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Safety Recommendation Details

Safety Recommendation A-12-068
Details
Synopsis: In the past six years, the National Transportation Safety Board (NTSB) has conducted or participated in the investigations of three catastrophic in-flight cargo fires aboard cargo airplanes. These investigations and a recent cargo container fire study1 conducted by NTSB investigators have revealed that current fire protection regulations for these aircraft are inadequate. As a result of these accident investigations and the study, the NTSB is issuing three safety recommendations to the Federal Aviation Administration (FAA) relating to cargo fires aboard cargo airplanes. These recommendations involve improving early detection of fires originating within cargo containers and pallets, developing materials standards for cargo containers to provide better fire resistance, and requiring active fire suppression systems in all cargo compartments or containers, or both.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Develop fire detection system performance requirements for the early detection of fires originating within cargo containers and pallets and, once developed, implement the new requirements. (This safety recommendation supersedes Safety Recommendation A-07-98)
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: Dubai, United Arab Emirates
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA10RA092
Accident Reports:
Report #: None
Accident Date: 9/3/2010
Issue Date: 11/28/2012
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Acceptable Response)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/25/2019
Response: We note that the research and testing you previously described in response to these recommendations was delayed because of higher priorities. We also note that, in response to the commercial aviation safety team’s (CAST’s) voluntary safety enhancements, you are developing guidance for air carriers to use to assess and mitigate risks associated with all aspects of hazardous material transportation. In addition, we note that you plan to revise Technical Standard Order C90 to specifically address fire containment assembly testing requirements, fire-resistant containers, and fire-containment covers to improve aircraft fire safety. We continue to believe that your planned and completed actions are responsive to these recommendations and demonstrate your commitment to addressing this complex safety issue. Pending completion of the CAST’s work, implementation of performance requirements to detect fires originating within cargo containers and pallets, and a requirement to install and use active fire-suppression systems in all aircraft cargo compartments or containers, Safety Recommendations A-12-68 and -70 remain classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/3/2019
Response: -From Daniel K. Elwell, Acting Administrator: The Federal Aviation Administration (FAA) continues the research and testing described in our previous responses. The FAA's William J. Hughes Technical Center continues testing necessary to determine the time delay between when a fire starts and when the airplane cargo compartment smoke detector alarm goes off (for a fire located within several different types or cargo compartments). In addition, we will evaluate alternative methods of detecting a fire in these types of cargo containers. Although we anticipated completion of this work by December 2018, this effort was delayed due to the higher priorities associated with airplane Type Certification. We now expect completion by mid-2019. We continue to work with the Commercial Aviation Safety Team (CAST) to conduct research programs and implement voluntary safety enhancements (SEs) aimed at mitigating the risk of cargo fires. We also support activities recommended in four recently approved SEs developed to mitigate the risk of cargo fires resulting from carriage of hazardous materials, including lithium batteries. • SE-223, Cargo - Hazardous Material Fires - Prevention and Mitigation; • SE-224, Cargo - Hazardous Material Fires - Enhanced Fire Detection Systems; • SE-225, Cargo - Hazardous Material Fires - Containment and Suppression; and • SE-226, Cargo - Hazardous Material Fires - Enhanced Protection of Occupants and Aircraft. In response to these CAST SEs, we are working to develop guidance for air carriers to assess and mitigate all aspects of the risk of carrying hazardous materials. This include means to prevent fires involving hazardous materials from occurring on-board aircraft, lessen their impact if they do occur, and provide additional training to enhance flight crew ability to continue safe flight and landing in response to an on-board fire. We also continue to support the research of operators and manufacturers that would result in the development and certification of technologies and systems that enhance detection of smoke, fire, fumes, and/or other fire effects within Class E cargo compartments and mitigate the effects of a fire involving hazardous materials through improved containment and/or suppression. The FAA' s Office of Security and Hazardous Materials Safety worked with aviation industry stakeholders to develop and implement improvements to industry best practices, methods, technology, and training to detect and prevent undeclared hazardous materials from entering the shipping systems. These actions completed our work on SE-125, Cargo - Hazardous Materials (Hazmat) Processing. In response to SE-127, Cargo - Fire Management, the FAA continues to support development of SAE draft AS6278, which is now renamed AS8992, Fire Resistant Container - Design, Performance and Testing Requirements. Upon completion of CAST SE-127, we plan to incorporate the following into a revised Technical Standard Order (TSO)-C90: • SAE AS6278 (now AS8992); • SAE AS6453, Fire Containment Cover - Design, Performance, and Testing Requirements; and • TS0-203, Fire Containment Covers. The revised TSO-C90 will specifically address fire containment assembly testing requirements, fire resistant containers, and fire containment covers to improve aircraft fire safety. Although we previously expected to publish a revised TSO-C90 in March 2018, we now anticipate publication by the end of 2019, due to administrative delays and resources constraints. I will keep the Board informed of the FAA's progress on these safety recommendations and anticipate providing an update by October 2019.

