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Safety Recommendation Details

Safety Recommendation A-97-065
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: Require that routine work cards used during maintenance of Part 121 aircraft (a) provide, for those work cards that call for the removal of any component containing hazardous materials, instructions, for disposal of the hazardous materials or a direct reference to the maintenance manual provision containing those instructions and (b) include an inspector's signature block on any work card that calls for handling a component containing hazardous materials.
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: 9/9/1997
Date Closed: 3/16/2006
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/16/2006
Response: With regard to Safety Recommendation A-97-65, the FAA's July 21, 2003, letter-and the Safety Board's February 23, 2004, response-discussed the FAA's belief that an inspector's stamp on a work card, by itself, was an effective means of preventing hazardous materials from being loaded on an aircraft without appropriate packaging and authorizations. The FAA noted that work cards are used for documenting and recording only maintenance functions/activities, and that an inspector's stamp/signature would not prove proper disposal, packaging, shipping, or loading of a component containing hazardous materials because these are not maintenance functions/activities. Although the Board continued to believe it important that a maintenance organization have and use the proper hazardous materials handling procedures, the Board agreed that requiring an inspector's signature on a work card was not the most effective way to achieve this goal. The Board also noted that the FAA had previously issued two handbook bulletins that amended the Airworthiness Inspector's Handbook regarding hazardous materials information. Further, on March 20, 2003, the FAA published Advisory Circular 120-16D, "Air Carrier Maintenance Programs," which informed air carriers that if their maintenance operations required the use of aircraft components or consumable materials containing hazardous materials or dangerous goods, the manuals should include procedures and information about these materials. In its February 23, 2004, letter, the Board indicated that the actions taken and planned by the FAA were an acceptable alternative to the recommended action of requiring an inspector's signature block on all work cards that call for handling a component containing hazardous materials. With the issuance of the final rule, the FAA has completed its actions in response to Safety Recommendation A-97-65, which is now classified "Closed-Acceptable Alternate Action."

From: FAA
To: NTSB
Date: 11/17/2005
Response: Letter Mail Controlled 11/30/2005 11:34:28 AM MC# 2050551Marion C. Blakey, Administrator, FAA, 11/17/05 The Federal Aviation Administration published its final rule on October 7, 2005, to revise 14 CFR Parts 119, 121, 135, and 145 Hazardous Materials Training Requirements. The final rule amends the current air carrier hazardous material manual requirements and training requirements for certain air carrier and commercial operators. The final rule also requires that certain repair stations provide documentation showing that persons handling hazardous materials for transportation have been trained as required by the Department of Transportation's Hazardous Materials Regulations. The final rule sets clear hazardous materials training standards and ensures uniform compliance with hazardous materials training requirements. I have enclosed a copy of the final rule for the Board's information. I believe that the FAA has satisfactorily responded to these safety recommendations, and I look forward to your response.

From: FAA
To: NTSB
Date: 2/28/2005
Response: In its 2/28/2005 report to Congress, "Open Statutory Mandates Regarding Pipeline and Hazardous Materials Safety," the DOT wrote: NPRM published on May 8, 2003. NTSB agrees with FAA’s argument that an inspector’s stamp/signature block is not needed.

