Testimony of Jim Hall, Chairman
National Transportation Safety Board
before the Committee on Transportation and Infrastructure

Subcommittee on Aviation, House of Representatives
Regarding Actions Taken by the Federal Aviation Administration Since the May 11, 1996, ValuJet Accident
May 15, 1997

Good morning Mr. Chairman and Members of the Committee. It is a pleasure to be here today to represent the National Transportation Safety Board and to discuss the progress made regarding the Federal Aviation Administration's response to hazardous materials and cargo fire protection issues since the May 11, 1996, ValuJet accident in the Everglades near Miami, Florida.

Before I begin, I would like to introduce the members of staff with me today. To my right is Dr. Bernard Loeb, Director of the Board's Office of Aviation Safety, and to my left is Mr. Robert Chipkevich, Chief of the Board's Pipeline and Hazardous Materials Division.

As you are aware, ValuJet flight 592, a DC-9, crashed on May 11, 1996, about 2:45 p.m. eastern daylight time, 12 minutes after takeoff from Miami International Airport, Miami, Florida. The airplane was a regularly scheduled flight to Atlanta, Georgia. Both pilots, the three flight attendants, and all 105 passengers were killed. Before the accident, the flightcrew reported to air traffic that it was experiencing smoke in the cabin and cockpit. The transcript of the cockpit voice recorder also contained remarks describing fire in the cabin.

The Safety Board's final report of this accident is being written, and it should be considered by the Board this summer. During the early stages of the investigation, the Safety Board became aware of urgent safety issues, and on May 31, 1996, we issued six safety recommendations to the Federal Aviation Administration (FAA) and the Research and Special Programs Administration (RSPA). I will discuss these later in my testimony.

I would like to provide some relevant historical information and briefly discuss three accidents that involved fires originating in Class D cargo compartments.

On August 19, 1980, a Lockheed L-1011 operated by Saudi Arabian Airlines, was forced to return shortly after departure from Riyadh, Saudi Arabia, because of an in-flight fire in the aft section of the airplane. Although the airplane landed successfully, the fire continued and spread throughout the cabin, killing all 301 occupants. The Safety Board participated in this investigation in accordance with the provisions of Annex 13 to the Convention on International Civil Aviation. As a result of findings from that accident, which involved a probable fire in the aft cargo compartment from an undetermined source, on February 10, 1981, the Safety Board issued two safety recommendations to the FAA to:

Reevaluate the "Class D" certification of the L-1011 C-3 cargo compartment with a view toward either changing the classification to "C," requiring detection and extinguishing equipment, or changing the compartment liner material to insure containment of a fire of the types likely in the compartment while in flight. (A-81-12)

Review the certification of all baggage/cargo compartments (over 500 cu. ft.) in the "D" classification to insure that the intent of 14 CFR 25.857 (d) is met. (A-81-13)

On May 11, 1982, the FAA responded to the Board and stated that fire safety would be improved with the installation of a Fiberglas ceiling liner, in lieu of the standard Nomex fabric ceiling liner. Based on this response and actions by airlines to comply with the intent of the recommendation, on November 2, 1982, the Safety Board classified the first recommendation as "Closed-Acceptable Action."

With regard to the second recommendation, in June 1983, the FAA Technical Center in Atlantic City, New Jersey, completed a project to study experimentally the effectiveness of transport category aircraft Class D cargo compartments in containing fires through oxygen starvation. The FAA study concluded that the Federal regulations did not ensure adequate burn-through resistance of Class D cargo liners subjected to realistic fires. The study also noted that the cargo compartment liner was the initial fire barrier for the protection of aircraft components, structure, passengers, and crewmembers from a fire inside the cargo compartment. The FAA report warned that some cargo compartments, although primarily lined with Fiberglas, have aluminum components and that the use of aluminum may nullify the fire containment capability of burn-through resistant cargo compartment liners.

Subsequently, on May 7, 1984, the FAA issued a notice of proposed rulemaking (NPRM), Notice 84-11, that addressed the problem of fire containment in cargo compartments by specifying a new test method for determining the flame penetration resistance of compartment liners. The Safety Board provided comments on the rulemaking on October 9, 1984, and advised the FAA that, while proposed flame penetration tests were more stringent than previous ones, a fire should not be allowed to persist in any state of intensity in an airplane without the knowledge of the flightcrew, and that a fire detection system should be required in Class D baggage/cargo compartments. Although not a formal safety recommendation letter to the FAA, the Safety Board's letter to the public docket for NPRM 84-11, which had the concurrence of all Board Members, formalized the Board's position on this issue.

