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  3. NTSB A-98-080
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NTSB · Safety Recommendation

Safety Recommendation A-98-080

Recommendation

THE NTSB RECOMMENDS THAT THE RSPA: REQUIRE, WITHIN 2 YEARS, THAT AIR CARRIERS TRANSPORTING HAZARDOUS MATERIALS HAVE THE MEANS, 24 HOURS PER DAY, TO QUICKLY RETRIEVE & PROVIDE CONSOLIDATED SPECIFIC INFO ABOUT THE IDENTITY (INCLUDING PROPER SHIPPING NAME), HAZARD CLASS, QUANTITY, NUMBER OF PACKAGES, & LOCATION OF ALL HAZARDOUS MATERIALS ON AN AIRPLANE IN A TIMELY MANNER TO EMERGENCY RESPONDERS.

Safety Issue and Context

ABOUT 0554 EASTERN DAYLIGHT TIME, ON 9/5/96, A DOUGLAS DC-10-10CF, N68055, OPERATED BY THE FEDERAL EXPRESS CORPORATION (FEDEX) AT FLIGHT 1406, MADE AN EMERGENCY LANDING AT STEWART INTERNATIONAL AIRPORT, NEWBURGH, NEW YORK, AFTER THE FLIGHTCREW DETERMINED THAT THERE WAS SMOKE IN THE CABIN CARGO COMPARTMENT. THE FLIGHT WAS OPERATING UNDER THE PROVISIONS OF TITLE 14 CODE OF FEDERAL REGULATIONS (CFR) PART 121 AS A CARGO FLIGHT FROM MEMPHIS, TENNESSEE, TO BOSTON, MASSACHUSETTS. THREE CREWMEMBERS & TWO NONREVENUE PASSENGERS WERE ABOARD THE AIRPLANE. THE CAPTAIN & FLIGHT ENGINEER SUSTAINED MINOR INJURIES WHILE EVACUATING THE AIRPLANE. THE AIRPLANE WAS DESTROYED BY FIRE AFTER THE LANDING.

Response History

August 18, 2003 · NTSB Correspondence · RSPA

The Safety Board notes that RSPA published the final rulemaking prepared in response to this recommendation on March 25, 2003. The Board appreciates RSPA's actions in requiring air carriers to have hazardous material information immediately available for emergency responders. However, we are disappointed that the requirement for a consolidated list was not included in the rulemaking. As was outlined in our original recommendation letter, the lack of a consolidated list was a significant safety problem identified during the investigation of the Newburgh, New York, accident.

The need for the consolidated list was reiterated in the Board's comments on the notice of proposed rulemaking submitted to the docket on April 26, 2002.

Because the final rule was published without a requirement for air carriers to provide a consolidated list, Safety Recommendation A-98-80 is classified "Closed--Unacceptable Action." However, the Safety Board notes that RSPA commented in the final rule that it agrees with the need for a consolidated list. The Board encourages RSPA to consider additional rulemaking to incorporate such a requirement.

June 3, 2003 · Recipient Response · RSPA

Letter Mail Controlled 6/12/2003 3:40:44 PM MC# 2030289 On March 25,2003 RSPA published a final rule under docket HM-206C, entitled "Hazardous Materials: Availability of Infonnation for Hazardous Materials Transported by Aircraft." A copy of the final rule is enclosed. The final rule adopts revisions to the Hazardous Materials Regulations (HMR) to insure that emergency response personnel have accurate and timely information regarding hazardous materials aboard an aircraft, in the event of an emergency. RSPA amended the HMR to require aircraft operators transporting a hazardous

material to: (1) place a telephone number, on the notification of pilot-in-command or in the cockpit of the aircraft. that can bc contacted during an in-flight emergency to obtain information about any hazardous materials aboard the aircraft; (2) retain and provide upon request a copy of the notification of pilot-in-command. or the information contained in it, at the aircraft operator’s principal place of business, or the airport of departure, for 90 days, and at the airport of departure until the flight leg is completed; and (3) make readily accessible, and provide upon request, a copy of the notification of pilot-in-command, or the information

contained in it, at the planned airport of arrival until the flight leg is completed. Based on publication of the HM-206C final rule, we request that this recommendation be reclassified as "Closed Acceptable Action."

