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Safety Recommendation Details

Safety Recommendation A-07-106
Details
Synopsis: On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and most of the cargo were destroyed by fire after landing. The scheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan. Night visual conditions prevailed at the time of the accident.
Recommendation: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Require aircraft operators that transport hazardous materials to immediately provide consolidated and specific information about hazardous materials on board an aircraft, including proper shipping name, hazard class, quantity, number of packages, and location, to on-scene emergency responders upon notification of an accident or incident.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Philadelphia, PA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA06MA022
Accident Reports: In-Flight Cargo Fire, United Parcel Service Company Flight 1307, McDonnell Douglas DC-8-71F, N748UP
Report #: AAR-07-07
Accident Date: 2/7/2006
Issue Date: 12/17/2007
Date Closed: 7/21/2010
Addressee(s) and Addressee Status: PHMSA (Closed - Acceptable Action)
Keyword(s): Cargo, Emergency Response, Hazmat, Records

Safety Recommendation History
From: NTSB
To: PHMSA
Date: 6/15/2011
Response: No response necessary.

From: PHMSA
To: NTSB
Date: 10/13/2010
Response: CC# 201000381: - From Cynthia Douglass, PHMSA: The NTSB's July 21 letter advised that this recommendation has been classified "Closed Acceptable Action."

From: NTSB
To: PHMSA
Date: 8/17/2010
Response: No response necessary.

From: PHMSA
To: NTSB
Date: 8/9/2010
Response: CC# 201000303: - From Ola Parsons, PHMSA, Executive Secretariat: Thank you for your letter of July 21 to the U.S. Department of Transportation (DOT) regarding Safety Recommendations A-07-104 through A-07-108 and A-08-1 and A-08-2 issued by the National Transportation Safety Board to the DOT, In light of the scope of your request and the need for DOT to coordinate its response, completion of our final response will take some time, We will provide a response as soon as possible, and we appreciate your patience. For your reference, we have assigned control number PHMSA-l 00803-002 to your letter.

From: NTSB
To: PHMSA
Date: 7/21/2010
Response: The NTSB has reviewed PHMSA’s final rule, titled "Hazardous Materials: Revision to Requirements for the Transportation of Batteries and Battery-Powered Devices; and Harmonization With the United Nations Recommendations, International Maritime Dangerous Goods Code, and International Civil Aviation Organization’s Technical Instructions." This final rule, published at 74 Federal Register 2200 on January 14, 2009, requires that aircraft operators provide, without delay, consolidated and specific information about hazardous materials on board an aircraft to on-scene emergency responders. PHMSA’s actions fully satisfy the intent of Safety Recommendation A-07-106. Accordingly, the recommendation is classified CLOSED -- ACCEPTABLE ACTION.

From: NTSB
To: PHMSA
Date: 4/2/2010
Response: The NTSB is currently reviewing the action taken by PHMSA on the above recommendations, identified in your letter, and expects to have a more substantive response back to you shortly. We apologize for the delay in responding regarding some of the recommendations; however, additional documentation was needed for these before their evaluation for closure could be completed. Action on Safety Recommendation R-89-53 (see enclosure) was completed on March 19, 2010.

From: PHMSA
To: NTSB
Date: 3/15/2010
Response: Letter Mail Controlled 3/16/2010 1:16:29 PM MC# 2100096: - From Cynthia L. Quarterman, Administrator: I greatly appreciated meeting with you last month concerning the National Transportation Safety Board's (NTSB) recommendations to the Pipeline and Hazardous Materials Safety Administration (PHMSA). I look forward to meeting with you again, along with staff, on Tuesday, March 16th. Your recommendations, based on lessons learned from accident investigations, provide valuable safety information to our programs. We are committed toconsidering each of the recommendations and implementing those that are positive improvements in safety. I have been meeting with PHMSA's hazmat and pipeline safety programs to assess our actions on the NTSB recommendations. We are addressing these safety issues by taking actions to assure that the "unacceptable actions" are moved into the "open-acceptable" category and to achieve a "closed-acceptable" in a timely manner on as many recommendations as possible. I recognize that a number of "open-acceptable" recommendations are works in progress and maytake a year or more to complete. You indicated your interest in getting these issues resolved as well. As you requested, I asked our pipeline and hazmat staff to compile a copy of outstanding letters to the NTSB that request a change in the classification of a recommendation. I have attached a copy of those letters and am hopeful you and I can successfully resolve a number of these issues. In addition, I have askedour Chief Safety Officer, Cindy Douglass, and our Associate Administrators, Jeff Wiese for Pipeline Safety and Magdy El-Sibaie for Hazardous Materials Safety, to meet with your staff to help us better understand each recommendation and to clarify the actions the NTSB considers necessary for closure. Again, I look forward to meeting with you on these safety concerns and believe that, together, we will make a positive difference in the safe transportation of hazardous materials, including those transported by pipelines.

