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NTSB · Safety Recommendation

Safety Recommendation A-88-127

Recommendation

THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: CONSIDER THE EFFECTS OF AUTHORIZED HAZARDOUS MATERIALS CARGO IN FIRES FOR ALL TYPES OF CARGO COMPARTMENTS, AND REQUIRE APPROPRIATE SAFETY SYSTEMS TO PROTECT THE AIRCRAFT AND OCCUPANTS.

Safety Issue and Context

ON FEBRUARY 3, 1988, AMERICAN AIRLINES FLIGHT 132, A MCDONNELL DOUGLAS DC-9-83, DEPARTED DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS, FOR NASHVILLE METROPOLITAN AIRPORT, TENNESSEE. IN ADDITION TO THE PASSENGER LUGGAGE IN THE MIDCARGO COMPARTMENT, FLIGHT 132 WAS LOADED WITH A 104 POUND FIBER DRUM OF TEXTILE TREATMENT CHEMICALS. UNDECLARED AND IMPROPERLY PACKAGED HAZARDOUS MATERIALS INSIDE THE FIBER DRUM INCLUDED 5 GALLONS OF HYDROGEN PEROXIDE SOLUTION AND 25 POUNDS OF A SODIUM ORTHOSILICATE-BASED MIXTURE. WHILE IN FLIGHT, A FLIGHT ATTENDANT AND A DEADHEADING FIRST OFFICER NOTIFIED THE COCKPIT CREW OF SMOKE IN THE PASSENGER CABIN.

THE PASSENGER CABIN FLOOR ABOVE THE CARGO COMPARTMENT WAS HOT AND SOFT, AND THE FLIGHT ATTENDANTS HAD TO MOVE PASSENGERS FROM THE AFFECTED AREA. THE CAPTAIN, WHO WAS AWARE OF A MECHANICAL DISCREPANCY WITH THE AUXILIARY POWER UNIT (APU) ON AN EARLIER FLIGHT WHICH RESULTED IN IN-FLIGHT FUMES, WAS SKEPTICAL ABOUT THE FLIGHT ATTENDANT'S REPORT OF SMOKE. NO IN-FLIGHT EMERGENCY WAS DECLARED. AFTER LANDING, THE CAPTAIN NOTIFIED NASHVILLE GROUND CONTROL ABOUT THE POSSIBILITY OF FIRE IN THE CARGO COMPARTMENT, AND HE REQUESTED FIRE EQUIPMENT. THE FLIGHT ATTENDANTS THEN INITIATED PROCEDURES TO EVACUATE THE AIRPLANE ON THE TAXIWAY.

ABOUT 2 MINUTES 8 SECONDS AFTER THE PLANE LANDED, THE 120 PASSENGERS AND 6 CREWMEMBERS BEGAN EVACUATING THE AIRPLANE. AFTER THE PLANE WAS EVACUATED, CRASH/FIRE/RESCUE PERSONNEL EXTINGUISHED THE FIRE IN THE CARGO COMPARTMENT.

Response History

October 17, 1997 · NTSB Correspondence · FAA

Notation 6818A: The National Transportation Safety Board has reviewed your Supplemental Notice of Proposed Rulemaking (NPRM), Docket No. HM-224A, Prohibition of Oxidizers Aboard Aircraft, published on August 20, 1997. The supplemental notice proposes to prohibit oxidizers in other than class D compartments on passenger-carrying aircraft, provides a proposed list of all oxidizing substances to be prohibited, proposes exceptions that would permit an aircraft operator to transport cylinders containing compressed oxygen in the passenger cabin, and proposes prohibiting spent chemical oxygen generators on both passenger-carrying and cargo aircraft.

As a result of its investigation of a February 3, 1988, in-flight fire involving an oxidizer on American Airlines flight 132, the Safety Board determined that hazardous materials involvement in a cargo compartment fire must be considered in all cargo compartment fire penetration safety standards and that hazardous materials deemed to present unacceptable threats should be prohibited. Further, the Board urged the FAA to consider the effects of authorized hazardous materials cargo in fires for all types of cargo compartments and to require appropriate safety systems to protect the aircraft and occupants (Safety Recommendation A-88-127).

On March 17, 1994, after the FAA failed to take any positive action, Safety Recommendation A-88-127 was classified "Closed-Unacceptable Action."

