Controlled Pod Into Terrain episode 9: Swissair 111

Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Hello, and welcome to Control Pod Into Terrain.

(00:16):
We are a multimedia podcast about air and space mishaps, aiming to put them in the broader
context of how and why things went wrong.
Now, to introduce myself and my co-hosts, my name is Ariadne Talchik.
I'm the business aviation industry experts.
My pronouns are she, her, and Hadas Hel.
Nice.
My name is Jay.

(00:37):
I'm a systems and engineering expert, and my pronouns are they, them, and just very,
very tired lately.
It is Pride Month.
And I'm Kira Dempsey, better known as aviation writer Admiral Cloudberg, and my pronouns
are she and her.
Next slide.
Today we are going to dive into the history of Swiss Air Flight 111, a tragic story about
how a desperately cash-strapped airline made a series of choices that ended in one of the

(01:00):
deadliest airline disasters in Canadian and Swiss history, leaving millions of pieces
of plane across the North Atlantic and a lot of unanswered questions.
But first, we have to do some kind of news thing.
Next slide.
We are never replacing this slide.
We're never replacing this slide.
That's so good.
All right, so on the 14th of May, the US Department of Justice found that the Boeing Company was

(01:26):
in violation of their Deferred Prosecution Agreement.
Now, what the hell does that mean?
It means that the DOJ had previously agreed not to prosecute Boeing for causing the Max
crashes by keeping the kill-all-humans mode a secret and then explaining away the crashes
with extreme racism.
So the deal was no punishments as long as Boeing agreed to stipulations and kept its

(01:49):
nose clean with no incidents for three years.
That deal was made on January 7, 2021.
Now, the stipulations were Boeing had to admit responsibility for defrauding regulators about
the safety, functionality, and history of the MCAS system, including how they engaged
in a massive conspiracy and cover-up.
The deal included a plea agreement of guilty of one count of conspiracy to commit fraud.

(02:14):
They had to pay a fine of 2.5 billion, which broke down as compensation to Boeing's customer
airlines of 1.77 billion, 500 million to the families of the crash victims, and a criminal
penalty of 243.6 million.
And it's kind of messed up that the order in which the payments went was big companies,

(02:36):
then victims, then fines, and each amount was less than half the one before.
And bearing in mind that these planes only cost like $90 million a piece anyway, so that's
like a criminal penalty of 2.5 planes.
Come on.
Yeah, they paid the family roughly what their revenue is for 1.777.

(02:56):
So they committed to enhancing internal compliance programs and to cooperate fully with ongoing
investigations, which, quote, includes making changes to how it assesses and communicates
safety critical information, both internally and with the FAA.
Seriously?
I'm sorry.
I'm sorry, FAA, but for decades, this public has seen you supervising as Boeing builds

(03:21):
planes with broken shit, and we watch you tolerate it.
Those speed brakes don't need to auto-stow when you go to Toga.
No, it's fine.
It turns out it's never going to be a problem.
It's fine.
It'll be fine.
Boeing also called for an independent monitor to oversee all of Boeing's safety and compliance
measures for the whole term to ensure adherence to the terms of the prosecution agreement.

(03:45):
So did they fire this guy now or like what?
Do they actually fire him?
I mean, this job's done, right?
So the deal was signed on January 7th, 2021.
It's a three-year deal.
Now Jay, what happened just two days shy of the third anniversary of that date?

(04:08):
Ooh ooh, is it a massive hole suddenly appeared in a brand new 737 MAX because Boeing's
failure of oversight meant that they forgot to put the bolts back in?
It sure was.
And the DOJ has learned, as we all have, that Boeing's pretty far down the hole right now.
So they announced they had found Boeing in violation of their parole and are now open

(04:32):
to prosecuting them for more crimes.
What crimes has not been determined?
More on this as we learn it.
To be continued ominously.
Dum dum dum.
Next slide.
Let's talk about the ongoing collapse of Spirit Airlines.
AKA Ari info dumping about her hyperfocus.
You host a podcast with an avibiz expert.
You're getting avibiz.

(04:52):
I'm sorry.
Understandable.
Spirit recently had another disappointing quarterly earnings call and the stock cratered
again.
And when you read between the lines interviews with the executives, it's pretty evident how
frustrated the company management is with their current situation.
And we'll kind of explain that in a second.
The long story short is that it will basically be next to impossible for the for Big Yellow

(05:13):
to return to any kind of profitability.
Not while they're grounding up to 40 aircraft this year and 17 aircraft next year because
of the engine issues they have with their A320 Neos.
As a refresher, Spirit has kind of been grappling with significant issues with Pratt and Whitney's
engines.
The P1000G engines is the only engines they picked on their their NIA fleet.

(05:35):
These are the ones that have a geared turbo fan, which is a way to try to sort of fool
nature by having a really huge bypass fan that also turns very slowly.
You have this absolutely cursed planetary gear reduction set that has to withstand staggering
amounts of continuous torque for 18 hours a day for decades.
But the thing about the universe is that she never lets you have anything without a trade.

(05:58):
And the trade here is these gearboxes are always desperate to become shrapnel.
So the metal has to be perfect.
And the metal Pratt and Whitney used wasn't.
Nature is a cold-hearted bitch who doesn't care about your plane.
This gearbox has to transmit something like 20 megawatts of mechanical power.
It's between 12 megawatts and 24 megawatts, according to Pratt and Whitney.

(06:23):
You know, they have various different versions of these engines.
And that is just a ridiculous amount of power.
It's unlike any other application.
And of course, these things have to be small and light because they're on a plane, right?
So it's like it's an impossible engineering problem or almost impossible.

(06:46):
Yeah, and the core of this problem stems from it's sort of metallurgical.
It stems from a contamination in the powdered metal they use.
I think they for the actual planetary gear set, they use additive manufacturing.
So it leads to cracks in what's called the rotating assembly.
And this makes a lot of people very angry and is widely regarded as a bad thing because
you have to ground the planes for a long time for very thorough inspections or else the

(07:09):
hubs might explode.
And you don't want Kira to write another article with the sentence, quote, for engineering
purposes hub disc fragments are assumed to have infinite energy at the moment of release.
They will cut through any reasonable material and cannot be contained.
That's probably one of the most iconic lines that I've written, I gotta say.

(07:30):
Now there are rumors in the AviBiz sort of communication channels about some significant
changes to their business model and market focus as a way of covering the damage from
these outages.
The question is how quickly any changes can have an effect before a $1.1 billion note
matures in 2025.
Changes include shuttling crew bases and hubs with their small Atlantic City base scheduled

(07:51):
for closure in the fall and about 260 pilots that were based there slated for furlough.
It doesn't mean they're abandoning New Jersey like a normal human should.
No, instead they're moving to Newark, which I mean, sure, I guess if really old crumbling
airports with terrible reliability are your thing.
It will still be less existentially depressing than Atlantic City, which is such a boring

(08:12):
piece of brown cardboard, I have literally no memory of it.
I've flown into and out of dozens of airports in my career, all around the world, big, medium,
small, all of them leave some kind of impression on me or have something memorable about them,
but not HCI.
It's just, someone out there is going to tell me I'm insane, but I've got a blank space.
The only thing that occurs to me when I hear the name Atlantic City is organized crime

(08:36):
and I can't tell you why.
Great.
No.
Now, given that Spirits operating about three quarters of their total fleet right now, there's
basically no way for them to earn a profit without closing this base.
It's also kind of common knowledge that this base has really been a dud for the big school

(08:57):
bus with departures down to about eight a day.
By contrast, their operations in Newark have grown considerably since the pandemic.
They won a lawsuit with the court authority, they got a bunch of new gates there, and it
became sort of the new hub for both their Florida and their transcontinental routes.
While Atlantic City was one of the company's first faces, it was heavily predicated on

(09:19):
a gambling market in Atlantic City that's been stagnant for years.
So they relied on a primary clientele of beachgoers and snowbirds that were seeking convenient
travel to Florida that avoided some of the larger airports in that area.
But online gambling, travel gambling, and sports gambling have all just really contracted
the Atlantic City tourist market.
And running the Jersey Shore Fort Lauderdale Express bus isn't enough and doesn't justify

(09:41):
maintaining our crew base there anymore.
That said, the current routes out of the Atlantic City airport are expected to continue as scheduled
staffed by pilots and flight attendants from other bases.
As for the planned furloughs, spirits negotiating with the unions, they're going to try and
do what they can to mitigate it.
They got a settlement from Pratt & Whitney, which came in the form of a couple hundred
million in billcrats.

(10:02):
Basically they get free maintenance on a couple of these planes for life.
It was clear from the earnings call that the CEO, the C-Sweets are really frustrated with
Pratt & Whitney.
Understaffing supply chain challenges, all of these things, Pratt & Whitney means that
they're not able to accelerate these inspections to the degree their customer need and to meet

(10:23):
the overhauls that the Airworthiness Directive requires.
Because this is actually a mandatory grounding.
That term will come up again later in this episode.
Obviously this affects a lot of different airlines that have these aircraft, but a lot
of them may have a limited number and they sort of hedge.
Currently these lead times average about 300 days per airframe.

(10:44):
Having a plane on the ground for a few days or a couple weeks is really bad.
Having it stuck there for almost a year is devastating to an airline.
And spirits struggling to stay operational, you can tell the C-Sweets is really just powerless
in this situation.
So this predicament really highlights the major drawback of operating a fleet that is

(11:05):
a single type rating, a single aircraft.
You know, it's like growing a single crop.
If some systematic problem comes in, you could lose the entire crop for an entire growing
season.
And it's the same with these.
It's a very high risk, high reward approach.
And Ted Christie just rolled snake eyes.

(11:28):
Yeah.
So for a point of comparison, Alaska Airlines received 160 million as initial compensation
for the blowout.
Alaska's fleet is a lot more diverse as far as engines go.
So they're not going to have the same problem that Spirit is.
Spirit is also losing a lot of what was a previously strong base, which was college

(11:48):
students, a lot of between inflation and post-COVID student loan moratoriums expiring, which is
should be a crime in itself.
They've eliminated a pretty significant pool of customers.
It's also kind of a thought that a lot of people are just kind of losing patience with
the sort of nickel and dime business ethos that airlines like Spirit or Ryanair embody

(12:11):
because they feel like they end up paying so many auxiliary and ancillary fees that
they end up paying just as much as they would have for a mainline carrier, but with a significantly
worse experience.
Spirit's declined is kind of a shame.
They actually were not as bad of an airline sort of operationally as you might think.
They were typically usually in some of the top five, top to end airlines in the US for

(12:35):
on-type performance.
They've never had a sort of operational meltdown like Southwest or JetBlue who tried to buy
them has had.
They have a weird cult following and obviously they cater to sort of a lower to lower middle
income customer base.
But because they've also been a brand that has been synonymous with mediocrity, they

(12:55):
have a lot of customer service horror stories that drive away potential passengers.
Yeah, right now their financial straits are mostly because of Pratt & Whitney.
You know, obviously building one of these engines is just, it's staggeringly hard.
It's also not entirely Pratt & Whitney's fault.

(13:16):
Spirit has been really slow to kind of get the times and improve their operational and
customer service experience in a way that does not necessarily cost a lot of money.
But really what they did was they just kind of kept kicking the can down the road until
they could get bought out by either Frontier or JetBlue.
And neither of those happens.
The Spirit brand has such has obviously been, it's a punchline.

(13:38):
It's gotten the lion's share of negative media coverage.
And I kind of want to close this absurdly long news story with a personal note, which
is to say it's very common for people that can afford not to fly on Spirit to make jokes
about the airline.
A lot of them are celebrating or reveling in these troubles and potential bankruptcy
of the company.
And I find this to be totally disgusting and unacceptable.

(14:00):
And in addition to providing a valuable service to plenty of people that couldn't afford a
mainline airline, Spirit employs 10,000 people.
And celebrating the potential unemployment of those people is ghoulish just because you
think it's acceptable to make fun of their customers for being poor.
I will stop hijacking the podcast now and we can go back to talking about crashes.
Next slide.

(14:20):
All right.
Thanks, Ari.
So I want to bring up this DC4 crash in Alaska from a little over a month ago because it's
very unusual and not just because when I heard about it and someone said, hey, a DC4 crashed
in Fairbanks and it's like, oh, what crashed in Fairbanks?
Anyway, so on April 23rd, a Douglas C-54D, which is the military version of the DC4,

(14:46):
tail number November 3054 Victor, crashed near Fairbanks, Alaska, tragically killing
both pilots.
Now, this particular DC4 was one of only a handful still flying and it was owned and
operated by Alaska Air Fuel, Incorporated, which ferries fuel to outlying villages.
So it left Fairbanks at about 10 o'clock bound for Cobuck, Alaska, which is just like way

(15:07):
the hell out in the middle of nowhere.
These places are so remote that these kinds of bush flights are pretty much the only way
to get supplies in, including fuel, which obviously, they're way inside the Arctic Circle,
so they definitely need that fuel, right?
Yeah.
Cobuck, Alaska is probably a place where a banana really does cost $10.

