/

PB98-9104O3

\

NTSB/AAR-98/03

DCA96MA079

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

IN-FLIGHT FIRE/EMERGENCY LANDING

FEDERAL EXPRESS FLIGHT 1406

DOUGLAS DC-1 0-10, N68055

NEWBURGH,

SEPTEMBER

NEW YORK

5, 1996

6800B
The National Transportation Safety Board is an independent Federal agency dedicated to

promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety.

Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the

accidents, issue safety recommendations, study transportation safety issues, and evaluate the

safety effectiveness of government agencies involved in transportation. The Safety Board makes

public its actions and decisions through accident reports, safety studies, special investigation

reports, safety recommendations, and statistical reviews.

Recent publications are available in their entirety on the Web at http://www.ntsb.gov/. Other information about available publications also may be obtained from the Web site or by by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(202) 314-6551

(800) 877-6799

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703) 605-6000
NTSB/AAR-98/03 PB98-910403

NATIONAL TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

IN-FLIGHT FIRE/EMERGENCY LANDING

FEDERAL EXPRESS FLIGHT 1406

DOUGLAS DC-10-10, N68055

NEWBURGH, NEW YORK

SEPTEMBER 5, 1996

Adopted: July 22, 1998

Notation 6800B

Abstract: This report explains the accident involving Federal Express flight 1406, a Douglas

DC-10-10, which made an emergency landing at Stewart International Airport on September 5,

1996, after the flightcrew determined that there was smoke in the cabin cargo compartment. Safety

issues in the report include flightcrew performance of emergency procedures, undeclared hazardous

materials in transportation, dissemination of hazardous materials information, airport emergency

response, and adequacy of aircraft interior firefighting methods. Safety Recommendations

concerning these issues were made to the Federal Aviation Administration, the Department of

Transportation, and the Research and Special Programs Administration.

iii

CONTENTS

ABBREVIATIONS ...................................................................................................................... vi

EXECUTIVE SUMMARY........................................................................................................viii

1. FACTUAL INFORMATION.................................................................................................. 1

1.1 History of Flight .................................................................................................................... 1

1.2 Injuries to Persons ............................................................................................................... 11

1.3 Damage to Airplane............................................................................................................. 11

1.4 Other Damage...................................................................................................................... 11

1.5 Personnel Information ......................................................................................................... 11

1.5.1 The Captain .................................................................................................................. 11

1.5.2 The First Officer........................................................................................................... 12

1.5.3 The Flight Engineer...................................................................................................... 13

1.6 Airplane Information........................................................................................................... 14

1.6.1 Air Ventilation System................................................................................................. 15

1.6.1.1 Cabin Air Shutoff...............................................................................................................16

1.6.2 Cabin Pressurization System—Cabin Outflow Valve Control .................................... 18

1.6.3 Fire/Smoke Detection System...................................................................................... 18

1.6.4 L1 Forward Passenger Door Design and Operation..................................................... 19

1.7 Meteorological Information ................................................................................................ 19

1.8 Aids to Navigation .............................................................................................................. 19

1.9 Communications ................................................................................................................. 19

1.10 Airport Information ........................................................................................................... 20

1.11 Flight Recorders ................................................................................................................ 20

1.11.1 CVR............................................................................................................................ 20

1.11.2 FDR ............................................................................................................................ 20

1.12 Wreckage and Impact Information.................................................................................... 20

1.13 Medical and Pathological Information .............................................................................. 23

1.14 Fire ................................................................................................................................ 23

1.14.1 Fire Damage to Lower Cargo Compartment .............................................................. 23

1.14.2 Fire Damage to Upper Cargo Compartment .............................................................. 23

1.14.2.1 Damage to Cargo Containers and Contents................................................................27

1.14.2.1.1 Contents of Cargo Containers in Position 6R and in Rows 8 and 9........................29

1.14.2.1.2 DNA Synthesizer Found in Container 6R ...............................................................32

1.14.3 Significance of Location of First Fuselage Burnthrough and Smoke Detector

Activation Sequence.............................................................................................................. 35

1.15 Survival Aspects................................................................................................................ 35

1.15.1 Use of Smoke Goggles and Oxygen Masks ............................................................... 35

1.15.2 Emergency Response.................................................................................................. 37

1.15.2.1 Dissemination of Hazardous Materials Information........................................................38

1.15.2.1.1 Other FedEx Accidents Involving Dissemination of Hazardous Materials

Information ................................................................................................................................41
iv

1.15.2.1.2 Postaccident Actions by FedEx ................................................................................42

1.16 Tests and Research ............................................................................................................ 43

1.16.1 Chemical Analysis of Substances Found in Container 6R......................................... 43

1.16.2 Procedures Used to Prepare the Synthesizer for Shipment ........................................ 45

1.16.3 Reanalysis of Fluids Found in DNA Synthesizer....................................................... 49

1.17 FedEx Organizational and Management Information ....................................................... 51

1.18 Additional Information...................................................................................................... 51

1.18.1 Postaccident Actions by FedEx.................................................................................. 51

1.18.2 Marijuana Shipments on the Accident Airplane ........................................................ 52

1.18.3 Programs to Deter Undeclared Hazardous Materials Shipments ............................... 53

2. ANALYSIS.............................................................................................................................. 57

2.1 General ................................................................................................................................ 57

2.2 Flightcrew Performance ...................................................................................................... 57

2.2.1 Crew Coordination ....................................................................................................... 57

2.2.2 Crew’s Use of Emergency Equipment ......................................................................... 59

2.3 Fire Initiation....................................................................................................................... 61

2.3.1 Location from Which the Fire Might Have Initiated.................................................... 61

2.3.2 Ignition Source of the Fire........................................................................................... 64

2.4 Undeclared Hazardous Materials on Airplanes................................................................... 66

2.4.1 The Synthesizer .......................................................................................................... 66

2.4.2 Other Prohibited Items ............................................................................................... 68

2.4.3 Federal and Industry Oversight .................................................................................. 68

2.5 Dissemination of Hazardous Materials Information ........................................................... 70

2.6 Emergency Response........................................................................................................... 72

3. CONCLUSIONS .................................................................................................................... 76

3.1 Findings............................................................................................................................... 76

3.2 Probable Cause.................................................................................................................... 77

4. RECOMMENDATIONS....................................................................................................... 78

5. APPENDIXES ........................................................................................................................ 81

APPENDIX A—INVESTIGATION AND HEARING............................................................ 81

APPENDIX B—COCKPIT VOICE RECORDER TRANSCRIPT ....................................... 82

APPENDIX C – DC-10 CHECKLIST “EMERGENCY EVACUATION (LAND)”.......... 111

APPENDIX D—CARGO CONTAINER EXAMINATION CHART.................................. 113

APPENDIX E—CONTENTS OF NINE CARDBOARD BOXES LABELED “9R” ......... 119

APPENDIX F - DETAILED EXAMINATION OF FIRE DAMAGE TO DNA

SYNTHESIZER ........................................................................................................................ 120
v

APPENDIX G—RINSE PROCEDURE AND QUANTITIES RINSED FOR 1996 NASA

CHEMICAL ANALYSIS ......................................................................................................... 125

APPENDIX H—SUMMARY CALIBRATION AND GC/MS DATA FOR 1996 NASA

TESTING................................................................................................................................... 127

APPENDIX I – SERVICE NOTE 89-006 ............................................................................... 128

APPENDIX J - DEMONSTRATION OF SYNTHESIZER PURGING AND

DECONTAMINATION PROCEDURES............................................................................... 136
vi

 ABBREVIATIONS

AFFF aqueous film-forming foam

AFIP Armed Forces Institute of Pathology

ANG Air National Guard

ARFF aircraft rescue and firefighting

ARTCC air route traffic control center

ATA Air Transport Association

ATC air traffic control

ATP airline transport pilot

CDL configuration deviations list

CFR Code of Federal Regulations

CRM crew resource management

CVR cockpit voice recorder

DEC Department of Environmental Control

DEGMBE diethylene glycol monobutyl ether

DOT Department of Transportation

EOC emergency operations center

FAA Federal Aviation Administration

FL flight level

FDR flight data recorder

FS fuselage station

FTIR Fourier Transform Infrared

GC/MS gas chromatography/mass spectrometry

GOCC Global Operations Command Center

HMIS Hazardous Materials Information System

HMRT Hazardous Materials Response Team

LOFT line oriented flight training

MEL minimum equipment list

mL milliliter

NASA National Aeronautics and Space Administration

NYSP New York State Police

PBE protective breathing equipment

pH hydrogen-ion concentration

POI FAA principal operations inspector
vii

psi pounds per square inch

RSPA Research and Special Programs Administration

SN serial number

SPAAT skin penetrator agent application tool

STC supplemental type certificate

THF tetrahydrofuran

TRACON terminal radar approach control

μl microliter
viii

EXECUTIVE SUMMARY

About 0554 eastern daylight time, on September 5, 1996, a Douglas DC-10-10CF,

N68055, operated by the Federal Express Corporation as flight 1406, made an emergency landing

at Stewart International Airport, Newburgh, New York, after the flightcrew determined that there

was smoke in the cabin cargo compartment. The flight was operating under the provisions of

Title 14 Code of Federal Regulations Part 121 as a cargo flight from Memphis, Tennessee, to

Boston, Massachusetts. Three crewmembers and two nonrevenue passengers were aboard the

airplane. The captain and flight engineer sustained minor injuries while evacuating the airplane.

The airplane was destroyed by fire after the landing.

The National Transportation Safety Board determines that the probable cause of

this accident was an in-flight cargo fire of undetermined origin.

Safety issues discussed in this report include flightcrew performance of

emergency procedures, undeclared hazardous materials in transportation, dissemination of

hazardous materials information, airport emergency response, and adequacy of aircraft interior

firefighting methods. Safety recommendations concerning these issues were made to the Federal

Aviation Administration, the Department of Transportation, and the Research and Special

Programs Administration.
NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

IN-FLIGHT FIRE/EMERGENCY LANDING

FEDERAL EXPRESS FLIGHT 1406

 DOUGLAS DC-10-10, N68055

NEWBURGH, NEW YORK

SEPTEMBER 5, 1996

1. FACTUAL INFORMATION

1.1 History of Flight

About 0554 eastern daylight time,1

 on September 5, 1996, a Douglas

DC-10-10CF, N68055, operated by the Federal Express Corporation (FedEx) as flight 1406,

made an emergency landing at Stewart International Airport (Stewart), Newburgh, New York,

after the flightcrew determined that there was smoke in the cabin cargo compartment. The flight

was operating under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121 as a

cargo flight from Memphis, Tennessee, to Boston, Massachusetts. Three crewmembers and two

nonrevenue passengers were aboard the airplane. The captain and flight engineer sustained minor

injuries while evacuating the airplane. The airplane was destroyed by fire after the landing.

The accident occurred on the first leg of a scheduled two-leg sequence from

Memphis to Boston with a return to Memphis. The flight engineer stated that before departing

Memphis, he received a hazardous materials briefing from a FedEx dangerous goods specialist.2

This briefing included discussions about the locations of hazardous materials that were on board

the airplane (in cargo containers 1L/1C and 3R3) and about the Halon4 hose connections to

container 1L/1C (which was designated for flammable dangerous goods). The dangerous goods

specialist then gave the captain the Notification of Dangerous Goods Loading Form (Part A)

 1 Unless otherwise indicated, all times are eastern daylight time, based on a 24-hour clock.

2

 FedEx dangerous goods specialists are responsible for verifying that shipments of declared

hazardous materials are properly packaged, identified, labeled and marked. They also inspect hazardous materials

packages for signs of damage or leakage, and ensure that all hazardous materials packages have been properly

loaded. Dangerous goods specialists are assigned to those stations in which hazardous materials are accepted and

loaded for transportation.

3 For cargo container locations, see figure 1.

4

 An inert chlorofluorocarbon gas used to extinguish fires.
CONTAINER

to

Figure 1.—DC-10-10, N68055, upper cabin cargo container positions and smoke detector

locations.
3

containing required hazardous materials information,5 which the captain signed.6 Flight 1406

departed Memphis at 0242 central daylight time (CDT); the flightcrew stated that the engine

start, taxi, takeoff, and climb were normal. The first officer was the pilot flying, and the captain

performed the duties of the nonflying pilot.

The airplane’s upper cargo deck was loaded with 23 cargo containers and 1 cargo

pallet. The lower forward cargo compartment contained six cargo containers; and the lower aft

cargo compartment contained seven containers.

At 0536:23, when the airplane was at flight level (FL) 330,7

 the cockpit voice

recorder (CVR) recorded the captain asking, “what [ ]’s that?”8 Two seconds later, both the first

officer and the flight engineer said, “cabin cargo smoke.” At 0536:27, the captain stated, “You

see that...we got cabin cargo smoke...cabin cargo smoke.” The flight engineer then stated,

“cabin cargo smoke, oxygen masks on.” The CVR indicates that the crew then donned oxygen

masks and established crew communications, as required by the first two steps on the “Fire &

Smoke” checklist (see figure 2).9

During postaccident interviews and in his deposition, the captain stated that he

initially donned his smoke goggles, but had to remove his eyeglasses to do so. During the

landing phase of the flight, he removed his goggles so he could replace his glasses. The captain

also said that the goggles were dirty and scratched. The first officer stated that he elected not to

wear his smoke goggles because he felt that they would unduly restrict his peripheral vision. The

flight engineer initially donned his smoke goggles, but then removed them after noting that no

smoke was entering the cockpit. At 0536:40, the flight engineer said, “okay it’s number nine

 5

 The Department of Transportation (DOT) hazardous materials regulations require the aircraft

operator to provide the pilot-in-command with certain information about hazardous materials on board the flight

(including proper shipping name, hazard class, identification number, total number of packages, net quantity or gross

weight per package, and location aboard the aircraft), in writing, before departure.

6 According to the FedEx Flight Operations Manual, “Appropriate parts (A; B and/or BR; C and/or

CR) of the Notification of Dangerous Goods Loading form, FEC-M-390 are required for each departure.” The Part

A forms list the class of hazardous materials and where they are on the airplane, and serves as the required written

notification to the pilot-in-command. The Part B forms are the individual shipping documents for each shipment of

hazardous materials, other than radioactive materials. The Part BR forms are for shipments of radioactive materials.

The Part C and CR forms are comparable to the Part B and BR forms, respectively, but are used for domestic

shipments only. Parts A and B are discussed in greater detail in section 1.15.2.1.

7

 33,000 feet mean sea level, based on an altimeter setting of 29.92 inches of mercury (Hg).

8

 See appendix B for a complete transcript of the CVR.

9

 Cockpit emergency equipment also included a portable oxygen cylinder with attached smoke

mask and a protective breathing equipment (PBE) smoke mask and hood, neither of which were used during the

emergency.

5

smoke detector.”10 (See figure 1 for location of smoke detectors.) Upon the first officer’s

suggestion, the nonrevenue passengers (who had been seated in the foyer area in the cabin

directly behind the cockpit) came into the cockpit, where they donned their oxygen masks.

During postaccident interviews, the passengers stated that at that point they had been unaware of

the developing emergency; they had both been reading magazines, and neither saw nor smelled

smoke in the foyer area (see figure 3 for a diagram of the foyer).

At 0537:56, the captain stated, “okay it’s moving forward whatever it is...it’s up

to seven.” According to the CVR, at 0539:13, the captain asked the flight engineer to test the

smoke warning system, which he did. During the test, several lights came on blinking, rather

than steadily.11 At 0539:28, the captain said, “that’s seven and eight.” At 0539:31, the flight

engineer stated, "those others may be failing in the blinking mode." At 0539:52, the captain said,

“I got ten now.”12 At 0540:07, the captain stated, “we’ve definitely got smoke guys...we need to

get down right now, let’s go.” At this time, according to postaccident interviews, the captain

decided that the first officer should continue flying the airplane while he coordinated with air

traffic control (ATC) and worked with the flight engineer on the checklists. At 0540:43, the

captain informed the Boston air route traffic control center (ARTCC) of the emergency. The

flight was immediately cleared to descend to 11,000 feet. The captain told investigators that he

did not call for the emergency descent checklist but said that he thought he had completed all of

the items from memory.

ARTCC informed the pilots that the Albany County Airport, New York, was

approximately 50 miles ahead of them and that Stewart was about 25 miles behind them. The

captain selected Stewart, and the flightcrew began to divert the flight there.

At 0541:41, the flight engineer began the “Cabin Cargo Smoke Light Illuminated”

checklist (see figure 4), in accordance with the last step of the “Fire & Smoke” checklist. At

0542:21, he stated, “and now we have 8, 9, and 10...we’ve lost detector 7...it’s gone out.” He

 10 In postaccident interviews conducted before the CVR transcript was available, the captain and

flight engineer stated that the first lights they saw illuminated were the master caution light and the No. 7, No. 8, and

No. 9 smoke warning lights. (These smoke warning lights corresponded with smoke detectors installed overhead in

the upper cabin of the airplane, slightly forward of cargo container rows 7, 8, and 9, respectively.) During the

deposition proceeding, the captain and the flight engineer again stated that they first saw the No. 7, No. 8, and No. 9

smoke detectors illuminated simultaneously, and the flight engineer stated that he did not recall the No. 9 smoke

detector being illuminated alone.

11 The FedEx DC-10 Flight Manual states, “If a flashing [cargo fire/smoke detector] indicator light

is observed during the normal test procedure of the cargo fire/smoke detector units, the crewmember is alerted that

the detector unit connected to the flashing light is beginning to deteriorate. A flashing indicator light does not

signify an inoperative fire/smoke detector. However, a log book entry must be made noting the position of the

flashing detector light, whereby maintenance is given a timeframe in which to replace the deteriorating fire/smoke

detection unit. The fire/smoke detection system will perform all fire/smoke detection functions normally. A totally

inoperative fire/smoke detector unit will not illuminate during the normal test procedure.” (Emphasis in original.)

12 During his deposition, the captain said that this comment referred to the number of lights

illuminated during the test of the smoke detector system, and not to smoke detector No. 10. Although there are 16

smoke detector lights, it could not be determined whether all 16 lights in fact illuminated during the test.
6

EscapeSlide/Raft(2)

(Stowed on Doors)

Smoke Curtain

‘ Lavatory 470

e

I ●

“r!?

Foyer

Area

*9A PBE Located behind

-cou ierseats

1

Cargo Door

615 to 775

Legend

● Crew Portable Oxygen m

Cylinder with Smoke Mask(2)

+ FirstAid Kit(1) b

~Exits (4) ●

*Escape Lines (2)

AA

Halon Fire

Extinguisher (4) (Type 1211) 14lb Foyer

Crash Axe(1) 9lb Foyer

Smoke Goggles (7)

PBE (2)

Figure 3.—Diagram of the DC-10-10, N68055, foyer area.

8

then stated at 0543:02, “I’m manually raising the cabin altitude...there is smoke in the ah cabin

area.” During postaccident interviews, the flight engineer said that he felt rushed with the

workload during the descent, and that he felt he had spent too much time trying to find the

correct station identifier for Stewart on the airport performance laptop computer.13 The CVR

transcript records the flight engineer asking what the three-letter identifier for Stewart was five

times between 0543:22 and 0549:09. At 0548:29, he announced that the “Cabin Cargo Smoke

Light Illuminated” checklist was complete.

During postaccident interviews, the flight engineer told Safety Board investigators

that he was confused by some items on the “Cabin Cargo Smoke Light Illuminated” checklist

and acknowledged that he did not accomplish step No. 6, “Cabin Air Shutoff T-Handle,” (when

the T-handle is pulled, airflow is maintained to the cockpit area, but all airflow is shut off to the

main deck cargo area). Regarding step No. 7, “Maintain 0.5 Diff Pressure Below FL 270, Or

25,000 Ft. Cabin Altitude Above FL 270,” he acknowledged that he did not attempt to maintain

0.5 pounds per square inch (psi) differential pressure, but said that he had selected “manual” on

the outflow valve control and “cranked it open a couple of times.” (For more information on the

cabin outflow valve control, see section 1.6.2.)

At 0546:56, the flight was handed off from Boston ARTCC to New York terminal

radar approach control (TRACON) controllers, who provided assistance until the airplane landed.

During postaccident interviews, the flight engineer said that during this portion of the flight, he

opened the cockpit door several times and saw grayish smoke accumulating in the foyer area.

At 0547:27, the captain advised the first officer, “keep the speed up man, don’t

slow to two-fifty...we’re in an emergency situation here.” At 0550:41, after about 3 minutes of

assisting the crew with the Stewart approach, the New York TRACON controllers asked if any

hazardous materials were on board, and the captain replied affirmatively.

The captain stated that as the airplane approached the airport, visibility remained

good in the cockpit, even though he could smell smoke through his oxygen mask. The airplane

was cleared to land on runway 27, and the first officer landed the airplane at 0554:28. The

captain then took control of the airplane and brought it to a stop on taxiway A3, where airport

aircraft rescue and firefighting (ARFF) trucks were waiting.

The flight engineer said that when he opened the cockpit door after landing, he

saw that the foyer area was full of smoke, and he could not see the smoke barrier14 at the aft end

of the foyer. The captain later told investigators that both he and the flight engineer called for an

emergency evacuation. The CVR indicates that at 0555:07, the captain stated, “we need to get

the [ ] out of here,” and that 12 seconds later the flight engineer said, “emergency ground egress.”

The captain told investigators that he then pulled all three engine fire handles and attempted to

 13 The airport performance laptop computer provides takeoff and landing performance data.

14 The smoke barrier is a curtain that separates the cockpit and foyer area from the cabin cargo

area.
9

discharge the engine fire agents (he was unsure whether all bottles discharged).15 After the

accident, the captain said that the “Emergency Evacuation” checklist had not been read. The

flight engineer confirmed that the “Emergency Evacuation” checklist had not been read, but he

stated that he had turned off the battery switch (which is item No. 18 on that checklist). (See

appendix C for the “Emergency Evacuation” checklist.)

The flight engineer attempted to open the primary doors (doors L1 and R1),16 but

the doors would not immediately open. Meanwhile, the captain attempted to open his cockpit

window and felt resistance, and when he broke the air seal he heard air escape with a hissing

noise. He shouted to the others that the airplane was still pressurized. The flight engineer then

rotated the outflow valve control to the open position (thereby depressurizing the airplane), and

again attempted to open the L1 and R1 doors. Both of the evacuation slides deployed; however,

the L1 door only partially opened. After the airplane was depressurized, both the captain and

first officer opened their cockpit windows. The captain said that at that point the smoke was

colored gray to black, and then turned black and had a “horrible acrid” smell. He said he had to

hold his breath until his window opened and the smoke “billowed out the window like a

chimney.”

Smoke coming out of the cockpit windows and evacuation doors was immediately

visible to the firefighters. After the captain and first officer opened their respective sliding

windows, they positioned their upper bodies outside the airplane. The captain knelt on his seat

with his upper body outside the window. The first officer was seated on the window sill with his

feet on his cockpit seat and his upper body outside. They remained in these positions until after

the flight engineer and the jumpseat riders had evacuated the airplane (via the R1 evacuation

slide) and called to them from the ground beneath their windows. The captain and the first

officer then evacuated the airplane using the cockpit windows’ escape ropes. During the

evacuation, the captain sustained rope burns on his hands, and the flight engineer received a

minor cut to his forehead.

The flight engineer said that while he was in the airplane, the smoke was “oily and

sooty” and acrid smelling, and that it made breathing unpleasant and difficult. He said that

before he left the cockpit, he used his oxygen mask to fill his lungs with oxygen and then entered

the foyer area. He stated during his deposition that he did not consider using the PBE that was

available in the cockpit because he was anxious to open the exit doors, and he thought this could

be accomplished relatively quickly. He also indicated that he forgot that the PBE was available

in the cockpit.

As soon as he evacuated the airplane, the flight engineer gave the top sheet of Part

A of the “Notification of Dangerous Goods Loading” form to a firefighter, who radioed the

 15 For more information about the fire protection system on the DC-10, see section 1.6.3.

16 The L1 door is the forward door on the left side of the airplane, and the R1 door is the forward

door on the right side of the airplane. (See figure 3.) These doors were the only doors available to the crew because

the other doors had been blocked by cargo modifications.
10

information contained on that sheet (the classes and locations of the declared hazardous materials

on board the airplane) to the incident commander. The flight engineer also told firefighters that

the cargo containers holding hazardous materials were located in cargo containers 1L/C and 3R

and recommended that the firefighters discharge the airplane’s Halon bottles that were connected

to those containers, even though the fire appeared to be aft of the hazardous materials containers.

The flight engineer also indicated that he told firefighters that the more detailed Part B shipping

papers were in a plastic folder on the outside of the cockpit door.

As soon as the occupants had evacuated the airplane, the firefighters punctured the

slide at the L1 door and used a ladder to enter the foyer area. They attempted to fight the fire

from there using handheld hose lines, but the cargo net and the forward cargo containers blocked

their access to the cargo compartment. The flight engineer then provided instructions to the

firefighters on how to open the fuselage cargo door using the door controls located on the floor of

the foyer area. During these efforts, one of the firefighters broke off the control handle.

However, they were able to open the cargo door with the damaged control by using pliers to grip

and position the control valve.17

After the cargo door was opened, firefighters began attempting to fight the fire by

aiming handheld hose lines through the cargo door into the cabin. Within approximately 5

minutes after the cargo door was opened, flames burned through the top of the fuselage. (The

airport operations log recorded that flames breached the crown of the fuselage about 0655.) In

postaccident interviews, many of the eyewitnesses who described seeing the flames coming

through the fuselage did not specify the portion of the fuselage where they saw the first flames.

Some of the witnesses, who did specify a location, and video footage taken by firefighters of the

right side of the airplane, indicate that early visible flames came through the top of the fuselage at

a point approximately even with the trailing edge of the wings (in the area roughly corresponding

to the junction of cargo container rows 8 and 9). However, a FedEx mechanic who had assisted

firefighters in opening the cargo door said that just before observing the fire erupting through the

top of the fuselage he saw paint bubbling, aluminum melting, and "fingers" of fire coming from

the left side of the fuselage 5 to 8 feet back from the leading edge of the left wing (which roughly

corresponds to the forward portion of cargo container position 6L). One other eyewitness, the

ATC tower operator,18 described the location where he first saw flames appearing as “the first

third of the fuselage.”

After the flames began venting through the fuselage, the incident commander

withdrew the firefighters from the interior of the airplane and reassessed his tactical approach to

fighting the fire. Shortly after the fire first burned through the crown of the fuselage, firefighters

began using truck-mounted turrets aimed at the breached areas of the fuselage. These firefighting

 17 According to section 8-18-2 of the FedEx DC-10 Flight Manual, the cargo “door is manually

controlled and hydraulically operated.... Pressure for the [door’s hydraulic] system is supplied by an electrically

operated pump. If electrical power is not available, the door may be operated by hydraulic pressure from a hand

pump, or by manually unlatching and opening with a crane.”

18 From the tower, he would have had a view of the left side of the airplane.
11

efforts continued until approximately 0925, when the fire was extinguished and cleanup

operations began.

The accident occurred during the hours of darkness. Stewart is at 41°30.25’ north

latitude and 74°06.29’ west longitude.

1.2 Injuries to Persons

Injuries Flightcrew Cabin Crew Passengers Other Total

Fatal 0 0 0 0 0

Serious 0 0 0 0 0

Minor 2 0 0 0 2

None 1 0 2 0 3

Total 3 0 2 0 5

1.3 Damage to Airplane

The airplane was destroyed by fire after landing. The estimated replacement cost

of the airplane is about $95 million.

1.4 Other Damage

Most of the cargo was destroyed by fire and smoke and by the firefighting agent

applied during the emergency response operation. Insurance estimates of the value of the

destroyed cargo totaled about $300 million.

1.5 Personnel Information

The captain, first officer, and flight engineer were certificated in accordance with

Federal Aviation Administration (FAA) regulations. A search of FAA records indicated no

history of accidents, incidents, or enforcement actions; a search of the National Driver Register

indicated no history of driver’s license suspension or revocation for the three crewmembers.

1.5.1 The Captain

The captain, age 47, was hired by FedEx on October 8, 1979. He held an airline

transport pilot (ATP) certificate with airplane multiengine and single-engine land and

commercial pilot ratings, and type ratings in the Boeing 727 (B-727), Cessna 500, Douglas

DC-10, and Lockheed L-382.

His first-class medical certificate was issued on August 8, 1996, with the

restriction, “must wear corrective lenses.” Company records indicate that at the time of the

accident, he had accumulated approximately 12,344 total flying hours. He had logged 883 hours

in the DC-10 as first officer and 1,621 hours as captain.
12

The captain’s most recent pertinent ground training, flight training, and checks,

according to FedEx records, were as follows:

June 6, 1996 Single visit proficiency check (simulator)

June 5, 1996 Recurrent ground training/special purpose operational training

(simulator)

June 4, 1996 Recurrent emergency equipment drills/recurrent line oriented flight

training (LOFT) 19

January 26, 1996 Recurrent crew resource management (CRM) LOFT (simulator)

December 15, 1995 Aircraft line check—observed by FedEx check airman

August 24, 1994 FAA en route cockpit surveillance

June 7, 1994 DC-10 transition oral examination

May 25, 1994 DC-10 transition ground training

November 12, 1992 CRM awareness training

November 6, 1990 Initial firefighting with PBE

Before his employment at FedEx, the captain was briefly employed as an air taxi

pilot, flying light twin-engine airplanes. Before that, beginning in 1971, he served in the U.S. Air

Force as a C-130 pilot.