The Safety Board continues to believe that RSPA and the FAA need to evaluate the effects of authorized hazardous materials in fires in cargo compartments. In comments on a December 30, 1996, NPRM, the Board supported a study initiated by the Research and Special Programs Administration (RSPA), in coordination with the FAA, to assess the risks associated with the transportation of hazardous materials in aircraft cargo compartments. The Safety Board urges RSPA and the FAA to complete this study and to ban any hazardous materials, including oxidizers, that cannot be safely transported in aircraft cargo compartments.

September 11, 1997 · NTSB Correspondence · FAA

Read Recommendation

Recommendation Facts

Status
Closed - Unacceptable Action
Issued
October 24, 1988
Priority
CLASS II
Recipient
FAA
Adopted
March 29, 1988
Closed
March 17, 1994
Related Investigation
DCA88MZ002
Related Report
HZM-88-02
Notation 6901: The National Transportation Safety Board has reviewed the Federal Aviation Administration's (FAA's) Notice of Proposed Rulemaking (NPRM), "Revised Standards for Cargo or Baggage Compartments in Transport Category Aircraft," Docket No. 28937, Notice No. 97-10, which was published at 62 Federal Register 32411 on June 13, 1997. The notice proposes to upgrade the fire safety standards for cargo and baggage compartments in certain transport category aircraft by eliminating class D compartments as an option for future type certification. Compartments that could no longer be designated as class D would have to meet the standards for class C or class E compartments.

Class D compartments on aircraft manufactured under existing type certificates and used in passenger service would have to meet the fire detection and suppression standards for class C compartments by early 2001 for use in air carrier, commuter, on-demand, or most other commercial service. The class D compartments in certain transport category aircraft manufactured under existing type certificates and used only for the carriage of cargo would have to meet such standards for class E compartments by that same date. The purpose of these changes is to increase protection from possible in-flight fires.

As long ago as 1981 with Safety Recommendations A-81-12 and -13, the Safety Board expressed concern about the adequacy of class D compartments, which are not required to be equipped with fire detection or suppression systems, but are designed to contain fire damage by the use of flame-resistant compartment liners and to control a fire by limiting the oxygen available to support combustion. On October 9, 1984, the Safety Board commented on an NPRM (Notice 84-11, dated August 8, 1984) that proposed a new testing method for determining the flame penetration resistance of compartment liners.

In its comments, the Safety Board advised the FAA that, although the proposed flame penetration tests were more stringent than previous ones, a fire should not be allowed to persist in any state of intensity in an airplane without the flightcrew's knowledge. The Board further stated that a fire detection system should be required in class D cargo compartments. While the final rule issued on May 16, 1986, required improved flame penetration resistance for compartment liners, it did not require fire detection systems.

On October 24, 1988, as a result of a February 3, 1988, in-flight fire involving a hydrogen peroxide solution (an oxidizer) aboard an American Airlines DC-9-83 (flight 132) en route to Nashville Metropolitan Airport, Nashville, Tennessee, the Safety Board recommended that the FAA require fire/smoke detection systems and a fire extinguishment system for all class D cargo compartments (Safety Recommendations A-88-122 and -123). The Board also recommended that the FAA consider the effects of authorized hazardous materials in fires for all types of cargo compartments and require appropriate safety systems to protect the aircraft and occupants (Safety Recommendation A-88-127).

On August 10, 1993, the FAA responded by stating that it did not believe that fire/smoke detection and fire extinguishment systems would provide a significant degree of protection to airplane occupants and that it had terminated its rulemaking action to require such systems. On October 14, 1993, Safety Recommendations A-88-122 and -123 were classified "Closed-Unacceptable Action." Safety Recommendation A-88-127 was classified "Closed-Unacceptable Action" on March 17, 1994, after the FAA failed to take any positive action.

The Safety Board concluded from its investigation of the in-flight fire and crash of a ValuJet Airlines DC-9-32 (flight 592) on May 11, 1996, that the activation of one or more chemical oxygen generators in the forward cargo compartment, a class D compartment, initiated the fire; that a smoke/fire warning device would have more quickly alerted the crew to the fire and may have allowed more time to land the aircraft; and that a fire suppression system may have delayed the spread of fire and, in conjunction with an early warning, would likely have provided time for the crew to land the aircraft safely.

