NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of December 4, 2007
(Information subject to editing)

Aviation Accident Report
In-Flight Cargo Fire, United Parcel Service Company Flight 1307,
McDonnell Douglas DC-8-71F, N748UP
Philadelphia, Pennsylvania, February 7, 2006
NTSB/AAR-07/07

This is a synopsis from the Safety Board's report and does not include the Board's rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

EXECUTIVE SUMMARY

On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport, Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated from the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and most of the cargo were destroyed by fire after landing. The scheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Night visual conditions prevailed at the time of the accident.

CONCLUSIONS

1. The flight crewmembers were properly certificated and qualified under Federal regulations. No evidence indicated any preexisting medical or physical condition that might have adversely affected the flight crew's performance during the accident flight.

2. No evidence was found indicating that fatigue degraded the performance of any of the flight crewmembers on the day of the accident.

3. Examinations of the recovered components revealed no evidence of any preexisting powerplant, structural, or system failures.

4. The flight crew's continued descent to Philadelphia International Airport was not inappropriate given that there was no evidence of abnormalities other than the odor, and that no cockpit alerts had been activated.

5. The increased airflow that resulted from the Fumes Evacuation checklist actions diluted the smoke and inhibited its detection by either the smoke detection system or flight crewmembers and provided the fire with additional oxygen.

6. The aviation industry initiative on smoke, fire, and fumes provides specific guidance on when and how flight crews should respond to evidence of a fire in the absence of cockpit smoke and/or fire warning.

7. The fire on board the accident airplane initiated as a smoldering fire.

8. The fire was detected by the airplane's smoke and fire detection system after the fire breached a cargo container, at which time, it proceeded to spread, and the growth of the fire after landing was fed by air entering through open doors and burnthrough holes.

9. The exact origin and cause of the in-flight fire on board the airplane could not be determined due to the destruction of potentially helpful evidence; however, available evidence suggests that the fire most likely originated in container 12, 13, or 14.

10. The current certification test standards and guidance for smoke or fire detection systems on board many aircraft are not adequate because they do not account for the effects of cargo containers on airflow around the detection sensors and on the containment of smoke from a fire inside a container.

11. The threat from cargo fires could be mitigated by the installation of fire suppression systems.

12. Flight crews on cargo-only aircraft remain at risk from in-flight fires involving both primary and secondary lithium batteries.

13. The emergency response for this accident was timely.

14. Some aircraft rescue and firefighting personnel are not adequately trained on the use of the high-reach extendable turret with skin-penetrating nozzle, reducing the effectiveness of the device in fighting interior aircraft fires.

15. Philadelphia International Airport aircraft rescue and firefighting personnel were not familiar with the accident airplane's main cargo door, which adversely affected their ability to access the airplane's interior to fight the fire.

16. The availability of accurate and complete airplane diagrams would improve aircraft rescue and firefighting personnel's knowledge and familiarity with fleet configurations and would facilitate emergency response operations.

17. A floor level emergency exit and when appropriate equipped with an evacuation slide would enable more efficient emergency egress for airplane occupants than cockpit window exits, and the associated, instructional placarding of such an exit would assist emergency responders with locating and operating the exit door and accessing the interior of the airplane.

18. United Parcel Service Company (UPS) guidance on hazardous materials information retrieval and dissemination was inadequate, which resulted in UPS personnel not providing emergency responders with detailed information about the hazardous materials on board the airplane in a timely manner.

19. The requirements of 49 Code of Federal Regulations 175.33(d) are not adequate because they do not require operators to provide hazardous materials information to emergency responders immediately upon notification of an accident.

20. Testing and incident data indicate that lithium batteries can pose a fire hazard.

21. Because many incidents involving lithium batteries are exempt from reporting requirements, the data regarding such incidents are incomplete, which has prevented a thorough assessment of the causes of these failures and the risks associated with transporting lithium batteries.

22. An in-depth analysis of the causes of secondary and primary lithium battery failures would improve the safe transportation of these batteries.

23. The Pipeline and Hazardous Materials Safety Administration's August 2007 final rule regarding the transportation of lithium batteries did not establish sufficient levels of safety for air transportation of small secondary lithium batteries (no more than 8 grams equivalent lithium content).