April 26, 2002 · NTSB Correspondence · RSPA

The National Transportation Safety Board has reviewed the Research and Special Programs Administration's (RSPA's) notice of proposed rulemaking (NPRM) "Hazardous Materials: Availability of Information for Hazardous Materials Transported by Aircraft," Docket No. RSPA-00-7762 (HM-206C), which was published at 67 FR 6669 on February 13, 2002. RSPA states that the NPRM addresses Safety Recommendation A?98?80 that was issued as a result of the Safety Board's investigation of an in-flight fire and emergency landing of Federal Express (FedEx) flight 1406 at Stewart International Airport in Newburgh, New York, on September 5, 1996.

Safety Recommendation A-98-80 urged RSPA to require, within 2 years, that air carriers transporting hazardous materials have the means, 24 hours per day, to quickly retrieve and provide consolidated specific information about the identity (including the proper shipping name), hazard class, quantity, number of packages, and location of all hazardous materials on an aircraft in a timely manner to emergency responders.

The NPRM proposes to amend the hazardous materials regulations (49 CFR Parts 171-180) by adopting new requirements for aircraft operators to make readily available a copy of the Notification of the Pilot-in-Command (NOPC), or the information contained in it, at the departure and arrival points for each aircraft transporting hazardous materials. The NPRM also would require that an air carrier provide a 24-hour telephone number on the NOPC that a flight crew can convey to air traffic controllers during an in-flight emergency when the crew does not have sufficient time to provide the information contained in the NOPC.

Air traffic controllers and other ground personnel would then use the 24-hour number to obtain a copy of the NOPC. These changes will enhance the availability of the NOPC and the documentation contained in the NOPC about the hazardous materials on board the aircraft. However, the NPRM fails to address the fundamental purpose of Safety Recommendation A-98-80, which is to ensure that the air carrier has the ability to quickly provide emergency responders with a consolidated list that not only identifies each hazardous material on board the aircraft but also the quantity and location of each hazardous materials package on the aircraft.

Further, simply maintaining the NOPC at the departure and arrival points of an aircraft transporting hazardous materials does not ensure that air carriers will provide the consolidated list in a timely manner. Under the proposed rules, emergency responders would still have to sift through numerous shipping papers to obtain the basic information that would appear on a consolidated list. Also, the proposed rules would have no effect if an accident or incident occurs at a location other than the departure or arrival airport. In such situations, the air carrier would still be forced to transmit a copy of the NOPC or to assemble a list and then transmit it to emergency responders.

November 13, 2000 · NTSB Correspondence · RSPA

RSPA'S 8/29/00, LETTER TRANSMITS A COPY OF THE ANPRM WAS PUBLISHED ON 8/15/00; THE BOARD NOTES THAT THE COMMENT PERIOD CLOSES 11/13/00. ALTHOUGH PLEASED THAT RSPA HAS TAKEN INITIAL STEPS TOWARDS RULEMAKING, THE BOARD IS DISAPPOINTED AND CONCERNED THAT, IN THE 2 YEARS SINCE RSPA'S 9/30/98, LETTER, LITTLE OR NO PROGRESS APPEARS TO HAVE BEEN MADE TO SATISFY THE INTENT OF THIS RECOMMENDATION. ON 7/25/00, THE SAFETY BOARD MET TO REVIEW THE AIRCRAFT ACCIDENT REPORT ON THE 7/31/97, CRASH-WHILE-LANDING OF FED EX FLIGHT 14, AN MD-11, AT NEWARK INT'L. AIRPORT.