The Safety Board also concluded that had the FAA required fire/smoke detection and/or fire extinguishment systems in class D cargo compartments, as the Safety Board recommended in 1988, ValuJet flight 592 likely would not have crashed.

The ValuJet accident prompted the Air Transport Association of America (ATA) to announce with Vice President Gore in December 1996 that its members would voluntarily retrofit existing class D cargo compartments with smoke detectors. As of the date of this letter, with the exception of one aircraft that has been retrofitted by Delta Air Lines, the Safety Board is unaware that any other aircraft in scheduled passenger service have been modified.

The Safety Board strongly supports the FAA's proposal to convert class D cargo compartments to class C compartments on passenger aircraft and to convert class D cargo compartments to class E compartments on cargo aircraft. However, more than 1 year after the ValuJet crash and 9 years after the American Airlines accident at Nashville, the class D cargo compartments on most passenger aircraft still lack fire/smoke detection or suppression equipment, and no requirement for such equipment is in place. The Safety Board believes that the FAA should expedite final rulemaking to require smoke detection and fire suppression systems for all class D cargo compartments.

Although the NPRM discusses the potential hazards from aerosol cans that use a mixture of propane, butane, and isobutane as propellants, the effect of fires initiated from other chemical sources still is not being addressed. The in-flight fires in the American Airlines and the ValuJet accidents were caused by the reaction of oxidizing materials that generate heat and liberate oxygen. In both accidents, the design features of the class D compartment (the flame-resistant capabilities of the compartment liners and the restriction of the air supply to the compartment) were not sufficient to control the fire or prevent flames from penetrating beyond the compartment.

The Safety Board will provide comments on this issue in its letter on the Research and Special Programs Administration NPRM "Prohibition of Oxidizers Aboard Aircraft," Docket HM-224A, issued on August 20, 1997.

The Safety Board appreciates the opportunity to comment on this NPRM.

February 28, 1997 · NTSB Correspondence · FAA

Notation 6818: The National Transportation Safety Board has reviewed your Notice of Proposed Rulemaking (NPRM), Docket No. HM-224A, Prohibition of Oxidizers Aboard Aircraft, published on December 30, 1996. The notice proposes prohibiting the carriage of oxidizers, including compressed oxygen, in Class D compartments of passenger-carrying and cargo aircraft.

The notice further proposes eliminating an exception for the transportation of personal chemical oxygen generators as checked baggage, creating a shipping name that specifically identifies chemical oxygen generators, requiring special approval for chemical oxygen generators, and initiating a study to assess the risks associated with the transportation of hazardous materials, other than oxidizers, in aircraft cargo compartments.

The Safety Board has expressed concern about the inadequacies of Class D cargo compartments for some time. On August 8, 1984, the Federal Aviation Administration (FAA) issued a notice of proposed rulemaking, Notice 84-11, that addressed the problem of fire containment in cargo compartments by specifying a new test method for determining the flame penetration resistance of compartment liners.

When the Safety Board provided comments on this rulemaking on October 9, 1984, it advised the FAA that although proposed flame penetration tests were more stringent than previous ones, a fire should not be allowed to persist in any state of intensity in an airplane without the flight crew's knowledge, and that a fire detection system should be required in Class D cargo compartments. While the final rule issued on May 16, 1986, required improved flame penetration resistance for compartment liners, it did not require fire detection systems.

On October 24, 1988, as a result of a February 3, 1988, in-flight tire involving a hydrogen peroxide solution (an oxidizer) aboard an American Airlines DC-9-83 (flight 132) en route to Nashville Metropolitan Airport, Nashville, Tennessee, the Safety Board issued Safety Recommendation A-88-122, which urged the FAA to require fire/smoke detection systems for all Class D cargo compartments. The Safety Board stated that because the cargo compartment on flight 132 was not equipped with fire or smoke dctection systems, the cockpit crew had no way of detecting the safety threat to the airplane until smoke and fumes reached the passenger cabin.

Further, after the smoke was detected in the passenger cabin, the cockpit crew had no means of identifying the fire's location. On August 10, 1993, the FAA responded to Safety Recommendation A-88-l22 by stating that it did not believe that fire/smoke detection and fire extinguishment systems would provide a significant degree of protection to airplane occupants and that it had terminated its rulemaking action to require such systems. On October 14, 1993, Safety Recommendation A-88-122 was classified "Closed--Unacceptable Action."