From: NTSB
To: FAA
Date: 10/26/2017
Response: We note that you continue to test the amount of time it takes for a cargo compartment smoke detector alarm to sound after a fire has initiated within several different types of cargo containers. We also note your ongoing work with the Commercial Aviation Safety Team (CAST) to develop new voluntary safety enhancements (SEs) and research programs aimed at mitigating the risk of cargo fires. You are addressing these SEs by developing standards for improved cargo containers that include fire-suppression or fire-containment systems, and you are working to reduce the risk of cargo fires resulting from hazardous materials, including lithium batteries. In addition, we are encouraged to learn that, although you are waiting on the results of FAA and industry research before you initiate rulemaking related to fire safety in cargo compartments, some operators and manufacturers are exploring either permanently installing fire protection systems in their cargo compartment or having these features installed in the actual cargo containers. Your efforts thus far demonstrate your commitment to addressing this important yet complex safety issue. Pending completion of the CAST’s work, subsequent implementation of performance requirements to detect fires originating within cargo containers and pallets, and a requirement to install and use active fire-suppression systems in all aircraft cargo compartments or containers, Safety Recommendations A 12 68 and 70 remain classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/11/2017
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) continues the research and testing noted in our July 2016 response. The FAA William J. Hughes Technical Center is in the process of completing testing necessary to determine the time delay between fire initialization and the cargo compartment smoke detector alarm going off, for a fire located within several different types of cargo containers. The testing is the same as described in our earlier responses and was expected to be completed by December 2016. However, testing was delayed due to higher priority research related to determining the flammability and hazards associated with the carriage of lithium batteries. Based on a reprioritized test plan, we now expect this testing to be completed in 2018. In addition, the FAA has worked with the Commercial Aviation Safety Team (CAST) to develop new voluntary safety enhancements (SEs) and research programs aimed at mitigating the risk of cargo fires. CAST SE 127, "Cargo - Fi re Management," recommends development of standards for the construction of standardized and improved cargo containers that include fire-suppression or fire-containment systems. In response to CAST SE 127, the FAA supported development of SAE Aerospace Standard 6453, '"Fire Containment Cover - Design, Performance, and Testing Requirements," and incorporated the SAE standards in Technical Standard Order (TSO) TSO-C203, "Fire Containment Covers.'' Also in response to CAST SE 127, the FAA continues to provide similar support in the development of SAE draft standard AS6278, "Fire Resistant Container- Design, Performance and Testing Requirements." Fire containment covers and fire resistant containers are expected to improve fire safety on aircraft. Furthermore, the FAA participated on the recent working group related to CAST SE 126,·cargo - Mitigations for Hazardous Material Fires.'· The working group included government and industry experts in cargo operations and hazardous materials. This working group concluded its activities and developed four new SEs that were approved by CAST in December 2016. These new SEs are specifically targeted at reducing the risk of cargo fires resulting from carriage of hazardous materials, including lithium batteries. In response to these SEs, the FAA plans to develop guidance for air carriers to assess and mitigate the risk of carrying hazardous materials. Finally, the Title 14, Code of Federal Regulations Part 25, Harmonization of Airworthiness Standards- Fire Extinguishers and Class B and F Cargo Compartments final rule (81 FR 7698), published on February 16, 2016, and associated Advisory Circulars (A Cs) 25.851 - 1, "Built-in Fire Extinguishing/Suppression Systems in Class C and Class F Cargo Compartments,'' and 25.857-1 , "Class Band F Cargo Compartments," both issued on February 3, 2016, afford airplane manufacturers with the choice of either: ( 1) permanently installing fire protection systems (e.g., fire detectors, fire suppression system, and fire resistant material) into the airplane cargo compartment or (2) having these features installed in the cargo containers (e.g., fire resistant cargo containers, fire containment covers, enhanced unit load devices) themselves. The final rule and both ACs can be found at: https://www.federalregister.gov/documents/2016/02/16/2016-03000/hannonization-ofairworthiness-standards-fire-extinguishers-and-class-b-and-f-cargo-compartments. https://www.faa.gov/regulations_policies/advisory_circulars/index.cfm/go/document.information/documentID/ 1028727. https://www.faa.gov/regulationspoIicies/advisorycirculars/index .cfm/go/document-information/document ID/1028751. Some operators and manufacturers are exploring the use of these options to improve cargo carriage fire safety in Class E cargo compartments. We continue to provide support to their activities to improve fire safety in these cargo compai1ments. As noted above, the FAA continues to develop guidance and minimum performance standards for pat1s approved through TSO authori zations. The FAA is waiting on the conclusion of FAA and industry research activities before reaching a decision on future rulemaking related to fire safety in cargo compartments. I will keep the Board informed of the FAA 's progress on these safety recommendations and provide an update by June 30, 2018.

