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Safety Recommendation Details

Safety Recommendation A-07-108
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: Analyze the causes of all thermal failures and fires involving secondary and primary lithium batteries and, based on this analysis, take appropriate action to mitigate any risks determined to be posed by transporting secondary and primary lithium batteries, including those contained in or packed with equipment, on board cargo and passenger aircraft as cargo; checked baggage; or carry-on items.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 11/12/2014
Addressee(s) and Addressee Status: PHMSA (Closed - Acceptable Alternate Action)
Keyword(s): Cargo, Fire, Hazmat

Safety Recommendation History
From: NTSB
To: PHMSA
Date: 11/12/2014
Response: We note that, on August 6, 2014, PHMSA published final rule Hazardous Materials-224F, revising the Hazardous Materials Regulations requirements for the transportation of lithium cells and batteries by air to make the requirements consistent with those of the 2013-2014 International Civil Aviation Organization Technical Instructions. Your actions constitute an acceptable alternate solution to the safety concern we identified; accordingly, Safety Recommendations A-07-108 and -109 are classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

From: PHMSA
To: NTSB
Date: 8/27/2014
Response: -From Timothy Butters, Deputy Administrator: In its December 26, 2012 letter to PHMSA, the NTSB indicated that the 2013-2014 International Civil Aviation Organization Technical Instructions (ICAO TI) on the Transport of Dangerous by Air provisions for lithium battery transport by air are responsive to recommendations A-07-108 and A-07-109 and PHMSA would satisfy the recommendations if it were to incorporate the ICAO TI provisions for lithium battery transport into the HMR. This was reiterated in its September 6, 2013 letter to PHMSA, in which the NTSB specifically states that it believes that a mandate for compliance with the 2013-2014 ICAO TI provisions for lithium battery transport is needed for PHMSA’s actions to constitute an acceptable alternate solution to the problem. Accordingly, on August 6, 2014, PHMSA published a final rule (HM-224F; 79 FR 46011) revising the HMR requirements applicable to the transportation of lithium cells and batteries by air to make them consistent with the ICAO TI. The rulemaking is available at our website at www.phmsa.dot.gov/hazmat or at www.federalregister.gov. PHMSA will continue to monitor incidents and analyze the causes of thermal failures and fires involving lithium metal and lithium ion batteries for possible future safety improvements, bearing in mind the statutory limitation to not be more stringent than the ICAO TI, except under certain conditions. PHMSA appreciates the NTSB’s continued efforts to improve safety in transporting lithium batteries by air.

From: NTSB
To: PHMSA
Date: 9/6/2013
Response: We are encouraged to learn that, effective January 1, 2013, the HMR reference the 2013 2014 ICAO technical instructions (TI), which allow shippers and carriers to use the 2013 2014 ICAO TI; however, the regulations do not mandate compliance. Although the revised regulations constitute a noteworthy improvement, we believe that a mandate for compliance with the 2013 2014 ICAO TI provisions for lithium battery transport is needed for PHMSA’s actions to constitute an acceptable alternate solution to the problem. Accordingly, pending our receipt and review of the revised HMR, including plans to mandate compliance as described above, Safety Recommendations A 07-108 and -109 remain classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: PHMSA
To: NTSB
Date: 6/25/2013
Response: -From Cynthia Quarterman, Administrator: In the December 26, 2012 letter, the NTSB indicated awareness that the 2013-2014 International Civil Aviation Organization Technical Instructions on the Safe Transport of Dangerous Goods by Air (“ICAO TI”) includes provisions for lithium battery transport that are responsive to these recommendations, and that incorporation into the Hazardous Materials Regulations (HMR; 49 CFR Parts 171-180) would satisfy the recommendations. Relative to this position, PHMSA recently published two rulemakings in the Federal Register on January 7, 2013. PHMSA published a final rule (78 FR 988) incorporating by reference the 2013–2014 ICAO TI into the HMR. Effective January 1, 2013, transport of lithium batteries in accordance with the 2013–2014 ICAO TI is authorized subject to limitations outlined in Part 171, Subpart C of the HMR (see 49 CFR 171.24(d)(1)(ii) and 171.24(d)(1)(iii)). Incorporation by reference of the 2013–2014 Edition of the ICAO TI provides shippers and carriers with the ability to use the 2013-2014 ICAO TI for transportation within the United States by aircraft and by motor vehicle or rail either before or after being transported by aircraft. PHMSA also published a notice of proposed rulemaking (78 FR 1119) seeking public comment on the impact of the changes made to provisions for lithium battery transport in the 2013–2014 ICAO TI. PHMSA issued this notice in consideration of the long-term impacts on domestic transportation of authorizing shippers and carriers to choose between compliance with the existing language for lithium battery transport in the HMR and compliance with the ICAO TI under the aforementioned final rule. Specifically, PHMSA sought comment on whether to make mandatory compliance with the 2013–2014 ICAO TI provisions for lithium battery transport for both domestic and international transport. Taking commenter feedback into consideration, PHMSA may issue a final rule to revise the HMR to incorporate the lithium battery provisions specified in the 2013–2014 ICAO TI into the HMR (i.e., incorporate regulatory text versus authorizing use of an international standard that contains that regulatory text). Although the 2013-2014 ICAO TI provisions for lithium battery transport are not incorporated verbatim into the HMR, the regulatory amendment to incorporate by reference will allow shippers and carriers to opt for the method of compliance appropriate to each specific shipment. Knowing that some domestic air carriers and all international air carriers comply with the ICAO TI (subject, of course, to limitations placed by the HMR for transport in the United States) for the transportation of hazardous material including lithium battery transport, we believe incorporation by reference of the 2013-2014 ICAO TI still satisfies Safety Recommendations A-07-108 and A-07-109.

