NTSB · Safety Recommendation
Safety Recommendation A-97-064
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Require airplane manufacturers to amend company maintenance manuals for airplanes that use chemical oxygen generators to indicate that generators that have exceeded their service life should not be transported unless they have been actuated and their oxidizer core has been depleted.
Safety Issue and Context
On 5/11/96, about 1415 eastern daylight time, a McDonnell Douglas DC-9-32 crashed into the everglades swamp shortly after takeoff from Miami International Airport, Miami Florida, the airplane, N904VJ, was operated by ValuJet Airlines, Inc., as ValuJet flight 592. Both pilots, the three flight attendants, and all 105 passengers were killed. Before the accident, the flightcrew reported to air traffic control that it was experiencing smoke in the cabin and cockpit. Visual meteorological conditions existed in the Miami area at the time of the takeoff. The destination of the flight was Hartsfield International Airport, Atlanta, Georgia.
Flight 592 was on an instrument flight rules flight plan.
Response History
April 24, 2001 · NTSB Correspondence · FAA
THE FAA HAS COMPLETED THE ACTIONS RECOMMENDED IN A-97-64, WHICH IS NOW CLASSIFIED "CLOSED--ACCEPTABLE ACTION."
October 2, 2000 · Recipient Response · FAA
Letter Mail Controlled 10/04/2000 3:48:25 PM MC# 2001485 THE FAA DETERMINED THAT A MORE EFFECTIVE WAY TO ADDRESS THE RISK POSED BY OXYGEN GENERATORS WOULD BE TO BAN ALL CARRIAGE OF THESE PRODUCTS. THE FAA CONSIDERED ITS ACTION TO BE COMPLETED WITH THE FINAL RULE ISSUED BY THE RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION PROHIBITING THE TRANSPORTATION OF ALL CHEMICAL OXYGEN GENERATORS AS CARGO ON PASSENGER-CARRYING AIRCRAFT. ON 1/27/00, THE BOARD CLASSIFIED THIS RECOMMENDATION IN AN "OPEN ACCEPTABLE" STATUS. THE BOARD STATED THAT MAINTENANCE MANUALS SHOULD INDICATE THAT CHEMICAL OXYGEN GENERATORS SHOULD NOT BE TRANSPORTED AS CARGO ON PASSENGER-CARRYING AIRCRAFT.
THE BOARD ASKED THAT THE FAA INFORM IT OF THE RESULTS OF THE AIRCRAFT EVALUATION GROUP'S REVIEW OF THE MAINTENANCE MANUALS FOR AIRPLANES THAT USE CHEMICAL OXYGEN GENERATORS. THE FAA HAS VERIFIED THAT ALL APPLICABLE AIRCRAFT MANUFACTURERS HAVE AMENDED THEIR MAINTENANCE MANUALS FOR THOSE AIRCRAFT THAT USE CHEMICAL OXYGEN GENERATORS. THE MANUALS INCLUDE A WARNING NOTE THAT GENERATORS THAT HAVE EXCEEDED THEIR SERVICE LIFE SHOULD NOT BE TRANSPORTED UNLESS THEY HAVE BEEN ACTUATED AND THEIR OXIDIZER CORE HAS BEEN DEPLETED.
I HAVE ENCLOSED, FOR THE BOARD'S INFORMATION, COPIES OF THE LETTERS SENT TO THE MANUFACTURERS ASKING THAT THIS AMENDMENT BE ACCOMPLISHED AND A COPY OF THE MANUFACTURER'S RESPONSE INDICATING THAT THE AMENDMENT WAS COMPLETED. I CONSIDER THE FAA'S ACTION TO BE COMPLETED ON THIS RECOMMENDATION.
January 27, 2000 · NTSB Correspondence · FAA
THE SAFETY BOARD IS PLEASED THAT THE FAA AND RSPA HAVE TAKEN POSITIVE ACTIONS TO PROHIBIT THE TRANSPORTATION OF CHEMICAL OXYGEN GENERATORS AS CARGO ON PASSENGER-CARRYING AIRCRAFT. TO DATE THE SAFETY BOARD HAS NOT BEEN ADVISED OF THE RESULTS OF THE AEG'S REVIEW OF THE MAINTENANCE MANUALS. THE BOARD BELIEVES THE POSSIBILITY REMAINS THAT MAINTENANCE MECHANICS MAY NOT BE FAMILIAR WITH THESE NEWLY ISSUED REGULATIONS. HOWEVER, THERE IS A GOOD PROBABILITY THAT A MAINTENANCE MECHANIC SERVICING THE CHEMICAL OXYGEN GENERATORS ON AN AIRCRAFT WILL REFER TO THE MAINTENANCE MANUAL.
THE BOARD CONTINUES TO BELIEVE THAT THESE MANUALS SHOULD INDICATE THAT CHEMICAL OXYGEN GENERATORS SHOULD NOT BE TRANSPORTED AS CARGO ON PASSENGER-CARRYING AIRCRAFT. PENDING THE FAA'S SUBMISSION OF THE RESULTS OF THE AEG'S EVALUATIONS OF THE AIRCRAFT MAINTENANCE MANUALS, A-97-64 IS CLASSIFIED AS "OPEN--ACCEPTABLE ALTERNATE RESPONSE."
October 18, 1999 · Recipient Response · FAA
Letter Mail Controlled 10/21/1999 1:50:15 PM MC# 991163 THE FAA AND THE RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION (RSPA) HAVE TAKEN ACTIONS THAT ADDRESS THIS SAFETY ISSUE COMPLETELY. ON 12/23/96, RSPA ISSUED ITS FINAL RULE TO PROHIBIT THE TRANSPORTATION OF ALL CHEMICAL OXYGEN GENERATORS AS CARGO ON PASSENGER-CARRYING AIRCRAFT. THIS PROHIBITION APPLIES TO CHEMICAL OXYGEN GENERATORS THAT HAVE EXCEEDED THEIR 12-YEAR SERVICE LIFE AS WELL AS THOSE THAT HAVE NOT PASSED THEIR EXPIRATION DATES.
ON 8/11/99, RSPA, IN CONSULTATION WITH THE FAA, ISSUED A FINAL RULE TO PROHIBIT THE CARRIAGE OF CHEMICAL OXIDIZERS IN INACCESSIBLE AIRCRAFT CARGO COMPARTMENTS THAT DO NOT HAVE A FIRE OR SMOKE DETECTION AND FIRE SUPPRESSION SYSTEM. I CONSIDER THE FAA'S ACTION TO BE COMPLETED, AND I PLAN NO FURTHER ACTION IN RESPONSE TO THIS RECOMMENDATION.
July 23, 1999 · NTSB Correspondence · FAA
BASED ON THE FAA'S RULEMAKING ACTION, THE BOARD CLASSIFIES A-97-64 "OPEN--ACCEPTABLE ALTERNATE RESPONSE," PENDING OUR REVIEW OF THE FINAL RULES.