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General Aviation Safety
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.
TO THE FEDERAL AVIATION ADMINISTRATION: Require that the smoke goggle 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.
Original recommendation transmittal letter:
Closed - Acceptable Action
Miami, FL, United States
In-Flight Fire and Impact With Terrain Valujet Airlines Flight 592 DC-9-32, N904VJ
Addressee(s) and Addressee Status:
FAA (Closed - Acceptable Action)
Safety Recommendation History
BASED ON THE ISSUANCE OF THIS GUIDANCE TO AIR CARRIERS, THE SAFETY BOARD CLASSIFIES A-97-58 AND -60 "CLOSED--ACCEPTABLE ACTION." HOWEVER, BECAUSE WE ARE UNAWARE OF ANY PREVIOUS REFERENCE TO THE 15-SECOND STANDARD FOR DONNING BOTH THE OXYGEN MASK AND SMOKE GOGGLES THAT WOULD CONFIRM COMPLIANCE WITH THE STANDARD, THE SAFETY BOARD REQUESTS DOCUMENTATION THAT THIS STANDARD IS CURRENTLY BEING MET BY AIR CARRIERS OR INFORMATION ABOUT THE CHANGES IN EQUIPMENT OR TRAINING THAT WILL ENSURE COMPLIANCE WITH THIS STANDARD.
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.
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.
The FAA is working with the airlines and industry to assess the efficiency of the packaging of smoke goggles and to determine if the packaging impedes rapid donning of the smoke goggles. I will keep the Board informed of the FAA's progress on this safety recommendation.
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