dangerous goods and air safety - flight safety foundation

F L I G HT SAFETY FOUN D A TI O N • F L I G H T S A F E T Y D I G E S T • SEPTEMBER 1990 1

The safety of civil aircraft is threatened bysubstances carried on board in passengers’baggage (whether in the hold or cabin), cargo,airmail, packages, aircraft stores and equip-ment, and explosives placed on board by sabo-teurs or hijackers. A serious threat is the in-creased number of hazardous materials pro-duced for use by all manner of legitimate busi-nesses and offered for shipment by air. Al-though a list of “dangerous goods” that maybe carried by air is regularly revised, it is achallenge for even the most careful shippersand carriers to keep up-to-date on dangerousgoods and the safest methods of handling andstoring them.

The Regulatory Scene

For many years, the International Air Trans-port Association (IATA) had prime responsi-bility for determining how hazardous materi-als were packaged and what restrictions wereto be placed on their transport. Its list of “re-stricted articles” was accepted by most coun-tries and used by almost all shippers and cargo-carrying airlines whether they were membersof IATA or not.

In 1983 the International Civil Aviation Orga-nization (ICAO) published its own regulationson dangerous goods, in addition to IATA’s “Re-stricted Articles Regulations,” and this was

Dangerous Goods and Air Safety

The list of dangerous goods that may be carried by air isgrowing at a rate that makes it difficult for shipper

and carrier alike to keep abreast of safe methodsof storage and handling.

byLaurie Taylor, OBE, FRAeS.

achieved through the publication of two docu-ments:

• Annex 18 to the Convention of Interna-tional Civil Aviation — The safe Trans-port of Dangerous Goods by Air; and

• The Technical Instruction for the SafeTransport of Dangerous Goods by Air(Doc. 9284).

Annex 18 and the Technical Instructions bothbecame applicable on January 1, 1984 and thesedocuments are now used throughout the worldby the 162 Member States of ICAO for interna-tional flights and, in most countries, for do-mestic flights. ICAO assumed this responsi-bility because of the need to harmonize thetransport of dangerous goods by air with othermodes of transport, to achieve compatibilitywith international regulations published bythe United Nations and the International AtomicEnergy Agency, and to give the regulations ahigher international legal status.

The use of different terms in civil air transportfor what are basically the same materials isundesirable, and “dangerous goods” used byICAO is replacing IATA’s “restricted articles.”A third term, “hazardous materials,” is stillused in the United States but means essen-tially the same as “dangerous goods.” Theterms are used to identify substances or mate-

F L I G H T SAFETY FOUN D A TI O N • F LI G H T S A F E T Y D I G E S T • SEPTEMBER 19902

rials that may pose an unreasonable risk tohealth, safety and property when transportedby any mode of transport. They are defined byICAO as explosives, gases, corrosive materi-als, flammable liquids, flammable solids, or-ganic peroxides, oxidizing materials, poisons,infectious substances, radioactive materials andother miscellaneous dangerous goods (in theUnited States referred to as other restrictedmaterials-ORM).

Familiar items are affected, including matches,some cigarette lighters, hair dryers, medicalsupplies, fireworks, wheelchairs with wet-cellbatteries, breathing apparatus with compressedair, paint thinners, ammunition and pyrotech-nics. Radioactive materials constitute a par-ticular hazard because they emit particles, raysor gases, which may be hazardous and cannotbe detected except by special instruments. Mostradioactive materials offered for transport onpassenger aircraft are intended for use in, orincident to, research or medical diagnosis ortreatment.

Some dangerous goods, or certain amountsthereof, are restricted to carriage in cargo air-craft only and these materials have to be stowedso as to be accessible to crew members whilein flight. A logical but necessarily complexsystem has been developed for labeling anddescribing dangerous goods; it uses colors,shapes and symbols to contend with problemscreated by lack of education or foreign lan-guages. The United States has its own nationalregulations, but the ICAO system may also beused domestically. The ICAO system must beused for all shipments transferred from a U.S.domestic route to an international one.

The ICAO system classifies dangerous goodsinto nine classes, with three packaging groups:

Packaging Group 1 = great danger.

Packaging Group 2 = medium danger.

Packaging Group 3 = minor danger.

Dangerous goods complicate aircraft emergencyprocedures especially if rescue and firefightingoperations must deal with hazardous materi-

als such as corrosive liquids and radioactivesubstances as well as dealing with occupantsand fires. Proposals to add an item to the trans-mitted flight plan of the aircraft that indicatedangerous goods are aboard have not yet beenadopted. The responsibility to notify the ap-propriate authorities during an emergency isleft with the aircraft commander — who mayhave more urgent duties in these circumstances.In the event of an in-flight emergency, the captainis required to inform the appropriate agencyof the class of dangerous goods on board sothat emergency services may be alerted.

Airlines have to ensure that all personnel in-volved in the acceptance, documentation, han-dling and transportation of dangerous goodsare trained to appropriate standards. They mustensure that dangerous goods accepted for airtransport meet government regulations andthat the pilot is informed of the presence ofany such materials. Airlines are also requiredto display in a prominent place, visible to board-ing passengers, notices concerning the require-ments and penalties associated with the car-riage of hazardous materials in baggage or aschecked baggage. A current problem is thatpilots are sometimes given a list of the dan-gerous goods immediately before the doorsare closed and engines started, preventing themfrom checking the loading and labeling.

Pilots are expected to ensure that regulationsfor dangerous goods are observed. They haveauthority to delay flights to ensure the properstowage and documentation of shipments, andto refuse carriage of any dangerous goods thatare not in compliance with the regulations.

Shippers, packers and forwarders are requiredto properly package, identify and documentall dangerous goods, and in a perfect worldthese precautions and the use of properly de-signed and equipped aircraft would come closeto guaranteeing safe transport. Unfortunately,in the real world serous accidents occur.

Dangerous Goods Accidents

In December 1973 a Pan American World Air-ways Boeing 707 cargo aircraft crashed min-


utes short of a landing at Boston’s Logan In-ternational Airport and the three crew mem-bers died when acrid smoke impaired theirvision and ability to function. Investigationsshowed that more that half the chemicals onboard were improperly packaged and almostall of the packages were improperly marked.Included in the shipment was nitric acid, anoxidizing material which reacts with many othermaterials causing intense heat and large amountsof smoke.

U.S. regulations require that nitric acid be pack-aged with suitable noncombustible cushion-ing material, but the boxes used for the outerpackaging of the shipment were not manufac-tured to U.S. Department of Transportationstandards — bottles were not packed in metalcontainers, and the cushioning material wascombustible sawdust. Some of the chemicalswere carried in portable “igloo” type contain-ers and labelled “electrical appliances.”

This evasion of the regulations was not anisolated incident. A similar shipment of nitricacid was loaded aboard another passenger air-craft (and again labelled as “electrical appli-ances”). Six months after the Pan Americanaccident, a potential tragedy for 75 passen-gers aboard an Aeromexico DC-9 was narrowlyaverted when its crew discovered a shipmentof nitric acid had spilled in the cargo compart-ment. An earlier U.S. interagency study hadrevealed that 175 of 300 packages inspectedviolated U.S. Federal Aviation Administration(FAA) regulations with 85 having incorrect ormissing labels, 72 having radiation levels ex-ceeding the amount stated on the package, 10packages having radioactive levels exceedingthe amount authorized per package and ninepackages having nonapproved or improperlymarked containers.

The U.S. Air Line Pilots Association (ALPA),studied these breaches of the regulations andin 1975 launched a 10-year campaign calledthe STOP (Safe Transport Of Passengers) pro-gram to reduce the risks associate with dan-gerous goods. The particular incident that causedALPA to initiate its campaign was a spill ofradioactive material in the cargo compartmentof a Delta Air Lines passenger aircraft that

exposed more than 900 persons in eleven cit-ies to unnecessary radiation.