The captain described his activities for the 72-hour period before the accident.

Regarding his sleep cycles, he said he went to bed at 2350 central daylight time (CDT) on

September 1, 1996, and awoke at 0900 CDT on September 2. He was off duty on September 2

and 3. He said he went to bed at 2230 CDT on September 2 and awoke at 0700 CDT on

September 3; he went to bed at 2000 CDT on September 3 and awoke at 0015 CDT on

September 4. On September 4, he served as captain on a flight from Memphis to Boston, which

was scheduled to leave Memphis at 0245 CDT. He slept at Boston for approximately 1 hour 45

minutes and arrived back at Memphis at 1116 CDT. He arrived home at 1215 CDT, ate lunch,

and ran some household errands. He slept from 1400 CDT until 1800 CDT and had dinner at

1830 CDT. He went to sleep at 2100 CDT.

He awoke at 0015 CDT on September 5, 1996, and checked in for the accident

flight at 0125 CDT.

1.5.2 The First Officer

The first officer, age 41, was hired by FedEx on December 27, 1989. He held an

ATP certificate with airplane multiengine and single-engine land, commercial pilot, rotorcraft–

helicopter, and instrument helicopter ratings, and a type rating in the Douglas DC-9 airplane.

 19 The captain told Safety Board investigators that during his last flight training session in June

1996, he was given a scenario that involved a cargo fire on a flight from Boston to Newark. He said that the scenario

was almost identical to the emergency on flight 1406.
13

His first-class medical certificate was issued on July 29, 1996, with the restriction,

“must wear corrective lenses.” The first officer indicated that he was wearing his glasses

throughout the accident flight. Company records indicate that at the time of the accident, the first

officer had accumulated 6,535 total flying hours. He had logged 1,101 hours in the DC-10 as

flight engineer and 237 hours as a first officer.

The first officer’s most recent pertinent ground training, flight training, and

checks, according to FedEx records, were as follows:

February 28, 1996 DC-10 LOFT simulator training

February 23, 1996 DC-10 upgrade simulator training/check

February 2, 1996 Upgrade DC-10 oral exam

February 1, 1996 Upgrade DC-10 ground training

January 24, 1996 Initial DC-10 emergency equipment drills

March 12, 1995 Aircraft line check—observed by FedEx check airman

July 8, 1992 CRM awareness training

January 9, 1990 Initial firefighting with PBE

Before being employed by FedEx, the first officer served in the U.S. Navy as a

naval aviator flying fixed-wing airplanes and helicopters. He began pilot training with the Navy

in November 1979.

The first officer described his activities for the 72-hour period before the accident.

Regarding his sleep cycles, he said he went to bed at 2030 CDT on September 1, 1996, and woke

up at 0830 CDT on September 2. He was off duty on September 2 and 3. He said that he went to

bed at 2245 CDT on September 2 and awoke at 0600 CDT on September 3; he went to bed at

2130 CDT on September 3 and awoke 21⁄2 hours later, at 2400 CDT. He left home at 0040 on

September 4 and flew on the same flight sequence as the captain. He arrived home on September

4 at 1215 CDT, had lunch, and went to bed at 1245 CDT. He woke up at 1830 CDT, had dinner,

and picked up his son from football practice. He went to bed at 2030.

He awoke at 2350 CDT on September 5, 1996, and checked in for the accident

flight at 0125 CDT.

1.5.3 The Flight Engineer

The flight engineer, age 45, was hired by FedEx on March 20, 1996. He held an

ATP certificate with airplane multiengine and single-engine land and commercial pilot ratings,

and a type rating in the B-737 airplane.

His first-class medical certificate was issued on March 11, 1996, with the

restriction, “must wear corrective lenses.” The flight engineer stated that his glasses are only for
14

distance vision, and that he removes them periodically when he does not need them. He stated

that he was not wearing them during the emergency portion of the accident flight.20 Company

records indicate that at the time of the accident, the flight engineer had accumulated 3,704 total

flying hours. He had logged 188 hours in the DC-10 as flight engineer.

The flight engineer’s most recent ground training, flight training, and checks,

according to FedEx records, were as follows:

June 11, 1996 Aircraft line check—observed by FedEx check airman

June 2, 1996 Simulator LOFT training

May 27, 1996 DC-10 simulator training/check

April 29, 1996 DC-10 initial oral examination

April 25, 1996 DC-10 initial oral examination

April 17, 1996 DC-10 emergency equipment drills

April 8, 1996 CRM awareness training

March 25, 1996 Initial firefighting with PBE

From October 1995 until his time of employment with FedEx, the flight engineer

was employed as a DeHavilland DHC-8 (Dash-8) first officer by Horizon Air. He flew the

Cessna 310 for Copper State Air Service from February 1995 until October 1995. He also flew

jet trainers and fighters in the U.S. Air Force.

The flight engineer described his activities for the 72-hour period before the

accident. Regarding his sleep cycles, he said he went to bed on September 1, 1996, at 2100 CDT

and awoke at 0600 CDT on September 2. He was off duty on September 2 and 3. He said that

he went to sleep at 2100 CDT on September 2 and awoke at 0600 CDT on September 3; he went

to sleep at 1830 on September 3 and awoke at 2400 CDT. On September 4, he flew on the same

flight sequence as the captain and first officer. After he arrived home, he exercised, ate lunch,

and took a 2-hour nap. He awoke and had dinner at 1700 CDT. After dinner, he went to bed,

sleeping approximately 6 hours.

He awoke at 2400 CDT on September 5, 1996, and checked in for the accident

flight at 0115 CDT.

1.6 Airplane Information

N68055, a DC-10-10CF, serial number (SN) 47809, was manufactured by the

Douglas Aircraft Company and was issued an airworthiness certificate on January 21, 1975. The

airplane was originally operated by Continental Airlines; FedEx acquired the airplane on May 14,

1980. In May 1989, the airplane underwent supplemental type certificate (STC) modifications to

its cabin interior, changing its configuration from a passenger-carrying to a cargo-only full

 20 The Safety Board understands that the FAA is aware of, and is taking action to address, this

issue.
15

freighter airplane. These STC modifications included changes to the overhead cabin ventilation

ducting, and installation of smoke detectors, cabin floor pallet tiedown and movement systems,

and panels covering the interior walls.

A review of the airplane records revealed that a possible hazardous materials spill

(of an unknown white powder) was reported on August 5, 1996, and was cleaned up on August

23, 1996. The spill occurred on the right side and at the rear of the main cargo deck areas at

cargo container positions 14R, 15R, and 16R. Testing at that time found the spilled substance

not to be corrosive, and no further action was taken. No other pertinent discrepancies were noted

in the maintenance logs, the minimum equipment list (MEL),21 or the configuration deviations

list (CDL).22

As of September 5, 1996, N68055 had been flown 38,271 hours, with 17,818

cycles. Three General Electric CF6-6D engines powered the airplane. The takeoff gross weight

of the airplane was 364,144 pounds. The maximum allowable takeoff gross weight was 446,000

pounds.

1.6.1 Air Ventilation System

The air conditioning/ventilation system on the DC-10 consists of three

environmental control units (air conditioning packs) located beneath the main cabin floor. The

three packs feed conditioned air through a distribution system for cooling/heating the airplane’s

cockpit and cabin compartments. (The system also provides pressurized air for cabin

pressurization.) On the accident airplane, air entered the main cabin from an overhead duct just

aft of the cockpit in the foyer area.

The STC modifications to the accident airplane in 1989 included modifications to

the overhead cabin ventilation ducting. No tests of upper cabin airflow patterns have been

conducted on this airplane configuration or with cargo pallets in place. A Boeing systems

engineer with Douglas Products Division who is familiar with the DC-10 ventilation system

testified at the Safety Board's deposition proceeding that although there is an attempt to minimize

axial airflow23 on passenger airplanes as much as possible, axial flow can and does occur in

cargo configurations. A FedEx engineer who is familiar with the accident airplane’s

configuration testified that he had observed axial (aft-flowing) airflow in an empty cargo airplane

(i.e., without any cargo containers in place).

Safety Board investigators considered conducting smoke/fire tests to observe what

the airflow patterns would have been during the accident sequence. However, because any such

 21 The MEL lists items of aircraft equipment that may be deferred when inoperable. The MEL is

developed by each operator of an aircraft and must be equivalent to or more conservative than the master MEL,

which is developed by the manufacturer and approved by the FAA.

22 The CDL lists changes to the aircraft configuration that may be deferred.

23 Airflow along the airplane’s longitudinal axis (fore and aft).
16

test would have had to include a re-creation of the heat produced by the fire (and not just the

smoke) and also the effects of the airplane’s maneuvering at altitude, the members of the fire

group determined that no meaningful tests could be done safely.

To further study the ventilation system, on January 30, 1998, Safety Board

investigators examined an undamaged FedEx DC-10 with the same configuration as the accident

airplane. From the initial entry point behind the cockpit, air was routed both into the cockpit area

and into the main cargo cabin. The main cargo cabin ducting consisted of a 12-inch diameter

fiberglass duct installed in the crown of the cabin. Eight outlets from the main overhead duct

(the first of which was installed at fuselage station (FS) 24 700 and the last at 1740) directed

conditioned air into the cabin. (The outlets were 4-inch tubes that extended about 4 inches down

into the cabin from the main duct.)25 The air exited the cabin through a series of metal floor

vents installed in the cabin floor where the floor abutted the cabin walls. The floor vents were

9.48 inches high and between 10.5 and 16.25 inches long. The floor vents were not evenly

distributed; more were installed in the aft portion than in the forward portion of the main cargo

cabin. (See figure 5 for the arrangement of floor vents.) After exiting the floor of the main cargo

cabin, the air passed through holes, known as cusp holes,26 and exited the airplane from the

outflow valve, which was located on the left side of the airplane forward of the wing.

The accident airplane’s pneumatic systems were examined for abnormal

conditions or malfunctions. The pneumatic lines from the engines and the auxiliary power unit

were found attached to the airframe except in the areas where the aft fuselage had separated

during the postlanding fire. The pneumatic lines from the environmental control units were

examined. They remained attached to the airframe throughout the lower portion of the airplane.

1.6.1.1 Cabin Air Shutoff

According to the March 20, 1994, edition of FedEx’s DC-10 Flight Manual, page

8-2-1:

Three shutoff valves are installed, one in each cabin conditioned air supply

duct.... A single handle recessed in the cockpit ceiling above the second

observer [flight engineer] operates the three shutoff valves in the cabin

conditioned air manifolds and the overpressure relief valve in the main

conditioned air manifold.

 24 See figure 1 for fuselage station locations.

25 The main cabin smoke detectors, most of which are mounted on the main overhead air duct, are

also suspended about 4 inches beneath the duct.

26 Cusp holes allow air to flow from the upper cabin to below the floor and eventually to the

outflow valve.

18

In the event of smoke indication in the cabin cargo compartment, pulling the

handle shuts off all air to the cabin and opens the relief valve under the floor

to dump excess air directly to the pressure control outflow valves.

1.6.2 Cabin Pressurization System—Cabin Outflow Valve Control

According to the March 20, 1994, edition of FedEx’s DC-10 Flight Manual, page

8-2-2/8-2-3:

Cabin pressure is controlled and maintained by metered release of conditioned

air in either an AUTO, SEMI-AUTO, or MANUAL mode.... The cabin

pressure controller maintains the desired cabin pressure in relation to the

altitude set.... In the AUTO mode, cabin pressurization is automatically

controlled during takeoff, climb, cruise, and descent conditions to the lowest

cabin altitude compatible with aircraft and flight requirement.

When MANUAL control is selected, the control wheel engages a locking

mechanism to secure the outflow valve in its existing position. After

selection, manual control is achieved by pressing the control wheel inward (to

disengage the control wheel locking device) and rotating the wheel to position

the outflow valve to attain the desired cabin altitude. When the control wheel

is released, the outflow valve is again locked in its existing position. Selecting

the valve at more than two-thirds open can cause a negative pressure and

create a noise in the cabin. At touchdown, the Second Officer [flight

engineer] must manually depressurize the aircraft.

In the DC-10, the manual cabin outflow valve control wheel projects vertically

through the flight engineer’s panel. Approximately one-third of the wheel projects through the

panel. During a ground test conducted by a Safety Board investigator on a similar DC-10, two

full manual cranks of the outflow valve control wheel in the cockpit did not perceptibly open the

outflow valve from the full-closed position. (During the test, a full “crank” of the control was

considered to be the most rotation of the wheel that could be obtained with one hand motion.)

During the test, the valve began to perceptibly open after about 3 full cranks and was completely

open after about 16 full cranks.

1.6.3 Fire/Smoke Detection System

Smoke detection systems were installed in the main cargo cabin and lower cargo

areas. The smoke detection system consisted of 16 main deck smoke detectors suspended from

the cabin ceiling, each of which was connected to an indicator light in the cockpit, and 4 lower

forward cargo compartment detectors. Postaccident examination of the smoke detection systems

in the upper cabin cargo area revealed that they had been destroyed by fire. The lower cargo

compartment detectors were in place and were not damaged. The system could not be

functionally tested because of the damage to the upper cabin system and the associated wiring

bundles.
19

The airplane had fire extinguishing systems for each of the three engines (two

bottles for each engine) and one bottle for the forward lower cargo compartment. In addition,

three Halon fire extinguishers were installed in the forward portion of the main deck cargo

compartment connected to cargo container 1L/1C.

Examination of the engines’ fire extinguishing systems revealed that on some of

the bottles, the squibs (discharge devices that rupture to discharge the fire extinguishing agent in

the bottle) had discharged. The No. 1 and No. 3 engines each had bottle 1 fired, and the lower

cargo compartment had its bottle fired. None of the three main deck Halon bottles had been

used. Neither of the No. 2 engine squibs had discharged.

1.6.4 L1 Forward Passenger Door Design and Operation

The L1 and R1 cabin doors are plug-type doors that are normally powered up and

down by an electric motor through a gearbox, cable drums, sprockets, and torque tube, and

1/8-inch nylon-coated drive cables that are attached to the door. During emergency operation, an

air motor drives the door open through the same electric motor gearbox, cable drums, sprockets,

torque tube, and drive cables. The air motor supply is provided by an air bottle charged with

nitrogen to 1,500 psi. When the door handle is moved to the emergency position, the air motor

opens the door within 9 seconds. A fully charged bottle is capable of providing air pressure for

up to approximately 30 seconds. The door is designed to open when activated when the cabin

pressure differs by less than approximately 0.5 psi from the external pressure. If an attempt to

open the door is made with the pressure differential greater than 0.5 psi, the bottle pressure will

bleed off and the door will not open. A ratchet-type lock prevents the door from closing all the

way if it is only partially opened.

1.7 Meteorological Information

The weather logged by the Stewart tower when flight 1406 landed was as follows:

Wind from 280o

 at 4 knots; surface visibility 2 statute miles restricted by mist;

a broken layer of clouds at 3,000 feet above the ground and an overcast layer

of clouds at 7,000 feet above the ground; temperature 64°F (18°C); dew point

63°F (17°C); altimeter setting 30.18 inches of Hg.

1.8 Aids to Navigation

No problems with aids to navigation were reported.

1.9 Communications

No communications difficulties were reported.
20

1.10 Airport Information

Stewart is located approximately 3.5 miles northwest of Newburgh, New York,

and has a published elevation of 491 feet above sea level. The airport has two intersecting

runways oriented approximately east-west (runway 9-27, which is 11,818 feet by 150 feet) and

northwest-southeast (runway 16-34, which is 6,006 feet by 150 feet). The airport is certificated

under 14 CFR Part 139 and is an Index C aircraft ARFF facility.

27

1.11 Flight Recorders

A digital flight data recorder (FDR) and a CVR were installed in the airplane.

The FDR was a 37-parameter Sundstrand Model UFDR (SN 2783). The CVR was a Fairchild

Model A100 (SN 4225). Both recorders were removed from the airplane by investigators and

sent to the Safety Board’s laboratory in Washington, D.C., for readout.

1.11.1 CVR

The four channels of the CVR contained information from the cockpit area

microphone, the captain’s position, the first officer’s position, and the flight engineer’s position.

Although the top of the CVR unit was lightly coated with a soot-like substance, it did not show

evidence of either fire or structural damage. The quality of the recording was excellent.28 A

transcript was prepared and is included as appendix B.

1.11.2 FDR

The FDR showed evidence of slight thermal damage and sooting, but the

recording medium was undamaged.

1.12 Wreckage and Impact Information

The upper cargo containers and fuselage were destroyed by fire. The fuselage had

separated in two places: at FS 1531, just aft of the rear wing spar, and at FS 1986, just forward of

the aft pressure bulkhead. Several areas of the fuselage were consumed by fire. (See section

1.14.) Examination of the L1 and R1 doors found that the doors were seized in their respective

 27 14 CFR Sections 139.319 and 139.315 require, for scheduled air carrier service with aircraft at

least 126 feet long but less than 159 feet long, that the airport be equipped with a minimum of two ARFF vehicles

with a total quantity of water of at least 3,000 gallons for foam production.

28 The Safety Board uses the following categories to classify the levels of CVR recording quality:

excellent, good, fair, poor, and unusable. Under the recently revised definitions of these categories, an “excellent”

recording is one in which virtually all of the crew conversations can be accurately and easily understood. The

transcript that was developed may indicate only one or two words that were unintelligible. Any loss in the transcript

is usually attributed to simultaneous cockpit/radio transmissions that obscure each other.
21

tracks with severe heat damage around the door jambs and their drive cables. (See figure 3 for

location of L1 and R1 doors.)

The nose of the airplane was lightly sooted above both cockpit windows. The

area above the L1 door was burned and sooted. The fuselage above the L1 and R1 doors was

heavily sooted, with soot trailing outwards from inside the airplane. The top two-thirds of the R1

door was also heavily sooted. The window in the R2 door was ruptured inwards. No smoke,

soot, or fire damage was observed in or around the ruptured portion of the door.

A light residue of soot and oil was observed trailing aft from both air conditioning

pack cooling outlets on the left side of the fuselage. There was a 6-inch diameter hole on the left

side of the airplane, forward of the main cargo door, slightly below the window line. Heavy soot

trailed approximately 2 feet aft of the outflow valve along the left side of the fuselage. The

cargo door’s hydraulic line remained attached at the lower right side of the fuselage and at the

upper fuselage crown at the centerline attachment. No evidence of soot or fire damage was found

on the lower fuselage and belly of the airplane.

The vertical stabilizer, rudder, horizontal stabilizers, and elevators were intact and

free of fire damage. The No. 2 engine nacelle was sooted about 4 feet aft of the engine intake

and was burned through the lower nacelle at four locations that corresponded to the consumed

fuselage below the nacelle. The right side of the No. 2 engine pylon and exterior fuselage were

sooted and burned from the top of the engine pylon to fuselage longeron29 13 at the right

horizontal stabilizer fairing. (See figure 6 for a diagram of longeron locations.) The tailcone and

lower fuselage skin were compressed vertically along its bottom surface, and there was a vertical

wrinkle 2 feet from the end of the tailcone.

The lower cargo compartments, wings, landing gear, and No. 1 and No. 3 engines

were undamaged and free of soot or fire damage.

At the separated empennage section, the upper interior fuselage crown and the

canted area of the aft pressure bulkhead were heavily sooted between longeron 15 left and

longeron 23 right. Four of the upper fuselage ring frames were burned and melted between

longeron 1 left and the upper canted bulkhead, parallel to longerons 18 left and right. The No. 2

engine bleed air duct was separated about 3 feet forward of the bulkhead. Electrical wires

protruded about 20 feet from the aft pressure bulkhead and had cut and separated ends. The wire

insulation remained intact on the wires that protruded from the left side of the aft pressure

bulkhead, and the wire insulation was burned around the wires that protruded from the right side

of the aft pressure bulkhead. No evidence of arcing of airplane wiring was seen. The lower

section of the aft pressure bulkhead that was common to the lower cargo area was undamaged

and had no soot or fire damage.

 29 Longerons are the principal longitudinal structural members in an aircraft fuselage.

23

The left No. 1 engine and its engine pylon and the right No. 3 engine and its

engine pylon were structurally intact and were attached to the fuselage. Neither of these engines

or their pylons had any sooting or heat damage.

1.13 Medical and Pathological Information

The captain, first officer, and flight engineer submitted urine specimens

approximately 25 hours after flight 1406 landed. The specimens were analyzed and found to be

negative for THC,30 cocaine, phencyclidine (PCP), amphetamines, and opiates. The results of

the postaccident breath alcohol tests conducted approximately 251⁄2 hours after flight 1406 landed

were invalid under DOT regulations because of the elapsed time since the accident.

1.14 Fire

1.14.1 Fire Damage to Lower Cargo Compartment

No evidence of smoke or fire was observed on any of the cargo containers from

the lower forward and lower center cargo compartments (the lower aft cargo compartment was

empty). The undersides of the main deck cabin flooring, above the center accessory

compartment, had several areas where the bottom fiberglass face of the main cabin flooring was

scorched. Two larger scorched areas were found near the forward inboard side near FS 1149,

below the 6R container position. A smaller scorched area was found under the forward outboard

side of FS 1515 (at the interface of container positions 8L and 9L), and another smaller scorched

area was found between FS 1641 and 1661 (under the vacant area aft of cargo container row 9).

There was some melting of the insulation blanket cover under the cabin return air grills in the

right forward corner of the center cargo compartment. Burned debris from the cabin had also

fallen through the return air grills in that area.

1.14.2 Fire Damage to Upper Cargo Compartment

There were melted and partially consumed aluminum fuselage skin, longerons,

and frames31 throughout the interior fuselage. The cabin interior of the forward fuselage was

burned and sooted between FS 470 and 765. The cabin sidewall panels in that area were

destroyed by fire on the right side of the fuselage, exposing the burned and melted fuselage ring

frame flanges. The center of the fuselage crown was consumed by fire from FS 515 through 575,

above container row 1. (See figure 7.) Two small areas of fuselage crown were consumed by the

fire between FS 595 and 615 on the right side of the fuselage and between FS 615 and 635 on the

left side of the fuselage, also above container row 1. The center of the fuselage crown was

consumed in the area of the main cabin cargo door from FS 635 through 735, above the location

of cargo container row 2.

 30 Delta-9-tetrahydrocannabinol (marijuana).

31 The frames run laterally every 20 inches along the airplane fuselage and provide support for the

longerons.
24

Figure 7.—DC-10-10, N68055, airplane with overlaid cargo container positions
25

The cabin sidewall panels were lightly sooted and remained attached to the left

side of the fuselage between FS 450 and 840, above container position 3L. Burned and sooted

upper sidewall panels hung down directly above the attached lower sidewall panels. The right

side of the fuselage between FS 808 and FS 919, next to container position 3R, exhibited severe

heat and fire damage, along with melted fuselage frame flanges. The airplane’s exterior paint

was scorched and bubbled on the left side, next to the first two windows between FS 859 and

899, near the aft of container row 3 and the front of container row 4.

The fuselage crown was consumed by the fire between FS 939 and FS 1039, from

approximately the middle of container row 4 to the middle of container row 5. The frame flanges

on either side of this consumed area of the fuselage crown were burned and melted. The left side

of the fuselage crown was also consumed by fire between FS 1179 and FS 1531, an area

corresponding to approximately the middle of cargo container 6L to the middle of cargo

container 9L.

Light soot deposits were found on the cusp holes under the cabin floor vents and

on floor structural components on the right side of the cabin between FS 1039 and FS 1099,

outboard of the 5R position (on the accident flight, position 5R was occupied by a loaded cargo

pallet, not a cargo container). A floor vent panel at FS 1119 was melted. Intense heat and fire

damage was observed in the area of container position 6R at the level of the cabin cargo deck

floor on the right side of the fuselage. Three floor vent panels outboard of container 6R were

melted or fire damaged, including a floor vent panel between FS 1199 and 1219, which was

melted on the corner near FS 1199 and at FS 1139, where the baffle and floor vent grill were

melted. The bottom surface of cargo container 6R was melted through the bottom of the

container onto a seat track and through the cargo compartment floor into the lower cargo

compartment. No other cargo container floors or bottom surfaces were breached.

Examination of the section of the fuselage that separated at FS 1531 and FS 1986

revealed interior skin sooted throughout the crown. Soot deposits on the left side of the cabin

interior just forward of FS 1531 (which was at the front of cargo container row 9) were in a “V”

pattern with the lowest point of the “V” being on the floor level at the fuselage separation point.

At this separation, there was no evidence of thermal damage to the cabin floor or to the fuselage

structure. The fiberglass floor board on the left side outboard between the interface of containers

8L and 9L was burned. Examination of the left outboard airplane structure just aft of the

separation showed soot deposits on the lower outboard floor panel between FS 1561 and FS

1581, adjacent to cargo container position 9L. There was no evidence of soot deposits on the

floor beam lightening holes32 between FS 1541 and FS 1561. The left side blow-out panel33

between FS 1561 and 1581 showed no evidence of heat damage.

 32 Lightening holes are areas of the aircraft structure left out (by the manufacturer) to reduce

weight without compromising the strength of the aircraft.

33 Blow-out panels are small areas of the floor designed to fail at certain pressure differentials to

provide in-flight decompression venting (to prevent overall failure of the floor structure).
26

There was a melted aluminum shield (a small wall panel that abuts the floor)

between FS 1581 and 1601 (outboard of 9R). The ventilation grill at this point was intact. There

was no evidence of soot flow along the left or right side tunnel in the area of the blow-out panel

or on the cusp holes under the floor. The binder in the fiberglass floor board on the outboard left

side of FS 1641 was burned away, leaving only the fiberglass strands. (No containers were in

this area [FS 1639-1728] on the accident flight.) There was some scorching of the underside of

the floor panel between FS 1641 and 1661. This heat damage was about 24 inches to the right of

the airplane centerline. Cabin sidewall panels on the left side of the cabin between FS 1621 and

1851 were burned and sooted throughout the upper half of the panels (this area began above

container 9L and extended through the forward portion of container 15L). A portion of the seat

track in the cabin floor was melted between FS 1641 and 1656. The fuselage skin and frames

between FS 1900 and 1986 were undamaged.

The center of the fuselage crown was consumed by fire between FS 1741 and

1781, above container row 14. The fuselage crown frames forward and aft of FS 1741 and 1781

were melted, and the fuselage skin was consumed on the right side of the fuselage between FS

1781 and 1821. The area surrounding the consumed skin was free of soot. Light sooting was

observed above the horizontal stabilizer between FS 1986 and 2163. The center of the fuselage

crown was also consumed by fire between FS 1868 and 1942, above container rows 15 and 16.

Three cabin fluorescent light ballasts were recovered. One ballast was found in

container 6R, one in container 4L, and one next to the forward cargo door near FS 695. All were

fire damaged but showed no evidence of arcing or internal failure. The switch for the cabin

fluorescent lighting, which was installed on a control panel aft of the L1 door, was found in the

“off” position. A FedEx representative reported that the main cargo compartment fluorescent

lights are normally turned on during cargo loading at night and are turned off before flight.

During the on-scene portion of the investigation, four aerosol cans were found in

the debris on the main cabin floor. Two of them were found in the area between cargo containers

6R and 7R. The tops of both of these cans were intact. The propellant filling port plug on the

bottom of one was missing; the plug on the bottom of the other one was present. Two additional

cans were found in the area of container 9L. The tops of both of these cans were missing, and the

metal bodies where the tops attached were unfolded (uncrimped).

A specially trained accelerant residue detection K-9 Labrador retriever (trained to

detect ignitable vapor residues from petroleum products, alcohol, and other common

accelerants), was brought into the main cargo compartment a few days after the accident to check

for accelerant residue. No accelerant residue was detected.
27

1.14.2.1 Damage to Cargo Containers and Contents34

After the accident, the cargo containers that had been in the main cabin were

removed from the airplane and arranged in the same order in which they had been in the airplane.

The bottom surface of each container was examined and photographed as the containers were

removed. None of the container bottom surfaces exhibited evidence of fire damage except for

container 6R. The forward inboard corner (as viewed from aft looking forward with container

6R in its original position in N68055) of container 6R’s bottom surface was melted.

The cargo containers were arranged with a 10-foot wide center walkway and

about 21⁄2 feet between the forward and aft sides of the containers for walkaround space. Orange

rubber traffic cones were placed along the center walkway to simulate the positions of the cargo

compartment smoke detectors in relationship to the individual positions of the cargo containers.

One-inch wide orange plastic surveyor’s tape was connected to cornerposts of each cargo

container, front to rear, on both sides to trace the height of the burned and melted container

corner posts. A conical “V” burn pattern was observed from right to left and from forward to

rear with the lowest (deepest burned) area centered over container 6R.35 It was observed that the

cargo in containers surrounding 6R (position 6L, 7R, and 5R) was burned to a greater depth

along the sides next to container 6R than in the other areas of those containers. For example, the

cargo in container 6L was burned to the floor along the inboard (right) side of the container,

which bordered on 6R. Likewise, the cargo in container 7R was burned deeper along the

container’s forward edge (next to the aft of container 6R). An overhead view of the cargo

containers also showed that the deepest (lowest level of consumed wreckage) fire damage had

occurred at container 6R.36

Container 6R's aluminum roof, three Lexan37 walls, and nylon roll-up curtain (the

fourth wall) were completely consumed by fire, except for a small portion at the bottom center of

 34 The Safety Board’s fire group was assisted with the examination and documentation of the firedamaged cargo containers by investigators from the New York State Office of Fire Prevention and Control Arson

Bureau (who conducted an independent examination a few days after the initial investigative team), and a safety

specialist from FedEx.

