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  3. NTSB A-07-099
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NTSB · Safety Recommendation

Safety Recommendation A-07-099

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Require that fire suppression systems be installed in the cargo compartments of all cargo airplanes operating under 14 Code of Federal Regulations Part 121.

Safety Issue and Context

On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and most of the cargo were destroyed by fire after landing. The scheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan.

Night visual conditions prevailed at the time of the accident.

Response History

April 27, 2011 · NTSB Correspondence · FAA

The FAA indicated that the benefits of Halon compartment fire suppression systems, or alternative systems, do not justify the cost of installing such systems in the main deck cargo compartments of cargo aircraft of any weight category. The NTSB is disappointed that, although the FAA requires passenger aircraft to have fire suppression systems installed in their cargo compartments, it has not instituted a similar requirement for cargo airplanes. Because the FAA has indicated that it has completed its actions in response to this recommendation, however, Safety Recommendation A-07-99 is classified CLOSED – UNACCEPTABLE ACTION.

September 6, 2010 · Recipient Response · FAA

CC# 201000359: - From J. Randolph Babbitt, Administrator: The FAA arranged for a cost-benefit analysis for the installation of on-board fire detection and extinguishment systems in all-cargo airplanes. In April 2009, we published results of the analysis in report DOT/FAAIAR-09/17, A Cost-Benefit Analysis for the Installation of Fire Suppression Systems in Cargo Compartments of Cargo Airplanes (enclosure 2).

The results show that benefits of Halon (a bromotrifluorocarbon fire suppressant manufactured by DuPont) compartment flooding fire suppression systems, or alternative compartment flooding systems likely to be developed for below-floor cargo compartments, do not justify the cost for the main deck cargo compartments of cargo aircraft of any weight category. After careful consideration of this analysis, we have decided not to pursue additional rulemaking at this time. However, the FAA continues to support efforts to improve fire protection on all-cargo airplanes.

For example, we continue to work with industry and other government agencies in evaluating the use of new, non-Halon fire extinguishing agents; directed fire suppression systems that apply agent to individual cargo containers or specific cargo compartment zones; new fire inerting systems utilizing nitrogen or water mist; and advanced cargo containers that incorporate smoke detection, fire containment, and fire suppression systems. Should research produce a viable option, we will consider further action.

April 14, 2010 · NTSB Correspondence · FAA

Notation 7772F: The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) notice of proposed rulemaking (NPRM), “Hazardous Materials: Transportation of Lithium Batteries,” that was published at 75 Federal Register 1302 on January 11, 2010. The NPRM requests comments on revisions to the requirements for the transportation of lithium batteries in the Hazardous Materials Regulations (HMRs). The primary purpose of the NPRM is to enhance the safe transportation of primary (non-rechargeable) and secondary (rechargeable) lithium batteries when transported as cargo in all modes, with an emphasis on aviation.

The NTSB believes that PHMSA has proposed requirements that should improve the level of safety for transporting lithium battery cargoes, particularly on aircraft. However, the NTSB offers the following comments to strengthen and clarify the proposed rule. Overview The NPRM proposes new requirements that address Safety Recommendations A-07-104, A-07-105, and A-07-107 through -109 that were issued as a result of the NTSB’s 2006 investigation of an in-flight cargo fire on a cargo airplane at Philadelphia International Airport in Philadelphia, Pennsylvania.

The NPRM specifically addresses these safety recommendations through proposed requirements concerning the stowage of lithium batteries, the reporting and analysis of lithium battery failures, and the elimination of regulatory exceptions for small lithium batteries. The NTSB has included detailed comments about each of these areas in subsequent sections of this letter. The NTSB notes that PHMSA also proposes other requirements, and those are addressed as well. The NPRM does not address Safety Recommendations A-08-1 and -2, which were issued separately from the Philadelphia accident report but also pertain to the transportation of lithium batteries.

Safety Recommendations A-08-1 and -2 concern the implementation and evaluation of public awareness programs for air passengers and crews who carry portable electronic devices containing lithium batteries or pack spare lithium batteries in their baggage or carry-on items. The NTSB notes that PHMSA plans to address these two recommendations under a separate rulemaking. However, because of the proliferation of personal electronic devices carried by the traveling public, the NTSB urges PHMSA to expedite its rulemaking regarding these recommendations. Stowage of Lithium Batteries

Cargo shipments of primary lithium batteries have been prohibited on passenger aircraft for more than 10 years, but they are still permitted on cargo-only aircraft. Cargo shipments of secondary lithium batteries are permitted on both passenger and cargo-only aircraft. The transportation of primary lithium batteries is potentially dangerous, particularly on board aircraft, because there is currently no known fire suppression system capable of extinguishing fires involving these types of batteries. Fires involving secondary lithium batteries are extinguishable by fire suppression systems approved by the Federal Aviation Administration (FAA).

February 4, 2009 · NTSB Correspondence · FAA

The FAA stated that it would review the guidance on Class E cargo-compartment fire protection and operators’ procedures for cargo-compartment fire containment to determine the effectiveness of the fire protection systems. The FAA will also review the service history of Class E cargo compartments and evaluate requiring the installation of fire suppression systems in Class E compartments.