From: NTSB
To: PHMSA
Date: 3/7/2013
Response: Notation 8477 (Dated 3/8/2013): The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) notice of proposed rulemaking (NPRM), “Hazardous Materials: Transportation of Lithium Batteries.” The notice requested additional comments about the impact of changes to the requirements for the air transport of lithium batteries that have been adopted into the 2013–2014 International Civil Aviation Organization Technical Instructions on the Transport of Dangerous Goods by Air (ICAO Technical Instructions) and subsequently incorporated by reference in the Hazardous Materials Regulations (HMR). The NTSB notes that PHMSA is considering the long-term impacts of permitting shippers and carriers to choose between compliance with the existing HMR or compliance with the ICAO Technical Instructions, when transporting lithium batteries domestically by air. The NTSB further notes that PHMSA is seeking comment on whether to require mandatory compliance with the ICAO Technical Instructions for all shipments of lithium batteries by air, both foreign and domestic. The NTSB believes that allowing domestic cargo shippers and carriers to choose between alternative standards for transporting lithium batteries would place carriers at greater risk when transporting such cargo in accordance with US regulations that currently provide less protection than the ICAO Technical Instructions. On April 14, 2010, the NTSB provided comments on the January 11, 2010, NPRM. The 2010 NPRM proposed new requirements to address NTSB Safety Recommendations A-07-104, A-07-105, and A-07-107 through -109 that were issued as a result of the NTSB investigation of the February 7, 2006, in-flight cargo fire on a United Parcel Service Company (UPS) cargo airplane at Philadelphia International Airport in Philadelphia, Pennsylvania. The 2010 NPRM acknowledged that under the HMR, materials that pose a specific and serious air transportation risk are regulated more stringently than materials that pose less of a risk when transported by air, with lithium batteries being the current exception to this standard. Included in the proposals at that time was the elimination of regulatory exemptions for packages of small lithium batteries. The NTSB stated that cargo shipments of small lithium batteries should be subject to the same packaging and identification requirements that apply to medium and large lithium batteries to increase the awareness of the risks associated with these batteries and to alert package handlers to exercise greater care when loading and unloading packages containing them. In its 2010 comments, the NTSB fully supported the proposal to eliminate exceptions for small lithium batteries, believing that implementation would have satisfied the intent of the following safety recommendation to PHMSA: Eliminate regulatory exemptions for the packaging, marking, and labeling of cargo shipments of small secondary lithium batteries (no more than 8 grams equivalent lithium content) until the analysis of the failures and the implementation of risk-based requirements asked for in Safety Recommendation A-07-108 are completed. (A-07-109) The NTSB recognizes that PHMSA was barred from implementing its original proposal to eliminate small lithium battery air cargo transport exceptions because of provisions in the Federal Aviation Administration (FAA) Modernization and Reform Act of 2012 that prohibit PHMSA from imposing requirements that are more stringent than the ICAO Technical Instructions. Since commenting on the 2010 NPRM, the NTSB has been involved in the investigation of two additional catastrophic in-flight cargo fires on aircraft that were transporting large quantities of lithium batteries. On September 3, 2010, a Boeing 747-400F, operated by UPS, crash landed at a military base in Dubai, United Arab Emirates, while the crew was trying to return to the airport for an emergency landing due to a fire in the main deck cargo compartment. Both crewmembers died as a result of injuries sustained during the crash, and the aircraft was a total loss. On July 28, 2011, a Boeing 747-400F, operated by Asiana Cargo, crashed about 70 miles west of Jeju Island, Republic of Korea, after the flight crew declared an emergency due to a cargo fire and attempted to divert to Jeju International Airport. Again, both crewmembers died as result of injuries sustained during the crash, and the aircraft was a total loss. Based on these ongoing accident investigations, the NTSB remains concerned about the risks to aircraft flight crews from in-flight fires involving lithium batteries. These investigations also prompted the NTSB to issue Safety Recommendations A-12-68 through -70 on November 28, 2012, to the FAA. These recommendations were issued to improve the early detection of fires originating in cargo containers and pallets, to develop materials standards for cargo containers that provide better fire resistance, and to require active fire-suppression systems in all cargo compartments or containers. Meanwhile, the current HMR for domestic air cargo transport continue to allow many small lithium batteries to be transported as general cargo without the safety precautions that are provided for other common hazardous materials. Under current regulations, certain shipments of small batteries are exempt from hazardous materials packaging and identification requirements. These exemptions potentially permit large quantities of unidentified small lithium battery shipments on board both cargo and passenger aircraft, while the revised ICAO Technical Instructions substantially reduce the sizes of small lithium batteries that are subject to regulation. Lithium battery shipments in aircraft are increasing in number, and batteries are increasing in energy density. Recent incidents and research continue to show that lithium battery failures (regardless of the source or cause) can release flammable electrolyte or result in violent, high temperature reactions that can ignite combustible or flammable material nearby or further fuel an existing fire. The PHMSA final rule incorporated the ICAO Technical Instructions by reference, thus permitting, but not mandating, domestic lithium battery shipments to be transported by air in accordance with the international standards (except where the HMR prohibit primary lithium batteries and unapproved prototype lithium batteries and cells aboard passenger carrying aircraft). The ICAO Technical Instructions increased restrictions for shipment of lithium batteries by significantly decreasing the excepted quantity permitted in international cargo shipments. If the HMR are harmonized with the ICAO Technical Instructions, a significantly larger number of fully regulated domestic air cargo shipments of lithium batteries would be subject to the greater level of safety provided by specification packaging requirements and United Nations safety testing, labeling, and hazard communication standards. Complying with such increased safety requirements and standards would reduce the risks associated with transporting these materials. The NPRM Question 1 asks if any unintended consequences are anticipated if PHMSA authorizes the use of the ICAO Technical Instructions as an optional method of compliance