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
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
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.
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
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
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 "
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
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
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
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