NTSB · Safety Recommendation
Safety Recommendation A-00-054
Recommendation
THE NTSB RECOMMENDS THAT THE U.S. POSTAL SERVICE: REINFORCE THE TRAINING PROVIDED TO YOUR HAZARDOUS MATERIALS EMERGENCY RESPONDERS CONCERNING THE NEED TO USE TECHNICAL INFORMATION, INCLUDING MATERIAL SAFETY DATA SHEETS, ABOUT THE HAZARDS AND THE CHEMICAL PROPERTIES OF MATERIALS WHEN RESPONDING TO A SPILL INSTEAD OF RELYING SOLELY ON MEMORY OR PREVIOUS EXPERIENCE.
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
December 4, 2003 · NTSB Correspondence · United States Postal Service
The Safety Board notes that the USPS conducts three levels of training for hazardous materials incident response, refresher training courses, and routine safety talks. The USPS reports that all training stresses the use of material safety data sheets and other appropriate guides for individuals responding to incidents.
The Safety Board appreciates the USPS's actions to reinforce the use of technical data during a spill or incident response. Based on this emphasis, Safety Recommendation A-00-54 is classified "Closed--Acceptable Action."
July 24, 2003 · Recipient Response · United States Postal Service
Letter Mail Controlled 8/7/2003 11:52:31 AM MC# 2030391 The USPS repeated information provided in their previous (7/13/00) letter concerning 3 levels of HAZWOPER training. There was additional information directly pertaining to the recommendation, such as four-hour refresher courses. Additionally a series of 15-minute safety talks are routinely given to all employees. All training stresses the use of MSDS, NIOSH guides, and DOT guidebooks when responding to accidents.
October 29, 2001 · NTSB Correspondence · United States Postal Service
Notation 7388: The National Transportation Safety Board has reviewed the Research and Special Programs Administration’s (RSPA’s) notice of proposed rulemaking (NPRM), “Applicability of Hazardous Materials Regulations to Loading, Unloading, and Storage,” Docket No. RSPA-98-4952 (HM-223), published at 66 FR 32420 on June 14, 2001.
RSPA is proposing in the NPRM that the applicability of the hazardous materials regulations (HMR) to loading and unloading activities be based on a “carrier-controlled” criterion under which transportation would begin when the container/package comes under the control of the carrier and end when the carrier relinquishes control. As stated in the preamble, “the HMR would apply to all carrier activities after the carrier takes possession of the hazardous material from an offeror for purposes of transporting it until the package is delivered to its destination, including loading and unloading activities conducted by carrier personnel.”
RSPA further states in the preamble that “consignee unloading is not part of transportation in commerce as we propose to apply that term because it occurs after movement in commerce is completed” and that “loading of a tank car by a shipper and unloading of a tank car by a consignee within a facility would not be subject to the HMR.” As RSPA is likely aware, rail carriers are not involved with the loading and unloading of tank cars unless a tank car begins to release its cargo during transit and the cargo must be transferred to another tank car.
As for motor carriers, carrier personnel may or may not be involved with the loading and unloading of cargo tanks at shippers’ and consignees’ facilities, depending upon the hazardous material to be handled and the procedures at the facility. Consequently, the Safety Board is primarily concerned that the HMR would not apply to loading and unloading operations for railroad tank cars, highway cargo tanks, and other bulk containers.
The Safety Board has historically and consistently considered loading and unloading operations, particularly of bulk containers such as railroad tank cars, highway cargo tanks, and intermodal bulk containers, to be transportation-related functions. Title 49 United States Code Section 5102 defines “transportation” as “the movement of property and loading, unloading, or storage incidental to movement.”
September 27, 2000 · NTSB Correspondence · United States Postal Service
THE SAFETY BOARD'S INVESTIGATION DETERMINED THAT THE LOCAL FIRE DEPARTMENT DID NOT PROVIDE AN MSDS TO THE USPS, NOR WAS IT REQUESTED BY THEM. INTERVIEWS WITH USPS PERSONNEL REVEALED THAT, UPON USPS SAFETY OFFICIAL'S ARRIVAL AT THE AIRPORT, POSTAL EMPLOYEES TOLD THE SAFETY OFFICER THAT THE MATERIAL SPILLED ON THE MAIL BAGS WAS HYDROGEN PEROXIDE. THE SAFETY OFFICER SAID THAT HE DID NOT REFER TO ANY SPECIFIC INFORMATION ON THE HAZARDS OR PROPERTIES OF THE CHEMICAL IN DETERMINING THE ACTIONS TO BE TAKEN, NOR DID HE CONTACT THE FIRE DEPARTMENT.
THE SAFETY OFFICER SAID THAT HE WAS FAMILIAR WITH HYDROGEN PEROXIDE AND THAT HE DIRECTED THE MAIL BE DUMPED FROM THE NYLON SACKS INTO LARGE OPEN WIRE BINS TO ALLOW IT TO DRY OUTSIDE. AS NOTED DURING THE BOARD'S INVESTIGATION, THIS PROCESS MAY HAVE RESULTED IN THE DRYING AND CONCENTRATION OF THE HYDROGEN PEROXIDE ON THE LETTERS, POSSIBLY RESULTING IN THEIR IGNITION. A REVIEW OF THE MSDS FOR THIS PRODUCT MAY HAVE RESULTED IN THE SAFETY OFFICER TAKING OTHER ACTIONS, SUCH AS TAKING PRECAUTIONS TO PREVENT OR LIMIT THE CONSEQUENCES OF IGNITION.