(15:30):
Anyway, so right now we have the preliminary report, which cites eyewitness accounts, is
backed up by some security camera footage, which is really unbelievable footage, by the
way.
So the eyewitness stated that they saw the far left number one engine was not rotating
and that it was emitting a small white flame of smoke.
So the airplane began to turn back to the airport and then the number one engine suddenly

(15:51):
had visible flames and an explosion occurred, resulting in the plane breaking up in mid-air.
In fact, you can see this on the security camera video from beginning to end.
The plane enters the frame on fire, there's a bright explosion, something separates from
the wing, and then the airplane very rapidly turns inverted and crashes.
And also at 100 feet off the ground, the number one engine separated entirely.

(16:12):
So it seems like an engine fire went from bad to really bad to out of control to removing
some critical portion of the left wingtip in about 30 seconds.
You know how idiots say that jet fuel can't melt steel beams?
It turns out that it's actually real freaking easy for a 100 low lead to melt aluminium
wing spars.

(16:34):
And obviously a plane full of gasoline and propane is going to burn like it's made of
wax paper.
So pretty much everything got incinerated in the crash.
Hats off to the FAA or to the NTSB investigators for trying to figure out what the hell this
was.
Yeah, and I'm really interested in the final report on this one because it's just not something
you see every day.
And also there's some evidence of past issues with engines exploding and separating on DC4s

(16:59):
that I think the NTSBs can have to take some real interest in.
So I wouldn't be shocked if this turns into a future article for me.
Stay tuned.
Yeah, this was pretty tragic because there's just like I said, I think there's less than
five or six of these still flying in the world.
To the point where when you saw the headline DC4 crashes, you go, no, no, you mean DC3,
right?

(17:19):
Not DC4?
Right.
Yeah, because the even older DC3 has way more operational examples.
By multiple orders of magnitude.
Yeah.
All right.
Next slide.
This is not sad.
Yeah.
Yeah, we have just one final news item.
The president of Iran apparently didn't follow our advice, did get in the helicopter, didn't

(17:42):
get out again.
We're just going to cover this one really briefly because this episode is already going
to be an editing nightmare.
And that means an editing nightmare for me.
These other two don't have to do the editing.
Yeah.
So on May 19th, a Bell 212 carrying the president of Iran crashed in the northwestern part of

(18:05):
the country in the mountains near the border with Azerbaijan.
He was there for a ribbon cutting on a new dam complex that Iran was joint building with
Azerbaijan.
So right now this seems to be a pretty clear case of flying a helicopter under visual flight
rules into bad weather, VFR into IMC as the cool kids say.
Although for some freaking reason, Iran claimed that it was a technical fault, I would argue

(18:28):
that the technical fault here was that the pilot was probably doing something the pilot
did not want to do because the president was telling him to do it.
Yeah.
Yeah.
A pilot flying VFR into IMC and then hitting a mountain is also what killed Academy Award
winning filmmaker Kobe Bryant in January of 2020.
Yeah.

(18:49):
And in this case, it killed not only the president of Iran who was being groomed to be the next
supreme leader, but also the foreign minister who was probably going to be the next president,
along with a major Imam, the governor of an Iranian province and some security guards.
And now it took them literally 17 hours to find the helicopter, which is a lot of time
to not know where your country's president is.

(19:10):
Just saying.
In fact, since then it's come out and has been reported by multiple news agencies that
when they were looking for the helicopter, someone called the pilot's cell phone and
the Imam actually picked up and they tried to get him to describe where they were.
However, he had no idea.
He was very disoriented and he just said he was in a burning forest and didn't know where
everyone else was.

(19:31):
And after a couple hours, he stopped talking.
So there are probably a lot of questions flying around within the Iranian government about
why it took so long to find the literal president, especially in light of the fact that at least
one official on board survived the crash only to die waiting for rescue.
Not that I'm particularly broken up about any of those guys dying of acute helicopter
syndrome, mind you.
Yeah.

(19:51):
This is a phenomenal case of what I think maybe the first ever recorded instance of
fog doing an entire decapitation strike on a government.
No, fog did a decapitation strike on Poland as well.
Oh, that's true.
Yeah, they definitely did that, right.
Turns out fog actually, it's actually pretty bad.

(20:11):
Yeah, fog, the world's best assassin.
All right, as always more to come on this as we learn it.
But I'd not count on ever getting the full truth about this one to be honest with you.
So next slide.
Oh, hey, it's 111 corner and you're all thinking that's the wrong 111, right?
You think Ariadne just hijacked the slides again?

(20:34):
But actually, no, it's not the wrong 111.
Next slide.
So I was reading about the Boeing 2707 and thinking, hey, why don't they do swing wing
planes anymore?
Those are really popular, like once upon a time.
So I started reading about swing wing planes and it turns out that Barnes Wallace, who

(20:55):
you can see here in the top left hand corner, invented them.
You know, the same Barnes Wallace who invented the bouncing bomb and the tall boy and like
a bunch of other things.
Turns out that he did a whole bunch of supersonic research.
And this was interesting to me because while everyone knows about the damn busters, not
everyone knows about the other stuff he did.

(21:16):
So I said in the post chat, hey, maybe we should do a bonus episode about Barnes Wallace.
And then I said, hey, watch it turn out that Barnes Wallace worked on the BAC 111 as well
as the F111, which it turns out he did.
It was not lost on me that this meant that the F111 and the BAC 111 were only one degree

(21:38):
of separation apart.
It turns out that he was the head aerodynamicist at BAC when both the 111 and Concorde were
being designed, which meant that not only did he design the Concorde intakes, but he
was also responsible for characterizing Deep Stall, which was first named on the 111.

(21:59):
And of course he consulted on the F111 variable geometry and control surface architecture.
And he built the world's first high altitude wind tunnel, which is to say Barnes damn busters
Wallace was instrumental in both the BAC 111 and the F111.

(22:22):
And how does this keep happening?
Seriously, this dumpy little airliner regional jet turns out to be secretly one of the most
influential and important planes ever built.
How does this keep happening?
I don't know.
It's pretty blessed.
Next slide.
Next slide.

(22:43):
Okay, so no corrections in this episode, but I just want to highlight an excellent comment
from the last episode that combines this show's love of cats, nuclear power, and poor quality
control.
A US waste facility had a runaway hot radiation incident because they had been using generic
kitty litter to seal drums of nuclear waste because it's normally inert and dry in a
way that apparently makes it a good material for that use.

(23:05):
But over time, someone got lax about ingredient control and used a bunch of cat litter with
different composition that became reactive to radioactive decay particles, causing it
becoming radioactive itself.
Standards, people.
Next slide.
All right, time to plug some capitalism.
Our Discord, as we like to say, is CPIT.
It is definitely the writer's room.

(23:25):
This podcast is just the output file.
We also want to celebrate our 150th patron and let you know that your contributions helped
keep our smallest host well stocked with plastic bricks and Sarah Candy.
And other things like food, but that's not as funny.
We also do bonus episodes.
We do do bonus episodes.
That's why we've gone so long since the last crash.

(23:45):
Sorry.
Our first bonus episode, Oops All News, had us talk in depth about Boeing issues.
The first time we told you not to get in a helicopter, unless you are a billionaire or
want to be dictator, in case we talk about why you should get your own helicopter license,
preferably just a VFR one.
We had dropped our second bonus recently about a terrible movie from Russia that features
a plane crash, a cover-up, and the craziest car chase I've seen this year.

(24:10):
We talked about the movie's cinematography, gave lessons about Russian name structure,
and have an extended argument over the value of going camping on your honeymoon.
Also as a reminder, at the $25 level, you get the care package above mailed to you,
even if you live near the poles, like some of our patrons.
We send a personalized letter with each one, and we do generally write like a half a dozen
original jokes for each letter.

(24:31):
We earn your money, sleep it, and we respect our audience.
Next slide.
Alright, so what is today's episode even about?
Today we are here to talk about Swiss Air.
Next slide.
Uh, pretty sure that's Swiss chocolate.
That is an illustration of the Swiss cheese model, which is...
Foreshadowing.
Foreshadowing.
Um, that's Switzerland from the air, but you are going in the right direction.

(24:57):
That's a Swiss airport.
We're very close.
Actually, this is Zurich Airport, which has a minor part in today's tale of woe.
Ah, there we go.
That's Swiss Air.
Okay.
So what is a Swiss Air?
Boy, are you all about to regret that question, because now I get to talk about airline financial
operations for the next five minutes.
Again.

(25:18):
I have broken all the relevant bits into three sections as defined by the movies you can
see on your screen.
So, from 1970s to 1980s, the Wolf of Wall Street.
This is the first, I've titled this section the first two thirds of most Scorsese movies.
So in this period, Switzerland's stability as a financial hub and one of the only countries
not flattened in World War II or spending most of their GDP trying to start World War

(25:41):
III meant that they were able to command a premium price for a premium product for
decades.
I mean, premium for the time.
Their first class in the era we're talking about in this episode is not even as nice
as Delta's domestic narrowbody first class.
I mean, 222 recliners, I'd rather die.
And at a time when everyone else was mixing their cabins or degrading quality to deal

(26:04):
with the oil crises, Swiss was doubling down on its premium product.
They did a full fleet replacement.
They embraced trijets, quad jacks.
They expanded their route networks and were one of the last airlines to fly routes into
Tehran and Baghdad during the Iran-Iraq war.
Remember, Swiss neutrality means that they can continue to operate even when everyone
else is trying to enforce sanctions.

(26:25):
LESLIE- Assumably this was before the war devolved into both sides trying to flatten
each other's capital cities with unguided missiles?
GERGES Yes, it was also before the US Navy was unable
to tell the difference between an airliner and an F-14.
NAREDA I have a note here saying that they even go
a little crazy and partner with Nestlé to buy and open hotels under the Swiss Hotel

(26:48):
brand name, which I had no idea was anything to do with them.
They were still kicking around.
GERGES They were just trying some shit.
NAREDA Yeah, they were still kicking around in 2005,
which was long after this escapade.
GERGES Alright, section 2, this is Mid 80s to 1991.

(27:11):
I have a chat of the section desperately trying to matter by joining the mean girls.
So Swiss decides that the new hotness is alliances.
They enter into the Global Excellence Alliance with Delta Airlines and Singapore Airlines
in 1989, hoping to help capture some of the market share from the dying Pan Am, who had
sold their transatlantic route slots to Delta for pennies on the dollar.

(27:31):
This was the progenitor of today's big three airline alliances, Star Alliance, One World
and the Absolute King, Sky Team.
They tried to merge with KLM, SAS, and Austrian Airlines to make a massive European airline.
It obviously did not work, was a massive waste of money and time, and the major Euro airlines
all split off and merged along different alliance lines, KLM and Air France, BA and Iberia,

(27:56):
Lufthansa and Austrian.
This failed merger is a huge black eye and sort of marks the beginning of the end for
Swiss Air.
Alright, section 3, 1991 to 2002.
I have a chat of the section.
Doc, I think she's bleeding now.
So the early 90s was really rough on everybody, especially in the European market.
The Gulf War and the subsequent torching of the Kuwaiti oilfields spiked the price of

(28:17):
gas.
The economy entered a recession.
They lost 99 million Swiss francs in the first half of 1991.
I don't know how much that is, but it sounds like a lot.
Yeah, US dollar was about 1.4 Swiss francs back then.
I suppose I could do math, but I'm not going to do it on air.
So they ended up having to dip into their stolen gold, I mean cash reserves, to stay
afloat.

(28:38):
This is also when they purchased Hotel Bravo in D'Aviski Foxtrot, the plane for today's
episode.
It doesn't end well for her, so don't get too attached.
Europe totally deregulated their domestic travel market in 1991, which took a toll on
the airline that was depending heavily on premium travelers and could not compete on
price.
Isair tries to aggro through the pain, trying to stem losses with expansion and aggressively

(29:01):
acquiring smaller stakes in several airlines.
As you can imagine, they lost all of their money.
Again.
The board fires the entire C-suite.
They keep chewing through operations management.
None of it's working.
They're just losing money too fast.
Eventually, they lost their entire credit line with Credit Suisse.
And pilots would occasionally be issued lock boxes full of actual cash to pay for fuel

(29:21):
and fees.
Currently Suisse will extend credit to the Sinaloa Cartel, but apparently they will draw
the lines at Jeté Payments to Swiss Air.
Yeah, and pilots paying for services with cash at the gate is something you only find
at the most esteemed global airlines such as Partnair.
Next slide.

