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  3. NTSB A-00-051
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NTSB · Safety Recommendation

Safety Recommendation A-00-051

Recommendation

THE NTSB RECOMMENDS THAT THE FAA: DEVELOP, WITH THE ASSISTANCE OF THE HYDROGEN PEROXIDE SAFETY PRODUCERS COMMITTEE, AND DISTRIBUTE TO CARRIERS GUIDANCE ABOUT THE DIFFICULTY OF IDENTIFYING A HYDROGEN PEROXIDE SPILL AND ABOUT THE DANGER OF ALLOWING HYDROGEN PEROXIDE TO DRY ON ORGANIC MATERIALS (INCLUDING PAPER, FABRIC, COTTON, AND LEATHER), WHICH MAY RESULT IN A FIRE.

Safety Issue and Context

ON THE MORNING OF 10/28/98, 2 GALLONS OF A 35-PERCENT HYDROGEN PEROXIDE SOLUTION IN WATER, AN OXIDIZER WITH CORROSIVE PROPERTIES, SPILLED IN A CARGO COMPARTMENT OF NORTHWEST AIRLINES (NORTHWEST) FLIGHT 957, A PASSENGER-CARRYING AIRPLANE EN ROUTE FROM ORLANDO, FLORIDA, TO MEMPHIS, TENNESSEE. THE SOLUTION LEAKED FROM TWO UNDECLARED 1-GALLON PLASTIC BOTTLES THAT HAD SPLIT. THE BOTTLES WERE IN AN ICE CHEST THAT BELONGED TO A PASSENGER ON THE FLIGHT. THE LEAKING HYDROGEN PEROXIDE CONTAMINATED THREE MAIL SACKS AND AN UNDETERMINED NUMBER OF BAGS.

Response History

April 3, 2002 · NTSB Correspondence · FAA

The action taken by RSPA to develop this precautionary guidance addresses Safety Recommendation A-00-51, which is classified "Closed--Acceptable Action." The action taken by the FAA in issuing DGAB 01-01 fully satisfies Safety Recommendation A-00-52, which is also classified "Closed--Acceptable Action."

January 3, 2002 · Recipient Response · FAA

Letter Mail Controlled 01/07/2002 11:49:52 AM MC# 2020024 On October 11, 2001, the Hydrogen Peroxide North American Producers Committee and the Department of Transportation's Research and Special Programs Administration approved precautionary guidance for industry on the difficulty of identifying a hydrogen peroxide spill and the hazards associated with hydrogen peroxide spills. On November 28, 2001, the Federal Aviation Administration (FAA) incorporated this information into Dangerous Goods Advisory Bulletin DGAB 01-01, Transportation of Hydrogen Peroxide (H202).

The bulletin alerts industry about the damage associated with hydrogen peroxide, advises of the difficulty in identifying this material when it leaks, and advises that special care should be taken if encountered. The FAA has directed its principal security inspectors to distribute DGAB 01-01 to U.S., foreign, and all cargo air carriers for which they have responsibility, as well as each indirect air carrier that has an approved security program. I have enclosed a copy of the bulletin for the Board's information. I believe that the FAA has met the full intent of these safety recommendations, and I consider the FAA's action to be completed.

December 20, 2001 · NTSB Correspondence · FAA

In a letter dated July 2, 2001, Ms. Goff advised the Board that RSPA had agreed to develop a technical document in cooperation with the Hydrogen Peroxide Safety Producers Committee and in coordination with the FAA; this document would provide information to airline personnel on (1) the hazards of hydrogen peroxide; (2) the difficulty of identifying a hydrogen peroxide spill; and (3) the danger associated with hydrogen peroxide contacting or drying on organic substances such as wood, cotton, paper, or leather. Ms.

