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Safety Recommendation Details

Safety Recommendation A-90-054
Details
Synopsis: ON FEBRUARY 24, 1989, A BOEING 747-122 OPERATED BY UNITED AIRLINES AS FLIGHT 811 DEPARTED LOS ANGELES, CALIFORNIA, AS A SCHEDULED FLIGHT TO SYDNEY, AUSTRALIA, WITH EN ROUTE STOPS AT HONOLULU, HAWAII, AND AUCKLAND, NEW ZEALAND. THE FLIGHT DEPARTED HONOLULU AT 0155 ON FEBRUARY 24, 1989, WITH 3 FLIGHT CREWMEMBERS, 15 CABIN ATTENDANTS, AND 337 PASSENGERS. ABOUT 20 MINUTES INTO THE FLIGHT, AND NEAR 23,000 FEET, A RAPID DECOMPRESSION OCCURRED WHEN THE FORWARD STARBOARD CARGO DOOR SEPARATED FROM PART OF THE CABIN FUSELAGE. THE AIRPLANE RETURNED TO HONOLULU INTERNATIONAL AIRPORT, LANDING SAFELY ON RUNWAY 8L AT 0234 WHERE AN EMERGENCY EVACUATION WAS CONDUCTED. OF THE 355 OCCUPANTS ON BOARD WHEN THE FLIGHT DEPARTED HONOLULU, 9 WERE LOST DURING THE DECOMPRESSION; AND 1 CREWMEMBER, 15 FLIGHT ATTENDANTS, AND 22 PASSENGERS WERE INJURED DURING THE DECOMPRESSION AND EMERGENCY EVACUATION.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: AMEND 14 CFR 1447 (C)(4) TO REQUIRE THAT FACE MASKS BE ATTACHED TO THE REGULATORS OF PORTABLE EMERGENCY OXYGEN BOTTLES.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: HONOLULU, HI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA89MA027
Accident Reports: Explosive Decompression - Loss of Cargo Door in Flight, United Airlines Flight 811 Boeing 747-122, N4713U
Report #: AAR-92-02
Accident Date: 2/24/1989
Issue Date: 5/4/1990
Date Closed: 3/29/2002
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/29/2002
Response: On July 16, 1996, the FAA issued a notice of proposed rulemaking (NPRM) to revise Title 14 CFR 121.333 to require that each oxygen mask used for portable oxygen equipment be connected to its oxygen supply. In its comments regarding the NPRM, the Safety Board endorsed this proposal, which was responsive to the recommendation. On December 20, 1996, pending review of the final rulemaking resulting from the NPRM, the Board classified Safety Recommendation A-90-54 "Open--Acceptable Response." The Safety Board is unaware of any final rule that resulted from this NPRM issued over 5 years ago. In addition, FAA staff recently advised Safety Board staff that no rule was expected in the near future. The Safety Board is aware that some oxygen masks are still provided separately from the oxygen bottles and believes this rulemaking is still necessary. Because more than 5 years have passed since the NPRM was issued, and more than 11 years have passed since the recommendation was issued, Safety Recommendation A-90-54 is now classified "Closed--Unacceptable Action."

From: NTSB
To: FAA
Date: 3/16/2000
Response: ON 3/16/00 THE SAFETY BOARD REQUESTED AN UPDATE ON THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 12/20/1996
Response: ON 7/16/96, THE FAA ISSUED A NOTICE OF PROPOSED RULEMAKING (NPRM) PROPOSING TO REVISE 14 CFR PART 121-333 TO REQUIRE THAT EACH OXYGEN MASK USED FOR PORTABLE OXYGEN EQUIPMENT BE CONNECTED TO ITS OXYGEN SUPPLY. IN ITS COMMENTS REGARDING THE NPRM, THE BOARD ENDORSED THIS PROPOSAL, WHICH IS RESPONSIVE TO THE INTENT OF A-90-54. PENDING REVIEW OF THE FINAL RULEMAKING THE RESULTS FROM THE NPRM THE BOARD CLASSIFIES A-90-54 "OPEN--ACCEPTABLE RESPONSE."