(29:42):
It is within this environment that we will meet the villain of our episode, the in-flight
entertainment system.
It was a pay-to-use IFE system and it was intended as a way to raise quick liquid capital.
It was the very first of its kind.
It could play media and browse a very, very rudimentary intranet, all on a tiny little

(30:03):
LCD that was about six inches by four inches.
It was aftermarket, but it was designed on Swiss Air's behalf.
It was designed by a firm called Interactive Flight Technologies, a Las Vegas company that
was founded in 1995.
They thought they were going to make a fortune in-flight gambling, so they started pushing
these on airlines.
And we are going to talk a lot about this IFE in the next section.

(30:26):
The design integration into the aircraft and installation were done by Hollingset International,
while the certification and hazard analysis were done by Santa Barbara Aerospace, and
the work itself was done at the facilities of a subsidiary, or rather a sister company
of Swiss Air called SR Technics.
Now, we are going to talk about three of these companies a lot more in the aftermath.

(30:46):
So post at the names of the companies Kira has just given you.
Also, this was only installed on the premium seats for most of the fleet.
Now, they originally intended for this to be installed in all 257 seats on Swiss Air's
MD-11s, but they did that for the first two airplanes that were retrofitted, and then
after that they restricted it to only the 61 business and first class seats.

(31:06):
And apparently that's because 257 seatback units was too expensive and they wanted to
save money.
It also drew a metric fuckton of power.
We are going to get into that detail later, and believe me, this goes deep.
Next slide.
Let us ask ourselves, what is an MD-11?
I mean, besides a DC-10 that is somehow worse.

(31:28):
I mean, yeah, it's basically like this.
Okay, so a bit of background on this.
By the mid-80s, the DC-10 was getting really old.
Twin jets of the new hotness, the 767 and the A300-310 are demonstrating themselves.
They're impressing customers.
The A330 is already pretty far to development.
McDon Douglas, or as I like to call them, McDouble Dragon, needs a way to stay relevant,

(31:51):
so they did what they always do.
They look at a plane they've already made, they've already paid off the tooling for,
and said, what if we stretched it?
Listeners, this behavior would continue long after they designed the MD-11.
Just jam another fuselage plug in at statements of the utterly deranged.
Who do they think they're fooling?
Okay, so they made this flight.

(32:12):
They took the DC-10, they stretched it, they put bigger engines on it, they updated the
flight deck to make it flyable with two people.
Bafflingly, they shrunk the tailplane to reduce drag.
This made it tricky to fly and land.
Remember that fact the next time we do an MD-11 incident.
Now this business strategy did not work.
The plane fell short of performance and range targets.

(32:33):
It was ACL's disaster.
The fallout was so bad, MDD had to offer themselves up to Boeing on a platter.
The 767 outsold it by 7 to 1, the A300 by 4 to 1.
5 to 1 if you count the A310.
Which you should because they are exactly the same plane.
Now we're not going to go into why the DC-10 and the MD-11 suck.
We'll cover that in an episode that lends itself to that.

(32:55):
As a plane, it sucks ass, but not in a way that is relevant to the accident today.
Except for the part where it was built by McDonald Cheap Ass, who suck in a way that
is relevant to the accident today as we will soon describe in great detail.
Now this particular plane as we've said is Hotel Bravo, India, Whiskey Foxtrot, which

(33:16):
you can see here, looking stupid, with its stupid tailplane that's too small, its nose
gear in the wrong place, and its tail engine not using an S-duct.
You know, we absolutely could have done a spinal tap joke about the MD-11 being one
more, but we didn't.
I don't get it.
Alright, next slide.

(33:37):
So we have a janky and rushed in-flight entertainment system installed on a lower mid-tier aircraft
owned and operated by a broke airline.
What can go wrong?
Well, let's fly to the side of the crash.
Next slide.
It's September 2nd, 1998, and our MD-11 is about to fly from JFK, New York to Geneva

(33:57):
on a code share with Delta.
This will become interesting afterwards, but only if you are a lawyer.
The call sign is SR-111.
On the flight deck were 49-year-old Captain Urs Zimmermann, 10,800 hours of flying time,
with 900 on the MD-11, formerly a pilot of the Swiss Air Force, 36-year-old Officer Stefan
Lowe, 4,800 hours, 230 on the MD-11, also ex-Swiss Air Force.

(34:25):
And can I just say, thank God we have an issue where I can pronounce all of the names on
the first try.
Skill issue.
We kill out these numbers on a lot of these episodes and we can usually derive some kind
of conclusion from it, but as we are about to describe to you, very similar to hero of
the show Matt Bell and the most absolutely annoyed Chad that we know or possibly could

(34:47):
ever exist, the crew of this flight were completely doomed from the start.
There was nothing they could have done to make this come out any better, and all of
the experience in the world wouldn't have saved them.
So behind that pair were 215 passengers and 12 cabin crew.
And also just like, what I put in the notes as weird shit.

(35:10):
Two paintings, including a Picasso, Le Pintier, two pounds of diamonds, including a large
diamond from the Smithsonian, four pounds of Swiss watches, 10 pounds in jewellery,
50 kilograms of currency bound for a Swiss bank.
What currency?
Not specified.
Just not to ask questions.
Anyway, SR111 departs uneventfully at 20.18 local time or 21.18 Nova Scotia time.

(35:35):
Now why do you need to know Nova Scotia time?
Don't ask questions about that either.
Point is, it was dark.
As an aside, during the climb there was a 13 minute communications blackout with ATC.
The flight deck tried to call air traffic control 11 times.
ATC tried to call them eight times.
Finally comms are established, as far as anyone knows, this is completely irrelevant to everything

(35:59):
that's about to happen.
And these guys just fat fingered the frequency on the radio.
Other than that, everything was normal for the first 52 minutes until the aircraft was
positioned off the coast of Nova Scotia.
Now before we can really tell you what happened at that point, we're going to have to do
quite a bit of material science.
So Jay, the floor is yours.

(36:21):
Next slide.
Oh boy.
So let's talk about insulation and why you shouldn't use birthday balloon material in
your airplane.
As a frantically whispered sidebar, we are going to cover two kinds of insulation, wiring
and thermal.
They're both called the same thing, both went wrong in different ways.
Sorry, don't blame me, blame the fact that thermal engineers and electrical engineers

(36:46):
have only recently started talking to each other and being invited to each other's parties.
Engineers have insulation around them because having the conductor exposed is very bad and
can cause short circuits.
There have been various different kinds of insulation used on aircraft wiring over the
last 80 years.
Kaptone, which is also known as polyimide, looked like a wonder material.

(37:10):
It's very light, unreasonably strong when pulled very thin, very heat resistant, really
doesn't want to burn.
But unfortunately it can become brittle over time.
It also carbonizes and becomes conductive if it gets too hot, which means that it's
subject to a phenomenon called arc tracking, where an arc kind of moves up the cable, kind

(37:31):
of like the fuse burning down in the Mission Impossible title sequence.
Not that this is relevant because this didn't appear to happen in this accident.
When it gets old, it can get brittle and crack and obviously that's bad because then you've
got exposed conductors, which as we previously said, very bad.
This plane had Kaptone insulated wiring.

(37:53):
This is not relevant to this accident because that's not where the fire started as far as
we're aware.
We don't believe that to be the case.
Another kind of insulation is Teflon, which is also known as polytetrafluoroethylene or
PTFE, which is a really good insulator, very thermally stable, will not burn unless it

(38:15):
gets extremely hot, does like to give off toxic fumes.
It's also almost comically soft as a plastic, almost impossible to attach to things because
I mean, it's Teflon, right?
You can't glue it or hold it by crimping.
It's very expensive to work with.

(38:36):
It's very easy to damage it by chafing or that kind of thing, which incidentally is
actually what killed the crew of Apollo 1 because that whole thing had been taken apart
and put back together so frequently that the wiring had become chafed and shorted out.
And so people don't like to work with it because it's very expensive to work with because you

(39:01):
have to do all of these complicated things to keep it safe.
Instead, a lot of planes have materials like ETFE, which is ethylene, tetrafluoroethylene
copolymer, and polyvinyl fluoride, which is like PVC except with fluorine instead of chlorine.
They are kind of similar.

(39:22):
They have a lower melting point, are somewhat mechanically stronger and are easier to deal
with, but they will burn if you get them hot enough.
And when you get them very hot, it will melt.
That makes it easier to manufacture into stuff, whereas PTFE tends to actually degrade before

(39:42):
it will melt.
So you can't like extrude it or things like that, or at least it's very difficult to do
so.
And of course, the other type of insulation on aircraft is very similar to the kind that
you might have inside your walls, which is thermal and acoustic insulation, which is
usually made of fiberglass batting with some kind of plastic on either side to keep it

(40:08):
from shedding fiberglass because in these spaces in planes, there's often a lot of air
movement and you obviously don't want bits of glass fibers landing in your cabin.
So this is stuffed in everywhere around the structural elements and skin and around air
ducts and all of that kind of thing.

(40:29):
To keep the cabin warm, to reduce cabin noise, to keep aerodynamic noise from the outside
of the plane from getting in, just sort of general thermal and acoustic insulation, which
is what it's called.
Next slide, please.
And so as I say, to stop the fiberglass insulation material from shedding, absorbing moisture,

(40:53):
getting damaged when people are sort of moving around it, each sheet is actually encased
in a blanket, a covering on either side, which in this case was made of metallized polyethylene
terephthalate, which is also known as BOPET, which is biaxially oriented polyethylene terephthalate,

(41:17):
which is also known as Mylar.
So yeah, that's stuff helium balloons are made of.
It's a great aerospace material.
I mean, there's a reason they call it a space blanket, right?
It doesn't get brittle when it's old.
You can make it very cold without it cracking or shattering.
It doesn't turn conductive when it gets too hot because it catches fire instead.

(41:42):
Is that foreshadowing?
Might be.
It's cheap and reflective and it's cheap and also it's cheap.
Did I mention it's cheap?
So you're saying it might have been used as a way by McDaisy Duck to cut costs?
Well, the answer we give largely has to depend on the statute of limitations for slander

(42:03):
and whether Boeing considers it as an actionable statement.
Given that it did later become an airworthiness directive to remove this stuff.
I feel like we would be pretty safe to say this was not a good material for this application.
But it was widely used by manufacturers.
So this was McDonald Douglas being cheap only to the extent that almost everybody was cheap.

(42:30):
It is a good material.
I mean, it's a great material as long as you're aware of its limitations.
Now as we said, Mylar is flammable.
If you ignite it, it will burn, which is sub optimal on an airplane.
If a less flammable material exists, which it did.
However, at that time, FAA flammability regulations were only very strict from materials inside

(42:52):
the passenger cabin and in certain designated fire zones, namely the engines, the auxiliary
power unit, the wheel wells, and a couple other places that routinely had very hot things
in them.
Inside the cabin, flammability requirements were strict in order to slow the spread of
a post crash fire.
If a fire erupted in the cabin in flight, it was expected that flight attendants could

(43:12):
put it out easily, which is generally the case.
However, materials in the hidden spaces of the airplane, which is where you find insulation,
have lower flammability standards because they weren't as critical to protecting human
life in a post crash fire scenario.
The side effect of this was paradoxically, that flammability standards were lower in
areas of the airplane where firefighting by the cabin crew was impossible.

(43:36):
Now fire testing of these materials generally consisted of Bunsen burner tests with flame
exposure at various angles for time periods up to 60 seconds with subsequent measurement
of continued flame time, burning drips, extended flame spread, etc.
And generally the burn rate had to be under about 4 cm per minute and there was no requirement
for these materials to be self extinguishing.

(43:57):
Now Mylar will pass these tests because it takes more than 60 seconds for Bunsen burner
to ignite it, but it will ignite fairly easily and once it does, it will propagate flame
indefinitely.
And yeah, if you have a source of heat that is hotter than a Bunsen burner, it will take
less than 60 seconds to ignite it.
Obviously.
As one would expect, this insulation did occasionally catch fire, thankfully mostly when planes

(44:23):
were on the ground.
The report that we have calls out 7 cases of non-fatal fires caused by Mylar insulation
blankets igniting between 1993 and 1999, three of which were on MD-11s.
Not so coincidentally.
Two of these incidents were investigated by the Civil Aviation Administration of China,

(44:47):
which was alarmed to find that the stuff had basically no fire resistant properties whatsoever.
So in 1996 they issued a recommendation to the FAA which stated and I quote, the insulation
blanket installed in the Boeing 737-300 and MD-11 airplanes is flammable.

(45:09):
They should make a prompt and positive response.
Which is about the most unequivocal any of these organisations is ever going to get.
As a result of this recommendation, McDarkwin Duck carried out more fire testing of Mylar
blankets and they actually agreed that the flammability characteristics of the material

(45:30):
were suboptimal.
So from 1996, McDaisy Dukes stopped using Mylar on its planes, but there were still
tons of planes out there that already had the stuff.
And so McDangerous Dave issued a service bulletin to all MD-11 operators recommending that they
replace any Mylar insulation blankets on their existing aircraft.