The action at first was almost a total embargoof all hazardous materials in cargo or passen-ger aircraft. During the early period of theALPA campaign, the following materials wereremoved, at the demand of pilots, from pas-senger flights:

• 150 pounds of flammable liquids

• 40 pounds of sodium bisulphate andhydrochloric acid

• containers of xylene, a chemical with alow flash point

• 60 pounds of compressed gas

By the middle 1980s, detected violations ofU.S. regulations had fallen to 600-800 per yearand ALPA suspended its STOP campaign inOctober 1984. However, a January 1989 U.S.National Transportation Safety Board (NTSB)report of a serious occurrence aboard an Ameri-can Airlines MD-80 aircraft in February 1988showed that serious safety problems contin-ued. An illegal, mislabelled shipment wasresponsible for the emergency landing andevacuation of the airliner at Nashville, Ten-nessee. Leakage of hydrogen peroxide and so-dium hydroxide caused extensive damage tothe floor and sub-floor of the passenger cabin.The way in which heat developed and dam-aged the inside of the cargo hold threatenedthe lives of 125 passengers and crew. Afterinvestigating this incident involving undeclared,or hidden, dangerous goods, the NTSB calledfor major changes in regulations, proceduresand equipment to ensure safer air travel.

Passengers’ Baggage

The following list is a selection of occurrencesin the United Kingdom over a 12-month pe-riod in 1983-1984:

• During a customs check a suitcase wasfound to contain three bottles of nitricacid and one bottle of hydrochloric acid.


• A kerosene lamp was stolen by a rugbyplayer on his way to the airport andsmuggled onto the aircraft.

• Smoke emanated from a suitcase whilethe aircraft was being unloaded; it wasfound to contain two burned books ofmatches.

• A passenger was found in possessionof a tear gas device.

• Two passengers were found to have 960disposable lighters in their hand bag-gage and 163 more in their suitcases.

• During the crew’s preflight inspectiona can of flammable liquid was found inthe luggage rack.

• During flight, fumes were seen ema-nating from paint carried in a passenger’sbag.

• A passenger undergoing a security checkwas found with 144 quarter-litre bottlesof hydrochloric acid in his baggage. Fourmembers of the security team were hos-pitalized for four days after being ex-posed to the fumes.

• School children informed the cabin crewthat they had fireworks in their pock-ets and in their luggage. There were sixmore similar incidents in the next twomonths, including one where 12 largeand 2,500 small pieces of fireworks werediscovered.

In February 1986, a British Airways passengeraircraft landed at London’s Heathrow Airport,although it was scheduled to land at Manchester.The diversion was made because several pas-sengers were suffering from exposure to fumesfrom two containers of ethyl chlorinate car-ried aboard by a passenger. He was chargedwith recklessly endangering the aircraft andall those aboard and was heavily fined.

In one case, a rocket engineer traveling as apassenger carried aboard a rocket motor thatcontained explosives. In another incident, a

passenger caused $12,000 of damage to thecarpet in a terminal building while carrying aleaking jar of corrosive substance from onecheck-in counter to another.

Although airlines display notices informingpassengers about prohibited items, difficul-ties continue to be experienced — perhaps be-cause the notices are unseen before the bagshave been packed and passengers are reluc-tant to leave behind any item. Prohibited haz-ardous materials are frequently found in thepossession of passengers when baggage is in-spected at airport security screening.

Airmail Packages

Millions of packages are airmailed each yearby a general public that is largely ignorant ofregulations applicable to dangerous goods. Atypical incident showing the risks posed bythe mailing of dangerous goods happened atBrisbane, Australia. One of three parcels con-signed from Taiwan to a “sporting arms dealer”exploded, causing serious injuries and dam-age. The investigation showed that after beingexempted from inspection by customs, the parcelswere being slid along a counter, and one ofthem fell four inches to a second counter anddetonated. The packages bore no hazard warninglabels, although each contained 44,000 start-ing pistol caps. The UN number (a serial num-ber assigned to the article or substance underthe United Nations classification system) usedon the packages was not one recognized bypostal or customs officers. The consignee claimedthat it was a duplication of an earlier orderbut denied knowledge of the mode of con-signment used on any other occasion.

FAA Cargo and BaggageHold Categories

Class A — Compartments where fire would beeasily discovered by a crew member and beeasily accessible in flight, such as coat closetsor overhead compartments in the passengercabin.

Class B — Typically much larger than Class A


with sufficient access in flight to enable a crewmember to reach any part of the compartmentwith a hand-held fire extinguisher; incorpo-rates smoke or fire detection to give warningat pilot or flight engineer station; requires linermeeting flame penetration standards; and ac-cess should be possible without smoke or fumesentering the passenger or flight deck areas.(The upper or main deck cargo compartmentsof “combi” aircraft, those which carry bothpassengers and cargo on the same deck sepa-rated by temporary or movable bulkheads, arenormally Class B.)

Class C — Compartment that does not meetthe accessibility requirements for Classes Aand B, but which has built-in fire extinguish-ing and fire detection systems. These com-partments are usually below the floor and canbe large in volume.

Class D — A compartment in which fire wouldbe completely contained without endangeringthe safety of the aircraft and its occupants, itis designed to contain a fire by restricting thesupply of oxygen. (Some hazardous materials,however, are themselves oxygen producers.)

Class E — Main deck compartment used onlyfor all-cargo flights; means must be providedto shut off ventilating air flow to or within aClass E compartment; a fire resistant liner mustbe capable of resisting the flame penetration;and the compartment is accessible to the crewand may be very large in volume. It mustincorporate fire and smoke detection and mustnot block crew member evacuation routes.

“Combi” Aircraft

It is forecast that air transport of dangerousgoods will increase at the rate of 20 percentper year. This prediction and the use of combiaircraft raise serious safety problems. In thelatter, the main-deck cargo compartments arefully ventilated and nearby flight control cablescould be exposed to very high temperaturesin the event of fire. Because dangerous goodscarried in these upper or main deck compart-ments are permitted on passenger aircraft, thereis a requirement that they be accessible to the

crew in flight (Class B).

Pilots are concerned by the absence of auto-matic extinguisher systems in Class B com-partments, difficulty of access to these com-partments with hand-held fire extinguishersand by doubts about performance and avail-ability of fire and smoke detectors. They be-lieve that the amount of ventilation providedin upper-and main-deck cargo compartmentsand the huge volume of oxygen available wouldsustain any fire that breaks out and perhapspermit it to become uncontrollable.

A 1987 conference of the International Federa-tion of Air Line Pilots Associations (IFALPA)stated that the Federation would prefer thatcarriage of dangerous goods be limited to all-cargo aircraft but accepted that early imple-mentation of that position is unlikely. Anotherpolicy stated that the Federation opposes thecarriage of dangerous goods on the upper andmain decks of combi aircraft because of thepossible hazards of smoke, fumes or radiationentering into the passenger cabin and flightdeck. The rationale for the policy was thattests show that the greater differential pres-sure required in a passenger compartment toprevent fumes and smoke from entering froma cargo compartment is not effective.

Another policy objective is to limit the car-riage of dangerous goods to Class C compart-ments that are sealed and equipped with firedetection and extinguishing systems. IFALPAcampaigns vigorously for improved cargo andbaggage compartments with an objective be-ing to limit the size of Class D compartmentsthat rely on lack of ventilation as the principlemeans of suppressing fires.

A Combi Aircraft Accident

The prophetic concerns expressed by IFALPAin 1987 received unwanted substantiation whena South African Airways Boeing 747-200B combiaircraft crashed into the Indian Ocean 134 milesnortheast of Mauritius with the loss of all 160persons on board. The accident happened onNovember 28, 1987, but the voice recorder wasnot recovered until January 6, 1989; the wreckage


was at a depth of more than 14,000 feet. Enoughwreckage was recovered for the official in-quiry to conclude that fire broke out in the aftupper deck cargo area and temperatures reached1,000 degrees C. Investigation showed that therewas a pressure build-up in the cargo area whichburst through to the galley. Some passengerbodies showed abnormally high carbon mon-oxide concentrations, indicating that smokepenetrated the passenger cabin.