35 According to basic fire science, a “V”(cone-shaped) burn pattern usually narrows at the point or

area of the fire’s origin; as the fire propagates, the cone widens as the fire spreads out to reach fuel. See, e.g.,

National Fire Protection Association’s Guide for Fire and Explosion Investigations, NFPA 921, 1995, “The analysis

of fire patterns is performed in an attempt to trace fire spread, identify areas and points of origin, and identify the

fuels involved." [Par. 4-1]; “The angled lines of demarcation, which produce the ‘V’ pattern, can often be traced

back, from the higher to lower levels, toward a point of origin. The low point or vertex of the ‘V’ may often indicate

the point of origin." [Par. 4-17.1]

36 The row of cargo containers on the left side of the airplane exhibited a similar burn pattern to

that seen on the right side, except that generally less fire damage was observed on the left side cargo containers and

their contents, and the melted cornerposts on the left side were taller than the cargo container posts on the right side

of the airplane.

37Lexan is a polycarbonate product manufactured by General Electric Plastics. It is easily molded

and is typified by its high-impact resistance.
28

the aft Lexan wall.38 The outboard forward cornerpost was completely consumed. The outboard

aft cornerpost measured 3 feet 9 inches, the inboard forward cornerpost measured 1 foot 2 inches,

and the inboard aft cornerpost measured 3 feet 6 inches. The roll-up door spring assembly,

including the spring cover, was melted to the floor near the inboard forward cornerpost.

Solidified melted aluminum was puddled on the container floor along the inboard side of the

container floor. Portions of the container’s 8-inch high aluminum lower sidewall had melted

along the outboard, inboard, and forward sides of the container.

Other containers that sustained significant fire damage were those in positions 6L,

rows 7 and 8, and 9R. Appendix D describes in detail the damage to each of the cargo containers

from the main cabin, except for containers 1L/1C and 3R, which contained declared hazardous

materials and are described below.

Containers in positions 1L/1C and 3R contained declared hazardous materials.

The container in position 1L/1C was a full-contour aluminum container designed for hazardous

materials. The container, when viewed from the side with its access door facing forward, had

soot in varying degrees of thickness on the outside of the upper half of the container. The roof of

the container had a hole approximately 12 inches left of its center and about 4 inches in from the

edge of the door side. The hole was 16 to 18 inches long (left to right) and 12 inches deep

(forward-aft dimension) and was centered in an area that had been dented inward. FedEx

reported that the hole had been caused by the equipment used to remove the container from the

airplane after the fire. No soot was observed on the container’s interior surfaces. A small

amount of water was present on the floor of the container.

The contents of container 1L/1C were secured by netting, and the packaging was

tight and in place. No discrepancies were noted during the postaccident examination regarding

the separation, segregation, and orientation of the packages in the container. On September 8,

1996, each package within the container was also inspected. The package containing a vial of an

infectious substance (HIV) appeared to be undamaged and was opened and examined. The inner

contents were intact and undamaged. One package containing a flammable liquid showed signs

of wetness along the bottom of the package, even though this box was on top of another box

within the container. When the wet box was opened, a cooler pack was found to be the source of

the wetness; the glass bottle of flammable liquid within the box was not damaged and did not

leak. Other than the light sooting of some packages, there was no evidence of damage or leakage

from any of the other packages in this cargo container.

The container in position 3R was a full Lexan container. It had an aluminum

floor, roof, frame, Lexan sides, and a draw-down nylon curtain to cover the door or opening of

the container. Eighty percent of the roof, 100 percent of the rear wall opposite the door, 75

percent of the left side, and 75 percent of the right side were consumed by fire. The floor area of

the container was intact. The inboard cornerposts were intact; the outboard cornerposts were

slightly burned at the top.

 38 This portion of the remaining wall had pieces of a cardboard box imbedded in it.
29

The cargo container was emptied and its radioactive contents inventoried. All of

the inner containers for the radioactive materials were found intact. Ten separate shipments of

radioactive materials were found in the container. All other recognizable shipments declared as

hazardous materials were also unloaded from 3R and inventoried. Some contents were

consumed by fire; others had sustained some level of water and/or fire damage. Excluding the 10

radioactive shipments, 36 packages were identified and inventoried as hazardous materials.

1.14.2.1.1 Contents of Cargo Containers in Position 6R and in Rows 8 and 9

Each of the containers was inspected to assess the degree of its fire damage and

the depth to which its contents were burned.39 A layered inspection of the debris in each cargo

container40 was initiated starting with the top, outermost layer of burned cargo and working

inward and down towards the center of the cargo. The examination revealed that container 6R

was the only cargo container that exhibited fire damage throughout its debris and down to the

container floor. The investigation found four cargo shipments in container 6R:41 one consisting

of industrial metal valves, one consisting of a DNA synthesizer, and two separate computer

shipments. All of the contents of 6R were removed and examined.

The metal valves were found in the aft outboard corner of 6R. The various-sized

valves were stacked on top of cardboard on a single wooden pallet, wrapped in newspaper, and

banded with steel bands. Some of the newspaper wrapping was slightly discolored by heat but

had not been impinged by flames. Other portions of newspaper and cardboard were charred.

The aft part of the pallet was unburned under the cardboard, but the forward part of the pallet was

charred and burned. A variety of electronic equipment was also found in the remains of

container 6R: a Texas Instruments Extensa laptop computer; two Power Station power servers; a

 39 During the on-scene portion of the investigation, no separate search was conducted specifically

for undeclared hazardous materials. However, investigators were told that any items discovered during the search

that appeared to be potentially hazardous were to be provided to the hazardous materials group for further

evaluation. Also, as discussed below, in November 1997, the debris stored in boxes labeled 9L and 9R was

examined in detail. During this examination a hazardous materials investigator searched specifically for undeclared

hazardous materials. Further, in March 1998 all of the stored cargo debris was searched for possible undeclared

hazardous materials.

40 Some items might have come to rest in cargo containers other than those in which they were

originally loaded. Firefighters reported that some cargo debris had been spread around from the force of the water

being sprayed on the fire.

41 The FedEx cargo manifest indicated the shipments (identified by airbill number) that were

loaded into each cargo container, but did not include descriptions of the contents of each shipment. The manifest

listed only airbill numbers and information about the shipper and receiving party. The nature of the shipments in

container 6R was determined by inspecting the contents of the container and by information obtained by FedEx when

it contacted the four shippers of the items in 6R. Although FedEx made the cargo manifest for the accident flight

available to the Safety Board, it was not considered useful to the Safety Board’s investigation and it was not

provided to the other parties to the investigation. FedEx indicated that the manifest is “proprietary, confidential, and

contains information about FedEx customers which we do not ordinarily release to third parties.” (January 22, 1998,

letter from FedEx to the Safety Board.)
30

computer manufactured by Power Computing Company; and a DNA synthesizer Expedite Model

8909 manufactured by PerSeptive Biosystems. Investigators examined all of this equipment to

assess internal and external fire damage and to search for possible ignition sources.

The Extensa plastic computer case was partially melted and burned along its left

side, but the remainder of the case was undamaged and remained encased in its Styrofoam and

plastic packaging materials. The computer was pried open, and a service invoice was found

between the keyboard and computer screen. The invoice revealed that the computer had been

repaired by Texas Instruments on the day before the accident. When questioned by investigators,

the Texas Instruments technician who repaired the computer stated that the computer’s

connectors to the hard drive had been upgraded. According to the technician, the computer’s

battery had not been recharged before it was shipped to its owner. Further examination of the

computer components and its battery pack found that the left side of the plastic computer case

was burned and melted, exposing the end of the battery pack. (The Extensa laptop is equipped

with two rows of seven nickel metal hydride batteries mounted to a plastic circuit board.) The

plastic covering on two of the outboard batteries in the pack was burned and melted, exposing

the metal cases, which were undamaged. The remainder of the batteries and the circuit board

were intact and showed no further fire damage. A voltage check across the positive and negative

battery leads measured 0.26 volt. No other fire damage was noted on the interior of the

computer.

On the two Power Station power servers, the plastic external surfaces were melted

and charred. No batteries or other power source was found in the power servers. No fire damage

was found inside the units.

The outer case of the Power Computing Company computer was burned on the

front of the case. No evidence of internal fire damage was found in the unit. No batteries were

found inside the computer. Several coils of burned and charred computer connection cables were

found near the power server and the computer monitor.

The following additional items, some of which were burned, were found among

the debris in 6R:

• Packages labeled Warrick Pharmaceutical Albuterol Sulfate USP Inhalation Solution .083

percent, and packaging and products labeled Sodium Chloride Inhalation Solution.

• A partially melted plastic bottle labeled ICE P___, empty B___, Contain water on___42

• A box labeled Texas Instruments Computer Box.

• Pieces of broken glass bottles (similar to wine bottle glass).

• Pieces of broken, flat, clear glass.

• Various unidentified electronic/electric components imbedded in melted and solidified

aluminum.

• Pieces of copper wire conductor of various gauges with many areas of melted copper.

 42 “___” indicates illegible/melted lettering on the plastic bottle.
31

• An unknown green, red, and cream-colored material on the inboard side of the container

floor.

• Fluid that leaked from a large, silver-colored valve.

(An analysis and identification of the unknown green, red, and cream-colored

material and the fluid sample are discussed in section 1.16.1.)

After removing the burned debris from container 6R, the container floor was

examined. It consisted of an aluminum top skin covering an aluminum framework that was on

top of another aluminum bottom skin. Most of the top skin of the flooring was melted and had

sagged down between the supporting framework underneath it. In several areas, the flooring had

melted through the bottom skin as well. Along a portion of the inboard edge of the container

(beginning approximately 3 feet aft of the front wall) molten aluminum had flowed through the

container floor onto the cargo tracks on the cabin floor in that area and had resolidified. The

floor along the aft edge of the container under the three wooden pallets that had supported the

industrial valves, computer equipment, and the DNA synthesizer, respectively, was not melted.

Because of the comments on the CVR regarding the smoke detector activation

sequence and because of the early fuselage crown burnthrough observed by ground witnesses in

the area of cargo rows 8 and 9, investigators also focused on the containers and cargo located in

this area. At the request of a party to the Safety Board’s investigation, the stored contents of

containers 9L and 9R were examined by members of the fire group on November 7, 1997. After

the accident, FedEx had hired a contractor to clean out the cargo containers from the accident

airplane and store the contents at Stewart. One large box labeled 9L was found in the storage

area. In addition to miscellaneous debris, this box contained some unburned computer parts and

some burned and unburned cardboard packaging material. A Packard Bell laptop computer was

found burned with a melted case and exposed internal circuit boards, but the circuit boards were

unburned and showed no heat damage. A substantial amount of material in the box was

unburned, including material with a low melting point, such as polyurethane, polystyrene, and

polyethylene. Ten plastic bottles containing liquid were found undamaged by heat. The caps

were tightly secured on the bottles. Analysis of the liquid in these bottles indicated that the

liquid was aqueous, rather than organic. The aqueous liquid in one of the bottles had a pH of 2.0

(acidic) and the liquid in the other nine bottles had a pH of 0.5 (also acidic).

A wooden pallet with the number 9L written on it was also found in the storage

area. It contained a computer tower and some pieces of aluminum structure that appeared to be

from an aluminum cargo container. There was a large piece of resolidified aluminum with two

bottle caps melted into it with what appeared to be sample bottle impressions. The smaller cap

had parts of the cardboard seal still inside of the cap, although it showed darkening/charring.

A small cardboard box labeled “Special, Hold for Security-Fire Investigation, 9L

#400,” which contained miscellaneous material, was also found in the storage area. The box

contained a 1-gallon paint-type can with a heavily carbonized lightweight solid inside. The can

was not distorted, and some of the black carbonized material was found over the edge of the can

inside the lid groove. The box also contained what appeared to be part of a microscope and two
32

parts of starter motor housing, a paint can cover, and what looked like an ashtray lid

(undamaged).

Another wooden pallet labeled 9L had miscellaneous parts stuck to burned debris,

including microscope slides, open sample bottles (about 2 inches high) and crimp-style closures,

main automotive engine bearings, an automotive seat track, and spools of magnetic tapes.

Nine large cardboard boxes were found in the storage area numbered 66 through

74 and labeled “9R.” The contents are listed in appendix E.

An additional examination of the stored cargo took place from March 24 through

26, 1998. The salvaged cargo (from containers other than 6R and the hazardous materials

containers), which had been packed and stored in approximately 122 large cardboard boxes, was

searched for aerosol cans and other items that might have constituted undeclared shipments of

hazardous materials. Seven aerosol cans and various other items were retrieved. Because all the

aerosol cans were breached, it was determined that their testing would not be of value because it

would not reveal their original contents. Testing of the other items revealed that the liquids in

four plastic bottles and several milliliter (mL) vials had a hydrogen-ion concentration (pH) of

1.0; the liquid in another plastic bottle had a pH of 1.8; the liquid in a plastic cylinder had a pH

of nearly 9.0. There were also two containers of liquid with flash points of 60oC (140oF) and

65oC (149oF), respectively.

1.14.2.1.2 DNA Synthesizer Found in Container 6R

The Expedite Model 8909 DNA synthesizer was found in the center of container

6R lying on its left side with the top facing forward (as viewed from aft looking forward), the

front towards the right side of the airplane, and the bottom facing aft (see figure 8 for a diagram

of the synthesizer). The unit contained several bottles with labels that included flammability

symbols, and some of the bottles contained liquid. One large bottle in the aft row had a very

strong odor when it was removed from the unit. Because this unit was found at the lowest point

of the "V" burn pattern, the Safety Board investigation evaluated and analyzed the liquids

contained in this unit.

The synthesizer, which was designed to produce synthetic DNA from a variety of

chemical reagents,43 was owned by the Chiron Corporation of Emeryville, California, and was

being shipped to Chiron Diagnostics, a subsidiary company in East Walpole, Massachusetts. The

manufacturer of the synthesizer was PerSeptive Biosystems, Inc., headquartered in Framingham,

Massachusetts.44

 43 A reagent is a substance used in a chemical reaction to detect, measure, examine, or produce

other substances.

44 According to Chiron, it purchased the synthesizer new on December 29, 1994, and the

synthesizer was installed in Chiron’s research laboratory in California on January 17, 1995. Chiron indicated that

the synthesizer was last used on February 5, 1996, and that Chiron employees did not flush or decontaminate the

instrument between the time it was last used and the time it was prepared for shipment.
33

Figure 8.—Expedite Model 8909 DNA synthesizer instrument cabinet.

According to PerSeptive, when the synthesizer is set up for normal operation, the

reagent bottles contain a variety of liquid reagents, several of which are regulated as hazardous

materials, including acetonitrile45 and tetrahydrofuran46 (THF), both of which are classified as

flammable liquids under the DOT hazardous materials regulations. Acetonitrile is the primary

reagent and solvent used in the machine.

The synthesizer was housed in a metal cabinet about 21⁄2 feet high. An access

door on the lower portion of the front was designed to include a glass panel in the top half.

Fifteen brown glass reagent bottles, ranging in size from 25 mL to 250 mL, were installed

 

Chiron noted the following operational problems with the synthesizer from its installation date to

its shipment date: the trityl monitor was replaced because it was not functioning properly when the unit was first

installed; blockage of the flow lines occurred on August 7, 1995, and on September 1, 1995; a leaking valve was

replaced in 1995 (the exact date is not known).

PerSeptive’s maintenance records reflect the replacement of the trityl monitor in February 1995

and five undated field service reports to repair blocked flow lines or low flow rates. The field service reports

indicate that the problems were resolved by flushing the flow lines and/or replacing the solenoids that operate the

valves.

The Chiron research scientist in charge of the laboratory where the synthesizer was located stated

that he was not aware of any problems with the instrument when it was prepared for shipment on August 28.

45 Acetonitrile has a flash point of 42oF and a flammability limit of 4.4 to 16 percent by volume in

air. (Flash point of a liquid is the lowest temperature at which it produces sufficient vapors to sustain a momentary

flame across the surface of the fuel. Standard methods for measuring flash point are ASTMD93 and ASTMD92.

Flammability limits are the concentration limits of a combustible fuel in an oxidant (usually air) through which a

flame, once initiated by a spark, will continue to propagate.) Acetonitrile vapors are heavier than air and may cause

a flame to travel back from a source of ignition to the source of the fuel.

46 THF has a flash point of -4oF and a flammability limit of 1.8 to 11.8 percent by volume in air.

After prolonged exposure to air, THF can form peroxides, which can explode on contact with strong bases or metal

or spontaneously if the peroxide concentration is greater than 0.5 percent. The THF supplied by PerSeptive for use

in its synthesizers contains a stabilizer to prevent the formation of peroxides. Because the stabilizer is consumed

over time, it has a recommended shelf life of 3 to 5 years, with the precaution that it should be discarded sooner if

the liquid is exposed regularly to air or moisture. The PerSeptive Nucleic Acid Synthesis System Service Guide

states that opened bottles of amidite solution containing THF should be discarded if “over six months old.”
34

internally in four rows and screwed into caps attached to the synthesizer. Each cap had a hole in

it, which allowed a tube to extend from inside of the synthesizer into each bottle. (When it was

set up for operation, the unit also included two external 4-liter reagent bottles and two external

waste bottles for spent reagents from the synthesis process. These four external bottles were not

shipped with the accident unit.) The unit weighed approximately 97 pounds.47

The bottom portion of the exterior of the synthesizer had areas of undamaged gray

paint. A substantial amount of solidified melted aluminum debris had adhered to the top of the

unit, and there was solidified melted aluminum vertically along the right side of the unit. The

glass panel was missing from the lower access door. The inside of the lower portion, when

viewed through the access door, revealed the four rows of brown glass bottles. The bottles were

found intact with a strip of shipping tape placed across the front of each row of bottles. The back

of the synthesizer was fire damaged.

Loose debris from the bottom of the synthesizer consisted of broken glass (the

unit’s access door window was made of glass) and other loose debris. A plastic drip tray had

some heat damage and was melted along the left side. A paper diagram on the inside of the large

access door was sooted but otherwise intact.

At the accident site, the glass bottles were removed one at a time along with

portions of the tubes extending into the bottles. The bottles were individually identified, capped,

and placed in plastic bags for further examination. The individual “O” rings for the bottles were

intact and in place. The tightness with which each bottle had been screwed into the machine was

assessed by the position that the shipping tape had been secured across each of the bottles. A

chemical analysis and testing of the fluids found in the bottles were conducted at the National

Aeronautics and Space Administration (NASA) Kennedy Space Center, the results of which are

discussed in section 1.16.1.

Investigators packaged the synthesizer in new shipping materials supplied by

PerSeptive and transported the package to Safety Board headquarters for further examination.

The synthesizer was then sent to PerSeptive Biosystems’ manufacturing facility, where, on

February 18, 1997, investigators further examined and documented the accident DNA

synthesizer. During that examination, an undamaged synthesizer provided by PerSeptive was

examined for comparison purposes.

(See appendix F for a detailed description of the fire damage to the DNA

synthesizer.)

 47 The airbill for the package containing the synthesizer listed its weight (including packaging

materials) as 145 pounds.
35

1.14.3 Significance of Location of First Fuselage Burnthrough and Smoke Detector

Activation Sequence

At the Safety Board's deposition proceeding several witnesses commented on the

usefulness of the location of the first fuselage burnthrough and the smoke detector activation

sequence in determining the origin of the fire. An FAA fire expert, who took part in the

investigation and has participated in numerous other Safety Board accident investigations,

testified that experience has shown that the location of first burnthrough is not always above the

point of the fire’s origin. He also testified that because of the many unknown factors at work

during a cargo fire (such as temperature, smoke buoyancy, tightness of cargo door seals, and the

effects of ventilation) the sequence in which smoke detectors activate cannot be correlated to the

location of the source of the fire. He stated that the purpose of smoke detection systems is to

detect the presence of fire, not to indicate the location of a fire. A Boeing engineer with the

Douglas Products Division, who also took part in the investigation, testified that smoke detectors

are installed to detect smoke, not to indicate the location of the fire’s origin.

A Boeing engineer, who participated in the design and development of the DC-10

airplane, testified that smoke tests conducted on passenger airplanes showed that the smoke

detectors closest to the source of smoke were not always the first detectors to activate.

A fire consultant to one of the parties stated in written reports and in his

deposition testimony that Safety Board accident reports show that the location of first

burnthrough does occur above the point of the fire’s origin. He also indicated that he believed

there was minimal axial flow in the DC-10; therefore, the first smoke detector to activate would

necessarily be directly above the source of the fire. Another fire consultant hired by the same

party indicated agreement with the first consultant’s conclusions; however, he also acknowledged

in his deposition testimony that smoke detector activation sequence is not necessarily an

indicator of the fire’s origin.

1.15 Survival Aspects

1.15.1 Use of Smoke Goggles and Oxygen Masks

The FedEx Aircraft Operating Manual for the DC-10 outlines emergency

procedures for use in the event of fire and smoke, and contains additional checklists for specific

types of smoke (electrical smoke, air conditioning smoke, or cabin cargo smoke). All of these

procedures call for the immediate donning of the oxygen masks and smoke goggles, if required,

by the cockpit crew followed by a series of steps including (for cabin cargo smoke)

depressurizing the airplane by manually opening the outflow valve.
36

In an informal survey of air carriers conducted by the Safety Board during its

investigation of the May 11, 1996, accident involving ValuJet Airlines flight 592,48 pilots from

several air carriers indicated that they would not don oxygen masks and smoke goggles for

situations such as reports of a galley fire, smoke in the cabin, or a slight smell of smoke in the

cockpit. Based on the circumstances of that accident and the results of its survey, the Safety

Board concluded that air carrier pilots had inadequate guidance about the need to don oxygen

masks and smoke goggles immediately in the event of a smoke emergency. Thus, the Safety

Board issued Safety Recommendation A-97-58 to the FAA, asking it to issue guidance to air

carrier pilots about the need to don oxygen masks and smoke goggles at the first indication of a

possible in-flight smoke or fire emergency. In a November 17, 1997, letter, the FAA responded

that it agreed “with the intent of this safety recommendation and will issue a flight standards

handbook bulletin...contain[ing] guidance on procedures to don protective breathing equipment

for smoke and fume protection.”

Title 14 CFR Part 121.333 requires that pilots of pressurized airplanes operating

above FL 250 be provided a “quick donning type of oxygen mask that...can be placed on the face

from its ready position, properly secured, sealed, and supplying oxygen upon demand, with one

hand and within five seconds.” This regulation also requires that the mask can be “put on

without disturbing eyeglasses and without delaying the flight crewmember from proceeding with

his assigned emergency duties.” The Safety Board notes (as it did in its ValuJet Miami accident

report) that FAA regulations do not establish any similar performance requirements for smoke

goggles.49 In that report, the Board issued Safety Recommendation A-97-59, which asked the

FAA to establish a performance standard for the rapid donning of smoke goggles and then ensure

that all air carriers meet this standard through improved smoke goggle equipment, improved

flightcrew training, or both.

In its November 17, 1997, response to this recommendation the FAA stated that it

believed this issue was addressed by 14 CFR 121.337, which establishes standards for PBE, and

14 CFR 121.337(8), which requires that such equipment be conveniently located and easily

accessible. The FAA further stated that a “preliminary review of industry practices concerning

equipment and carrier procedures indicate a need for further guidance on the location and

donning of this equipment. The FAA will issue a flight standards handbook bulletin to provide

additional guidance on the location and donning of this equipment. The bulletin will also include

equipment and procedural guidance on flightcrew training requirements.”

 48 National Transportation Safety Board. 1997. In-flight Fire and Impact with Terrain, ValuJet

Airlines Flight 592, DC-9-32, N904VJ, Everglades, near Miami, Florida, May 11, 1996. NTSB/AAR-97/06.

Washington, DC.

49 The Safety Board has expressed its concerns to the FAA about the performance of smoke

goggles beginning in 1974, as a result of its investigation of the Pan American World Airways B-707 freighter

accident at Boston and in 1983, as a result of the Air Canada DC-9 accident at Cincinnati. The Board recognizes

that the FAA currently has design requirements for smoke goggles in 14 CFR Part 25.1439 and Technical Standard

Order C99. However, none of these requirements establishes minimum performance standards for donning time or

difficulty.
37

1.15.2 Emergency Response

ARFF at Stewart is primarily provided by the New York Air National Guard

(ANG). Pursuant to mutual assistance agreements, municipal fire departments also responded

and provided assistance during this accident. Other state and local agencies that responded to the

accident included the New York State Emergency Management Office, the New York State

Police (NYSP), the New York Department of Environmental Conservation (DEC), the New York

Department of Health, the Orange County Office of Emergency Management, and the Orange

County Hazardous Materials Response Team (HMRT).

At 0545, about 10 minutes before the airplane landed at Stewart, the ATC tower at

Stewart notified the airport operations department and the ANG fire department about the

inbound DC-10 and its emergency and advised them that hazardous materials were on board the

airplane. About the same time, the NYSP detail at Stewart was also notified of this information.

No details about the specific hazardous materials or the quantities on board were provided.

Six trucks from the ANG fire department responded and were in standby position

when the airplane landed. The assistant fire chief on duty assumed the role of incident

commander. Airport operations and NYSP personnel were also on scene when the airplane

landed. After the airplane landed on runway 27 and stopped on taxiway A3, the ANG fire trucks

were positioned around the airplane to fight the fire.

About 0600, the Stewart FedEx station manager was advised by his ramp

personnel that a FedEx DC-10 was on the runway and that smoke was coming from the airplane.

The station manager arrived about 0603 at the ramp facility, where ramp personnel were on the

telephone with the FedEx Global Operations Command Center (GOCC) in Memphis.

Approximately 0615 or 0620, an airport operations employee arrived at the ramp facility and

transported a FedEx ramp agent and an aircraft mechanic to the accident scene to provide

assistance to the firefighters in opening the cargo door.

About 0630, an off-duty assistant fire chief, who had been called from his home

by the incident commander, arrived on the scene. He suggested the use of a skin penetrator agent

application tool (SPAAT)50 to puncture the fuselage. During his deposition, the assistant fire

chief, who was at that time serving as the incident commander, testified that at the flight

engineer’s suggestion,51 they attempted (without success) to call Douglas to find out if there were

alternate methods for entering the airplane without damaging it. He acknowledged that this

effort delayed the use of the SPAAT tool somewhat. Before the SPAAT was rigged and ready to

use, and just as the firefighters succeeded in opening the cargo door, flames were observed

venting through the fuselage. Accordingly, the SPAAT tool was never used. The fire chief

 50 The SPAAT is a penetration-type firefighting tool used to puncture the fuselage and introduce

extinguishing agent into the interior.

51 During his deposition, the flight engineer indicated that he was unaware that firefighters wanted

to cut a hole in the airplane fuselage.
38

testified that, based on “lessons learned” from this accident, if a similar situation were to arise

again they would immediately employ a penetrator tool with a firefighting agent.

About 0700, the ANG fire chief arrived on scene and took over as the incident

commander, relieving the assistant fire chief who had until then been serving in that role. The

fire chief continued to serve as the incident commander until approximately 1430 or 1445 when

he turned command of the scene over to the joint control of the State DEC and the Orange

County HMRT.

By 0730, an emergency operations center (EOC) had been activated in building

110 of the airport operations department, staffed by representatives from airport operations, the

NYSP, and the Orange County Office of Emergency Management. About 0925, officials from

the FedEx corporate office in Memphis advised airport operations that a team from Memphis was

en route to Stewart.

After this accident, the Stewart Airport emergency plan was revised to provide for

enhanced coordination with state and local agencies. (For more information about emergency

response, see Section 1.1, History of Flight.)

1.15.2.1 Dissemination of Hazardous Materials Information

FedEx uses multiple forms for documenting the shipment of hazardous materials

on board its cargo airplanes. The “Notification of Dangerous Goods Loading (Part A)” is

completed for all flights, including those without hazardous materials on board. The Part A is an

envelope with a multicopy form on the front that identifies the cargo containers by their positions

on the airplane and the classes of hazardous materials (such as flammable liquids or corrosives)

in each container. The Part A envelope contains copies of all shipping documentation about the

hazardous materials on the airplane, and the top form is signed by a hazardous materials

specialist and the captain of the airplane.

A “Dangerous Goods Separation Pouch” for each cargo container that transports a

declared hazardous materials package is inserted into the Part A envelope. The separation pouch

is also an envelope with a multicopy form on the front that identifies the various classes of

hazardous materials in a specific cargo container. A copy of the form on the separation pouch is

also affixed to both ends of each hazardous materials cargo container. The Part A and the

separation pouch do not indicate the specific hazardous materials and the quantities on board the

airplane.

Specific information about the hazardous materials in a given package, such as the

proper shipping name, United Nations identification number, and hazard class, quantity, and 24-

hour emergency telephone number, is found on the “Notification of Loading of Dangerous Goods

(Parts B or C)” or, if applicable, a “Notification of Loading of Dangerous Goods Radioactive

Materials (Parts BR or CR).” This form, which is affixed to a package containing hazardous

materials, also has the FedEx tracking number and remains on the package throughout shipment.
39

Copies of these forms (Parts B, C, BR, or CR) are placed in the separation pouch for the

appropriate cargo container.