From: NTSB
To: FAA
Date: 2/23/2004
Response: The Safety Board has considered the FAA's argument that an inspector's stamp/signature is not an appropriate mechanism to ensure the proper handling, packaging, and shipment of hazardous materials associated with an aircraft maintenance operation. Although the Board continues to believe it important that a maintenance organization have and use the proper hazardous materials procedures, the Board agrees that requiring an inspector's signature on a work card is not the appropriate means to achieve this goal. The Board notes that the FAA previously issued two handbook bulletins that resulted in amendments to the Airworthiness Inspector's Handbook regarding hazardous materials information. The Board further notes that on March 20, 2003, the FAA published Advisory Circular (AC) 120-16D, "Air Carrier Maintenance Programs," which informs air carriers that if their maintenance operations require the use of aircraft components or consumable materials containing hazardous materials or dangerous goods, the manuals should include procedures and information about these materials. Finally, the Board notes that on May 8, 2003, the FAA issued a notice of proposed rulemaking (NPRM) titled "Hazardous Materials Training Requirements." The NPRM proposes to amend the current air carrier hazardous material manual requirements and training regulations in 14 Code of Federal Regulations (CFR) Parts 121, 135, and 145 to incorporate requirements for improved and specific hazardous material training programs, authorizations, and notifications. The Safety Board believes that the actions taken and planned by the FAA are an acceptable alternative to the recommended action of requiring an inspector's signature block on all work cards that call for handling a component containing hazardous materials. Pending issuance of the final rule as a result of the NPRM, Safety Recommendation A-97-65 is classified "Open--Acceptable Alternate Response."

From: FAA
To: NTSB
Date: 7/21/2003
Response: Letter Mail Controlled 8/7/2003 10:17:48 AM MC# 2030379 The Board expressed concern that Flight Standards Handbook Bulletin for Airworthiness (FSAW) 98-10, Air Carrier Control and Handling of Aircraft Components or Consumable Materials That Contain Hazardous Materials, dated May 22, 1998, does not meet the intent of this safety recommendation because it does not require an inspector's signature block on work cards that call for handling a component containing hazardous materials. The FAA has considered the Board's concerns and has determined that it cannot conclude that an inspector's stamp on a work card, by itself, is an effective means of preventing hazardous material from being loaded on an aircraft without appropriate packaging and authorizations. Work cards are used for documenting and recording maintenance functions/activities. An inspector's stamp/signature would not provide for the disposal, packaging, shipping, loading, etc., of a component containing hazardous materials, as these are not maintenance functions/activities. Requiring an inspector's signature on a work card would necessitate AD action or rulemaking, which would require a full cost/benefit analysis that may not show a clear benefit for an inspector's stamp on a work card. In addition, some airlines do not employ inspectors and other airlines do not use work cards. The FAA continues to believe that its current and planned actions are appropriate and adequately respond to the safety intent of this safety recommendation. The FAA issued two handbook bulletins that resulted in hazardous materials information amendments to the Airworthiness Inspector's Handbook. Manufacturers have included hazardous materials information in their maintenance and other technical documents. The FAA has recently published Advisory Circular (AC) 120-16D, Air Carrier Maintenance Programs, on March 20, 2003. I have enclosed a copy of the AC for the Boards information. The AC informs air carriers that if their maintenance operations require the use of aircraft components or consumable materials containing hazardous materials or dangerous goods as defined in 49 CFR 173.34, the manuals should include procedures and information about these materials. The FAA also issued a notice of proposed rulemaking (NPRM) to amend the current air carrier hazardous material manual requirements and training regulations in 14 CFR Parts 121, 145, and 135. I have enclosed a copy of the NPRM for the Board's information. The NPRM proposes to incorporate requirements for improved and specific hazardous material training programs, authorizations, and notifications. Once the final rule is issued, all of the new requirements will make hazardous materials handling an organized, systemic process within an air carrier's organization. I will keep the Board informed of the FAA's progress on this safety recommendation.