On May 9, 1986, the FAA issued a final rule to amend fire safety standards for cargo or baggage compartments. The final rule adopted more stringent cargo liner burn-through tests and smaller Class D cargo/baggage compartments, but rejected a requirement for fire detection systems in the Class D compartments.

Further, the FAA's cargo compartment fire protection research and testing did not consider the various effects that hazardous materials involved in a fire could have on the capability of a cargo compartment to contain an in-flight fire. The FAA concluded in its final rule that the effects of hazardous materials were beyond the scope of its rulemaking notice.

At that time, the Board believed the FAA's final rule did meet the intent of its second recommendation following the Saudi accident, so in June 1986, classified Safety Recommendation A-81-13, "Closed-Acceptable Action."

On February 3, 1988, American Airlines flight 132, a McDonnell Douglas DC-9-83, experienced an in-flight fire while en route to Nashville Metropolitan Airport, Tennessee, from Dallas/Fort Worth International Airport, Texas. As the aircraft was on a final approach, a flight attendant and a deadheading first officer notified the cockpit crew of smoke in the passenger cabin. The Safety Board found that hydrogen peroxide solution (an oxidizer) and a sodium orthosilicate-based mixture had been shipped and loaded into the midcargo compartment of the airplane. The chemicals were improperly packaged, and were not identified as hazardous materials. After the hydrogen peroxide leaked from its container, a fire started in the cargo compartment. The fire eventually breached the cargo compartment, and the passenger cabin floor over the midcargo compartment became hot and soft. Although the fire was not extinguished in-flight, the airplane landed without further incident. The 120 passengers and 6 crewmembers safely evacuated the aircraft after landing, and a catastrophic fatal accident was avoided.

As a result of the incident involving American Airlines flight 132, on October 24, 1988, the Safety Board issued five safety recommendations. Let me first discuss two of them that urged the FAA to require fire/smoke detection systems for all Class D cargo compartments (A-88-122), and require a fire extinguishment system for all Class D cargo compartments (A-88-123).

After a series of correspondence between the Safety Board and the FAA, on August 10, 1993, the FAA responded to Safety Recommendations A-88-122 and -123 by stating that it did not believe that fire/smoke detection systems would provide a significant degree of protection to occupants of airplanes and that it had terminated its rulemaking action to require such systems. The FAA rationale included an economic analysis that showed that the cost of compliance with the provisions of its proposed rule did not meet cost/benefit criteria established in Executive Order 12291. On October 14, 1993, the Safety Board classified Safety Recommendations A-88-122 and -123 as "Closed-Unacceptable Action." The Board expressed its disappointment to the FAA and added, "… the Safety Board is concerned that the FAA failed to consider the effects of hazardous materials (declared or undeclared) in cargo compartment fires when it approved burn-through test requirements for cargo compartment liners in 1986 in lieu of fire detection and extinguishment systems."

In November 1996, the airline industry announced that it would voluntarily retrofit existing Class D cargo compartments with smoke detectors. Moreover, on November 24, 1996, the FAA announced that it would move forward with rulemaking to require both fire detection and fire suppression systems in the cargo compartments of all passenger aircraft. Specifically, the FAA stated that it would issue an NPRM by the end of the summer of 1997 proposing to require retrofit of all Class D cargo compartments to Class C compartments of about 2,800 older aircraft. The FAA has also announced that the retrofit program would be for newly manufactured aircraft and existing aircraft with a 5-year phase in period.

There are currently 2,800 U.S. domestic passenger aircraft, and 685 cargo planes with Class D cargo compartments. Worldwide, there are more than 6,700 commercial jet aircraft with Class D cargo compartments. Mr. Chairman, the fact remains that pilots taking off today in aircraft having Class D cargo compartments have no more ability to be alerted to the existence of a fire in the cargo compartment, much less the ability to suppress it, than did the crew of ValuJet flight 592, or indeed, the crew of the American Airlines flight 132 in 1988.

The Safety Board issued three other safety recommendations following the Nashville accident. Safety Recommendation A-88-124 urged the FAA to evaluate prohibiting the transportation of oxidizers in cargo compartments that do not have fire/smoke detection, and fire extinguishment systems, and determine if other classes of hazardous materials also should be excluded from cargo compartments without these safety systems.

