NTSB · Safety Recommendation
Safety Recommendation A-90-093
Recommendation
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: PROHIBIT AIR CARRIERS FROM SERVICING OXYGEN SYSTEMS WHILE PASSENGERS ARE ON THE AIRCRAFT.
Safety Issue and Context
ON OCTOBER 14,1989, ABOUT 1411 MOUNTAIN DAYLIGHT TIME, A FIRE ERUPTED ON N530DA, A BOEING 727-232 THAT HAD BEEN PARKED AT GATE C4 AT SALT LAKE CITY INTERNATIONAL AIRPORT (SLC), SALT LAKE CITY, UTAH. THE AIRPLANE HAD BEEN OPERATED UNDER TITLE 14 CODE OF FERDERA REGULATIONS (CFR) PART 121 AS DELTA AIR LINES FLIGHT 1558, A SCHEDULED INTERNATIONAL REVENUE PASSENGER FLIGHT FROM LOS ANGELES, CALIFORNIA, TO EDMONTON, ALBERTA, CANADA, WITH A STOP AT SLG. THREE FLIGHT CREWMEMBERS, 4 FLIGHT ATTENDANTS AND 12 THROUGH PASSENGERS WHO HAD BOARDED AT LOS ANGELES WERE ON BOARD THE AIRPLANE WHEN THE FIRE ERUPTED.
THE SECOND OFFICER WAS SEATED AT THE FLIGHT ENGINEER'S CONSOLE WHILE THE CAPTAIN AND FIRST OFFICER, WHO HAD JUST ENTERED THE AIR PLANE, WERE STANDING JUST FORWARD OF THE ENTRANCE TO THE COCKPIT. A DELTA AIR LINES MECHANIC WAS IN THE ELECTRICAL EQUIPMENT (EE) COMPARTMENT BELOW THE CABIN SERVICING THE PASSENGER OXYGEN SYSTEM.
Response History
March 4, 1993 · NTSB Correspondence · FAA
THE BOARD NOTES THAT THE FAA BELIEVES THAT THIS RECOMMENDATION CAN BEST BE ADDRESSED BY PROVIDING POLICY GUIDANCE REGARDING THE SERVICING & MAINTAINING OF AIR CARRIER OXYGEN SYSTEMS WHILE PASSENGERS ARE ON BOARD. MOREOVER, THE FAA HAS ISSUED NOTICE 8300.85, SERVICING & MAINTAINING OXYGEN SYSTEMS ON AIR CARRIER AIRCRAFT WHILE PASSENGERS ARE ABOARD, WHICH STATES THAT DIRECT BOTTLE-TO-BOTTLE SERVICING MUST BE PROHIBITED. THE BOARD FURTHER NOTES THAT THE NOTICE ALLOWS OXYGEN SERVICING UTILIZING AIRCRAFT EXTERIOR SERVICING PANELS, UNDER A CONTROLLED & ADEQUATE SERVICING & MAINTENANCE PROGRAM, & ADDRESSES THE OPERATOR'S MAINTENANCE PROGRAM FOR OXYGEN SYSTEMS & INSPECTION INTERVALS.
BASED ON THIS INFO, RECOMMENDATION A-90-93 IS CLASSIFIED "CLOSED--ACCEPTABLE ALTERNATE ACTION."
August 17, 1992 · Recipient Response · FAA
THE FAA DISAGREE WITH THE RECOMMENDATION FOR REGULATORY ACTION FOR A BLANKET PROHIBITION FROM SERVICING OXYGEN SYSTEMS WHILE PASSENGERS ARE ON AIR CARRIER AIRCRAFT. HOWEVER, THE FAA BELIEVES THAT THERE IS A NEED TO PROVIDE POLICY GUIDANCE REGARDING THE SERVICING AND MAINTAINING OF AIR CARRIER OXYGEN SYSTEMS WHILE PASSENGERS ARE ON BOARD. AS A RESULT, THE FAA ISSUED NOTICE 8300.85 SERVICING AND MAINTAINING OXYGEN SYSTEMS ON AIR CARRIER AIRCRAFT WHILE PASSENGERS ARE ABOARD. THE NOTICE STATES THAT DIRECT BOTTLE-TO-BOTTLE SERVICING OF AIRCRAFT OXYGEN SYSTEMS WHILE PASSENGERS ARE ON BOARD MUST BE PROHIBITED.
HOWEVER, OXYGEN SERVICING UTILIZING AIRCRAFT EXTERIOR SERVICING PANELS, UNDER A CONTROLLED AND ADEQUATE SERVICING AND MAINTENANCE PROGRAM, IS NOT PROHIBITED. THE NOTICE ALSO ADDRESSES THE OPERATOR'S MAINTENANCE PROGRAM FOR OXYGEN SYSTEMS AND INSPECTION INTERVALS. AFTER THE NOTICE WAS ISSUED, THE FAA SURVEYED INDUSTRY TO DETERMINE HOW INDIVIDUAL AIRLINES WERE COMPLYING WITH THE GUIDANCE. NO ADVERSE CONDITIONS OR PRACTICES WERE NOTED DURING THE SURVEY. MOREOVER, BY INSTITUTING THE PROCEDURES DETAILED IN NOTICE 8300.85 UNDER THE PURVIEW OF 14 CFR 121.135(B)(24), THE FAA HAS ACCOMPLISHED THE INTENT SPECIFIC RULEMAKING ACTION AS RECOMMENDED BY SAFETY RECOMMENDATION A-90-30.
February 21, 1991 · NTSB Correspondence · FAA
Safety Recommendation A-90-93 states that the FAA should prohibit air carriers from servicing oxygen systems while passengers are on the aircraft. The Safety Board is pleased that the FAA recognizes the hazards associated with servicing air carrier oxygen systems while passengers are on board the aircraft. However, the Safety Board is concerned that the FAA's proposal to issue a notice to principal maintenance inspectors (PMI) that they advise operators that this practice must be prohibited may not provide the desired level of assurance that all operators will comply.
Thus, the Safety Board believes that the FAA should follow the proposed action with an amendment to the Federal Aviation Regulations to prohibit the servicing of oxygen with passengers on board. Pending further consideration by the FAA, Safety Recommendation A-90-93 is classified "Open--Acceptable Response."
November 21, 1990 · NTSB Correspondence · FAA
The Safety Board notes that the FAA is reviewing Safety Recommendations A-90-93 through -96 and A-90-98 and -99 and that it will apprise the Safety Board of its course of action. We will hold these safety recommendations in an "Open--Await Response" status.
October 15, 1990 · Recipient Response · FAA
SERVICING OXYGEN SYSTEMS FROM TANK TO TANK WHILE PASSENGERS ARE ON BOARD THE AIRCRAFT IS NOT AN ACCEPTED PRACTICE. THE FAA WILL REQUEST PMI'S TO ADVISE APPROPRIATE OPERATORS THAT THIS MUST BE PROHIBITED. THE NOTICE WILL ALSO ADDRESS MAINTENANCE PROCEDURES FOR REPLACING OXYGEN BOTTLES. I BELIEVE THAT THE FAA'S ACTION MEETS THE INTENT.
September 6, 1990 · Recipient Response · FAA
"THE FAA IS IN THE PROCESS OF REVIEWING THESE SAFETY RECOMMENDATIONS. I WILL APPRISE THE BOARD OF THE FAA'S COURSE OF ACTION TO ADDRESS EACH OF THESE SAFETY RECOMMENDATIONS AS SOON AS THE REVIEW IS COMPLETED."