The assembled Part A, separation pouches, and copies of the Parts B, C, BR, or

CR forms are carried in the cockpit so they can be available to the flightcrew. Copies of the Parts

B, C, BR, or CR forms for each shipment of hazardous materials are also retained at the

originating station where the shipment is accepted. Further, copies of these forms and the Part A

and the separation pouches for a given flight are retained at the departing hub of the flight. The

DOT hazardous materials regulations require that the proper shipping name, hazard class,

identification number, packaging group, and total quantity of the material appear on the shipping

papers for hazardous materials. Further, the regulations require an operator to provide this

information in writing to the pilot-in-command and also require that a copy of the shipping

papers accompany the shipment on board the airplane.

Both the initial incident commander and the ANG fire chief (who took over at

0700 as incident commander) indicated that they were concerned about the safety of the

firefighters and the possible exposure of personnel at the scene to the hazardous materials or their

combustion byproducts.52 Consequently, both requested (but did not receive) copies of what they

referred to as “manifests” from the flightcrew and other FedEx representatives so they could

identify the specific hazardous materials on board and their quantities and locations on the

airplane. The ANG fire department log had entries at 0730, 0815, and 1125 logging ANG

personnel’s efforts to have FedEx fax copies of the “manifest” to airport operations or to the

FedEx ramp facility at Stewart. The fire chief also stated that he gave a local FedEx employee

two fax numbers at the ANG command center, and he assigned two ANG personnel to stand by

those machines. However, no faxes from FedEx were received at those machines.

According to FedEx personnel, the FedEx dangerous goods hub in Memphis and

the GOCC faxed several copies of the Part A, Parts B, BR, or CR, the dangerous goods loading

pouches, and the weight and load plans throughout the morning to various fax numbers at

Stewart. Although the receipt of the faxes by the facilities to which they were sent could not be

verified in most instances, the faxes appear to have been transmitted to the fax numbers located

at the FedEx ramp facility at Stewart, the airport operations office, and the NYSP barracks at

Stewart. The airport operations log contained entries at 0635 that the FedEx “manifest” had

arrived by fax, and, at 0656, that additional hazardous materials “manifest” information had been

received. Airport officials who received those faxes indicated that they were of poor quality and

therefore did not provide them with the needed information. Twenty-eight partially legible Part

B forms were received by 0733 by the Orange County HMRT coordinator. Additional Part Bs

were faxed from the GOCC from 0858 and throughout the morning, with the last fax transmitted

by 1340.

 52 During postaccident interviews, the HMRT coordinator said that he had also been concerned

about the potential threat to the surrounding communities be posed by the release of any of the hazardous materials

on board.
40

According to postaccident interviews, many of the Parts B, BR, and CR forms

containing the specific information sought by the incident commander were seen by airport

operations staff, the NYSP personnel, New York DEC law enforcement officers and spill

technicians, and the Orange County HMRT coordinator and team members. Representatives

from airport operations, the NYSP, and the Orange County HMRT indicated that the information

they received was forwarded to the incident command post. The ANG fire department log did

not contain any entries of faxes received from FedEx about the hazardous materials on the

airplane.

Of the shipping documentation carried on board the airplane, only the original

form on the Part A envelope was retrieved by the flightcrew before the evacuation (the flight

engineer had placed the form in his pocket). Immediately after evacuating (about 6 minutes after

the airplane had landed), the flight engineer provided the Part A form to one of the ANG

firefighters. The firefighter immediately read the information on the Part A53 over the radio to

the incident commander and then placed the Part A in his fire vehicle where it remained until the

fire was extinguished, when another firefighter recovered it. Some time before 0700, the initial

incident commander received a one-page typewritten sheet from the FedEx station at Stewart

containing the same information.

The flight engineer stated that he told firefighters that the Part Bs and other

shipping documents were located on the back of the cockpit door. However, they were not

retrieved until the day after the accident when the burned and water-soaked remains of the

shipping documents were recovered. During the deposition proceeding, the ANG fire chief

stated that about 1 hour and 15 minutes after the firefighting operation began, FedEx employees

advised that the Part Bs were on the aircraft. The fire chief indicated that no attempt was made

to retrieve the Part Bs at that time because of the severity of the fire.

About 0915, the HMRT coordinator gave the fire chief (who was by then serving

as the incident commander) a handwritten list of chemicals and United Nations identification

numbers provided by local FedEx personnel. The local FedEx personnel also gave the fire chief

a copy of the weight and load plan. During postaccident interviews, the fire chief acknowledged

receiving the handwritten list, but noted that the list did not specify the amounts of the hazardous

materials on board.

About 1200, the ANG base commander received a call from FedEx’s vice

president for security in Memphis. According to the base commander, the vice president called

to provide the ANG with what information he could about the hazardous materials on board the

airplane, but he indicated that hazardous materials were not his area of specialty. The base

commander provided the vice president with a fax number located in the ANG incident

 53 The Part A indicated that (1) the hazardous materials were carried in the cargo containers in

positions 1L/1C and 3R; (2) the container in 1L/1C was carrying flammable liquids, corrosive materials, infectious

substances, materials that were spontaneously combustible, and magnetized materials; and (3) the container in 3R

contained radioactive materials, shipments with dry ice, and “ORM-D. [a material that presents a limited hazard

during transportation because of its form, quantity, and packaging (49 CFR 173.144)].”
41

command post. When checked an hour later, no information had been received at the command

post. Shortly before 1300, the base commander directed the chief of the ANG command post to

contact the FedEx vice president for the information. According to the ANG command post

chief, the vice president advised the command post chief that he could not provide the

information because the Safety Board had taken over the investigation.

In a January 27, 1997, letter of explanation to the Safety Board, FedEx stated that

the vice president’s actions were consistent with company policy, which dictates that once the

Safety Board has taken control of an aircraft accident investigation, all information pertaining to

that investigation is to be forwarded to the Board. The FedEx letter also stated that at the time of

the ANG request, the senior DEC law enforcement officer, the NYSP, and other appropriate state

officials already had copies of documents listing the hazardous materials on board.

1.15.2.1.1 Other FedEx Accidents Involving Dissemination of Hazardous Materials

Information

In the July 31, 1997, postcrash fire involving a FedEx MD-11 operating as flight

14 at Newark International Airport, Newark, New Jersey (still under investigation), the shipping

papers were destroyed. The flight had originated in Narita, Japan, and copies of the shipping

documentation for the hazardous materials had been retained there. Approximately 11⁄2 to 2

hours after the accident, FedEx provided the incident commander with information about the

quantity and identification numbers for the hazardous materials on board, including a notation

that there were “maybe 36 pounds of an unknown haz.mat.”

On March 5, 1998, a Cessna 208B owned by FedEx and operated by Baron

Aviation Services, Inc., crashed near Clarksville, Tennessee. Information from the ongoing

investigation indicates that the Part B hazardous materials shipping papers on board the airplane

and on file at FedEx’s Memphis hub did not accurately reflect what was on board the airplane54

and include an emergency response telephone number.

On April 7, 1998, another Cessna 208 operated by FedEx crashed near Bismarck,

North Dakota. Preliminary information indicates that, although no declared hazardous materials

were on board that flight, it took 2 hours and 49 minutes from the time the information was

requested for FedEx to answer the question about whether hazardous materials were on board.

(The accident is still under investigation.)

 54 Although the Part A was accurate in that it properly listed the classes of hazardous materials that

were on board, one of the Part Bs did not accurately reflect the hazardous materials on board. The Part B in question

listed a total of 31 packages of flammable liquids; however, only 5 of the 31 packages were on board the aircraft.

The remaining 26 packages had been part of the airplane’s cargo on a previous flight, but were subsequently

removed from the airplane and transported via ground transportation.
42

1.15.2.1.2 Postaccident Actions by FedEx

Safety Board investigators surveyed seven other operators who carry cargo55 to

determine whether they had the ability to quickly retrieve and produce complete information

about hazardous materials carried on board a particular flight. They found that only one carrier

(SwissAir) had a computerized capability to provide information about the declared hazardous

materials on board its airplane. The remaining carriers, like FedEx, keep track of this

information only by retaining at the departing station paper copies of the hazardous materials

shipping documentation carried on board the airplane.

During an April 1998 meeting with the Chairman of the Safety Board, FedEx

officials indicated that FedEx intended to develop and implement an improved system for

tracking and retrieving information about hazardous materials being carried on board FedEx

flights. In a May 5, 1998, letter, the President and Chief Executive Officer confirmed that FedEx

was committed to developing “systems and procedures which will reduce substantially the length

of time required to provide firefighters and other emergency responders with detailed information

concerning [hazardous materials] shipments aboard FedEx aircraft.” He indicated that FedEx

planned to phase in the new system, first creating an “intermediate solution” consisting of an

“electronic notification system upon which basic [hazardous materials] information of interest to

fire fighters will be entered by a DG [dangerous goods] specialist at airport ramps at departure of

FedEx aircraft.” This system would include information on hazard class, quantity, and location

of all hazardous materials on the airplane, excluding dry ice. This information would be

available on computer terminals at FedEx facilities worldwide.

The May 5 letter indicated that the “permanent solution” envisioned by FedEx

would “allow the tracking, by container and aircraft, of [hazardous materials] shipments

throughout the shipping cycle. Completed [hazardous materials] information, including inbound

and outbound [hazardous materials] manifests, will be available on an immediate basis at the

FedEx GOCC, which is manned 24 hours-a-day, 7 days a week, and all FedEx facilities.” A

FedEx dangerous goods technical advisor explained during the deposition proceeding that FedEx

hoped that the development of this new system would prompt a regulatory reexamination of

information that needs to be immediately available to emergency responders. Specifically, he

indicated that the proper shipping names of a hazardous material would not be relevant to

emergency responders.

The letter further indicated that “[t]his solution will require extensive system

development efforts, along with scanning technologies which are currently under development.

This effort is estimated to be at least 18 months away from testing.” Finally, the letter indicated

that the current regulatory scheme, which requires that detailed shipping documents be

maintained by the operator and carried on board the aircraft, would need to be adjusted to permit

electronic documentation of this information in place of the currently required paper records.

 55 The carriers surveyed were Airborne Express, United Parcel Service, Northwest Airlines,

SwissAir, United Airlines, British Airways, and Delta Air Lines.
43

1.16 Tests and Research

1.16.1 Chemical Analysis of Substances Found in Container 6R

On December 16 and 17, 1996, at the NASA Kennedy Space Center, investigators

documented and analyzed the fluids and debris recovered from the DNA synthesizer; fluid

removed from the industrial valves; green, red, and cream-colored material found on the inboard

side of the container floor; and burned debris that had been removed from cargo container 6R.

Gas chromatography/mass spectrometry (GC/MS) was used to analyze the residues

left in the bottles on the accident synthesizer. Specifically, investigators looked for the presence of

the 15 chemicals used in the DNA synthesizer and for the presence of aqueous film-forming foam

(AFFF), a firefighting agent that was sprayed on the accident airplane. Calibration information was

collected through the GC/MS analysis of standard solutions containing known concentrations of

AFFF and the other 15 chemicals. Three concentrations (1 percent, 0.1 percent, and 0.01 percent)

of a mixture of each of the 15 chemicals were prepared by dilution for calibration of the GC/MS

system.

Visual inspection of each of the bottles from the accident synthesizer showed that

some bottles had liquid in the bottoms. These liquids were poured into glass vials and sealed with

Teflon-lined (airtight) caps with septums. The bottles from the accident synthesizer that did not

show evidence of liquid in the bottoms were rinsed with methanol, and the methanol rinse was

transferred into glass vials and sealed for injection into the gas chromatograph. The NASA

laboratory provided clean, clear glass bottles for the methanol rinse. The amount of methanol rinse

used differed depending on the conditions of the sample. The rinse procedure and the quantities of

fluid rinsed from each bottle are detailed in appendix G.

Each of the samples were analyzed by injecting 0.1 (microliter) μl of each fluid into

the GC/MS system. The following table shows, for each bottle identification, the estimated quantity

of fluid in each bottle and the identity and amount of each chemical identified in that sample. The

vials containing the methanol/residue solutions were retained for later use. More definitive

quantitative results of some of the chemicals were determined in a reanalysis discussed in section

1.16.3. (See appendix H.)

Bottle

Identification

Approximate Quantity of Fluid in Bottle Chemicals Identified (Approximate

Quantity)

AUX 3 4-5 mL (yellowish) • acetonitrile56

• THF (.01%)

• DEGMBE57 (.03%)

 56 No percentages are given on this chart for acetonitrile because this test did not produce an

accurate measurement of the amount of acetonitrile left in the bottles. Because of the relatively large quantities of

acetonitrile in most of the bottles (as compared with the other substances found to be present), the quantity of

acetonitrile in the sample used for this test exceeded the calibration limits of the GC/MS. The samples were

subsequently diluted and retested.
44

ACT 4 less than 1 mL • acetonitrile

• DEGMBE (<1%)

• 1-chloro-octane (trace)

• 1-bromo-octane (trace)

7 50 to 100 μl58 • acetonitrile

• DEGMBE (<1%)

8 methanol rinse (added 200 μl) • acetonitrile

• DEGMBE (<1%)

• hexanedinitrile (trace)

• aminocaproic acid (trace)

OX 2 methanol rinse (added 500 μl) • acetonitrile

• THF (>1%)

WSH 1 methanol rinse (added 1 mL) • acetonitrile

• chloroform (~15ppm)

CAP B6 methanol rinse (added 1 mL) • acetonitrile

• THF (~0.03%)

• pyridine (~0.03%)

• 1-methylimidazole (~0.01%)

• DEGMBE (<<0.01%)

5 methanol rinse (500 μl) • acetonitrile (>1%)

• DEGMBE (0.01%)

T/U methanol rinse • acetonitrile

A methanol rinse • acetonitrile

CAP A5 methanol rinse • acetonitrile

• THF (~1%)

• 4-chloro-butanoic acid

9 methanol rinse (500 μl) • acetonitrile

• DEGMBE

G methanol rinse (500 μl) • acetonitrile

• DEGMBE

C methanol rinse (500 μl) • DEGMBE

6 undiluted • acetonitrile

• DEGMBE

The results of the analysis of other fluids found in cargo container 6R were as

follows:

 57 DEGMBE (Diethylene glycol monobutyl ether) is the principal ingredient in the firefighting

agent AFFF.

58 It is generally accepted that 50 μl (or 0.050 mL) is equal to one drop. (1 μl = 0.001 mL.)
45

Description of Fluid in Bottle Chemicals Identified (Approximate

Quantity)

Sample Preparation

AFFF (Sample provided by

NASA)

• DEGMBE

• 1-chloro-octane

• 1-bromo-octane

• 1-chloro-decane

0.1 μl injection

methanol extraction of

synthesizer spill; tray debris

• AFFF (trace) 0.1 μl injection

Valve liquid • H20

• DEGMBE

0.1 μl injection

Re-methanol extracted from

cargo container floor

• DEGMBE 0.1 μl injection

Fourier Transform Infrared (FTIR) spectroscopy was used to identify the solid

materials found in cargo container 6R.59 The red, green, and cream-colored materials were

separated under a microscope. Each of the materials was prepared in a diamond cell60 and

transferred to the microscope of the FTIR apparatus for the infrared spectrum. The infrared

spectrum of the red, green, and cream-colored material was consistent with a substance used for

packing material.

1.16.2 Procedures Used to Prepare the Synthesizer for Shipment

According to the PerSeptive field engineer who prepared the instrument for

shipment, a few days before he came to Chiron to prepare the instrument, he called the Chiron

research scientist and asked that the reagent bottles be emptied and filled with acetonitrile before

he arrived, and the research scientist agreed to do so. According to a laboratory technician who

helped prepare the synthesizer for shipping, the research scientist directed her to empty old

reagents from all the reagent bottles for the synthesizer. In a September 16, 1996, interview, the

technician stated that on the morning of August 28, 1996, she emptied all of the internal reagent

bottles of the synthesizer and filled them about one quarter full with clean acetonitrile. However,

in a document submitted to the Safety Board on October 31, 1996, Chiron indicated that "[a]ll

reagent bottles, except DBLK 8 and AUX 361 were emptied, rinsed, and refilled partially with

acetonitrile on August 28, 1996, before [the PerSeptive field engineer] arrived.” That document,

which also listed the chemicals Chiron believed were contained in each of the reagent bottle

positions after the unit was last used for synthesis and on the morning of August 28, 1996,

characterized the status of the AUX 3 bottle at the time of the PerSeptive field engineer's visit as

“inconclusive.” During the deposition proceeding, the Chiron research scientist and laboratory

technician and Chiron’s Director of Environmental Health and Safety indicated, when asked

 59 The FTIR analysis identifies functional groups (groups of atoms in a molecule that give that

molecule its unique physical and chemical properties) and molecular structure based on a library of known

absorption bands.

60 A diamond cell is used to make a solid sample into a thin film for analysis.

61 Chiron stated that the reagent bottle in position AUX 3 was not generally used in the synthesis

process.
46

about the meaning of the “inconclusive” characterization, that the AUX 3 bottle was either empty

or contained acetonitrile.

The PerSeptive field engineer arrived at the Chiron laboratory on the afternoon of

August 28. According to the research scientist, he told the field engineer that the bottles had

been emptied of old reagents and partially filled with acetonitrile. The research scientist then left

the field engineer alone to decontaminate and package the unit for shipment. In a postaccident

interview, the field engineer said that he determined that all of the internal bottles (which are

brown-colored glass) had acetonitrile in them by using smell and visual examination, but also

stated “it depends on the customer’s word.” However, he acknowledged that he would not be

able to determine by his sense of smell whether the acetonitrile had been contaminated with other

chemicals. The field engineer said that he noted one of the two external reagent bottles, DBLK

8, (which was made of clear glass) had some old reagent in it. The field engineer removed this

bottle and replaced it with a bottle partially filled with acetonitrile.

In a September 16, 1996, interview 11 days after the accident, the field engineer

described the next steps he took to prepare the machine for shipment as follows. He ran the

“prime all” function62 three times on each column position, and then emptied all of the bottles by

turning them upside down until they stopped dripping. He then replaced the bottles so that the

filter at the bottom of the tubes came into contact with the outer edge of the bottom of the

bottle.63 He then ran the “prime all” function again three times on each column position to dry

the instrument. (When the “prime all” function runs without liquid in the bottles, a dry, inert gas

is pumped through the flow paths and bottles.) He said that he did not remove the internal

reagent bottles after these drying cycles, but that he visually inspected them and they appeared

dry. He said that he then depressurized the synthesizer by disconnecting the inert gas supply and

loosening each internal reagent bottle to relieve the internal pressure.

On April 4, 1997, Chiron forwarded to the Safety Board a computer disk

containing a data file named “history.log” that contained a record of manual inputs to the

synthesizer made at the time of the field engineer’s visit and other operating data.64 A printout

of this file showed a total of 59 entries between 1603 and 1708 on August 28, 1996. The first

 62 The “prime all” cycle function draws some liquid from every reagent bottle so that every flow

path in the machine is flushed. During this function, a fixed volume of liquid is pumped from each internal and

external reagent bottle through the flow paths and column positions before it is discharged into one of the two waste

bottles. The elapsed time for one “prime all” cycle to run on a given column position is about 3 minutes. The

“prime all” cycle must be manually activated from the menu display and control panel on the front of the synthesizer.

63 He stated that the filter “acts like a sponge,” so that any remaining fluid in the bottle would “get

sucked up into the tubing.”

64 The disk was found at the Chiron Diagnostics facility in East Walpole, Massachusetts, the

destination of the accident synthesizer. According to Chiron, the research scientist in charge of the synthesizer at

Chiron’s California laboratory packed the disk in a box with copies of the user manual for the synthesizer and four

other 3.5-inch disks. According to Chiron, the scientist in East Walpole had stored the disks and not used them

while they were in his possession. Before sending the disk to the Safety Board, Chiron had examined all five disks

and found that only one (the one forwarded to the Board) had files with any activity in 1996.
47

and second entries indicated “power restored” and “instrument diagnostic run.” The remaining

57 entries indicated “manual function invoked.”

A followup interview with the PerSeptive field engineer was conducted on August

28, 1997. He acknowledged that the “history.log” file was a record of the functions and

operations he performed on August 28, 1996. The field engineer stated that before he began

flushing the synthesizer, he ran a test to confirm that the inert gas used to pressurize the system

was not leaking. The field engineer further explained that the first 765 and the last 6 of the 37

“manual function invoked” entries represented the “prime all” functions that he ran on each

column position to flush and dry the instrument. (The “history.log” times indicated that the

amount of time that elapsed after each of these entries before the next entry was recorded ranged

from 21⁄2 minutes to 7 minutes.)

The field engineer explained that the remaining 44 “manual function invoked”

entries in the “history.log” file (those recorded between the first 7 and the last 6 entries) were the

result of his having invoked the “prime individual” 66 function a number of times for each reagent

position on each of the two columns. (The “history.log” files file indicated that the amount of

time that elapsed after each of these entries before the next entry was recorded ranged from 4

seconds to 17 seconds.) He acknowledged that these additional functions were not prescribed by

PerSeptive as part of the normal purging procedure, but indicated that he took these additional

steps to ensure that fluid from each reagent position was being properly delivered. (He stated

that he did not have written guidance with him when he purged the accident synthesizer, but that

he based the purging on Service Note 89-006, “Preparing An Expedite System For Storage Or

Transport” (see appendix I).) The field engineer stated that he saw liquid coming out of the

waste line during the “prime individual” functions, indicating to him that the fluid was flowing

properly. The field engineer indicated that it was his standard practice to take these additional

“prime individual” steps when purging instruments not in his normal service territory.

The field engineer again stated (as he had at his earlier interview) that before

running the last 6 “prime all” functions (to dry the machine), he emptied all of the reagent bottles

and held them upside down until they stopped dripping. At the conclusion of his August 28,

1997, interview, the field engineer stated that he was “100 percent certain” that no visible fluids

remained in the instrument when he completed the purging procedure. The field engineer stated

that he saw no leakage, malfunction, or operational problems and that he did not observe

anything unusual about the instrument during the purging and drying process.

During both his September 1996 and August 1997 interviews, the field engineer

described the remainder of the steps he took to prepare the instrument for shipment as follows.

 65 He stated that when he started the flushing cycles, he inadvertently ran “prime all” on column 2

instead of beginning with column 1, and thus 13 (rather than 12) of the entries recorded on the data file were

attributable to the “prime all” functions.

66 The field engineer stated that invoking the “prime individual” function for a particular bottle

position would cause the machine to make between 10 and 20 pulses, each of which would pump some fluid from the

selected bottle. He further stated that each pulse would contain between 15 and 19 microliters of fluid.
48

He placed the plastic flow lines for the two external reagent bottles and the two waste lines in a

plastic zip-lock bag that was sealed with a clear, plastic shipping tape, and then taped it to the

outside of the synthesizer. He stated that the reagent bottles that were external to the unit, WSH

A 7 and DBLK 8, were not shipped with the synthesizer or in an accompanying package. The

field engineer stated that he left the two external reagent bottles and the two waste bottles in

Chiron’s lab on a laboratory bench under a ventilation hood. After the accident, Chiron located

the two external reagent bottles in its lab and accounted for the two waste bottles. The field

engineer stated that he packaged the unit for shipment using a PerSeptive-supplied wooden pallet

with a foam support, cardboard container, and other shipping materials that were provided

previously to Chiron. He placed the synthesizer on the pallet, positioned the foam supports at the

bottom and top of the synthesizer, used an empty box to fill in space, and then slid the outer

cardboard container over the top of the synthesizer. He said that he left the packaged synthesizer

in the laboratory and departed from Chiron about an hour and a half after he had arrived.

The Chiron research scientist completed and signed an internal Chiron form titled,

“Outgoing Procedure Checklist,” which was dated August 30, 1996. The form provides

information to Chiron’s shipping department about the contents of the package and other

shipping information, such as the recipient’s address and telephone number. The entry to

indicate if the package contained hazardous materials was marked “N” (for “No”) and had a

handwritten entry reading, “Instrument was thoroughly decontaminated of all chemicals.” The

research scientist acknowledged that he did not verbally confirm with the PerSeptive field

engineer that the synthesizer had been decontaminated. The checklist was left on top of the

packaged synthesizer.

Personnel from Chiron’s shipping department transferred the packaged

synthesizer from the laboratory to the shipping department and loading dock, where two

synthetic straps were placed around the boxed unit. The shipping department employee who

handled the synthesizer reviewed the information on the internal checklist, including the entry

about hazardous materials and decontamination, but stated that he had no reason to suspect that

anything was amiss. Shipping department personnel did not have a written record of when the

synthesizer was picked up from the laboratory and could not recall the date. The shipping

manager at Chiron indicated that he was aware of only one synthesizer that had been shipped (the

accident synthesizer).

Chiron’s shipping manager acknowledged that 20 to 30 infectious substance

shipments are made each day from Chiron. The shipping manager further stated that research

personnel do receive awareness training on the handling and transportation of hazardous

materials. Excerpts from Chiron’s Chemical Safety Manual instruct employees to consult with

the shipping department before preparing any hazardous materials for shipment or transporting

hazardous materials off site. According to the shipping manager, shipping department personnel

complete hazardous materials training required under the DOT hazardous materials regulations.

Training courses taken by Chiron shipping personnel were conducted by FedEx.

A FedEx courier who picked up the synthesizer from Chiron’s loading dock on

September 4 stated that he did not ask any Chiron shipping department personnel whether any of
49

the packages he picked up from Chiron contained any hazardous materials, nor did the Chiron

employees comment on the contents of the packages. The courier delivered the packaged

synthesizer to the FedEx Oakland terminal for air transport to Memphis on flight 1200. (Flight

1200 departed at 1921 on September 4 and arrived at 0107 on September 5.) On September 5, it

was loaded on flight 1406 to Boston.

1.16.3 Reanalysis of Fluids Found in DNA Synthesizer

Demonstrations of PerSeptive's purging and drying procedures were conducted on

February 18, 1997, at PerSeptive's manufacturing facility,67 and on June 17, 1997, at the Armed

Forces Institute of Pathology (AFIP). The residues left in the bottles after the AFIP

demonstration were then analyzed to determine the concentrations of any chemicals in the

residues. The results of the analysis were compared with the results of the analysis of the

concentrations of chemicals in the residues found in the accident synthesizer.

Investigators convened at NASA on July 23, 1997, to reanalyze the concentrations

of liquids found in the accident synthesizer and to compare the results with the concentrations of

liquids left in the synthesizer that were purged at AFIP in accordance with PerSeptive’s

procedures. A reanalysis of the residues of selected bottles was undertaken with increased

dilution to prevent instrument saturation (the concentration of relevant chemicals had exceeded

the calibration during the November 1996 tests). The bottles reanalyzed were taken from

positions AUX 3, CAP A5, CAP B6, and OX 2. These bottles were chosen for reanalysis

because the first analysis found that they contained residues of THF (a chemical used in the

synthesis process), which was the most volatile of the chemicals found in the accident

synthesizer. Table 1 shows the amount of chemical residue left after the purging at AFIP, and

table 2 shows the amount of chemical residue left in bottles from the accident synthesizer as

determined in the reanalysis.

Table 1. Quantitative GC/MS Analysis of Bottles from the DNA Synthesizer Purged at AFIP

(Percent of Total Liquid Removed)

Substance CAP A5 CAP B6 OX 2 AUX 3

Total liquid 69 μl 51.8 μl 20.81 μl 71.4 μl

Acetonitrile 85.8%

(59 μl)

91.9%

(47.6 μl)

81.2%

(17 μl)

93.6%

(67 μl)

THF 1.4%

(1.2 μl)

0.4%

(0.2 μl)

1.4%

(0.3 μl)

0.3%

 (0.2 μl)

Water 12.8%

(8.8 μl)

7.7%

(4.0 μl)

17.3%

(3.6 μl)

6.2%

 (4.4 μl)

 67 For a detailed description of this demonstration, see appendix J.
50

Table 2. Quantitative GC/MS Analysis of Bottles from the DNA Synthesizer on the Accident

Flight

(Percent of Total Liquid Removed)

Substance CAP A5 CAP B6 OX 2 AUX 3

Total liquid 28.8 μl 27.4 μl 56.1μl Approx. 4-5

mL

Acetonitrile 55.9%

(16 μl)

38.7%

(10.6 μl)

68.6%

(39 μl)

4.3%

(172-215 μl)

THF 13.9%

(4 μl)

12.0%

(3.3 μl)

8.7%

(4.9 μl)

0.01%

(0.4-0.5 μl)

Water 27.1% (7.8

μl)

40.1%

(10.9 μl)

22.3%

(12.5 μl)

95.6%

(3.8-4.8 mL)

DEGMBE 3.1%

(0.9 μl)

1.5%

(0.4 μl)

0.4%

(0.2 μl)

0.05%

(2-2.5 μl)

Pyridine ---- 0.4%

(0.1 μl)

---- ----

N-Methyl

imidazole

---- 7.3%

(2.0 μl)

---- ----

Safety Board investigators met with the Associate Administrator for Hazardous

Materials Safety, Research and Special Programs Administration (RSPA), regarding the

applicability of the DOT hazardous materials regulations to small quantities of hazardous

materials. The Associate Administrator is the senior DOT official responsible for the

development, implementation, and interpretation of the hazardous materials regulations for all

modes.

