Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-16-001
Details
Synopsis: On July 28, 2011, about 04:11 Korean standard time, Asiana Airlines Flight 991, a B747 400F airplane on a scheduled cargo flight from Incheon, Republic of Korea, to Shanghai, China, crashed into international waters about 130 km west of Jeju International Airport. The flight crew reported a cargo fire to Shanghai Area Control Center and attempted to divert to Jeju International Airport. The two pilots aboard the flight died. The wreckage of the airplane was distributed on the sea floor at an average depth of 85 meters (m), in an area 3 km by 4 km in a southwest-northeast direction. The ARAIB determined that the cause of this accident was a fire that developed on or near two pallets containing dangerous goods packages, including hybrid-electric vehicle lithium ion batteries and flammable liquids, but no physical evidence of the cause of the fire was found. The fire rapidly grew large and uncontained, which resulted in a loss of control and some portions of the fuselage separating from the aircraft in midair, thereby resulting in the crash. The ARAIB report cited as a contributing factor the flammable materials and lithium-ion batteries that were loaded together either in the same or adjacent pallets.
Recommendation: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTATION: Require that Class 3 flammable liquids and fully regulated Class 9 lithium batteries be physically segregated when stowed on board an aircraft such that packages containing these materials may not be placed on the same or adjacent pallets or ULDs.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: Jeju Island, Korea, Republic Of
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA11RA087
Accident Reports:
Report #: None
Accident Date: 7/27/2011
Issue Date: 2/9/2016
Date Closed:
Addressee(s) and Addressee Status: PHMSA (Open - Acceptable Response)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: PHMSA
Date: 9/21/2017
Response: We note that, during the International Civil Aviation Organization (ICAO) Dangerous Goods Panel (DGP) Working Group meeting held in Montreal in April 2017, the International Air Transport Association (IATA) submitted a working paper to establish segregation requirements for lithium batteries, flammable materials, and other hazardous materials. The DGP Working Group agreed to the proposal as drafted. The ICAO DGP will review this decision at its next scheduled meeting in October 2017, and will incorporate it into the 2019–2020 edition of the ICAO “Technical Instructions for the Safe Transport of Dangerous Goods by Air.” Pending the US delegation to the ICAO DGP fully supporting the IATA working paper, and revisions to PHMSA’s hazardous materials regulations to harmonize with the revision, Safety Recommendation A-16-1 remains classified OPEN--ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 7/14/2017
Response: -From Howard W. McMillan, Acting Deputy Administrator: During the International Civil Aviation Organization (ICAO) Dangerous Goods Panel Working Group Meeting (DGP-WG/17) held in Montreal, Canada on April 24-28, 2017, the International Air Transport Association (IATA) submitted a working paper (DGP-WG/17-WP/6) to establish segregation requirements for lithium batteries, flammable materials, and other hazardous materials. Specifically, IATA proposed a restriction on shipper packing or overpacking of lithium batteries required to bear the Class 9 label with materials of Class 1 (other than 1.4S), Division 2.1, Class 3, Division 4.1, and Division 5.1, as well as a requirement for air operators to segregate packages of lithium batteries bearing a Class 9 label and packages bearing hazard labels of Class 1 (other than l.4S), Division 2.1, Class 3, Division 4.1, and Division 5.1. After much discussion, the ICAO DGP Working Group agreed to the proposal as drafted. The ICAO DGP will review this decision at the next meeting on October 16-27, 2017, for subsequent incorporation into the 2019-2020 edition of the ICAO Technical Instructions for the Safe Transport of Dangerous Goods by Air.

From: NTSB
To: PHMSA
Date: 8/18/2016
Response: We note that temporary measures to mitigate the hazards of lithium battery transport by cargo aircraft—including segregating lithium batteries from other dangerous goods, such as flammable liquids—were proposed to the International Civil Aviation Organization (ICAO) Dangerous Goods Panel (DGP). We further note your position that, given the complex nature of the associated safety problem, segregation may not constitute the ultimate solution, and we note that the ICAO DGP is considering other measures in addition to, or in lieu of, segregation, including alternatives that take into account that all operators do not use the same mitigation tools, which are based on the size of the operation and the types of cargo compartments and fire suppressions systems available on the particular aircraft. We understand that possible alternatives the ICAO DGP is considering include fire containment covers, fire-resistant containers, and unit load devices (ULDs) that could contain or suppress a fire. We also understand that you will consider adopting any new DGP guidelines within your Hazardous Materials Regulations (HMRs) as soon as possible. You stated that recent measures approved by the ICAO Governing Council, which you plan to incorporate into the HMR as an interim final rule, may provide an alternative approach that would satisfy Safety Recommendation A-16-1. Among these are three measures, effective April 1, 2016, that (1) prohibit the transport of lithium-ion batteries as cargo aboard passenger aircraft, (2) require lithium-ion batteries to be transported at not more than a 30-percent state of charge, and (3) limit small lithium batteries to be shipped in no more than one package per consignment. Our purpose in issuing Safety Recommendation A-16-1 was to encourage you to act even if the ICAO guidelines were not revised; however, we acknowledge the safety benefit that will result from a consistent international set of guidelines and regulations regarding segregation if they are enacted by the DGP. We encourage your continued participation and advocacy in the DGP, but if it does not act, we believe that this safety problem must be addressed sooner rather than later, as the Asiana accident illustrates. We will consider whether alternatives developed by the DGP satisfy this recommendation, but we point out that— 1. We believe that segregation is the least expensive, most readily and quickly implemented, and most effective mitigation to address the hazardous materials safety issues associated with carrying lithium batteries in conjunction with other flammable materials as cargo on aircraft. 2. The measures adopted by the ICAO Governing Council on April 1, 2016, are valuable, but they are not alternatives to satisfying Safety Recommendation A-16-1. Pending your taking the recommended action, Safety Recommendation A-16-1 is classified OPEN--ACCEPTABLE RESPONSE.

