NTSB · Safety Recommendation
Safety Recommendation A-00-056
Recommendation
THE NTSB RECOMMENDS THAT NORTHWEST AIRLINES, INC.: AMEND YOUR EMERGENCY RESPONSE PROCEDURES AND TRAINING TO INCLUDE THE IMPORTANCE OF ISOLATING BAGGAGE AND OTHER CARGO THAT HAS BEEN INVOLVED WITH A HAZARDOUS MATERIALS SPILL UNTIL IT CAN BE DETERMINED WHICH ITEMS HAVE BEEN CONTAMINATED AND WHAT MEASURES ARE NECESSARY TO PREVENT FURTHER CONTAMINATION OF BAGGAGE AND AIRCRAFT OR OTHER HAZARDS (SUCH AS FIRE OR POISONING).
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 19, 2001 · NTSB Correspondence · Northwest Airlines, Inc.
NWA REPORTS THAT IT HAS REVISED ITS DGCG, SECTION NWDG-11, TO INCORPORATE THOSE SUGGESTIONS MADE BY THE BOARD. NWA HAS ALSO ISSUED THE REVISED DGCG. NWA'S ACTIONS SATISFY A-00-56, WHICH IS NOW CLASSIFIED "CLOSED--ACCEPTABLE ACTION."
February 14, 2001 · Recipient Response · Northwest Airlines, Inc.
Letter Mail Controlled 02/20/2001 11:11:27 AM MC# 2010125 THE WORDING THE BOARD SUGGESTS IS ACCEPTABLE. WE HAVE REVISED THE WORDING OF THE GUIDE AS FOLLOWS: NWA DANGEROUS GOODS COMPLIANCE GUIDE, SECTION NWDG-11 - ISOLATION AND EVACUATION - IMMEDIATELY ISOLATE ANY SPILLED, ODOROUS OR SMOKING, MATERIAL, BAGGAGE, MAIL, OR OTHER CARGO THAT HAS BEEN INVOLVED WITH A POSSIBLE HAZARDOUS MATERIAL SPILL. THIS IS DONE TO PREVENT HARM TO PERSONNEL AND DAMAGE TO EQUIPMENT AND/OR THE ENVIRONMENT. A MINIMUM EVACUATION AREA OF 15 FEET IN DIAMETER IS REQUIRED. OUTDOORS, BE SURE THAT ALL PERSONNEL IN THE VICINITY OF THE SPILLED MATERIAL ARE LOCATED UPWIND FROM THE SITE OF THE SPILL.
WHENEVER ANY PACKAGE IS LEAKING, SMOKING, OR EMITTING ODORS, MAKE EVERY EFFORT TO LOCATE AND STOP SIMILAR PACKAGES IN THE SAME SHIPMENT FROM THE SAME SHIPPER. FURTHERMORE, ENSURE THAT ALL PIECES OF LUGGAGE, CARGO, OR COMAT THAT MAY HAVE BEEN SURROUNDING THE SOURCE OF THE SPILLED MATERIAL IS ACCOUNTED FOR. *IF POSSIBLY CONTAMINATED LUGGAGE OR CARGO HAS BEEN TRANSFERRED TO ANOTHER FLIGHT, HAVE THE FLIGHT DECK CREW OF THAT FLIGHT NOTIFIED ASAP. THE FLIGHT SHOULD BE GROUND-STOPPED UNTIL IT CAN BE ASCERTAINED IF THE POSSIBLY CONTAMINATED TRANSFER MATERIAL IS ABOARD THEIR AIRCRAFT OR HAS BEEN REMOVED.
*IF THE FLIGHT WITH POSSIBLY CONTAMINATED TRANSFER MATERIAL IS AIRBORNE, IMMEDIATELY NOTIFY THE SOC DUTY DIRECTOR WITH PERTINENT DATA REGARDING THE FLIGHT. HAVE THEM NOTIFY THE FLIGHT DECK CREW SO THAT A JOINT DECISION CAN BE MADE AS TO WHAT COURSE OF ACTION THE CAPTAIN SHOULD TAKE. *ADDITIONALLY, NOTIFY THE STATION OF THE AIRCRAFT'S INTENDED ARRIVAL AND REQUIRE APPROPRIATE EMERGENCY RESPONSE TEAM MEMBERS TO AWAIT THE AIRCRAFT'S ARRIVAL.
