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Safety Recommendation Details

Safety Recommendation A-96-027
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: IN COOPERATION WITH RSPA, PERMANENTLY PROHIBIT THE TRANSPORTATION OF CHEMICAL OXYGEN GENERATORS AS CARGO ON BOARD ANY PASSENGER OR CARGO AIRCRAFT WHEN THE GENERATORS HAVE PASSED EXPIRATION DATES, & THE CHEMICAL CORE HAS NOT BEEN DEPLETED. (URGENT)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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: 12/5/2000
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/1/2004
Response: Notation 6704D: The National Transportation Safety Board has reviewed the Research and Special Programs Administration (RSPA) notice of proposed rulemaking (NPRM), “Hazardous Materials Regulations: Transportation of Compressed Oxygen, Other Oxidizing Gases and Chemical Oxygen Generators on Aircraft,” Docket No. RSPA-04-17664 (HM-224B), which was published at 69 Federal Register 88 on May 6, 2004. The Safety Board notes that RSPA previously issued regulations addressing the transportation of chemical oxidizers and compressed oxygen cylinders aboard aircraft on August 19, 1999, under docket HM-224A. Under that rulemaking, RSPA amended the Hazardous Materials Regulations by requiring that no more than a combined total of six compressed oxygen cylinders be stowed in inaccessible cargo compartments that were not equipped with fire or smoke detection systems and fire suppression systems. The amendments also required that no more than six compressed oxygen cylinders and one cylinder of medical-use compressed oxygen per passenger be carried in a crew-accessible cargo compartment equipped with a fire or smoke detection system but not a fire suppression system. Every compressed oxygen cylinder was also required to be placed in an overpack or outer packaging that met Air Transport Association (ATA) specifications for a 300 Type 1 container. According to RSPA, testing by the Federal Aviation Administration indicated that these shipping containers provided an “incremental” level of thermal protection. Finally, the amendments prohibited the transportation of any other package containing an oxidizing material in an inaccessible cargo compartment that did not have a fire or smoke detection system or fire suppression system. The Safety Board notes that, in this NPRM under docket HM-224B, RSPA proposes to require that overpacks or outer packaging for cylinders of compressed oxygen and chemical oxygen generators not only meet the specifications for an ATA 300 Type I container, but also meet the same flame penetration resistance standards that are required for cargo compartment sidewalls and ceiling panels in transport-category aircraft. The outer packaging must also provide certain thermal protection capabilities so as to retain its contents during an otherwise controllable cargo compartment fire. The Board also notes that if these new standards are adopted, RSPA would remove the present limitation on the number of cylinders of compressed oxygen that may be transported in cargo compartments that are not equipped with a fire suppression system. The Safety Board has reviewed the flame penetration resistance standards and believes that overpacks meeting these standards will provide an improved level of protection for compressed oxygen cylinders. However, the Board believes that RSPA should not remove the present limits on the number of compressed oxygen cylinders that may be transported until sufficient data on the performance and durability of the new overpacks are collected, analyzed, and proved to provide adequate protection with regular use. The Safety Board also notes that RSPA is proposing to revise requirements for pressure relief devices on compressed oxygen cylinders to reduce the release of oxygen when the cylinder is exposed to fire, and to prohibit the transportation of all other oxidizing gases aboard cargo and passenger aircraft. The Safety Board notes that RSPA is also proposing new standards that would require chemical oxygen generators without any packaging to withstand a drop test without actuation or loss of contents, and to have one of four designated features to prevent inadvertent activation. RSPA also proposes to require chemical oxygen generator overpacks that meet the same flame and thermal resistance standards as would be required for compressed oxygen cylinders overpacks. The Safety Board believes that these proposed amendments would enhance the safe transportation of hazardous materials by air and therefore supports the rulemaking as noted. The Safety Board appreciates the opportunity to comment on this proposed rulemaking. If additional clarification or information is needed regarding our comments, please feel free to contact us.

