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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.

Read Recommendation

Recommendation Facts

Status
Closed - Acceptable Action
Issued
June 8, 2000
Priority
CLASS II
Recipient
United States Postal Service
Adopted
May 17, 2000
Closed
December 4, 2003
Related Investigation
DCA99MZ001
Related Report
HZB-00-01
The U.S. Department of Transportation (DOT) HMR at 49 Code of Federal Regulations 107.4 similarly defines transportation
“as any movement of property by any mode, and any loading, unloading, or storage incidental thereto.”

Accordingly, the Safety Board believes that the DOT has both the statutory mandate and authority to regulate loading and unloading operations. The Safety Board notes that the DOT has exercised its authority to regulate loading and unloading operations in the past with the adoption of such regulatory provisions as 49 CFR 173.30 (loading and unloading of transport vehicles in all modes), 174.67 (tank car unloading), 174.101 – 174.115 (loading explosive materials by rail), and 177.834 (general loading and unloading requirements for highway).

Also, the Federal Railroad Administration (FRA) has issued hazardous materials bulletins that explain FRA policy and provide guidance about various regulated activities, including tank car unloading, attendance requirements during the unloading of tank cars, and hazardous materials training. In the Board’s view, the DOT has, by these actions, established that loading and unloading operations are properly regulated by the HMR.

The carrier-controlled criterion proposed by RSPA, as it applies to loading and unloading operations for hazardous materials being transferred to (or from) railroad tank cars, highway cargo tanks, and other bulk containers, will have a significant impact on public safety. The Safety Board has investigated more than 15 accidents since 1971 that have involved the loading or unloading of hazardous materials transported in bulk containers and has issued 18 Safety Recommendations addressing loading and unloading operations to the DOT and its modal administrations. (See enclosures 1 and 2.)

Collectively, these accidents have resulted in 18 fatalities, 261 injuries, 6,600 evacuations, and more than $28.5 million in damage. The impact of these accidents upon public safety has been significant and demonstrates the need for effective Federal oversight of loading and unloading operations involving bulk transportation containers containing hazardous materials. Further, the Safety Board is currently investigating an accident that occurred on July 14, 2001, at the ATOFINA Chemicals, Inc., plant in Riverview, Michigan.

The accident involved the release of methyl mercaptan (a poisonous and flammable gas) and resulted in 3 fatalities, 6 injuries, and the evacuation of nearly 2,000 local residents. The release of the methyl mercaptan was from a tank car being prepared for offloading.

Also, recent statistics obtained through the DOT’s Hazardous Materials Information System (HMIS) indicate that from 1995 through July 27, 2001, there were 6,947 incidents related to the unloading of hazardous materials from highway cargo tanks. These statistics also reveal that 16 fatalities and more than 250 injuries were associated with these incidents. During the same time, there were 186 railroad tank car unloading incidents, causing a total of 1 fatality and more than 45 injuries.

Under this proposed rule, written incident reports on many of these accidents may not be submitted to RSPA and entered into the HMIS, and the capability to detect accident trends and causes in future loading and unloading accidents would be lost.

In two recent Safety Board investigations that involved unloading operations, the June 4, 1999, Whitehall, Michigan, and November 19, 1998, Louisville, Kentucky, accidents, the Safety Board determined that enhanced safety requirements were needed for loading and unloading hazardous materials involved in transport and recommended on June 29, 2000, that RSPA:

I-00-6 Within 1 year of the issuance of this safety recommendation, complete rulemaking on Docket HM-223 “Applicability of the Hazardous Materials Regulations to Loading, Unloading and Storage,” to establish, for all modes of transportation, safety requirements for loading and unloading hazardous materials.

In addition, as a result of the Clymers, Indiana, accident, the Safety Board reiterated Safety Recommendation I-00-6 on March 5, 2001. In an April 5, 2001, response, RSPA noted that publication of the NPRM was scheduled for mid-2001, but it did not otherwise indicate that the NPRM would address Safety Recommendation I-00-6. In a July 23, 2001, letter to RSPA, the Safety Board stated that it considered the establishment of safety standards and requirements for loading and unloading operations to be an essential part of HM-223.

The Safety Board also expressed its concern about RSPA’s lack of progress in addressing these issues in HM-223 and noted that the DOT is not providing sufficient direction to ensure that personnel involved in these operations are properly trained and provided with clearly written procedures. Safety Recommendation I-00-6 remains classified “Open—Unacceptable Response.”

RSPA’s own accident data from the HMIS indicate that loading/unloading accidents significantly affect public safety, and yet the proposed criterion excludes the submission of incident/accident notification reports about loading/unloading accidents and negates the improvements being proposed under the “Hazardous Materials: Revisions to Incident Reporting Requirements and the Hazardous Materials Incident Report Form,” Docket No. RSPA-99-5013 (HM-229), rulemaking.

The Safety Board is also concerned that certain proposed standards undermine RSPA’s longstanding policy of encouraging uniform national standards for transporting hazardou