The Safety Board has investigated at least two other incidents where oxidizers or oxidizing materials, transported as cargo, were believed to have started in-flight fires. One inflight fire occurred aboard a Pan American World Airways Boeing 707-32lC after nitric acid (a corrosive and oxidizing material) leaked from a shipment. Smoke filled the cockpit and the plane crashed on approach to Logan International Airport, Boston, Massachusetts, on November 3, 1973. In the other incident, an in-flight fire occurred on July 16, 1986, aboard a Federal Express Boeing 727-1 OOA after nitric acid leaked. When smoke was detected, the aircraft diverted and landed safely in Cincinnati, Ohio.

On May 31, 1996, Safety Recommendations A-96-28 and -30 were issued as a result of the Safety Board's investigation of the accident involving an in-flight fire on ValuJet flight 592 in the Everglades near Miami, Florida, on May 11, 1996. Preliminary evidence indicated that five cardboard boxes of chemical oxygen generators, most with unexpended oxidizer cores, were loaded on this aircraft in a Class D cargo compartment.

The parallel recommendations urged the Research and Special Programs Administration (RSPA) and the Federal Aviation Administration (FAA) to permanently prohibit the transportation of oxidizers and oxidizing materials (for example, nitric acid) in cargo compartments that do not have fire or smoke detection systems. RSPA and the FAA agreed with these recommendations and on August 19, 1996, Safety Recommendations A-96-28 and -30 were classified "Open--Acceptable Response" pending completion of a final rule.

Class D cargo compartments have not been required to have smoke and fire detection systems because they were designed to contain fire damage by use of flame-resistant compartment liners and to suppress a fire involving combustibles by limiting the oxygen available to support combustion. Oxidizers and certain other hazardous materials, however, can neutralize the latter design safeguard by generating their own oxygen. A leaking cylinder filled with compressed oxygen could also provide an oxygen source for a fire. Further, the pressure relief device on a cylinder of compressed oxygen can open when exposed to sufficient heat from a fire.

The Safety Board supports prohibiting the carriage of oxidizers, including compressed oxygen, in Class D compartments in passenger-carrying and cargo aircraft because these compartments do not have smoke and fire detection systems and because oxidizers, including compressed oxygen, can provide a source of oxygen that will neutralize the compartment's design feature to suppress a fire by limiting the oxygen available to support combustion.

The NPRM also proposes eliminating the exception provided for personal oxygen generators that meet the conditions of Title 49 Code of Federal Regulations (CFR) Section 175.1 0(a)(24) to be carried on aircraft as checked baggage. Like the chemical oxygen generators installed in aircraft, these personal oxygen generators contain oxidizers that, when actuated, produce oxygen. This exception currently permits placement of oxidizers in cargo compartments that do not have fire or smoke detection systems and that are designed to suppress a fire by limiting the oxygen available to support combustion. Therefore, the Safety Board supports eliminating this exception.

The Safety Board is concerned that the rulemaking does not include the prohibition of the limited quantities of oxidizers that are shipped as consumer commodities. l For example, section 173.152 allows the shipment of inner packages that contain over 2 Y:, times the net quantity of sodium chlorate contained in each of the chemical oxygen generators that were loaded on ValuJet flight 592, provided they meet the definition of a consumer commodity. Section 172.101 permits loading a gross weight of 30 kilograms per package of consumer commodities in both passenger and cargo aircraft.

Further, the consumer commodity exception allows these materials to be shipped without an oxidizer label on the package to warn air carrier personnel that the package contains an oxidizer. This exception currently permits the placement of oxidizers in cargo compartments that do not have fire or smoke detection systems and are designed to suppress a fire by limiting the oxygen available to support combustion. The Safety Board therefore believes that the consumer commodity exception for oxidizers should also be eliminated.

