Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Quick Launch
Safety Recommendation A-11-087
Details
Synopsis: On September 3, 2010, about 1941 local time (1541 coordinated universal time), United Parcel Service (UPS) flight 6 (UPS6), a Boeing 747-400F, N571UP, crashed inside an Emirati army post about 9 miles from Dubai International Airport (DXB), Dubai, United Arab Emirates (UAE). The flight crew encountered a “Fire Main Deck” master warning about 22 minutes into the flight at a cruise altitude of 32,000 feet, declared an emergency, and initiated a return to DXB. The two flight crewmembers were fatally injured; there were no ground injuries. The airplane was destroyed by impact and postcrash fire. The airplane was registered to and operated by UPS under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a cargo flight. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight had departed DXB about 45 minutes earlier en route to Cologne, Germany. The UAE General Civil Aviation Authority is investigating this accident with the assistance of an accredited representative from the National Transportation Safety Board (NTSB) under the provisions of Annex 13 to the International Convention on Civil Aviation. Although the accident investigation is ongoing, preliminary findings have revealed safety issues related to the training for and use of oxygen masks; communicating with oxygen masks donned; and oxygen mask stowage and the smoke, fire, or fumes checklists.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require operators to install full-face oxygen masks on aircraft used for 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operations and provide training on their use.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Dubai, United Arab Emirates
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA10RA092
Accident Reports:
Report #: None
Accident Date: 9/3/2010
Issue Date: 9/20/2011
Date Closed: 12/7/2015
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/7/2015
Response: The intent of this recommendation is to ensure that aircraft are equipped with full-face oxygen masks?which are easier to don, adjust, and use than a mask/goggle set?allowing flight crews more time to respond to a smoke, fire, or fumes event during flight. We note that you do not intend to require operators to install full-face oxygen masks, as recommended, because you consider the guidance for combating in-flight fires contained in Advisor Circular (AC) 120-80A, “In Flight Fires,” to constitute an acceptable alternate solution. The AC does not encourage operators either to install or use full-face oxygen masks; therefore, we do not believe that it satisfies this recommendation. Although we continue to believe that operators should be required to provide flight crews with a safer alternative to the oxygen mask or goggles currently mandated, you have stated that you consider your actions complete. Accordingly, Safety Recommendation A-11-87 is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 10/16/2015
Response: -From Michael P. Huerta, Administrator: On December 22, 2014, the Federal Aviation Administration (FAA) published Advisory Circular (AC) 120-80A. Inflight Fires. AC 120-80A provides clear guidance to operations training managers at parts 121, 135, and subpart 91 K operators and discusses the importance of flight crew member initial and recurrent hands-on training in the operation and use of oxygen masks and goggles. The AC was posted for public comment for 90 days and received 15 comments from the public, trade and labor organizations, a11d international civil aviation authorities. All of the comments were reviewed and several were incorporated into the AC or added as a reference. Both full-face oxygen masks and oxygen masks/goggles are approved for use in part 25 aircraft, and both types of oxygen masks and smoke goggles are available for operators to use in their operations. Using system safety methodologies and a safety risk assessment, each operator determines which type is most appropriate for their operation. As discussed in our May 1, 2013, letter, our review of the available safety data did not support a requirement for parts 121, 135,and 91 subpart K operators to use only full face oxygen masks. This is an acceptable alternate means of addressing the safety issue, and based on the publication of the AC. I believe the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 9/6/2013
Response: We note that the FAA is in the process of revising Advisor Circular (AC) 120-80, “In-Flight Fires,” to include clear guidance for operations training managers at 14 CFR Part 121, 135, and 91 subpart K, concerning recommendations for “smoke, fire and fumes” checklists. We emphasize that the intent of this recommendation was to provide flightcrews with a safer alternative to the oxygen mask/goggle set that is currently used during a smoke, fire, or fumes event, and that a full face oxygen mask is easier to don, adjust, and use than a mask/goggle set, allowing flightcrews more time to respond to these events during flight. Although UPS retrofited the cockpits of its airplanes with full-face oxygen masks having integrated smoke goggles, we remain concerned that other operators have not taken similar action and that a requirement is therefore needed. Accordingly, pending the FAA’s requiring operators to (1) install full-face oxygen masks on the specified aircraft and (2) provide training on their use, Safety Recommendation A-11-87 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/1/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) continues to work on a revision to Advisory Circular (AC) 120-80, In-Flight Fires. As noted in our previous response, the revised AC would provide clear guidance to operations training managers at part 121, 135, and 91 subpart K operators concerning recommendations for designating "smoke, fire, and fumes" checklists. However, we reviewed the available safety data and determined that it does not support a requirement for part 121, 135, and 9 1 subpart K operators to use only full face oxygen masks. We note that both full face oxygen masks and oxygen masks/goggles are currently approved for use in part 25 aircraft. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an updated response by March 2014.