(45:54):
However this was only a service bulletin, it wasn't actually enforceable because the
FAA did not issue an airworthiness directive mandating compliance.
Well guess what, it wasn't an airworthiness directive so it didn't get done.
It wasn't just Swissair, it was everyone who had McDonnell Douglas planes.

(46:14):
Nobody did this.
Every airline's just going, that service bulletin sounds like a hassle, let's not
do that one.
And that's why airworthiness directives are a thing.
I mean no shit, McDonnell Douglas more like McDonnell Don't-gless.
Pathetic.
Well if it was important, it would be an AD.
I mean literally yes, you know like a totally captured agency like the FAA gets hassled

(46:37):
every single time they list an AD.
Some airline or manufacturer or parts supplier, CEO calling the FAA director and going, come
on man seriously, why can't this just be a service bulletin?
So anyway, the end result was that our plane, Hotel Bravo India Whiskey Foxtrot, was still
chock full of this stuff in 1998.

(46:59):
Next slide.
Okay, so we're moving to our next topic, the MD-11's electrical system.
So what is an AC bus and why did we include a picture of a home circuit panel?
Okay, because that's an AC bus.
That's all an AC bus is.
A bus is literally a set of conductors that has sort of things attached to it.
In the case of an electrical power bus, it's loads that are connected to the conductors

(47:26):
and obviously sources of power connected to the conductors as well.
It's not anything special, it's just a name for some parallel conductors that you use
to have things all connected in one place.
So on an airplane, electricity is generated by engine driven generators, sometimes inverters

(47:46):
as well, and it goes to various buses and those buses then distribute it to other buses,
which then distribute it to aircraft systems.
So for example, every system in the passenger cabin, like the lights and the fasten seatbelt
signs and so on, is hooked up to one of eight AC cabin buses.

(48:08):
So you would think that the in-flight entertainment system would be two, right?
Okay, so on that, we briefly mentioned earlier how the IFE system drew a ton of power.
Well, specifically it drew so much power it could not be hooked up to the main cabin buses.
Yeah, the cabin bus had too small of a breaker to run both the existing loads and the new

(48:28):
in-flight entertainment system.
It would have tripped constantly.
However, the main AC buses actually have heavy loads like electric hydraulic pumps and the
heaters and the oven in the galley and this kind of thing.
So they are rated for much higher currents.
So when the in-flight entertainment system was implemented, it was actually hooked up

(48:53):
to main AC bus two and not the cabin bus.
We're going to get into why that was such a problem in a bit.
But first, I'm going to digress into ass clownery in embedded systems.
Now some of you may know that I have a long and tawdry career in embedded systems and

(49:13):
the system that IFT had built was a bunch of embedded computers.
There was a computer at every seat and every interface had a magnetic card reader because
the Swiss national motto is fuck you pay me and they wanted to get money out of the passengers.
This would have been fine if they'd been like iPads, but unfortunately the iPad hadn't

(49:37):
been invented yet and so they were x86 PCs.
And because of function creep, their seatback unit went from basically a cable TV set-top
box controlling an analogue tuner to do pay-per-view movies and the processor in a first generation
Apple Airport base station to a late 90s high-end desktop replacement laptop and they were much

(50:03):
too big to go inside the seatback.
At least, you know, you could probably have fitted them in there but they wouldn't have
been able to cool themselves.
A 1998 desktop replacement laptop also consumes a lot more power than an iPad does.
You know, they had aimed at using this ultra-low power processor like an AMD SC400 or a NAT

(50:25):
semi-geode running at a low frequency but they weren't fast enough to run these crappy
flash-based lottery games that they were trying to charge people for and have them, you know,
gamble real money.
So they had to be upgraded to much faster PCs and which for some reason instead of running

(50:46):
something like, I don't know, VXWorks or QNX or Linux, yeah, Linux was around in the mid-90s.
It was a thing.
I did it for a living.
It was kind of raw.
They instead decided that they should run the latest and greatest from Redmond, Windows

(51:07):
NT4 on all of these seatback computers which, you know, if you remember that, that was a
bold move.
You know, most people wouldn't run that on their desktop computer, never mind, you know,
some very lightweight machine.
And so the reason they were doing this is because they got it into their heads that

(51:29):
they needed all of this security and obviously Windows 98 wasn't going to do it.
And this all meant that it ended up consuming more power and just way more power than they
were expecting.
Yes, if you're wondering, you could actually run Doom on it.
One of the things you could do was pay to play Doom.

(51:50):
No fucking way.
There also had to be a pretty sizeable server in the galley running Windows NT4, actually
two of them.
One of them for running the pay-per-view video system which was basically an entire cable
TV system, like the kind of thing that you would have in your town to run a cable TV

(52:16):
system but in small and in an electronics rack in this play.
And also a second one for actually running a data network, an ethernet network, that
handled all of these gambling games.
So there were actually two big meaty servers and they also drew a sizeable amount of power.

(52:42):
The specification was that for just the restricted installation on the accident aircraft, it
was rated at 4.4 kilowatts.
Next slide please.
So they completely blew the power budget for this system.
The power architecture that Hollingshead had designed had the in-flight entertainment system's

(53:03):
load broken into four separate cables, each of which would be attached to one of the eight
cabin power buses by a breaker.
And there's a cross section or a...
Is it really a cross section?
They've just taken the lid off.
An aircraft style breaker.
You're looking across it and it's a section of it.
That's a cross section.
Okay.

(53:23):
Well, it's anyway, it's a clicks on type circuit breaker, very similar to the kind that they
use on aircraft or in fact, specifically the kind they use on aircraft.
Although I don't know if these exact ones were the ones that they used on the accident
plane.
Anyway, as the in-flight entertainment system's actual power consumption increased, Hollingshead

(53:49):
moved everything from being spread across cabin buses to being attached to one huge
eight gauge cable, which was connected to a breaker on main AC bus two, which I'm sorry,
we really tried to find out what the exact specification of this breaker was, but unfortunately

(54:10):
the TSB doesn't really give you access to the original documents.
They just give you their interpretation of them.
NTSB would have just had a, like a folder on their website with all of the original
documents and you know, as you've seen, we are not afraid to go through those to try
and find out what actually happened, but unfortunately Canada's TSB just doesn't do that.

(54:36):
So the only information we have about this, because Hollingshead does not make these documents
public and the other companies involved are long since bankrupt.
So we have no access to those original documents.
We did try.
Anyway, it's connected to this main AC bus two, which has all of these major aircraft

(55:02):
systems on it.
It has a lot of power and a lot of instantaneous current available at this bus, which has this
big chunky eight gauge cable attached to it.
And we should note that nobody involved in designing any of this had any real knowledge
of the MD-11's electrical system or its design philosophy.

(55:23):
And obviously as far as we can tell, no one called McDouble there.
Hey, we're going to call the company that made the jet.
Nah?
Cool.
So the load shedding architecture, which is actually what they call it of the MD-11, which
is basically a DC-10, except that the flight engineer is literally an empty chair.

(55:47):
Actually that's not a joke or an exaggeration.
The flight engineer's station is still there.
It's just that they renamed it to the observer's seat.
It's the most ridiculous thing.
Anyway, this load shedding architecture is such that in an emergency, there's a relay

(56:08):
system that can shut down these cabin buses, which saves power and reduces the scope of
any electrical faults that might happen.
The in-flight entertainment system was no longer on this cabin power supply.
So if they hit the, I have an electrical emergency button, it would not shut down the in-flight

(56:31):
entertainment system.
Because as a passenger, you want to continue playing Doom as your plane plunges toward
the sea.
I want to make a knee deep in the dead reference, but it's just too bad taste even for me.
Oh my God.
How about an I'm too young to die?
Nope, nope.

(56:52):
There's so many we could do.
Not that this was really relevant in this case, but it's symptomatic of a wider problem
with this whole job, which is that nobody seems to have actually bothered doing any
sort of reasonable failure mode analysis or safety design at any point, because the whole

(57:13):
system was non-essential.
Literally.
Hollingsed contracted the hazard analysis to Santa Barbara Aerospace, which characterized
the system as non-essential, meaning that legally they were only required to do a qualitative
hazard analysis, which means have a guy look at it and think real hard.
There's nothing quantitative about it.

(57:34):
And also, the guy isn't even required to know what an MD-11 is or be an electrical engineer.
Which needless to say, totally fucked the safety case.
If you've done this in your house, the city would red tag it.
This is the kind of shit that gets your electricity meter taken away.
When you choose a breaker, you're supposed to choose a value that is lower than the carrying

(57:57):
capacity of the conductors it's protecting.
And you're supposed to make sure that you can sustain the short circuit current long
enough to trip the breaker without anything catching fire.
When you make modifications to wiring on a plane, you're supposed to understand what
you did and what that does to the assumptions on which the safety case is based.

(58:19):
Unfortunately, the Inflite Entertainment Systems wiring was not rated for much higher current.
So the breaker on this main bus was probably rated too highly to protect these relatively
skinny IFE system cables.
And the 8 gauge cable that goes back there can supply a lot of instantaneous current

(58:40):
from this AC bus which has a lot of rotating mass on it.
Because remember, the alternator on each of those jet engines is directly connected mechanically
to the rotating assembly in the jet engine.
And so if you short out the power that is coming out of that, there is a lot, a lot

(59:05):
of inertia behind it and there is a lot, a lot of current that can flow very briefly.
It falls to the Inflite Entertainment breakers themselves to do this.
Four 15 amp three phase breakers protecting four 12 gauge cables.
Literally the extension cord you use to run your lawnmower.

(59:27):
Next slide.
So Jay is going to tell you a little bit about what happened after the terrible system required
a ton of power and why none of the fail safes stopped it from causing a short.
Actually Jay, what is a short?
Let's go into it.
Okay.
So it's kind of the opposite of the thing that crashed that Antonov in your recent article.
In that case, a ground came disconnected and it made the electricity take the long way

(59:50):
around the houses to get back to where it came from.
Even electricity knows you can always go around or go to ground, go around, go to ground.
Indeed, indeed.
In the case of a short circuit, inadvertently you gave electricity a shortcut.
Instead of going through whatever load it was supposed to power, it just says well and

(01:00:11):
goes home and all of that energy is going to go somewhere.
And the place it's going to go is heat.
Heat is where it's going to go because all energy ultimately wants to be heat.
You're going to get this current spike, which in theory should trip the circuit breaker
and cut off power, but it will take a time to do that, which depends on the breaker's

(01:00:31):
time current curve.
Because a lot of stuff like motors and power supplies and things like that draw a lot of
current when they're first turned on, but rapidly settle down as they charge up their
capacitors or start rotating or warm up.
This is called inrush current, which is obviously a nuisance if it keeps tripping breakers.

(01:00:53):
So these breakers have a time delay factor.
If you draw massively too much current, then it trips faster than if you only draw a little
bit too much.
And for any given breaker, you can plot this relationship as a graph, which is a time current
curve.
So the way this actually works is that the current flows through a heater and there's

(01:01:13):
a bimetallic strip, kind of like an old school thermostat, that will actually cause this
switch to click over and open when it gets too hot, except that it doesn't turn itself
back on when it cools down.
At a certain temperature, this strip bends and the breaker pops out.

(01:01:34):
The problem with this during a short circuit that's not grossly above the rating of the
circuit breaker, the current can persist for a while before the breaker trips, during which
time the wire can get really hot, form a hot spot, break open and arc over.
Because the electricity has sort of inertia, we call it inductance, where it will resist

(01:01:56):
changes in current.
So if it's flowing, it wants to keep flowing.
And so if you open a little gap in the wire, it will actually jump that gap and it will
make plasma.
And that plasma is extremely hot.
It can rapidly set fire to materials around it.
Foreshadowing.

(01:02:17):
So part of the safety design for the MD-11 electrical system is that buses that need
to supply a lot of power are separated into multiple different loads.
This is very common in aircraft.
And each of these loads has its own breaker.
And there are actually eight cabin buses in the MD-11 so that each one can have its own
breaker with a lower amp rating so that it can pop before anything catches fire.

(01:02:41):
And the reason that they did this is that the risk of cable damage obviously increases
as cables get longer because there's just more cable, right?
Cables that go all the way around the cabin tend to be quite long on a plane that seats
more than 250 people.
Especially if it's been stretched out of all reasonableness because that is McNingle

(01:03:01):
Dongle's one move.
The company that installed the Inflate Entertainment System could have done the same thing.
And they did use four separate 15 amp breakers.
But a better safety margin could have been achieved if they'd had more.
The short circuit current available to AC bus 2 is a lot higher than the cabin buses.