IN THAT ACCIDENT, EMERGENCY RESPONDERS NEEDED TO QUICKLY IDENTIFY ANY HAZARDOUS MATERIAL PRESENT, BUT WERE UNABLE TO OBTAIN THIS INFORMATION IN A TIMELY MANNER. A-98-80 WAS ISSUED TO ADDRESS JUST SUCH SITUATIONS AS THE ONE AT NEWARK. BECAUSE OF RSPA'S DELAY IN IMPLEMENTING THIS RECOMMENDATION, THE BOARD RECLASSIFIED A-98-80 "OPEN--UNACCEPTABLE RESPONSE," AT ITS JULY 25 BOARD MEETING. PENDING ISSUANCE AND REVIEW OF A FINAL RULE, A-98-80 REMAINS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

August 29, 2000 · Recipient Response · RSPA

Letter Mail Controlled 09/05/2000 3:53:10 PM MC# 2001218 THE SAFETY BOARD ISSUED THE SAME RECOMMENDATION TO THE FAA. IN OUR 7/20/00 LETTER TO YOU WE STATED THAT WE WERE WORKING WITH THE FAA TO DEVELOP AN ADVANCE NOTICE OF PROPOSED RULEMAKING (ANPRM) TO SEEK PUBLIC COMMENT ON THESE RECOMMENDATIONS. THE ANPRM UNDER DOCKET (HM-206C) WAS PUBLISHED IN THE FEDERAL REGISTER ON 8/15/00. A COPY IS ENCLOSED FOR YOUR INFORMATION. WE WILL KEEP YOU INFORMED OF OUR PROGRESS. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT ME OR JACK MURRAY, ASSOCIATE ADMINISTRATOR FOR THE OFFICE OF POLICY AND PROGRAM SUPPORT, AT 202-366-4831.

July 20, 2000 · Recipient Response · RSPA

Letter Mail Controlled 07/25/2000 12:49:25 PM MC# 2000943 IN OUR 9/30/98 LETTER TO YOU ON THIS RECOMMENDATION, WE STATED THAT WE WERE WORKING WITH THE FAA TO DEVELOP AN ADVANCE NOTICE OF PROPOSED RULEMAKING (ANPRM) TO SEEK PUBLIC COMMENT ON THESE RECOMMENDATIONS. RSPA BELIEVES THAT IT NEEDS EXTENSIVE PUBLIC INPUT IN ORDER TO APPROPRIATELY EVALUATE THE MEANS AND COSTS OF IMPLEMENTING THE RECOMMENDATION. AN ANPRM IS THE VEHICLE FOR RECEIVING THAT PUBLIC INPUT. RSPA AND THE FAA ARE IN THE FINAL STAGES OF DEVELOPING THE ANPRM AND ANTICIPATE PUBLISHING IT IN THE FEDERAL REGISTER BY 9/1/00. I REQUEST THAT A-98-80 BE CONTINUED TO BE CLASSIFIED AS "OPEN--ACCEPTABLE ACTION."

WE THANK YOU FOR CONSIDERATION OF OUR REQUEST.

June 28, 2000 · NTSB Correspondence · RSPA

PLEASE INFORM THE BOARD OF RSPA'S CURRENT AND PLANNED ACTIVITIES IN RESPONSE TO THIS RECOMMENDATION, AND THE PLANNED COMPLETION DATE OF THESE ACTIVITIES. RSPA'S RESPONSE TO THIS RECOMMENDATION MAY BE DISCUSSED AT A BOARD MEETING CURRENTLY SCHEDULED FOR 7/25/00, INVOLVING FEDERAL EXPRESS.

November 9, 1998 · NTSB Correspondence · RSPA

THE BOARD ISSUED THE SAME RECOMMENDATION TO THE FAA. RSPA STATES THAT IT & THE FAA ARE JOINTLY DEVELOPING AN ADVANCE NOTICE OF PROPOSED RULEMAKING UNDER DOCKET HM-206C TO SEEK PUBLIC COMMENT ON THESE RECOMMENDATIONS. PENDING COMPLETION & REVIEW OF THE FINAL RULE, A-98-80 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

September 30, 1998 · Recipient Response · RSPA

(Letter Mail Controlled 10/5/98 4:23:04 PM MC# 981214) THE BOARD ISSUED THE SAME RECOMMENDATION TO THE FAA. RSPA & FAA ARE JOINTLY DEVELOPING AN ADVANCE NOTICE OF PROPOSED RULEMAKING UNDER DOCKET (HM-206C) TO SEEK PUBLIC COMMENT ON THESE RECOMMENDATIONS. I REQUEST A-98-80 BE CLASSIFIED AS "OPEN--ACCEPTABLE ACTION." IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT ME OR MR. WILLIAM E. VINCENT, DIRECTOR OF THE OFFICE OF POLICY & PROGRAM SUPPORT, AT (202) 366-4831.

