CSB Root Cause Analysis Work Finds Unspent Aircraft Oxygen Generators Contributed to Rapid Spread of Fire at EQ Facility in Apex, N.C. in 2006 Safety Advisory and Urgent Recommendation Issued
CSB Finds Unspent Aircraft Oxygen Generators Contributed to Rapid Spread of Fire at EQ Facility in Apex, N.C. in 2006 Safety Advisory and Urgent Recommendation Issued
Raleigh, N.C., June 27, 2007 - The U.S. Chemical Safety Board (CSB) today announced it is issuing a Safety Advisory concerning the dangers of transporting and handling unspent aircraft chemical oxygen generators. The action follows a CSB investigative finding that the devices most likely contributed to the rapid spread of a fire at the EQ Industrial Services (EQ) hazardous waste facility in Apex, NC on the night of October 5, 2006. The fire resulted in the evacuation of thousands of residents of Apex, located about 16 miles southwest of Raleigh, and destroyed the EQ facility’s hazardous waste building.
Chemical oxygen generators are used in commercial aircraft to supply supplemental oxygen to passengers in drop-down masks should the cabin depressurize. They are similar to the ones that started a fire in the cargo compartment aboard a ValuJet airplane that crashed in 1996 in Florida. The National Transportation Safety Board (NTSB) investigation report of that accident stated that expired but fully functioning chemical oxygen generators should be expended before being transported.
The devices that contributed to the EQ fire were past their projected service life but remained fully charged and hazardous. They originated at an aircraft maintenance facility in Mobile, Alabama, that did not expend the contents prior to transport. In addition, shipping documents did not identify them as unspent chemical oxygen generators as required by Department of Transportation regulations.
CSB Safety Advisories are issued during the course of investigations that develop information the Board believes should be communicated rapidly to prevent recurrence of accidents.
At a news conference held in Raleigh, CSB Board Member William B. Wark said, ‘We issued this advisory to alert aircraft maintenance and hazardous waste facility personnel to the hazards associated with transporting and storing expired but unspent aircraft oxygen generators. These can be very dangerous and if mishandled can cause fires, property damage and personal injury.’
Lead Investigator Robert Hall, P.E., said, ‘Our investigation found that the unspent oxygen generators were stored in the area where the fire is believed to have originated. The generators can be activated by heat, which results in the release of oxygen, further accelerating and intensifying the fire. When firefighters first arrived, the fire was small. But it quickly spread to an adjacent bay.’
The CSB earlier apprised the Federal Aviation Administration (FAA), U.S. Department of Transportation (DOT), and the NTSB of the CSB investigative finding in this case.
Chemical oxygen generators in passenger aircraft have a limited useful life and must be periodically replaced. Even after their expiration dates, they remain potentially hazardous materials. In this case, the CSB found, an aircraft maintenance facility in Mobile, Alabama, sent the chemical oxygen generators to a hazardous waste facility in Birmingham, Alabama, without activating and expending the contents as recommended by the NTSB. The receiving hazardous waste facility misidentified the oxygen generators as general oxidizer waste on shipping documents they prepared for aircraft maintenance facility.
The CSB issued an Urgent Recommendation – the third in the agency’s history – to the maintenance facility, Mobile Aerospace Engineering, Inc. (MAE). Urgent recommendations are issued when in the view of the CSB Board Members, there is an ‘imminent hazard.’
The CSB recommended the aircraft maintenance company revise or develop procedures to ensure the generators are expended before shipping, revise as necessary procedures for assuring hazardous waste is correctly described on shipping manifests, and that the company communicate to all of its waste brokers and waste facilities that the incorrect shipping name and code was or might have been used for unspent oxygen generators shipped from its facility.
The CSB investigation continues with a final report planned to be released by the end of the year.
Board Member Wark said, ‘I want to emphasize that we are continuing to look at the operations at EQ, as well as the national regulations that govern the hazardous waste facilities. We are looking at fire protection practices; we note that there was no automatic fire detection or suppression system to extinguish the blaze after it started; we also note the lack of firewalls to separate hazardous materials from one another. And, there are issues concerning the lack of information available to emergency responders during this incident. We believe that even with the oxygen generators fueling the blaze, had the facility been equipped with automated fire detection and extinguishing systems, this accident may have been avoided.’
At the news conference, Investigator Hall played an edited version of a 1997 NTSB ValuJet investigation fire test involving unspent chemical oxygen generators. The generators contain sodium chlorate, which produces oxygen once activated by a small explosive contained in the device. Heat is also a byproduct of the exothermic reaction, and the outside temperature of the generator can reach up to 500 degrees Fahrenheit. The reaction may also be initiated by heat from other sources. The test video dramatically shows how quickly a fire results and spreads once the oxygen generator contents begin reacting.
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For more information, contact Sandy Gilmour, CSB Public Affairs, cell 202.251.5496; or CSB Public Affairs Specialists Jennifer Jones, 202.261.3603, cell 202.577.8448; Hillary Cohen 202.261.3601; or Kate Baumann, 202.261.7612, cell 202.725.2204. Mr. Gilmour and Ms. Baumann will be in Raleigh for the news conference.
This message was transmitted at 11:17 AM Eastern Time (U.S.A.) on June 27, 2007.