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Safety Recommendation A-11-091
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 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%.
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: 2/4/2013
Response: The FAA is continuing its efforts to revise advisory circular 120-80, “In-Flight Fires,” to provide appropriate guidance in developing and designing smoke, fire, and fumes checklists. In addition, the FAA plans to issue a safety alert for operators (SAFO) that requires FAA principal operations inspectors (POI) to review their assigned certificate holders’ emergency action checklists that deal with smoke, fire, and fumes to ensure that the checklists require pilots, as the first action, to don their oxygen masks and verify that the oxygen regulator is set to 100%. We are aware that a SAFO is only an advisory document and cannot mandate compliance. In response to other recommendations for which the FAA developed and issued a SAFO, we have asked the FAA to ask its POIs to determine how many operators had incorporated the guidance provided in the SAFO. Our experience has been that the FAA has not been successful in ensuring that all of its POIs are making these determinations. Accordingly, although we believe that for all POIs to review their assigned carriers’ emergency action checklists would satisfy this recommendation, we are concerned that issuing a SAFO may not ensure that all POIs are doing so. Therefore, we ask the FAA to explain how an advisory document such as a SAFO will be able to require POIs to perform the recommended reviews. Pending our receipt of an answer to that question and completion of the recommended action, Safety Recommendation A-11-91 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/3/2013
Response: -From Michael P. Huerta, Acting Administrator: As we stated in our initial response to the Board, the Federal Aviation Administration (FAA) is revising Advisory Circular (AC) 120-80, In-Flight Fires, to provide clear guidance in developing and designing smoke, fire, and fumes checklists. This revision will include human factors considerations so that no delay or confusion inhibits crewmembers from responding quickly and positively to an emergency condition. In addition to revising this AC, we plan to issue a Safety Alert for Operators that requires FAA Principal Operations Inspectors to review their assigned certificate holders' emergency action checklists that deal with smoke, fire, and fumes to ensure that the checklist requires pilots, as the first action, to don their oxygen mask and verify that the oxygen regulator is set to 100 percent. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by November 2013.

From: NTSB
To: FAA
Date: 3/6/2012
Response: As discussed above, the FAA is in the process of revising AC 120-80 to provide clear guidance to operations training managers regarding “smoke, fire and fumes” checklists, and plans to review whether setting oxygen masks to 100 percent is warranted in all cases. Pending completion of the recommended action, Safety Recommendation A-11-91 is classified OPEN—ACCEPTABLE RESPONSE. We point out that UPS has formed a safety task force, composed of 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 crew members in better managing smoke or fire events on aircraft. We are pleased with UPS’s decision to adopt the task force’s recommendations, which are similar to Safety Recommendations A-11-87 through -91.

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 are revising AC 120-80, In-Flight Fires, to provide clear guidance to operations training managers for parts 121, 135, and 91 subpart K operators concerning designing smoke, fire, or fumes checklists. As part of the AC update, we plan to review whether setting the oxygen mask to 100 percent in all cases is warranted. We are coordinating the AC revision with the FAA Fire Safety Branch as well as FAA Aeromedical staff specializing in flight deck human factors. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an updated response by July 2012.

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. We established a checklist working group on August 23, 2011 whose goal is to develop new aircraft checklists incorporating the latest human factors research and becoming 100% CAP 676 compliant which includes verifying the regulator is set to 100 %. UPS fully supports the NTSB recommendations related to the ongoing Flight 6 accident investigation. We believe simplified full-face oxygen masks with enhanced training are necessary 10 improve safety. In addition, as our Safety Task Force has recommended, UPS is committed to purchasing the Emergency Vision Assurance Systems (EVAS) for all aircraft in our fleet. UPS believes the combination of these two technologies represent an enhanced solution to assist crewmembers in managing in-flight smoke, fire and fumes events. I can assure you the NTSB and the United Arab Emirates General Civil Aviation Authority (GCAA) will continue to have our full support.