From: NTSB
To: PHMSA
Date: 12/19/2008
Response: PHMSA stated that it is considering amending the HMR to require that emergency response information be provided without delay and that it plans to propose this change in an upcoming rulemaking. PHMSA is also initiating a research project to study and demonstrate ways that electronic transmission of emergency response and shipping information can enhance safety. Pending revisions being made to the HMR to require that aircraft operators provide, without delay, consolidated and specific information about hazardous materials on board an aircraft to on-scene emergency responders, Safety Recommendation A-07-106 is classified OPEN -- ACCEPTABLE RESPONSE.

From: NTSB
To: PHMSA
Date: 11/19/2008
Response: Notation 7772E: The National Transportation Safety Board has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA’s) Notice of Proposed Rulemaking (NPRM), “Hazardous Materials: Revision to Requirements for the Transportation of Batteries and Battery-Powered Devices; and Harmonization With the United Nations Recommendations, International Maritime Dangerous Goods Code, and International Civil Aviation Organization’s Technical Instructions,” which was published at 73 Federal Register 44804 on July 31, 2008. The notice requested comments on a revision to the requirements for the transportation of batteries and battery-powered devices and on revisions meant to harmonize the Hazardous Materials Regulations (HMRs) with the United Nations recommendations, the International Maritime Dangerous Goods Code, and the International Civil Aviation Organization’s (ICAO’s) “Technical Instructions for the Safe Transport of Dangerous Goods by Air” (Technical Instructions). The Safety Board notes that the primary purpose of the NPRM is to align the HMRs with international requirements and has no comments on that subject. The Safety Board also notes that the NPRM includes proposals on two safety issues addressed in a previous Safety Board investigation: • A requirement that air carriers provide emergency responders with complete information about hazardous materials cargo on an aircraft that is involved in an accident or incident. • A requirement that air carriers submit telephonic and written incident reports about any incident involving lithium batteries that produces smoke, sparks, or a dangerous evolution of heat. Our comments on these issues follow. Hazardous Materials Information for Emergency Responders The Safety Board most recently addressed the timeliness of an air carrier in providing this information to emergency responders in its investigation of an inflight cargo fire in Philadelphia, Pennsylvania, on February 7, 2006. In this accident, air carrier personnel failed to quickly access specific hazardous materials information and provide it to emergency responders, which could have potentially created a safety hazard. For the protection of emergency responders and the public, the HMRs (40 Code of Federal Regulations 175.33(d)) require air carriers to make a copy of the shipping documentation for the hazardous materials cargoes on board an aircraft available to emergency responders “upon request.” As stated in the Board’s report, this requirement suggests that the voluntary transfer of hazardous materials information, without a formal request, is optional for the carrier. ICAO’s Technical Instructions promote a more proactive approach to information dissemination than the HMRs, as ICAO requires that an aircraft operator provide such information “without delay.” Consequently, the Safety Board recommended that PHMSA: Require aircraft operators that transport hazardous materials to immediately provide consolidated and specific information about hazardous materials on board an aircraft, including proper shipping name, hazard class, quantity, number of packages, and location, to on-scene emergency responders upon notification of an accident or incident. (A-07-106) The NPRM proposes that aircraft operators transporting hazardous materials be required to make complete information about hazardous materials on an aircraft immediately available to on-scene emergency responders in the event of a reportable incident. The proposal would ensure that on-scene emergency responders receive accurate information regarding hazardous materials potentially involved in an accident or incident in a timely manner. Further, in a March 28, 2008, letter to the Safety Board, PHMSA indicated that it was undertaking a research project to study and demonstrate how electronic transmission of emergency response and shipping information could enhance safety. The Safety Board fully supports the NPRM’s proposal and believes that the proposal, if implemented, will satisfy the intent of Safety Recommendation A-07-106. PHMSA’s research about electronic transmission of this information potentially can further enhance the timely communication of this information to emergency responders. The Safety Board commends PHMSA on these initiatives. Lithium Battery Safety The Safety Board addressed this issue also in its investigation of the Philadelphia accident. During the investigation, the investigators found that the number of aviation incidents involving both primary and secondary lithium batteries was increasing, that millions of laptop computers containing lithium batteries had been recalled because of potential overheating hazards, and that the failure modes of lithium batteries and devices containing them were still not well understood. Consequently, the Safety Board recommended that PHMSA: Require commercial cargo and passenger operators to report to the Pipeline and Hazardous Materials Safety Administration all incidents involving primary and secondary lithium batteries, including those contained in or packed with equipment, that occur either on board or during loading or unloading operations and retain the failed items for evaluation purposes. (A-07-107) The Safety Board believes that the NPRM addresses only one aspect of Safety Recommendation A-07-107. Although the proposed change requires that all incidents involving lithium batteries and devices containing them be immediately reported, it does not specify that the failed batteries and battery-powered devices be retained for evaluation purposes. The reason the safety recommendation calls for evaluating the failed batteries is to collect information that can be used to assess the risk of transporting such items. The Safety Board acknowledges that PHMSA indicated in its March 28, 2008, response to the safety recommendation that it is working with the Federal Aviation Administration and the airlines to establish ways of effectively securing and preserving evidence. The Safety Board, however, believes that unless the HMRs specifically require that failed items be retained, there is no way to ensure that failed batteries will be properly analyzed. Therefore, the Safety Board believes that the NPRM can be improved by also requiring that failed batteries and/or equipment with lithium batteries be retained as recommended. The Safety Board appreciates the opportunity to comment on the notice.

