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Safety Recommendation Details

Safety Recommendation A-97-066
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 manufactures to affix a warning label to chemical oxygen generators to effectively communicate the dangers posed by unexpended generators and to communicate that unexpended generators are hazardous materials; then require that aircraft manufacturers instruct all operators of aircraft using chemical oxygen generators of the need to verify the presence of (or affix) such labels on chemical oxygen generators currently in their possession.
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: 9/9/1997
Date Closed: 7/29/1999
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
RSPA (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: RSPA
Date: 7/29/1999
Response: THE SAFETY BOARD NOTES THAT A REVIEW OF 49 CFR PARTS 100 THROUGH 185 SHOWS THAT CHEMICAL OXYGEN GENERATORS HAVE BEEN ADDED TO THE LIST OF HAZARDOUS MATERIALS, AND THAT A STANDARD AND UNIFORM CODE ADDRESSES THE PROPER MARKING FOR THESE DEVICES TO ENSURE THAT THEY ARE HANDLED IN THE APPROPRIATE MANNER. THE BOARD ALSO NOTES THAT, FOR DEVICES CURRENTLY IN USE, PROCEDURES AND MATERIALS HAVE BEEN MADE AVAILABLE SO THAT THE DEVICES CAN BE RETROFITTED WITH PROPER MARKINGS. BASED ON INDUSTRY'S ACTIONS AND THE RULE REQUIRING DEPT. OF TRANSPORTATION APPROVAL OF THE SHIPMENT OF OXYGEN GENERATORS EQUIPPED WITH ACTUATING DEVICES, WHICH ALSO REQUIRES THAT GENERATORS BE MARKED WITH THE "OXIDIZER 5.1" LABEL, A-97-66 IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION." THE FAA HAS BEEN INFORMED OF THIS CLASSIFICATION.

From: RSPA
To: NTSB
Date: 6/16/1998
Response: RSPA HAS THE REGULATORY RESPONSIBILITY FOR MARKING AND LABELING CHEMICAL OXYGEN GENERATORS. IN A 11/17/97 FAA LETTER, THE FAA REQUESTED THAT A-97-66 BE TRANSFERRED TO RSPA FOR EVALUATION AND RESPONSE. RSPA CONCURS WITH THAT RECOMMENDATION. IN FINAL RULES PUBLISHED ON JUNE 5 AND JUNE 27, 1997, RSPA AMENDED THE HAZARDOUS MATERIALS REGULATIONS TO ADD A SPECIFIC SHIPPING DESCRIPTION TO THE HAZARDOUS MATERIALS TABLE FOR CHEMICAL OXYGEN GENERATORS AND TO REQUIRE APPROVAL OF A CHEMICAL OXYGEN GENERATOR AND ITS PACKAGING WHEN IT IS TO BE TRANSPORTED. INCLUDED IN EACH APPROVAL IS A REQUIREMENT THAT, "THE BODY OF EACH OXYGEN GENERATOR MUST BE PLAINLY AND DURABLE MARKED: OXYGEN GENERATOR, CHEMICAL." OXYGEN GENERATORS WERE PREVIOUSLY TRANSPORTED UNDER SEVERAL DIFFERENT SHIPPING DESCRIPTIONS WHICH IDENTIFIED CHEMICAL CONSTITUENTS BUT NOT THE FACT THAT THE PACKAGED ARTICLES WERE OXYGEN GENERATORS. AT THE REQUEST OF RSPA AND THE FAA, THE AIRCRAFT MANUFACTURERS DEVELOPED A PROGRAM TO RETROFIT LABELS TO ALL DEVICES WHICH WERE ALREADY IN SERVICE. THIS PROGRAM BECAME MANDATORY THROUGH THE MANUFACTURER'S OPERATING SPECIFICATIONS. THE GENERATOR MANUFACTURERS DEVELOPED SERVICE KITS FOR THE RETROFIT OPERATION. THE MECHANISMS TO EFFECT THIS RETROFIT WERE IN PLACE APPROXIMATELY 90 DAYS AFTER OXYGEN GENERATORS BECAME SUSPECT AS BEING CAUSAL IN THE ACCIDENT. OLDER DEVICES WHICH ARE REMOVED FROM SERVICE AND WHICH DO NOT HAVE THE PROPER LABELING MUST BE SHIPPED UNDER EXEMPTION AND ARE LIMITED, NORMALLY, TO SURFACE TRANSPORTATION ONLY.

From: NTSB
To: FAA
Date: 7/29/1999
Response: THE SAFETY BOARD NOTES THE FAA'S REQUEST THAT THIS RECOMMENDATION BE TRANSFERRED TO THE RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION (RSPA) FOR RESOLUTION. THE BOARD FURTHER NOTES THAT IT HAS RECEIVED AND REVIEWED RSPA'S 6/16/98, RESPONSE TO A-97-66. ON THE BASIS OF THE NEW REGULATIONS ISSUED BY RSPA AND THE FAA'S EFFORTS TO MAKE AIRCRAFT AND OXYGEN GENERATOR MANUFACTURERS PROVIDE MARKINGS FOR CHEMICAL OXYGEN GENERATOR CANISTERS AND THE PACKAGING FOR SUCH CANISTERS, THE BOARD CLASSIFIES A-97-66 "CLOSED--ACCEPTABLE ACTION." RSPA HAS BEEN INFORMED OF THIS CLASSIFICATION.

From: FAA
To: NTSB
Date: 1/5/1999
Response: ON 11/27/97, THE FAA INFORMED THE BOARD THAT THE RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION (RSPA) HAD THE REGULATORY RESPONSIBILITY FOR LABELING CHEMICAL OXYGEN GENERATORS. THE FAA ASKED THAT THE BOARD TRANSFER THIS RECOMMENDATION TO RSPA FOR EVALUATION AND RESPONSE. ON 6/16/98, RSPA PROVIDED THE BOARD WITH A COMPLETE RESPONSE TO THIS RECOMMENDATION. RSPA ALSO INFORMED THE BOARD THAT IT CONCURRED WITH THE FAA THAT THIS RECOMMENDATION SHOULD BE TRANSFERRED TO RSPA AS THE AGENCY RESPONSIBLE FOR THIS SAFETY ISSUE. I HAVE ENCLOSED A COPY OF THE LETTER FROM RSPA IN RESPONSE TO THIS RECOMMENDATION FOR THE BOARD'S INFORMATION.

From: FAA
To: NTSB
Date: 6/16/1998
Response: Letter Mail Controlled 7/21/98 3:17:15 PM MC# 980910:

From: FAA
To: NTSB
Date: 11/17/1997
Response: RSPA has the regulatory responsibility for labeling chemical oxygen generators. I plan no action in response to this recommendation, and I request that the Board transfer this safety recommendation to RSPA for evaluation and response.