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NTSB · Safety Recommendation

Safety Recommendation A-74-007

Recommendation

REQUIRE ALL OPERATORS OF AIRCRAFT WHICH CONTAIN INDIVIDUAL CHEMICAL OXYGEN-GENERATING UNITS TO INSPECT THESE INSTALLATIONS TO ENSURE THAT CANISTERS ARE CORRECTLY INSTALLED IN THE MOUNTS AND THAT APPROVED PACKING PROCEDURES HAVE BEEN FOLLOWED FOR THE SUPPLY HOSES AND OXYGEN MASKS.

Safety Issue and Context

The National Transportation Safety Board 1 s continuing investigation of the National .Airlines DC-10 accident near Albuquerque, New Mexico, on November 3, 1973, has disclosed unsafe conditions in the passenger oxygen system, portable oxygen system, and cabin pressurization system. The Board believes that these unsafe conditions merit your immediate attention and the attentions of all air carriers which operate aircraft with this equipment.

When the aircraft lost a cabin window and the passenger cabin decompressed, many of the passenger's oxygen-generating units were activated. Three oxygen canisters came out of their mountings in the seatback oxygen compartment and fell onto passenger seat cushions. Two of these canisters, which become very hot when operating, scorched the cushions and burned fingers when seat occupants tried to remove them. The third reportedly caused a small fire. The canisters came out of their mounting brackets because of the pulling force exerted on either the initiation lanyard of the canisters or the oxygen supply hose.

The Safety Board believes that these canisters constitute a potential fire and injury hazard when they are not retained properly in their mountings.

Response History

June 11, 1974 · NTSB Correspondence · FAA

Closed--acceptable action.

February 21, 1974 · Recipient Response · FAA

THE FAA IS ISSUING A MAINTENANCE BULLETIN WHICH WILL INSTRUCT PRINCIPAL INSPECTORS TO REVIEW THE AIR CARRIER OPERATORS' MAINTENANCE PROGRAMS TO DETERMINE THAT SUFFICIENT INSPECTIONS ARE SPECIFIED FOR THE OXYGEN GENERATING UNITS AND ASSOCIATED SUPPLY HOSES AND MASKS. PRINCIPAL INSPECTORS WILL REQUEST MORE FREQUENT INSPECTIONS IF NECESSARY.

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Recommendation Facts

Status
Closed - Acceptable Action
Issued
February 7, 1974
Priority
CLASS II
Recipient
FAA
Adopted
February 7, 1974
Closed
June 11, 1974
Related Investigation
DCA74AZ031
Related Report
AAR-75-02