Goff further indicated that a review would be conducted to determine whether further guidance would be required to address what procedures airline personnel should follow when passenger baggage or commercial cargo comes into contact with hazardous materials. In addition, Ms. Goff indicated that RSPA, in cooperation with the FAA, was developing a proposed amendment to the International Civil Aviation Organization's (ICAO) Technical Instructions for the Safe Transport of Dangerous Goods for consideration at an October 2001 meeting of the ICAO committee responsible for the Technical Instructions. According to Ms.

Goff, the proposed amendment would ensure that passenger baggage or commercial cargo that has been contaminated is isolated and that any hazards are addressed before the baggage or cargo is permitted to be transported by air. The Safety Board is aware that representatives from RSPA made a presentation on contaminated packages carried by airlines to the October 2001 meeting of the ICAO committee, and that the committee agreed to adopt this proposal and include it in the next revision to the Technical Instructions. Although the Safety Board has not received or reviewed a copy of the proposed amendment adopted by ICAO in October 2001, the actions described by Ms.

Goff indicate positive steps taken in response to the recommendations. Pending receipt by the Board of a copy of the amendments presented to and adopted by the ICAO committee and completion of the recommended actions, Safety Recommendations A-00-51 and -52 are classified "Open--Acceptable Response."

July 2, 2001 · Recipient Response · FAA

In response to your June 5 letter concerning Safety Recommendations A-00-51 and A-00-52 addressed to the Federal Aviation Administration (FAA), please be advised that I have met with officials from both that organization and the Research and Special Programs Administration (RSPA). RSPA has agreed to develop a technical document in cooperation with the Hydrogen Peroxide Safety Producers Committee and in coordination with the FAA (A-00-51).

This technical document will provide information to airline personnel on the hazards of hydrogen peroxide, the difficulty of identifying a hydrogen peroxide spill, and the danger associated with hydrogen peroxide contacting or drying on organic substances (e.g., wood, cotton, paper, and leather). RSPA and FAA will work to incorporate this information into guidance material that will be distributed to the airline industry. Also, a review will be conducted to determine if further guidance in the form of another document is required to address what procedures airline personnel should follow when passenger baggage or commercial cargo comes into contact with hazardous materials (A-00-52).

In addition, RSPA, in cooperation with the FAA, is developing a proposed amendment to the International Civil Aviation Organization's Technical Instructions for the Safe Transport of Dangerous Goods for consideration at the October 2001, meeting. This proposed amendment will ensure that passenger baggage or commercial cargo that have been contaminated are isolated and that any hazards are dealt with before they are permitted to be transported by air. The FAA will prepare and disseminate to the aviation community one or more Dangerous Goods Advisory Bulletins (DGAB) that incorporates the above information.

The DGAB will be issued to domestic and foreign passenger air carrier and major all-cargo air carriers. In addition, the DGAB will be provided to the Air Transportation Association, the Regional Airlines Association, the International Civil Aviation Organization, and my office. The DGAB will also appear on FAA's intemet website at: http://cas.faa.qov/dqp.html. The FAA accepts responsibility for distributing the technical guidance developed by RSPA and the Hydrogen Peroxide Safety Producers Committee to air carriers and taking whatever steps are necessary to effect its implementation.

After distribution of the technical guidance, FAA will prepare a letter to the NTSB in response to these safety recommendations and request that Safety Recommendations A-00-5 1 and A-00-52 be closed and classified as

June 5, 2001 · NTSB Correspondence · FAA

A recent meeting between staff from the FAA and the Safety Board concerning these recommendations revealed that the FAA believes that it lacks the technical expertise and the statutory authority to develop guidance material on handling specific hazardous chemical agents as requested in Safety Recommendation A-00-51. The FAA believes that the expertise and responsibility for this recommendation lie with the Research and Special Programs Administration (RSPA). The FAA accepts its role in air carrier safety oversight and has indicated to the Safety Board that it will distribute to the carriers whatever guidance is developed or approved by RSPA.

Therefore, the Safety Board would appreciate your office coordinating with the FAA and RSPA, in consultation with the Hydrogen Peroxide Safety Producers Committee, to develop appropriate guidance material to be provided to the FAA for distribution to air carriers and inclusion into their individual hazardous materials safety programs. A copy of the letter transmitting these recommendations to the FAA is enclosed.