with the HMR and does not issue a final rule revising the HMR to require domestic shipments of lithium batteries to comply with the provisions specified in the ICAO Technical Instructions. The NTSB strongly believes that unintended negative consequences would result if shippers and carriers were permitted to choose compliance with alternative standards for domestic cargo shipments as suggested in the NPRM. Such action would undermine the safety benefit offered by the improved ICAO Technical Instructions. Domestic carriers who choose not to apply the ICAO Technical Instructions would be placed at higher risk of cargo fires than their foreign competitors because of the current disparity between requirements in the HMR and the ICAO Technical Instructions. Failure to require domestic shipments of lithium batteries to comply with regulations equivalent to the international provisions would also place the United States in an inexplicable position of having weaker safety standards at a time when it should be leading the way in response to serious safety concerns about transporting these materials. The NPRM would be improved if the excepted amounts authorized by the HMR are at least consistent with the provisions in the ICAO Technical Instructions. The proposal should require that all lithium batteries, consistent with current ICAO packaging criteria, such as battery power, size, and quantity limitations in air transportation, be regulated as class 9 materials and subjected to the requirements of Title 49 Code of Federal Regulations 173.185, including packaging standards and hazard communication requirements. Adoption of this proposal would reduce the risk of lithium battery fires during shipment. The proposal also should require personnel involved in packaging and shipping lithium batteries to be properly trained in their respective hazardous materials handling functions. The proposal should further ensure that these packages are clearly labeled, providing a visible indication of the presence of hazardous materials for flight crews, cargo handlers, and emergency responders. Finally, the proposal should ensure that all lithium battery shipments are listed on the Notice to Pilot in Command or hazardous materials cargo manifest to inform flight crews about the quantity, location, and type of lithium batteries on board an aircraft. The NTSB appreciates the opportunity to comment on the notice.

From: NTSB
To: PHMSA
Date: 12/26/2012
Response: PHMSA indicated that it is currently evaluating the 2013–2014 ICAO technical instructions to determine whether the instructions address either of these recommendations. The NTSB is aware that the 2013–2014 ICAO technical instructions would include (1) a restriction on exemptions from full regulation under Class 9 for small quantities and small packages, (2) new language in the packing instructions to bring some small shipments of Li metal and Li ion cells and batteries under Class 9, but also to provide some relief from full Class 9 requirements that apply to bulk shipments, and (3) a net-weight limit per package for batteries packed with, or contained in, equipment. We believe that these revisions are responsive to these recommendations and, if included in the HMRs, would constitute an acceptable alternate solution to the problem. Accordingly, pending our receipt and review of the revised HMRs, Safety Recommendations A 07-108 and -109 are classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: PHMSA
To: NTSB
Date: 6/6/2012
Response: -From Cynthia L. Quarterman, Administrator: This is in response to your June 15, 2011 letter regarding NTSB Safety Recommendations A-07-104 through -108. This letter provides an update on Pipeline and Hazardous Materials Safety Administration (PHMSA) actions relative to those recommendations (excluding A-07-106, that has been closed) as well as Safety Recommendation A-07-109. The National Transportation Safety Board (NTSB) issued the recommendations based on an investigation of a fire on a United Parcel Service cargo aircraft at Philadelphia International Airport, Philadelphia, Pennsylvania, and on concerns about the increasing number of incidents documented by the Federal Aviation Administration (FAA) involving overheating and fires initiated by rechargeable lithium ion batteries. As you may know, recent Congressional action limits PHMSA’s ability to address several of the referenced recommendations. On February 14, 2012, Congress enacted the FAA Modernization and Reform Act of 2012 (the FAA Act). The FAA Act specifically restricts PHMSA’s authority to issue any regulations that are more stringent than the requirements of the International Civil Aviation Organization’s Technical Instructions on the Safe Transport of Dangerous Goods by Air (ICAO Technical Instructions). The FAA Act, in part, says: The Secretary of Transportation, including a designee of the Secretary, may not issue or enforce any regulation or other requirement regarding the transportation by aircraft of lithium metal cells or batteries or lithium ion cells or batteries, whether transported separately or packed with or contained in equipment, if the requirement is more stringent than the requirements of the ICAO Technical Instructions. Pub. L. 112-95 section 828.The FAA Act does, under certain conditions, allow for more stringent PHMSA action only when PHMSA obtains a credible report that demonstrates that the presence of lithium cells or batteries, transported in accordance with the ICAO Technical Instructions, substantially contributed to the initiation or propagation of an onboard fire. PHMSA is currently evaluating the safety impacts of changes made to the ICAO Technical Instructions relative to these recommendations and will provide NTSB with an update after a determination is made based on the evaluation. The January 2010 proposed rule effectively eliminated the regulatory exceptions for packages of small lithium batteries when transported aboard aircraft. PHMSA chose this regulatory approach because a multi-layered safety system encompassing packaging, hazard communication and employee training has proven to be effective for ensuring the safe transport of larger lithium batteries as well as other hazardous material. Since publication of the proposal, the ICAO Dangerous Goods Panel has adopted more stringent rules with regard to the air transport of lithium batteries under the 2013-2014 ICAO Technical Instructions. These new rules would subject packages containing more than 8 small lithium cells or 2 small lithium batteries, which were previously excepted from most of the requirements of the ICAO Technical Instructions, to additional requirements. These requirements include package weight limits (10 kg for lithium ion cells and batteries and 2.5 kg for lithium metal cells and batteries) and hazard communication requirements including a notice to the pilot in command and a requirement for air carrier personnel to inspect such packages. PHMSA recently published a notice (70 FR 21714; April 11, 2012) seeking additional comment on the impact of these changes and others. PHMSA is considering whether to harmonize with these requirements and the notice will allow opportunity to supplement comments to our January 2010 proposed rule.

