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Safety Recommendation Details

Safety Recommendation A-96-025
Details
Synopsis: ON 5/11/96, ABOUT 1415 EASTERN DAYLIGHT TIME, A MCDONNELL DOUGLAS DC-9-32 CRASHED INTO THE EVERGLADES SWAMP SHORTLY AFTER TAKEOFF FROM MIAMI INTERNATIONAL AIRPORT, MIAMI FLORIDA, THE AIRPLANE, N904VJ, WAS OPERATED BY VALUJET AIRLINES, INC., AS VALUJET FLIGHT FLIGHT 592. BOTH PILOTS, THE THREE FLIGHT ATTENDANTS, AND ALL 105 PASSENGERS WERE KILLED. BEFORE THE ACCIDENT, THE FLIGHTCREW REPORTED TO AIR TRAFFIC CONTROL THAT IT WAS EXPERIENCING SMOKE IN THE CABIN AND COCKPIT. VISUAL METEOROLOGICAL CONDITIONS EXISTED IN THE MIAMI AREA AT THE TIME OF THE TAKEOFF. THE DESTINATION OF THE FLIGHT WAS HARTSFIELD INTERNATIONAL AIRPORT, ATLANTA, GEORGIA. FLIGHT 592 WAS ON AN INSTRUMENT FLIGHT RULES FLIGHT PLAN.
Recommendation: THE NTSB RECOMMENDS THAT THE FAA: IMMEDIATELY EVALUTE THE PRACTICES OF & TRAINING PROVIDED BY ALL AIR CARRIERS FOR ACCEPTING PASSENGER BAGGAGE & FREIGHT SHIPMENTS (INCLUDING COMPANY MATERIALS) & FOR IDENTIFYING UNDECLARED OR UNAUTHORIZED HAZARDOUS MATERIALS THAT ARE OFFERED FOR TRANSPORT. THIS EVALUATION SHOULD APPLY TO ANY PERSON, INCLUDING RAMP PERSONNEL, WHO ACCEPTS BAGGAGE OR CARGO FOR TRANSPORT ON PASSENGER & CARGO AIRCRAFT. (URGENT)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: Miami, FL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA96MA054
Accident Reports: In-Flight Fire and Impact With Terrain Valujet Airlines Flight 592 DC-9-32, N904VJ
Report #: AAR-97-06
Accident Date: 5/11/1996
Issue Date: 5/31/1996
Date Closed: 7/13/1999
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Cargo,Hazmat,Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/13/1999
Response: AS NOTED IN ITS 8/1/97, LETTER, THE SAFETY BOARD WOULD PREFER THAT ALL AIR CARRIER PROGRAMS BE EVALUATED IN THIS VERY CRITICAL AREA. HOWEVER, A REVIEW OF THE HAZMAT PROCEDURE MANUALS PRODUCED BY THE FAA AS A RESULT OF THEIR ANALYSIS INDICATES THAT, WHEN APPLIED TO ALL CARRIERS, THERE SHOULD BE A SIGNIFICANT IMPROVEMENT IN SAFETY. IT IS OUR UNDERSTANDING THAT ANY AIR CARRIER THAT TRANSPORTS HAZMAT AS EITHER "WILL CARRY," OR "WILL NOT CARRY," CERTIFICATE HOLDERS MUST HAVE THE APPROPRIATE PRINCIPAL OPERATIONS INSPECTOR APPROVE AND INSPECT ITS OPERATIONS, AS NOTED IN THE OPERATIONS MANUAL. BECAUSE THE FAA'S RANDOM SAMPLING PROVIDED ADEQUATE DATA TO DETERMINE HOW AIR CARRIERS' HAZMAT PRACTICES AND TRAINING NEEDED TO BE REVISED, A-96-25 IS CLASSIFIED "CLOSED--ACCEPTABLE ALTERNATE ACTION." PENDING COMPLETION OF THE FAA'S PROPOSED ACTIONS RESULTING FROM THIS DATA, A-96-26 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 6/3/1998
Response: Letter Mail Controlled 6/8/98 3:43:00 PM MC# 980734 THE FAA HAS REVIEWED ITS PREVIOUS POSITION AND HAS CONCLUDED THAT ADDITIONAL SAMPLING TO EVALUATE THE PRACTICES OF, AND TRAINING PROVIDED BY, ALL AIR CARRIERS IS NOT NECESSARY. RANDOM SAMPLING OF AIR CARRIERS CERTIFICATED UNDER 14 CFR PARTS 121, 125 AND 135, TAKEN IN NINE DIFFERENT REGIONS, PROVIDED THE FAA WITH ADEQUATE DATA REFLECTING THE STATUS OF THE REGULATED COMMUNITY AS A WHOLE. I CONSIDER THE FAA'S ACTION TO BE COMPLETE ON THIS RECOMMENDATION, AND I PLAN NO FURTHER ACTION.

