NTSB · Safety Recommendation
Safety Recommendation A-00-058
Recommendation
THE NTSB RECOMMENDS THAT NORTHWEST AIRLINES, INC.: REINFORCE THE TRAINING PROVIDED TO GROUND OPERATIONS AND MAINTENANCE PERSONNEL ON ACTIONS TO TAKE FOR A SUSPECTED FIRE IN AN AIRCRAFT CARGO COMPARTMENT. ALSO FOR THOSE EMPLOYEES, REVIEW AND MODIFY, AS APPROPRIATE, PROCEDURES AND TRAINING FOR A SUSPECTED HAZARDOUS MATERIALS SPILL IN AN AIRCRAFT CARGO COMPARTMENT.
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.
THE SAFETY BOARD IS PLEASED BY NWA'S ACTIONS IN RESPONSE TO THIS RECOMMENDATION. CONSEQUENTLY, A-00-58 IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION."
February 14, 2001 · Recipient Response · Northwest Airlines, Inc.
Letter Mail Controlled 02/02/2001 11:11:27 AM MC# 2010125: Enclosed for the Board's review is a copy of NWA's newly produced dangerous goods, annual recurrent training video for 2001 entitled "Leave No Stone Unturned." The video speaks directly to the Memphis, October 1998, incident and the lessons we have learned from it. The video also reviews actions to be taken in the event of a hazardous materials spill or fire.
Additionally, NWA has revised section NWDG-1 1 of the NWA Dangerous Goods Compliance Guide to more fully incorporate the actions to be taken at the threat of fire in an aircraft's cargo compartment as follows: NWA DANGEROUS GOODS COMPLIANCE GUIDE, Section NWDG-11 - Definition and Guidelines *A dangerous goods (DG) incident can be defined as any unintentional release of dangerous goods from a package - this can be either liquid, powder, granules, gas, fumes, or odor. *According to 49 CFR 171.15 an incident during the course of transportation that directly results from dangerous goods requires immediate verbal notice to the FAA.
A follow-up written report is required when a dangerous goods incident results in or is involved with: a person's death, a person who is hospitalized with injuries, property damage exceeding $50,000, evacuation of the general public lasting one (1) or more hours, the closing of a major transportation facility or artery for one (1) hour or more, the operational flight pattern or routine of an aircraft is altered (e.g., the flight is diverted), suspected radioactive or infectious substance contamination, a continuing danger to life at the scene of the incident, NOTE 1: U.S. regulation 49 CFR, 175.31 requires that the FAA be notified whenever discrepancies are revealed that were not ascertainable at the time of initial dangerous goods acceptance.
The Dangerous Goods Program Manager will make the necessary government contacts in consultation with parties referenced in the second note below. It is imperative that all discrepancies be reported to the Mgr., Dangerous Goods Programs/SHEM as soon as possible after the discovery of a DG incident. Any incident that the local manager deems to be reportable. NOTE 2: The Dangerous Goods Program Manager, NWA-SHEM determines, in consultation with the Director, Flight Safety; Corporate Legal Counsel; V.P., Operations of affected operating department, what governmental notifications need to be made and when to make them.
It is imperative to immediately note the following critical incident resources on discovery of a suspected occurrence: SOC Director/MSP 612-727-0307, Mgr. Dangerous Goods Programs/NWA-SHEM 612-726-4613, Martin L. Thon Pin #72024 Pager #1-600-759-7243 OV:MLTHON. FIRE EMERGENCY: It is essential that any sign or indication of smoke coming from a package, cargo, baggage, or mail inside a cargo compartment of any NWA, KLM or airlink aircraft be dealt with as if the package was on fire.
January 5, 2001 · NTSB Correspondence · Northwest Airlines, Inc.
ALTHOUGH THE ACTIONS BEING TAKEN BY NWA ARE RESPONSIVE TO THE RECOMMENDATION, IT IS NOT CLEAR TO THE SAFETY BOARD HOW THE VIDEO WILL DIRECTLY ADDRESS THESE TWO ISSUES (ACTIONS TO TAKE FOR A SUSPECTED CARGO COMPARTMENT FIRE AND ACTIONS TO TAKE FOR A HAZARDOUS MATERIALS SPILL IN AN AIRCRAFT CARGO COMPARTMENT). THE BOARD WOULD APPRECIATE FURTHER INFORMATION FROM NWA ON HOW THESE TWO ISSUES WILL BE ADDRESSED IN THE VIDEO. PENDING RECEIPT OF ANSWERS TO THIS QUESTION, PRODUCTION OF THE VIDEO, AND INCORPORATION OF THE VIDEO INTO THE CURRENT TRAINING FOR ALL AFFECTED OPERATING EMPLOYEES, A-00-58 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 PRODUCES A TRAINING VIDEO ANNUALLY FOR DANGEROUS GOODS AWARENESS AND FUNCTION OR INCIDENT SPECIFIC TRAINING FOR ITS HAZARDOUS MATERIAL EMPLOYEES (AS DEFINED IN 49 CFR, PART 172-600 AND 14 CFR). THE NTSB CHIEF INVESTIGATOR OF THIS INCIDENT SHOWED CLIPS FROM A 1999 DG TRAINING VIDEO THAT FOCUSED ON THE MEMPHIS INCIDENT AND COMMENTED DURING HIS PRESENTATION ON NWA'S EFFORTS IN THE AREA OF TRAINING THAT THIS ANNUAL, NEW TRAINING VEHICLE WAS UNIQUE AMONG THE AIRLINE DG TRAINING PROGRAMS HE HAS REVIEWED.
NWA IS CURRENTLY PRODUCING THE DG VIDEO TRAINING TAPE FOR YEAR 2001 RECURRENT DG TRAINING AND IS FEATURING THE MEMPHIS INCIDENT AGAIN, IN LIGHT OF THE NTSB'S SUMMARY OF ITS FINDINGS IN ITS INVESTIGATION, WITH SPECIFIC FOCUS ON THE FINDINGS RECOMMENDED BY THE NTSB. THIS VIDEO WILL BE SHOWN TO ALL AFFECTED OPERATING EMPLOYEES INCLUDING PILOTS AND GROUND EMPLOYEES. WE BELIEVE THE ACTIONS THAT NWA HAS TAKEN AND IS TAKING ADDRESSES FULLY THE RECOMMENDATIONS THAT THE NTSB HAS MADE. NWA APPRECIATED THE COOPERATION AND PROACTIVE APPROACH UNDERTAKEN BY THE NTSB FOLLOWING THIS EVENT. NWA IS COMMITTED TO WORKING CONSTRUCTIVELY WITH THE NTSB TO IMPROVE THE SAFETY OF THE AIR TRANSPORT SYSTEM.
IF THE NTSB HAS FURTHER QUESTIONS OR COMMENTS REGARDING THIS EVENT, PLEASE CONTACT MY OFFICE.