On August 23, 1993, Safety Recommendation A-88-124 was closed "Acceptable Action" based on a June 30, 1993, letter from the FAA that stated that the FAA and RSPA had completed an evaluation of the transportation of oxidizers and other hazardous materials by air. Both the FAA and RSPA concluded that oxidizers and other classes of hazardous materials that are authorized to be transported by air are safe when properly packaged, declared, and segregated. The Board noted in its evaluation of FAA's and RSPA's actions in response to A-88-124 that "… the FAA and RSPA also recognize that undeclared or hidden shipments of hazardous materials are a threat to safety and have taken actions to improve public awareness of this threat and enforcement of regulations."

Safety Recommendation A-88-125 asked the FAA to review the certification of all types of cargo compartments to identify any aluminum or other components that fail to meet thermal protection requirements at least equal to cargo compartment liner thermal protection requirements, and require that all safety deficiencies be corrected.

On July 20, 1990, Safety Recommendation A-88-125 was classified "Closed Unacceptable" based on the FAA's January 29, 1990, response that aluminum materials in portions of cargo compartment liners were not a hazard and were not a factor in the February 3, 1988, American Airlines incident. The Safety Board stated that "… we strongly believe that these liners should be removed from service because they do not provide the required protection."

Safety Recommendation A-88-127 asked the FAA to consider the effects of authorized hazardous materials cargo in fires for all types of cargo compartments, and require appropriate safety systems to protect the aircraft and occupants.

On April 19, 1993, the Safety Board reminded the FAA that there had been no correspondence received from the FAA since the Board's July 20, 1990, letter classifying the recommendations "Open Acceptable." On March 17, 1994, the Safety Board classified Safety Recommendation A-88-127 "Closed-Unacceptable Action," because no response had been received from the FAA and there had been no apparent actions to meet the intent of this recommendation.

Mr. Chairman, since the American Airlines flight 132 incident in 1988, there were no in-flight fires involving fatalities aboard a large airliner in the U.S. or overseas until the ValuJet flight 592 accident in 1996. Although an in-flight fire is a rare occurrence, the Safety Board nevertheless is concerned that previous Board recommended actions may have prevented the ValuJet accident.

At this point, I would like to briefly describe recent actions taken by the FAA and RSPA in response to the Safety Board's recommendations stemming from the ValuJet investigation.

On May 24, 1996, thirteen days after the ValuJet accident, RSPA issued an interim final rule that prohibited the transportation of chemical oxygen generators on passenger aircraft until January 1, 1997, and the FAA issued an emergency notice that any person who offers for transportation or transports oxygen generators as cargo aboard passenger aircraft would be subject to swift enforcement action. The Safety Board supported these actions but believed that further action should be taken, as evidenced by its urgent safety recommendations.

On May 31, 1996, the Safety Board issued six safety recommendations based on its findings to date in the ValuJet investigation. On July 16, 1996, the FAA and RSPA responded in a joint letter addressing those recommendations, all of which we classified "Open Acceptable."

Safety Recommendation A-96-25 asked the FAA to immediately evaluate the practices of and training provided by all air carriers for accepting passenger baggage and freight shipments (including company materials) and for identifying undeclared or unauthorized hazardous materials that are offered for transport. This evaluation should apply to any person, including ramp personnel, who accepts baggage or cargo for transport on passenger and cargo aircraft. Safety Recommendation A-96-26 asked the FAA to require air carriers, based on the evaluation performed under A-96-25, to revise their practices and training for accepting passenger baggage and freight shipments and for identifying undeclared or unauthorized hazardous materials that are offered for transport.

With regard to these two safety recommendations, the FAA cited actions that had been taken or were planned. In general, the FAA agreed with the recommendations and stated that it had initiated an immediate evaluation of air carrier hazardous materials manuals and training programs to determine if methods were included to identify undeclared or unauthorized hazardous materials.

The FAA has now completed its evaluation of 215 air carriers certified under 14 CFR 121, 125, and 135. According to the FAA, it reviewed FAA-approved air carrier manuals to ascertain what information is currently provided to prompt air carrier employees to recognize suspicious cargo or baggage, and to ask additional questions before rejecting or accepting such cargo or baggage. Also, the FAA has advised that it completed follow-up inspections of those carriers to determine if they are complying with the established procedures in their manuals. Based on the outcome of its analysis of the evaluations, the FAA stated that it should have the necessary information to recommend appropriate actions to correct any noted deficiencies and to address the issues raised in Safety Recommendations A-96-25 and B26.

