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Safety Recommendation Details

Safety Recommendation A-97-059
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 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: TO THE FEDERAL AVIATION ADMINISTRATION: Establish performance standard for the rapid donning of smoke goggles; then ensure that all air carriers met this standard through improved smoke goggle equipment, improved flightcrew training, or both.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Miami, FL, United States
Is Reiterated: Yes
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: 9/9/1997
Date Closed: 4/24/2001
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Fire, Flightcrew, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/24/2001
Response: ALTHOUGH THE SAFETY BOARD REMAINS CONCERNED THAT FLIGHT CREWS MAY NOT USE SMOKE GOGGLES AT THE FIRST INDICATION OF SMOKE IN AN AIRCRAFT, THE FAA HAS COMPLETED THE ACTIONS RECOMMENDED. THEREFORE, A-97-59 IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 10/2/2000
Response: Letter Mail Controlled 10/04/2000 3:48:25 PM MC# 2001485 ON 8/31/98, THE FAA ISSUED FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIR TRANSPORTATION 98-29, SMOKE GOGGLES AND OXYGEN MASKS (PBE), TO ADDRESS THIS RECOMMENDATION. THE BULLETIN DIRECTED PRINCIPAL OPERATIONS INSPECTORS (POI) TO ENSURE THAT CERTIFICATE HOLDERS HAVE GUIDANCE TO FLIGHT CREWMEMBERS TO DON BOTH SMOKE GOGGLES AND OXYGEN MASKS AT THE FIRST INDICATION OF ANY UNIDENTIFIED ODOR. FLIGHT CREWMEMBERS MUST BE ABLE TO DON THE SMOKE GOGGLES AND OXYGEN MASK WITHIN THE 15-SECOND DESIGN OBJECTIVE ESTABLISHED IN TECHNICAL STANDARD ORDER C99 AND SOCIETY OF AUTOMOTIVE ENGINEERS AEROSPACE STANDARD 8031. THE FAA CONSIDERED ITS ACTION TO BE COMPLETED IN RESPONSE TO THIS RECOMMENDATION. ON 7/23/99, THE BOARD ASKED THAT THE FAA PROVIDE DOCUMENTATION THAT THE 15-SECOND STANDARD FOR DONNING BOTH THE OXYGEN MASK AND SMOKE GOGGLES IS BEING MET BY AIR CARRIERS OR PROVIDE INFORMATION ABOUT THE CHANGES IN EQUIPMENT OR TRAINING THAT WOULD ENSURE COMPLIANCE WITH THIS STANDARD. THE BOARD CLASSIFIED THIS RECOMMENDATION IN AN "OPEN ACCEPTABLE" STATUS PENDING FURTHER INFORMATION FROM THE FAA. THE FAA HAS REVIEWED VARIOUS CERTIFICATE HOLDERS' APPROVED TRAINING PROGRAMS TO ENSURE THAT SUFFICIENT HANDS-ON TRAINING WITH ALL PROTECTIVE BREATHING EQUIPMENT IS PROVIDED. THE FAA CONFIRMS THAT EACH TRAINING PROGRAM ENSURES THAT FLIGHT CREWMEMBERS ARE PROFICIENT IN DONNING THE OXYGEN MASK AND SMOKE GOGGLES. FLIGHT CREWMEMBERS MUST BE ABLE TO DON THE SMOKE GOGGLES AND OXYGEN MASK WITHIN THE TIMEFRAME ESTABLISHED IN TECHNICAL STANDARD ORDER (TSO) C99 AND SOCIETY OF AUTOMOTIVE ENGINEERS AEROSPACE STANDARD (AS) 8031. TSO C99 AND AS 8031 ADDRESS A DESIGN OBJECTIVE SO THAT SMOKE GOGGLES EQUIPMENT SHALL BE CAPABLE OF BEING DONNED WITHIN 15 SECONDS. CONSEQUENTLY, THE FAA BELIEVES THAT THIS RECOMMENDATION HAS BEEN ADDRESSED WITH THE REQUIREMENTS OF 14 CFR PARTS 25 AND 121, TSO C99, AND AS 8031. IN ADDITION, ANY CERTIFICATE HOLDER WHO HAS SMOKE GOGGLES AND OXYGEN MASKS APPROVED BY A METHOD OTHER THAN THE PERFORMANCE STANDARDS SPECIFIED IN TSO C99 AND AS 8031 MUST MAKE THAT INFORMATION AVAILABLE TO ITS ASSIGNED POI WHO WILL DETERMINE IF THE 15-SECOND PERFORMANCE STANDARD IS ACCOMPLISHED. EACH CERTIFICATE HOLDER IS ENCOURAGED TO DEVELOP NEW EQUIPMENT AND PROCEDURES THAT MIGHT REDUCE THE 15-SECOND TIMEFRAME. THE FAA ALSO FOUND THAT FLIGHT CREWMEMBERS RECEIVE ADDITIONAL TRAINING CONCERNING THE REQUIREMENT THAT SMOKE GOGGLES MUST BE STORED IN A MANNER SO AS TO BE IMMEDIATELY AVAILABLE FOR USE. BASED ON THE ABOVE INFORMATION, I CONSIDER THE FAA'S ACTION TO BE COMPLETED ON THIS SAFETY RECOMMENDATION.