The Safety Board recognizes that the actions described are the first steps that the FAA needs to take to implement the recommended regulatory change. Pending the establishment of a requirement that all cargo compartments of all cargo aircraft be equipped with fire suppression systems, Safety Recommendation A-97-99 is classified OPEN -- ACCEPTABLE RESPONSE.

September 8, 2008 · Recipient Response · FAA

Letter Mail Controlled 9/18/2008 12:11:57 PM MC# 2080573: - From Robert A. Sturgell, Acting Administrator: We understand this recommendation refers to installation of fire suppression systems in previously approved Class E cargo compartments. We will review the guidance on Class E cargo compartment fire protection and operators’ cargo compartment fire containment procedures to determine the effectiveness of the fire protection relative to compartments which require fire suppression systems. In addition, we will review the service history of Class E cargo compartments and evaluate the safety benefits, costs, and operational impact of requiring the installation of fire suppression systems.

I will provide a status update by January 2009. I will keep the Board informed of the FAA’s progress on this safety recommendation.

Read Recommendation

Recommendation Facts

Status
Closed - Unacceptable Action
Issued
December 17, 2007
Priority
CLASS II
Recipient
FAA
Adopted
December 4, 2007
Closed
April 27, 2011
Related Investigation
DCA06MA022
Related Report
AAR-07-07

Although fire suppression systems are required in cargo compartments of passenger aircraft, they are not required in cargo-only aircraft. The investigation of the Philadelphia accident showed that flight crews on cargo-only aircraft remain at risk from in-flight fires involving primary lithium batteries and from fires involving secondary lithium batteries on aircraft not equipped with fire suppression systems. Consequently, the NTSB issued the following recommendations to PHMSA:

Require aircraft operators to implement measures to reduce the risk of primary lithium batteries becoming involved in fires on cargo-only aircraft, such as transporting such batteries in fire resistant containers and/or in restricted quantities at any single location on the aircraft. (A-07-104) Until fire suppression systems are required on cargo-only aircraft, as asked for in Safety Recommendation A-07-99, require that cargo shipments of secondary lithium batteries, including those contained in or packed with equipment, be transported in crew-accessible locations where portable fire suppression systems can be used. (A-07-105)

The NTSB believes that the NPRM fully addresses Safety Recommendation A-07-105 but only partially addresses Safety Recommendation A-07-104. The proposed rule would require that if either primary or secondary lithium batteries are transported in inaccessible cargo compartments or freight containers, the compartments or containers must be equipped with an FAA-approved fire suppression system, or that the packages of batteries must be transported in an FAA-approved fire-resistant container.

Because current FAA-approved suppression systems are ineffective on fires involving primary lithium batteries, the NTSB believes that the NPRM would be improved if it explicitly required that shipments of primary lithium batteries be transported in FAA-approved fire-resistant containers. When the FAA approves a fire suppression system that is proven to be effective on fires involving primary lithium batteries, the NTSB would consider such a suppression system an acceptable alternative to an FAA-approved fire-resistant container.

Because current FAA-approved fire suppression systems are effective on fires involving secondary lithium batteries, the NTSB supports the NPRM in that it would require that inaccessible shipments of secondary lithium batteries be transported in either cargo compartments or freight containers equipped with an FAA-approved fire suppression system or in FAA-approved fire-resistant containers. PHMSA states in the NPRM that it is considering whether a limit on the number of primary lithium battery packages transported in a single airplane or single container would further enhance safety.

Although PHMSA acknowledges the cumulative effect and the potential risks of packaging thousands of small primary batteries in close proximity, it has not proposed any requirements to mitigate the risks. The NTSB believes that the NPRM would be improved if restrictions were imposed on the clustering of primary lithium battery shipments on cargo-only aircraft. Reporting and Analysis of Lithium Battery Failures In the Philadelphia accident report, the NTSB noted that the causes of secondary lithium battery failures are not well understood or documented.

The NTSB suggested that this may be due, in part, to the fact that proper evaluation of failed lithium batteries is not always performed, and that, in many cases, these batteries are disposed of before the incident is reported, precluding an accurate analysis of the failures. As a result, the NTSB issued the following recommendations to PHMSA:

Require commercial cargo and passenger operators to report to the Pipeline and Hazardous Materials Safety Administration all incidents involving primary and secondary lithium batteries, including those contained in or packed with equipment, that occur either on board or during loading or unloading operations and retain the failed items for evaluation purposes. (A-07-107)

Analyze the causes of all thermal failures and fires involving secondary and primary lithium batteries and, based on this analysis, take appropriate action to mitigate any risks determined to be posed by transporting secondary and primary lithium batteries, including those contained in or packed with equipment, on board cargo and passenger aircraft as cargo; checked baggage; or carry-on items. (A-07-108) On July 31, 2008, PHMSA published an NPRM to revise requirements for the transportation of battery-powered devices and batteries and to harmonize the U.S. Department of Transportation HMRs with international standards.

The NPRM included a proposal to require that all incidents involving lithium batteries and devices containing them be immediately reported. In a letter dated November 19, 2008, the NTSB suggested that the