(01:03:22):
So when a short happens, it is just more energetic for that interval of time before the breaker
pops.
And I do want to point out that circuit breakers being rated too high and allowing short circuits
to persist was a big problem in aviation in general, which was called out in the final
report.
And I sort of assume the issue is that you can only fit so many circuit breakers in a

(01:03:43):
cockpit.
So I don't necessarily think the level of protection that was provided to the Inflate
Entertainment Network by its four 15 amp circuit breakers was lower than usual, even though
it was also, as we will soon see, not enough.
I mean, another problem is that the thermal miniature circuit breaker technology that

(01:04:04):
they use is very old and not very good.
And there's a lot of type approval inertia in aviation.
You know, the magnetic circuit breakers you have in your house can trip hundreds of times
faster.
And there are even special circuit breakers that detect arcs specifically.
They're called arc fault circuit interrupters that are mandatory in some applications and

(01:04:28):
in all new construction in the United States.
And of course, aviation just doesn't use them.
And next slide.
Jay, when you said electricity wants to become heat, I always made a joke that was like,
I also want to only be hot.
True.
OK, so the big issue here was that design was just overall kind of shitty and oversight

(01:04:51):
was even shittier.
It was poor to non-existent.
The FAA wasn't really involved because they designated Santa Barbara Aerospace as a company
that was certified to determine its own regulatory compliance of a supplemental type certificate.
But in practice, SBA was just, I don't know, I would call it a half-assed job.

(01:05:12):
It was maybe quarter-assed.
The TSB report does point this out and they are quite snippy about it.
There's also the matter of the total lack of documentation or total lack of being able
to keep the documentation up to date as things changed.

(01:05:33):
And due diligence between Hollingshead and SBA was just extremely lacking.
There were a lot of subcontractors involved here and none of them had the full picture.
And none of them really understood the MD-11.
And another question is what was SR Technics involvement in all of this?

(01:05:55):
SR Technics was at that time a wholly owned subsidiary of the Essair Group, which also
owned Swissair.
And they owned, and I guess they still do, a hangar at Zurich where this work was being
done.
They may or may not have provided staff for this.
The TSB report doesn't provide original documents, isn't very clear on this topic.

(01:06:17):
They may not have been able to determine it themselves.
Subcontractors not talking to each other and sharing updates and designs is an extremely
common failure point.
Poor governance among sub-case is the bane of the implementation consultant's entire
existence.
Because you don't even get to this could have been an email.
The default setting becomes, eh, they'll figure it out, or someone else on the team

(01:06:38):
will make sure they get notified of the change order and it doesn't happen.
Their two most common communication failures between implementation parties are oversharing
to the point of noise and what happened here, undersharing, which the team or person managing
governance end up with the exact same result.
Ultimately, they should have re-architected the wiring and made sure it was capable of
carrying a short circuit current without the cables failing, split the system into multiple

(01:07:01):
segments with separate breakers, but they did not.
They didn't even upgrade the cables carrying the power when they moved them from the cabin
buses with relatively limited short circuit energy to AC bus 2, which is pretty much directly
connected to the engine alternators.
As an aside, the plane's wiring was insulated with Kapton, which is polyimide, but the IFE

(01:07:26):
system's wiring was insulated with ETFE, which is, as we said earlier, a soft polymer
similar to Teflon.
It's a thermoplastic and will melt if you get it hot enough, but also notable is that
it is much, much softer than Kapton.
If you rub a Kapton insulated wire against an ETFE insulated one, the ETFE insulation

(01:07:47):
will get chafed away.
There is a non-binding FAA advisory circular which advises manufacturers not to run wires
insulated with different hardness insulation in the same bundle or to allow them to come
into contact or cross each other.
There's no sign that HollingsEd or SBA gave any kind of shits about this, and we don't

(01:08:12):
know, because everything was so variable, whether this was a factor in this situation.
So Jay made a joke earlier about this kind of work getting red tagged.
I actually checked.
This work literally would not have been approved within King, San Mateo, or Fulton Counties.
If my electrician had taken this many shortcuts when wiring my new induction stove, I would

(01:08:33):
have sent him back out to redo the work.
He didn't because he's really good at it, and he always uses a cable rig for the worst
case scenario plus a safety margin.
A solution that was not obvious to any of these parties, including McDon Draper.
So I actually checked and it's the same in San Francisco County, which is very relevant
to me right now because I just bought a house and my world is permits, pulling permits.

(01:08:58):
And to be entirely fair to McDownward's dog, there's zero evidence that they had any idea
that Switzer was doing any of this shit.
At no point did HI or SBA actually consult with them, which should have been a huge red
flag but apparently wasn't.
And this failure of oversight and poor system design ultimately removed many layers of protection

(01:09:24):
against the catastrophic failure.
SBA was allowed to self-certify to the FAA that the system was compliant, which it wasn't.
There were wire bundles containing wires that were insulated by soft ETFE that could have
come in contact with hard polyimide.
There were narrow gauge wires attached to circuits with extremely high instantaneous

(01:09:47):
current capability.
The circuit breakers were not capable of rapidly tripping when a momentary short circuit occurs.
The wiring shared space with flammable material including metallized mylar insulation, nylon
hook and loop fasteners, polyvinyl fluoride sheeting, and there was no way to rapidly

(01:10:07):
isolate the system while leaving essential systems powered because AC bus 2 has essential
loads on it.
And technically you could pull the circuit breakers for the IFE, but only if you knew
the IFE was specifically causing a problem, which you wouldn't.
So the IFE breakers are actually behind the right hand seat and are probably kind of difficult

(01:10:29):
to reach from the normal seated position.
A brief interjection.
So our research on these IFE units and the MD-11 Selectable System was pretty extensive.
We only scratched the surface of it here.
If you want to discuss this in detail with us or any other aspect of this crash, give
Kira money and you can do it on the Discord with the three of us.
Unlike other engineering podcasts with slides, we actually hang out on our own server and

(01:10:54):
we know a lot more about the covered subjects that gets left out and on the editing room
floor.
But anyway, this brings us back to Flight SR111, which is currently cruising off the
coast of Nova Scotia.
So next slide, let's get to our accident sequence.
The time is 2210.
The accident sequence is about to begin.
So we are now in whoop whoop, pull up, Kira, all yours.

(01:11:15):
So sometime before 2210 local time, one of the four in-flight entertainment system power
supply cables short-circuited in the space above the upper right-hand side of the cockpit.
We don't actually know what it short-circuited with or why.
To get a short circuit like this, you need two wires with damaged insulation near each
other or two wires near a third thing that's conductive or an exposed wire touching a fuselage

(01:11:39):
element.
So how is this wire or wires damaged?
We don't know, but we can actually mostly rule out chafing due to multiple insulation
types, which Jay discussed earlier, because this wire was in a bundle that was just IFE
wires, which were all ethylene, tetrafluoroethylene, ETFE.
It can't be totally ruled out that there was a polyimide wire in the vicinity that crossed

(01:12:00):
paths with it and chafed it, but there's no evidence of that.
So just keep in mind that the exact wire routing was different on every aircraft because the
documentation and installation were shit, so we can't be completely sure.
In fact, after the accident, the TSB actually looked at all of the other MD-11s that had
had this work done by Swissair, and they were all different.

(01:12:21):
No two of them were identical.
The wiring layout, the cable restraints, all slightly different, which makes it very hard
to know exactly what happened.
And speaking of that shitty installation, damage during the rushed and haphazard installation
process could very well be the root cause of this short circuit.
So the damaged power supply cable might have short circuited with another power supply

(01:12:43):
cable, or two damaged power supply cables may have short circuited via an aluminum wire
support bracket that was in the area.
Spoiler alert, only the one shorted power cable was ever found, so the other half of
the equation remains a mystery.
But what we do know is the short circuit melted the copper conductor inside the wires, at
which point the high current 115 volts AC arced over the gap, and an arc is basically

(01:13:07):
just a persistent spark where the current jumps past the damaged area through a superheated
bridge of plasma like Jay described earlier.
Thing is, this arc was not of a high enough current to immediately trip the 15 amp IFE
circuit breakers, see previous foreshadowing.
Therefore, it persisted for long enough to ignite a nearby Mylar insulation blanket inside

(01:13:28):
the cockpit attic space, because remember, that stuff will ignite and propagate flame
if it's exposed to a heat source for more than a few seconds.
So now we have a fire onboard the aircraft, and at 2210 and 38 seconds, First Officer
Low notices a smell of smoke and thus begins our accident sequence.
And almost at the same time as Low makes the comment about smell, Captain Zimmerman spots

(01:13:53):
smoke coming down from the ceiling in the back of the cockpit.
Quick note everyone.
We normally read out lines verbatim, but we can't do that in this episode.
The TSB does not publish CVR transcripts, only paraphrasing, so that's kind of what
we're going off of here.
Yeah, I mean, they publish select lines when they think those lines are especially relevant,
but it's not consistent, so we're not using them.

(01:14:14):
Yeah, also, when the NTSB tends to release the original documents, TSB only releases
their interpretations of them, which is particularly frustrating when the companies involved have
purged all evidence of themselves from the internet, so you can't go back to the source
material.
And you know, the TSB?

(01:14:34):
Not actually electrical engineers.
I mean, they probably, they had, I'm sure they have electrical engineers in their employ.
But anyway.
We also have to minimize the number of aircraft we become obsessed with and try to find documentation
for.
Yeah, true.
Anyway, tensions aside.
So at this point, the fire was still relatively small.
It was burning across the surface of the Mylar blankets toward the rear cockpit wall, and

(01:14:57):
smoke was escaping through holes and seams in the ceiling at the back of the cockpit.
This also happened to be where one of the overhead air diffusers was located, which
coincidentally led the crew to believe that the smoke was coming from the air conditioning
system.
Now, air conditioning smoke is relatively common and can usually be isolated pretty
easily.
So them going with this was not a bad call.

(01:15:19):
It's not super uncommon for an oil leak in one of the air packs to produce foul-smelling
smoke.
And it's the most likely source of smoke in the cabin.
I've personally experienced this while flying for work.
If you fly enough, you probably experience it eventually.
Yeah, actually, there's interesting statistics in the TSB report, which is that we tend to
assume that the air conditioning is the default source whenever there's smoke, even though

(01:15:42):
actually statistics show that over 50% of smoke and fume events on aircraft are electrical
in origin.
This is also as an aside because so many of these smoke and fume events and benignly land
was the last item on the air conditioning smoke checklist and applied only if the smoke
was persistent, quote unquote.
Informally, Swissair taught pilots that if the smoke didn't go away within five minutes,

(01:16:05):
then it was considered persistent.
But we should note that if you have a fire on board, those five minutes can be the difference
between life and death.
We'll analyze that a bit more later.
So anyway, the pilots pull up the air system synoptic page on their multifunction display
to try and diagnose the problem.
But actually, within a minute, the visible smoke goes away.
And they don't know that this is actually because the flame front has progressed aft

(01:16:28):
through a cutout in the rear smoke barrier above the cockpit door and the smoke is no
longer being drawn into the cockpit, but it's still burning.
So at 2212, the pilots call a flight attendant to double check if she can smell anything.
And she says she can in the cockpit, but there's no smell in the cabin.
And other than that, there's no longer any sign of a problem.
But at 2213, the smoke comes back because the fire is spreading to more insulation material

(01:16:52):
and other flammable elements in the attic, and some of it is making its way back into
the cockpit.
However, at this point, the seat of the fire is actually just behind and above the cockpit
door inside the galley ceiling.
Now, the pilots obviously know nothing about this.
In fact, pilots in general weren't even aware that the attic contained both ignition
sources and flammable materials.
So the idea that there was a fire in the attic wouldn't have crossed their minds initially.

(01:17:15):
Instead, they were looking at a situation with very limited smoke, no signs of problems
in the cabin, no equipment failures, no fire alarms, and no pop circuit breakers.
However, since the smoke wasn't going away, they did decide that they should make a precautionary
landing.
Notably, this was not an emergency at this stage.
They were going to make a normal, stable descent to an alternate airport to get the plane checked

(01:17:37):
out.
Remember weather at New York, Boston, and Moncton, none of which are particularly nearby?
However, just before 2214, Captain Zimmerman comments that, quote, that's not doing well
at all up there, which is suggesting that the smoke is getting thicker and the urgency
to divert starts to increase.
So at 2214, the flight crew calls Moncton Air Traffic Control Center and declares Pan

(01:18:00):
Pan due to smoke in the cockpit.
Pan Pan tells ATC that you need priority, but it doesn't carry the same weight as a
full Mayday.
And the crew initially request to return to Boston, which is 300 nautical miles behind
them, and they're cleared to turn back to Boston and descend to 31,000 feet.
However, one minute later, the controller suggests Halifax, Nova Scotia, which is 62

(01:18:21):
nautical miles ahead of them, and Captain Zimmerman agrees to go into Halifax because
it's closer.
So before beginning the diversion, both pilots don their oxygen masks, and the pilots begin
a rather ordinary 2,000 foot per minute descent, indicating that at this point they still weren't
viewing the situation as an emergency.
Because in fact, there were still no signs of anything technically wrong with the aircraft.

