eventually caused the crash.

Firstly, a probable cause on how the fire started can be attributed to electrical arcing from wiring

of the in flight entertainment network system which did not trip up the circuit breakers. This

could have been prevented if better design factors like having a form of failsafe were available.

For example, if the circuit breakers did not trip automatically, there should have been a buzzer to

indicate that the temperature had actually exceeded its limit. In this case the in flight

entertainment system could have been turned off manually. Also, there could have been a

redundant circuit breaker which would trip off in case the first component fails.

Also, the electrical arcing ignited the flammable covering on MPET insulation blankets which

also rapidly spread across other flammable materials. In this case, the MPET material used as

insulation blankets should have been subjected to further reliability analysis studies to determine

its suitability for use and what factors could cause the material to fail.

Furthermore, when the power supply to the cabin was switched off, the in flight entertainment

system was still working thereby heating up. The vacuum created allowed the fire to spread back

rapidly to the cockpit. To prevent this failure, better consideration should have been taken to

ensure there was an emergency switch available to turn off power to the in flight entertainment

system.

The failure of key display systems which later led to the crew being unable to control the plane

was caused by the rapid spread of the fire. This failure should have been prevented at the initial

stage by better fire monitoring and detection design plans. There should have been cameras and

smoke detectors in designated locations in order to enable the crew...