From: NTSB
To: FAA
Date: 12/5/2000
Response: THE SAFETY BOARD AGREED THAT THE RSPA FINAL RULE MET THE FULL INTENT OF THIS RECOMMENDATION WHEN, ON 10/27/99, IT CLASSIFIED A-96-29 ISSUED TO RSPA AS "CLOSED--ACCEPTABLE ACTION." ACCORDINGLY, A-96-27 IS NOW CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 8/25/2000
Response: Letter Mail Controlled 08/30/2000 4:06:49 PM MC# 2001182 IN AUGUST 1998, THE FAA ISSUED NOTICE OF PROPOSED RULEMAKING (NPRM) 98-12. THE NPRM PROPOSED TO BAN THE TRANSPORTATION OF ANY DEVICE DESIGNED AS A CHEMICAL OXYGEN GENERATOR ON BOARD DOMESTIC PASSENGER-CARRYING AIRCRAFT THAT CONDUCT OPERATIONS UNDER 14 CFR PARTS 91, 121, 125, AND 135. THE NPRM ALSO PROPOSED TO BAN THE TRANSPORTATION OF DEVICES DESIGNED AS CHEMICAL OXYGEN GENERATORS IN CERTAIN DOMESTIC ALL-CARGO OPERATIONS EXCEPT FOR THE CARRIAGE OF UNEXPIRED CHEMICAL OXYGEN GENERATORS (THOSE THAT ARE CHARGED BUT THE EXPIRATION DATES HAVE NOT YET PASSED). SINCE THE ISSUANCE OF THE NPRM, THE RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION (RSPA) ISSUED A FINAL RULE ON 8/19/99, TO PROHIBIT THE CARRIAGE OF CHEMICAL OXIDIZERS IN INACCESSIBLE AIRCRAFT CARGO COMPARTMENTS THAT DO NOT HAVE A FIRE OR SMOKE DETECTION AND FIRE SUPPRESSION SYSTEM. THE FINAL RULE ALSO PROHIBITS THE TRANSPORTATION OF SPENT CHEMICAL OXYGEN GENERATORS FOR TRANSPORT ON BOARD PASSENGER OR CARGO AIRCRAFT. AS A RESULT OF THE RSPA SUBSEQUENT RULEMAKING ACTIONS, THE FAA IS EVALUATING WHETHER OR NOT TO WITHDRAW MOST OF THE BANS THAT WERE SET OUT IN NPRM 98-12. THE FAA IS DEVELOPING A SUPPLEMENTAL NPRM THAT WILL CLARIFY, FOR ALL-CARGO OPERATIONS, THE PROPOSAL THAT CHEMICAL OXYGEN GENERATORS BE SEPARATED FROM OTHER CARGO BEFORE FLIGHT. THIS ADDITIONAL RULEMAKING GOES BEYOND THE INTENT OF THIS RECOMMENDATION, AND REGARDLESS OF THE OUTCOME OF THE FAA'S ADDITIONAL RULEMAKING EFFORT, THE FULL INTENT OF THIS RECOMMENDATION HAS BEEN ADDRESSED BY THE RSPA FINAL RULE. THE BOARD AGREED THAT THE RSPA FINAL RULE MET THE FULL INTENT OF THIS RECOMMENDATION WHEN IT CLASSIFIED A-96-29 ISSUED TO RSPA IN A "CLOSED ACCEPTABLE" STATUS. CONSEQUENTLY, I CONSIDER THE FAA'S ACTION TO BE COMPLETED IN RESPONSE TO A-96-27 WITH THE ISSUANCE OF THE RSPA FINAL RULE. SINCE A-96-29 ISSUED TO RSPA IS IDENTICAL TO A-96-27 ISSUED TO THE FAA, I REQUEST THAT THE BOARD CLASSIFY A-96-27 IN A "CLOSED ACCEPTABLE" STATUS.

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

From: NTSB
To: FAA
Date: 12/2/1998
Response: THE BOARD AGREES WITH THE FAA, PENDING COMPLETION OF THE RULEMAKING PROCESS, CLASSIFIES A-96-27 "OPEN--ACCEPTABLE RESPONSE."