January 5, 2001 · NTSB Correspondence · Northwest Airlines, Inc.
THE SAFETY BOARD NOTES THAT NWA IS TAKING THE ACTION RECOMMENDED. HOWEVER, THE BOARD IS CONCERNED THAT THE SECTION OF THE DGCG SUBMITTED BY NWA MENTIONS ONLY THE SPILLED MATERIAL. THE RECOMMENDATION SPECIFICALLY MENTIONS THE NEED FOR "ISOLATING BAGGAGE AND OTHER CARGO THAT HAS BEEN INVOLVED WITH A HAZARDOUS MATERIALS SPILL," WHICH WOULD INCLUDE BAGGAGE OR CARGO CONTAMINATED BY THE HAZARDOUS MATERIAL. THE BOARD URGES NWA TO REVISE THE LANGUAGE IN THE DGCG FROM "ISOLATE ANY SPILLED MATERIAL IMMEDIATELY.." TO "IMMEDIATELY ISOLATE ANY SPILLED MATERIAL, BAGGAGE, AND OTHER CARGO THAT HAS BEEN INVOLVED WITH A HAZARDOUS MATERIALS SPILL.."
PENDING FINAL REVISIONS TO THE OPERATING MANUALS FOR EACH OPERATING DIVISION TO ATTAIN COMPATIBILITY WITH THE DGCG POLICY DIRECTIVE, AND RESPONSE FROM NWA REGARDING THE BOARD'S SUGGESTED REVISION, A-00-56 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."
September 29, 2000 · Recipient Response · Northwest Airlines, Inc.
Letter Mail Controlled 10/02/2000 3:14:52 PM MC# 2001436 NORTHWEST AIRLINES HAS CONDUCTED A REVIEW OF ALL COMPANY OPERATING PROCEDURES THAT REFER TO THE HANDLING OF DANGEROUS GOODS (HAZARDOUS MATERIALS) INCIDENTS AND SIMULTANEOUSLY HAS PRODUCED A DANGEROUS GOODS COMPLIANCE GUIDE (DGCG) FOR ALL THE OPERATING DIVISIONS OF THE CORPORATION - GROUND OPERATIONS, FLIGHT OPERATIONS, CARGO OPERATIONS, INFLIGHT SERVICES AND TECHNICAL OPERATIONS. THIS GUIDE SPECIFICALLY OUTLINES WHAT ACTIONS MUST BE TAKEN IN THE EVENT OF A SPILL, LEAKAGE, ODOR, SMOKE OR FUMES COMING FROM ANY PIECE OF LUGGAGE, CARGO SHIPMENT, COMPANY MATERIAL (COMAT) SHIPMENT OR MAIL PIECE.
IT SPECIFICALLY EMPHASIZES THE NEED TO "ISOLATE" THE SUSPICIOUS PIECE AND THE IMMEDIATE ACTIONS TO TAKE. ATTACHMENT 1 IS AN EXCERPTED SECTION FROM THE DGCG. THE PERTINENT OPERATING MANUALS FOR EACH OPERATING DIVISION ARE BEING REVISED AS NECESSARY TO BE COMPATIBLE WITH THE DGCG POLICY DIRECTIVE. ATTACHMENT 1: ISOLATION AND EVACUATION - ISOLATE ANY SPILLED MATERIAL IMMEDIATELY TO PREVENT HARM TO PERSONNEL AND DAMAGE TO EQUIPMENT AND THE ENVIRONMENT. A MINIMUM EVACUATION AREA OF 15 FEET IS REQUIRED. IF OUTSIDE, BE SURE ALL PERSONNEL IN THE VICINITY OF THE SPILLED MATERIAL ARE LOCATED UPWIND FROM THE SITE OF THE SPILL.