According to the Associate Administrator, the DOT hazardous materials

regulations are generally consistent with internationally developed standards. They are based on a

system that first requires the identification and classification of hazardous materials and then

compliance with applicable regulatory standards for packaging, marking, labeling, and shipping

documentation. If a material is listed in the hazardous materials regulations or classified (i.e., it

meets defining criteria) as a DOT-regulated hazardous material, the transportation of that

material in any quantity is subject to the hazardous materials regulations. Once a material has

been identified and classified as a hazardous material, the quantity and form of that hazardous

material will then determine how it is regulated in transportation.

The Associate Administrator further stated that the transportation of any type of

equipment that contains a hazardous material, even in minute quantities, is also subject to the

hazardous materials regulations in the same manner as the transportation of that material in more

typical containers such as drums, cylinders, jars, and tanks. He also noted that although there are

special regulatory exceptions for small quantity, limited quantity, and consumer commodity

shipments, very few exceptions apply to the transportation of hazardous materials aboard aircraft.

The Associate Administrator explained that RSPA has on infrequent occasions

issued de minimus rulings exempting a specific form and quantity of specific hazardous materials
51

from the DOT hazardous materials regulations when it does not pose a risk to life and property

when transported in commerce (e.g., the lithium batteries in wrist watches). In such cases, the

person requesting such a ruling must demonstrate to RSPA that the quantity and form of a

hazardous material does not pose a risk in transportation. The Associate Administrator

emphasized that RSPA alone has the discretionary authority to issue a de minimus ruling, and

that permitting thousands of shippers nationwide to exercise their own discretion in such cases

would erode the consistent application and interpretation of the hazardous materials regulations.

As provided by law, RSPA is authorized to issue exemptions that recognize

alternative means for compliance with the hazardous materials regulations, usually based on

selection of alternative safety control measures that will provide an equivalent level of safety.

According to the Associate Administrator, the exemptions do not signify that the materials are

not subject to the hazardous materials regulations.

1.17 FedEx Organizational and Management Information

FedEx began operations on April 17, 1973. In fiscal year 1996, FedEx reported

revenues of $10.3 billion. Approximately 2.5 million packages were handled daily by 122,000

employees, of which approximately 3,200 were flightcrew members. The airline served 325

airports worldwide in 211 countries with its fleet of 559 airplanes. Of the 2.5 million packages,

only about 6,000 (less than 0.25 percent) are declared shipments of hazardous materials.

FedEx received its first DC-10 in March 1980. At the time of the accident, FedEx

had 13 DC-10-10 and 22 DC-10-30 airplanes.

1.18 Additional Information

1.18.1 Postaccident Actions by FedEx

After the accident, FedEx revised its “Fire & Smoke” checklist by renaming it

“Fire, Smoke & Fumes” and adding a step titled, “Land at Nearest Suitable Airport (if required),”

and noting under that step that a new “Quick Evacuation” checklist is to be used for emergencies

that require immediate evacuation. This step also instructs the crew to consider stopping on the

runway to allow emergency equipment access to the aircraft.

FedEx also revised its “Cabin Cargo Smoke Light Illuminated” checklist to

include an introductory paragraph indicating that the procedures are intended to depressurize the

aircraft, ventilate the cockpit, and deprive the cargo section of oxygen for fire suppression, and

emphasizing the importance of depressurizing. It also has a reminder to ensure that the “Fire &

Smoke” checklist is completed before beginning the checklist. Step No. 6, to “PULL” the

“Cabin Air Shutoff Handle,” has been moved to step No. 2, with the direction to “PULL DOWN

AND FORWARD.” Step No. 4 (formerly step No. 3), “Courier Masks and Goggles,” now has

information about the oxygen mask settings. Under step No. 5, “Cab/Press Man/Auto Handle,”

(formerly step No. 4, “Airplane Altitude”) the directions have been expanded to include specific

instructions on how to manually raise the cabin altitude and maintain the 0.5 pressure
52

differential, and to incorporate former steps No. 5 and No. 7. Step No. 7 (formerly step No. 9),

“If It Is Necessary To Leave The Cockpit To Fight A Fire [DON/ACTIVATE Protective

Breathing Equipment],” has been revised to include donning and activating a walk-around

oxygen bottle and donning leather gloves. Two new steps have been added to the end of the

checklist. After step No. 8 (formerly step No. 10), “Land at the Nearest Suitable Airport,” are

step No. 9, “Manual CAB ALT Control Wheel..........OUTFLOW VALVE/FULL OPEN,”

which directs crews to “Accomplish immediately after landing to ensure clearview windows

and/or doors will open,” and step No. 10, “Accomplish the EMER EVAC [emergency

evacuation] Checklist, Chapter 2-13, as required.” Both the revised “Emergency Evacuation

(Land)” and “Fire, Smoke & Fumes” checklists direct crews to “Evacuate with a copy of DG

[dangerous goods] Form Part A and all Part Bs, if possible.”

FedEx also added to its “Emergency Evacuation (Land)” checklist a step to

manually open the cabin outflow valve once the airplane has landed and stopped. It has also

created a new one-page “Quick Evacuation” checklist, which is designed to be used in

emergencies that require immediate evacuation of the aircraft and when time and conditions do

not permit the use of the longer checklist.

1.18.2 Marijuana Shipments on the Accident Airplane

According to a November 1996 NYSP Investigation Report, a total of 91.55

pounds of green material, later positively identified as marijuana, were removed from the

wreckage. This total amount comprised four separate items that were given to the police during

the inspection of the cargo debris.

According to the police report, the first item was turned over to the police on

September 16, 1996, after it was found by a “FedEx Inspector” in the debris from cargo container

4L. It consisted of a box containing 38.35 pounds of marijuana. According to the police report,

the box “was partially burned along with its attached packing/routing slip leaving no positive

leads or suspects relative to ownership.” The second item, found on September 19, 1996, by

another FedEx employee identified as a “security supervisor” consisted of “a clear plastic bag

(extensive fire damage) containing approx. 13.90 lbs. of green veg. matter,” later identified as

marijuana. The police report provided no information about the location of this package other

than that it was found “in a large pile of debris.” The report also noted that no airbill or

identification was found with this item. The third item, turned over on September 21, 1996, by

the same FedEx security supervisor who turned over the second item, consisted of “two plastic

bags containing approx. 11.30 lbs. of green veg. matter (marijuana).” The police report indicated

that this item was found “in the general area of” cargo container 7L, but noted that it could not be

determined “if the item was in fact from that container due to the extensive amount of debris

from numerous containers present as [the item] was secured.” The fourth item, turned over by

another FedEx security employee to police on September 23, 1996, consisted of “a clear plastic

bag containing green veg. matter (marijuana),” weighing approximately 28 pounds.

The NYSP investigator who prepared the report testified during the Safety

Board’s deposition proceeding that each of the four packages was damaged by fire and water. He
53

also stated that the packages were all wrapped differently and appeared to him to have been

prepared by different shippers.

The police report stated that “no leads were developed...due to the fact that no

airbill slip was recovered with [any of the items,] along with the fact that the original exact

weights of the items could not be established.” On September 25 and 26, 1996, a K-9 dog search

of the remaining debris was conducted. According to the report, “no additional contraband was

detected.” The police report further stated that on November 7, 1996, the marijuana was

destroyed.

During the deposition proceeding, the police investigator stated that the specially

trained dogs used by police to search for such contraband are highly sensitive to the smell of

marijuana. He stated that the dog brought into the accident airplane would have detected the

presence of additional marijuana, if any had been on board, even if it had been totally consumed

in the fire. In response to questioning during his deposition, he stated that during his 20 years as

a police investigator, he had never heard of a fire being caused by heat generation inside a

package of marijuana, nor was he aware of any information or research regarding the

spontaneous combustion of marijuana.

1.18.3 Programs to Deter Undeclared Hazardous Materials Shipments

The number of hidden and undeclared shipments of hazardous materials is

unknown; however, statistics compiled by the Air Transport Association (ATA) and the DOT

indicate an increase in the air transportation of cargo. According to the ATA, the volume of cargo

transported by air increased from 8.26 billion freight/express ton-miles in 1987 to 17.96 billion

freight/express ton-miles in 1997, an increase of 117 percent.68 An official of the ATA estimated

that industry-wide, declared shipments of hazardous materials represent less than 1⁄2 of 1 percent

of the total cargo volume.

The number of hazardous material releases for aviation, as reported to the DOT

Hazardous Materials Information System (HMIS), increased from 163 incidents in 1987 to 1,015

incidents in 1997, an increase of 523 percent. Following changes in the HMIS incident reporting

format in 1990, the number of incidents caused by declared versus undeclared shipments could

also be distinguished. Of the 297 total aviation incidents reported for 1990, 234 incidents (79

percent) were attributed to declared shipments and 63 incidents (21 percent) to undeclared

shipments. In comparison, of the 1,015 incidents reported in 1997 (an increase of 242 percent

from 1990), 666 incidents (65 percent for 1997) were attributed to declared shipments and 349

incidents (35 percent for 1997) to undeclared shipments. Thus, between 1990 and 1997, the

number of hazardous material releases attributed to declared shipments increased by 185 percent,

and the number of hazardous material releases attributed to undeclared shipments increased by

454 percent. Further, in the 2-year period from 1996 through 1997, the number of incidents

 68 Air Transport Association. 1998 Annual Report. Washington, DC. 1998. A freight/express tonmile is 1 ton of cargo other than U.S. mail transported 1 mile.
54

resulting from undeclared shipments rose 82 percent, from 192 incidents in 1996 to 349 incidents

in 1997.

The manager of the dangerous goods program for FedEx testified during the

deposition proceeding that hidden and undeclared shipments of hazardous materials are typically

discovered when the package leaks, emits odors, or results in a release after the package is in the

FedEx system. He also stated that FedEx employees receive hazardous materials awareness

training and are trained to report any instance that indicates a package may contain an undeclared

hazardous material. FedEx does not ask customers to identify the contents of a package when it is

presented for shipment. The FedEx manager stated that although it would be beneficial to have

customers identify the contents of their packages, such a practice would be so burdensome as to

drive express carriers out of business. The manager also stated that FedEx has a revised airbill

that asks the customer to indicate whether the package being presented for shipment contains

dangerous goods or hazardous materials. However, older versions of the airbill (which do not

include this question) are still in use and can be used until their supply is depleted. He stated that

other measures employed by FedEx to screen and detect hidden shipments include the use of

posters at receiving stations about the shipment of hazardous materials and enhancement of its

education and outreach programs for FedEx customers.

During the deposition proceeding, the manager of the FAA’s Dangerous Goods

and Cargo Security Division described FAA initiatives within the past 12 months to reduce the

incidence of hidden shipments of hazardous materials. He stated that subsequent to the crash of

ValuJet 592 in May 1996, the FAA hired 118 new agents dedicated to the dangerous goods and

cargo security enforcement program. (Before the ValuJet crash, the FAA had 14 dedicated agents

for its hazardous materials enforcement program. Agents from other specialties were also used

periodically.) All of the newly hired agents had experience in hazardous materials safety. In

conjunction with hiring the new agents, the FAA lengthened its hazardous materials training

course and developed and implemented a new training course for cargo security. The FAA

dangerous goods manager estimated that after the new programs are established, these agents will

spend 60 percent of their time on the hazardous materials enforcement program and 40 percent

on the cargo security program.69

The FAA has also initiated an inspection program known as “Haz Strikes.” Under

this program, agents from the FAA and other Federal and State agencies, such as RSPA, U.S.

Customs, the U.S. Postal Service, Federal Highway Administration, and State police, conduct

intensive inspections to check the movement of hazardous materials on all carriers serving a

particular airport. The inspections have not only included carrier freight operations, but also the

operations of shippers and freight forwarders (companies that consolidate shipments from

multiple shippers into containers) who are typically located off the airport property. The

 69 The hazardous materials enforcement program includes assessment of carriers’ hazardous

materials program (training, manuals, policies and procedures), package inspections, ramp inspections, and

inspections of shippers. The cargo security program addresses carrier and shipper programs to detect and prevent

the introduction of a bomb or some type of weapon onto an aircraft.
55

inspections are conducted over several days at all hours of the day. Haz Strike inspections to date

have been conducted in major cities including Chicago, Miami, Los Angeles, and at New York’s

Kennedy airport where large volumes of freight are handled.

The FAA is also publicizing dangerous goods enforcement actions in which civil

penalty fines of $50,000 or more have been levied. According to the FAA dangerous goods

manager, this negative publicity serves as an incentive for shippers and carriers to strengthen

their compliance efforts. The FAA manager estimated that of the 36 press releases announcing

fines of $50,000 or more, nearly all were for undeclared shipments of hazardous materials.

The FAA is also promoting an outreach program with all major associations

involved with air transportation, including the Air Transport Association, Airline Pilots

Association, International Federation of Airlines, Council on Safe Transportation of Hazardous

Articles, Chemical Manufacturers Association, Repair Station Association, and paint

manufacturers. Through presentations, speeches, and attendance at meetings and conferences of

these associations, the FAA has emphasized the need for training to ensure that company

employees are knowledgeable about the shipment and transportation of dangerous goods. The

FAA manager stated that the vast majority of undeclared shipments by air occur because of a lack

of understanding of the regulations. To address this, the FAA has developed and distributed

brochures, posters, videos, and compact discs to increase understanding of requirements that

apply to the shipment of dangerous goods by air and to heighten the awareness of the types of

materials that are regulated for air transportation. The FAA is also meeting monthly with the U.S.

Postal Service and providing guidance on general awareness training for postal employees.

According to the FAA manager, the FAA has also established a database that will

be used to conduct trend analyses of the sources and causes of dangerous goods releases in air

transportation. The FAA will utilize the hazardous materials incident system maintained by

RSPA and supplemental data obtained through reports made directly to the FAA. Based on its

analysis of this data, the FAA will adjust its outreach program to address identified trends.

The FAA dangerous goods manager also stated that the FAA is continuing its

evaluation and oversight of carrier programs for accepting dangerous goods shipments and

screening for hidden shipments in response to urgent Safety Recommendations A-96-25 and -26,

issued following the crash of ValuJet 592 in May 1996.70 The FAA conducted an initial survey

 70 Safety Recommendation A-96-25 asked the FAA to “immediately evaluate the practices of and

training provided by all air carriers for accepting passenger baggage and freight shipments (including company

materials) and for identifying undeclared or unauthorized hazardous materials that are offered for transport. This

evaluation should apply to any person, including ramp personnel, who accepts baggage or cargo for transport on

passenger and cargo aircraft.” In a June 3, 1998, letter, the FAA Administrator stated that the FAA had “concluded

that additional sampling to evaluate...all air carriers is not necessary,” and that “[r]andom sampling of air

carriers...taken in nine different regions, provided the FAA with adequate data reflecting the status of the regulated

community as a whole.” She indicated that she considered the FAA’s action to be completed on this safety

recommendation.

Safety Recommendation A-96-26 asked the FAA to “require all air carriers, based on the

evaluation performed under Safety Recommendation A-96-25, to revise as necessary their practices and training for
56

of more than 300 carriers and is now concentrating on those carriers that do not accept dangerous

goods. The FAA manager estimated that 1,200 inspections of air carriers would be conducted

this year. (A given air carrier may be inspected in different cities and thereby have multiple

inspections.) Because the FAA manager considered these inspections to be continuous and

ongoing, he did not specify a completion date for conducting these evaluations and requiring

changes as may be needed.

The FedEx and FAA managers both questioned the practicality of requiring

customers to identify the contents of their shipments, developing and using enhanced technology

such as x-raying packages, or seeking the authority to open suspicious packages. Both of them

also indicated that they knew of no efforts within the aviation or shipping community to consider

or evaluate such measures. They expressed the opinion that public education, awareness, and

carrier training were the most effective methods to reduce the number of hidden and undeclared

shipments of hazardous materials.

 

accepting passenger baggage and freight shipments and for identifying undeclared or unauthorized hazardous

materials that are offered for transport.” In the June 3, 1998, letter, the Administrator stated that the FAA was

clarifying the regulatory requirements for, and developing standardized procedures and training guidelines for,

hazardous materials recognition training for “persons under the operational control of the certificate holder.”
57

2. ANALYSIS

2.1 General

The flightcrew was properly certificated and qualified in accordance with the

applicable regulations and company requirements. Evidence from crew duty time, flight time,

rest time, and off-duty activity patterns did not indicate that behavioral or psychological factors

related to fatigue affected the flightcrew on the day of the accident.

The smoke detection system installed on the airplane functioned as intended and

provided the crewmembers with sufficient advance warning of the in-flight fire to enable them to

land the airplane safely.

The ATC personnel involved with the flight were all properly certificated and

qualified. The Boston Center ARTCC and New York TRACON controllers responded

appropriately once they were aware of the emergency and provided appropriate and needed

information to assist the crew in the emergency descent and landing.

The airplane was properly certificated, equipped, and maintained in accordance

with applicable regulations. No evidence of systems, mechanical, or structural failures was

found.

2.2 Flightcrew Performance

2.2.1 Crew Coordination

Although the airplane was landed successfully, several required items were not

accomplished during the descent and landing. The flight engineer failed to perform step No. 6 of

the “Cabin Cargo Smoke Light Illuminated” checklist (pulling the cabin air shutoff T-handle).71

If he had done so, airflow would have been shut off to the main cargo deck area while being

maintained to the cockpit. The Safety Board concludes that the flight engineer’s failure to pull

the cabin air shutoff T-handle, as required by the “Cabin Cargo Smoke Light Illuminated”

checklist, allowed the normal circulation of air to continue to enter the main cargo area, thereby

providing the fire with a continuing source of oxygen and contributing to its rapid growth.

However, the Safety Board could not determine the degree to which it might have contributed to

the severity of the fire.

The flight engineer also failed to complete step No. 7 of the “Cabin Cargo Smoke

Light Illuminated” checklist (to maintain a 0.5 psi differential cabin pressure). As a result, the

occupants were unable to immediately open and exit from the primary evacuation exits (the L1

 71 Although the CVR recorded the flight engineer stating, “pull cabin air” at 0538:40, its position

after the accident indicates that the cabin air shutoff T-handle had not been pulled.
58

and R1 doors) because the airplane was still pressurized. The flight engineer acknowledged that

instead of manually maintaining the appropriate pressure differential, after he had placed the

outflow valve control in the manual position, he only “cranked it open a couple of times [turns].”

Because they were at 33,000 feet and operating on only one pressurization pack, the outflow

valve would have been almost completely closed before the flight engineer cranked it. As

demonstrated in the Safety Board’s test on a similar DC-10, manually cranking the outflow valve

control two times will not perceptibly open the outflow valve from fully closed on a static

airplane. The Safety Board concludes that the evacuation was delayed because the flightcrew

failed to ensure that the airplane was properly depressurized.

The CVR transcript reveals that the flight engineer was overloaded and distracted

from his attempts to accomplish the “Fire & Smoke” and “Cabin Cargo Smoke Light

Illuminated” emergency checklists (in addition to his normal descent and before-landing

checklist duties) by his repeatedly asking for the three-letter identifier for Stewart so that he

could obtain runway data for that airport.

After the accident, the captain said that he had allowed the first officer to continue

flying the airplane during the emergency so that he could coordinate with ATC and work with the

flight engineer on completing the checklists. This should have resulted in an effective

apportionment of the workload among the three crewmembers, in that the flying pilot would not

have been overly distracted from flying the airplane, the flight engineer would have received

needed assistance with his duties,72 and the captain would have had the opportunity to oversee

the actions of both. However, the Safety Board is concerned that, despite the captain’s stated

intention to serve in a monitoring and coordinating role, he failed to provide sufficient oversight

and assistance to ensure completion of all necessary tasks.

The captain did not call for any checklists to address the smoke emergency, which

was contrary to FedEx procedures.73 (The flight engineer initiated the "Fire & Smoke" and

"Cabin Cargo Smoke Light Illuminated” checklists.) Nor did he explicitly assign specific duties

to each of the crewmembers. The captain also did not recognize the flight engineer’s failure to

accomplish required checklist items, provide the flight engineer with effective assistance, or

intervene to adjust or prioritize his workload. In fact, the captain repeatedly interrupted the flight

engineer during his attempts to complete the “Fire & Smoke” checklist,74 thereby distracting him

further from those duties.

 72 At the time of the accident, the flight engineer had only 188 hours as a DC-10 flight engineer

and had been working for FedEx for less than 6 months.

73 The FedEx DC-10 Flight Manual indicates, under “Emergency and Abnormal Checklist

Procedures,” that “Phase One [memory]” items are to be “performed when directed by the Captain.” Further, it

states, “all checklists containing Phase One items should be requested by the Captain by name” and strongly

recommends that the captain and flight engineer “work together on the review of the Phase One items and the

accomplishment of the Phase Two items.”

74 At 0538:38 and 0539:13, the captain interrupted him to ask whether he had run a test on the

smoke detector system, which is not an item listed on the checklist.
59

Further, the captain did not initiate the “Emergency Evacuation” checklist, which

was required to be initiated during the preparation for landing. The “Emergency Evacuation”

checklist includes depressurizing the airplane before landing. If this checklist had been initiated,

it would have provided another opportunity for the crew to accomplish the necessary

depressurization that was missed on the “Fire & Smoke” checklist. In addition, the captain told

investigators that he did not initiate the emergency descent checklist, but said that he thought he

had accomplished the items on that checklist by memory. Although the emergency descent

checklist (titled “Rapid Depressurization/Emergency Descent”) was probably not applicable to

this situation, the captain’s statement is troubling because it suggests a belief that checklist items

can be adequately accomplished from memory alone. Finally, the CVR transcript indicates that

the captain did not call for an emergency evacuation. (After the captain said “we need to

get...out of here,” the flight engineer said “emergency ground egress.”)

The Safety Board concludes that the captain did not adequately manage his crew

resources when he failed to call for checklists or to monitor and facilitate the accomplishment of

required checklist items. Therefore, the Safety Board believes that the FAA should require the

principal operations inspector (POI) for FedEx to review the crew’s actions on the accident flight

and evaluate those actions in the context of FedEx emergency procedures and training (including

procedures and training in crew resource management) to determine whether any changes are

required in FedEx procedures and training.

2.2.2 Crew’s Use of Emergency Equipment

Within 48 seconds after the first indication of a problem, the crew donned oxygen

masks, as required by the “Fire & Smoke” checklist. The captain elected not to don his smoke

goggles because they did not fit over his eyeglasses and they were dirty and scratched. The first

officer elected not to wear his smoke goggles because he felt that they unduly restricted his

peripheral vision. The flight engineer put his smoke goggles on but subsequently removed them

because there was no smoke in the cockpit.

The Safety Board is concerned that cockpit smoke may affect crewmembers’

vision, imperiling their ability to operate the airplane or properly address the emergency.

Evidence in this accident indicates that smoke did not enter the cockpit in significant amounts

until after the crew landed and stopped the airplane. However, the Safety Board is concerned

that under different circumstances, the failure of crewmembers to don smoke goggles or to keep

the goggles on during an emergency could adversely affect the outcome.

In connection with its investigation of the May 11, 1996, accident involving

ValuJet flight 592,75 the Safety Board concluded that there is inadequate guidance for air carrier

pilots about the need to don oxygen masks and smoke goggles immediately in the event of a

smoke emergency. In Safety Recommendation A-97-58, the Safety Board asked the FAA to

 75 National Transportation Safety Board. 1997. In-flight Fire and Impact with Terrain, ValuJet

Airlines Flight 592, Everglades, Near Miami, Florida, May 11, 1996. Aircraft Accident Report NTSB/AAR-97/06.

Washington, DC.
60

issue guidance on this point to air carrier pilots. In a November 17, 1997, response, the FAA

indicated it would issue a flight standards handbook bulletin in November 1997 containing

guidance on procedures to don PBE for smoke and fume protection. The FAA did not issue the

bulletin. Recently, it has been learned that the bulletin will not be issued until after the FAA

reviews the results of a special emphasis inspection of smoke goggles during en route and ramp

inspections. On March 20, 1998, the FAA called for this special survey of smoke goggles as part

of its response to Safety Recommendation A-97-60 (also from the ValuJet report), which sought

a requirement that smoke goggles currently approved for use by the flightcrews of transportcategory aircraft be packaged in such a way that they can be easily opened by the flightcrew. The

survey has been completed, and the FAA is reviewing the results. The Board has been assured

that the FAA is still in agreement with the intent of the recommendations addressing flightcrew

smoke goggles and that action on Safety Recommendations A-97-58, -59, and -60 will follow the

results of the survey. The Board is very concerned that the issuance of the guidance bulletin

regarding the need for flightcrews to don smoke goggles at the first indication of a possible inflight smoke or fire emergency has been delayed until after the completion and review of the

special survey. Based on this delay, the Board classifies Safety Recommendation A-97-58

“Open—Unacceptable Response.”

In the ValuJet report, the Safety Board also concluded that the smoke goggle

equipment currently provided on most air carrier transport aircraft requires excessive time, effort,

attention, and coordination by the flightcrew to don and, in Safety Recommendation A-97-59,

asked the FAA to establish a performance standard for the rapid donning of smoke goggles and

ensure that all air carriers meet this standard through improved smoke goggle equipment,

improved flightcrew training, or both. In response, the FAA indicated that it believed the intent

of this recommendation is addressed in 14 CFR 121.337, which establishes standards for PBE for

smoke and fume protection and requires that the equipment be conveniently located on the flight

deck and easily accessible for immediate use. However, there is no standard for the optimum

equipment location that will facilitate quick donning of such equipment or for the time required

to don the equipment. The FAA also stated that it would issue a flight standards handbook

bulletin to provide additional guidance on the location and donning of this equipment and

procedural guidance on flightcrew training requirements. However, it did not address the

recommendation to establish a standard to ensure that, through equipment design, equipment

installation, or flightcrew training, a specific performance standard is achieved for donning

smoke goggles. The FAA has indicated that it will await the results of the special emphasis

inspection before it takes further action. The Safety Board classifies Safety Recommendation

A-97-59 “Open—Unacceptable Response.”

This accident again demonstrates that crews may not use the equipment currently

available and that some characteristics of the current equipment may interfere with the

flightcrew’s performance of its duties. Accordingly, the Safety Board reiterates Safety

Recommendations A-97-58 and -59.

During the evacuation, the flight engineer stated that before he entered the foyer

area to evacuate via the R1 door, he filled his lungs with oxygen from his oxygen mask. He did

not use the PBE, which would have provided him with protection from the smoke while he
61

attempted to open the foyer doors. In postaccident interviews, he stated that he was anxious to

open the exit doors quickly, and he forgot that the PBE was available. The Safety Board

concludes that crewmembers who do not use PBE during a smoke or fire emergency may place

themselves at unnecessary risk in attempting to address or escape from the situation. Although

most carriers’ emergency evacuation checklists instruct crewmembers to don PBE when

circumstances warrant, there is no reference to the PBE in the FedEx “Emergency Evacuation”

checklist. Therefore, the Safety Board believes that the FAA should require FedEx to modify its

evacuation checklist and training to emphasize the availability of PBE during evacuations in an

environment containing smoke, fire, or toxic fumes.

The L-1 door was not available as an emergency exit because it only opened

partially as a result of the flight engineer’s attempt to open the door while the airplane was still

pressurized. As discussed in section 1.6.4, when there is no electric power to the airplane the

motor that operates the door is powered by a charged air bottle. If an attempt is made to open the

door when the cabin pressure differential is above 0.5 psi, the bottle pressure will bleed off and

the door will not open. Although the lack of the L-1 door as an escape route was not a significant

factor in this accident, the Safety Board is concerned that under other circumstances the loss of a

passenger exit door could have serious safety consequences. The Safety Board concludes that

crewmembers may not be adequately aware that attempting to open a passenger exit door when

the airplane is still pressurized may result in the door not opening. Therefore, the Safety Board

believes that the FAA should require all Part 121 operators of airplanes that rely on air pressure

to operate exit doors to make crewmembers aware of the circumstances of this accident and

remind them of the need to ensure that the airplane is depressurized before attempting to open the

passenger exit doors in an emergency.

2.3 Fire Initiation

2.3.1 Location from Which the Fire Might Have Initiated

Because the fire burned for about 4 hours after smoke was first detected in the

cabin cargo compartment, under changing conditions, much of the potentially helpful evidence

was destroyed by the fire.76 The growth of the fire was likely affected by the failure to pull the

cabin air shutoff T-handle and the opening of doors L1 and R1 about 0556, which (even though

L1 did not open completely) would have provided additional ventilation (oxygen), and thus

increased the rate of fire growth. An even greater addition of oxygen occurred about 0650 when

the cargo door was opened. (Witnesses reported that flames first broke through the fuselage

shortly after the cargo door was opened. The airport operations log recorded that flames

breached the crown of the fuselage about 0655, which was 1 hour after the airplane landed and

about 1 hour and 19 minutes after the illuminated smoke detector lights were first noted by the

flightcrew.) Despite the length of time the fire burned and the resulting destruction of potentially

 76 It should nonetheless be noted that even after the prolonged fire, many containers (including

those in rows 1, 2, 3, 14, 15, and 16) were not severely compromised, or still contained substantial quantities of

highly combustible materials (such as magazines, technical manuals, dry cleaning bags, bubble wrap, and clothing)

that remained unburned.
62

helpful evidence, the postfire condition of the airplane and its contents were nonetheless

examined for clues as to the location from which the fire might have initiated.

One factor that investigators considered was the "V" burn pattern that originated

at container 6R. It is a basic premise of fire science that such a “V” pattern often points to the

origin of a fire. However, as explained in the National Fire Protection Association’s Guide for

Fire and Explosion Investigations, NFPA 921, “each time another fuel package is ignited or the

ventilation to the fire changes, the rate of energy production and heat distribution will change.