(01:18:43):
Zimmerman does the proper CRM move and orders Lowd to take over as pilot flying so he can
troubleshoot and get a better idea of what is happening.
So they're now 56 nautical miles from Halifax.
Moncton Air Traffic Control Center clears them down to 10,000 feet.
The crew extends the speed brakes for a 4,000 feet per minute descent.
Zimmerman calls the lead flight attendant to the cockpit and he tells her to brief the

(01:19:06):
passengers that they're going to divert to Halifax and land in 20 to 30 minutes, and
that he's running checklists for smoke in the air conditioning system.
So at 22, 18 they're cleared down to 3,000 feet, but Lowd says they need to stay at 8,000
to give the cabin crew time to prep for landing, because they were in the middle of the dinner
service at that point.
ATC starts giving them radar vectors to runway 06.

(01:19:29):
However, at this point they were still at 21,000 feet with only 30 miles to the runway,
which was too high to go straight in, so the controller cleared them to start in orbit
to lose altitude.
The pilots were conscious of the risks.
They discussed how they might expedite the descent if the smoke got any thicker.
However, there was another complication, because at 22, 20, First Officer Lowd points out that

(01:19:50):
they're above their maximum landing weight, because it's still early in the flight and
they haven't burned most of their planned fuel.
In an emergency you can land overweight, but the landing gear just has to be thoroughly
inspected afterwards, and you might set the brakes on fire trying to stop on the runway.
But so far the symptoms hadn't changed.
There was still just a bit of smoke drifting around the cockpit and galley with no alarms

(01:20:10):
or failures, so they decided that it would be safer to try to dump their excess fuel
rather than land overweight.
Now we have to talk about dumping fuel.
In short, dumping fuel is exactly what it sounds like.
Small valves, usually in the back of the wingtips as you can see.
They get raw fuel directly into the air behind the aircraft.
This capability is effectively exclusive to widebodies because the difference between

(01:20:35):
their maximum takeoff weight and the maximum landing weight can be huge.
For instance, on an A320 the difference is 26,500 pounds, and on an A350-1000 on the
other hand the difference is 183,000 pounds, which is an entire A320, complete with fuel.

(01:20:57):
And that difference is enough that it makes a serious difference in landing performance.
So on an aerobody, when you're pretty close, you don't really need the dump valves.
You either fly in circles to burn gas, or you chance it and you pick the longest runway
you can get too quickly.
On this flight they'd taken off weighing 530,419 pounds.

(01:21:17):
Their maximum emergency landing weight was 480,470 pounds.
The weather was marginal, and the runway at Halifax is less than 10,000 feet, so the pilots
may have wanted to play it safe, not knowing the extent of their emergency.
You might be inclined to second guess their decision, and you shouldn't, and we'll
discuss why at the end.
So if you want to dump fuel, you'll want to try and be over water if you can, because

(01:21:39):
it's not a good idea to spray kerosene all over people's housing if you can avoid it.
And our flight crew, having no idea how bad things were about to be, decides to try to
get below max landing weight, but they're already over land, so they request vectors
to try to get back to over water.
So ATC gives them a new course of 200, which is out over St. Margaret's Bay, southwest

(01:21:59):
of Halifax, and Low tells ATC they're going to stay at 10,000 feet while they dump the
fuel.
So the crew steer to the south, they set up for fuel dumping, and they program the flight
management system for an approach to runway 6 as soon as they're done.
So this time Zimmerman indicates he's still working on the air conditioning smoke check
list, but it soon becomes clear that it hasn't helped their situation at all, and this is

(01:22:21):
when he presumably switches over to the smoke and fumes of unknown origin checklist for
the first time.
Smokes of unknown origin, of course, are what you get handed when you're hanging out with
some dudes in Egypt, and they offer you a pack with an Arabic label, and you don't
want to be rude.
I take it this comes from experience.
No comment.
Yeah, so the first item on the new checklist, the smoke of unknown origin checklist, calls

(01:22:43):
for turning off the cabin bus switch, remember that?
So the idea behind this checklist is that if the smoke is electrical in origin, turning
off each electrical bus in turn will help the crew isolate which one is causing the
problem, and the cabin bus is obviously first because it's the least essential.
So Zimmerman confirms with Lo that he's going to switch off the cabin bus, which he then
does.

(01:23:04):
Now, if this were a horror movie, this would be in slow motion, and a close up shot of
his hand pulling the breaker out while the anxious music gets really loud.
Because as soon as Zimmerman disables the cabin AC bus, a lot of things are about to happen
very quickly and all of them are very bad.
Because by this time, the fire had broken through the thin wall between the insulation

(01:23:24):
and the AC ventilation system, so air conditioned air was being fed to the fire, causing it
to expand rapidly.
However, the predominant airflow was aft, so the fire was being drawn toward the cabin
recirculating fans located approximately overhead first class.
And the cabin air filters were then taking this air and filtering most of the smoke out
of it, so the majority of the passengers probably still didn't have a direct knowledge of the

(01:23:47):
fire at this point.
However, once Zimmerman turns off the cabin AC bus, the recirculating fans are depowered.
Critically, this reverses the airflow direction inside the attic space.
So now the fire, which is growing rapidly in the attic above the galley, surges back
forward.
It's being drawn by airflow that comes down through the cockpit into the avionics bay

(01:24:08):
and then is exhausted overboard.
So as the fire surges forward, it overcomes the smoke barrier at the cockpit rear wall,
and it roars back into the cockpit attic, which contains wiring to the circuit breakers
for about a million different critical aircraft systems.
As you can see in this cutaway diagram, that's where these circuit breaker panels are, if
you're looking at the slides.

(01:24:30):
Next slide please.
So starting 24 seconds after the cabin bus was switched off, everything goes to hell
for the airplane as the fire starts killing one circuit breaker after another.
So autopilot 2 is the first thing to fail.
The autopilot trips off with a continuous alarm.
The MD-11 has another autopilot, but it's unknown if they tried to engage it.
Both pilots called ATC at the same time to declare an emergency.

(01:24:53):
Low indicates that they're flying manually now.
Shortly afterward, they report that they're dumping fuel.
This wasn't recorded on the FDR yet.
And then one minute after the cabin bus switch was turned off, more systems started to bite
the dust.
First, they lost one of their four yaw damper control circuits, followed three seconds later
by the channel A of the number one flight computer, which caused some parameters to

(01:25:19):
drop off the captain's instruments, and the flight data recorder also started shedding
parameters.
Nine seconds after that, they lose the entire left emergency AC bus.
This resulted in the loss of air data computer 1, the captain's electronic display unit,
and the captain's side pitot tube heaters.
The data recorder lost the airspeed and altitude parameters, and a master caution light illuminated.

(01:25:40):
All of the captain's instrument displays were lost.
The loss of altitude data from ADC-1 also caused the loss of the traffic collision avoidance
system and the mode C transponder capability, so the aircraft stopped broadcasting altitude
to air traffic control.
At almost exactly that same time, the VHF radio number one failed, cutting off all voice
contact with air traffic control, and ACARS stops broadcasting diagnostic data to the

(01:26:04):
airline.
And, the sound of the voices on the cockpit voice recording starts to become weird and
distorted as the signal is being affected.
At this point, LO is still flying the airplane.
They're still turning south over St. Margaret's Bay, flying away from Halifax.
ATC tries to contact them, but he gets no response, nor will he ever get any response,

(01:26:25):
except for a very brief garbled message that might have been from SR-111 shortly after
this.
So, the aft cockpit ceiling at this point melts clean through, and the fire bursts into
the cockpit.
Captain Zimmerman shouts that something is burning already.
And additional channels of the yaw damper control fail.
LO says his instruments have failed, and he's using the standby instruments on the center

(01:26:48):
console, and then finally at 22, 25, and 41 seconds, both the CVR and the FDR fail and
the recordings stop.
Now the flight didn't end at this point, in fact the plane remained airborne for another
six minutes.
And through careful examination of the wreckage and other data, investigators have been able
to tell us a little bit about what happened during that time.

(01:27:09):
We know that at some point Zimmerman got out of his seat, maybe to try to fight the fire
with an extinguisher, we don't really know.
All we know is that his seat was in the egress position.
The abnormal checklist booklet was found open to the Smoke of Unknown Origin page, with
the laminated pages melted together, indicating exposure to extreme heat.

(01:27:30):
On the ground, beachfront homeowners reported seeing the plane flying low and possibly dumping
fuel.
The instruments were switched to a backup power supply, which briefly brought the transponder
back online for a few seconds, but then that also burnt through and it went back offline.
The only other item we know about is that the FADAC, the Full Authority Digital Engine

(01:27:52):
Controller, recorded that about four minutes later, engine 2, which is the tail engine,
was manually shut down, probably because the fire damaged the wiring for the engine fire
warning light, which fails on.
There wasn't actually anything wrong with engine 2.
But by that point, the conditions in the cockpit would have been hellish beyond all imagination.
The pilots would have been surrounded by choking, toxic smoke, they would have been blinded,

(01:28:17):
unable to see anything, systems would have been failing left and right, molten aluminum
was literally dripping off the ceiling onto the observer's station at the back of the
cockpit.
It was later estimated that the temperature at the back of the overhead CB panel, which
is like three feet from the pilot's heads, would have been over a thousand degrees Fahrenheit.
Meanwhile, in the cabin, the passengers in first and business class would have seen smoke

(01:28:40):
and flames, however passengers in economy might not have had any real sense of what
was happening.
We know that the pilots were still somewhat in control until very late into the accident
sequence, but it would have been obvious they couldn't reach Halifax, there was just no
way.
So the only option would have been a forced landing or ditching, but we don't know that
they considered this.
The lead flight attendant was found strapped into their seat without a life vest on, indicating

(01:29:05):
that there was never an announcement about a ditching, although given that the fire was
between the pilots and the galley, I'm not sure they could have given it such an announcement.
However, a passenger in business class, who happened to be a pilot, did have a life vest
on, so clearly some people, at least very discerning ones, could tell that they were
definitely going down at this point.
And anyway, about six minutes after the failure of the black boxes, and twenty minutes after

(01:29:28):
low first saw smoke, the plane started to make an uncontrolled right turn over the water
and it went into an inverted dive.
We don't know why it did this, or whether or not this maneuver was commanded.
It's possible that low finally perished from the smoke and flames, or he may have become
confused and disoriented in the darkness and smoke, but whichever it was, the final result

(01:29:50):
was the same.
At 22.31 and 18 seconds, descending in a 20 degree nose down angle with a steep right
bank, the plane hit the water with a speed at impact of 300 knots, and all 229 souls
on board were instantly lost.
Alright, so let's talk about the aftermath, and oh boy do we have a lot for this.
Next slide.

(01:30:10):
So before anything else, I want to talk about the search and salvage.
We're going to talk about whether this plane could have been saved, but that's sort of
towards the end of the episode.
The first thing you need to know about this plane is that it hit the water at such a speed
that it totally disintegrated.
The plane broke into three million pieces.
One of the articles I found in my research talked about how this crash consumed the work
hours of a decent percentage of Eastern Canada's entire forensic pathology profession for years,

(01:30:32):
trying to identify victims with what remained of the crash.
Bits of wreckage were washing up on shore for several weeks afterwards.
The entire area around the impact site was closed to marine traffic, including local
fishery and tour operations.
During salvage operations, it lasted for 13 months.
Now SeaPitt's resident mermaid gets to talk about diving a little bit.
Yay!

(01:30:52):
Okay, so they send in the divers.
Now because this is relatively shallow water, it's only about 180 feet.
180 feet is three times deeper than your typical open water or dive someone sees when they
take the family to Cancun.
Diver is going to be licensed to, and it's a third and again deeper than even ALGO with
a deep water license.
But it's not dangerous.
Just complicated.
You're going to be running a deco plan at the end of a dive, so you're going to be running

(01:31:15):
twin tanks.
And given that this is 1998 and helium is still incredibly cheap, you're probably also
running Trimix with minimum oxygen.
Divers focus on the largest pieces and the most delicate one, including the black boxes.
I suppose we have had one crash now in waste deep water and one in two and a half miles
of water and this one splits the difference, right?
Yeah.