From: PHMSA
To: NTSB
Date: 6/6/2016
Response: -From Marie Therese Dominguez, Administrator: PHMSA concurs with the intent of both safety recommendations to enhance the safe transportation of lithium batteries by air and shares your concerns regarding the potential for lithium batteries to initiate and contribute to the severity of a fire in the cargo compartments of aircraft in the presence of flammable liquids. The safe transport of lithium batteries by air has been an ongoing concern for PHMSA, the Federal Aviation Administration (FAA), and the U.S. Department of Transportation. PHMSA participates in a number of international forums, including the International Civil Aviation Organization (ICAO) Dangerous Goods Panel (DGP), as part of the ongoing process of harmonizing the Hazardous Materials Regulations (HMR; 49 CFR Parts 171-180) with international standards and regulations and is committed to ensuring the ICAO Technical Instructions for the Safe Transport of Dangerous Goods by Air and the HMR provide a level of safety such that lithium batteries can be carried without putting an aircraft or its occupants at risk. As you stated in your letter, the ICAO DGP met in Montreal, Quebec, Canada in October 2015 to consider the development of further measures to mitigate the risks associated with the transport of lithium batteries when carried as cargo. With respect to Safety Recommendation A-16-001, temporary measures to mitigate the hazards of lithium battery transport by cargo aircraft were proposed (pending a comprehensive solution that would mitigate these hazards) to the DGP. These measures included, among others, the segregation of lithium batteries from other dangerous goods (e.g., flammable liquids). Given the complex nature of the safety problem that underlies Recommendation A-16-001, segregation or the other identified measures may or may not provide the ultimate solution to the problem. The DGP may also consider measures that are in addition to or in lieu of segregation, such as those that recognize that different operators have different mitigating tools available to them based on the size of their operation and the types of cargo compartments and fire suppressions systems available on their aircraft. Such measures would also need to provide enough flexibility to allow for the use of fire containment covers, fire resistant containers and unit load devices that could contain or suppress a lithium battery fire. PHMSA, in cooperation with the FAA, will continue to work within the ICAO DGP to address this issue during the current 2016-2017 biennium. Decisions taken by the DGP would be considered for adoption within the HMR in the earliest possible rulemaking once this work is complete. With respect to Safety Recommendation A-16-002, PHMSA has been engaged with FAA in determining the best course of action to address this recommendation. Discussions and collaboration are ongoing and we plan to provide you with a more detailed plan of action on this recommendation in a follow-up response to this letter. We note that recent measures approved by the ICAO Governing Council may provide for an alternative approach that would address the NTSB 's concerns of stowage of lithium batteries with flammable liquids. Based on recommendations from the ICAO Air Navigation Commission, as well as the Dangerous Goods, Flight Operations, and Airworthiness panels, the ICAO Governing Council approved three new measures to enhance lithium battery safety, effective April1, 2016. These measures include: (1) prohibiting the transport of lithium ion batteries as cargo aboard passenger aircraft; (2) requiring lithium ion batteries to be transported at not more than a 30 percent state of charge; and (3) limiting current provisions for small lithium batteries to no more than one package per consignment. PHMSA supports ICAO's measures and intends to incorporate these amendments into the HMR in an interim final rule anticipated for publication in September 2016. The timeline for this rulemaking may be reviewed at: https://www.transportation.gov/regulations/report-on-significant-rulemakings. In addition, the ICAO Dangerous Goods and Flight Operations panels recommended that operators conduct a safety risk assessment on the transport of dangerous goods and lithium batteries. The safety risk assessment process should include the implementation of necessary mitigation measures in order to ensure the safe transport of dangerous goods including lithium batteries as cargo on aircraft. In summary, PHMSA is engaged in a number of important actions to further ensure the safety of lithium batteries on aircraft. PHMSA will continue to coordinate with FAA through the international standards organizations in consultation with industry and research institutions to assess incident data focusing on root causes and ongoing research to gauge any necessary changes to lithium battery transport requirements. Finally, PHMSA will follow-up with the NTSB with greater detail on all of its initiatives affecting lithium battery safety with respect to Safety Recommendations A-16-001 and A-16-002 when we have collectively determined a planned course of action to further address the recommendations.