ALSO, AS PART OF THE INVESTIGATION, THE BOARD REVIEWED THE USPS HAZARDOUS MATERIALS SPILL RESPONSE TRAINING AND FOUND THAT THE SAFETY OFFICER DID NOT FOLLOW THE PROCEDURE IN THE USPS TRAINING "..TO USE REFERENCE MATERIAL AND OTHER RESOURCES IN MAKING DETERMINATIONS RELATIVE TO A HAZARDOUS MATERIAL SPILL." THUS, IT APPEARS THAT THE USPS HAD PROPER PROCEDURES IN PLACE, BUT THAT THEIR SAFETY OFFICIAL WAS UNFAMILIAR WITH THESE PROCEDURES.
THE USPS REPORTS THAT IT WILL REINFORCE WITH APPROPRIATE PERSONNEL THE NEED FOR THEM TO REFER TO THAT MSDS AND OTHER TECHNICAL RESOURCES REGARDING THE HAZARDS AND CHEMICAL PROPERTIES OF MATERIALS WHEN RESPONDING TO A SPILL INSTEAD OF RELYING SOLELY ON MEMORY OR PREVIOUS EXPERIENCE. THE SAFETY BOARD REQUESTS THAT THE USPS INFORM THE BOARD ON HOW THIS INFORMATION WILL BE REINFORCED, AND WHEN ALL APPROPRIATE PERSONNEL HAVE RECEIVED THIS TRAINING. PENDING NOTIFICATION OF THESE CHANGES, A-00-54 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."
July 13, 2000 · Recipient Response · United States Postal Service
Letter Mail Controlled 07/17/2000 3:42:24 PM MC# 2000904 BASED UPON THIS REPORT'S FINDINGS, IT IS CLEAR THAT MAIL WAS NOT A CONTRIBUTING FACTOR TO THIS INCIDENT. IT IS ALSO EVIDENT THAT NORTHWEST AIRLINES RELEASED THREE WET SACKS OF MAIL TO THE POSTAL SERVICE PRIOR TO THE EMERGENCY RESPONSE UNIT'S IDENTIFICATION OF THE MATERIAL THAT SPILLED FROM A PASSENGER'S LUGGAGE. ONCE RELEASED, THE CONTAMINATED SACKS WERE UNDER POSTAL CONTROL AND WERE NOT AN AIR TRANSPORTATION ISSUE.
THE REPORT ALSO STATES THAT THE FIRE DEPARTMENT RESPONDING TO THIS INCIDENT FOLLOWED THE PROPER NORTH AMERICAN EMERGENCY RESPONSE GUIDE PROCEDURES AND OBTAINED THE MATERIAL SAFETY DATA SHEET INFORMATION FROM THE MINNESOTA POISON CONTROL CENTER. THIS INFORMATION WAS PROVIDED TO THE POSTAL SERVICE'S SAFETY OFFICIAL UPON HIS ARRIVIAL AT THE AIRPORT. POSTAL SERVICE HAZARDOUS MATERIALS RESPONSE PROGRAMS ARE BASED ON THE PRINCIPLE THAT NO POSTAL EMPLOYEE WILL RESPOND TO EMERGENCY RELEASES (AS DEFINED BY OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION [OSHA]) OF HAZARDOUS MATERIALS FROM MAILED ITEMS.
IN ACCORDANCE WITH THE OSHA EMERGENCY RESPONSE STANDARD (29 CFR 1910.120) AND EMERGENCY ACTION PLAN STANDARD (29 CFR 1910.38), EMPLOYEES ARE TRAINED TO A LEVEL SUFFICIENT TO ALLOW THEM TO DETERMINE IF A SPILL OR LEAK IS AN INCIDENTAL OR EMERGENCY RELEASE OF HAZARDOUS MATERIALS. IF INCIDENTAL IN NATURE (AS DEFINED BY OSHA), POSTAL EMPLOYEES MAY CLEAN UP THE SPILL, DECONTAMINATE, AND TAKE OTHER ACTIONS AS NECESSARY TO PROTECT THEMSELVES, OTHER EMPLOYEES, THE MAIL, AND PROPERTY. IF THEY DETERMINE, HOWEVER, THAT AN EMERGENCY RELEASE IS OCCURRING, OR HAVE ANY DOUBTS ABOUT THE NATURE OF THE RELEASE, THEY ARE TRAINED TO RETREAT, ISOLATE THE SPILL, AND TAKE OTHER DEFENSIVE ACTIONS.
THESE PROCEDURES ARE INCLUDED AS PART OF THE FACILITY EMERGENCY ACTION PLAN AND CALL FOR OUTSIDE EMERGENCY RESPONDERS WITH APPROPRIATE TECHNICAL TRAINING. IN THE CASE OF THE 10/28/98, SPILL, THE HAZARDOUS MATERIAL WAS NOT CONTAINED WITHIN THE MAIL AND THE IDENTITY OF THE MATERIAL HAD ALREADY BEEN DETERMINED BY THE FIRE DEPARTMENT. POSTAL SERVICE'S SAFETY POLICY IDENTIFIES SEVERAL LAYERS OF HAZARDOUS MATERIAL RESPONDER TRAINING THAT ARE PROVIDED TO OUR EMPLOYEES. THIS TRAINING CONFORMS TO THAT RECOMMENDED BY OSHA IN ITS EMERGENCY RESPONSE STANDARDS.