Any burning item can produce a plume and, thus a ‘V’ pattern. Determining which pattern was

produced at the point of origin by the first material ignited becomes more and more difficult as

the size and duration of the fire increases.” [Par. 3-7]77

Several areas in the main cabin cargo compartment exhibited extensive fire

damage; however, the deepest and most severe heat and fire damage was found in and around

container 6R.78 More of 6R's structure was consumed than of any other container, and it was the

only container that exhibited severe floor damage, which was likely caused by burning/melting

Lexan wall material that fell inward onto the unprotected container floor. (Container 6R was one

of the more sparsely loaded containers, enabling fire to reach the floor level without having to

consume much cargo in the process.) Further, 6R was the only container to exhibit heat damage

on its bottom surface, and the area below container 6R showed the most extensive evidence of

scorching of the composite flooring material. In addition, the overall burn damage pattern to the

cargo containers in the main cargo cabin showed that the deepest burned-out area centered over

container 6R and that the cargo containers surrounding 6R and the contents in these containers

were all burned to a greater depth along the sides common to container 6R.

There was heat damage to the cabin floor just aft of container 9L, but there was no

cargo container in this area on the accident flight. This damage to the floor was consistent with

burning material falling from the burning fuselage crown or contents from cargo container 9L

falling into this empty space. Two aerosol cans found in this area showed evidence that they had

been heated by fire on the outside of the cans, and that they had overpressurized and ruptured.

If the fire had not burned so long, the "V" burn damage pattern and the

extensiveness of the fire damage to 6R would have been stronger evidence of a fire originating

inside 6R. Further, the deep burn and severe damage found in container 6R could also be

accounted for by the fact that it was relatively empty and therefore largely unprotected by cargo.

Thus, the Lexan side walls and nylon curtain could have fallen directly onto the floor of 6R and

burned there, resulting in the severe damage to the floor of 6R and the exterior surfaces of the

synthesizer. When Lexan is heated, it typically burns, melts, and puddles, producing heat that

would be sufficient to cause the damage to container 6R and its contents. Thus, a fire that

 77 See also Par. 3-7.2, which states, “[a]reas of great damage are indicators of a high heat release

rate, ventilation effects, or long exposure. Such areas, however, are not always the point of fire origin.”

78 In every other cargo container there was a layer of unburned cargo covering the container floor.
63

originated outside of 6R but eventually spread to that area could have resulted in a similar

damage pattern.

Comments on the CVR suggest that the smoke detector activation sequence might

have begun with detector number 9 and initially moved forward; this suggests that the fire might

have started aft of row 6. Further, some of the first flames to have breached the crown were

observed approximately above the area occupied by cargo container rows 8 and 9.79 Although

the smoke detector activation sequence and location of the early breakthrough of flames cannot

be considered reliable indicators of a fire’s initial location,80 a possible connection between these

factors and the location of the fire’s origin could not be discounted. Therefore, the Safety Board

also considered the possibility that the fire originated aft of container row 6.

Although there was some significant burn damage to the containers in rows 8 and

9, their contents, and the surrounding area of the aircraft, this damage appeared to have been less

than the damage in the area of container 6R. For example, container 8L’s aluminum roof and

two of its three Lexan walls were consumed by fire, as was the upper two-thirds of the third

Lexan wall; its inboard forward and aft cornerposts measured 5 feet 10 inches and 5 feet 2

inches, respectively, and its outboard forward and aft cornerposts measured 1 foot 4.5 inches and

3 feet 6.5 inches, respectively. Container 9R’s aluminum roof and two of its three Lexan walls

were consumed by fire, as was the upper portion of the third Lexan wall; its inboard cornerposts

were intact, but its outboard forward and aft cornerposts measured 1 foot 3.5 inches and 1 foot 5

inches, respectively. However, 9L contained a significant quantity of undamaged materials81

with a low melting point (polyurethane, polystyrene, and polyethylene), and the cornerposts of

 79 It should be noted that a FedEx mechanic who was standing near the cargo door indicated that at

about the same time that flames were first seen venting from the aft section of the airplane in the 8/9 area, or possibly

earlier, flames were also starting to break through the side of the fuselage in the area of 6L. His observations were

not contradicted by the other eyewitnesses. Rather, they suggest that flames might have been breaking through the

fuselage at more than one place at the same time. The video footage showing flames breaking through farther aft

was taken from the right of the airplane and would not have captured a breakthrough of flames on the left side.

80 The breakthrough principle is illustrated by several previous main cabin aircraft fires. For

example, a cabin fire occurred in Atlanta in 1995 on a ValuJet DC-9 after an engine failure started in the aft end of

the cabin from a failed engine compressor disk that punctured a fuel line and penetrated the cabin. (See, National

Transportation Safety Board. 1996. Uncontained Engine Failure/Fire, ValuJet Airlines Flight 597, DC-9-32,

N908VJ, Atlanta, Georgia, June 8, 1995. NTSB/AAR-96/03. Washington, DC.) In a report submitted to the Safety

Board, an FAA fire specialist noted that in that accident, in spite of rapid fire department response, the fire gutted the

cabin and penetrated the fuselage skin just behind the cockpit—at the opposite end of the cabin from where the fire

started. Another example is an in-flight fire that originated in the left rear lavatory of an Air Canada DC-9 that

forced the flightcrew to make an emergency landing on June 2, 1983, at the Greater Cincinnati Airport. In that fire,

the first evidence of fuselage breakthrough occurred at the front of the aircraft, significantly forward of the initiation

point. In addition, in a fire that originated below the floor immediately aft of the right galley on a Delta 737 while it

was on the ground at Salt Lake City, Utah, on October 14, 1989, the first fuselage breach was in the first-class cabin,

well forward of the fire’s origin.

81 Although 6R also contained a small amount of unburned combustible material (for example,

newspaper wrapped around the industrial valves loaded in the outboard aft corner of the container), unlike the

contents of containers in rows 8 and 9, the vast majority of easily burned unprotected material in 6R was consumed

by the fire.
64

that container sustained fire damage only to the forward outboard post. Similarly, containers 9R

and 8R contained significant amounts of unburned combustibles (such as paper items) after the

fire.

In analyzing the significance of the unburned materials in rows 8 and 9, the Safety

Board recognized that when material towards the top of the containers in those rows burned, it

could have formed an insulating layer of charred debris that would have slowed the downward

progress of the fire.82 Postaccident examination revealed a significant amount of burned material

(as well as unburned material) in that area. However, the high-pressure water streams from the

firefighting efforts would have disrupted the arrangement of the burned and unburned materials,

thus erasing any obvious signs of an insulating layer.

Finally, investigators also noted that there was a "V" soot pattern on the interior of

the fuselage originating at the floor level of the junction between 8L and 9L, but this is consistent

with the exposure of that area when the fuselage separated and the fire vented at that point and is

probably not related to the location of the fire’s origin.

Thus, in comparing the fire damage in 6R with that in rows 8 and 9, it is possible

that the fire in those rows was as significant as that in the area of 6R, but it might have started at

or near the top of a container and was unable to progress very far into the volume of cargo loaded

into those containers.

In sum, there was insufficient reliable evidence to reach a conclusion as to where

the fire originated.

2.3.2 Ignition Source of the Fire

Because of an initial recognition among the fire investigators participating in the

investigation that “V” burn patterns are generally highly significant, investigators examined the

contents of 6R to try to identify a possible source of the fire. All items found in, or known to

have been shipped in, container 6R were examined in detail (see section 1.14.2.1.1). In particular,

the Safety Board examined the DNA synthesizer as a potential source of ignition because of the

chemical smell noticed inside the unit and because the other items in that container were ruled

not likely to have provided a source of ignition. The nature and degree of the fire damage to the

synthesizer, particularly the heavy damage to the internal circuitry of the synthesizer’s controller

panel (which is made of a low-flammability material), was thought to be suggestive of a source

of fuel inside the synthesizer. (However, given the presence of volatile chemicals, and possibly

vapors, inside the synthesizer, it is possible that a fire ignited external to the synthesizer could

have produced a damage pattern similar to that resulting from an internal ignition source.)

 82 According to the National Fire Protection Association’s Guide for Fire and Explosion

Investigations, NFPA 921, “[a] protected area results from an object preventing the products of combustion from

depositing on the material that the object protects, or prevents the protected material from burning.” [Par. 4-15.2]
65

Tests of the liquids from the accident synthesizer showed that flammable

chemicals (THF and acetonitrile) were still present in the bottles on the machine after the fire.

The quantity of chemicals remaining in the synthesizer’s bottles after the fire was insufficient to

have caused the extensive internal fire damage to the synthesizer and the cargo container.

However, it is likely that significant amounts of the chemicals were consumed in the prolonged

and intense fire and thus the synthesizer probably contained much larger quantities of these

flammable chemicals before the fire. (The presence of firefighting agent inside most of the

bottles and the damage to many of the tubes that entered the bottles indicates that the bottles had

been open to the atmosphere during at least part of the fire sequence.)

These volatile chemicals—particularly the THF—could ignite a fire. THF, which

is highly flammable under any circumstances, can also form unstable peroxides that can explode

on contact with certain other materials or autoignite (spontaneously explode) in sufficient

concentrations. Although the investigation examined this as a possible ignition scenario, it

could not be determined whether the chemicals in the synthesizer played any role in igniting the

fire. The investigation could not develop a viable and convincing scenario to explain how the

synthesizer could have started a fire.

Further, although the cargo debris from all of the cargo containers that had been

carrying general cargo was also examined for possible ignition sources, it was not initially

examined in as much detail as the items known to have been loaded into 6R because of the

volume and condition of the debris. When a more detailed examination of that cargo debris was

conducted later in the investigation, no ignition sources were identified in that cargo debris.

However, because of the deteriorated condition of the cargo debris and the possibility that some

cargo had been completely destroyed in the fire, the Safety Board could not rule out that on the

accident flight, an ignition source was present in one of those cargo containers.

In light of the discovery of several shipments of marijuana on board the accident

flight and the suggestion of one of the parties that marijuana is subject to spontaneous

combustion, investigators considered this as a possible ignition source. The Safety Board

recognizes that some organic matter, such as hay, can generate a biological/organic reaction

producing heat and combustion if it is both wet and sufficiently compressed yet still exposed to

oxygen. However, all of the marijuana shipments on board the airplane had been vacuum

packed. (The police investigator who documented the marijuana seizures testified that the

specially trained dog would have detected the presence of additional packages of marijuana, if

any had been on board, even if the packages were completely consumed in the fire.) The police

investigator who documented the marijuana seizures explained that shippers of contraband such

as marijuana attempt to reduce the size of the package by “using a vacuum to vacuum out all the

air and get it as compact as possible.” Thus, although the marijuana would have been

compressed, there would have been little or no oxygen available to permit or support the

biological reaction needed to lead to spontaneous combustion. Further, neither the police

investigator nor any of the fire experts or consultants questioned during the course of the Safety

Board’s investigation were aware of a fire being initiated by spontaneous combustion of a

marijuana shipment. Therefore, spontaneous combustion of a marijuana shipment was ruled out

as a possible ignition source.
66

Finally, all of the airplane systems were examined for possible ignition sources;

the electrical system showed no evidence of arcing, and none of the other aircraft systems

showed any evidence of malfunction. Further, neither the crew interviews nor the FDR or CVR

data indicated any failures or malfunctions in the airplane’s systems that might have played a part

in initiating the fire. Therefore, aircraft systems were ruled out as a possible ignition source for

the fire.

In sum, the Safety Board could not conclusively identify an ignition source for the

fire.

2.4 Undeclared Hazardous Materials on Airplanes

2.4.1 The Synthesizer

As noted above, the DNA synthesizer in container 6R was found to contain

flammable liquids after the fire. The largest liquid sample in the accident synthesizer

(approximately 5 mL in the AUX 3 reagent bottle) had a concentration of 4.3 percent of

acetonitrile and .01 percent of THF. This is equivalent to about 200 μl of acetonitrile and 0.5 μl

of THF. In comparison, the AUX 3 bottle from the synthesizer that was purged at AFIP, according to

the procedures in Perseptive’s manual, contained only 66 μl of acetonitrile and 0.2 μl of THF. Thus,

after the accident, the AUX 3 bottle from the accident synthesizer contained about two and a half

times the amount of acetonitrile and THF as did the AUX 3 bottle from the synthesizer purged at

AFIP using the prescribed PerSeptive procedures. Further, the OX 2 bottle from the accident

synthesizer contained about 5 μl of THF, which is about five times as much as the most THF that

was left in any of the bottles from the synthesizer purged at AFIP. (The most THF in the

synthesizer purged at AFIP was found in the CAP A5 bottle, which contained approximately

0.966 μl of THF. The CAP A5 bottle from the accident synthesizer contained approximately 4 μl

of THF.)

To determine why acetonitrile and THF were present in the accident synthesizer in

quantities greater than those of a properly purged unit, investigators reviewed the operating and

maintenance history of the synthesizer and the procedures used to prepare the instrument for

shipment. The instrument had sat idle for more than 6 months without being flushed or cleaned

before the PerSeptive field engineer prepared it for shipment on August 28, 1996. Although the

field engineer stated that he noted no malfunctions or problems, and that the synthesizer

functioned properly during the purging procedure, the output log that recorded his actions during

the purging procedure showed 44 “manual function invoked” entries that could not be accounted

for by the steps prescribed in PerSeptive's Service Note 89-006. When questioned about these

entries, the field engineer explained that they represented multiple “prime individual” functions

that he had invoked for each of the individual reagent positions on both column positions. (The

priming function pumps a small, fixed amount of liquid from each individual reagent position

through the flowpath.)
67

Although the field engineer asserted that there were no problems with the purging

of the machine, he also indicated that he performed the additional individual priming functions as

an additional measure to ensure that liquid was flowing through the machine. This suggests that

he wanted to ensure that liquid was flowing properly. These additional manual priming functions

could be consistent with his having made repeated attempts to isolate or correct a perceived

problem. Further, the existence of a breach in the system might also explain how chemicals

found their way to enclosed areas of the machine that later exhibited severe fire damage.

Although the Safety Board could not positively determine the specific deficiency

in the purging process, the purging and drying procedures performed at PerSeptive’s corporate

offices and at AFIP demonstrated that if the procedures in Service Note 89-006 were properly

carried out, it would result in the synthesizer bottles containing trace amounts of chemicals less

than those found in the accident synthesizer.83 Thus, based on the results of the Safety Board’s

tests at NASA, it is clear that this process was not followed correctly and that chemicals in

amounts greater than should have existed were left in at least some of the bottles.

The most reasonable explanation for the presence of excessive quantities of

chemicals in the synthesizer is that one or more of the bottles containing chemical reagents used

in the DNA synthesis process (at least one of which contained THF) was not sufficiently emptied

before the purging process began.

This error alone (failure to sufficiently empty one or more of the bottles before the

flushing cycle) might not have resulted in chemical residues being left in the synthesizer if the

bottles had been replaced with new, dry, empty bottles before the drying cycle. However, it is

unclear from Perseptive’s procedures whether this was expected. In any event, the quantities of

chemicals found in some bottles (for example, AUX 3, OX 2, CAP A5, and CP B6) indicate that

the field engineer probably failed to sufficiently empty one or more of the internal reagent bottles

after the flushing process and before the drying cycle, and that some of the chemicals left in those

bottles remained in the synthesizer even after the drying cycle was complete. Therefore, the

Safety Board concludes that the DNA synthesizer was not completely purged of volatile

chemicals (including acetonitrile and THF) before it was transported on board flight 1406.

The RSPA Associate Administrator for Hazardous Material Safety indicated that

the shipment of any amount of material classified by the DOT hazardous materials regulations as

hazardous materials (as are acetonitrile and THF) is subject to DOT requirements for packaging,

labeling, and shipping documentation to accurately identify the hazardous nature of a shipment.

He also indicated that the transportation of any type of equipment that contains hazardous

materials, even in minute quantities, is also subject to the hazardous materials regulations just as

it would be if it were shipped in more typical containers. Because the synthesizer was not

intended to be shipped with any hazardous materials, it was shipped as general freight and was

not packaged or labeled in accordance with DOT requirements and was not accompanied by the

required paperwork.

 83 If the instructions in Service Note 89-006 to replace the bottles with “dry empty” bottles before

the drying step is interpreted as a requirement that new bottles be installed, then even smaller quantities of trace

chemicals (or none at all) would be found inside them. During the purging demonstrations, the bottles were simply

emptied and shaken between the flushing and drying, rather than replaced with new, clean bottles.
68

Because the presence of flammable chemicals in the DNA synthesizer was wholly

unintended and unknown to the preparer of the package (PerSeptive) and the shipper (Chiron), it

is unlikely that the shipment of those chemicals on board flight 1406 would have been prevented

by better hazardous materials education or improved screening of packages offered for

transportation. However, it does demonstrate the safety threat posed by undeclared and

improperly packaged hazardous materials.

2.4.2 Other Prohibited Items

Several other items discovered on board the accident airplane might also have

constituted shipments of undeclared hazardous materials. As discussed in section 1.14.2.1.1,

seven aerosol cans and several plastic bottles containing acidic or alkaline liquids that could be

corrosive, and two samples containing potentially flammable or combustible liquids were found

in the cargo debris.84 Although the original contents of the aerosol cans recovered from the

accident aircraft could not be determined, aerosol cans, as pressurized containers with

compressed gases, are regulated hazardous materials. The acidic and alkaline liquids in the

plastic bottles were also likely subject to the DOT hazardous materials regulations as corrosive

materials. Although the DOT hazardous materials regulations allow exceptions to packaging,

marking, labeling, or shipping paper requirements, depending on the quantity and form of the

material being shipped, these exceptions generally are not applicable when the item is being

transported by air. Consequently, the aerosol cans and the containers of acidic liquid likely

constituted undeclared shipments of hazardous materials. Although these items were ruled out as

possible ignition sources, they again raise concerns about the prevalence of unknown hazardous

materials being carried on board airplanes.

The ease with which prohibited materials can find their way onto commercial

airplane flights was further highlighted by the discovery of several illegal shipments of marijuana

on board the accident flight. Marijuana is not classified as a hazardous material for purposes of

air transportation, and the marijuana found on board flight 1406 was not a factor in the accident.

Further, the Safety Board notes that most undeclared shipments of hazardous materials are

unintentional, although the shipment of marijuana is clearly a deliberate attempt to ship

contraband material. Nonetheless, the Safety Board concludes that the presence of the aerosol

cans, the containers of acidic liquid, as well as several packages of marijuana on board the

accident flight illustrates that common carriers can be unaware of the true content of many of the

packages they carry.

2.4.3 Federal and Industry Oversight

 84 The hazardous materials regulations define a corrosive material as “a liquid or solid that causes

full thickness destruction of human skin at the site of contact within a specified period of time; [or a] liquid that has a

severe corrosion rate on steel or aluminum.” (49 CFR 173.136.) They also prescribe packaging standards based on

the length of exposure of the corrosive material to human skin and the time after exposure for destruction of the skin

to occur. (49 CFR 173.137.)
69

The shipment of undeclared and improperly packaged hazardous materials on

board airplanes and the oversight by the FAA and air carriers to detect and identify such

shipments was most recently addressed by the Safety Board in its report of the May 11, 1996,

accident involving ValuJet Airlines. The Safety Board determined that the in-flight fire was

initiated by the actuation of one or more chemical oxygen generators being improperly carried as

cargo. These generators had not been identified as hazardous materials and were not properly

packaged for transportation.

The Safety Board stated in the ValuJet report that the practices, procedures, and

training of the personnel involved in the identification and handling of undeclared hazardous

materials have remained inadequate. The Safety Board further noted that the ValuJet accident

and incidents that occurred after that accident clearly demonstrate that the shipment of

undeclared hazardous materials in air transportation is a serious problem that has not been

adequately addressed. In the ValuJet report, the Safety Board further stated the following:

[T]he FAA has initiated the evaluation requested by the Safety Board in Safety

Recommendations A-96-25 and -26 of the practices and training provided by

all air carriers for accepting passenger baggage and freight shipment

(including COMAT [company materials]) and for identifying undeclared or

unauthorized hazardous materials that are offered for transport and, based on

this evaluation, to require air carriers to revise as necessary their practices and

training in this area.

Further, the FAA is developing a hazardous materials education and

enforcement program that will focus on air freight forwarders. Also, shortly

after August 1996, the FAA issued, under 14 CFR Part 109 (Indirect Air

Carrier Security), shipper endorsement requirements that require all shippers,

and freight forwarders to certify that all packages being shipped do not contain

unauthorized explosives, destructive devices, or hazardous materials. Signing

the endorsement also gives permission to search the shipment. Because the

transport of oxygen generators has continued since the accident, despite the

regulations, the Safety Board will closely monitor the FAA’s progress in

fulfilling these proposed improvements.

The FAA initiatives that have been undertaken since the ValuJet accident (e.g.,

hiring new agents, comprehensive inspections of carriers’ and shippers’ facilities, increased

penalties for violations, a renewed outreach program, and the establishment of a database for

trend analysis) are positive measures to reduce the number of hidden or undeclared shipments of

hazardous materials. However, although the Safety Board supports these efforts, this accident

illustrates that there is continued cause for concern. The Safety Board is especially concerned

that, except in the case of properly packaged and declared shipments of hazardous materials,

carriers generally do not inquire about the content of packages being shipped domestically, nor

are they required to do so. The Safety Board also notes that the dangerous goods managers for

FedEx and the FAA questioned the practicality and usefulness of carriers questioning a shipper

about the contents of packages offered for shipment. Although air carriers and the FAA
70

apparently agree on the seriousness of the problem, consideration is not being given to innovative

measures, such as identifying package contents on the airbills or using technologies like x-ray

machines to detect undeclared hazardous materials.

The Safety Board concludes that transportation of undeclared hazardous materials

on airplanes remains a significant problem and more aggressive measures to address it are

needed. Thus, the Safety Board believes that, in addition to the efforts already underway by the

FAA, the DOT should require, within 2 years, that a person offering any shipment for air

transportation provide written responses, on shipping papers, to inquiries about hazardous

characteristics of the shipment, and develop other procedures and technologies to improve the

detection of undeclared hazardous materials offered for transportation. The inquiries may

include answering individual and specific questions about whether a package contains a

substance that might be classified hazardous, (e.g., “does this package contain a substance that

might be corrosive [or flammable, a poison, an oxidizer, etc.]”)

2.5 Dissemination of Hazardous Materials Information

After the occupants had successfully evacuated the airplane, the most immediate

problem for the firefighters and other emergency responders was to prevent the fire from

spreading and involving the fuel that remained on the airplane. In this case, the unavailability to

the incident commander of specific information about the declared hazardous materials on board

did not affect the firefighting strategy of the NY ANG. (For more information see Section

1.15.2, Emergency Response.) Nevertheless, in accidents that involve hazardous materials, it is

critical that firefighters and other emergency responders receive timely information regarding the

identity, quantity, number of packages, and location of declared hazardous materials. Such

information can influence the type and level of response and may be necessary to adequately

protect emergency response personnel, the environment, and the surrounding communities.

Neither the assistant fire chief who served as the initial incident commander nor

the ANG fire chief received specific information during the firefighting phase of the emergency

(before 0925) about the identity of the hazardous materials, their quantities, or the number of

packages on the airplane. By 0700, about 1 hour after the airplane had landed, the only

information about the hazardous materials on board the airplane that had been provided to the

initial incident commander came from the Part A form and a handwritten list provided by the

FedEx station at the airport. This information indicated only the hazard classes of the hazardous

materials on board the airplane and their location in the airplane by cargo container position.

Emergency guidance about specific chemicals was available through the Orange County HMRT

and its communications link to CHEMTREC; however, this information was of little use until

the specific identity and quantities of the declared hazardous materials on board the airplane were

known. About 0915, approximately 10 minutes before the fire was extinguished, the fire chief

received from the Orange County HMRT coordinator a copy of the weight and load plan and a

handwritten list identifying some of the chemicals on board.

The NY ANG and other participating emergency response agencies, including

airport operations at Stewart, repeatedly requested specific information about the hazardous
71

materials on board the airplane. Throughout the morning (beginning at 0635) and into the early

afternoon, FedEx, primarily through its GOCC in Memphis, faxed as many as 12 transmissions

of various hazardous materials shipping documents to the EOC at the airport operations building

and the NYSP barracks at Stewart, although many of the faxes were illegible. However, none of

these reached the incident commander. (The lack of coordination among the involved agencies is

addressed in section 2.6.)

Another problem was that FedEx did not have the capability to generate, in a

timely manner, a single list indicating the shipping name, identification number, hazard class,

quantity, number of packages, and the location of each declared shipment of hazardous materials

on the airplane. To prepare such a list, FedEx would have had to compile information from

copies of all of the individual Part Bs for each individual shipment of hazardous materials on the

airplane. Because FedEx did not have the capability to quickly consolidate that information, it

relied on faxing copies of the individual Part Bs for the approximately 85 hazardous materials

packages on board, which proved to be burdensome, time consuming and, in this case,

ineffective. Also, because of the poor quality and legibility of many of the handwritten Part Bs,

much of the information was unusable.

In contrast, railroads operating freight trains can generate a computerized list of

all of the freight cars in the train that identifies which freight cars are transporting hazardous

materials and provides the shipping name, hazard class, identification number, and type of

packaging, quantity, and emergency response guidance for each hazardous material transported.

Such a printed, comprehensive list can be generated quickly and thus the information can be

provided in a timely fashion to the appropriate emergency responders and in a more useful format

than numerous faxed copies of partially legible Part B forms.

In both this accident and the crash of the FedEx MD-11 at Newark, the on-board

Part B hazardous materials shipping papers were not available to emergency responders,85 and

FedEx was unable to provide complete information to emergency responders in a timely manner.

Further, in two subsequent accidents near Clarksville, Tennessee, and Bismarck, North Dakota,

the effectiveness of FedEx’s hazardous materials recordkeeping system was again called into

question. In the Clarksville accident, the shipping papers on board the airplane and on file at

FedEx’s Memphis Operations Center were found to be inaccurate. And in the Bismarck

accident, FedEx was unable to confirm whether there were hazardous materials on board the

airplane until 2 hours and 49 minutes after receiving the request for this information.

Safety Board investigators surveyed the capability of other carriers to provide this

information in similar circumstances and found that only one carrier had an on-line capability to

provide detailed information about the hazardous materials on board its airplane. The remaining

 85 The DOT hazardous materials regulations [49 CFR Part 173] require that the proper shipping

name, hazard class, identification number, packaging group, and total quantity of the material appear on the shipping

papers for any shipment of hazardous materials. Further, the regulations stipulate [49 CFR Part 175] that an operator

must provide this information in writing to the pilot-in-command and that a copy of the shipping papers must

accompany the shipment on board the airplane.
72

carriers, like FedEx, rely on paper copies of the hazardous material shipping documentation

retained at the departing station if the on-board documentation is destroyed. The Safety Board is

pleased that FedEx has committed to developing and implementing an electronic system for

tracking and retrieving information about hazardous materials being carried on board FedEx

flights. As discussed in section 1.15.2.1.2, FedEx plans to implement intermediate and long-term

plans that would make computerized information about hazardous materials information

available from all FedEx facilities. However, the Safety Board does not agree with FedEx’s

position that the proper shipping name is not relevant to emergency responders. Although this

information may not always be required, in many cases it may be vital that emergency responders

know exactly what substances are on board an aircraft so that appropriate measures can be taken

to address potential risks.

Compared to the other modes of transportation, it is less likely that shipping

papers on board an accident aircraft will survive or be accessible because of the greater

likelihood of fire and destruction of the airplane. Because of the danger of fire, a flightcrew is

also less likely to have time to retrieve the shipping papers after a crash. The Safety Board

concludes that the DOT hazardous materials regulations do not adequately address the need for

hazardous materials information on file at a carrier to be quickly retrievable in a format useful to

emergency responders. Therefore, the Safety Board believes that the FAA and the RSPA should

require, within 2 years, that air carriers transporting hazardous materials have the means, 24

hours per day, to quickly retrieve and provide consolidated, specific information about the

identity (including proper shipping name), hazard class, quantity, number of packages, and

location of all hazardous materials on an airplane in a timely manner to emergency responders.

Another obstacle in this case to emergency responders receiving hazardous

materials information was FedEx’s inappropriate statement to the ANG command post (at about

1300) that copies of the hazardous materials shipping documentation could not be provided to

them because the Safety Board had taken over the investigation. This created the false

impression that such information could not be released without the Safety Board’s approval.

FedEx later stated that this was consistent with company policy that once the Safety Board has

taken control of an aircraft accident investigation, all information pertaining to that investigation

should be forwarded to the Safety Board. Although the Safety Board appreciates FedEx’s efforts

to recognize the Board’s primacy in aircraft accident investigations, the Safety Board has not

promoted, nor does it support, a policy that would interfere with a carrier’s ability to assist

emergency responders in transportation emergencies, especially when hazardous materials are

involved. The Safety Board concludes that FedEx’s policy of providing information only to the

Safety Board after the Safety Board initiates an investigation is inconsistent with the need to

quickly provide emergency responders with essential information to assess the threat to

themselves and the local community. Therefore, the Safety Board believes that the FAA should

require the POI for FedEx to ensure that all FedEx employees who may communicate with

emergency responders about a transportation accident involving hazardous materials understand

that they should provide those emergency responders with any available information about

hazardous materials that may be involved.