RSPA proposes the creation of a new shipping description for chemical oxygen generators that more accurately describes the generators. The current shipping name used for the generators, "Oxidizing solid, N.O.S.," does not address the explosives contained in many types of actuators or the hazards posed by a device capable of initiating and sustaining a reaction that generates both heat and oxygen. The Safety Board supports development of a specific shipping description for chemical oxygen generators that more accurately describes the product shipped and its hazard char

March 17, 1994 · NTSB Correspondence · FAA

TO DATE, WE HAVE NOT RECEIVED A RESPONSE. APPARENTLY, THE FAA HAS TAKEN NO POSITIVE ACTION ON THIS RECOMMENDATION SINCE IT WAS ISSUED ON OCTOBER 24, 1988. THEREFORE, WE HAVE CLASSIFIED RECOMMENDATION A-88-127 "CLOSED--UNACCEPTABLE ACTION."

April 19, 1993 · NTSB Correspondence · FAA

OUR RECORDS SHOW THAT WE HAVE NOT RECEIVED ANY FURTHER RESPONSE FROM THE FAA REGARDING THESE RECOMMENDATIONS. WE WOULD APPRECIATE BEING INFORMED ABOUT EFFORTS THAT HAVE BEEN OR ARE BEING MADE TO IMPLEMENT THESE RECOMMENDATIONS.

July 20, 1990 · NTSB Correspondence · FAA

Safety Recommendation A-88-127 asks the FAA to consider the effects of authorized hazardous materials in fires for all types of cargo compartments and to require appropriate safety measures to protect the aircraft and its occupants. The Safety Board noted on page 27 of the Nashville accident report (NTSB/HZM-88/02) that the FAA did not consider the effects of hazardous materials in the fire safety standards that became effective June 16, 1986. To assert that a problem does not exist, simply because there is not a history of problems, is inappropriate. The Safety Board believes that authorized hazardous materials must be considered in cargo compartment emergency preparations.

Although the FAA has improved the capabilities of cargo compartments to withstand extreme heat, which is applicable to Safety Recommendation A-88-125, this improvement does not apply to the intent of Safety Recommendation A-88-127. The FAA has not shown that consideration has been given to amounts of allowable hazardous materials, or that compartment evaluations have empirically demonstrated that the safety systems proposed would maintain compartment integrity. We will hold Safety Recommendation A-88-127 in an "Open--Unacceptable Action" status pending our review of any FAA regulatory activity on this issue.

January 5, 1989 · Recipient Response · FAA

THE FAA IS CONSIDERING THE ISSUANCE OF A NOTICE OF PROPOSED RULEMAKING (NPRM) PROPOSING TO AMEND 14 CFR PARTS 25, 121, AND 135 TO REQUIRE FIRE AND SMOKE DETECTION SYSTEMS AND A FIRE EXTINGUISHING SYSTEM FOR ALL CLASS D CARGO COMPARTMENTS THAT ARE MORE THAN 200 CUBIC FEET IN VOLUME. THE FAA BELIEVES THAT THE CURRENT REQUIREMENTS OF 14 CFR PART 25, COMBINED WITH THE RECENTLY AMENDED CARGO COMPARTMENT LINER AND CARGO CONTAINER REQUIREMENTS OF 14 CFR 25.855, PROVIDE AN ACCEPTABLE LEVEL OF SAFETY FOR CARGO COMPARTMENTS OF 200 CUBIC FEET OR LESS IN VOLUME.

ADDITIONALLY, THE FAA HAS REVIEWED ALL OF THE COMMENTS TO NOTICE 87-11 WHICH PROPOSES TO MAKE THE RECENT CHANGES TO 14 CFR 25.855 APPLICABLE TO 14 CFR PARTS 121 AND 135. SERVICE INCIDENTS OF FIRE INVOLVING AUTHORIZED AND PROPERLY PACKAGED HAZARDOUS MATERIALS DO NOT INDICATE THAT COMPLIANCE WITH THIS SAFETY RECOMMENDATION IS AS CRITICAL AS THE FAA'S ONGOING FIRE SAFETY EFFORTS. THE FAA'S ACTION IN RESPONSE TO THIS SAFETY RECOMMENDATION WOULD DEPEND ON THE FIRE PROTECTION CAPABILITIES OF THE CARGO COMPARTMENTS. THE FAA WILL RESPOND TO THE ISSUES OF THIS SAFETY RECOMMENDATION AS SOON AS A DETERMINATION HAS BEEN MADE REGARDING THE ISSUANCE OF ANY REGULATORY DOCUMENT.