From: NTSB
To: FAA
Date: 7/23/1999
Response: PENDING THE RECEIPT OF THIS INFORMATION, A-97-59 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 2/8/1999
Response: Letter Mail Controlled 2/10/99 2:37:39 PM MC# 990131:

From: FAA
To: NTSB
Date: 10/9/1998
Response: Letter Mail Controlled 10/14/98 6:26:57 PM MC# 981243: In previous letters, the Federal Aviation Administration (FAA) told the Board that while it agreed with the intent of these safety recommendations, a substantive response required specific data on this issue. In March 1998, the FAA surveyed the industry by conducting over 300 Special Emphasis En Route Inspections. These inspections evaluated the packaging of smoke goggles, the checklist procedures of certificate holders when encountering fumes or smoke, and the training provided to flightcrews concerning the use of smoke goggles and oxygen masks. The results of these 300 inspections are included in Appendix A of Flight Standards Handbook Bulletin for Air Transportation 98-29 issued on August 31, 1998. I have enclosed a copy of the bulletin for the Board's information. The bulletin directs principal operations inspectors (POI) to ensure that each certificate holder's approved training program reflects sufficient hands-on training for protective breathing equipment so that each crewmember is proficient in donning the oxygen mask and smoke goggles. The POI's will also ensure that certificate holders have established requirements in appropriate checklists, training programs, and operations manuals that will result in the checking of each item of protective breathing equipment at crewmember duty stations by the crewmember using that equipment. The bulletin also directs POI's to ensure that the certificate holder has guidance to flight crewmembers to don both smoke goggles and oxygen masks at the first indication of any unidentified odor. Flight crewmembers must be able to don the smoke goggles and oxygen mask within the 15-second design objective established in Technical Standard Order C99 and Society of Automotive Engineers Aerospace Standard 8031. The FAA's action in response to Safety Recommendation A-97-60 has not been classified by the Board. However, on August 12, 1998, the Board classified Safety Recommendations A-97-58 and A-97-59 as "open unacceptable" because the FAA elected not to issue the bulletin until it had developed proper background and data on the broad issue of protective breathing equipment. That work has been completed, and I believe the bulletin properly addresses these safety recommendations issued by the Board. I consider the FAA's action to be completed.

From: NTSB
To: FAA
Date: 8/12/1998
Response: (IN GREENSHEET) THE BOARD HAS BEEN ASSURED THAT THE FAA IS STILL IN AGREEMENT WITH THE INTENT OF THE RECOMMENDATIONS ADDRESSING FLIGHTCREW SMOKE GOGGLES & THAT ACTION ON A-97-58, -59 & -60 WILL FOLLOW THE RESULTS OF THE SURVEY. IN THE VALUJET REPORT, THE BOARD ALSO CONCLUDED THAT THE SMOKE GOGGLE EQUIPMENT CURRENTLY PROVIDED ON MOST AIR CARRIER TRANSPORT AIRCRAFT REQUIRES EXCESSIVE TIME, EFFORT, ATTENTION, & COORDINATION BY THE FLIGHTCREW TO DON &, IN A-97-59 , ASKED THE FAA TO ESTABLISH A PERFORMANCE STANDARD FOR THE RAPID DONNING OF SMOKE GOGGLES & ENSURE THAT ALL AIR CARRIERS MEET THIS STANDARD THROUGH IMPROVED SMOKE GOGGLE EQUIPMENT, IMPROVED FLIGHTCREW TRAINING, OR BOTH. THE BOARD CLASSIFIES A-97-59 "OPEN--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 7/23/1998
Response: Letter Mail Controlled 7/27/98 3:17:30 PM MC# 980931: On November 17, 1997, the FAA told the Board that it agreed with the intent of these safety recommendations. The FAA planned to issue a flight standards handbook bulletin to provide guidance on procedures for donning protective breathing equipment for smoke and fume protection (A-97-58) and equipment and procedural guidance on flightcrew training requirements (A-97-59). On March 20, 1998, the FAA issued Flight Standards Information Bulletin for Air Transportation 98-09, Special Emphasis Inspection of Smoke Goggles, in response to Safety Recommendation A-97-60. This bulletin directed principal operations inspectors (POI) to conduct a special emphasis inspection of smoke goggles during en route and ramp inspections. The POI's were directed to gather specific information on the type of packaging used for approved smoke goggles. The information from the special emphasis inspection will be used to determine if corrective actions are necessary. The FAA is currently evaluating the results of the inspection. After further evaluation of the FAA's proposed actions to respond to Safety Recommendations A-97-58 and -59, the FAA has decided to develop guidance material based on the results of the inspection in response to Safety Recommendation A-97-60. I will provide the Board with a copy of the guidance material as soon as it is issued.