From: NTSB
To: FAA
Date: 11/10/1998
Response: Notation 7078: The National Transportation Safety Board has reviewed the FAA's April 27, 1998, Notice of Proposed Rulemaking (NPRM), Docket No. 29318, Prohibition on the Transportation of Devices Designed as Chemical Oxygen Generators as Cargo in Aircraft. The NPRM proposes banning the transportation of chemical oxygen generators on domestic passenger and cargo aircraft. It excepts generators carried on cargo aircraft that are packaged as approved by the Research and Special Programs Administration (RSPA), located in a Class B or E cargo compartment equipped with a fire/smoke detection system, separated from other cargo, and within the quantity limits specified in the Hazardous Materials Regulations (49 Code of Federal Regulations [CFR] Subchapter C). As mentioned in the preamble to the NPRM, the Safety Board issued Safety Recommendations A-96-27 and -29 as a result of its investigation of the May 11, 1996, accident involving ValuJet flight 592 in the Everglades near Miami, Florida. The recommendations urged the FAA and RSPA to permanently prohibit the transportation of chemical oxygen generators as cargo on board passenger or cargo aircraft when the generators have passed their expiration dates and the chemical core has not been depleted. On December 30, 1996, RSPA amended Federal regulations (HM-224A) and prohibited the transportation of all .chemical oxygen generators as cargo on passenger aircraft. In response, the Safety Board classified its safety recommendations "Open- Acceptable Response." In comments to the RSPA notice and in subsequent letters to the FAA and RSPA, the Board expressed its concern that its recommendations had not been fully addressed because RSPA's final rule did not prohibit the transportation on cargo aircraft of undepleted generators that had passed their expiration dates. The FAA's NPRM proposes prohibitions that reinforce RSPA's amendment concerning passenger aircraft. In addition, the NPRM proposes prohibiting the transportation on cargo aircraft of undepleted generators that have passed their expiration dates and have undepleted chemical cores. The Safety Board strongly supports this proposal. The FAA's NPRM also proposes prohibiting the transportation of discharged or spent generators on passenger or cargo aircraft, and the Board supports this proposal. On August 20, 1997, RSPA issued an NPRM (HM-224A, Notice No. 97-8) that proposed prohibiting the transportation of discharged or "spent" generators on both passenger and cargo aircraft. In responding to RSPA's NPRM, the Safety Board supported the prohibition and agreed with RSPA's argument that it is difficult to determine whether all of the oxidizing material in a spent generator has been depleted, thereby ensuring that the generator is no longer hazardous. Finally, the FAA's NPRM proposes prohibiting the transportation of "a device designed as a chemical oxygen generator...that is newly manufactured but not charged with chemicals for the generation of oxygen." As far as the Safety Board knows, the only generators that fit that description are those that are used in awareness training. Nevertheless, even though the FAA's prohibition may restrict the transportation of useful training tools that have never contained oxidizers, the Safety Board supports the prohibition. The Board agrees with the FAA's assessment of possible human error in distinguishing a charged chemical oxygen generator from an uncharged or discharged one. The Safety Board agrees that it would be helpful if both the FAA and RSPA were to cross-reference each other's regulations concerning devices designated as chemical oxygen generators.