From: NTSB
To: PHMSA
Date: 6/15/2011
Response: The NTSB is pleased to learn that an interagency agreement was reached between PHMSA and the U.S. Department of Defense Naval Surface Warfare Center (NSWC) and that the NSWC will test and examine lithium battery remnants and packaging from incidents and will analyze the probable cause. So that we can verify that the program will result in comprehensive analyses of lithium battery failures, the NTSB requests a copy of the agreement between NSWC and PHMSA. In addition, we have the following questions regarding this document: • When does the agreement become effective and for how long will it be in place? • How many failed batteries will NSWC test? If not all, then what is the limit and what criteria will be used to determine which batteries will be tested? • What types of tests will be conducted, and what will NSWC do with the data gathered? Pending our receipt and review of this additional information, Safety Recommendation A-07-108 is classified OPEN—ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 4/4/2011
Response: CC# 20110149: - From Cynthia L. Quarterman, Administrator: I appreciate the effort you have made in the area of hazardous material and pipeline safety transportation. We share an interest in taking strong actions to continually improve the safe transportation of these materials throughout our country. In that regard, I have been meeting with the Pipeline and Hazardous Materials Safety Administration (PHMSA)'s hazardous materials and pipeline safety programs to assess our actions on the NTSB recommendations in the last six months. My goal is to continually address your safety recommendations 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 may take a year or more to complete. In the last six months you have issued four "Closed-Acceptable Action" classifications for the following recommendations: P-04-02, P-07-07, P-07-08 and P-10-01. In an effort to continue this progress, I have asked our hazardous material and pipeline staff to compile outstanding letters to the NTSB that request a change in the classification of a recommendation. I have enclosed a copy of the PHMSA letters requesting that the following five recommendations be classified as "Closed-Acceptable Action": A-07-107, A-07-108, R-07-05, A-08-01, and A-08-02. I am hopeful that you will review these letters and close the recommendations if you believe we have been responsive. In addition, I ask that you review NTSB Recommendation H-04-23 requiring that periodic nondestructive testing be conducted on nurse tanks to identify material flaws that could result in a failure. PHMSA published a final rule on February 1, 2011, requiring inspection and nondestructive testing to allow continued use of nurse tanks with missing or illegible ASME plates. I have enclosed a copy of the Final Rule as published in the Federal Register. In addition, our sister agency, the Federal Motor Carrier Safety Administration contracted with Virginia Polytechnic Institute to research nurse tank safety. If you have questions regarding any of these recommendations, please do not hesitate to call. Together, we are making a positive difference in the safe transportation of hazardous materials, including those transported by pipelines.

From: PHMSA
To: NTSB
Date: 10/13/2010
Response: CC# 201000381: - From Cynthia Douglass, Administrator: In its comments to the January 11 NPRM, NTSB stated that PHMSA did not propose a retention requirement for lithium batteries and equipment, but only requested comments about how retention of failed batteries and equipment might be achieved and a analyzed properly. The PHMSA has proposed to modify 49 C.F.R. § 171.21 to require a shipper, carrier, package owner, or person reporting an incident under the provisions of §§ 171.15 or 171.16 to provide upon request, by an authorized representative of the Federal, State, or local government agency, reasonable assistance in investigating a transportation incident. Such assistance would include providing reasonable access to the damaged package or article, if available. The PHMSA believes this requirement would meet the intent of Safety Recommendation A-07-107 and facilitate the accomplishment of Safety Recommendation A-07-018, while still permitting a reporting person or other responsible person discretion in the disposition of the damaged package or article consistent with protecting human health and the environment. The NTSB has also expressed concern that PHMSA did not discuss the reliability of the data used to determine the causes of the observed incidents. The risk assessment for transportation of lithium batteries discussed in the NPRM is based on an analysis of historical incident data on lithium batteries compiled by FAA. This incident data was the primary source of data used in the analysis. The data includes a narrative report completed by field inspectors that describes the nature of the incidents to the extent that information is available. Other information in the incident reports include the type of battery, the devices in which batteries were contained, if applicable, and the aircraft type (e.g., passenger or cargo aircraft). Despite its limitations, FAA data is the most comprehensive publicly available source to perform a data-driven risk assessment for lithium batteries flown on passenger and cargo aircraft. In support of its ongoing efforts to understand the causes of lithium battery incidents, PHMSA recently finalized an interagency agreement with the U.S. Department of Defense Naval Surface Warfare Center, Carderock Division, to perform compliance and risk assessment testing of lithium batteries in an effort to ensure manufacturer compliance and to further enhance risk reduction for the transportation of such batteries. A major component of this agreement includes the testing and examination on lithium battery remnants and packaging that were involved in an incident and an analysis of the probable cause of the incident. This program will greatly enhance PHMSA's knowledge of the causes of transportation incidents and assist in investigations and appropriate enforcement. Based on the actions outlined above and pending the issuance of the final rule, we request that Safety Recommendations A-07-107 and A-07-108 be classified as "Closed-Acceptable Action." We appreciate your consideration of this request.

From: PHMSA
To: NTSB
Date: 8/9/2010
Response: CC# 201000303 - From Ola Parsons, Pipeline Hazardous Materials Safety Administration, 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: Although this final rule included a requirement to report incidents involving failed lithium batteries and devices containing them, it did not include a requirement to retain the failed batteries and equipment. The January 11, 2010, NPRM requested comments about how retention of failed batteries and equipment might be achieved and a proper analysis conducted. This document also indicated that available incident data suggest the most likely causes of lithium battery incidents comprise the following: - External short circuiting (an exposed battery terminal contacts a metal object) - In-use situation (improper charging or discharging conditions associated with the use of equipment, including inadvertent activation and overheating) - Noncompliance (faulty battery design, false certification, or improper packaging) - Internal short circuit (foreign matter within the cell or battery, or physical damage) Because PHMSA does not discuss the reliability of the data used to determine these causes, the NTSB is concerned that such determinations are being made without retaining and analyzing failed batteries. In the absence of sound failure analyses, the establishment of appropriate and effective transportation requirements is questionable, and, without the implementation of a regulatory requirement to retain failed batteries and a program to analyze the retained batteries and equipment, the NPRM fails to fully address Safety Recommendations A-07-107 and -108. Accordingly, pending action by PHMSA to require operators to retain and analyze failed batteries and equipment, Safety Recommendations A-07-107 and -108 are classified OPEN -- UNACCEPTABLE RESPONSE.