The only fire fighting equipment available tothe crew was a single 16-pound rated Halonextinguisher with a stream duration of 12 sec-onds. In this situation, a flight attendant wouldhave had to enter through a partition door,put on asbestos gloves, unfasten the 9-G cargorestraint net, rig the extinguisher, locate thefire in a particular pallet in conditions of thicksmoke, and direct the extinguisher’s contentsonto the fire.

After this accident the airline converted itsremaining Boeing 747 combi aircraft to all-passenger configurations.

There were media reports that some shippersof cargo on the ill-fated combi aircraft did notfile claims for their losses, leading to uncon-firmed speculation that illegal shipments wereon board. Another suspicion was that the firewas “pyrotechnic” in origin.

Regulatory ResponseTo the Accident

In September 1989 the FAA published an Air-worthiness Directive (AD) that affects all ClassB cargo compartments in combi aircraft wherepassengers and cargo are accommodated onthe same deck, and will be implemented intwo stages over a three-year period. The com-partments have to be modified to Class C stan-dard or have flame-resistant cargo containersequipped with smoke detectors and fire extin-guishing systems. The AD also calls for imple-mentation of numerous measures involvingupper- or main-deck cargo compartments ofcombi aircraft within three years, some of whichare:

• Smoke or fire detection systems withaural or visual warning at the stationassigned to the person trained to fightfires.

• Fire extinguishing system to “knockdown” a fire and suppress it so that thecrew can find and put out the fire.

• Provision for a ventilation shut-off op-erable from the flight deck.

• Designated individuals trained to fightcargo fires.

• Provision of a cargo compartment linerthat is flame and smoke resistant.

• Two-way communication between theflight deck, the fire fighter’s duty sta-tion and cargo compartment.

• Cargo loading envelope limitations toprovide access to all cargo to fight fires.

• Provision of a cargo compartment tem-perature indication system to both theflight deck and firefighter’s station.

The FAA states that the firefighter must be aperson trained to its standards and be addi-tional to crew members required by currentoperational rules. The firefighter must searchthe cargo compartment before takeoff and ev-ery 30 minutes in flight unless an approvedtemperature-monitoring system is installed.Additional portable fire extinguishers are alsorequired as is improved protection for cockpitvoice and flight data recorders, windows, safetydevices and flight control systems.

The AD provoked criticism from airlines be-cause modification costs for Boeing 747 air-craft could be as high as $2.2 million per air-craft. British Airways has stated that it hasimproved its combi aircraft by covering pal-lets with fire-resistant blankets, installing firecurtains in cargo containers; increasing thenumber of fire extinguishers; and providing acargo area viewing window, fire suits and ad-ditional training in fire fighting. Other air-lines have responded in similar fashion, but


some sought to extend the period allowed forcompliance with the AD or to reduce the re-quirements. This was accommodated in thefinal ruling dated May 3, 1990 that allowedapproximately six months of additional timefor compliance.

Current Trends

A tendency to reduce the strictness of the originalICAO Technical Instructions for the Safe Trans-port of Dangerous Goods by Air, and to exceptfrom the regulations some small shipments ofdangerous goods seems likely to increase lev-els of risk. These excepted shipments will notcarry normal labels and thus the pilot-in-com-mand will not be aware of their presence andtheir being mixed in with non-dangerous andidentified dangerous goods. There will, there-fore, be a greater risk requiring an increasedawareness by all persons concerned if that riskis to be kept to an acceptable level.

Some experts believe that there is a need toprovide better training to shippers, packers,forwarders and airline personnel; to educatethe public about risks posed by dangerous goods;and to license cargo shippers and forwarders.An industry investment in improved technol-ogy could detect and deter both innocent anddeliberate evasion of the regulations by in-stalling equipment capable of detecting verysmall quantities of hazardous materials by meansof “super sniffing” techniques, albeit at veryhigh cost. Cargo or baggage loaded in con-tainers or igloos is passed through the installedequipment at a rate of up to 20 containers perhour and it is claimed that the equipment candetect minute quantities of any material whichit has been designed and programed to detect.Air samples gathered from the containers arepassed through a test section containing a specialdisposable cartridge. Detection is based on thedifferent molecular weights of the aromaticcomponents of the target material and it is

claimed that even if explosives or drugs aretightly enclosed in film wrap, sufficient odorswill be detected to raise the alarm.

Because each installation costs more than $3million they are unlikely to be widely used. Itis possible that the cost of later versions of theequipment will be less and they will then beused at airports and the premises of freightforwarders. In October 1987 it was announcedthat the Japanese Customs Bureau had pur-chased four of the units and two systems arealready in use in an unidentified Middle East-ern country where they are combined with X-ray equipment. It is not known if the supersniffer equipment can be used to detect alldangerous goods but it does raise hopes ofequipment being developed in the future.

Until such detection equipment is widely avail-able, ICAO regulations are enforced with in-creased emphasis on undeclared and hiddendangerous goods and the FAA’s AD regardingClass B compartments is implemented world-wide, it is probable that many of the dangersposed by air carriage of hazardous materialswill continue. ♦

About the Author

Laurie Taylor flew with the British Royal Air Forcein World War II and later with British OverseasAirways Corp. (BOAC) and its successor, BritishAirways.

Taylor was chairman of the British Air Line PilotsAssociation (BALPA) and served as principal vicepresident, and later executive secretary of theInternational Federation of Air Line PilotsAssociations. He has sat on the council of theU.K. Air Registration Board and was a member ofthe Airworthiness Committee of the InternationalCivil Aviation Organization (ICAO) and of theFlight Time Limitations Committee of the U.K.Civil Aviation Authority (CAA).

He was awarded the Order of the British Empire(OBE), is a member of the Association of BritishAviation Consultants and is a fellow of the RoyalAeronautical Society.

Taylor is the author of “Air Travel, How Safe IsIt?” published by BSP Professional Books.


“Corporation Executive Indicted for Toxic WasteViolation.” Has a headline like this caughtyour eyes? Well, a toxic waste violation canhappen in any industry, even in such a highlysafety conscious business as a commercial air-line.

Toxic or hazardous chemicals are used in manyoperations in the airline industry. Jet fuel isconsidered an ignitable hazardous waste. Greasesolvents used in equipment maintenance areconsidered to be toxic waste by the U.S. Envi-ronmental Protection Agency (EPA). Hydrau-lic fluids and lubricating oils are classified ashazardous waste by several states (New Jer-sey, Massachusetts and Connecticut, amongothers). Cleaning compounds that are used inairplane cabins, airframes, electronics, cargobays and control systems may contain toxic orcorrosive chemicals. Worse yet, items shippedas cargo could become hazardous waste if spilledor damaged.

If any of these toxic chemicals are improperlydisposed of, the law may place the blame onmanagement, even if a manager or operatorhas only a very indirect responsibility for theiruse or misuse, and even if misuse took placeyears ago. Managers have even been foundliable for improper actions of independent con-

Hazardous Waste and Aviation

Many substances commonly used in aviation becomehazardous waste the moment they are spilled or aredisposed of — that is when stringent environmental

laws must be meticulously adhered to.

byJohn H. Kehoe

Senior Materials Routing SupervisorLaidlaw Environmental Services Inc.

tractors. The law assigns responsibility forproper waste disposal primarily to the “gen-erator” (the company that first produces thewaste material) of the waste regardless of howmany other companies handle the material af-terward. The fines and jail terms handed outto corporate management, as well as consider-ations of safety and health of workers and thepublic, mean that managers should be awareand knowledgeable about toxic waste laws andthe way that their companies deal with suchmaterials.

A hazardous material is a substance that isregulated when it is in transportation. In theUnited States, hazardous material transporta-tion is regulated and controlled by the U.S.Department of Transportation (DOT). Haz-ardous waste is a substance that is being dis-posed of that may pose a danger to humanhealth and the environment. Hazardous wasteis regulated by the EPA and various state agen-cies.