(01:31:35):
All right, next slide.
So after a couple of months, the water gets too cold even for dry divers and the visibility
is bad enough that you couldn't stay down with a hot water suit either.
What we have on screen is basically what they were seeing.
It was a lot of muddled ocean floor with tiny little bits across of it.
Also marine operations are extremely expensive on the order of thousands of dollars per
hour.
The TSB would end up spending almost 60 million Canadian dollars on the entire salvage and

(01:31:59):
investigative operation, which is 105 million in 2024 money.
The most expensive investigation in Canadian history by probably an order of magnitude.
Yeah.
So eventually they give up and they just trawl a whole last day.
They do this for a year.
Eventually they find 98% of the plane.
They do not ever find any of the valuable treasure, supposedly.

(01:32:20):
Look, it's a big ocean and it's not inconceivable that treasure hunters found stuff.
I don't know.
Lloyds of London ends up paying 300 million pounds out for all of the valuables.
That's a lot of valuables.
Next slide.
So the TSB in their most painstaking and detailed investigation ever manually rebuilt the entire
cockpit onto this wire frame.

(01:32:40):
And when we say detailed, we mean this report is well over 300 pages long, not counting
any of the appendices.
The cover page does denote that it's available on CD-ROM, but you need at least Windows 98
to run it.
So like up to you if you want that or the PDF.
Yeah, I don't know.
Incidentally, I will take offers if anyone wants this podcast on DVD-ROM or MiniDisc.

(01:33:04):
Anyway, so the TSB sorts through all of the recovered wiring and they find any wires that
arced.
And then they did forensic analysis to determine when the arcing damage occurred to each wire
until they found the only one with damage that was definitely before the fire started,
which was an in-flight entertainment wire located right where the fire propagation model

(01:33:29):
said the ignition should have been to meet all the known conditions of this incident.
Now the report stops short of doing an I do declare and blaming the IFE.
Instead it finds it highly likely that this wiring system was the culprit.
I'd just like to point out that there's over 30 miles of wiring in an MD-11.

(01:33:51):
I think it was more than that to be honest.
No, there's over 30 miles of wiring in an MD-11 and they recovered.
So it could be a thousand miles and you're technically right.
No, no, it's something like 35 or 40, but I forget what the actual figure is.
All right, so Swissair realizes it was Agatha all along, completely disconnects all of the

(01:34:13):
IFE systems for good, unclear if they slapped huge in-op stickers on each one.
There's also a huge ass lawsuit, everyone sues everyone, Boeing, who is now the new
owner of McDonnie Darko, Swissair and Delta Airlines all agreed to share liability amongst
themselves.
See, I told you the Delta code share would be interesting if you were a lawyer.
I didn't say how interesting it was.

(01:34:35):
So then the TSB looks at a bunch of Canadian MD-11s and other planes, including DC-10s
and finds a surprising number of what they describe as wiring discrepancies.
Then the TSB notifies the NTSB that they should maybe take a look at this.
And then the NTSB tells the FAA that they should maybe take a look at this.

(01:34:57):
FAA sort of stumbles into life, wakes up and groggily issues an airworthiness directive
requiring everyone to take a look at this.
Then mumbles Boeing, fix it and goes back to sleep.
And Boeing issues a bunch of corrective action plans in two main phases, the places that
this particular plane appears to have gone on fire and then the entire plane.

(01:35:22):
Meanwhile, the FAA overhauls the training for aircraft wiring practices, both for the
technicians who do it and the inspectors who examine it.
And then TSB decides to require two-hour cockpit voice recorders, as well as independent CVR
power supplies, particularly because the rodents of unusual size, sorry, I mean, smoke of unknown

(01:35:46):
origin checklist has you turn each of the three main buses off one at a time, which
includes the CVR and FDR on generator bus three, which was originally chosen, get this,
because it was supposed to be the most reliable one.
Yeah, except that doesn't help if you have a checklist that tells you to turn it off.

(01:36:06):
Right, exactly.
Oh, and last but definitely not least, the FAA finally issued an airworthiness directive
mandating the removal of Vilar insulation from every passenger aircraft.
Next slide.
Okay, so what happened to Swissair?
Well, the crash definitely helped end Swissair, but 9-11 was really what did them in.

(01:36:27):
I mean, to be fair, if they weren't hard up for cash in the first place, this wouldn't
have happened.
Eventually, they're so broke, their regulators ordered the grounding of the entire Swissair
fleet in October of 2001.
The Swiss government issues two large-bred loans at absurd interest rates to resume operations.
Look, I told you the Swiss national motto is Scheiß auf dich, bezahl mich.

(01:36:49):
Is that you speaking Scheißdeutsch?
The writing was really on the wall at this point.
In April of 2002, it was all over.
Today, we have Swiss International, which is really just kind of a subsidiary of the
Lufthansa Group and trades on nostalgia, the financial sector, the UN, and anyone deranged
enough to want to connect in Zurich and literally any other airport in Europe.

(01:37:09):
And then the TSB and the NTSB agree that CVRs and FDRs should be on separate independent
power supplies.
The FAA says, yeah, that's a good idea.
Quote, the FAA agreed with the intent of the NTSB recommendations and indicated that it
would initiate a notice of proposed rulemaking action by the end of summer 1999.

(01:37:33):
By August 1999, the FAA advised the NTSB that because of competing priorities, the NPRM
would be delayed until March 2000.
Responding to an update request from the NTSB dated June 2000, the FAA announced in April
2001 that rulemaking based on the CVR and FDR recommendations would be further delayed

(01:37:56):
until the end of 2001.
As of this writing, the FAA advises that the NPRM action will take place in the spring
of 2003.
It has been 20 years.
Would anyone like to guess whether this has actually happened?

(01:38:16):
Come on, son.
It hasn't.
It hasn't, right?
Yeah, I know it hasn't because this is still cropping up in reports to this day.
I just may like some explanations for the FAA's behavior.
Next slide.
Okay, listeners.
Now, I want to talk more about those IFE systems because we dug into it and we found a shocking

(01:38:38):
amount out about these companies and actual crimes?
It was a wild night in the host chat because the more we read, the worse it got.
It was a wild night in the host chat because the more we read, the worse it got.
Over the course of a couple of hours, we discovered that this specific failure in airline crash
was linked to, among other things, Nixon's chief of staff, Russians, Clinton's chief

(01:39:02):
of staff, the Swiss lottery, and one of the richest families in the world.
All of these individuals were founders or board members of Interactive Flight Technologies,
the company we talked about earlier that designed the IFE.
Now, Jay talked about how this system was a hacked up mess designed to extract revenue.
We also talked about how the system drew an insane amount of power and was set up on circuit

(01:39:23):
breakers that had to take so many amps they didn't trip on the wiring arc.
This thing was a thermal and electrical mess that blew its mass budget by 10 to 1, its
power budget by 3 to 1.
IFT's boxes were reportedly so hot that they were prone to cooking their own hard drives
and yes, they did have spinning hard drives, 340 megabyte hard drives, within an hour of

(01:39:46):
being turned on.
One hour.
And actually, they got so hot that they had, like, on the planes that had 257 of these things in there,
when they were all being turned on, it would actually overpower the capabilities of the
air conditioning system to keep the cabin cool.
Flash memory existed at this time.

(01:40:07):
They didn't use it.
This box was shit, its servers were shit, it was a bad design, and it was being pushed
by IFT, who absolutely needed this work.
Its board and investors were some very rich and very well-connected people, who are also
very litigious and we're not going to mention all of their names, but we feel safe to say

(01:40:28):
that Interactive Flight Technologies management and ownership was really kind of sketchy.
Here's what we will say by quoting court records.
Interactive Flight Technologies was formed in 1994 with a $276,000 personal investment
by Yuri Itkis, a Russian-degreed scientist and engineer, and his sons Boris and Mikhail.

(01:40:54):
Yuri Itkis was the founder and president of a Las Vegas-based company that manufactured
electronic bingo equipment, and prior to 1994, both sons were employed by their father's business.
Why is it always fucking Russians?
Russians in 1994, even more so.
I mean, as far as I can tell, early 90s Russia was just the mafia colonizing an imploded economy.

(01:41:22):
And public record again, IFT's IPO was one of those cited in charges against the underwriter,
D.H. Blair, for securities fraud.
D.H. Blair has a history of involvement in pump-and-dump schemes that left unsuspecting
stockholders penniless, while brokers and insiders greedily raked in the profits.

(01:41:45):
There were allegations against Blair that included…
…mob involvement.
Oooh.
D.H. Blair was a boiler operation, the kind made famous by the movie Boiler Room and later
The Wolf of Wall Street.
These guys preyed on middle-income folks by hawking them mostly useless stocks backed
by already rich people, who would quickly take out their profits early and leave later

(01:42:06):
investors holding the bag when the company turned out to mostly be worthless.
Russians check.
Vegas check.
D.H. Blair check.
I guess we shouldn't really have been surprised that there might have been mob involvement.
I mean, it was early 90s Russia, right?
Early 90s Russia crossed with Las Vegas.
I mean…

(01:42:27):
Right.
The mob wasn't involved with this.
It was like, this was involved with the mob.
Yes, this was mob-affiliated business at this point.
Yeah, this was…
Mob's doing a business on the side.
I want to make a joke about Swiss Air being a raclette-influenced corrupt organization.
Now, this was also pushed by the Swiss lottery administrators who saw frank signs.

(01:42:51):
Now, remember, this was pay to play and it was quite expensive.
So as far as I'm able to discern, the revenue from gambling was split 40-40 between IFT
and the Swiss lottery, while Swiss Air capped it at 20.
For media, it was 70-30 between Swiss Air and IFT.
This is the Swiss motto again.
Watte faire foutre, paye moi.

(01:43:13):
And after all of this, IFT blocked.
Everyone in first class hated the nickel and dime system.
They hated having to pay to watch movies that had been free before.
The gambling was basically useless.
Swiss Air admitted afterwards that in the first quarter after the installation, only
50 people had ever gambled the maximum per flight amount of $200.

(01:43:34):
IFT pitched the system hard to Qantas because Australians gamble more than just about anyone,
but Qantas came to Vegas, saw it, and immediately said, no, no, no, just no, hell no.
So IFT started losing money hand over fist by May of 1998, two years after the installation.
But a few months before this accident, IFT announced that they were closing up shop and

(01:43:55):
becoming, we are very serious about this, a dry cleaning company.
I couldn't believe this when I read it.
And they actually, they actually didn't become a dry cleaning company because their shareholders
sued them to stop that from happening.
Seriously.
Yeah.
Okay.
Next slide.

(01:44:16):
Now we want to talk about the company that certified the design as safe, which was Santa
Barbara Aerospace.
Santa Barbara Aerospace was seemingly subcontracted by Hollings Ed International to the certification
work on the FAA's behalf.
Actually they were sub subcontracted because Hollings Ed International was itself a subcontractor
contracted by IFT to design the system that IFT was then going to build.

(01:44:41):
And then Hollings Ed International sub subcontracted Santa Barbara Aerospace to certify the system.
And sub sub sub subcontracted SR Technics to actually do the work.
So it was maybe full circle.
Maybe maybe it went full circle.
We don't know.
We're vague on a lot of this because the documentation is appallingly poor.

(01:45:03):
In fact, the way the TSB actually does these things is that they have these appendices
where they actually list the documentation process.
And at one point they're like, we believe that this was the document that this company
was using while this other company was using this other document.

(01:45:24):
But we haven't actually seen either of these two documents.
And it's like, we have absolutely no idea what actually happened to the degree that
most of the clarity on these arrangements came in the form of discovery from some of
the lawsuits as well as a huge expose that USA Today did in 2001.

(01:45:46):
I will say the last episode and this episode both share a sort of shocking lack of documentation
and the investigating agency having to kind of throw their hands up.
And the last episode, it was because it was a developing country in West Africa.
This is the Swiss and the Americans and yet still somehow disastrous documentation.

(01:46:10):
So SBA from the word go was doing crimes.
Like we did not set out to find crimes in this episode like we did last time.
We just wanted to know whatever happened to SBA.
But then we started to find actual crimes.
So let's start with the paperwork that was filed before the work ever began on the first
aircraft.
SBA filed for what is called an STC or supplemental type certificate from the FAA.

(01:46:35):
On it, they said that Hollings Ed International would be doing a work on one jet in California
and they would be responsible for the ongoing maintenance work.
Almost none of these statements were true.
They did not disclose that the STC was not for one plane, but was for 16 of them, all
to be modified under incredibly tight schedules because Swiss Air could not afford to have

(01:46:55):
these jets down and out of revenue service for a day longer than they had to be.
The systems cost single digit millions per plane, so they needed them to generate money
fast.
They did not disclose that Hollings Ed would be doing the work outside the US, nor that
Hollings Ed had subcontracted the actual installation to SR Technics in Switzerland.
They did not disclose that the ongoing maintenance work would be done by SR Technics, which was

(01:47:17):
not involved in the design, and would try to have to maintain after the fact given only
documentation.
Documentation we now know was based on wildly inaccurate assumptions.
They did not disclose that the IFE installation involved adding circuit breakers to the cockpit,
or that it would be connected to AC Main Bus 2, both of which made it a system with actual
operational impact.