From: PHMSA
To: NTSB
Date: 3/28/2008
Response: MC# 2080191: - From Stacey L. Gerard, Assistant Administrator/ Chief Safety Officer: The Hazardous Materials Regulations require an aircraft operator to: (1) place on the notification of pilot-in-command (NOPC) or in the cockpit of the aircraft a telephone number that can be contacted during an in-flight emergency to obtain information about any hazardous materials aboard the aircraft; (2) retain and provide upon request a copy of the NOPC, or the information contained in it, at the aircraft operator’s principal place of business, or the airport of departure, for 90 days, and at the airport of departure until the flight leg is completed; and (3) make readily accessible, and provide upon request, a copy of the NOPC, or the information contained in it, at the planned airport of arrival until the flight leg is completed. The International Civil Aviation Organization’s Technical Instructions for the Safe Transport of Dangerous Goods by Air (ICAO TI) provides the following guidance on the transfer of hazardous materials information between aircraft operators and emergency personnel: In the event of an aircraft accident or serious incident, the operator of an aircraft carrying dangerous goods as cargo must provide information, without delay, to emergency services responding to the accident or serious incident about the dangerous goods on board, as shown on the copy of the information to the pilot-in-command. The majority of operators follow the ICAO requirements through their adoption in the International Air Transport Association (IATA) Dangerous Goods Regulations and therefore will adopt the practice of providing emergency response information quickly without delay. We are considering amending the Hazardous Materials Regulations to require that emergency response information be provided without delay and plan to propose this change in an upcoming rulemaking. We are also studying options for more effectively communicating emergency response information electronically and will be undertaking a research project under the Hazardous Materials Cooperative Research Program to study and demonstrate how electronic transmission of emergency response and shipping information can enhance safety. This is one of our top safety priorities and we are applying significant resources to minimizing the risk associated with the transportation of lithium batteries as cargo and by passengers aboard aircraft. As we complete our analyses and propose additional requirements, we will keep you informed of our progress. If you have any questions, please contact me at (202) 366- 4433. We request that you classify recommendations A-07-104, 105, 106, 107 and 109 as Open - Acceptable Action and A-07-108 as Closed Acceptable Action. We thank you for consideration of our request.