From: NTSB
To: PHMSA
Date: 4/14/2010
Response: Notation 7772F: The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) notice of proposed rulemaking (NPRM), “Hazardous Materials: Transportation of Lithium Batteries,” that was published at 75 Federal Register 1302 on January 11, 2010. The NPRM requests comments on revisions to the requirements for the transportation of lithium batteries in the Hazardous Materials Regulations (HMRs). The primary purpose of the NPRM is to enhance the safe transportation of primary (non-rechargeable) and secondary (rechargeable) lithium batteries when transported as cargo in all modes, with an emphasis on aviation. The NTSB believes that PHMSA has proposed requirements that should improve the level of safety for transporting lithium battery cargoes, particularly on aircraft. However, the NTSB offers the following comments to strengthen and clarify the proposed rule. Overview The NPRM proposes new requirements that address Safety Recommendations A-07-104, A-07-105, and A-07-107 through -109 that were issued as a result of the NTSB’s 2006 investigation of an in-flight cargo fire on a cargo airplane at Philadelphia International Airport in Philadelphia, Pennsylvania. The NPRM specifically addresses these safety recommendations through proposed requirements concerning the stowage of lithium batteries, the reporting and analysis of lithium battery failures, and the elimination of regulatory exceptions for small lithium batteries. The NTSB has included detailed comments about each of these areas in subsequent sections of this letter. The NTSB notes that PHMSA also proposes other requirements, and those are addressed as well. The NPRM does not address Safety Recommendations A-08-1 and -2, which were issued separately from the Philadelphia accident report but also pertain to the transportation of lithium batteries. Safety Recommendations A-08-1 and -2 concern the implementation and evaluation of public awareness programs for air passengers and crews who carry portable electronic devices containing lithium batteries or pack spare lithium batteries in their baggage or carry-on items. The NTSB notes that PHMSA plans to address these two recommendations under a separate rulemaking. However, because of the proliferation of personal electronic devices carried by the traveling public, the NTSB urges PHMSA to expedite its rulemaking regarding these recommendations. Stowage of Lithium Batteries Cargo shipments of primary lithium batteries have been prohibited on passenger aircraft for more than 10 years, but they are still permitted on cargo-only aircraft. Cargo shipments of secondary lithium batteries are permitted on both passenger and cargo-only aircraft. The transportation of primary lithium batteries is potentially dangerous, particularly on board aircraft, because there is currently no known fire suppression system capable of extinguishing fires involving these types of batteries. Fires involving secondary lithium batteries are extinguishable by fire suppression systems approved by the Federal Aviation Administration (FAA). Although fire suppression systems are required in cargo compartments of passenger aircraft, they are not required in cargo-only aircraft. The investigation of the Philadelphia accident showed that flight crews on cargo-only aircraft remain at risk from in-flight fires involving primary lithium batteries and from fires involving secondary lithium batteries on aircraft not equipped with fire suppression systems. Consequently, the NTSB issued the following recommendations to PHMSA: Require aircraft operators to implement measures to reduce the risk of primary lithium batteries becoming involved in fires on cargo-only aircraft, such as transporting such batteries in fire resistant containers and/or in restricted quantities at any single location on the aircraft. (A-07-104) Until fire suppression systems are required on cargo-only aircraft, as asked for in Safety Recommendation A-07-99, require that cargo shipments of secondary lithium batteries, including those contained in or packed with equipment, be transported in crew-accessible locations where portable fire suppression systems can be used. (A-07-105) The NTSB believes that the NPRM fully addresses Safety Recommendation A-07-105 but only partially addresses Safety Recommendation A-07-104. The proposed rule would require that if either primary or secondary lithium batteries are transported in inaccessible cargo compartments or freight containers, the compartments or containers must be equipped with an FAA-approved fire suppression system, or that the packages of batteries must be transported in an FAA-approved fire-resistant container. Because current FAA-approved suppression systems are ineffective on fires involving primary lithium batteries, the NTSB believes that the NPRM would be improved if it explicitly required that shipments of primary lithium batteries be transported in FAA-approved fire-resistant containers. When the FAA approves a fire suppression system that is proven to be effective on fires involving primary lithium batteries, the NTSB would consider such a suppression system an acceptable alternative to an FAA-approved fire-resistant container. Because current FAA-approved fire suppression systems are effective on fires involving secondary lithium batteries, the NTSB supports the NPRM in that it would require that inaccessible shipments of secondary lithium batteries be transported in either cargo compartments or freight containers equipped with an FAA-approved fire suppression system or in FAA-approved fire-resistant containers. PHMSA states in the NPRM that it is considering whether a limit on the number of primary lithium battery packages transported in a single airplane or single container would further enhance safety. Although PHMSA acknowledges the cumulative effect and the potential risks of packaging thousands of small primary batteries in close proximity, it has not proposed any requirements to mitigate the risks. The NTSB believes that the NPRM would be improved if restrictions were imposed on the clustering of primary lithium battery shipments on cargo-only aircraft. Reporting and Analysis of Lithium Battery Failures In the Philadelphia accident report, the NTSB noted that the causes of secondary lithium battery failures are not well understood or documented. The NTSB suggested that this may be due, in part, to the fact that proper evaluation of failed lithium batteries is not always performed, and that, in many cases, these batteries are disposed of before the incident is reported, precluding an accurate analysis of the failures. As a result, the NTSB issued the following recommendations to 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) Analyze the causes of all thermal failures and fires involving secondary and primary lithium batteries and, based on this analysis, take appropriate action to mitigate any risks determined to be posed by transporting secondary and primary lithium batteries, including those contained in or packed with equipment, on board cargo and passenger aircraft as cargo; checked baggage; or