Learn the Acronyms

Hazardous chemical law has grown to be ascomplex and obscure as tax law. Most of theselaws are usually known by their acronyms:


TOSCA (Toxic Substances Control Act), CERCLA(Comprehensive Environmental Response Com-pensation and Liability Act), ECRA (The Envi-ronmental Cleanup Responsibility Act), FIFRA(Federal Insecticide, Fungicide and Rodenti-cide Act), SARA (Superfund Authorization andRecovery Act), but there are also The CleanAir Act and The Clean Water Act. As usual,ignorance of the law is no excuse in court.The law that affects almost every large corpo-ration is known as the Resource Conservationand Recovery Act (RCRA). RCRA governs thestorage, treatment and disposal of hazardouswaste. RCRA is enforced by the U.S. EPA aswell as similar agencies at the state level. RCRAmandates “cradle to grave” recordkeeping forall hazardous waste activity.

Cradle to grave means that proper records mustbe kept from the moment waste is produced,while it is being stored or transported, andafter it is disposed of. Most hazardous wasteviolations stem from improper or incompleterecordkeeping. To begin, any company thatproduces more than a certain minimum of wastemust file a “Notification of Hazardous WasteActivity” form with the EPA and the appro-priate state agency. In return, the company isgiven a control number known as the “EPAidentification number” which must be presenton all reports, records and shipping papers.RCRA requires that annual reports of all haz-ardous waste activity must be filed. Somestates require quarterly reports as well.

Because of past improper treatment and dis-posal, current hazardous waste regulation andenforcement is both complicated and strict.Most large generators of hazardous waste areonly allowed to store their waste for ninetydays after it has been produced. After thisperiod, the generator is liable to suffer finesand legal actions. The storage time limit onwaste has a purpose; some of the biggest toxicwaste sites began with improperly stored waste.Long-term storage results in many problems.Containers may begin to leak onto the ground.Containers left outside may rust or decom-pose and labels of contents of waste contain-ers may fall off or become obscured with thepassage of time. Congress put the storagetime limit into law in order to correct prob-

lems like these. The less waste that is stored,the fewer problems will result. Because wastedisposal is expensive, many companies mightotherwise choose to delay this chore — in thepast the delays have often been for years. Manytoxic waste sites arose when a company wentout of business leaving behind a large quan-tity of stored toxic waste and no funds to payfor its disposal. Of course, the 90-day timelimit only applies to regulated hazardous waste,not to nonregulated waste, so it is importantto keep the two distinct.

‘Start Date’ Is Important

To enforce storage limitations, RCRA requiresthat all hazardous waste containers be identi-fied with a specific label that states thegenerator ’s name, address, EPA identificationnumber, and the “start date” (the date that thewaste was produced). The EPA also requiresthat detailed inventory records be kept on allwaste. When waste is shipped offsite, specialmanifests are required, copies of which mustbe sent to state agencies where they become amatter of public record.

Even after the waste is shipped for disposal,liabilities remain. RCRA makes the originalgenerator of the waste ultimately responsiblefor what happens to it even after it leaves hishands. Generators have been prosecuted forimproper actions of contractors, i.e., haulersand disposal sites. For this reason it is veryimportant for a waste generator to hire onlyresponsible licensed hauling and disposal firms.Check your waste hauler thoroughly. Somecompanies are hiring their own environmen-tal specialists. Like the tax laws, the wastelaws are complicated and technical. A spe-cialist can save a company money and legalfees.

“What exactly is hazardous waste and how doI know if my company produces any?” Mosthazardous waste consists of common indus-trial chemicals used every day in a wide vari-ety of operations. They become hazardouswaste only when they are spilled or disposed.Waste types are identified by category andnumber in the U.S. Code, Title 40, beginning


with Part 261.

The first category is called Characteristic Waste.Characteristic Waste is waste that exhibits acharacteristic of ignitability, corrosivity or re-activity, or contains certain heavy metals orpesticides. Jet fuel that has become dirty orcontaminated and has to be disposed is a goodexample of an ignitable waste. Inline fuel fil-ters may also be considered ignitable waste.Many paints and paint thinners also fall intothis category. Some cleaning compounds maybe considered to be corrosive waste when theyare disposed of. Air bag inflation devices thatcontain sodium azide may be reactive waste.Many common industrial waste materials, con-taining certain heavy metals such as lead orchromium, are called “Hazardous Waste fromNonspecific Sources.” This category includesorganic solvents and waste from metal platingoperations. The grease solvents used in air-craft machine shops and maintenance opera-tions fit into this category. Several states con-sider waste hydraulic fluid and lubricatingoils hazardous waste. In addition, there aremany other waste categories and specific wastetypes.

Hazardous Chemicals Are Air-borne

Many hazardous chemicals are shipped by aireach day. Hazardous waste as such is notshipped by air, but many other non-waste chemi-cals travel as air freight on both passengerand cargo aircraft. For safety reasons, extremelyhazardous chemicals are forbidden from trans-port on passenger aircraft except in very smallquantities that are well packaged. Such ex-tremely hazardous chemicals are marked “cargoaircraft only.” The U.S. DOT has strict rulesabout the packaging and labeling of all haz-ardous materials for air transport. Bulk chemicalsare seldom shipped by air because the freightcharge would be too high. Nevertheless, haz-ardous materials are probably present on mostflights. Samples of chemical products, lab chemi-cals and samples for analysis travel throughthe mail and the air every day. Some materi-als that would not normally be thought of asdangerous can be damaging to aircraft. Switches

and electrical equipment can contain metallicmercury, which, if it escapes from its container,can damage aluminum airframes. Commonhousehold drain cleaner can damage airframesas well. For this reason, such materials areallowed on aircraft only when securely pack-aged in leak-proof containers. In addition,despite the warning signs about hazardousmaterial posted at all commercial air termi-nals, passengers unknowingly often carry haz-ardous materials in their luggage.

What happens to hazardous waste after it leavesthe site where it was produced? In the past,most waste went to landfills or was injectedinto underground rock formations. Becauseof numerous incidents of leaking landfills andpolluted groundwater, the U.S. Congress, whenit reauthorized RCRA in 1984, mandated a phase-out of all forms of land disposal over a five-year period starting in 1986. Known by vari-ous terms, this “landban” is making dramaticchanges in the ways that hazardous waste istreated and disposed of.

Today, incineration and treatment are becom-ing the rule. Incineration in high-temperaturestate-of-the-art incinerators is a popular, butexpensive, method of waste disposal. Thelandban provides strict standards for the ex-tent to which materials have to be treated.Waste water treatment is the preferred methodfor many other types of waste. Acids andalkalies are neutralized in this process andheavy metals are precipitated out of the waste,rendering it nonhazardous. The waste watergoes to the public sewer and the solid residuegoes to secure landfills. Of course, even whenthe waste is treated to the maximum extentrequired by law, a residue remains. This resi-due, which may consist of incinerator ash ortreatment sludge, goes to modern landfills thatare a far cry from their sometimes primitivepredecessors.

The modern, licensed, secure landfill uses severaldifferent strategies to ensure that waste that isdeposited there remains at the site. Currentlandfills contain at least four separate highdensity polyethylene liners along with addi-tional layers of impermeable compacted claythat forms a chemical-proof barrier to any out-


ward migration of the waste. In addition tothese barriers, the modern landfill containsleachate collection systems to remove any liq-uid that may collect in the landfill. One ulti-mate goal of the landban is to make sure thatonly waste that has been treated to the maxi-mum extent required by law goes into the ground.

Recycling — A Viable Option

Recycling of waste materials is among the bestand most economical methods of treatmentavailable. Certain organic materials such asgrease solvents lend themselves to recycling.Congress requires waste minimization effortsfrom all producers of waste. The goal is tominimize the amount of waste that is pro-duced, either through recycling, or redesignof processes and procedures in order to pro-duce less waste in the first place. The landbanhas dramatically increased the cost of wastecollection, treatment and disposal. This in-creased cost, in addition to waste taxes thatare levied by many states, has created a strongincentive towards waste minimization. Somecompanies have switched to nonhazardous andnontoxic grease solvents. Others no longeruse paints that require hazardous thinners.Switching to products that are not hazardous,or those that are easier to treat, can actuallysave companies money even if the initial out-lay for the products is greater. Waste disposalcosts, as well as waste taxes and environmen-tal consulting fees, should be taken into ac-count before purchasing new products.