From: NTSB
To: FAA
Date: 10/12/2016
Response: We note your continuing support for the efforts of the Commercial Aviation Safety Team (CAST), whose Safety Enhancements 125, 126, and 127 are being developed to improve aircraft fire-detection and containment systems. We also note that the CAST made multiple presentations on this topic at the FAA’s 2015 International Aircraft Systems Fire Protection Working Group. Pending completion of the CAST’s work, subsequent implementation of performance requirements to detect fires originating within cargo containers and pallets, and a requirement to install and use active fire-suppression systems in all aircraft cargo compartments or containers, Safety Recommendations A 12 068 and 070 remain classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 7/6/2016
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) continues the research and testing noted in our October 2014 response. We continue to expect testing to be completed by December 2016. The FAA continues to work through the Commercial Aviation Safety Team (CAST) to address improvements for cargo fire protection, including the aircraft's capability to detect and control fires that could be exacerbated by the presence of hazardous cargo. CAST Safety Enhancements 125, 126, and 127 are expected to improve cargo fire containment systems for air cargo operations. In addition, the FAA's International Aircraft Systems Fire Protection Working Group convened on October 21-22,2015. During this meeting, CAST provided multiple presentations related to the analysis and improvement of aircraft fire protection systems. These presentations are available at the following Web site: https://www.fire.tc.faa.gov/systems.asp#pres. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an update by April 30, 2017.

From: NTSB
To: FAA
Date: 11/20/2014
Response: We note your continuing support for the efforts of the Commercial Aviation Safety Team’s Safety Enhancements 125, 126, and 127, which are developing improved fire containment systems, and the other activities described in your letter to develop and evaluate new fire extinguishing agents and delivery systems. Pending completion of those efforts and the subsequent implementation of appropriate requirements, Safety Recommendations A 12 68 and 70 remain classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/7/2014
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration continues to support the Commercial Aviation Safety Team Safety Enhancements 125, 126, and 127 to develop improved fire containment systems. We are evaluating the use of new methods for the carriage of cargo and to develop new fire extinguishing agents and delivery systems. We are currently testing means to detect fires in cargo containers and cargo pallet and net assemblies. In addition, we have completed several fire tests with an enhanced cargo container and are in the process of approving an enhanced cargo container that incorporates fire protection features that can detect and suppress a fire originating within the container. As we complete testing, we are assessing if a higher level standard would provide a safety benefit proportionate to the likely cost. We expect to complete testing by December 31, 2016. I will keep the Board informed of our progress on this recommendation and provide an update by July 31, 2015.