From: FAA
To: NTSB
Date: 10/8/1998
Response: (Letter Mail Controlled 10/14/98 6:17:32 PM MC# 981239) THE FAA ISSUED NOTICE OF PROPOSED RULEMAKING (NPRM) 98-12 ON 8/21/98. THE NPRM PROPOSES TO BAN THE TRANSPORTATION OF ANY DEVICE DESIGNED AS A CHEMICAL OXYGEN GENERATOR ON BOARD DOMESTIC PASSENGER-CARRYING AIRCRAFT THAT CONDUCT OPERATIONS UNDER 14 CFR PART 91, 121, 125 & 135. THE NPRM ALSO BANS THE TRANSPORTATION OF SUCH DEVICES IN CERTAIN DOMESTIC ALL-CARGO OPERATIONS. THE DEFINITION IN THE NPRM FOR DEVICES DESIGNED AS A CHEMICAL OXYGEN GENERATOR INCLUDES ALL OF THE FOLLOWING: DEVICES THAT ARE CHARGED WITH OR CONTAIN A CHEMICAL/CHEMICALS THAT PRODUCE OXYGEN BY CHEMICAL REACTION, REGARDLESS OF WHETHER THE EXPIRATION DATE FOR THE DEVICE HAS PASSED; DEVICES THAT HAVE ALREADY BEEN DISCHARGED, REGARDLESS OF WHETHER THERE IS RESIDUE REMAINING IN THE DEVICE; & NEWLY MANUFACTURED DEVICES THAT WOULD, UPON BEING CHARGED WITH THE APPROPRIATE CHEMICALS, HAVE THE POTENTIAL OF GENERATING OXYGEN BY CHEMICAL REACTION UPON INITIATION. THE PROHIBITIONS PROPOSED IN THE NPRM ARE MORE EXTENSIVE THAN THOSE CONTAINED IN THE DECEMBER 30, 1996, RULE ISSUED BY THE RESEARCH & SPECIAL PROGRAMS ADMINISTRATION. IN ADDITION, THE PROHIBITIONS ARE MORE EXTENSIVE THAN THOSE RECOMMENDED IN THIS RECOMMENDATION. THE MORE STRINGENT PROPOSALS ARE BASED ON THE FAA'S ASSESSMENT OF THE PROBABILITY OF HUMAN ERROR IN DISCRIMINATING AMONG CHEMICAL OXYGEN GENERATORS THAT ARE CHARGED VERSUS THOSE THAT HAVE NEVER BEEN CHARGED VERSUE THOSE THAT HAVE BEEN DISCHARGED.

From: NTSB
To: FAA
Date: 8/1/1997
Response: THE BOARD RECOGNIZES THAT RSPA PUBLISHED A FINAL RULE ON 12/30/96, THAT PERMANENTLY PROHIBITS CHEMICAL OXYGEN GENERATORS AS CARGO IN PASSENGER AIRCRAFT. FURTHER, RSPA PUBLISHED ANOTHER FINAL RULE ON 6/5/97, THAT ADDS A SPECIFIC SHIPPING DESCRIPTION AND REQUIREMENTS FOR CHEMICAL OXYGEN GENERATORS TO THE HAZARDOUS MATERIALS TABLE (49 CFR 172.101) AND REQUIRES RSPA APPROVAL OF A CHEMICAL OXYGEN GENERATOR AND ITS PACKAGING WHEN THE GENERATOR IS TO BE TRANSPORTED WITH ITS MEANS OF INITIATION ATTACHED. HOWEVER, NEITHER OF THES RULEMAKING PROHIBITS THE TRANSPORTATION ON CARGO AIRCRAFT OF UNDEPLETED CHEMICAL OXYGEN GENERATORS THAT HAVE PASSED THEIR EXPIRATION DATES. A-96-27 SPECIFICALLY ADDRESSED CHEMICAL OXYGEN GENERATORS THAT HAVE PASSED THEIR EXPIRATION DATES. THESE GENERATORS ARE NOT DESIGNED TO BE REUSED. GIVEN THE DESTRUCTIVE POTENTIAL OF A FIRE INVOLVING THESE GENERATORS, AS WAS DEMONSTRATED DURING THE BOARD'S TESTS OF GENERATORS AT THE FAA'S TEST FACILITY IN ATLANTIC CITY, NEW JERSEY, THE BOARD BELIEVES THAT THEY SHOULD NOT BE TRANSPORTED ON BOARD ANY AIRCRAFT. PENDING ACTION BY THE FAA AND RSPA TO PROHIBIT THE TRANSPORTATION OF THESE CHEMICAL OXYGEN GENERATORS ON CARGO AIRCRAFT, RECOMMENDATION A-96-27 REMAINS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 3/24/1997