(01:47:39):
The key takeaway is that this STC application was completely fraudulent.
These guys had committed a federal crime before they'd ever picked up a wrench.
This also means that the resultant type certificate was also fraudulent.
None of these aircraft should ever have been allowed to leave the ground, let alone run
revenue routes.
When I said that this electrical work would get your house red tagged, I am not kidding.

(01:48:01):
This is literally the kind of shit that gets your house condemned.
In the report, the TSB is kind of incredulous that nobody even asked Mcdance Dance Revolution
for any installation advice.
They just apparently yoloed it like they were installing underglow on a 2017 Honda Accord.

(01:48:22):
So this STC was issued pro forma without any inspections.
While I find it totally believable that someone at the FAA saw a reputable name like Hollingshead
International and didn't bother to look into it any further, still, still.
The IFEN system is powered by four cables connected to AC Bus 2.

(01:48:43):
No, it's supposed to be on four of the cabin buses.
I've heard it both ways.
Oh, I want to add that the reason the FAA didn't even look at this is because they had
previously certified SBA as a company that was able to certify things on behalf of the
FAA, and the FAA only needed to get involved if the system was quote unquote essential,
which as we discussed earlier, SBA characterized the system as non-essential, even though it

(01:49:09):
had real operational impact as Ari just said.
So that's how they kept the FAA out of this.
This episode of Sesame Street was brought to you by the phrase regulatory capture.
Eventually the work gets so bad that the local FAA inspector takes notice, and he blows a
whistle, weirdly coincidentally right before he retires.

(01:49:31):
He files a report with DC, and they do take notice.
Quoting the USA Today and AP article, quote, 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

(01:49:53):
and instructed the company to store its STCs in locked cabinets to restrict access to them.
Were they at the bottom of a stairs with no lights on and a sign on the door saying, beware
of the leopard?
Fuck yes, I love that reference, I use that one all the time.
I bet they were.
So the FAA goes to the baseball bat option, and they pull SBA's operating certificate.

(01:50:17):
Now this is catastrophic.
It means there is instant stop work order made by the FAA.
Nobody at SBA, Hollingshead, or SR Technic is supposed to be picking up a wrench and
working on jets.
So listeners, I'm sure you will be shocked to hear that SBA did in fact not stop working,
in fact they continued overseeing the Swissair IFE project while their certificate was suspended.

(01:50:40):
For reasons that we are very specifically choosing not to speculate on, five days after
the FAA orders a stop work at SBA, they reverse their decision calling it a mistake and blaming
the now retired inspector for everything.
We don't know who was responsible for getting the FAA to remove their stop order on SBA
or why.

(01:51:01):
It might have been any member of IFT's very rich and well-connected board of directors,
it might have been Swissair, it might have just been the guy deciding to do something
nice that day.
We will call this, charitably, the first opportunity to force someone to sound the alarm over the
IFE systems at Swissair, force them to do what they ended up doing anyway, pulling the
physical plug on the IFE systems.

(01:51:22):
The second chance came in May of 1997 when SBA was mentioned in the fallout to the May
of 96 crash of Value Jet 596 into the Everglades.
Isn't it 592?
Anyway, it doesn't matter.
Yeah, about that.
So SBA is actually mentioned in the Value Jet final report as one of several companies.
It was caught shipping unlabeled oxygen generators on a commercial aircraft.

(01:51:44):
Now they weren't the company that put them on the Value Jet flight 592, that was Saber
Tech that did that.
But what's somehow worse is they were one of the companies that was caught continuing
to do it after the crash.
The third chance to stop this was in May of 1998, the same month IFT went bust.
The FAA performed another audit of SBA.

(01:52:04):
Again from the AP.
Quote, the FAA 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 even eligible for certification.
Yeah, but despite the fact they'd found that they had issued STCs with inappropriate approvals,
they didn't go back and take a second look at the STC for the Swissair's MT-11 in-flight

(01:52:28):
entertainment system, which was completely fraudulent, remember.
That fall, WestJet decided to repo a plane after SBA fell four months behind in fixing
it.
WestJet set pilots to California, repoed the plane, but it still had three employees of
SBA on board, so they landed at an airport somewhere in rural central California.

(01:52:51):
WestJet kicks the SBA employees off the plane, hands the three of them $200 in cash for cab
fare, and then leaves for Canada.
Absolutely base Canadian behavior.
This repo was followed by WestJet realizing that SBA's work was so bad they needed Boeing
to come in and effectively undo it.
I mean, to be honest, at this point, Swissair probably knew that the work that had been

(01:53:14):
done on their planes was shoddy too, and they didn't give a shit.
I mean, you've probably got a lot of people in suits going, it's literally an IFE system,
it's not safety critical, what's the worst that could happen?
I just want to point out that any time that you're savior in a poor workmanship situation
is post-merger Boeing, you are in serious trouble.

(01:53:38):
Any of these should have been enough for the FAA to at least force inspections on work
overseen and signed off by SBA, but that never happened.
One of the incidental facts we found that was wild was that SBA was cited by the state
of California because the guy that signed off on the electrical load analysis was advertising
himself as an electrical engineer, but he did not have a degree.

(01:54:00):
However, at a federal level, you actually do not have to have an electrical engineering
degree to sign off on a little engineering analysis for a system that involves electrical
engineering.
So SBA ended up going out of business as a result of this specific accident.
One more time from the USA Today.
Jay Ackley, a former mechanic who joined SBA after the accident, says that he and other

(01:54:20):
inexperienced mechanic were instructed to do jobs they weren't qualified for 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.
That must have really pissed Boeing off, they're the only ones allowed to do that.
This quote and this work was after the accident.

(01:54:43):
After.
So eventually the FAA decides that they have no choice, they have to shut SBA down for
good.
Next slide.
Now what the fuck did we learn?
Next slide.
Well, to start with, in-flight fires are extraordinarily lethal.
Now this is the second crash we've covered that was an in-flight fire and much like that
one, this flight was pretty much doomed from the moment of ignition.

(01:55:04):
However, we do need to go into a bit of detail as to why exactly that was the case.
Yeah, when we wrote UPS 6, we gamed out every possible scenario that could have happened
after the first smoke alarm went off over the Persian Gulf and there was not a single
one of them that was even remotely survivable.
And this time, well, it works out pretty much the same, but let's discuss it.

(01:55:28):
So the TSB report concludes that if they had turned for Halifax at the instant of the Pan-Pan
call with no fuel dumping, maintaining the optimal descent rate and airspeed, then the
soonest they would have been on the ground would have been 2227 local time.
But by that point, the fire was eating the overhead CB panel and a bunch of stuff had
kicked off line, including all of the primary instruments, the autopilot and the flight

(01:55:52):
computers, meaning no instrument landing system or auto land.
Low would have had to make the landing by hand at night in debatable weather the first
time with smoke filling the cockpit and also on fire.
In fact, by 2227, the cockpit was on fire and filled with smoke.
So good luck with that.
The yaw dampers were offline and all of the stability assistance was offline.

(01:56:16):
And we are talking about the MD-11 here.
Yeah, the MD-11 is a very tricky bird to land when everything is working properly.
It has a very high landing speed, the nose gear is very far behind, it has a tendency
to do sort of a low rider bounce and then flip over on its back if you bring the nose
down too quickly.
And just to really confirm that Low is in hell, it's very likely that the fire had disabled

(01:56:38):
the slats, ground spoilers, auto brakes, and anti-skid systems, which all have CBs on the
overhead panel that was currently burning, so even if Low had managed to make a flawless
landing, he probably wouldn't have been able to stop.
In fact, the TSB ran the numbers and found that with the known technical failures that
had already occurred when the FDR failed, they would have needed at least 8,700 feet

(01:57:01):
of runway to land.
If the other systems on the overhead CB panel that I just listed also failed, which they
presumably did, we don't know for sure, then they might have needed up to 12,000 feet of
runway to stop the plane.
And the runway at Halifax is only 8,800 feet long, so they would have only barely stopped
even in the absolute best case scenario, which probably wasn't the scenario they were actually

(01:57:24):
in.
And this is not a runway you want to overrun.
In 2018, a Skylis Cargo 747 overran the specific runway that 111 was aiming for.
Those guys only overran by 845 feet into a grassy area.
The plane was declared a hull loss.
Beyond that grassy overrun is a major road, then a downhill slope to a very thick wooded

(01:57:45):
forest.
Almost certainly not a survivable landing for a plane as crippled as this aircraft was.
Yeah, and by hull loss she means that the plane broke in half.
Anyway, as a result of all this, the TSB is clear that the delay in starting the diversion
and the pilot's decision to turn away to dump fuel probably didn't make any difference.
Let's also provide a bit of perspective.

(01:58:06):
If you decide to declare an emergency and then turn around and land hundreds of thousands
pounds overweight and potentially total out a widebody aircraft because you smell a bit
of smoke, the chief pilot is going to have some very specific words for you.
As an interesting aside, the catastrophic failure of the avionics was caused, or at
least accelerated, by the act of turning off the cabin recirculation fans, which allowed

(01:58:27):
the fire to move forwards into the attic space above the cockpit.
We do want to stress though that this was exactly what the checklists for smoke called
for, so it would be wrong to assess this decision as incorrect in hindsight.
There was just no way that anyone could have foreseen that happening and it would have
been expressly against their training to do anything else other than that checklist.

(01:58:51):
And besides, it's entirely possible that all it did was move the timeline up by a few minutes
on something that was going to happen very shortly anyway.
So in conclusion, there was really nothing the pilot specifically could have done to
save themselves in this scenario, which is profoundly scary and while the industry should
do what it can to mitigate this kind of scenario, I think what you really just have to do is

(01:59:15):
hope that an uncontrolled fire in an inaccessible area never happens again because it's really
just so hard to do anything about it.
This was a crash with a lot of blame to go around.
McDougall dongle for building a plane with cheap mylar insulation, Holling Zedd for doing
the aeronautical equivalent of daisy chaining 10 power strips together, SVA for covering
it all up, IFT for making wild promises about equipment designed to rip you off, and building

(01:59:38):
equipment that could charitably be described as not ready and realistically be described
as a dangerous hack job, and of course Swissair for not doing dougillants on any of this shit
because they had too many Frank signs in their eyes.
And I want to talk specifically about how this crash speaks to the nature of white collar
crime.
The last episode was smuggling guns and diamonds into war zone crimes.

(02:00:01):
Make a movie starring two Oscar winners about U-level crimes, the kind of crimes that multiple
intelligence agencies have binders full of stuff on.
None of those crimes occur around this crash.
I mean, unless you count the National Treasure but underwater heist that we like to believe
occurred on all the precious cargo.
So these crimes are all low-level managerial crimes.
They're what you call paperwork crimes.

(02:00:24):
All the crimes we haven't discussed in this episode today are awful and they are directly
causal.
These kinds of actions are as serious crimes that do real damage every day all the time
to real people and most of the time not in such a dramatic and awful manner, they result
in atomizing a wide-body airliner into an ocean next to a sleepy Canadian town.
At the moment of action, when they occur, these crimes don't seem like a big deal.

(02:00:46):
These crimes were absolutely causal to the crash but would never have seemed so to the
people doing them.
Any crash that caused by them would have been fantastically hypothetical.
So people do these things every day without realizing it.
They don't really think about the harm that might happen to 20 civilizations six turns
from now when the law of unintended consequences happens as a game event.
In the moment these decisions are made, it's just a way to get your boss to shut up.

(02:01:09):
He tell you to write one jet instead of 16 in the form because we don't really want
the hassle of an extra inspections because then we might not make the deadline to get
the milestone payments and then the company wouldn't be able to hand out bonuses and
after all the guys in the shop do good work right so it's probably fine.
And all this works because it's siloed.
No one has total visibility into everything going on except management.
But management is insulated from implication because they don't know the details of the

(02:01:33):
small paperwork crimes being committed.
But these things absolutely add up and sometimes they add up in a way that gets people killed.
If you're wondering if any of these guys received any sort of punishment, the answer
is not really.
I tracked as many down as I could on LinkedIn and most of them are either retired after
this or went to work for other Aerotechnical Services companies.
So I guess some rich people lost money when IFT and SBA went out of business which is

(02:01:56):
something, I guess.
The Vice President of IFT and 12 other IFT employees went to jail but not for killing
several hundred people but for defrauding investors because of course the investors
were the real victims here, right?
And on that depressing note, thanks for listening.
Alright everybody, our next episode will be on Malaysia Air 370.

(02:02:19):
Bye!
Bye!
bland

(02:02:51):
you

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