From: NTSB
To: FAA
Date: 5/25/2013
Response: We believe the FAA’s efforts, with industry and other government agencies, to evaluate the use of new fire extinguishing agents, delivery systems, and advanced cargo containers that would detect and suppress a fire originating within the container are responsive to these recommendations. Pending our receipt and review of the FAA’s findings and completion of the recommended actions, Safety Recommendations A-12-68 and -70 are classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 3/8/2013
Response: Notation 8477 (Dated 3/8/2013): The National Transportation Safety Board (NTSB) has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) notice of proposed rulemaking (NPRM), “Hazardous Materials: Transportation of Lithium Batteries.” The notice requested additional comments about the impact of changes to the requirements for the air transport of lithium batteries that have been adopted into the 2013–2014 International Civil Aviation Organization Technical Instructions on the Transport of Dangerous Goods by Air (ICAO Technical Instructions) and subsequently incorporated by reference in the Hazardous Materials Regulations (HMR). The NTSB notes that PHMSA is considering the long-term impacts of permitting shippers and carriers to choose between compliance with the existing HMR or compliance with the ICAO Technical Instructions, when transporting lithium batteries domestically by air. The NTSB further notes that PHMSA is seeking comment on whether to require mandatory compliance with the ICAO Technical Instructions for all shipments of lithium batteries by air, both foreign and domestic. The NTSB believes that allowing domestic cargo shippers and carriers to choose between alternative standards for transporting lithium batteries would place carriers at greater risk when transporting such cargo in accordance with US regulations that currently provide less protection than the ICAO Technical Instructions. On April 14, 2010, the NTSB provided comments on the January 11, 2010, NPRM. The 2010 NPRM proposed new requirements to address NTSB Safety Recommendations A-07-104, A-07-105, and A-07-107 through -109 that were issued as a result of the NTSB investigation of the February 7, 2006, in-flight cargo fire on a United Parcel Service Company (UPS) cargo airplane at Philadelphia International Airport in Philadelphia, Pennsylvania. The 2010 NPRM acknowledged that under the HMR, materials that pose a specific and serious air transportation risk are regulated more stringently than materials that pose less of a risk when transported by air, with lithium batteries being the current exception to this standard. Included in the proposals at that time was the elimination of regulatory exemptions for packages of small lithium batteries. The NTSB stated that cargo shipments of small lithium batteries should be subject to the same packaging and identification requirements that apply to medium and large lithium batteries to increase the awareness of the risks associated with these batteries and to alert package handlers to exercise greater care when loading and unloading packages containing them. In its 2010 comments, the NTSB fully supported the proposal to eliminate exceptions for small lithium batteries, believing that implementation would have satisfied the intent of the following safety recommendation to PHMSA: Eliminate regulatory exemptions for the packaging, marking, and labeling of cargo shipments of small secondary lithium batteries (no more than 8 grams equivalent lithium content) until the analysis of the failures and the implementation of risk-based requirements asked for in Safety Recommendation A-07-108 are completed. (A-07-109) The NTSB recognizes that PHMSA was barred from implementing its original proposal to eliminate small lithium battery air cargo transport exceptions because of provisions in the Federal Aviation Administration (FAA) Modernization and Reform Act of 2012 that prohibit PHMSA from imposing requirements that are more stringent than the ICAO Technical Instructions. Since commenting on the 2010 NPRM, the NTSB has been involved in the investigation of two additional catastrophic in-flight cargo fires on aircraft that were transporting large quantities of lithium batteries. On September 3, 2010, a Boeing 747-400F, operated by UPS, crash landed at a military base in Dubai, United Arab Emirates, while the crew was trying to return to the airport for an emergency landing due to a fire in the main deck cargo compartment. Both crewmembers died as a result of injuries sustained during the crash, and the aircraft was a total loss. On July 28, 2011, a Boeing 747-400F, operated by Asiana Cargo, crashed about 70 miles west of Jeju Island, Republic of Korea, after the flight crew declared an emergency due to a cargo fire and attempted to divert to Jeju International Airport. Again, both crewmembers died as result of injuries sustained during the crash, and the aircraft was a total loss. Based on these ongoing accident investigations, the NTSB remains concerned about the risks to aircraft flight crews from in-flight fires involving lithium batteries. These investigations also prompted the NTSB to issue Safety Recommendations A-12-68 through -70 on November 28, 2012, to the FAA. These recommendations were issued to improve the early detection of fires originating in cargo containers and pallets, to develop materials standards for cargo containers that provide better fire resistance, and to require active fire-suppression systems in all cargo compartments or containers. Meanwhile, the current HMR for domestic air cargo transport continue to allow many small lithium batteries to be transported as general cargo without the safety precautions that are provided for other common hazardous materials. Under current regulations, certain shipments of small batteries are exempt from hazardous materials packaging and identification requirements. These exemptions potentially permit large quantities of unidentified