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Safety Recommendation Details

Safety Recommendation A-96-029
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, & ALL 105 PASSENGERS WERE KILLED. BEFORE THE ACCIDENT, THE FLIGHTCREW REPORTED TO AIR TRAFFIC CONTROL THAT IT WAS EXPERIENCING SMOKE IN THE CABIN & 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 RECOMMDNS THAT THE RSPA: IN COOPERATION WITH THE FAA, PERMANENTLY PROHIBIT TRANSPORTATION OF CHEMICAL OXYGEN GENERATORS AS CARGO ON BOARD ANY PASSENGER OR CARGO AIRCRAFT WHEN THE GENERATORS HAVE PASSED EXPIRATION DATES, & 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: 10/27/1999
Addressee(s) and Addressee Status: RSPA (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: RSPA
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: RSPA
Date: 10/27/1999
Response: A-96-29 ASKED RSPA, IN COOPERATION WITH THE FAA, TO PERMANENTLY PROHIBIT THE TRANSPORTATION OF CHEMICAL OXYGEN GENERATORS AS CARGO ON BOARD ANY PASSENGER OR CARGO AIRCRAFT WHEN THE GENERATORS HAVE PASSED EXPIRATION DATES, AND THE CHEMICAL CORE HAS NOT BEEN DEPLETED. BECAUSE RSPA'S ACTIONS MEET THE INTENT OF A-96-29, IT IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: RSPA
To: NTSB
Date: 6/30/1999
Response: Letter Mail Controlled 7/6/99 2:11:10 PM MC# 990711 RSPA DOES NOT ALLOW THE TRANSPORTATION OF "EXPIRED" CHEMICAL OXYGEN GENERATORS AS CARGO ON BOARD PASSENGER OR CARGO AIRCRAFT. (EMPHASIS ADDED) RSPA PROHIBITED THE TRANSPORTATION OF CHEMICAL OXYGEN GENERATORS AS CARGO ON PASSENGER CARRYING AIRCRAFT IN AN INTERIM FINAL RULE PUBLISHED ON 5/24/96 (61 FED. REG. 26418), AND IN A FURTHER FINAL RULE PUBLISHED ON 12/30/96 (61 FED. REG. 68952). THIS PROHIBITION APPLIES TO CHEMICAL OXYGEN GENERATORS THAT HAVE EXCEEDED THEIR TWELVE-YEAR SERVICE LIFE AS WELL AS THOSE THAT HAVE NOT PASSED THEIR EXPIRATION DATES. IN A SEPARATE FINAL RULE PUBLISHED ON 6/5/97 (62 FED. REG. 30767), AND CORRECTED ON 6/27/97 (62 FED. REG. 34667), RSPA ADDED CERTAIN REQUIREMENTS FOR THE TRANSPORTATION OF CHEMICAL OXYGEN GENERATORS ON CARGO-ONLY AIRCRAFT. UNDER THESE PROVISIONS, WHICH HAVE BEEN IN EFFECT SINCE 8/7/97, ANY CHEMICAL OXYGEN GENERATOR THAT IS TO BE SHIPPED (BY ANY MODE) WITH ITS MEANS OF INITIATION ATTACHED MUST (1) INCORPORATE AT LEAST TWO POSITIVE MEANS OF PREVENTING UNINTENTIONAL ACTIVATION, AND (2) BE CLASSED AND APPROVED BY RSPA'S ASSOCIATE ADMINISTRATOR FOR HAZARDOUS MATERIALS SAFETY. COPIES OF RSPA'S JUNE 5 AND JUNE 27, 1997 FINAL RULES ARE ENCLOSED. AN ADDITIONAL REQUIREMENT IN RSPA'S 6/5/97 FINAL RULE PROVIDES THAT, WHEN TRANSPORTED BY CARGO AIRCRAFT, A CHEMICAL OXYGEN GENERATOR MUST BE TRANSPORTED IN A PACKAGING PREPARED AND ORIGINALLY OFFERED FOR TRANSPORTATION BY THE APPROVAL HOLDER. THIS MEANS THAT A CHEMICAL OXYGEN GENERATOR THAT HAS BEEN REMOVED FROM AN AIRCRAFT MAY NOT BE OFFERED FOR TRANSPORTATION ON A CARGO AIRCRAFT UNLESS THE OFFEROR APPLIES FOR AND OBTAINS A NEW APPROVAL FROM RSPA'S ASSOCIATE ADMINISTRATOR FOR HAZARDOUS MATERIALS SAFETY, BECAUSE THE GENERATOR HAS BEEN REMOVED FROM ITS ORIGINAL PACKAGING. EACH APPROVAL IS LIMITED TO "SERVICEABLE" CHEMICAL OXYGEN GENERATORS, AND RSPA HAS NOT ISSUED ANY APPROVAL FOR THE TRANSPORTATION BY CARGO AIRCRAFT OF A CHEMICAL OXYGEN GENERATOR THAT IS BEYOND ITS EXPIRATION DATE. A GENERATOR THAT HAS PASSED ITS EXPIRATION DATE IS NOT SERVICEABLE. FOR THESE REASONS RSPA BELIEVES THE ACTIONS IT HAS TAKEN MEET THE PROVISIONS OF A-96-29 AND I RESPECTFULLY REQUEST THAT THE BOARD CLASSIFY A-96-29 AS "CLOSED--ACEPTABLE ACTION."