Recent regulations such as the Superfund Re-authorization Act and Occupational Safety andHealth Administration (OSHA) laws have in-creased the reporting burden on companies.Companies must have data on file on all thehazardous chemicals they use in their opera-tions. This data usually takes the form of aMaterial Safety Data Sheet (MSDS). An MSDSis an OSHA-mandated form that lists the haz-ardous ingredients of a product and it shouldcontain necessary safety and health informa-tion. OSHA requires that MSDS informationbe made available to all employees and thatthey be informed about any possible occupa-tional exposure to hazardous chemicals.

Public concern about chemical exposure hasresulted in “right to know” laws which man-date that not only workers, but also the publicmust be informed about any hazardous chemicalsthat companies use. This new regulation, partof the Superfund Reauthorization Act, requiresthat companies send chemical inventories andMSDS information to state agencies as well aslocal governments and fire departments. Thisinformation remains on file and available forpublic inspection. Companies also must re-port all spills of hazardous chemicals to thesesame agencies and this information is also freelyavailable to the public. Information on spillsand releases often finds its way into news ar-ticles, which can result in embarrassing expla-nations and poor public relations.

Another important new law is ECRA, now onthe books in New Jersey and some other statesand which may become federal law. ECRAmandates that before commercial property canbe sold, it must pass an environmental audit,requiring that the site be certified to be cleanof any hazardous chemical contamination frompast activities. Past improper disposal prac-tices are resulting in many expensive cleanupoperations. The ECRA laws evolved becausein the past, companies often sold contaminatedsites to unsuspecting new owners.

One of the largest sources of hazardous wasteresults from spills and leaks during normaloperations. Almost any kind of routine main-tenance is bound to produce spillage of somesort. Oil and grease spills often accompanyengine work. Small fuel leaks frequently oc-cur during refueling and filter changes. Hy-draulic fluid may escape during inspectionsand servicing. Many companies still followthe same procedures with this spill materialthat they have been following for years; namely,cover the spill with an absorbent, sweep it up,and throw it away with the trash. This methodof waste handling is not good practice. Spilledmaterial must be identified, correctly cleanedand put into proper containers. The contain-ers should then be properly stored accordingto the hazardous waste regulations. Keepinghazardous trash and spill materials separatefrom nonhazardous debris is essential, in or-der to keep costs down and stay in legal com-


pliance. If hazardous trash is mixed with non-hazardous refuse, the entire mixture is con-sidered to be hazardous. Oil or grease spills,though not considered hazardous by federallaw, are strictly regulated waste in several states.Failure to clean spills properly can result inthe materials washing into soil and streamswith consequent widespread pollution. In ad-dition, fines and other legal penalties are al-ways a possibility for companies that do notcorrectly clean or properly report spills.

Where to Go for Help

Suppose you are responsible for a site thatmay have environmental problems or you justneed advice on these matters. Who shouldyou ask for information? What kind of com-pany should you hire?

Much will depend on what kind of companywith which you are associated and what kindof site is being used. The first and most im-portant resource is your own company’s envi-ronmental and safety compliance department.Most large firms have such a department. Un-fortunately, many of these departments havetheir hands full with other problems, and youmay be operating at a site which has never

come to their attention. Thefirst step is to determine whatyour operation is currentlydoing with its hazardouschemicals and what its spillprocedures are. Because wasteis not a producing part ofbusiness, and had little glamoror advancement potential as-sociated with it in the past,your operation may still behandling its waste materialsthe same way it handles or-dinary trash. Nontechnicalcleanup and maintenancepeople are probably not awareof what is necessary to be inlegal compliance with today’scomplicated regulations.

Many environmental informa-tion firms are in existence andcan provide extensive infor-mation on proper procedures.If you suspect that you areoperating at a contaminatedsite, or that problems mightexist, you may wish to hire atechnical consulting firm inorder to determine the extentof the problem. If you knowthat your site produces waste,and you need someone topackage, transport and dis-pose of it, then you shouldhire the services of a full ser-vice waste management com-Figure 1

Products Possible Hazardous ConstituentsAdhesives Organic solventsAntifoaming agents Phthalate estersBatteries: Lead acid Lead, sulfuric acid

Nickel cadmium Nickel, cadmium, caustic alkaliesNickel iron Nickel, caustic alkaliesMercury Mercury

Belt dressings Lead, organic solventsBrake fluids Glycol ethersBrake System Flushing Fluid Methyl alcohol, other alcoholsCaulking compounds Solvents, leadCleaning compounds Corrosives, solvents, glycol ethersCorrosion inhibitors Chromates, nitrites, nitrites,

amines, hydrazineCutting oils Nitrites, chromates, glycol ethersDegreasing compounds Chlorinated solvents, cresol, phenol,

caustic alkaliesFiber glass repair chemicals Organic peroxides, solventsFire extinguishers:

Foam Glycol ethersHalon Chlorinated solvents

Frost removers Alcohols, glycolsFuel driers AlcoholsGear oils Lead, organic phosphates, bariumGreases Lead, barium, chrome, glycol ethers,

chlorinated solventsHydraulic fluids Organic phosphatesPaints Lead, zinc, chrome, solventsRadiator flushes Caustics, acids, solventsRefrigerants ChlorofluorocarbonsTire cleaners Caustics, alcohols, glycol ethersTire repair compounds SolventsTransmission fluids Organic phosphatesWelding fluxes Acids


pany. Waste disposal companies, waste trans-porters, consulting services and environmen-tal laboratories can be found listed, by state,in Industrial and Hazardous Waste ManagementFirms, published annually by EnvironmentalInformation, Ltd., 7400 Metro Blvd., Suite 400,Minneapolis, MN 55435, U.S. Its telephonenumber is (612) 831-2473.

If you are hiring a waste management agency,you should make sure that you are dealingwith a reputable firm. Good sources to checkare the state EPAs. These agencies cannot rec-ommend anyone, but they can inform you aboutany legal compliance problems a company mighthave had.

Many companies that do business outside theUnited States would do well to become in-

formed on other countries’ environmental regu-lations. These can be quite strict, particularlyin Western Europe and Japan. In order to findout more information, the appropriate agen-cies should be contacted for each individualcountry. Some of these agencies are listedbelow. ♦

About the Author

John H. (Jack) Kehoe works as the senior materialsrouting supervisor for Laidlaw EnvironmentalService, Inc. at its Laurel, Md., transfer station.For the past five years, Kehoe has been responsiblefor overseeing the disposal of waste materials thatthe company handles on a contract basis. Previouslyhe worked as a chemist in the company’s fieldoperations unit.


BelgiumMarcel LambertCellule EnvironnementMinistèré de la Santé Publique et del’enviornnementQuartier VésaleCité administrative de l’Etat1010 Bruxelles

CanadaPierre BeaudeinWaste Control DivsionEnvironment CanadaW. Mary Blvd.Ottowa, Ontario K1A OH3

DenmarkWaste Management DivisionNational Agency of Environmental ProtectionStrandégade, 291401 Copenhagen K

FinlandMinistry of EnvironmentEnvironmental Protection DepartmentWaste Management DivisionP.O. Box 399SF-00121 Helsinki

FranceJean Louis DutaretService des DéchetsMinistère de l’Environnement14, Blvd du Général Leclere92524 Neuilly s/Seine Cedex

GermanyBrudesministerium für UmweltNaturschutz und ReaktorsicherheitPostfach 12 06 295300 Bonn 1

GreeceMinistère de l’Environnement de l’Urbanisme des Travaux PublicsDirection des Activités Internationales et des Sujets CEEPatission 14711251 Athènes

ItalyENEA125 Viale Regina Margherita00198 Rome

NetherlandsMinistry of Public HousingPhysical Planning and Environmental ProtectionDepartment of Waste and Clean TechnologiesP.O. Box 4502260 MB Leidschendam

NorwayState Pollution Control AuthorityB.P. 8100 Dep.0032 Oslo 1

SpainD.G.M.A.Ministerio de Obras Publicas y UrbanismoCastellana 6728071 Madrid

Division EnvironnementMinisterio de Obras Publicas y UrbanismoCastellana 6728071 Madrid

SwedenNational Environmental ProtectionBoardBox 130217125 Solna

SwitzerlandOffice Fédéral pour la Protection de l’Environnement3003 Berne

TurkeyConseiller JuridiqueMinistère des Affaires EtrangèresMesrutiyet Caddesi 27Yenisehir06650 Ankara

United KingdomJack BentlyDepartment of EnvironmentRoom B5.48Romney House43, Marsham StreetLondon SW1 3PY

United StatesWendy GriederOffice of International ActivitiesU.S. Environmental Protection Agency401 M Street, S.W.Washington, DC 20460 U.S.