From: NTSB
To: FAA
Date: 4/24/2001
Response: PENDING FURTHER INFORMATION DOCUMENTING THAT THE FAA'S CURRENT OR PLANNED ACTIVITIES WILL REQUIRE AN INSPECTOR'S SIGNATURE BLOCK ON WORK CARDS THAT CALL FOR HANDLING A COMPONENT CONTAINING HAZARDOUS MATERIAL, A-97-65 REMAINS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 10/2/2000
Response: Letter Mail Controlled 10/04/2000 3:48:25 PM MC# 2001485 ON 5/22/98, THE FAA ISSUED FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIRWORTHINESS 98-10, AIR CARRIER CONTROL AND HANDLING OF AIRCRAFT COMPONENTS OR CONSUMABLE MATERIALS THAT CONTAIN HAZARDOUS MATERIALS. THE BULLETIN PROVIDED INFORMATION AND GUIDANCE TO PRINCIPAL INSPECTORS WITH CERTIFICATE AND SURVEILLANCE RESPONSIBILITIES FOR AIR CARRIERS THAT HAVE AIRCRAFT COMPONENTS OR CONSUMABLE MATERIALS CONTAINING HAZARDOUS MATERIALS. THE BULLETIN PROVIDED SIMILAR HAZARDOUS MATERIALS INFORMATION FOR REPAIR STATIONS. THE FAA ALSO INFORMED THE BOARD THAT ADVISORY CIRCULAR (AC) 120-16C, CONTINUOUS AIRWORTHINESS MAINTENANCE PROGRAMS, WOULD BE REVISED TO INCORPORATE THE INFORMATION CONTAINED IN THE BULLETINS. ON 7/23/99, THE BOARD STATED THAT IT DID NOT BELIEVE THE BULLETIN MEETS THE INTENT OF A-97-65 BECAUSE IT DID NOT REQUIRE AN INSPECTOR'S SIGNATURE BLOCK ON WORK CARDS THAT CALL FOR HANDLING A COMPONENT CONTAINING HAZARDOUS MATERIALS. THE BOARD FURTHER STATED THAT IT WAS CONCERNED THAT WORK DONE BY 14 CFR PART 145 REPAIR STATIONS AND 14 CFR PART 121 OR 135 AIR CARRIERS IS NOT ADDRESSED IN THE BULLETIN. THE BOARD CLASSIFIED A-97-65 IN AN "OPEN UNACCEPTABLE" STATUS PENDING ADDITIONAL INFORMATION. A-97-67, -69, AND -73 WERE CLASSIFIED IN AN "OPEN ACCEPTABLE" STATUS PENDING THE ISSUANCE OF ORDER 8300.10 AND REVISED AC 120-16C. THE FAA HAS CONSIDERED THE BOARD'S CONCERNS AND BELIEVES ITS CURRENT AND PLANNED ACTIONS ARE APPROPRIATE TO ADDRESS THESE RECOMMENDATIONS. THE FAA ISSUED HAZARDOUS MATERIALS INFORMATION AMENDMENTS TO THE AIRWORTHINESS INSPECTOR'S HANDBOOK THROUGH FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIRWORTHINESS 98-10 FOR AIR CARRIERS AND FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIRWORTHINESS 99-10 FOR REPAIR STATIONS. THESE TWO BULLETINS HAVE SIGNIFICANTLY HEIGHTENED AWARENESS OF CURRENT HAZARDOUS MATERIALS HANDLING AND SHIPPING REGULATIONS FOR AIR CARRIERS AND REPAIR STATIONS. THE FAA IS CONTINUING ITS EFFORT TO REVISE AC 120-16C TO INCLUDE HAZARDOUS MATERIAL INFORMATION. IN THE LONG TERM, THE FAA IS CONSIDERING RULEMAKING ACTIVITY TO AMEND THE CURRENT AIR CARRIER HAZARDOUS MATERIALS MANUAL REQUIREMENTS AND TRAINING REGULATIONS IN 14 CFR PARTS 121, 145, AND 135 TO INCORPORATE SPECIFIC REQUIREMENTS FOR IMPROVED AND SPECIFIC HAZARDOUS MATERIALS TRAINING PROGRAMS. THE RULES WOULD IDENTIFY THE SPECIFIC HAZARDOUS TRAINING NEEDED FOR EACH AIR CARRIER OR REPAIR STATION EMPLOYEE BASED ON THE NATURE OF THE HAZARDOUS MATERIALS FUNCTION OR RESPONSIBILITY PERFORMED BY THE EMPLOYEE. IT IS ANTICIPATED THAT THE AC WILL BE ISSUED BY DECEMBER 2000. I WILL PROVIDE THE BOARD WITH A COPY OF THE AC AS SOON AS IT IS ISSUED.