From: NTSB
To: FAA
Date: 12/3/1996
Response: Notation 6776: Attention: Rules Docket (AGC-200) Docket No. 28637 The National Transportation Safety Board has reviewed your Notice of Proposal Rulemaking (NPRM), "Miscellaneous Cabin Safety Changes," Docket No. 28637, Notice 96-9, published in 61 F.R. 38551 on July 24, 1996, and offers the following comments. The Safety Board notes that the proposed amendments to 14 Code of Federal Regulations (CFR) Parts 25 and 121 would require airplane safety features that have to some extent already been in use but have not been addressed in a standardized manner. These features include assist handles at floor level exits that have a designated assist space, a means to view the area outside an exit, and exit doors that have a means to automatically lock in the open position. Further, the proposed amendments would require a minimum "assist space" of a 12 x 20-inch rectangle on the floor and be useable at exits. Finally, the proposed amendments include a requirement that oxygen masks be connected to portable oxygen equipment, whieh was called for in the Safety Board's safety recommendation A-90-54. This safety recommendation resulted from the Safety Board's investigation of a B-747 that experienced decompression of the airplane's cabin, due to a loss of its forward cargo door followed by extensive structural damage, which caused fatal and serious injuries to passengers. Flight attendants, who attempted to assist the passengers, had difficulty attaching oxygen masks to portable oxygen bottles. If the masks had been attached to the oxygen bottles, these difficulties would not have occurred. The Safety Board agrees that the amendments proposed to 14 CFR Parts 25 and 121 are necessary. The Safety Board notes that the proposals contained in the NPRM have been coordinated with the Joint Airworthiness Authorities (JAA), that the JAA may provide comments on the proposed amendments, and that the JAA will incorporate the amendments into paragraph 25 of the Joint Aviation Requirements after the amendments are finalized by the FAA. The Safety Board appreciates the opportunity to comment on this proposed rulemaking.

From: FAA
To: NTSB
Date: 10/28/1996
Response: ON 7/16/96, THE FAA ISSUED A NOTICE OF PROPOSED RULEMAKING (NPRM) PROPOSING TO REVISE AIRWORTHINESS STANDARDS RELATING TO CABIN SAFETY. THE NPRM PROPOSES TO REVISE 14 CFR 121-333 TO REQUIRE THAT EACH MASK USED FOR PORTABLE OXYGEN EQUIPMENT BE CONNECTED TO ITS OXYGEN SUPPLY. I WILL PROVIDE THE BOARD WITH A COPY OF THE FINAL REGULATORY DOCUMENT AS SOON AS IT IS ISSUED.

From: NTSB
To: FAA
Date: 8/29/1995
Response: THE BOARD NOTES THAT A NOTICE OF PROPOSED RULEMAKING WILL BE PUBLISHED ON THIS SUBJECT IN DECEMBER 1995. GIVEN THE TIME THAT HAS PASSED SINCE THE RECOMMENDATION WAS ISSUED, THE BOARD WOULD APPRECIATE RECEIVING INFO ON THE ANTICIPATED DATES FOR COMPLETION OF THE ACTIONS NECESSARY TO FULFILL THE RECOMMENDATION. THEREFORE, THE BOARD CLASSIFIES A-90-54 "OPEN--ACCEPTABLE RESPONSE," PENDING A FORECAST TIMEFRAME FOR COMPLETED ACTION."

From: FAA
To: NTSB
Date: 6/26/1995
Response: THE FAA HAS COMPLETED THE INTERDIRECTORATE COORDINATION OF THE DRAFT NOTICE OF PROPOSED RULEMAKING. THE NPRM IS SCHEDULED FOR PUBLICATION IN DECEMBER 1995. I WILL PROVIDE THE BOARD WITH A COPY OF THE NPRM AS SOON AS IT IS ISSUED.

From: NTSB
To: FAA
Date: 3/9/1992
Response:

From: FAA
To: NTSB
Date: 9/23/1991
Response:

From: NTSB
To: FAA
Date: 1/24/1991
Response: Safety Recommendation A-90-54 states that the FAA should amend 14 CFR 25.1447(c)(4) to require that face masks be attached to the regulators of portable emergency oxygen bottles. The Safety Board notes that the FAA agrees with the intent of this safety recommendation and is considering a notice of proposed rulemaking (NPRM) to address this issue. Pending further information regarding this NPRM, Safety Recommendation A-90-54 is classified as "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 7/26/1990
Response: The FAA agrees with the intent of this safety recommendation and is considering the issuance of a notice of proposed rulemaking (NPRM) to address this issue. I will provide the Board with a copy of any document that may be issued.