May 11, 1996: ValueJet Flight 592 plunges into the Florida Everglades. Cause? Undeclared dangerous goods—specifically oxygen generators.
An Australian dangerous goods inspector recently found an oxygen generator that had travelled by cargo only air. The problem? The oxygen generator had not been properly packed – it was able to roll around the package. And the oxygen generator lacked the proper pin to prevent activation.
An investigation into the airline’s Stores section found many incorrectly packaged oxygen generators, including legacy stores from other airlines. The investigation also found that maintenance staff were not removing in-service oxygen generators correctly and did not have the required tool to insert the pin. In addition, the maintenance staff were re-using the original packaging that was incomplete and were expecting Stores personnel to re-package the oxygen generators. And the Stores personnel were under the impression that the maintenance staff had correctly packaged the oxygen generators and were ready for shipping. Inspection of the oxygen generators in Stores found that 95% of the oxygen generators that had been removed from service were not properly prepared for shipment nor prepared for prevention of unintentional activation.
The airline has since banned the shipping of oxygen generators that have been removed from service. The airline’s procedures and maintenance manuals are being reviewed as they have been found to be inadequate.
The Dangerous Goods Secretariat has been made aware of this incident and will make recommendations to revise PI523 (PI565 in 2011 Ed.) to make a reference that two (2) positive means of preventing unintentional activation must be in place.
All airlines are encouraged to discuss this incident with their maintenance staff and Stores personnel. And it is strongly recommended that they check their procedure manuals.
The FAA has published a presentation that provides guidance on oxygen generators and can be found in the Documents & Downloads section of IATA’s dangerous goods community.