carry-on items. (A-07-108) On July 31, 2008, PHMSA published an NPRM to revise requirements for the transportation of battery-powered devices and batteries and to harmonize the U.S. Department of Transportation HMRs with international standards. The NPRM included a proposal to require that all incidents involving lithium batteries and devices containing them be immediately reported. In a letter dated November 19, 2008, the NTSB suggested that the NPRM could be improved by also requiring that failed lithium batteries and associated equipment be retained in order to ensure proper analysis. The reporting requirement was included in the final rule published on January 14, 2009; however, the retention requirement was not. The NTSB is disappointed that the current NPRM also does not propose the retention requirement, but only requests comments about how retention of failed batteries and equipment might be achieved and a proper analysis conducted. The NPRM notes that available incident data suggest that the most likely causes of lithium battery incidents are • External short circuiting (an exposed battery terminal contacts a metal object). • In-use situation (improper charging or discharging conditions associated with the use of equipment, including inadvertent activation and overheating). • Noncompliance (faulty battery design, false certification, or improper packaging). • Internal short circuit (foreign matter within the cell or battery, or physical damage). However, PHMSA does not discuss the reliability of the data used to determine these causes, and the NTSB is concerned that such determinations are being made without retaining and analyzing failed batteries. In the absence of sound failure analyses, the establishment of the appropriate and effective transportation requirements is questionable, and without a regulatory requirement to retain failed batteries and a program to analyze the retained batteries and equipment, the NPRM fails to fully address Safety Recommendations A-07-107 and -108. The NTSB believes that the proposed rule would be significantly improved if retention and analysis of failed batteries and equipment were required. Elimination of Regulatory Exceptions for Small Lithium Batteries The NTSB’s investigation of the Philadelphia accident also dealt with regulatory exceptions for packages of small secondary lithium batteries, such as those used to power laptop computers, cameras, cell phones, and other personal electronic devices. Under these exceptions, based on battery power, size, and weight, certain shipments of small batteries are exempt from the hazardous materials packaging and identification requirements. The exceptions allowed batteries to be shipped undetected on both cargo and passenger aircraft. Because small secondary lithium batteries have been involved in at least nine documented aviation incidents and their failure modes are not fully understood, the NTSB expressed concern about the exceptions. The NTSB stated that cargo shipments of small lithium batteries should be subject to the same packaging and identification requirements that apply to medium and large lithium batteries in order to increase public and industry awareness of the risks associated with these batteries and to alert package handlers to exercise greater care when loading and unloading packages containing them. Consequently, the NTSB issued the following recommendation to PHMSA: Eliminate regulatory exemptions for the packaging, marking, and labeling of cargo shipments of small secondary lithium batteries (no more than 8 grams equivalent lithium content) until the analysis of the failures and the implementation of risk-based requirements asked for in Safety Recommendation A-07-108 are completed. (A-07-109) The NPRM proposes to eliminate the regulatory exceptions for lithium cells and batteries transported on board aircraft. The proposal would require that all lithium cells and batteries be regulated as class 9 materials in air transportation and subjected to the requirements found in Title 49 Code of Federal Regulations (CFR) 173.185, including the packaging standards and the hazard communication requirements. Adoption of this proposal would ensure that all lithium battery shipments are packaged appropriately and that packages are clearly labeled, providing a visible indication of the presence of hazardous material. The proposal also would ensure that all aviation shipments of lithium batteries are listed on the notice to the pilot in command. The NTSB fully supports the proposal to eliminate exceptions for small lithium batteries and believes that the proposal, if implemented, will satisfy the intent of Safety Recommendation A-07-109. Other Proposed Requirements The NPRM proposes new requirements that have not been the subject of NTSB safety recommendations. The new proposals are discussed below. The NPRM proposes to change all references to primary and secondary lithium batteries in the HMRs to “lithium metal batteries” and “lithium ion batteries,” respectively. Because the chemistry, functionality, and fire exposure behavior of lithium metal batteries and lithium-ion batteries are notably different, PHMSA identified a need to distinguish between them. As a result, the NPRM proposes creating separate shipping names and entries for lithium metal and lithium-ion batteries, reassigning existing United Nations (UN) identification numbers for lithium batteries to lithium metal batteries, and creating new UN identification numbers for lithium-ion batteries. These changes would facilitate the development and implementation of transportation requirements that are most appropriate for each battery type. The NPRM proposes to adopt a methodology for determining the relative hazard associated with lithium-ion batteries by using measurements of watt-hours instead of equivalent lithium content. The NTSB agrees with PHMSA’s assessment that “watt-hours” is a more commonly used unit of measurement that is easier to calculate and understand. The NPRM notes that most of the recent lithium battery incidents in the aviation industry have involved noncompliant shipments. PHMSA contends that noncompliance often results from confusion regarding regulatory requirements, which in turn results from a lack of proper training. The NPRM points out that while shippers of small lithium batteries are currently exempted from the training requirements found in 49 CFR Part 172, Subpart H, the proposal to eliminate regulatory exceptions for shipments of small lithium batteries would require that these shippers train employees who prepare such shipments. PHMSA believes that the training would ensure that employees are knowledgeable about applicable regulatory requirements and that shipments conform to the requirements, which would ultimately result in a reduction of lithium battery incidents. The NTSB supports these additional proposals. The NTSB appreciates the opportunity to comment on this proposed rule and PHMSA’s continuing efforts to improve the safety of lithium battery transportation. Should you require any additional information or clarification, please contact us.