2.6 Emergency Response
73

Postaccident evaluations by airport personnel and representatives of the

participating agencies indicated that many believed that communication and coordination among

the agencies were lacking during the emergency response. Although all participating agencies

recognized the ANG fire chief as the incident commander,86 representatives from these agencies

had differing opinions about who was to be present at the EOC, who was in charge at the EOC,

the role of other agencies (including the Safety Board), and which emergency plan had been

implemented in this accident. Although each of the participating agencies has conducted drills

and exercises under their respective emergency plans for transportation and nontransportation

hazardous materials incidents, joint exercises had not been conducted at Stewart for a simulated

hazardous materials incident. The failure of the incident commander to receive the hazardous

materials information that was being provided to other emergency responders indicates that

communication and coordination among the participating agencies were not effective. Further,

inadequate emergency preplanning and coordination among the responding emergency response

agencies resulted in confusion about the responsibilities of the participating agencies and

contributed to the failure of information about the hazardous materials on the airplane to reach

the incident commander.

The Safety Board concludes that more effective preparation for emergencies

involving hazardous materials and a system for coordination among the ANG, Stewart

International Airport management, and all local and State emergency response agencies are

needed. The Safety Board recognizes that after this accident Stewart revised its emergency plan,

and that airport operations personnel at Stewart have acknowledged the need to address those

deficiencies in the airport’s emergency plan. However, the Safety Board is concerned that FAA

requirements87 do not specifically address the need to prepare for hazardous materials

emergencies, and that other airports may be similarly unprepared for hazardous materials

emergencies. The Safety Board concludes that airport emergency plans should specifically

address hazardous materials emergencies. Therefore, the Safety Board believes that the FAA

should require all certificated airports to coordinate with appropriate fire departments, and all

State and local agencies that might become involved in responding to an aviation accident

involving hazardous materials, to develop and implement a hazardous materials response plan for

the airport that specifies the responsibility of each participating local, regional, and State agency,

and addresses the dissemination of information about the hazardous materials involved. Such

plans should take into consideration the types of hazardous materials incidents that could occur at

the airport based on the potential types and sources of hazardous materials passing through the

airport. The Safety Board also believes that the FAA should require airports to coordinate the

scheduling of joint exercises to test these hazardous materials emergency plans.

 86 The assistant fire chief on duty served as incident commander until 0700, when the fire chief

arrived on scene.

87 14 CFR 139.325 specifies what must be included in airport emergency plans of airports

certificated under Part 139.
74

Firefighters were positioned on scene before the airplane landed and began

firefighting efforts immediately. Although the firefighters initially attempted to conduct an

interior attack on the fire from the foyer area, the location of the cargo containers prevented them

from approaching the seat of the fire. After the cargo door was opened, firefighters observed

orange flames and heavy smoke in the airplane, and the incident commander evacuated them

from the airplane. The initial incident commander’s decision to evacuate the firefighters from

the interior of the airplane was appropriate given the danger posed by the smoke and fire-filled

airplane. However, the initial incident commander acknowledged that use of the SPAAT tool to

penetrate the fuselage was delayed while he attempted to accommodate the flight engineer’s

request that damage to the airplane be minimized.88 Although it is not clear whether an earlier

entry would have improved the effectiveness of the firefighting efforts in this case, the Safety

Board is concerned that more aggressive measures to enter the airplane, such as use of a fuselage

penetrating tool, were not taken sooner. The Safety Board notes that the ANG fire chief testified

that based on “lessons learned” from this accident, if a similar situation were to occur, he would

immediately “get right in there with a hand line and deploy some type of penetrating tool on the

outer skin of the aircraft.”

The Safety Board has long been concerned about the lack of success of airport fire

departments in extinguishing interior fires.89 On June 4, 1996, the FAA published “Airport

Rescue and Firefighting Mission Response Study,” in the Federal Register and invited comments

from interested parties. According to the Federal Register notice, the study was undertaken to

compare the mission and requirements for civil airport fire services to those of the Department of

Defense. On August 1, 1996, the Safety Board commented:

[T]he current mission set forth in 14 CFR Part 139 to “provide an escape path

from a burning airplane” no longer suffices. The Safety Board supports a full

study of the mission statement by the FAA with a view towards providing

adequate [ARFF] resources to rapidly extinguish aircraft interior fires and to

extricate aircraft occupants from such interior fires. All aspects of this issue,

including staffing, extinguishing agents, firefighter training, and response

times, should be evaluated and compared with DOD standards to develop a

broader mission statement that includes interior cabin fire suppression and

extrication of aircraft occupants.

 88 The assistant fire chief who served as the initial incident commander testified that at the flight

engineer’s suggestion a telephone call was placed to the airplane manufacturer (Douglas) in an unsuccessful attempt

to determine whether there were alternate means for entering the airplane.

89 Air Canada DC-9-32 in Covington, Kentucky, June 2, 1983 (23 persons killed by smoke/and or

fire); USAir 737 collision with a Skywest Fairchild Metro 227 in Los Angeles, California, on February 1, 1991 (22

persons killed by smoke/and or fire); Northwest Airlines DC-9 collision with a Northwest 727 in Detroit, Michigan,

on December 3, 1990 (eight persons killed by smoke and/or fire); Air Transport International DC-8-62 in Jamaica,

New York, on March 12, 1991 (freight only); Ryan International Airlines B-727 in Hartford, Connecticut, on May 3,

1991 (freight only); and TWA Lockheed L1011 in Jamaica, New York, on July 30, 1992.
75

Accident history suggests that the environment inside a burning airplane’s interior

may be beyond the current technological capabilities of fire departments to extinguish within

adequate time frames to successfully evacuate occupants or protect cargo. The Safety Board is

aware that the FAA has researched fire extinguishing systems for airplane interiors, including

testing of a water spray system that would discharge water into a particular area of the airplane

when triggered by sensors in that area. Because the system would discharge water only to a

focused area of potential fire, it would minimize the total amount of water that would need to be

carried on board, thereby reducing the weight penalty of such a system. FAA tests showed that

when this system was used to fight a fire, it delayed the onset of flashover, reduced cabin air

temperatures, improved visibility, and increased potential survival time.

The Safety Board is concerned about the number of losses that have occurred and

concludes that currently, inadequate means exist for extinguishing on-board aircraft fires.

Therefore, the Safety Board believes that the FAA should reexamine the feasibility of on-board

airplane cabin interior fire extinguishing systems for airplanes operating under 14 CFR Part 121

and, if found feasible, require the use of such systems.

The Safety Board realizes that requiring on-board extinguishing systems may not

entirely resolve these safety concerns because they may become disabled by crash impacts.

Further, the Safety Board realizes that the full implementation of such technology will require a

number of years. Therefore, the Safety Board concludes that in addition to the safety benefits

provided by on-board extinguishing systems, ARFF capabilities must also be improved so that

firefighters are able to extinguish aircraft interior fires in a more timely and effective manner.

Therefore, the Safety Board believes that the FAA should review the aircraft cabin interior

firefighting policies, tactics, and procedures currently in use, and take action to develop and

implement improvements in firefighter training and equipment to enable firefighters to

extinguish aircraft interior fires more rapidly.
76

3. CONCLUSIONS

3.1 Findings

1. The flightcrew was properly certificated and qualified in accordance with the

applicable regulations and company requirements. Evidence from crew duty

time, flight time, rest time, and off-duty activity patterns did not indicate that

behavioral or psychological factors related to fatigue affected the flightcrew

on the day of the accident.

2. The smoke detection system installed on the airplane functioned as intended

and provided the crewmembers with sufficient advance warning of the inflight fire to enable them to land the airplane safely.

3. The Boston Center air route traffic control center and New York terminal

radar approach control controllers responded appropriately once they were

aware of the emergency and provided appropriate and needed information to

assist the crew in the emergency descent and landing.

4. The airplane was properly certificated, equipped, and maintained in

accordance with applicable regulations. No evidence of systems, mechanical,

or structural failures was found.

5. The flight engineer’s failure to pull the cabin air shutoff T-handle, as required

by the “Cabin Cargo Smoke Light Illuminated” checklist, allowed the normal

circulation of air to continue to enter the main cargo area, thereby providing

the fire with a continuing source of oxygen and contributing to its rapid

growth. However, the Safety Board could not determine the degree to which

it might have contributed to the severity of the fire.

6. The evacuation was delayed because the flightcrew failed to ensure that the

airplane was properly depressurized.

7. The captain did not adequately manage his crew resources when he failed to

call for checklists or to monitor and facilitate the accomplishment of required

checklist items.

8. Crewmembers who do not use protective breathing equipment during a smoke

or fire emergency may place themselves at unnecessary risk in attempting to

address or escape from the situation.

9. Crewmembers may not be adequately aware that attempting to open a

passenger exit door when the airplane is still pressurized may result in the

door not opening.
77

10. The DNA synthesizer was not completely purged of volatile chemicals

(including acetonitrile and tetrahydrofuran) before it was transported on board

flight 1406.

11. The presence of the aerosol cans, the containers of acidic liquid, as well as

several packages of marijuana on board the accident flight illustrates that

common carriers can be unaware of the true content of many of the packages

they carry.

12. The transportation of undeclared hazardous materials on airplanes remains a

significant problem and more aggressive measures to address it are needed.

13. The Department of Transportation hazardous materials regulations do not

adequately address the need for hazardous materials information on file at a

carrier to be quickly retrievable in a format useful to emergency responders.

14. FedEx’s policy of providing information only to the Safety Board after the

Safety Board initiates an investigation is inconsistent with the need to quickly

provide emergency responders with essential information to assess the threat

to themselves and the local community.

15. More effective preparation for emergencies involving hazardous materials and

a system for coordination among the Air National Guard, Stewart International

Airport management, and all local and State emergency response agencies are

needed.

16. Airport emergency plans should specifically address hazardous materials

emergencies.

17. Currently, inadequate means exist for extinguishing on-board aircraft fires.

18. In addition to the safety benefits provided by on-board extinguishing systems,

aircraft rescue and firefighting capabilities must also be improved so that

firefighters are able to extinguish aircraft interior fires in a more timely and

effective manner.

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of

this accident was an in-flight cargo fire of undetermined origin.
78

4. RECOMMENDATIONS

As a result of the investigation of this accident, the National Transportation Safety

Board makes the following recommendations:

To the Department of Transportation:

Require, within 2 years, that a person offering any shipment for air

transportation provide written responses, on shipping papers, to inquiries

about hazardous characteristics of the shipment, and develop other

procedures and technologies to improve the detection of undeclared

hazardous materials offered for transportation. (A-98-71)

To the Federal Aviation Administration:

Require the principal operations inspector for Federal Express (FedEx) to

review the crew’s actions on the accident flight and evaluate those actions

in the context of FedEx emergency procedures and training (including

procedures and training in crew resource management) to determine

whether any changes are required in FedEx procedures and training.

(A-98-72)

Require Federal Express to modify its evacuation checklist and training to

emphasize the availability of protective breathing equipment during

evacuations in an environment containing smoke, fire, or toxic fumes.

(A-98-73)

Require all Part 121 operators of airplanes that rely on air pressure to open

exit doors to make crewmembers aware of the circumstances of this

accident and remind them of the need to ensure that the airplane is

depressurized before attempting to open the passenger exit doors in an

emergency. (A-98-74)

Require, within 2 years, that air carriers transporting hazardous materials

have the means, 24 hours per day, to quickly retrieve and provide

consolidated, specific information about the identity (including proper

shipping name), hazard class, quantity, number of packages, and location

of all hazardous materials on an airplane in a timely manner to emergency

responders. (A-98-75)

Require the principal operations inspector for Federal Express (FedEx) to

ensure that all FedEx employees who may communicate with emergency

responders about a transportation accident involving hazardous materials

understand that they should provide those emergency responders with any
79

available information about hazardous materials that may be involved. (A98-76)

Require all certificated airports to coordinate with appropriate fire

departments, and all State and local agencies that might become involved

in responding to an aviation accident involving hazardous materials, to

develop and implement a hazardous materials response plan for the airport

that specifies the responsibility of each participating local, regional, and

State agency, and addresses the dissemination of information about the

hazardous materials involved. Such plans should take into consideration

the types of hazardous materials incidents that could occur at the airport

based on the potential types and sources of hazardous materials passing

through the airport. Airports should also be required to coordinate the

scheduling of joint exercises to test these hazardous materials emergency

plans. (A-98-77)

Reexamine the feasibility of on-board airplane cabin interior fire

extinguishing systems for airplanes operating under 14 Code of Federal

Regulations Part 121 and, if found feasible, require the use of such

systems. (A-98-78)

Review the aircraft cabin interior firefighting policies, tactics, and

procedures currently in use, and take action to develop and implement

improvements in firefighter training and equipment to enable firefighters

to extinguish aircraft interior fires more rapidly. (A-98-79)

To the Research and Special Programs Administration:

Require, within 2 years, that air carriers transporting hazardous materials

have the means, 24 hours per day, to quickly retrieve and provide

consolidated specific information about the identity (including proper

shipping name), hazard class, quantity, number of packages, and location

of all hazardous materials on an airplane in a timely manner to emergency

responders. (A-98-80)

Additionally, the Safety Board reiterates the following recommendations to the FAA:

Issue guidance to air carrier pilots about the need to don oxygen mask and

smoke goggles at the first indication of a possible in-flight smoke or fire

emergency. (A-97-58)

Establish a performance standard for the rapid donning of smoke goggles;

then ensure that all air carriers meet this standard through improved smoke

goggle equipment, improved training, or both. (A-97-59)
80

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS

Vice Chairman

JOHN HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

July 22, 1998
81

5. APPENDIXES

APPENDIX A—INVESTIGATION AND HEARING

1. Investigation

The National Transportation Safety Board was initially notified of this accident

about 0700 on September 5, 1996, by the FAA communications center. Two investigators from

the Safety Board’s Northeast Regional Office were immediately dispatched to the scene and

arrived about 1200. A partial go-team, comprising the investigator-in-charge and five specialists,

arrived about 1500. Washington-based specialists provided assistance in the areas of

airworthiness, fire, hazardous materials, operations, and air traffic control/weather.

Parties to the investigation were the Federal Aviation Administration; Federal

Express; Boeing, Douglas Products Division; PerSeptive Biosystems, Inc.; and Chiron

Corporation.

2. Public Hearing

No public hearing was held in connection with this accident investigation.

Depositions were conducted from May 18 through 20, 1998, in Memphis, Tennessee, and on

May 29, in Washington, D.C. A total of 27 witnesses were questioned during those deposition

proceedings.
-1

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-3

-4

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Notes :

82

APPENDIX B-CVR TRANSCRIPT

Radio transmission from accident aircraft 

Cockpit Area Microphone sound or source

Voice

Voice

Voice

Voice

Voice

Miami

Miami

Miami

identified as

identified as

identified as

identified as

unidentified

Captain

First Officer

Second Officer

male ground personnel

Local Controller (tower)

Ground Controller

Clearance Controller

Houston HF radio

Unknown source

Unintelligible word

Nonpertinent word

Expletive deleted

Break in continuity

QuestionAle text

Editorial insertion

Pause

All times are

savings time.

involving the

transcribed.

expressed in eastern daylight

only radio transmissions

accident aircraft were
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0536:00CAM [start of transcript]0536:00CAM-1 oh you were back there when we discussed all this, I forgot.0536:04CAM-1 this thing's on a .. this thing is on a check status.0536:07CAM-2 is it?0536:07CAM-1 it's just the fact that they got the paperwork all screwed up.0536:10CAM-2 we'll couple it up?0536:12CAM-1 you just want to go ahead and couple it yourself and just go

ahead and make the landing?

0536:15CAM-2 yeah, do they want an autoland though?0536:17CAM-1 yeah.0536:18CAM-2 they do want an autoland?0536:18CAM-1 yeah.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0536:19CAM-2 * * *.0536:20CAM-1 just follow through on it? .. it's visual, I don't give a #.0536:23CAM-1 what the hell's that?0536:25CAM-2,3 cabin cargo smoke.0536:27CAM-1 you see that .. we got cabin cargo smoke ... cabin cargo

smoke.

0536:31CAM-3 cabin cargo smoke, oxygen masks on.0536:36CAM-3 slash courier communication established.0536:38CAM-1 alright we got it.0536:40CAM-3 okay it's number nine smoke detector.

0536:40BCNTR fedex fourteen zero six turn twen

behind company for boston.

0536:44CAM-3 let the courier know.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0536:46RDO-1 understand twenty left for fourteen z0536:49BCNTR that's correct .. I have company 

north of ya at thirty-three also goin

airbus.

0536:56RDO-1 roger.0536:59BCNTR I didn't figure I'd have to vector this e

0537:03CAM-2 why don't you have those guys come up here.0537:08INT-1 there you go .. everybody checked in.0537:09INT-2 okay why don't you have those -0537:11INT-3 okay second officer up.0537:18INT-2 why don't you have those guys come up here.0537:22INT-1 okay we're getting two of them now.0537:26INT-1 let's get on it .. on the red tabs there and ah -
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0537:29INT-2 why don't you have those guys come up here?0537:31INT-1 let's open the door and see what it looks like.0537:42CAM-3 why don't you guys come up.0537:48INT-1 let's find out what we've got going here.0537:56INT-1 okay it's moving forward whatever it is .. it's up to seven.0538:06INT-3 okay fire and smoke .. oxygen mask and smoke goggles as

required on one hundred percent .. crew and couriercommunication established .. that completes the phaseones.

0538:14INT-1 roger.0538:17INT-3 cockpit door and smoke screen closed.0538:27INT-3 it's closed ... if descent is required proceed to step six ... if

descent not required proceed to step fourteen.

0538:38INT-1 have you run a a-
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0538:40INT-3 pull cabin air.0538:42INT-3 type of smoke or fire on step fourteen .. descent not

required.

0538:48INT-3 cabin cargo smoke.0538:55INT-3 can best be recognized by checking smoke detectors

second officer's panel by observing smoke or fire in the

main deck cargo area .. that completes ah fire and smoke

going to cabin cargo smoke.

0539:07INT-1 what we've got is cabin cargo, correct?0539:11INT-3 that's affirmative.0539:13INT-1 alright ... have you run the test on it yet?0539:18INT-3 doing that now.0539:28INT-1 that's seven and eight.0539:31INT-3 those others may be failing in the blinking mode.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0539:37INT-1 the blinking mode is a normal test is it not?0539:41INT-3 pardon me?0539:43INT-1 they should come on blinking on the test, isn't that correct?0539:45INT-3 no they should come on steady on the test.0539:47INT-1 okay.0539:47INT-3 everything should come on steady.0539:49INT-1 okay.0539:50INT-3 okay ready to run the cabin cargo smoke light -0539:52INT-1 I got ten now.0539:55INT-3 ready to run the cabin cargo smoke light illuminated.0539:57INT-1 go ahead.0540:01INT-3 okay it says pack function selectors two off .. two are off.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0540:07INT-1 we've definitely got smoke guys .. we need to get down right

now let's go.

0540:18RDO-1 okay what's the closest field I wond

them here.

0540:22RDO-1 center fedex fourteen zero six.0540:24BCNTR - saying something about the clos

that in a second but one hundred h

expect straight in runway six.

0540:30RDO-1 let's run it, let's get this thing dep

down.

0540:34RDO-1 center fedex fourteen zero six.0540:38RDO-1 center fedex fourteen zero six.0540:40BCNTR fedex fourteen zero six go ahead .. y0540:43RDO-1 yes sir we do .. we have smoke in 

we're at three three zero .. we'd likwe need to descend at this time.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0540:53BCNTR fedex fourteen zero six roger des

one thousand .. stewart altimeter thyou want to go to albany it's in y

about fifty miles .. stewart is probabbe at ah hundred and eighty degree five miles.

0541:11RDO-1 okay stewart field ah and a right tu

eighty degrees now?

0541:17BCNTR you'd make a left hand turn to a h

and it is uhm let's see now twenheading two four zero.

0541:27RDO-1 left turn two four zero .. say the wea

0541:32CAM-1 (go ahead turn).0541:35INT-3 okay ready to run when you are.0541:38INT-1 okay run the checklist.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0541:41INT-3 okay courier mask and goggles verify on one hundred

percent .. cockpit air outlets open ... they are open ... it saysah land as soon as possible ... and we are descending now

... if unable to extinguish fire and smoke manually raise

cabin altitude to twenty-five thousand .. while you're in adescent to eleven?

0542:03INT-1 roger, go ahead and start raising it.0542:07INT-3 okay continue the descent.0542:21INT-3 and we now have just detectors eight, nine and ten .. we've

lost detector seven .. it's gone out.

0542:28INT-1 roger.0542:30INT-3 okay what's that ah .. stand by.

0542:36BCNTR fedex fourteen zero six I've got alba

to stewart you can do that .. I've go

o'clock and about forty-five milesouthwesterly position and ah forty m

0542:49RDO-1 okay we need to get it on the grou

stewart .. give us vectors.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0542:53BCNTR okay fedex fourteen zero six roger t

zero .. you can remain in a left hand open for ya.

0543:00RDO-1 roger.

0543:02INT-3 and I'm manually raising the cabin altitude .. there is smoke

in the ah cabin area.

0543:03CAM [sound of overspeed warning alert]0543:06INT-1 roger.0543:12INT-2 okay .. okay you have an approach plate for us?0543:25CAM-? *.0543:22INT-3 what's the three letter identifier for stewart.

0543:30RDO-1 give me a plate for -0543:38BCNTR fedex calling boston say again pleas0543:43RDO-1 center .. stewart field .. what's that li
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0543:47BCNTR sierra whiskey foxtrot newburgh new 

0543:49CAM-? newburgh new york.

0543:51RDO-1 okay.0544:04BCNTR fedex fourteen zero six if you could 

the uhm fuel on board and souls ple

0544:12INT-3 thirty-three thousand pounds.

0544:14RDO-1 thirty-three thousand pounds .. five s0544:18BCNTR could you say that one more time pl0544:19RDO-1 thirty-three thousand pounds .. five s

0544:19CAM [sound of overspeed warning alert]

0544:22BCNTR thirty-three thousand five souls .. tha

0544:25INT-3 and ah current altimeter.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0544:27RDO-1 current altimeter setting please?0544:28BCNTR stewart altimeter three zero one five0544:32RDO-1 three zero one five.

0544:34INT-3 three zero one five set in the back.

0544:44BCNTR fourteen zero six descend and main

can proceed direct to kingston V

november .. that's for the VOR stewart.

0544:55RDO-1 okay what's that frequency?0544:57BCNTR stand by one second ..... frequency

six, sir.

0545:15INT-3 and it looks like we just have smoke detector ten lit now.

0545:19RDO-1 okay, sir, we don't have the VOR ap

file here on the airplane.

0545:34BCNTR fedex fourteen zero six roger .. woul

airport?
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0545:36RDO-1 roger, get us down to the airport an

the only thing we have on board is fo

0545:44BCNTR alright ILS to nine is the only thing 

it's a two one zero heading now 

twenty-eight point two miles from yo

you can expect a visual.

0545:55RDO-1 roger two one zero.

0545:57INT-3 okay what is the three letter identifier for -

0545:58BCNTR and fedex fourteen zero six maintain 0546:08RDO-1 it's cleared to four thousand now 

six?

0546:10BCNTR fedex fourteen zero six affirmative m

0546:14INT-3 three letter identifier again for that airport?

0546:19RDO-1 ah stewart?

0546:21INT-3 yeah.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0546:21RDO-1 S-T-W.0546:26BCNTR sierra whiskey foxtrot is stewart.

0546:31INT-3 okay we are depressurized.0546:34INT-1 alright.

0546:41RDO-1 and center, I don't know if I did it b

six is declaring an emergency and standing by.

0546:44BCNTR fourteen zero six, that's already be

equipment will be standing by.

0546:51RDO-1 roger.

0546:52INT-3 okay, it says fire .. check extinguished .. the lights are off ..

it's still smoky out there.

0546:56BCNTR fourteen zero six fly your present he

approach to the stewart airport frcontrol .. contact new york approaseven five.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0547:05RDO-1 three two seven five, roger.

0547:08INT-3 caution .. no crewmember should leave the cockpit to fight

a fire ... we're not gonna do that.

0547:14RDO-1 approach, fedex fourteen zero six.0547:17NYAPP fedex fourteen zero six new yor

altimeter is three zero one eight .

four thousand ... did you figure out w

yet?

0547:24RDO-1 three zero one eight down to four th0547:27RDO-1 keep the speed up man, don't slow 

emergency situation here.

0547:31NYAPP american fourteen zero six spee

speed's not a problem .. I just need you want?

0547:36RDO-1 roger we do not have a two seven 

have is runway nine .. if we can g

there visually if you can line us up.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0547:43NYAPP roger fourteen zero six .. do you wa

runway niner or runway two seven?

0547:47RDO-1 two seven.0547:49NYAPP american fourteen zero six roger .. f

.. correction fly heading one niner ze

0547:54RDO-1 one nine zero.

0548:07INT-3 I need the three letter identifier for that airport so I can call it

up.

0548:11RDO-? S-W-F.0548:13NYAPP american fourteen zero six be adv

of zero nine four five zulu winds visibility .. fog and a broken layer a

stewart altimeter's three zero one ei

0548:26RDO-1 three zero one eight, roger.

0548:27CAM-2 slats extend.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0548:29INT-3 okay, land at nearest suitable airport .. cabin cargo smoke

light illuminated checklist complete.

0548:36RDO-1 okay, they're out, aren't they?

0548:38CAM [sound of overspeed warning alert]

0548:38RDO-1 get rid of it .. but we still need t

ground.

0548:41CAM-2 what's the field elevation?

0548:41NYAPP american fourteen zero six roger 

seven approach course goes off th

radial if you want to tune that in.

0548:50CAM [sound of altitude alert and overspeed warnings]

0548:54RDO-1 roger, two forty-four degree radial.0548:59NYAPP american fourteen zero six desce

thousand.

0549:02RDO-1 three thousand, fourteen zero six.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0549:08RDO-1 boy this sucks doesn't it.

0549:09CAM [interrupt in CVR audio from tape splice]0549:09INT-3 is there a three letter identifier -0549:10CAM-2 is there a VOR or something on the field?

0549:13RDO-1 yeah, two forty-four here .. interce

kingston VOR .. going into the runw

0549:17NYAPP fedex fourteen zero six that's affirma

turn ten degrees right to intercept th

radial.

0549:23RDO-1 intercept the two four four radial .. te

0549:25CAM [sound of altitude alert warning]0549:28INT-3 I can't give you any take-off or landing data.0549:32INT-1 you can't?
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0549:33INT-3 I can't find the airport in my directory.

0549:37RDO-1 just get a weight and use your table 0549:43RDO-1 get rid of the boards.0549:48RDO-1 three hundred and thirty thousand p0549:53RDO-1 V ref is one thirty-one for flaps fifty .

five.

0550:03NYAPP fedex fourteen zero six turn right h

intercept the kingston two four fou

maintain two thousand five hundred

0550:11RDO-1 two thousand five hundred and 

heading.

0550:13CAM [sound of altitude alert warning]0550:20INT-3 in range .. airspeed bugs.

0550:22RDO-1 okay we're working on it ... two seve
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0550:30RDO-1 one eighty-seven's the next one .. 

one -

0550:41NYAPP fedex fourteen zero six when you 

department needs to know if there's on the plane.

0550:48INT-1 (Larry)?0550:49INT-3 yes.

0550:50RDO-1 yes there is, sir.

0550:53INT-1 okay, it's coming alive.

0550:59RDO-1 go to twenty-five hundred feet.

0551:04INT-3 and I've got additional smoke detectors on now.

0551:06NYAPP fedex fourteen zero six the lights a

can expect to stay on this frequenanother frequency change .. you'll 

this ah on this frequency .. the airand ten miles .. report in sight.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0551:16RDO-1 fourteen zero six wilco.0551:21RDO-1 okay, what's your double bug?0551:23NYAPP fedex fourteen zero six descend and 

three hundred.

0551:26RDO-1 twenty-three hundred, roger.

0551:27CAM-2 flaps fifteen.

0551:28RDO-1 twenty-three hundred.0551:30RDO-1 what's the double bug in there on 

three hundred thirty thousand?

0551:32CAM [sound of altitude alert warning]0551:36INT-3 ah three thirty .. stand by.

0551:41NYAPP fedex fourteen zero six .. this is not 

this is an angled approach to the run
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0551:42INT-3 two fifty-eight is optimum.

0549:32RDO-1 roger.

0551:50INT-1 what'd you get for a double bug?0551:52CAM-2 hey bruce, I don't have the plate .. you're gonna have to talk

me in to this.

0551:56RDO-1 I am talkin' you into it .. we don't 

either .. we're doing a visual.

0551:59INT-3 okay for thirty-five ah .... thirty-five extend that's all I've got.0552:06CAM-2 flaps twenty-two.

0552:08NYAPP fedex fourteen zero six desce

thousand.

0552:10RDO-1 two thousand fedex fourteen zero si

0552:12INT-3 V ref thirty-five extend is one thirty-six.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0552:13CAM [sound of altitude warning alert]

0552:15NYAPP fedex fourteen zero six field is twelv

a half miles.

0552:17RDO-1 roger.

0552:21INT-3 one thirty-six for V ref flap .. thirty-five extend.0552:26CAM-2 gear down .... before landing checklist.

0552:32RDO-1 I think I'm starting to see the runw

o'clock.

0552:38RDO-1 it comes in at an angle.0552:42NYAPP fedex fourteen zero six field is now 

miles .. do you need lower?