John AtchesonPollution Prevention DivisionOPPEU.S. Environmental Protection Agency401 M Street, S.W.Washington, DC 20460 U.S.

Matthew StrausU.S. Environmental Protection Agency401 M Street, S.W.Washington, DC 20460 U.S.

International Hazardous Materials Information


During 1989, transportation fatalities in theUnited States totaled 48,234 — a drop of threepercent from 49,904 in 1988, according to theU.S. National Transportation Safety Board(NTSB). A breakdown of fatalities by trans-portation modes for calendar years 1988 and1989 is shown in Table 1.

NTSB statistics show that general aviation fa-talities were down from 796 in 1988 to 763, thelowest ever recorded annually in U.S. generalaviation history. Air carrier accidents claimedthe lives of another 277, down from 285 in1988. However, the fatalities involving com-

Aviation Statistics

U.S. Transportation Fatalities and TrendsIn the Eighties

muter air carrier and on-demand air taxi op-erations rose between 1988 and 1989, from 21to 32 for commuters and 58 to 86 for air taxis.

As a comparison with surface transportationstatistics, grade crossing accidents involvingtrains and highway vehicles resulted in 791fatalities in 1989, up approximately 15 percentfrom 689 deaths in 1988. This is the highestnumber grade crossing fatalities since the be-ginning of the decade when 833 persons werefatally injured. The NTSB also reported thatrail fatalities were up from 563 in 1988 to 601in 1989. Of the 601 rail fatalities, more than 90percent were non-passengers, six percent wererail employees and only about three percentwere rail passengers.

In highway fatalities, which account for about95 percent of total transportation, fatalitiesdropped more than three percent in 1989 from47,087 in 1988 to 45,454. “While the decline inhighway fatalities in heartening,” the NTSBreport noted, “the number of people killed inalcohol- and drug-related accidents is totallyunacceptable. Alcohol and drug abuse con-tinued to be one of greatest threats to trans-portation safety facing the nation.” Althoughthe NTSB did not release the most recent alco-hol/drug-related transportation fatality sta-tistics, the U.S. National Highway Traffic SafetyAdministration (NHTSA) 1987 statistics as shownin Table 2 reveal that of all motor vehicle driv-ers involved in highway fatal accidents, in-cluding motorcycle operators, eight percenthad a .01-.09 percent blood-alcohol concentra-tion (BAC) level and 25 percent had a .10 per-cent or higher BAC level.

In aviation, the U.S. Federal Aviation Regula-

Table 1 - U.S. Transportation FatalitiesBy Transportation Modes

1988 - 1989

Modes 1988 1989

Highway 47,087 45,454

Grade Crossing 689 791

Rail 563 601

Aviation

Airline 285 277

Commuter 21 32

Air Taxi 58 86

General Aviation 781 763

Marine Commercial 128 95

Recreational 946 896

Pipeline 20 39

Total 50,578 48,243


tions (FAR) prohibit the use of alcohol by crewmembers within eight hours of flight time andalso prohibit anyone from acting as a flightcrew member while under the influence ofalcohol. In a recent alcohol-related incidentinvolving airline pilots, it was reported thatthe FAA in March this year revoked the li-censes of three airline crew members who werecharged with flying a jetliner from Fargo, NorthDakota, to Minneapolis, Minnesota, while un-der the influence of alcohol. The NTSB hasnot released any more recent alcohol-relatedaccident statistics to substantiate its concernabout alcohol/drug abuse in aviation.

In a safety study, published in April 1984, theNTSB reported that during the years 1975-1981,more than 10 percent of the toxicological testson all deceased pilots were positive for alco-hol, but no deceased airline pilots were foundto have positive alcohol tests in the same pe-riod. Toxicological tests were positive for al-cohol in 6.4 percent of the tests made on fa-tally injured commuter air carrier pilots andin 7.4 percent of fatally injured air taxi pilots.In general aviation, 10.5 percent of toxicologi-cal tests on fatally injured pilots were positivefor alcohol. The extent to which alcohol isinvolved in non-fatal accidents was not knownbecause there is no federal authority to testsurviving pilots for alcohol.

A graphical presentation of the annual fatalitydistribution over the past decade by transpor-tation modes is show in Figure 1. Note thatover the 10-year period, the annual fatalitiesof general aviation and recreational boatingshowed a very steady trend of improvement.Airline fatalities were up one year and downthe next, with a low of one fatality in 1980 andfour fatalities in 1981, 1984 and 1986, and a

54,00053,00052,00051,00050,00049,00048,00047,00046,00045,00044,00043,00042,00041,000

••

••

• •

• • ••

Highway

Annual Distribution of Transportation Fatalities by Transportation Mode Calendar Year 1980-1989

1,4001,3501,3001,2501,2001,1501,1001,000

950900850

750700650600550500

•

• ••

• •• • •

•

Recreational Boating

••

•

• •• •

•• •

800 ••

• ••

• • ••

•

General Aviation

Grade Crossing* **

*

*

* * * * *Rail

020406080

100120140160180200220240260280300

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989

Year

••

•

• •

• •

•

••

Marine-Commercial

• •• • • • • • • •Air Taxi

* * * * * * *

** *

• •

•

• •

•

• ••

•

Airline

Commuter

high of 526 fatalities in 1985; there was obvi-ously not a trend in this category. Of all othertransportation modes, including highway, rail,grade crossing, commuter, air carrier and airtaxi, the annual fatalities show a decline in theearly 1980s, but the trends for these categoriesturned upward since 1985-1986. ♦

Figure 1

Table 2 - Motor Vehicle Drivers, Pedestrians and Cyclists Involved in Highway Fatal AccidentsCalendar Year 1987

Persons involved Number Blood Alcohol Concentration LevelNone Less than .10% More than .9%

Vehicle Drivers 60,486 67% 8% 25% Male 46,882 63% 9% 28% Female 13,604 79% 6% 15%Pedestrians and Bicyclists 7,751 64% 7% 29%Motorcycle Operators 3,848 49% 13% 38%


Reports Received at FSFJerry Lederer Aviation Library

Reports

Human Factors of Flight-Deck Checklists: The NormalChecklist / Asaf Degani (NASA Ames ResearchCenter) and Earl L. Wiener (University of Mi-ami). — Washington, D.C. : National Aero-nautics and Space Administration; Springfield,Va. : Available through NTIS*; May, 1990. Re-port NASA-CR-177549; Contract NCC2-377. 72p.

Key Words1. Airplanes — Piloting — Checklists.2. Airplanes — Piloting — Human Factors.3. Air Pilots — Errors.4. Air Pilots — Workload.5. Airlines — Operational Procedures.

Summary: Although the aircraft checklist haslong been regarded as the foundation of pilotstandardization and cockpit safety, it has es-caped the scrutiny of the human factors pro-fession. The improper use, or the non-use, ofthe normal checklist by flight crews is oftencited as the probable cause or at least a con-tributing factor to aircraft accidents. In thisreport, the authors attempt to analyze the nor-mal checklist, its functions, format, design, length,usage, and the limitations of the humans whomust interact with it. The manufacturers, gov-ernment, airlines, and pilots all influence theultimate design and usage of the checklist.The effects of airline mergers and acquisitionson checklist usage and design are noted. Theinteraction between production pressures (“mak-ing schedules”) and checklist usage and checklistmanagement are addressed. A list of designguidelines for normal checklists is provided.[author]

The Practice of Aviation Safety: Observations fromFlight Safety Foundation Safety Audits / Capt.E.R. Arbon (Flight Safety Foundation), Capt.L. Homer Mouden (L. H. Mouden Associates),Robert A. Feeler (Robert A. Feeler Associates).— Arlington, Va.: Flight Safety Foundation,June 1990. Report FSF/CP-90/12. 45p. Avail-

able: FSF, $25.00 (U.S.)(member), $35.00(U.S.)(nonmember).