From: PHMSA
To: NTSB
Date: 10/16/2009
Response: Letter Mail Controlled 10/22/2009 3:09:01 PM MC# 2090655: - From John D. Porcari, Deputy Secretary of Transportation: We agree with NTSB that air carriers should be required to report all incidents involving lithium batteries, consistent with Safety Recommendation A-07-107. To this end, on January 14, PHMSA published a final rule under Docket No. HM-215JlHM-224D entitled "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" (74 2200; copy enclosed). In this final rule, we amended the Ilazardous Materials Regulations (HMR) to include a comprehensive incident reporting requirement for batteries and battery-powered devices. As specified in the final rule, incidents involving batteries and battery powered devices that result in a fire, violent rupture, explosion, or dangerous evolution of heat must be reported. In addition to the written incident report, the final rule requires immediate telephonic reporting of incidents involving batteries and battery-powered devices in air transportation. We agree that an examination of failed batteries and associated electronic devices and equipment will provide valuable data and information as we continue to assess the transportation risks associated with these items. To that end, we are working with FAA and airlines to establish a cooperative program for effectively securing and preserving evidence and passenger information when incidents occur. We developed a standard protocol to be used by aircraft operators in the event of an incident. This protocol includes procedures for: (1) immediate reporting of the incident to DOT; (2) preservation of the batteries and/or electronic equipment that failed and transfer to appropriate authorities for analysis and evaluation; and (3) obtaining relevant information from passengers and crewmembers, including contact information for follow-up interviews as necessary. In addition, we are proposing a regulatory change to require a shipper, carrier, package owner or person reporting an incident to provide upon request by an authorized government representative reasonable assistance in investigating the damaged package or article. Consistent with Safety Recommendation A-07-108, PHMSA has completed an analysis of the causes of lithium battery incidents (copy enclosed). The data suggest that the most likely causes of lithium batte~yin cidents are: 1. External short circuiting - occurs when an exposed battery terminal contacts a metal object. When this happens, the battery can heat up and may cause ignition of the battery andlor the surrounding combustible materials. 2. In-use situation - generally relating to improper "chirging" andlor "discharging" conditions associated with the use of equipment (e.g., computer or cell phone). This also includes inadvertent activation and subsequent overheating (such was the case when a power drill activated and burned in a passenger's checked baggage). 3. Non-compliance - includes faulty design of the battery (cells or battery packs), false certification of compliance with regulatory testing/classification requirements, and improper packing afid handling inciudingsome counterfeit batteries. 4. Internal shall circuit - can be caused by foreign matter introduced into a cell or battery during the manufacturing process. An internal short circuit can also occur when a battery is physically damaged (e.g. dropped or punctured). PHMSA has initiated a rulemaking project to propose enhanced regulatory requirements to mitigate the risks identified in the incident analysis. The rulemaking is intended to strengthen the current regulatory framework by imposing more effective safeguards, including design testing, packaging, and hazard communication measures for various types and sizes of lithium batteries in specific transportation contexts. PHMSA plans to publish an NPRM this fall. The rulemaking will address the following issues: Elimination of current exceptions for small lithium batteries. Currently, shipments of small lithium batteries are excepted from certain packa-g in-g and hazard communication requirements. Instead, packages must conform to minimum packaging requirements and must be identified as containing lithium batteries for which special procedures should be followed in the event the package is damaged. We are considering eliminating the exceptions for small lithium batteries and imposing more stringent packaging and hazard communication requirements, including shipping papers, package marks and labels, and emergency response information. Elimination of the current exceptions would enhance safety by ensuring that all lithium batteries would be packaged to reduce the possibility of damage to the batteries that could lead to an incident and accompanied by hazard information that would ensure appropriate and careful handling by air carrier personnel and inform transport workers and emergency response personnel of actions to be taken in the event of an emergency. UN design tvpe test results. Currently, all lithium battery and cell types must be subjected to a series of tests as specified in the UN Manual of Tests and Criteria. The tests are intended to ensure that lithium batteries and cells will withstand conditions encountered during transportation. We are considering adopting a requirement for manufacturers to provide evidence of satisfactory completion of the UN design type tests for each lithium battery and cell that is offered for transportation in commerce. The intended effect would be to enhance compliance with the test requirements. Lithium battery shipping descriptions. Currently, all types of lithium batteries are transported using the same UN identification number. However, differences in chemistry, functionality and behavior when exposed to a fire are well documented for different types of batteries. The fact that all types of lithium batteries share the same UN number has the potential to cause significant problems in acceptance procedures for carriers and may unnecessarily hinder or delay the transportation of these products. Thus, we are considering revising the current shipping descriptions to account for different battery types and chemistries and for consistency with shipping descriptions in international transport standards and regulations. Stowage in crew accessible locations. We are proposing restricting stowage of lithium batteries on an aircraft to crew accessible locations to permit immediate investigation and response to smoke or fire. Recalled batteries. We are considering the development of appropriate safety measures for the air transport of lithium cells or batteries identified by the manufacturer, the Consumer Product Safety Commission, or the Department of Transportation as being defective for safety reasons, or those that have been damaged or are otherwise being returned to the manufacturer. PHMSA and FAA also plan to continue to evaluate the risks posed by all types and sizes of lithium batteries with a view towards further risk reduction. Depending on the availability of resources, we plan to address the following areas: Fire behavior. Test fire behavior of lithium batteries of various sizes and packaging configurations to better understand the transportation risks posed by these batteries and to develop more effective requirements to prevent fires and overheating. Fire resistant containers. Develop performance standards for fire resistant containers, including fireproof overpacks and ULDs, which