From: NTSB
To: FAA
Date: 7/23/1999
Response: THE SAFETY BOARD DOES NOT BELIEVE THAT THE BULLETIN MEETS THE INTENT OF A-97-65 BECAUSE IT DOES NOT REQUIRE AN INSPECTOR'S SIGNATURE BLOCK ON WORK CARDS THAT CALL FOR HANDLING A COMPONENT CONTAINING HAZARDOUS MATERIALS. ADDITIONALLY, THE BOARD IS CONCERNED THAT THE BULLETIN MAY NOT ADDRESS WORK DONE BY PART 145 REPAIR STATIONS FOR PART 121 OR 135 AIR CARRIERS. AS STATED IN THE RECOMMENDATION LETTER, INSPECTION OF THE WORK PERFORMED BY A MECHANIC IS CRITICAL, PARTICULARLY MAINTENANCE THAT INVOLVES THE HANDLING OF HAZARDOUS MATERIALS. THEREFORE, PENDING ADDITIONAL ACTION TO IMPLEMENT A-97-65, IT IS CLASSIFIED "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 May 22, 1998, the FAA issued Flight Standards Handbook Bulletin for Airworthiness 98-10, Air Carrier Control and Handling of Aircraft Components or Consumable Materials That Contain Hazardous Materials. The bulletin provides information and guidance to principal inspectors with certificate and surveillance responsibilities for air carriers that have aircraft components or consumable materials containing hazardous materials. The bulletin directs principal inspectors to ensure that their air carriers include the following information in their manuals and that they provide appropriate personnel training * Procedures and information to assist maintenance, shipping, and stores personnel in identifying or recognizing aircraft components or consumable materials that contain hazardous materials. If those aircraft components or consumable materials are to be moved, stored, or handled within the air carriers or contract maintenance providers' facilities, procedures and instructions relating to the safe movement, storage, or handling of those aircraft components or consumable materials must be included. * Procedures and information for determining the proper packaging, marking, labeling, and materials compatibility, including instructions for the safe movement, storage, and handling of aircraft components or consumable materials that contain hazardous materials while they are within the air carriers' facilities. * Information, guidance, and precautions regarding the specific hazards associated with aircraft components or consumable materials containing hazardous materials that are to be moved, stored, or handled within the air carriers' facilities. * Information, instructions, and detailed procedures for the proper disposal of unserviceable aircraft components or consumable materials containing hazardous materials. The bulletin also directs principal inspectors to ensure that air carriers are aware of all regulations governing air transportation of hazardous materials, that they conduct hazardous materials training in accordance with 14 CFR Part 172, and that they implement a system to ensure that their personnel remain current on the hazardous materials regulations. I have enclosed a copy of the bulletin for the Board's information. The FAA is also revising FAA Order 8300.10, Airworthiness Inspector Handbook, and Advisory Circular (AC) 120-16D, Continuous Airworthiness Maintenance Programs, to incorporate the information contained in the bulletin. I will provide the Board with copies of the order and AC as soon as they are revised.

From: FAA
To: NTSB
Date: 11/17/1997
Response: The FAA agrees with the intent of these safety recommendations and is revising FAA Order 8300.10, Airworthiness Inspector Handbook, and Advisory Circular (AC) 120-16D, Continuous Airworthiness Maintenance Programs. These documents will be revised to incorporate the information to address each of these safety recommendations. It is anticipated that the order will be revised by April 1998 and the AC by October 1998. I will provide the Board with copies of these documents as soon as they are revised. As an immediate response, the FAA will issue a flight standards handbook bulletin to address specific programs, procedures, information, and training to assist maintenance, shipping, and stores personnel in identifying or recognizing aircraft components or consumable material that contains hazardous materials. The bulletin will provide information, guidance, and precautions regarding specific hazards associated with aircraft components or consumable materials that are to be moved, stored, or handled by air carrier or maintenance provider personnel. 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.