Key Words1. Aeronautics — Safety Measures — Audit-

ing.2. Airlines — Operational Procedures — Au-

diting.3. Corporate Flying — Operational Procedures

— Auditing.4. Airports — Safety Measures — Auditing.5. Air Pilots — Performance — Auditing.6. Airplanes — Piloting — Auditing.7. Safety Audits.

Table of Contents: Safety Audits and Opera-tor Goals — A Typical Aviation Safety Audit— Lessons Learned from Safety Audits — Or-ganizational Characteristics:

Policies and Procedures; Communication; MoraleIssues; Organizing Safety Activities; Training;Flight Operations; Cabin Services; Maintenanceand Engineering; Inspection Quality Assurance;Ramp Activities and Ground Operations; Air-craft, Equipment and Facilities; Corporate Air-craft Standards; Summary — Appendix [Bibli-ography].

Summary: This publication “shares, in anonattributive manner, some of the Foundation’saccumulated audit experience acquired from60 audits conducted worldwide during the pastdecade, from small corporate aviation opera-tions to large international air carriers. Thedimensions of both internal self-audits andexternal independent audits, including gen-eral guidelines for conducting them, are alsoaddressed. ... It is the aim of this document toprovide operators with a perspective on howsafety is or is not achieved; the recommenda-tions and observations may be useful in self-examination of their own operations.” [Fore-word]

Report of the Board of Inquiry into the Loss of


South African Airways Boeing 747 - 244B CombiAircraft “Helderberg” in the Indian Ocean on No-vember 28th 1987 / Republic of South Africa.— Pretoria, South Africa; Government Printer,May 14, 1990. 264p [Two volumes bound to-gether as one volume.]

Key Words1 Aeronautics — Accidents — 1987.2. Aeronautics — Accidents — Cargo Area.3. Aeronautics — Accidents — Fire — Cargo

Area.4. Aeronautics — Accidents — Smoke Detec-

tors.5. Airplanes — Airworthiness.6. Airplanes — Design and Construction.7. Boeing 747 (Jet Transports) — Accidents.8. Operation Resolve.9. South African Airways — Accidents — 1987.

Letter to The Honorable Minister of Transportand of Public Works and Land Affairs submit-ting the final Report of Board of Inquiry, C.S.Margo, Chairman.

Summary: South African Airways Flight 295,B747-244B “Combi,” Taipei to Plaisance, 5 flightcrew, 14 cabin crew, 140 passengers on aboard.Some 46 minutes before the estimated time ofarrival at Plaisance Airport, Mauritius, the flightdeck informed the approach control at Plaisancethat there was a smoke problem in the air-plane and that an emergency descent to flightlevel 140 had been initiated. Eighteen min-utes later, at about 04:07 local time, the air-plane crashed into the Indian Ocean 134 nau-tical miles North-East of Plaisance Airport. Therewere no survivors. The wreckage, consistingof thousands of fragments, sank to the oceanat depths of the order of 15,000 feet, althoughmany of the lighter materials floated away onthe currents. “...sufficient evidence has beenrecovered to enable the Board to determinethat the fire broke out in the forward pallet onthe right side, the circumstances being suchthat a similar fire could occur again in anotheraircraft; that the fire got out of control, andgenerated consequences, either by way of damageto the aircraft, or by way of loss of control ofthe aircraft, or by way of incapacity (whichterm includes distraction) of the crew, whichcaused the aircraft to crash into the sea. On

these firm bases, the Board is able to makerecommendations of a practical nature whichare aimed at ensuring that such a situationwill not happen again.” (p. 146). The NTSB,Boeing, U.S. FAA participated in the accidentinvestigation. The NTSB issued recommenda-tions A-88-61 through A-88-63 recommendingthat the FAA require cargo be carried in fireresistant containers; conduct research on firedetection and suppression methods; establishfire resistant requirements for the ceiling andsidewall liners.

Aircraft Accident Report: Evergreen InternationalAirlines McDonnell Douglas DC-9-33F, N931FSaginaw, Texas, March 18, 1989. — Washington,D.C. : National Transportation Safety Board;Springfield, Va. : Available through NTIS*, April23, 1990. Report NTSB/AAR-90/02, PB90-910402. 85p.

Key Words1. Aeronautics — Accidents — 1989.2. Aeronautics — Accidents — Cargo Doors.3. Evergreen International Airlines — Acci-

dents — 1989.

Summary: This crash occurred during theturn to final approach as the pilot was at-tempting to return to Carswell AFB, FortWorth, TX, after a cargo door opened. Thiscargo flight was on an IFR flight plan. Nightvisual meteorological conditions existed atthe time of accident. The captain & firstofficer, the only persons onboard, were killed.NTSB determines that the probable cause ofthis accident was the loss of control of theairplane for undetermined reasons follow-ing the inflight opening of the improperlylatched cargo door. Contributing to the ac-cident were inadequate procedures used byEvergreen Airlines and approved by the FAAfor preflight verification of cargo door secu-rity, Evergreen’s failure to mark properlythe airplane’s external cargo door lock pinmanual control handle, and the failure ofMcDonnell Douglas to provide flightcrewguidance and emergency procedures for aninflight opening of the cargo door. Also con-tributing to the accident was the failure ofthe FAA to mandate modification to the door-open warning system for DC-9 cargo-con-


figured airplanes, given the previously knownoccurrences of inflight door openings. NTSBissued Safety Recommendations A-90-86 andA-90-87, requiring flight manual amendmentson the cargo doors for the DC-9. [Executivesummary]

Proceedings of the Flight Safety Foundation Digi-tal Flight Data Recording Workshop. — Arling-ton, Va.: Flight Safety Foundation, 1990. Re-port FSF/CP-90/11. 79p.

Key Words1. Aeronautics — Safety Measures.2. Airlines — Operational Procedures.3. Airlines — Employees — Training of.4. Flight Recorders.5. Flight Crews — Performance — Analysis.6. Flight Operations — Monitoring.

Table of Contents: Operational Flight Data Re-cording in the United Kingdom Civil AviationAuthority — Special Event Monitoring: AnEngineering Perspective — Special Events Searchand Master Analysis (SESMA) — The BALPAInvolvement in DFDR Monitoring — FlightData Recorder Replay and Analysis System —Prevention-Protection — The Scandinavian

Airlines System Flight Analysis and AircraftMonitoring System — Viewpoints on the Useof DFDR Data in an Operational Trend Analy-sis Program — Flight Data Evaluation in Swissair— DFDR Programs and Their Use at Swissair:The AEROPERS View — Legal Issues — Infor-mation Security: The Critical Element in DFDRMonitoring — ALPA Perspective — TrainingImplications — Workshop Summary.

Summary: Digital Flight Data Recorders pro-vide the means to automatically and system-atically obtain comprehensive data on flightoperations which can be analyzed and pro-vide information to prevent accidents. Theseproceedings include papers from airlines whoare using DFDR procedures and pilot unionrepresentatives who discuss their experienceswith DFDR. According to FSF, DFDR ... “nowmakes possible the timely identification of spe-cific exceedances resulting from crew decisionsas well as shortcomings in crew training, ATCprocedures, airport design and aircraft design.And of course, being able to specify a problemis the first step toward positive corrective ac-tion.” ♦

*U.S. Department of CommerceNational Technical Information Service (NTIS)Springfield, VA 22161 U.S.Telephone: (703) 487-4780

This information on accidents and incidents isintended to provide an awareness of problem areasthrough which such occurrences may be preventedin the future. Accident/incident briefs are basedupon preliminary information from governmentagencies, aviation organizations, press informa-tion and other sources. The information may notbe accurate.