December 5, 2000 · NTSB Correspondence · FAA

THE SAFETY BOARD DISAGREES WITH THE FAA THAT RSPA IS THE APPROPRIATE ORGANIZATION TO ACT ON THESE RECOMMENDATIONS. NEITHER OF THE RECOMMENDATIONS DEALS DIRECTLY WITH REGULATIONS CONCERNING THE TRANSPORTATION OF HAZARDOUS MATERIALS, WHICH IS RSPA'S RESPONSIBILITY. RATHER, THESE RECOMMENDATIONS CONCERN HOW TO IDENTIFY AND RESPOND TO HYDROGEN PEROXIDE AND OTHER HAZARDOUS MATERIALS SPILLS. A RESPONSE TO A-00-51 MIGHT TAKE THE FORM OF A DANGEROUS GOODS ADVISORY BULLETIN, WHICH THE FAA ROUTINELY DEVELOPS AND DISTRIBUTES TO AIR CARRIERS. A-00-52 CONCERNS THE APPROPRIATE RESPONSE TO SPILLS OF HAZARDOUS MATERIAL THAT MAY AFFECT THE SAFETY OF AN AIRCRAFT.

THE SAFETY BOARD ASKS THE FAA TO RECONSIDER ITS RESPONSE TO THESE RECOMMENDATIONS. PENDING ACTION IN RESPONSE TO A-00-51 AND -52, THEY ARE CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

August 18, 2000 · Recipient Response · FAA

Letter Mail Controlled 08/23/2000 3:14:28 PM MC# 2001130 THE FAA HAS REVIEWED THESE RECOMMENDATIONS AND BELIEVES THAT THE EMERGENCY RESPONSE GUIDEBOOK PUBLISHED BY THE RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION (RSPA) AND THE EMERGENCY RESPONSE GUILDANCE PUBLISHED BY THE INTERNATIONAL CIVIL AVIATION ORGANIZATION OFFER EXCELLENT GUIDANCE ON IDENDIFICATION AND RESPONSE TO HAZARDOUS MATERIALS SPILLS. HOWEVER, THE BOARD NEEDS TO DIRECT ITS REQUEST FOR DEVELOPING AND ISSUING THE ADDITIONAL GUIDANCE REQUESTED IN THESE RECOMMENDATIONS TO RSPA. RSPA HAS BEEN DELEGATED THE AUTHORITY AND RESPONSIBILITY FOR ISSUING THE GUIDANCE REQUESTED IN THESE RECOMMENDATIONS.

IT WOULD BE INAPPROPRIATE FOR THE FAA TO RESPOND TO THESE RECOMMENDATIONS SINCE IT DOES NOT HAVE RESPONSIBILITY TO IMPLEMENT THE CHANGES REQUESTED BY THE BOARD. THE FAA WILL WORK WITH RSPA TO DEVELOP AND ISSUE ANY ADDITIONAL GUIDANCE, BUT THE AUTHORITY AND RESPONSIBILITY FOR THIS EFFORT LIES WITH RSPA. THE FAA REQUESTS THAT THE BOARD TRANSFER THESE RECOMMENDATIONS TO RSPA FOR FUTURE RESPONSES. I CONSIDER THE FAA'S ACTION TO BE COMPLETED IN RESPONSE TO THESE RECOMMENDATIONS.

Read Recommendation

Recommendation Facts

Status
Closed - Acceptable Action
Issued
June 8, 2000
Priority
CLASS II
Recipient
FAA
Adopted
May 17, 2000
Closed
April 3, 2002
Related Investigation
DCA99MZ001
Related Report
HZB-00-01
"Closed-Acceptable Response."
.We feel that the above procedures are responsive to the safety recommendations issued by your organization. In the event that you should need additional information, please feel free to contact me at 202/366-5781.