Read Recommendation

Recommendation Facts

Status
Closed - Unacceptable Action
Issued
August 12, 1998
Priority
CLASS II
Recipient
RSPA
Adopted
July 21, 1998
Closed
August 18, 2003
Related Investigation
DCA96MA079
Related Report
AAR-98-03

Neither option will be timely. However, if the air carrier has the consolidated list before the departure of each flight, the air carrier could easily transmit a consolidated list to emergency responders at the scene.

In the Newburgh accident, the NOPC, which was carried in the cockpit and included the specific information identifying the declared hazardous materials shipments on board the aircraft, was not recovered by crash-fire personnel. The incident commander made multiple requests to FedEx to provide a list identifying the hazardous materials on board, their quantities, and their locations on the aircraft. Because it had no consolidated list of hazardous materials shipments on board the aircraft, FedEx had to fax each of the 85 individual shipping documents to the emergency operations center at Stewart Airport in Newburgh.

Many of these faxed documents were illegible or of such poor quality that they were useless to the emergency responders. As a result of FedEx's inability to provide a consolidated list in a timely manner, the incident commander did not have information about the hazardous materials on board during the emergency.

In three subsequent accidents, FedEx again was unable to provide emergency responders with timely or accurate information about the hazardous materials on the accident aircraft. In the crash of an MD-11 at Newark International Airport on July 31, 1997, FedEx was not able to provide the incident commander with information about the quantity and identification numbers for the hazardous materials on board until 1 1/2 to 2 hours after the accident.

In the crash of a Cessna 208B near Clarksville, Tennessee, on March 5, 1998, the hazardous materials shipping papers on board the aircraft and on file at FedEx's Memphis hub did not accurately reflect what was on board the aircraft or include an emergency response telephone number for the shipper of the hazardous material. When a Cessna 208 crashed near Bismarck, North Dakota, on April 7, 1998, FedEx was asked to provide information about any hazardous materials on board. The company required 2 hours and 49 minutes to confirm that the aircraft was not transporting hazardous materials.

The Safety Board's investigations of these four accidents indicated that the problem with providing timely and accurate information was due primarily to the format of the NOPC documents used by FedEx and many other carriers. The NOPC used by FedEx and many other carriers consists of multi-part forms and envelopes that are frequently handwritten and are almost never generated electronically. The critical information that identifies the hazardous material and its quantity is found on an individual shipping paper for each hazardous materials shipment. These shipping papers are then usually put in an envelope that is provided to the flight crew of the aircraft.

The envelope typically identifies the classes (e.g. flammable liquids, radioactive materials, etc.) of all the hazardous materials on board and may identify the location of hazardous materials. The assembled NOPC must be carried in the cockpit and be accessible to the flight crew. The carrier also retains a copy of the NOPC at the point of origin of the flight.

If an aircraft is involved in an accident and the onboard NOPC is not available or accessible, the carrier must retrieve the copy of the NOPC at the point of origin and collect the shipping papers for the individual hazardous materials shipments. The carrier must then either transmit copies of the individual shipping papers, as attempted in Newburgh, or consolidate the information into a list before transmitting it to emergency responders. In either case, the accurate transmission of hazardous materials information is delayed unnecessarily.

The NPRM refers to a 1993 National Academy of Sciences (NAS) study of the feasibility and necessity of a national central reporting system for tracking the transportation of every shipment of hazardous materials. The study areas included (1) receiving, storing, and retrieving data concerning all daily shipments of hazardous material; (2) identifying hazardous materials being transported by any mode of transportation; and (3) providing information to facilitate responses to accidents and incidents involving the transportation of hazardous materials.

The NAS study report, published on April 29, 1993, concluded that "the government should not attempt to implement a system such as the originally proposed national central reporting system…." RSPA states in the NPRM that "nothing submitted by NTSB or the commenters contradicts the previous NAS finding that a computer tracking system would be extremely complicated, burdensome, expensive to implement, and of questionable benefit."

The Safety Board is not seeking the development of a national central reporting system through Safety Recommendation A-98-80. However, the Safety Board notes that the NAS study also concluded and recommended t