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable cause of this accident was an in-flight cargo fire that initiated from an unknown source, which was most likely located within cargo container 12, 13, or 14. Contributing to the loss of the aircraft were inadequate certification test requirements for smoke and fire detection systems and the lack of an on-board fire suppression system.

SAFETY RECOMMENDATIONS

As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations:

To the Federal Aviation Administration:

1. Provide clear guidance to the operators of passenger and cargo aircraft operating under 14 Code of Federal Regulation Parts 121, 135 and 91K on flight crew procedures for responding to evidence of a fire in the absence of a cockpit alert based on the guidance developed by the 2004 smoke, fire, and fumes industry initiative.

2. Ensure that the performance requirements for smoke and fire detection systems on cargo airplanes account for the effects of cargo containers on airflow around the detection sensors and on the containment of smoke from a fire inside a container, and establish standardized methods of demonstrating compliance with those requirements.

3. Require that fire suppression systems be installed in the cargo compartments of all cargo airplanes operating under 14 Code of Federal Regulations Part 121.

4. Provide guidance to aircraft rescue and firefighting personnel on the best training methods to obtain and maintain proficiency with the high-reach extendable turret with skin-penetrating nozzle.

5. Require airport inspectors to ensure that Part 139 airports with cargo operations include cargo aircraft in their aircraft rescue and firefighting aircraft familiarization training programs.

6. Require cargo operators to designate at least one floor level door when appropriate equipped with an emergency slide as a required emergency exit.

7. Require all emergency exits on cargo aircraft that are operable from the outside to have a 2-inch contrasting colored band outlining the exit.

To the Pipeline and Hazardous Materials Safety Administration:

8. Require aircraft operators to implement measures to reduce the risk of primary lithium batteries becoming involved in fires on cargo-only aircraft, such as transporting such batteries in fire resistant containers and/or in restricted quantities at any single location on the aircraft.

9. Until fire suppression systems are required on cargo-only aircraft, as asked for in Safety Recommendation [3], require that cargo shipments of secondary batteries, including those contained in or packed with equipment, be transported in crew-accessible locations where portable fire suppression systems can be used.

10. Require aircraft operators that transport hazardous materials to immediately provide consolidated and specific information about hazardous materials on board an aircraft, including proper shipping name, hazard class, quantity, number of packages, and location, to on-scene emergency responders upon notification of an accident or incident.

11. Require commercial cargo and passenger operators to report to the Pipeline and Hazardous Materials Safety Administration all incidents involving primary and secondary lithium batteries, including those contained in or packed with equipment, that occur either on board or during loading or unloading operations and retain the failed items for evaluation purposes.

12. Analyze the causes of all thermal failures and fires involving secondary and primary lithium batteries and, based on this analysis, take appropriate action to mitigate any risks determined to be posed by transporting lithium batteries, including those contained in or packed with equipment, on board cargo and passenger aircraft as cargo; checked baggage; or carry-on items.

13. Eliminate regulatory exemptions for the packaging, marking, and labeling of cargo shipments of small secondary lithium batteries (no more than 8 grams equivalent lithium content) until the analysis of the failures and the implementation of risk-based requirements asked for in Safety Recommendation [12] are completed.

To the Cargo Airline Association:

14. Work with its member airlines and other groups, such as the Air Transport Association, major aircraft manufacturers, and the Aircraft Rescue and Firefighting (ARFF) Working Group, to develop and disseminate accurate and complete airplane Emergency Response diagrams for ARFF personnel at airports with cargo operations.

PREVIOUSLY ISSUED SAFETY RECOMMENDATION RESULTING FROM THIS ACCIDENT INVESTIGATION

15. Safety Recommendation A-06-65 was issued on September 25, 2006, and is classified "Open - Acceptable Response."

PREVIOUSLY ISSUED SAFETY RECOMMENDATION CLASSIFIED IN THIS REPORT

16. Safety Recommendations A-99-80, -82, and -85 (previously classified "Open-Acceptable Response") are classified "Closed-Acceptable Action."