Despite these activities, the Safety Board is concerned, based on the facts developed during the ValuJet flight 592 accident investigation, that the practices, procedures, and training of the personnel involved in the identification and handling of hazardous materials remain inadequate.

According to the FAA, total air freight, domestic and international, has increased from 7 billion ton miles in 1987 to over 14 billion ton miles in 1995. Total air freight is growing at a rate of seven percent annually, and 60 percent of the air freight moves on passenger carriers. The FAA estimates hazardous materials freight to be between two and three percent of the total. Consequently, the Safety Board urges early resolution of the safety issues cited in Safety Recommendations A-96-25 and -26.

Safety Recommendations A-96-27 and -29 asked the FAA and RSPA to permanently prohibit the transportation of chemical oxygen generators as cargo on board any passenger or cargo aircraft when the generators have passed expiration dates, and the chemical core has not been depleted. With regard to these recommendations, the joint FAA/RSPA response cited the May 24, 1996, interim final rule that prohibited until January 1, 1997, the offering for transportation and the transportation of all chemical oxygen generators as cargo on passenger-carrying aircraft. The interim final rule requested public comments within 60 days. On December 30, 1996, RSPA issued its final rule (effective December 31, 1996) to prohibit oxygen generators as cargo on passenger-carrying aircraft. The effect of this rule will limit the carriage of oxygen generators to accessible areas of cargo aircraft only.

Safety Recommendations A-96-28 and -30 asked the FAA and RSPA to prohibit the transportation of oxidizers and oxidizing materials (e.g., nitric acid) in cargo compartments that do not have fire or smoke detection systems. With regard to these recommendations, the FAA/RSPA response stated that the existing regulations forbid the air transportation of the highest risk oxidizing materials on board passenger-carrying aircraft. The letter stated that there are extensive RSPA regulations that limit the amount of permissible oxidizing materials that may be carried in air transportation and that set forth requirements for labeling, packaging, and handling of these materials. Nevertheless, at the urging of the FAA, RSPA initiated a rulemaking project to propose a prohibition of oxidizers in Class D cargo compartments of both passenger and cargo aircraft. The proposed rule (HM 224A) would permit oxidizers in accessible locations on cargo aircraft. The FAA added that it would initiate rulemaking by October 1996, to require the clear identification (labeling) of Class C and D cargo compartments for easy identification by ground personnel. No proposed rule has been issued to date.

The Safety Board has not formally issued its evaluation of these actions; however, it fully supported the final rule on prohibition of oxygen generators. In its February 28, 1997, comments to the docket for NPRM HM-224A, the Safety Board supported the adoption of the proposed rules with a few exceptions. Specifically, the Safety Board expressed its concerns that the proposed rules did not prohibit the limited quantities of oxidizers that are shipped as consumer commodities. Further, the consumer commodity exception allows shipment of these materials without labeling to warn air carrier personnel that the package contains oxidizing materials. Consequently, they could be carried in Class D cargo compartments that do not have smoke/fire detection.

The Safety Board's comments to the docket on NPRM HM-224 also urged RSPA to complete its study of the effects of authorized hazardous materials in cargo compartment fires and to require appropriate safety systems to protect aircraft and their occupants. This is the same issue addressed in a recommendation after the American Airlines accident in 1988 that was classified "Closed-Unacceptable Action" on April 19, 1993.

In summary Mr. Chairman, the record shows that in-flight fires in the cargo compartments of passenger-carrying aircraft are relatively rare events. Similarly, fatal accidents from such fires are extremely rare (Saudi L-1011 in 1980, and ValuJet DC-9 in 1996, which occurred over a 17-year period). However, despite the rarity of such events, the Safety Board believes that the traveling public would agree that the potential for catastrophic accidents is real, and steps must be taken to reduce the chances of such accidents as much as possible.

We agree that there have been significant positive developments in the past year by the FAA and RSPA to adopt more stringent requirements to prevent fires in cargo compartments of air carrier aircraft. However, much more needs to be done without delay. The delays of the past and the failures of the FAA and industry to act on earlier safety recommendations should not be repeated or we may experience another catastrophic in-flight fire aboard an air carrier aircraft in the next few years.

Thank you for the opportunity to testify before your Committee today.

Jim Hall's Speeches