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Safety Recommendation A-11-088
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 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.
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: 1/19/2018
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/19/2018
Response: Although the guidance contained in Advisory Circular (AC) 120-80A, “In-Flight Fires,” is responsive to Safety Recommendations A-11-88 through -91, we previously told you that, because compliance with an AC is not mandatory, you would need to require principal operations inspectors to verify that their assigned operators have incorporated the appropriate elements of the AC into their operations manuals. We note, however, that you do not intend to verify this information, nor do you intend to take any additional actions in response to these recommendations. Consequently, Safety Recommendations A-11-88 through -91 are classified CLOSED--UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 10/25/2017
Response: -From Michael P. Huerta, Administrator: On December 22, 2014, the Federal Aviation Administration (FAA) issued Advisory Circular (AC) 120-80A, In-Flight fires. This AC updates information regarding the hazards and risks of in-flight fires on transport category aircraft and includes recommended crewmember procedures and training for combating in-flight fires. AC I 20-80A directs operations training managers of parts 121 , 135, and 91 subpart K (91 K) operators to the related regulations in parts 25, 91 , 121 , and 135. This AC also provides clear guidance and discusses the importance of flight crewmember initial and recurrent hands-on training in the operation and use of oxygen masks and goggles. AC 120-80A can be found at the following Web site: https://www.faa.gov/regulations policies/advisory_ circulars/index.cfm/ go/document. information/document! Oil 026526 The AC was posted for public comment for 90 days and received 15 comments from the public, trade and labor organizations, and international civil aviation authorities. Each comment was reviewed and several were incorporated into the AC or added as a reference. AC l 20-80A encourages each operator to determine the most appropriate action for their specific operation using the AC, while remaining consistent with relevant regulatory requirements, system safety methodologies, and safety risk assessments. In its letter dated December 7, 2015, the Board stated that AC l 20-80A contains guidance that addresses Safety Recommendations A-11 -88 through -91 , but noted that compliance with an AC is not mandatory. Although the AC is an advisory document and not regulatory in nature, it is applicable to, and directs operators certificated under parts 91 K, 121, 125, and 135 to acceptable forms of compliance with regulatory requirements. Accordingly, we do not plan to pursue rulemaking to require operators to include recommended crewmember procedures and training for combating in-flight fires or the operation and use of oxygen masks and goggles. We believe the existence of current regulatory requirements is adequate to ensure operators implement their safety and emergency procedures. I believe the FAA has effectively addressed these safety recommendations and consider our actions complete.

From: NTSB
To: FAA
Date: 12/7/2015
Response: We believe that AC 120-80A contains guidance that addresses Safety Recommendations A-11-88 through -91, except that compliance with an AC is not mandatory. Therefore, to satisfy the intent of these recommendations, you would also need to verify that air carriers have incorporated the appropriate elements of the AC into their operations manuals. Pending completion of this final action, Safety Recommendations A-11-88 through -90 are classified OPEN—ACCEPTABLE RESPONSE, and Safety Recommendation A-11-91 remains classified “Open—Acceptable Response.”

From: NTSB
To: FAA
Date: 9/6/2013
Response: The FAA’s plan to revise AC 120-80, “In-Flight Fires,” to recommend that operators include the training specified above in their initial and recurrent training programs will not satisfy these recommendations. Although principle operations inspectors are expected to monitor whether the air carriers assigned to them have incorporated the appropriate elements of ACs into their ops manuals, compliance with an AC is not mandatory. Therefore, a requirement is needed to ensure that operators have taken the recommended action. Pending our review of a plan that will ensure that the specified training is incorporated by all operators, Safety Recommendations A-11-88 through -90 are classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/23/2013
Response: -From Michael P. Huerta, Administrator: As mentioned in our response dated December 14, 2011, the Federal Aviation Administration (FAA) had planned to issue a Notice directing all principal operations inspectors to conduct a review of their assigned parts 121, 135, and 91 subpart K operators' training programs and emergency checklists concerning the use of oxygen masks. Recognizing the importance of proper oxygen mask use, we decided to revise Advisory Circular (AC) 120-80, In Flight Fires, instead of issuing a Notice. While compliance with ACs is not mandatory, FAA principal operations inspectors are expected, as part of their routine work, to monitor that the air carriers assigned to them have incorporated the appropriate elements of ACs into their operations manuals. For this reason, we have determined that an AC is an appropriate response to these recommendations. The AC is applicable to operations under parts 121, 135, and 91 subpart K. The AC recommends that initial and recurrent training for parts 121, 135, and 91 subpart K operators include the following: • 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 s_moke goggles; • Aircraft-specific training on establishing and maintaining internal cockpit communications when the oxygen masks are donned; and • Flight crew education about the importance of stowing their oxygen masks set to 100 percent. The AC revision is currently in internal review at the FAA, and we anticipate publication in June 2014. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an updated response by December 2013.

From: NTSB
To: FAA
Date: 3/6/2012
Response: The FAA reported that it plans to (1) issue a notice to direct all principal operations inspectors to review their assigned operator’s training programs and emergency checklists that address the use of oxygen masks and then (2) review this information to determine whether operators should revise the safety and emergency procedures as they relate to oxygen mask and goggle use. Accordingly, pending completion of the recommended actions, Safety Recommendations A-11-88 through -90 are 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: We agree that are-emphasis of the proper use of oxygen masks is important. We plan to review parts 135, 121, and 91 subpart K operators' training programs to determine if operators should revise their safety and emergency procedures as they relate to oxygen mask and goggle use. We also plan to develop a Notice directing all principal operations inspectors to conduct a review of their assigned parts 121, 135, and 91 subpart K operator's training programs and emergency checklists concerning the use of oxygen masks. We anticipate publishing the Notice by January 1, 2012, with a 90-day suspense date. The information collected from this review will determine what future steps the FAA make take with regard to these recommendations.

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. In January 2011, UPS began utilizing our new video and also enhanced the in-simulator hands-on training given to all crewmembers about proper oxygen mask use. Extensive hands-on training is being given to pilots in classroom and simulators on best practices for locating the 100% oxygen lever, emergency selector and, in the case of separate goggles, the oxygen mask vent valve every time they don their oxygen mask. This muscle training enables pilots to ensure proper settings are selected even in a smoke-filled environment. In addition, a full-page graphic in the UPS safety publication, "The Leading Edge," provides clear identification of oxygen mask components and explains musk venting and dc-fogging procedures.