From: NTSB
To: FAA
Date: 8/1/1997
Response: THE SAFETY BOARD NOTES THAT THE FAA HAS EVALUATED THE MANUALS OF 215 AIR CARRIERS. THE BOARD UNDERSTANDS THAT THESE EVALUATIONS INCLUDED ALL 155 AIR CARRIERS CERTIFICATED UNDER 14 CFR PART 121 AND A RANDOM SAMPLING OF CARRIERS CERTIFICATED UNDER PARTS 125 & 135. THE BOARD ALSO NOTES THAT ON 4/30/97, THE FAA COMPLETED FOLLOWUP FIELD INTERVIEWS & OBSERVATIONS OF 264 AIR CARRIER EMPLOYEES TO DETERMINE WHETHER AIR CARRIER PERSONNEL ARE FOLLOWING THE PROCEDURES FOUND IN THEIR COMPANY MANUALS FOR IDENTIFYING UNDECLARED OR UNAUTHORIZED HAZARDOUS MATERIALS. THE FAA INDICATED THAT IT IS COMPILING ITS FINDINGS TO DETERMINE WHAT ACTIONS ARE NECESSARY TO ADDRESS ALL ISSUES IDENTIFIED AND BELIEVES THAT IT HAS COMPLETED ACTION ON THIS RECOMMENDATION. THE BOARD DOES NOT CONSIDER THE FAA'S ACTION COMPLETE & IS CONCERNED THAT THE AGENCY HAS ONLY EVALUATED A SMALL SAMPLING OF MANUALS FROM THE OVER 3,000 AIR CARRIERS CERTIFICATED UNDER PARTS 125 & 135. ALSO, THE RESPONSE DOES NOT ADDRESS WHAT ACTION THE FAA MAY HAVE TAKEN TO EVALUATE THE ADEQUACY OF TRAINING PROVIDED BY THE AIR CARRIERS. IN ITS 8/19/96, LETTER, THE BOARD STATED THAT THE FAA SHOULD ENSURE THAT ALL CERTIFICATED AIR CARRIERS HAVE ADEQUATE PRACTICES & TRAINING FOR IDENTIFYING UNDECLARED OR UNAUTHORIZED HAZARDOUS MATERIALS. PENDING FURTHER ACTION BY THE FAA TO ENSURE THAT ALL CERTIFICATED AIR CARRIERS HAVE ADEQUATE PRACTICES & TRAINING FOR IDENTIFYING UNDECLARED OR UNAUTHORIZED HAZARDOUS MATERIALS, RECOMMENDATION A-96-25 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 5/13/1997
Response: THE FAA HAS COMPLETED BOTH PHASES OF ITS EVALUATION AND HAS REVIEWED 215 AIR CARRIERS CERTIFIED UNDER 14 CFR PARTS 121, 125, AND 135. THE 215 AIR CARRIERS SURVEYED INCLUDED THOSE THAT ACCEPT HAZARDOUS MATERIALS FOR TRANSPORTATION AND THOSE THAT DO NOT. DURING THIS EVALUATION, THE FAA REVIEWED FAA-APPROVED AIR CARRIER MANUALS TO ASCERTAIN WHAT INFORMATION IS CURRENTLY PROVIDED TO PROMPT AIR CARRIER EMPLOYEES TO RECOGNIZE SUSPICIOUS CARGO OR BAGGAGE AND TO ASK ADDITIONAL QUESTIONS BEFORE REJECTING OR ACCEPTING THAT CARGO OR BAGGAGE. ON APRIL 30, 1997, THE FAA COMPLETED PHASE II. THEY CONDUCTED FOLLOWUP FIELD INTERVIEWS & OBSERVATIONS OF 264 AIR CARRIER EMPLOYEES, INCLUDING RAMP PERSONNEL, WHO ACCEPT BAGGAGE OR CARGO FOR TRANSPORT ON PASSENGER AIRCRAFT. THE FIELD INSPECTIONS WILL VERIFY WHETHER THE AIR CARRIERS WHICH HAVE PROCEDURES IN THEIR MANUALS ARE FOLLOWING THESE PROCEDURES. THE FAA IS CURRENTLY LOADING THE RESULTS OF THE EVALUATION INTO A DATA BASE IN ORDER TO DETERMINE ACTIONS NEEDED TO ADDRESS ALL ISSUES IDENTIFIED. THE FAA CONSIDERS THIS ACTION TO BE COMPLETED ON THIS RECOMMENDATION, & REQUESTS THAT THE BOARD CLASSIFY THE RECOMMENDATION IN A CLOSED STATUS.