small lithium battery shipments on board both cargo and passenger aircraft, while the revised ICAO Technical Instructions substantially reduce the sizes of small lithium batteries that are subject to regulation. Lithium battery shipments in aircraft are increasing in number, and batteries are increasing in energy density. Recent incidents and research continue to show that lithium battery failures (regardless of the source or cause) can release flammable electrolyte or result in violent, high temperature reactions that can ignite combustible or flammable material nearby or further fuel an existing fire. The PHMSA final rule incorporated the ICAO Technical Instructions by reference, thus permitting, but not mandating, domestic lithium battery shipments to be transported by air in accordance with the international standards (except where the HMR prohibit primary lithium batteries and unapproved prototype lithium batteries and cells aboard passenger carrying aircraft). The ICAO Technical Instructions increased restrictions for shipment of lithium batteries by significantly decreasing the excepted quantity permitted in international cargo shipments. If the HMR are harmonized with the ICAO Technical Instructions, a significantly larger number of fully regulated domestic air cargo shipments of lithium batteries would be subject to the greater level of safety provided by specification packaging requirements and United Nations safety testing, labeling, and hazard communication standards. Complying with such increased safety requirements and standards would reduce the risks associated with transporting these materials. The NPRM Question 1 asks if any unintended consequences are anticipated if PHMSA authorizes the use of the ICAO Technical Instructions as an optional method of compliance with the HMR and does not issue a final rule revising the HMR to require domestic shipments of lithium batteries to comply with the provisions specified in the ICAO Technical Instructions. The NTSB strongly believes that unintended negative consequences would result if shippers and carriers were permitted to choose compliance with alternative standards for domestic cargo shipments as suggested in the NPRM. Such action would undermine the safety benefit offered by the improved ICAO Technical Instructions. Domestic carriers who choose not to apply the ICAO Technical Instructions would be placed at higher risk of cargo fires than their foreign competitors because of the current disparity between requirements in the HMR and the ICAO Technical Instructions. Failure to require domestic shipments of lithium batteries to comply with regulations equivalent to the international provisions would also place the United States in an inexplicable position of having weaker safety standards at a time when it should be leading the way in response to serious safety concerns about transporting these materials. The NPRM would be improved if the excepted amounts authorized by the HMR are at least consistent with the provisions in the ICAO Technical Instructions. The proposal should require that all lithium batteries, consistent with current ICAO packaging criteria, such as battery power, size, and quantity limitations in air transportation, be regulated as class 9 materials and subjected to the requirements of Title 49 Code of Federal Regulations 173.185, including packaging standards and hazard communication requirements. Adoption of this proposal would reduce the risk of lithium battery fires during shipment. The proposal also should require personnel involved in packaging and shipping lithium batteries to be properly trained in their respective hazardous materials handling functions. The proposal should further ensure that these packages are clearly labeled, providing a visible indication of the presence of hazardous materials for flight crews, cargo handlers, and emergency responders. Finally, the proposal should ensure that all lithium battery shipments are listed on the Notice to Pilot in Command or hazardous materials cargo manifest to inform flight crews about the quantity, location, and type of lithium batteries on board an aircraft. The NTSB appreciates the opportunity to comment on the notice.

From: FAA
To: NTSB
Date: 2/12/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) continues to support efforts to improve fire protection in transport airplane cargo compartments. Fire protection in aircraft cargo operations involves numerous considerations. We agree that improvements can be made in several elements of aircraft cargo fire protection systems, including improvements in installed aircraft systems and equipment and cargo containers. The FAA is working through the Commercial Aviation Safety Team (CAST) to address improvements for cargo fire protection, including the aircraft's capability to detect and control fires that could be exacerbated by the presence of hazardous cargo. These CAST initiatives are expected to develop improved cargo fire containment systems to achieve safety improvements for air cargo operations. To address Recommendations A-12-68 and -70, the FAA is working with industry and other Government agencies to evaluate the use of new fire extinguishing agents and delivery systems as well as advanced cargo containers that incorporate fire protection features that may detect and suppress a fire originating within the container. The FAA is evaluating whether a new higher-level standard would provide a safety benefit commensurate to the likely cost. Regarding Recommendation A-12-69, the FAA agrees that cargo container materials should not exacerbate a fire. However, we are not aware of any service evidence that demonstrates FAA regulations for approved cargo containers are inadequate for ordinary combustibles. We will evaluate the results of the Board's cargo containment fire study to determine what, if any, further action may be needed to address this recommendation. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an update by December 2013.