From: NTSB
To: FAA
Date: 7/22/1998
Response: From the accident report of an in flight fire and emergency landing of a Douglas DC-10-10 in Newburgh, New York (report adopted 7/22/1998): Within 48 seconds after the first indication of a problem, the crew donned oxygen masks, as required by the “Fire & Smoke” checklist. The captain elected not to don his smoke goggles because they did not fit over his eyeglasses and they were dirty and scratched. The first officer elected not to wear his smoke goggles because he felt that they unduly restricted his peripheral vision. The flight engineer put his smoke goggles on but subsequently removed them because there was no smoke in the cockpit. The Safety Board is concerned that cockpit smoke may affect crewmembers’ vision, imperiling their ability to operate the airplane or properly address the emergency. Evidence in this accident indicates that smoke did not enter the cockpit in significant amounts until after the crew landed and stopped the airplane. However, the Safety Board is concerned that under different circumstances, the failure of crewmembers to don smoke goggles or to keep the goggles on during an emergency could adversely affect the outcome. In connection with its investigation of the May 11, 1996, accident involving ValuJet flight 592, the Safety Board concluded that there is inadequate guidance for air carrier pilots about the need to don oxygen masks and smoke goggles immediately in the event of a smoke emergency. In Safety Recommendation A-97-58, the Safety Board asked the FAA to issue guidance on this point to air carrier pilots. In a November 17, 1997, response, the FAA indicated it would issue a flight standards handbook bulletin in November 1997 containing guidance on procedures to don PBE for smoke and fume protection. The FAA did not issue the bulletin. Recently, it has been learned that the bulletin will not be issued until after the FAA reviews the results of a special emphasis inspection of smoke goggles during en route and ramp inspections. On March 20, 1998, the FAA called for this special survey of smoke goggles as part of its response to Safety Recommendation A-97-60 (also from the ValuJet report), which sought a requirement that smoke goggles currently approved for use by the flightcrews of transport category aircraft be packaged in such a way that they can be easily opened by the flightcrew. The survey has been completed, and the FAA is reviewing the results. The Board has been assured that the FAA is still in agreement with the intent of the recommendations addressing flightcrew smoke goggles and that action on Safety Recommendations A-97-58, -59, and -60 will follow the results of the survey. The Board is very concerned that the issuance of the guidance bulletin regarding the need for flightcrews to don smoke goggles at the first indication of a possible inflight smoke or fire emergency has been delayed until after the completion and review of the special survey. Based on this delay, the Board classifies Safety Recommendation A-97-58 “Open—Unacceptable Response.” In the ValuJet report, the Safety Board also concluded that the smoke goggle equipment currently provided on most air carrier transport aircraft requires excessive time, effort, attention, and coordination by the flightcrew to don and, in Safety Recommendation A-97-59, asked the FAA to establish a performance standard for the rapid donning of smoke goggles and ensure that all air carriers meet this standard through improved smoke goggle equipment, improved flightcrew training, or both. In response, the FAA indicated that it believed the intent of this recommendation is addressed in 14 CFR 121.337, which establishes standards for PBE for smoke and fume protection and requires that the equipment be conveniently located on the flight deck and easily accessible for immediate use. However, there is no standard for the optimum equipment location that will facilitate quick donning of such equipment or for the time required to don the equipment. The FAA also stated that it would issue a flight standards handbook bulletin to provide additional guidance on the location and donning of this equipment and procedural guidance on flightcrew training requirements. However, it did not address the recommendation to establish a standard to ensure that, through equipment design, equipment installation, or flightcrew training, a specific performance standard is achieved for donning smoke goggles. The FAA has indicated that it will await the results of the special emphasis inspection before it takes further action. The Safety Board classifies Safety Recommendation A-97-59 “Open—Unacceptable Response.” This accident again demonstrates that crews may not use the equipment currently available and that some characteristics of the current equipment may interfere with the flightcrew’s performance of its duties. Accordingly, the Safety Board reiterates Safety Recommendations A-97-58 and -59.

From: FAA
To: NTSB
Date: 11/17/1997
Response: The FAA believes that the intent of this safety recommendation is addressed by 14 CFR 121.337, Protective Breathing Equipment. This section establishes standards for protective breathing equipment for smoke and fume protection. The oxygen system and smoke goggles provide flightcrew protection from smoke and fumes. Performance standards for protective breathing equipment are established by 14 CFR 121.337(8), which requires, in part, that protective breathing equipment (for smoke and fume protection) must be conveniently located on the flight deck and be easily accessible for immediate use by each required flight crewmember at that assigned duty station. A preliminary review of industry practices concerning equipment and carrier procedures indicates a need for further guidance on the location and donning of this equipment. The FAA will issue a flight standards handbook bulletin to provide additional guidance on the location and donning of this equipment. The bulletin will also include equipment and procedural guidance and guidance on flightcrew training requirements. It is anticipated that the bulletin will be issued in November 1997. I will provide the Board with a copy of the bulletin as soon as it is issued.