From: NTSB
To: RSPA
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: NTSB
To: RSPA
Date: 10/19/1998
Response: A-96-29 SPECIFICALLY ADDRESSED CHEMICAL OXYGEN ADDRESSED CHEMICAL OXYGEN GENERATORS THAT HAVE PASSED THEIR EXPIRATION DATES. THESE GENERATORS ARE NOT DESIGNED TO BE REUSED; THEREFORE, GIVEN THE DESTRUCTIVE POTENTIAL OF A FIRE INVOLVING THESE GENERATOR, DEMONSTRATED DURING THE BOARD'S TESTS OF GENERATORS AT THE FAA'S TEST FACILITY IN ATLANTIC CITY, NEW JERSEY, THE BOARD BELIEVES THAT THESE EXPIRED & UNDEPLETED GENERATORS SHOULD NOT BE TRANSPORTED ON BOARD ANY AIRCRAFT. PENDING ACTION RSPA & THE FAA TO PROHIBIT THE TRANSPORTATION ON CARGO AIRCRAFT OF CHEMICAL OXYGEN GENERATORS THAT HAVE PASSED THEIR EXPIRATION DATES & HAVE NOT HAD THEIR CHEMICAL CORES DEPLETED, A-96-29 IS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: RSPA
To: NTSB
Date: 5/4/1998
Response: (Letter Mail Controlled 5/8/98 3:25:29 PM MC# 980596) AS WE MENTIONED IN OUR EARLIER RESPONSE, MITSUBISHI MOTORS' REPRESENTATIVES WORKED WITH THE NHTSA ON THE NEW AIRBAG WARNING LABELS, WHICH THE NHTSA ISSUED AS A FINAL RULE ON 11/27/96. MITSUBISHI MOTORS VOLUNTARILY INSTALLED THE NEW LABELS ON VEHICLES MANUFACTURED PRIOR TO THE FINAL RULE'S 2/25/97 EFFECTIVE DATE. IN ADDITION, MITSUBISHI MOTOR SALES OF AMERICA, INC. (MMSA) VOLUNTARILY SENT LETTERS WITH AIRBAG WARNING LABELS TO OWNERS TOMITSUBISHI MOTORS VEHICLES EQIPPED WITH AIR BAGS

From: NTSB
To: RSPA
Date: 5/4/1998
Response: RSPA PUBLISHED A FINAL RULE ON 12/30/96 (6) FR 68952, DOCKET HM-224, PERMANENTLY PROHIBITING THE TRANSPORTATION OF CHEMICAL OXYGEN GENERATORS AS CARGO ON BOARD PASSENGER CARRYING AIRCRAFT. THE RULEMAKING APPLIES TO BOTH FOREIGN & DOMESTIC PASSENGER-CARRYING AIRCRAFT ENTERING, LEAVING OR OPERATING IN THE UNITED STATES, & TO ANY PERSON OFFERING AN OXYGEN GENERATOR FOR TRANSPORTATION ON ANY PASSENGER CARRYING AIRCRAFT.

From: NTSB
To: RSPA
Date: 10/17/1997
Response: Notation 6818A: The National Transportation Safety Board has reviewed your Supplemental Notice of Proposed Rulemaking (NPRM), Docket No. HM-224A, Prohibition of Oxidizers Aboard Aircraft, published on August 20, 1997. The supplemental notice proposes to prohibit oxidizers in other than class D compartments on passenger-carrying aircraft, provides a proposed list of all oxidizing substances to be prohibited, proposes exceptions that would permit an aircraft operator to transport cylinders containing compressed oxygen in the passenger cabin, and proposes prohibiting spent chemical oxygen generators on both passenger-carrying and cargo aircraft. As a result of its investigation of a February 3, 1988, in-flight fire involving an oxidizer on American Airlines flight 132, the Safety Board determined that hazardous materials involvement in a cargo compartment fire must be considered in all cargo compartment fire penetration safety standards and that hazardous materials deemed to present unacceptable threats should be prohibited. Further, the Board urged the FAA to consider the effects of authorized hazardous materials cargo in fires for all types of cargo compartments and to require appropriate safety systems to protect the aircraft and occupants (Safety Recommendation A-88-127). On March 17, 1994, after the FAA failed to take any positive action, Safety Recommendation A-88-127 was classified "Closed-Unacceptable Action." The Safety Board continues to believe that RSPA and the FAA need to evaluate the effects of authorized hazardous materials in fires in cargo compartments. In comments on a December 30, 1996, NPRM, the Board supported a study initiated by the Research and Special Programs Administration (RSPA), in coordination with the FAA, to assess the risks associated with the transportation of hazardous materials in aircraft cargo compartments. The Safety Board urges RSPA and the FAA to complete this study and to ban any hazardous materials, including oxidizers, that cannot be safely transported in aircraft cargo compartments.

From: NTSB
To: RSPA
Date: 8/19/1996
Response: THE BOARD UNDERSTANDS THAT RSPA & THE FAA 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 NOT NEED TO TRANSPORT UNDEPLETED GENERATORS THAT HAVE THEIR PASSED THEIR EXPIRATION DATE ON BOARD ANY AIRCRAFT, & WE BELIEVE RSPA & THE FAA 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, A-96-29 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: RSPA
To: NTSB
Date: 7/16/1996
Response: ON 5/25/96, RSPA PUBLISHED AN INTERIM FINAL RULE THT 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 AIRCRAFT 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 REFERENCE 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 SHOULD 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.