Response: ON 12/23/96, RSPA ISSUED ITS FINAL RULE TO PROHIBIT THE OFFERING FOR TRANSPORTATION & THE TRANSPORTATION OF ALL CHEMICAL OXYGEN GENERATORS AS CARGO ON PASSENGER-CARRYING AIRCRAFT. THE EFFECT OF THIS PROHIBITION WILL LIMIT OXYGEN GENERATORS TO ACCESSIBLE LOCATIONS ON BOARD CARGO AIRCRAFT. THIS PROHIBITION IS BROADER THAN THE BOARD'S RECOMMENDATION FOR PASSENGER AIRCRAFT BECAUSE IT PROHIBITS TRANSPORTATION OF ALL GENERATORS, NOT ONLY THOSE THAT HAVE PASSED EXPIRATION DATES. THE FAA CONSIDERS THE FAA'S ACTION TO BE COMPLETED ON THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 8/19/1996
Response: THE BOARD IS AWARE OF RSPA'S INTERIM FINAL RULE, ISSUED ON 5/24/96, THAT TEMPORARILY PROHIBITS OYGEN GENERATORS AS CARGO ON PASSENGER AIRCRAFT UNITL 1/1/97. & NOTES THAT THE FAA & RSPA WILL CONSIDER MAKING THE BAN PERMANENT; HOWEVER, THIS PROHIBITION DOES NOT APPLY TO CARGO AIRCRAFT. THE BOARD UNDERSTANDS THAT THE FAA & RSPA WILL CONSIDER PERMANENTLY PROHIBITING THE SHIPMENT OF CHEMICAL OXYGEN GENERATORS ON BOARD PASSENGER & CARGO AIRCRAFT IN RULEMAKING PROJECTS. BECAUSE A CHEMICAL OXYGEN GENERATOR IS NOT DESIGNED TO BE REUSED AFTER ITS SHELF LIFE HAS EXPIRED, WE AGAIN EMPHASIZE THAT THERE IS NO NEED TO TRANSPORT UNDEPLETED GENERATORS THAT HAVE PASSED THEIR EXPIRATION DATES ON BOARD ANY AIRCRAFT, & WE BELIEVE THE FAA & RSPA SHOULD ACT IMMEDIATELY TO PROHIBIT THEIR SHIPMENT ON CARGO AIRCRAFT. PENDING COMPLETION OF RULEMAKING TO PERMANENTLY PROHIBIT THE TRANSPORTATION OF SUCH GENERATORS ON BOARD ANY PASSENGER OR CARGO AIRCRAFT AIRCRAFT, A-96-27 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 7/16/1996
Response: ON 5/24/96, RSPA PUBLISHED AN INTERIM FINAL RULE THAT PROHIBITS THE OFFERING FOR TRANSPORTATION & THE TRANSPORTATION OF ALL CHEMICAL OXYGEN GENERATORS AS CARGO ON PASSENGER-CARRYING AIRCRAFT. THE INTERIM FINAL RULE REQUESTS COMMENTS WITHIN 60 DAYS ON THE PROHIBITION. THIS PROHIBITION IS BROADER THAN THE BOARD'S RECOMMENDATION FOR PASSENGER AIRACRAFT BECAUSE IT PROHIBITS TRANSPORTATION OF ALL GENERATORS, NOT ONLY THOSE THAT HAVE PASSED EXPIRATION DATES. WITH REGARD TO THE BOARD'S RECOMMENDATIONS, THE INTERIM FINAL RULE DOES NOT EXTEND THE PROHIBITION TO CARGO AIRCRAFT. HOWEVER, THIS WILL BE CONSIDERED AS PART OF THE OXIDIZER RULEMAKING INITIATIVE REFERENCED IN A-96-28 & & 30. RSPA & FAA WILL CONSIDER THESE RECOMMENDATIONS, ALONG WITH COMMENTS RECEIVED AS A RESULT OF THE INTERIM FINAL RULE, TO DETERMINE WHETHER ADDITIONAL RULEMAKING ACTION SHULD BE TAKEN. RSPA IS PLACING A COPY OF THE RECOMMENDATION IN THIS RESPONSE IN THE PUBLIC DOCKET. WE WILL APPRISE THE BOARD OF THE FUTURE COURSE OF ACTION TO ADDRESS THESE RECOMMENDATIONS AS SOON AS THE COMMENTS HAVE BEEN REVIEWED. IT IS ANTICIPATED THAT THIS REVIEW WILL BE COMPLETED BY THE END OF THE YEAR.