Aircraft Accident Report - Inflight Cargo Fire, United Parcel Service Company Flight 1307, McDonnell Douglas DC-8-71F, N748UP

Philadelphia, Pennsylvania
February 7, 2006

NTSB Number AAR-07-07
NTIS Number PB2007-910408
Adopted December 4, 2007
PDF

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 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.

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 the inadequate certification test requirements for smoke and fire detection systems and the lack of an on-board fire suppression system.

The safety issues discussed in this report include inadequacies in the following areas: guidance and checklists relating to in-flight fire and smoke, smoke and fire detection system test certification requirements, fire suppression system requirements, aircraft rescue and firefighting training, cargo airplane emergency exit requirements, hazardous materials information dissemination procedures, and transport of lithium batteries on board aircraft. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration, the Cargo Airline Association, and the Pipeline and Hazardous Materials Safety Administration.

Safety Recommendations

New Safety Recommendations

As a result of its investigation of the February 7, 2006, accident involving United Parcel Service Company flight 1307, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

Provide clear guidance to operators of passenger and cargo aircraft operating under 14 Code of Federal Regulations 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. (A-07-97)

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. (A-07-98)

Require that fire suppression systems be installed in the cargo compartments of all cargo airplanes operating under 14 Code of Federal Regulations Part 121. (A-07-99)

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. (A-07-100)

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. (A-07-101)

Require cargo operators to designate at least one floor level door as a required emergency exit and equip the door with an evacuation slide, when appropriate. (A-07-102)

Require all emergency exits on cargo aircraft that are operable from the outside to have a 2-inch contrasting colored band outlining the exit. (A-07-103)

As a result of this investigation, the National Transportation Safety Board makes the following recommendations to the Pipeline and Hazardous Materials Safety Administration

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. (A-07-104)

Until fire suppression systems are required on cargo-only aircraft, as asked for in Safety Recommendation A-07-99, require that cargo shipments of secondary lithium batteries, including those contained in or packed with equipment, be transported in crew-accessible locations where portable fire suppression systems can be used. (A-07-105)

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. (A-07-106)

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. (A-07-107)

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. (A-07-108)

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 A-07-108 are completed. (A-07-109)

As a result of this investigation, the National Transportation Safety Board makes the following recommendation to the Cargo Airline Association:

Work with your 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. (A-07-110)

Previously Issued Safety Recommendations Resulting From This Accident Investigation

As a result of its investigation of this accident, the Safety Board issued the following safety recommendation to the Federal Aviation Administration on September 25, 2006:

Amend Federal Aviation Administration Order 7110.65, "Air Traffic Control," to require that, when amending a runway assignment, controllers provide a specific instruction to the pilot advising of the runway change. For example, "UPS 1307, change to runway 25L, cleared to land." (A-06-65)

Safety Recommendation A-06-65 is classified "Open–Unacceptable Response" in this report. For additional information about this safety recommendation, see section 1.18.2.

Previously Issued Safety Recommendations Classified in this Report

As a result of the April 28, 1999, fire that destroyed freight, including lithium atteries, on two aircraft cargo pallets at a Northwest Airlines cargo facility, the Safety Board issued the following safety recommendations to the Research and Special Programs Administration on November 16, 1999:

With the Federal Aviation Administration, evaluate the fire hazards posed by lithium batteries in an air transportation environment and require that appropriate safety measures be taken to protect aircraft and occupants. The evaluation should consider the testing requirements for lithium batteries in the United Nations' Transport of Dangerous Goods Manual of Tests and Criteria, the involvement of packages containing large quantities of tightly packed batteries in a cargo compartment fire, and the possible exposure of batteries to rough handling in an air transportation environment, including being crushed or abraded open. (A-99-80)

Require that packages containing lithium batteries be identified as hazardous materials, including appropriate marking and labeling of the packages and proper identification in shipping documents, when transported on aircraft. (A-99-82)

The Safety Board also issued the following safety recommendation to the Federal Aviation Administration on November 16, 1999:

With the Research and Special Programs Administration, evaluate the fire hazards posed by lithium batteries in an air transportation environment and require that appropriate safety measures be taken to protect aircraft and occupants. The evaluation should consider the testing requirements for lithium batteries in the United Nations' Transport of Dangerous Goods Manual of Tests and Criteria, the involvement of packages containing large quantities of tightly packed batteries in a cargo compartment fire, and the possible exposure of batteries to rough handling in an air transportation environment, including being crushed or abraded open. (A-99-85)

Safety Recommendations A-99-80, -82, and -85 (previously classified "Open-Acceptable Response") are classified "Closed-Acceptable Action" in this report. These classifications are discussed in section 2.9 of this report.