can be used for the transportation of lithium cells Ad batteries of all types onboard aircraft. Cargo compartments. Analyze aircraft cargo compartment configurations and how both current and performance based container designs and their locations may decrease potential risks of fire. Fire detection and suppression. Analyze possible container internal detection and suppression methods and their effectiveness on the control or containment of lithium bazery fires. We are continuing our efforts to heighten public awareness related to the hazards associated with the air transportation of lithium batteries, including batteries contained in electronic devices. This is a key component of our comprehensive strategy to enhance safety and reduce incidents. Since 2007, PHMSA has been working with air carriers, battery manufacturers, air travel associations, airline pilot and flight crew associations and other government agencies, including the Transportation Security Administration, to educate the public about potential safety problems and measures that will reduce or eliminate those problems. PHMSA agrees that these efforts must be highly visible and continuous to be effective. One of our most visible programs to promote battery safety is the SafeTravel Web site, which includes guidance and information on how to travel safely with batteries and battery-powered devices. We have also been working with the major airlines, travel and battery industries to provide SafeTravel information for ticketed passengers and frequent flyers, and place printed battery safety materials in seat pockets on passenger planes. We have recorded several million hits on our SafeTravel Web site. PHMSA continues to maintain and update the SafeTravel website as new information becomes available and is currently in the process of a major revision to the site. TSA includes SafeTravel information and links on its popular public website and FAA has issued Travel Tips and FAQs on Batteries Carried by Airline Passengers with a link to the SafeTravel website. We are mindful that NTSB stressed actions to promote lithium battery safety awareness among flight crew specifically, and that Recommendation A-08-002 focuses on more robust assessment of passenger and flight crew awareness and behavior. We are working with FAA, ATA, its member airlines, the Airline Pilots Association, and the Association of Flight Attendants (AFA) to raise flight crew awareness of measures they can take to avoid incidents as well as how to respond effectively should an incident occur in the cabin. Thousands of pilots and flight attendant personnel have been trained in how to appropriately respond to and mitigate a fire involving lithium batteries in a passenger aircraft cabin. Additionally, the ICAO Dangerous Goods Panel added the appropriate procedures to the ICAO Emergency Response Guidance for Aircraft Incidents Involving Dangerous Goods (Red Book). We have requested available metrics for partner actions, and are coordinating with FAA to continually assess incident data focusing on root causes, in order to gauge any changes in passenger behavior. In the coming year, we will work to capture information about passenger behaviors independent of incidents, and work with FAA and with partners representing airline flight crews to ensure that battery safety and response information is made available. We also will develop a method for evaluating the effectiveness of our efforts to educate the public and flight crews.

From: NTSB
To: PHMSA
Date: 12/19/2008
Response: In its March 28, 2008, letter, PHMSA described the results of a recently completed analysis of 90 incidents that occurred between 1991 and 2008 involving both lithium and other batteries carried on aircraft. PHMSA stated that it comprehensively analyzed the root causes of all incidents involving lithium batteries that overheated or caused fires aboard aircraft, and it will use this information to refine mitigations of the risks associated with transporting lithium batteries. In the investigation report of the February 7, 2006, accident in Philadelphia, the Safety Board described a 2006 review that was conducted of the reported battery incident data for the previous 10 years. This review showed that the number of incidents involving both primary and secondary lithium batteries has been increasing. Specifically, from February 2001 to February 2006, secondary lithium batteries were involved in four aviation incidents compared to one incident in the previous 5-year period. Data from February 2006 to July 2007 showed nine incidents involving secondary lithium batteries, nearly double the number of incidents compared to the previous 10 years. Similarly, primary lithium batteries were involved in three incidents from February 1996 to 2001, four incidents in the following 5-year period, and six incidents from February 2006 to July 2007. The Safety Board appreciates receiving the information about the analysis that PHMSA prepared but believes that PHMSA’s analysis must also consider the factors causing the significant increase in the number of these incidents. The Board asks that PHMSA describe what actions it will take as a result of its additional analysis. Pending the completion of actions to mitigate risks posed by lithium batteries, Safety Recommendation A-07-108 is classified OPEN -- ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 3/28/2008
Response: MC# 2080191: - From Stacey L. Gerard, Assistant Administrator/ Chief Safety Officer: We recently completed an analysis of the incidents that have occurred involving lithium batteries. Our analysis suggests the following likely root causes of these incidents: (1) external short circuits resulting from exposed battery terminals that come into contact with metal objects; (2) internal short circuits resulting from manufacturing defects, poor battery design, or damage to a battery; (3) improper use resulting in problems with the interaction between the battery and the device it charges or the battery and its charging device; and (4) a non- compliance situation, such as batteries that were not manufactured to basic industry standards and regulatory requirements, undeclared shipments, or improper packaging. The analysis of incidents and probable root causes was recently updated to take into account the most recent incidents (see enclosure). Incident information gathered by the Federal Aviation Administration (FAA) on 90 incidents occurring from 1991 to 2008 indicates that: 27 % of the incidents involved lithium batteries and 68 % involved non-lithium batteries. Of the lithium battery incidents, 73 % resulted from short-circuiting (external and internal short combined); 12 % from charging/discharging; 6 % from unintentional activation of devices; and 9 % from other causes (malfunction of devices, improper handling of cargo and unknown causes). For non-lithium batteries, 72 % of the incidents resulted from short-circuiting (mostly external); 11 % from unintentional activation of devices; 4 % from improper handling; and 13 % from other causes (malfunction of devices, improper handling of cargo and unknown causes). We intend to comprehensively analyze the root causes of all incidents involving lithium batteries that overheat or cause fires aboard aircraft. We will use this information to further refine the strategies we have developed to mitigate the risks associated with transporting lithium batteries. 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.