From: FAA
To: NTSB
Date: 3/24/1997
Response: THE FAA HAS COMPLETED BOTH PHASES OF ITS EVALUATION AND HAS REVIEWED 215 AIR CARRIERS CERTIFIED UNDER 14 CFR PARTS 121, 125, AND 135. THE 215 AIR CARRIERS SURVEYED INCLUDED THOSE THAT ACCEPT HAZARDOUS MATERIALS FOR TRANSPORTATION AND THOSE THAT DO NOT. DURING THIS EVALUATION, THE FAA REVIEWED FAA-APPROVED AIR CARRIER MANUALS TO ASCERTAIN WHAT INFORMATION IS CURRENTLY PROVIDED TO PROMPT AIR CARRIER EMPLOYEES TO RECOGNIZE SUSPICIOUS CARGO OR BAGGAGE AND TO ASK ADDITIONAL QUESTIONS BEFORE REJECTING OR ACCEPTING THAT CARGO OR BAGGAGE. ON APRIL 30, 1997, THE FAA COMPLETED PHASE II. THEY CONDUCTED FOLLOWUP FIELD INTERVIEWS & OBSERVATIONS OF 264 AIR CARRIER EMPLOYEES, INCLUDING RAMP PERSONNEL, WHO ACCEPT BAGGAGE OR CARGO FOR TRANSPORT ON PASSENGER AIRCRAFT. THE FIELD INSPECTIONS WILL VERIFY WHETHER THE AIR CARRIERS WHICH HAVE PROCEDURES IN THEIR MANUALS ARE FOLLOWING THESE PROCEDURES. THE FAA IS CURRENTLY LOADING THE RESULTS OF THE EVALUATION INTO A DATA BASE IN ORDER TO DETERMINE ACTIONS NEEDED TO ADDRESS ALL ISSUES IDENTIFIED. THE FAA CONSIDERS THIS ACTION TO BE COMPLETED ON THIS RECOMMENDA-TION, & REQUESTS THAT THE BOARD CLASSIFY THE RECOMMENDATION IN A CLOSED STATUS.

From: NTSB
To: FAA
Date: 8/19/1996
Response: THE BOARD NOTES THAT THE FAA AGREES WITH RECOMMENDATIONS & HAS INITIATED AN IMMEDIATE EVALUATION OF THE HAZARDOUS MATERIALS MANUALS & TRAINING PROGRAMS OF AIR CARRIERS CERTIFICATED UNDER 14 CFR PART 121 TO DETRMINE WHETHER METHODS ARE INCLUDED TO IDENTIFY UNDECLARED OR UNAUTHORIZED HAZARDOUS MATERIALS. FOLLOWING THE INITIAL PHASE OF THE EVALUATION, THE FAA WILL MAKE FOLLOW-UP FIELD INSPECTIONS TO ENSURE THAT EMPLOYEES ARE FOLLOWING PROPER PROCEDURES. WE APPRECIATED THE FAA'S QUICK RESPONSE TO THESE RECOMMENDATIONS BUT ARE CONCERNED THAT ONLY A RANDOM SAMPLING OF AIR CARRIERS NOT CERTIFICATED UNDER 14 CFR PART 121 WILL BE CONDUCTED. THE BOARD BELIEVES THAT THE FAA SHOULD ENSURE THAT ALL CERTIFICATED CARRIERS HAVE ADEQUATE PROGAMS & PRACTICES FOR IDENTIFYING UNDECLARED OR UNAUTHORIZED HAZARDOUS MATERIALS. WE NOTE THAT THE FAA WILL REQUIRE REVISIONS TO AIR CARRIER PRACTICES & TRAINING PROGRAMS, AS NECESSARY, & THAT THE FAA WILL APPRISE THE BOARD OF ITS PROGRESS. PENDING COMPLETION OF ACTION ON THESE ISSUES. A-96-25 & -26 ARE CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 7/16/1996
Response: THE FAA AGREES WITH THIS RECOMMENDATION & HAS INITIATED AN IMMEDIATE EVALUATION OF AIR CARRIER HAZARDOUS MATERIALS MANUALS & TRAINING PROGRAMS TO DETERMINE IF METHODS ARE INCLUDED TO IDENTIFY UNDECLARED OF UNAUTHORIZED HAZARDOUS MATERIALS. DURING THE FIRST PHASE OF THE EVALUATION, THE FAA WILL REVIEW ALL 155 AIR CARRIERS CERTIFICATED UNDER 14 CFR PART 121. THIS EFFORT WILL RESULT IN THE EVALUATION OF THOSE AIR CARRIERS WHICH TRANSPORT 95 PERCENT OF THE PASSENGERS IN THE UNITED STATES' DOMESTIC MARKET. THE FAA WILL ALSO REVIEW A RANDOM SAMPLING OF 150 OTHER CERTIFICATED AIR CARRIERS. THE FAA EXPECTS TO COMPLETE THIS PHASE WITHIN 120 DAYS. FOLLOWING THE INITIAL PHASE OF THE EVALUATION, THE FAA WILL CONDUCT FOLLOW-UP FIELD INSPECTION OF THESE AIR CARRIERS TO ENSURE THAT APPROPRIATE EMPLOYEES ARE FOLLOWING PROPER PROCEDURES. BASED ON THE RESULTS OF THE INITIAL EVALUATION, THE FAA WILL ASSESS THE NEED TO REQUIRE ALL 3,705 OPERATORS TO PROVIDE METHODS TO IDENTIFY UNDECLARED HAZARDOUS MATERIALS. THE FAA WILL KEEP THE BOARD APPRISED OF ITS PROGRESS ON THIS RECOMMENDATION.