From: NTSB
To: FAA
Date: 3/6/2012
Response: We note that the FAA is in the process of revising Advisor Circular (AC) 120-80, In-Flight Fires, to include clear guidance for operations training managers at 14 CFR Part 121, 135, and 91 subpart K operations concerning recommendations for “smoke, fire and fumes” checklists. Available safety data will also be reviewed to determine whether a requirement for operators to use only full-face oxygen masks is supported. Pending such a review and implementation of a requirement for operators to (1) install full-face oxygen masks on the specified aircraft and (2) provide training on their use, Safety Recommendation A-11-87 is classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 1/27/2012
Response: Thank you for the United Parcel Service’s (UPS) October 11, 2011, response to the National Transportation Safety Board (NTSB) regarding Safety Recommendations A-11-87 through -91, stated below. These recommendations were issued to the Federal Aviation Administration (FAA) on September 20, 2011, as a result of the NTSB’s investigation of the September 3, 2010, accident near Dubai International Airport, Dubai, United Arab Emirates, of UPS flight 6, a Boeing 747-400F. We note that UPS has formed a Safety Task Force, comprising UPS flight-qualified and non-flight-qualified management personnel and Independent Pilots Association Safety Group members, to review and make recommendations to UPS regarding new technology, methods, and training that could assist crewmembers in better managing smoke or fire events in aircraft. We are pleased with UPS’s decision to adopt the task force’s recommendations, which are similar to NTSB Safety Recommendations A-11-87 through -91. A-11-87 Require operators to install full-face oxygen masks on aircraft used for 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operations and provide training on their use. We note that UPS has purchased full-face oxygen masks for all of its aircraft and that all Captain, First Officer, and First Observer positions will receive training on the proper use of these masks. A-11-88 Require operators of 14 Code of Federal Regulations Part 121, 135, and 91 subpart K flights to include, during initial and recurrent training, tactile, hands-on training on the use of operable oxygen mask/goggle sets, including the use of the regulator’s emergency selector and the venting of the smoke goggles. We note that all crewmembers are now required to receive enhanced in-simulator, hands-on training on proper oxygen mask use, which includes best practices for locating the 100-percent oxygen lever and emergency selector. In addition, we note that UPS created a new oxygen mask and goggle training video and featured a full-page graphic in the UPS safety publication, which provides clear identification of oxygen mask components and explains mask venting and de-fogging procedures. A-11-89 Require operators of 14 Code of Federal Regulations Part 121, 135, and 91 subpart K flights to include, during initial and recurrent training, aircraft-specific training on establishing and maintaining internal cockpit communications when the oxygen masks are donned. We note that UPS plans to include training in communication in smoke-filled environments in addition to the already-required, aircraft-specific training on establishing and maintaining internal cockpit communications when oxygen masks are donned. A-11-90 Require operators of 14 Code of Federal Regulations Part 121, 135, and 91 subpart K flights to educate flight crews about the importance of stowing their oxygen masks set to 100 percent. UPS indicated that the importance of stowing flight crew oxygen masks set to 100 percent is covered extensively during recurrent training. We note that UPS developed a video, titled “Oxygen Mask and Goggle Training,” which shows this step being performed, and that UPS plans to further refine the video to include a narrative stressing the importance of stowing masks set to 100 percent. A-11-91 Require that operators’ smoke, fire, or fumes checklists include, as the first step, that flight crewmembers don their oxygen masks and verify that the regulator is set to 100 percent. We note that UPS has established a working group to develop new aircraft checklists, which will incorporate the latest human factors research and verify that the regulator is set to 100 percent. Although the FAA has not yet responded to these recommendations, we commend UPS’s efforts to address these recommendations in a timely manner and without an FAA requirement. Thank you for your cooperation and your commitment to transportation safety.

From: FAA
To: NTSB
Date: 12/14/2011
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) is revising Advisory Circular (AC) 120-80, In-Flight Fires, to provide clear guidance to operations training managers at part 121, 135, and 91 subpart K operators concerning recommendations for designating "smoke, fire, and fumes" checklists. Both full face oxygen masks and oxygen masks/goggles are approved for use in 14 CFR part 25 aircraft. As part of the AC update, we plan to review whether requiring part 121, 135, and 91 subpart K operators to use only full face oxygen masks is supported by available safety data. We are coordinating the AC revision with the FAA Fire Safety Branch as well as FAA Aeromedical staff specializing in flight deck human factors.

From: FAA
To: NTSB
Date: 10/11/2011
Response: CC# 201100387: THIS LETTER IS FROM MITCHELL R. NICHOLS, PRESIDENT OF UNITED PARCEL SERVICE CO. (UPS). THIS LETTER IS NOT FROM THE ADDRESSEE, THE FEDERAL AVIATION ADMINISTRATION: I commend the NTSB for issuing crewmember oxygen mask recommendations A-11-87 through -91 on September 20, 2011. As UPSers, we are also deeply interested in improving safety and training for smoke and fire events and, as a result of early information from the investigation fed back into the company for safely purposes, have taken steps toward improving our emergency procedures and crew training. As a result of the Flight 6 accident, UPS formed a Safety Task Force (STF) composed of UPS flight-qualified and non-flight-qualified management personnel and Independent Pilots Association (IPA) safety group members. Their mission is to provide solutions which increase safety by developing methods, evaluating technology and enhancing training for successfully managing smoke or fire events in an aircraft. In February 201 I the UPS/IPA Safety Task Force issued oxygen mask and checklist recommendations to the company nearly identical to those recently issued by the NTSB. UPS management agreed with the Task Force recommendations and acted quickly to improve safety. On June 30, 2011, UPS announced the purchase of new simplified full-lace oxygen masks for all Captain, First Officer and First Observer positions on all aircraft. These new masks can be deployed using one hand in three seconds versus the cumbersome mask/goggle combination in use on many aircraft. On January 7, 2011, UPS created a new oxygen mask and goggle training video by which all crewmembers receive extensive training on the proper use of both existing and simplified full-face oxygen masks. All crew members are required to take this training.