Accident/Incident Briefs

Air CarrierAir Carrier

Excessive ExpeditingLeads to Embarrassment

Lockheed L-1011 TriStar: No damage. No injuries.

Maintenance personnel were taxiing thewidebody aircraft from a hangar to anotherlocation on the airport to run up engine num-ber 1 and perform vibration tests on it. Theaircraft was being moved using engines 2 and3.

After stopping at a holding point, the crewwas cleared to cross a runway and was in-structed to expedite clearing the runway. Af-ter the brakes were released and power wasapplied, the aircraft swerved to the left and


the nose and left main landing gear left thepaved surface, rolling onto the grass. The air-craft was stopped partially on the runway at a90-degree angle to the centerline. Emergencyservices responded but there was no evidenceof malfunction or damage, and the aircraft’sbrakes and nosewheel steering responded nor-mally.

With clearance from the control tower, the air-craft was taxied back onto and across the run-way to the runup area where the engine testwas carried out without further incident.

The incident was attributed to the use of ex-cessive assymetric thrust when the operatorattempted to expedite the crossing of the run-way. The three maintenance personnel involvedwere counseled on taxiing procedures whichinclude a stipulation both in the training syl-labus and taxi checklist to never exceed 35percent N1 for ground operations. The carrieralso prohibited further taxiing with an engineout.

Check That LoadsheetTo Prevent Surprises

Lockheed L-1011 TriStar: No damage. No injuries.

The aircraft had been flown to Athens withoutpassengers and with only 330 pounds of cater-ing aboard for the crew. At Athens, 6,600 poundsof catering was loaded for a passenger flightto London. The load control agent assumedthat the new catering data was automaticallyentered into the departure control system.

After the aircraft arrived at London, a numberof discrepancies were noted in the loading andon the load sheet. These included: the cateringweight indicated 330 pounds — the actual weightwas 6,600 pounds; the paperwork indicatedcargo compartment 1 was empty — the actualload included a spares pack weighing 1,500pounds; and bags of a total weight of 1,500pounds were recorded as being in cargo com-partment 5, but the spares pack with the sameindicated weight that was found in compart-ment 1 was not entered. Compartment 5 wasempty.

The responsible loading staff member was sus-pended pending further training and flightcrews were reminded to check loadsheet en-tries, especially for non-scheduled or unusualflight operations.

Continued ApproachAfter Windshear

British Aerospace BA 31 Jetstream: Substantialdamage. Various injuries.

The aircraft was approaching to land in theearly afternoon in daylight conditions in a winterday. There were six passengers and a crew ofone aboard.

The aircraft encountered low-level windshearon final approach but the pilot continued thelanding attempt. The aircraft landed hard andbounced. It then dove onto the runway, thelanding gear collapsed and control was lost. Itsubsequently impacted a snow bank. The air-craft was destroyed and serious injuries weresustained by the pilot and one passenger, withminor injuries to the other five passengers.

Causal factors included the presence of thewindshear, the failure to go around, inadequatewind compensation and improper recovery.

Unneeded Training RealismGives Hard Lesson

Fairchild (Swearingen) SA-227 III: Aircraft de-stroyed. Various injuries to three.

The pilot was receiving a currency check ride.It was a half hour before midnight on a fallevening.

Air Taxi/CommuterCommuter

Air Taxi


Beechcraft B-58 Baron: Substantial damage. Noinjuries.

The aircraft was approaching its destinationafter a cross-country flight. The pilot was theonly occupant.

It was evening and dark, and the runway waswet. The pilot made an ILS approach but, be-cause of excessive airspeed, landed long. Withthe wet runway and high speed, the aircrafthydroplaned and the pilot was unable to brakeit to a stop before it ran off the end of therunway. The aircraft skidded 300 feet and col-lided with a rock pile. The aircraft was dam-aged substantially but the pilot exited unharmed.

Factors in this accident included excessive air-speed, failure to go around and hydroplaningconditions.

Continued VFR Flight into…

Piper PA-25-235 Pawnee: Aircraft destroyed. Fa-tal injuries to one.

The pilot of the aerial application aircraft hadtaken off at 0600 hours in the mid-summerday on a crop-spraying mission. Weather con-ditions were good but numerous fairly largepatches of fog had been reported in the area,but these were expected to burn off later inthe morning. About an hour and a quarterafter the aircraft took off, witnesses reportedan aircraft at a low altitude struck a powerline after which it continued about 500 feetand out of control when it impacted the ground.The aircraft exploded and burned and the pi-lot sustained fatal injuries.

The instructor simulated an engine failure duringtakeoff. The aircraft did not climb as expectedand struck the instrument landing system (ILS)antenna. A wingtip separated and the aircraftimpacted the ground and was destroyed. Ofthe three crew members aboard, one was in-jured seriously and the other two sustainedminor injuries.

Factors that contributed to the accident in-cluded the fact that the flaps were extendedmore than 50 percent during takeoff (a reflec-tion on improper use of the checklist); inad-equate supervision by the check pilot; and in-adequate preflight planning and preparation.

Go-Around AttemptAfter No-gear Touchdown

Beechcraft B-55 Baron: Aircraft destroyed. Fatalinjuries to one.

During an arrival early in the morning, thepilot initiated a go-around during the landingroll. He retracted the landing gear and madeanother approach.

On roundout during the second landing at-tempt, the propellers struck the runway. Thepilot added power and lowered the gear butthe aircraft rolled inverted and crashed. TheBaron was destroyed by post-crash fire andthe pilot sustained fatal injuries.

Among factors involved were failure to lowerthe gear, improper crew decisions and a fail-ure of a propeller control.

Twas a Dark and Rainy Night

Corporate ExecutiveCorporateExecutive

Other GeneralAviation

OtherGeneralAviation


aircraft stalled. There was no opportunity torecover from the stall because of the low alti-tude and lack of engine power.

Late Change of MindHas Unwelcome Result

Bell 206B: Substantial damage. No injuries.

The air taxi helicopter lost power while climb-ing through 6,000 feet. The pilot was not ableto restart the engine and selected a forced landingspot near the shoreline of a lake.

Just prior to the touchdown, the pilot changedhis intended landing site because of uneventerrain in the original location he had chosen.The maneuvering to get the helicopter to thenew site caused excessive rotor energy to beexpended and a hard landing resulted. Thehelicopter was damaged substantially but thepilot and three passengers were able to exitwithout injury.

Untimely Gust EncounterUpsets Rotorcraft

Bell 47: Substantial damage. No injuries.

During the downwind approach to a swathrun, the aerial application rotorcraft experi-enced a sudden gust. The result was a retreat-ing blade stall.

The helicopter struck the ground and rolledover. The pilot was able to evacuate withoutinjury but the aircraft sustained substantialdamage. ♦

The witnesses also reported that there had beenno fog when the aircraft began spraying butthat fog quickly enveloped the area, restrict-ing visibility to a half mile or less. Most ofthem stated also that it was difficult to followthe aircraft and to see the power line becauseof the fog.

Investigators surmised that the pilot attemptedto use the power line as a guide to the landingstrip but that he lost visual contact because ofthe fog. When he attempted to re-establishvisual contact, the reduced visibility preventedhim from seeing the cable in time to avoidhitting it. The finding was the classic “… at-tempted to continue the visual flight rules flightin unfavorable weather conditions.”

Low ReversalAfter Takeoff

Cessna 206: Aircraft Destroyed. Fatal injuries totwo.

The aircraft was departing in mid-afternoonon a summer day. It had just taken off and wasclimbing through 500 feet during the initialclimb when the engine lost power.

The pilot turned back toward the runway. Theaircraft stalled and struck the ground to theside of the runway in a nose-down attitude ata high rate of descent. The aircraft was de-stroyed and both occupants sustained fatal in-juries.

Examination of the engine revealed that a cyl-inder had failed because of thermal stressesand service life, resulting in the loss of power.Investigators reported that a suitable forcedlanding field was ahead of the aircraft whenthe power failed. When the pilot attempted toreturn to the takeoff point, the tight turn hemade caused the airspeed to decay until the

RotorcraftRotorcraft

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