Hazardous Materials Incident Brief - Resulting from a spill of hydrogen peroxide in cargo compartment on Northwest Airlines Flight 957 from Orlando, Florida to Memphis, Tennessee on October 28, 1998.

Memphis, Tennessee
October 28, 1998

NTSB Number: HZB-00-01
Accident No.: DCA-99-MZ-001
Adopted May 17, 2000
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Description of Incident

On the morning of October 28, 1998, 2 gallons of a 35-percent hydrogen peroxide solution in water, an oxidizer1 with corrosive properties, spilled in a cargo compartment of Northwest Airlines (Northwest) flight 957, a passenger-carrying airplane en route from Orlando, Florida, to Memphis, Tennessee. The solution leaked from two undeclared 1-gallon plastic bottles that had split. The bottles were in an ice chest that belonged to a passenger on the flight. The leaking hydrogen peroxide contaminated three mail sacks and an undetermined number of bags.

The leak was not discovered until cargo handlers in Memphis began to unload the baggage on flight 957. Thinking that the spilled liquid was water, the cargo handlers ignored it and transferred some of the baggage to other Northwest passenger-carrying flights, including flight 7, which then departed for Seattle, Washington. When flight 7 arrived in Seattle, two bags in a cargo compartment were smoldering, including one that had come from flight 957.

As a result of the spill, several people required treatment. In Memphis, 11 employees were treated at the airport's first aid station because their hands had been exposed to the hydrogen peroxide, and 2 more employees went to a local clinic, where they were treated and released. In Seattle, the employee who removed the smoldering bags from the cargo compartment was exposed to fumes. He went to a hospital for treatment and was released. None of the injuries were serious. Northwest estimated that the total cost of the damage to and the downtime on the aircraft and of the damage to the baggage was more than $40,000.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the release of undeclared hazardous material aboard Northwest Airlines flight 957 was the passenger's failure to properly package and identify the hazardous material and inadequate inquiries from the Northwest Airlines agent about the contents of the cooler offered by the passenger. Contributing to the consequences of the release were inadequate carrier procedures, which allowed contaminated baggage to be transferred to other aircraft.

Recommendations

As a result of this accident, the National Transportation Safety Board makes the following safety recommendations:

To the Federal Aviation Administration:

Develop, with the assistance of the Hydrogen Peroxide Safety Producers Committee, and distribute to carriers guidance about the difficulty of identifying a hydrogen peroxide spill and about the danger of allowing hydrogen peroxide to dry on organic materials (including paper, fabric, cotton, and leather), which may result in a fire. (A-00-51)

Issue guidance to air carriers about the need to isolate baggage and cargo that have been involved with a hazardous materials spill until it can be determined which items have been contaminated and what measures are necessary to prevent further contamination of baggage and aircraft or other hazards (such as fire or poisoning). Then require principal operations inspectors to review and amend, as necessary, air carrier manuals to ensure that air carrier procedures are consistent with this guidance. (A-00-52)

Issue guidance to air carriers about the need to notify pilots in flight when baggage and cargo that are believed to have been involved in a hazardous materials spill have been placed on their aircraft; notifying the pilots includes clearly identifying the hazards posed by the material involved in the spill and the procedures that the pilots should take. Then require principal operations inspectors to review and amend, as necessary, air carrier manuals to ensure that air carrier procedures are consistent with this guidance. (A-00-53)

To the U.S. Postal Service:

Reinforce the training provided to your hazardous materials emergency responders concerning the need to use technical information, including material safety data sheets, about the hazards and the chemical properties of materials when responding to a spill instead of relying solely on memory or previous experience.(A-00-54)

To the Air Transport Association:

Inform your members about the Memphis incident and make them aware of the following: the difficulty of identifying a hydrogen peroxide spill, the danger of allowing hydrogen peroxide to dry on organic materials, the need to isolate baggage and cargo that have been involved with a hazardous materials spill until it can be determined which items have been contaminated and what measures are necessary to prevent further contamination of baggage and aircraft or other hazards (such as fire or poisoning), and the need to notify pilots in flight when baggage and cargo that are believed to have been involved in a hazardous materials spill have been placed on their aircraft (such notification includes informing the pilots clearly about the hazards presented by the material involved in the spill and the procedures that the pilots should take). (A-00-55)

To Northwest Airlines, Inc.:

Amend your emergency response procedures and training to include the importance of isolating baggage and other cargo that has been involved with a hazardous materials spill until it can be determined which items have been contaminated and what measures are necessary to prevent further contamination of baggage and aircraft or other hazards (such as fire or poisoning). (A-00-56)

Amend your emergency response procedures and training to include notification to pilots in flight when baggage and cargo that are believed to have been involved in a hazardous materials spill have been placed on their aircraft; notifying the pilots includes clearly identifying the hazards posed by the material involved in the spill and the procedures that the pilots should take. (A-00-57)

Reinforce the training provided to ground operations and maintenance personnel on actions to take for a suspected fire in an aircraft cargo compartment. Also for those employees, review and modify, as appropriate, procedures and training for a suspected hazardous materials spill in an aircraft cargo compartment. (A-00-58)

To the Hydrogen Peroxide Safety Producers Committee:

Urge your members to revise their material data safety sheets for hydrogen peroxide to include warnings about the dangers of allowing hydrogen peroxide to dry on organic materials (including paper, fabric, cotton, and leather), which may result in a fire. (A-00-59)

Assist the Federal Aviation Administration in developing guidance for air carriers about the difficulty of identifying a hydrogen peroxide spill and about its hazards. Include, at a minimum, the fact that hydrogen peroxide is colorless, has little odor, and may be mistaken for water; the guidance should also warn of the danger of allowing hydrogen peroxide to dry on organic materials (including paper, fabric, cotton, and leather), which may result in a fire. (A-00-60)