0552:48RDO-1 yeah affirmative .. have they got th

we don't see the runway.

0552:52NYAPP fedex fourteen zero six that's affirm

the way up.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0552:57INT-3 landing gear?0552:59INT-1 down and three green.

0553:00NYAPP fedex fourteen zero six descend and 

two hundred.

0553:01INT-3 twelve o'clock.

0553:02RDO-1 that's not it.

0553:06INT-3 thrust computer.

0553:08RDO-1 fourteen zero six ... fourteen zero s

here, sir ... we've ah we're visual cosee the runway.

0553:15NYAPP fedex fourteen zero six say again.0553:17RDO-1 yes sir, we do not see the runway a

have it in sight.

0553:21INT-3 over here at the left.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT

0553:23NYAPP fedex fourteen zero six you said you 0553:26RDO-1 yes sir, I do believe we have the fiel0553:28NYAPP fedex fourteen zero six you're clea

seven.

0553:31CAM-2 flaps thirty-five .. go right to fifty.

0553:33RDO-1 that's not the right runway I don't thin

0553:37INT-3 thrust computer.

0553:38RDO-1 okay that's the runway right there.

0553:42CAM [GPWS one thousand foot call]0553:42INT-3 thrust computer .. antiskid .. spoiler.

0553:45RDO-1 test and armed.0553:49RDO-1 want some flaps fifty.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0553:55INT-1 want the autothrottles?0554:01INT-3 flaps and slats?

0554:02RDO-1 okay I've got fifty land.

0554:05INT-3 before landing checklist complete.0554:06CAM [GPWS five hundred foot call]0554:08CAM [two GPWS sink rate warnings]

0554:11RDO-1 pull it on up.0554:16RDO-1 everything's done.

0554:20CAM [GPWS one hundred foot call]0554:21CAM [GPWS sink rate warning]0554:23CAM [GPWS fifty, forty, thirty, twenty and ten foot calls]0554:28CAM [sound similar to that of touchdown]
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0554:29CAM [sound similar to that of auto-spoiler deployment]0554:37CAM [sound similar to that of reverse thrust]0554:44CAM [sound similar to that of engine spooling down]0554:46INT-1 okay, I've got it ... nice job.

0554:56NYAPP fedex fourteen zero six when able y

frequency twenty-one eight.

0555:01RDO-2 twenty-one what?0555:02NYAPP one two one point eight.

0555:03INT-3 okay on the lights we've got a .. (forward fire .. I'm deploying

aft).

0555:07RDO-1 we need to get the hell out of here.

0555:10CAM [sound of engine fire warning alarm starts]0555:12INT-3 agent arm cylinder one switch.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0555:19INT-3 emergency ground egress.0555:23CAM [sound of engine fire warning alarm stops]

0555:24RDO-1 blow blow the door.

0555:27CAM [end of tape]


113

APPENDIX D—CARGO CONTAINER EXAMINATION CHART

Each description includes the position that the container had occupied on flight

1406, the type of cargo container construction,90 and the fire damage.

Container Position Fuselage Station

Number

Description of Container Damage

1R 543-631 The AYY cargo container’s aluminum roof, outboard

wall, and forward Lexan doors were consumed by fire.

The upper inboard aluminum wall of the cargo

container exhibited heat damage, but the 8-inch lower

side wall and cargo container were intact and

undamaged by fire. The outboard forward and aft

cornerposts measured 1 foot 9 inches and 1 foot 6

inches, respectively. Both inboard cornerposts were

intact.

2L 631.5-757 The AMJ cargo container’s aluminum roof and

outboard side were intact. The top quarter of the aft

and forward Lexan walls were melted and distorted

from heat. The upper portion of the inboard and

outboard cargo container wall showed no fire or heat

damage, but its contents were sooted.

2R 631-757 The AMJ cargo container’s aluminum roof and upper

Lexan walls were consumed by fire, and the lower

walls were heat damaged. The upper two-thirds of the

nylon fabric roll-up door was consumed by the fire.

The lower aluminum side walls and cargo containers

were intact. The outboard forward and aft cornerposts

measured 2 feet and 4 feet 1.5 inches, respectively.

Both inboard cornerposts were intact.

 90 The International Air Transport Association identifies types of cargo containers using a threeletter designator. The first letter describes the general type of unit. (An “A” designation indicates that the

compartment is a certified aircraft container and “P” indicates a certified aircraft pallet.) The second letter indicates

base dimensions. (“G” and “M” are 96 by 125 inches, and “Y” indicates miscellaneous sizes with the largest

dimension being no bigger that 96 inches.) The third position relates to the container’s contour and compatibility

and indicates in what part of the aircraft the container will fit.
114

3L 757-883 Approximately two-thirds of the aft portion of the AMJ

cargo container’s aluminum roof was consumed by

fire. The remainder of the forward section of roof

exhibited heat, soot, and smoke damage. The outboard

Lexan wall was intact. The upper portion of the aft

Lexan wall was mostly consumed by the fire, and the

lower portion was heat damaged. The forward Lexan

wall exhibited heat damage and the lower wall and 8-

inch aluminum side wall were intact. The upper

portion of the nylon fabric roll-up door was consumed,

but the lower portion was intact. The outboard forward

and aft cornerposts measured 3 feet 8 inches and 2 feet

3 inches, respectively. The inboard cornerposts were

both intact.

4L 883-1009 The AMJ cargo container’s aluminum roof and forward

Lexan upper wall were completely consumed by fire;

the lower Lexan wall and 8-inch aluminum side walls

were intact. The aft and forward Lexan wall and nylon

roll-up door were consumed by the fire. The outboard

forward and aft cornerposts measured 7 feet 7.5 inches

and 2 feet 9 inches, respectively. The inboard forward

and aft cornerposts measured 6 feet 2 inches and 5 feet

6 inches, respectively.

4R 883-1009 The AMJ cargo container’s aluminum roof and Lexan

aft and outboard walls were consumed by fire. The

inboard lower half of the forward wall exhibited heat

damage, and the upper wall was consumed by the fire.

The aluminum floor and 8-inch aluminum side walls

were intact. The outboard forward and aft cornerposts

measured 3 feet 11.5 and 1 foot 6 inches, respectively.

The inboard forward cornerpost was intact, and the aft

cornerpost measured 5 feet 2 inches.

5L 1009-1135 The AMJ cargo container’s aluminum roof and the aft,

forward, and outboard Lexan walls were consumed by

fire, but the aluminum floor and 8-inch aluminum side

walls were intact. The outboard forward and aft

cornerposts measured 3 feet 2.5 inches and 3 feet 5

inches, respectively. The inboard forward and aft

cornerposts measured 5 feet 9.5 inches and 5 feet 6

inches, respectively.

5R 1009-1135 This position was occupied by a PAG pallet that was

loaded with footwear in cardboard boxes piled in

stacks that were 3 feet in height. The shoes and boxes

were burned along the aft side of the pallet, but the

aluminum floor was intact.
115

6L 1135-1261 The AMJ cargo container’s aluminum roof, the nylon

fabric roll-up door, and all Lexan walls were consumed

by fire, but the aluminum floor and 8-inch aluminum

side walls were intact. Two-thirds of the upper door

assembly spring cover was consumed by fire along the

aft portion. The outboard forward and aft cornerposts

measured 2 feet 7 inches and 3 feet, respectively. The

inboard forward and aft cornerposts measured 2 feet

9.5 inches and 2 feet 10.5 inches, respectively.

6R 1135-1261 The AMJ cargo container’s aluminum roof and the

Lexan walls were consumed by fire except for a small

portion of the center aft lower wall. The nylon fabric

roll-up door spring assembly, including the spring

cover, was melted to the floor near the inboard forward

cornerpost. Melted aluminum was puddled on the floor

along the inboard side of the door. There were three

areas where the 8-inch aluminum side wall had melted

along the edge of the cargo container: 5 feet along the

outboard side, 12 inches along the inboard forward

edge, and 17 inches along the center of the forward

edge. The outboard forward cornerpost was completely

consumed by the fire, and the outboard aft cornerpost

measured 3 feet 9 inches. The inboard forward

cornerpost measured 1 foot 2 inches, and the inboard

aft cornerpost measured 3 feet 6 inches.

7L 1261-1387 The AMJ cargo container’s aluminum roof and Lexan

outboard, forward, and aft walls were consumed by

fire. The outboard forward cornerpost measured 3 feet

1 inch, and the outboard aft cornerpost measured 1 foot

4.5 inches. The inboard forward wall cornerpost

measured 4 feet, 3 inches; the inboard aft cornerpost

measured 6 feet 1.5 inches. The aluminum floor and 8-

inch aluminum side wall were intact.
116

7R 1261-1387 The AMJ cargo container’s aluminum roof and the

lower outboard forward and aft walls were consumed

by fire except for a small area at the lower center

position of the forward wall. There was also a

horizontal burn through the contents positioned along

the forward outboard edge of the cargo container next

to the aft contents in 6R. The nylon fabric roll-up door

was consumed by fire. However, the door assembly

was intact. The outboard forward and aft cornerposts

measured 2 feet 1 inch and 5 feet 7.5 inches,

respectively. The inboard forward cornerpost

measured 4 feet 6 inches, and the aft cornerpost

measured 7 feet 1.5 inches.

8L 1387-1513 The AMJ cargo container’s aluminum roof and the

Lexan outboard and forward walls were consumed by

fire. The lower third of the center area of the aft Lexan

wall was distorted from heat, and the upper two-thirds

was consumed by fire. The inboard forward and aft

cornerposts measured 5 feet 10 inches and 5 feet 2

inches, respectively. The outboard forward and aft

cornerposts measured 1 foot 4.5 inches and 3 feet 6.5

inches, respectively.

8R 1387-1513 The AMJ cargo container’s aluminum roof was

consumed by fire. The bottom half of the forward

Lexan wall was distorted from heat and the upper twothirds was consumed by fire. The upper three-quarters

of the outboard Lexan wall was consumed by fire, and

the bottom quarter was distorted by heat. The nylon

fabric roll-up door (inboard wall) was also consumed

by fire. The inboard forward cornerpost measured 5

feet 10 inches, and the inboard aft cornerpost measured

6 feet 2 inches. The outboard forward cornerpost

measured 5 feet 5.5 inches, and the outboard aft

cornerpost measured 1 foot 6 inches.
117

9L 1513-1639 This AMJ cargo container’s aluminum roof and

outboard Lexan wall were consumed by fire. The

lower mid-section of the forward Lexan wall was

intact, but the upper wall was consumed by fire. The

Lexan aft wall was consumed. The nylon fabric roll-up

door was partially consumed by fire. However, some

fabric was visible at the bottom of the door. The

vertical roof support remained attached to the

cornerposts. The 8-inch aluminum lip that extends up

from the cargo container floor was melted down to a

height of approximately 3 inches along an 18 inch

length in the center of the outboard edge. The

underside of the container was undamaged. The

outboard forward cornerpost measured 3 feet. All other

cornerposts were intact.

9R 1513-1639 The AMJ cargo container’s aluminum roof was

completely consumed by fire. The lower section of the

forward Lexan wall was intact, but the upper wall was

consumed by fire, as was the aft wall and the outboard

wall. The nylon fabric roll-up door was consumed by

fire, but the aluminum door assembly frame was intact.

The vertical roof support remained attached to the

cornerposts. No damage was done to the floor side wall

of the container. The underside of the container was

undamaged. The outboard forward and aft cornerposts

measured 1 foot 3.5 inches and 1 foot 5 inches,

respectively. The inboard cornerposts were intact.

1639-1728 Note: The space, normally occupied by two AYY

cargo containers, between cargo containers 9 and 14,

was vacant for the accident flight.

14L 1728-1817 The AYY (Demi) cargo container’s aluminum roof and

one-third of the outboard wall were consumed by fire.

Two-thirds of the lower outboard wall was intact. The

forward aluminum wall was heat damaged and

distorted from excessive heat along the upper third of

the wall. The upper third of the aft Lexan door was

consumed by fire. The inboard and outboard cargo

container walls were distorted from heat, and the lower

two-thirds of the wall was intact.

14R 1728 -1817 The AYY (Demi) cargo container’s aluminum roof, the

outboard, inboard, forward, and aft walls were

completely consumed by fire. The outboard forward

and aft cornerposts measured 3 feet 7 inches and 2 feet

10.5 inches, respectively. The inboard cornerposts

were intact.
118

15L 1817-1906 The AYY (Demi) cargo container’s aluminum roof and

one-third of the outboard wall was consumed by fire.

The remaining two-thirds of the lower outboard wall

was intact. The forward aluminum wall was heat

damaged and distorted from excessive heat along the

upper third of the wall. The upper third of the aft Lexan

door was also consumed by fire. The inboard and

outboard cargo container walls were distorted from

heat, and the lower two-thirds of the wall were intact.

15R 1817-1906 The AYY (Demi) cargo container’s aluminum roof and

the forward and aft Lexan doors were completely

consumed by fire. The outboard aluminum wall was

distorted from heat, and the aft section of the aluminum

inboard wall was consumed by fire. The upper twothirds of the remaining inboard wall was distorted from

heat but intact.

16L 1906-1995 The AYY (Demi) cargo container’s aluminum roof and

one-third of the outboard wall were consumed by fire.

Two-thirds of the lower outboard wall was intact. The

forward aluminum wall was heat damaged and

distorted from excessive heat along the upper third of

the wall. The inboard and outboard cargo container

walls were distorted from heat.

16R 1906-1995 The AYY (Demi) cargo container’s aluminum roof and

Lexan outboard wall were completely consumed by

fire. The forward Lexan door was consumed by fire,

and the aft lower portion of the aluminum door was

intact. The upper half of the inboard Lexan wall was

consumed by fire, and the lower half remained intact.
119

APPENDIX E—CONTENTS OF NINE CARDBOARD BOXES LABELED “9R”

Box 66—a package of medical vials (containing unidentified liquid) in what

appeared to be a cold pack. The package was heat damaged, but the vials were intact. The box

also contained paychecks and four additional airbills.

Box 67—computer cables in reasonably good condition. A laptop computer was

located. The internal components were not fire damaged, and the outer case was slightly melted.

There was also one vial identical to those located in 9L.

Box 68—a small-size crimp top empty amber vial, cold pack (silicone), and

plastic capped-centrifuge vials (melted).

Box 69—seven intact plastic bottles containing liquid. This box also contained

miscellaneous paper products (manuals, photos, etc.), two more plastic bottles containing fluid,

disks, software, and plastics. Some of the items exhibited minor fire damage, others did not.

Box 70—two large boxes wrapped in bubble-type wrap. The wrap material and

the box were unburned. There was also a severely burned electronic unit that appeared to be a

monitor.

Box 71—two 1-quart plastic bottles as well as an electronic component that

appeared to be a portable printer and exhibited minor heat damage.

Box 72—miscellaneous debris, paper, computer materials, silicone-filled bags,

metal strips, and software. Some of the items exhibited minor fire damage, others did not.

Box 73—what appeared to be a laptop computer that was extensively fire

damaged. The cells of the battery pack were exposed. This box also contained other

miscellaneous, unidentified electronic equipment and numerous rings, which appeared to be

costume jewelry.

Box 74—a considerable amount of burned, printed material. One printed

computer board was found with little fire damage. One small plastic bottle was found that

contained a solid material, resembling pills. A badly burned computer board and a metal

cosmetic box with some contents were also found.
120

APPENDIX F - DETAILED EXAMINATION OF FIRE DAMAGE TO DNA

SYNTHESIZER

The following describes the results of an examination of the accident synthesizer

conducted by the Fire Group at PerSeptive Biosystems’ manufacturing facility in Framingham,

Massachusetts from February 18 through 20, 1997.

A 3-inch piece of white, unburned crumpled paper and a 3-inch piece of unburned

cardboard were observed on the top rear of the synthesizer between the RS 422 port and the

printer port. (See figure A.) The floppy drive port was severely damaged and empty. Melted

aluminum was observed on the outside surface of the right side of the synthesizer. The left side

of the synthesizer was blackened except for two 4- by 4-inch areas at the bottom corners

consistent with the location of the Styrofoam packaging blocks and four areas consistent with the

location of the packing tape used for packaging the synthesizer. The bottom two unburned areas

had yellow packaging tape attached. Glass normally installed in the front door window was

missing, and the column door window was intact. The outside face of the keypad assembly was

severely damaged and unrecognizable. The RS 422 and option ports were not visible. The

printer port and the Event Out ports were fire and heat damaged.

The back panel of the damaged synthesizer was removed. (The exterior and

interior of the back panel exhibited fire, soot, and corrosion damage.) Debris, ashes, and other

unidentified materials adhered to the interior side of the panel. The on/off switch for the power

inlet module and the receptacle plug-in were destroyed by fire.

A paper diagram of the bottle locations and system schematic taped inside the

front door of the synthesizer exhibited slight soot damage. The paint on the inside of the door

below the window frame was undamaged but exhibited some sooting. The inside of the door

exhibited heavier heat damage above the lower window frame than was observed below the

window frame. The stainless steel bottle bracket was heavily sooted behind bottles 4, 5, and 6.

The plastic dip tubes were cut off during the on-site accident phase. The upper third of the right

side of the stainless steel bottle bracket exhibited some sooting and discoloration. The left side

was sooted from the base to the top of the synthesizer. The polyethylene drip tray was melted

along the right rear side and was heavily sooted along the left and forward walls. An 81⁄2- by 91⁄2-

inch rectangular soot-free area was observed approximately 1 inch from the left side of the drip

tray. Pieces of broken glass and a large amount of debris were found in the bottom of the drip

tray. The floor of the synthesizer was heavily sooted and also contained pieces of debris. There

was some blue discoloration along the right side of the stainless steel bracket where it intersected

the mounting for bottles 1, 2, and 3.

Removal of the synthesizer controller top revealed that the controller top’s interior

exhibited extensive fire damage, and all of the electrical wire insulation was destroyed. The wire

conductors were intact and brittle. The inside of the top was heavily sooted. Most of the paint

was charred and missing under the controller PC board and around the floppy drive at the rear of

the controller top. The resin binder for the controller PC board was destroyed by fire. The
121

Waste

(ORG 1)

BL A

(6

(ORG2) \._._._._.—.-.A

Fluidics diagram.

Drive

Gas

Electrical hookup and gas lines. 

Figure A.—Expedite Model 8909 DNA synthesizer instrument diagram.
122

component side of the controller PC board was discolored and charred. The surface normally

covered by the battery had a thin layer of shiny black material that flaked off readily. The printed

circuits in positions U6 and U7 with the sockets were found separated from the controller PC

board. Various other smaller electrical components were found separated from the controller PC

board. The controller PC board was removed and its underside was observed to be severely

burned.

The three-cell battery pack was detached from the PC controller board. The

ribbon cable and header normally located next to the battery on the controller PC board was

fused to the battery pack with the other end of the ribbon cable still connected. One of the

battery lead sockets had separated from the circuit board and was attached to the battery lead.

When investigators later examined the batteries in more detail, no indication of internal damage

was observed.

The drive port for the 31⁄2-inch floppy disk was removed and examined. No

evidence of the 31⁄2-inch floppy disk was found. The drive was severely fire damaged, and the

ribbon cable insulation was destroyed with the wires intact and embrittled.

The display driver was burned and delaminated along the top edge, but the bottom

of the circuit board remained structurally intact. The ribbon wire insulation was destroyed, and

the wire conductors were embrittled but remained intact. The bottom right side of the board

remained intact with the word “Millipore”91 inscribed on the board. The keypad driver was

severely heat damaged except for the lower right corner. The front side of the driver board’s

crystal display was a bluish color with a darkened heat-damaged area on the right side,

approximately 1 inch from the edge.

The exterior metal case of the trityl monitor was heat damaged on its top and sides.

The monitor’s external wire insulation was burned, and the plastic spill tray was deformed. A

legible inspection test sticker with a test date of August 26, 1994, was found on the bottom of the

monitor. A partially legible SN label was observed on the side of the unit. A third label was seen

on the top of the monitor and it was melted, shrunken, and unreadable. Disassembly of the monitor

showed that all the internal components and wire insulation were intact. The circuit board inside the

trityl monitor had little or no fire damage. The rear ribbon cable insulation inside the monitor had

some heat damage.

The fluid access panel, which separated the fluidics module from the upper housing

of the synthesizer, was removed. The upper surface of the fluidics access panel was sooted and

showed extensive fire and heat damage. The right rear lower surface of the panel was more sooted

and heat damaged than on the remaining panel surface. The plastic insulators on the wiring boards

of the instrument also exhibited greater melting on the right side than on the left side. The fluidic

solenoids and wire insulation were heavily sooted, and the wire insulation was not damaged.

 91 PerSeptive Biosystems acquired the synthesis products business from Millipore BioScience

Division in 1994.
123

The sides and top of the fluidics module were heavily sooted; however, the

pneumatics umbilical area was clean except for a lightly sooted area above the pneumatic umbilical

fittings. The four vertical umbilical gas fittings along the far right side of the module were melted.

The polyethylene gas lines (located directly above the monomer bottles) for pressurizing the

monomer bottles were uniformly melted. The polyethylene pressurizing tubing was melted, and

holes or openings in some bottle cap assemblies (the block for screwing the bottles to the

instrument) were found in positions 6, 7, and WSH 1. These openings provided direct access to the

interior of the bottles that had been screwed to the damaged DNA synthesizer. The inert gas

polyethylene tubing for pressurization of bottle positions 1 through 6 was melted and thermally

distorted. The fluid lines were sooted and were not melted.

The spiral wrap that bundled the caddy tube line was intact to the point where the

line exited the machine and was melted at its termination point. The spiral-wrapped bundle was

intact, the gas lines within the spiral wrap were melted, and the fluid lines were intact. A portion of

the caddy line external to the machine was not recovered, and the waste tubing bundle was also

missing about 2 inches from the point where it would have exited the machine. The internal

portion of the waste bundle was intact and sooted.

The pneumatic module was extensively sooted and contained debris throughout the

module’s chassis. The lower portion of the module that contained the regulator and pneumatic

components was heat and soot damaged, and the lower portion of the regulator contained a name

plate with a “Wilkerson” manufacturing label. Melted debris was also affixed to the bottom of the

regulator and the power wires. Insulation within the compartment was intact, and heat and soot

damage was observed throughout the wiring. The connector for the power wiring transitioning out

of the compartment was intact with heat and soot damage and some melting. The wire insulation

from the right isolation valve was intact, and the grommet transitioning out of the compartment was

melted. The wires and insulation from the left isolation valve were intact and had some heat and

soot damage. The grommet through the chassis on the left side was displaced and brittle. The

plastic tubing attached to the fittings on the isolation valves dripped downwards vertically towards

the base of the synthesizer towards the pneumatic drip tray, and melted residue was next to the

melted tubing.

The two barostats had fire and heat damage, and the gas inlet fitting ring was found

adhered to the power supply. An 11- by 6-inch mass of debris was removed from the aft left side of

the unit between the inside chassis wall and pneumatic module frame. This is the same side on

which the unit was found resting in the airplane. The debris was similar to the burned and watersoaked cargo residue that was among the wreckage. Another mass of debris, which measured 51⁄2

by 5 inches, was removed from the inside left pneumatic frame. The adjustment knob for the

pressure regulator had fire and heat damage with wires to two isolation valves entrapped in the

melted portion. The aluminum frame surfaces were intact and were heavily sooted. The plastic

solenoid mufflers were melted. The pressure gauge glass window was intact, and it was covered

with debris and soot.
124

All four ribbon cables remained attached to the valve/solenoid driver printed circuit

board (PCB), and the insulation on the ribbon cables and their connectors were destroyed by heat

and fire. All the insulation on the electrical wiring and the connectors above the regulator

adjustment knob were destroyed by heat and fire. All the electrical wires in the same area were

intact and brittle. The gas inlet quick disconnect fitting was missing, and the fitting’s spring was

found fused in plastic to the power supply case.

Examination of the upper portion of the pneumatic module found that the power

wire pair connector had some melting and soot damage, the fiberglass circuit board’s resin was

consumed, and the board was delaminated. The bottom side of the valve/solenoid driver PCB was

charred and the pneumatic solenoid distribution PCB beneath the driver PCB was similarly

damaged by extensive heat and fire. The electronic components that were mounted on the board

were unrecognizable from the extensive fire damage. The wiring to the PCB had its insulation

burned off and the wires were brittle. The etched copper on the circuit board remained intact.

The aluminum gas distribution block that housed the gas solenoid valves had soot

damage and was not melted. The exhaust fan was dislodged from its mount, was sagging

downward, and was found resting against the bottom of the fan housing. Three of the seven fan

blades were partially melted and fused to the fan housing.
125

APPENDIX G—RINSE PROCEDURE AND QUANTITIES RINSED FOR 1996 NASA

CHEMICAL ANALYSIS

Position 8

The Pos 8 bottle contained about 10 μl of fluid and a filter. 100 μl of methanol was

rinsed through the filter into a clear glass sample vial. Another 100 μl of methanol was added. The

100 μl flushed through the filter was added and swished about to mix the remaining residue on the

sides of the bottle with the methanol. The solution was then transferred to a clear sample vial and

analyzed. The final solution had a yellowish tint.

OX 2

Three droplets adhered to the side of the bottle, which contained a filter. 100 μl of

methanol was rinsed through the filter and placed into a separate clear, glass sample vial. Another

400 μl of methanol was added to the bottle to rinse it. The rinse from the OX 2 was then

transferred to the clear sample vial that contained the 100 μl of methanol from the filter rinse and

sealed. The solution appeared to have a slight yellow tint.

WSH 1

This bottle appeared to be empty. Therefore, 1 mL of methanol was added to the

WSH 1 bottle. The bottle was rinsed, and then the rinse liquid was transferred to a clear sample

vial that was sealed and labeled. The solution was clear.

Position A

This bottle appeared to be dry, so 500 μl of methanol was added to the bottle. The

bottle was rinsed, and then the liquid was transferred to a clear sample vial that was sealed and

labeled. The solution was clear.

Position G

500 μl of methanol was added to the empty bottle, rinsed around, and then

transferred to a clear sample vial that was sealed and labeled. The solution was clear.

Position 9

500 μl of methanol was added to the empty bottle, rinsed around, and then

transferred to a clear sample vial that was sealed and labeled. The solution was clear.

Position T/U

500 μl of methanol was added to the empty bottle, rinsed around, and then

transferred to a clear sample vial that was sealed and labeled. The solution appeared to have a

slight yellow tint.

Position 5 (Spacer Reagent)

500 μl of methanol was added to the empty bottle, rinsed around, and then

transferred to a clear sample vial that was sealed and labeled. The solution was clear.

CAP B6
126

1 mL of methanol was added to the empty bottle, rinsed around, and then transferred

to a clear sample vial that was sealed and labeled. The solution contained some small black

particulate in clear liquid.

CAP A5

1 mL of methanol was added to the empty bottle, rinsed around, and then transferred

to a clear sample vial that was sealed and labeled. The solution was clear.

Position C

500 μl of methanol was added to the empty bottle, rinsed around, and then

transferred to a clear sample vial that was sealed and labeled. The solution was amber colored.

Position 6

The volume of liquid in the bottle was estimated by visual inspection to be 250 μl.*92

Therefore, the sample for injection was pulled directly from the bottle, instead of being transferred

to a sample vial. The solution was clear.

Position 7

The volume of liquid in the bottle was estimated by visual inspection to be 50 to 100 

μl.* Therefore, the sample for injection was pulled directly from the bottle, instead of being

transferred to a sample vial. The solution was clear.

AUX 3

This bottle contained between 4 and 5 mL.* The liquid was transferred to sterile

vial for a visual examination. The liquid had a slight yellowish tint.

ACT 4

This bottle contained a quantity of fluid estimated at 1 mL.* The liquid was

transferred to a sterile vial and a slight yellowish tint was observed.

 92 The volumes marked with an asterisk (*) were estimated by viewing a side-by-side comparison

of the liquids with a hand-graduated sterile vial.
127

APPENDIX H—SUMMARY CALIBRATION AND GC/MS DATA FOR

1996 NASA TESTING

CHEMICAL PURITY % SOURCE IDENTIFICATION EXPIRATION

Tetrahydrofuran 98.5 Chem. Service O-574 7/90

Acetic Anhydride 95 Chem. Service O122 2/89

Acetonitrile 99 Chem. Service O-834 5/89

Pyridine 99.2 Chem. Service O-706 3/90

Dichloroacetic acid 96 Chem. Service O-45 9/89

Trichloroacetic acid 99 Chem. Service O-46 11/89

Trichloroacetic acid PerSeptive

t-BPA PerSeptive

1-Methylimidazole PerSeptive

DEGMBE 95 Chem. Service O-172 3/90

The GC/MS data could not be obtained for iodine because it does not elute from the

GC column. The injection port on the GC was set at 250°C, and an injection of 0.1 μl of the

standard solutions and unknown fluids from the reagent bottles from the accident synthesizer were

extracted with a 0.5 μl syringe. The syringe was flushed 10 to 20 times with methanol after each

injection and was followed by a vacuum pull on the syringe at an elevated temperature. This was

done to make sure the syringe was not contaminated.








136

 APPENDIX J - DEMONSTRATION OF SYNTHESIZER PURGING AND

DECONTAMINATION PROCEDURES

On February 18, 1997, Safety Board investigators and representatives from the

parties to the investigation conducted, at PerSeptive’s manufacturing facility, a demonstration of

the purging and drying processes that the PerSeptive field engineer who prepared the accident

unit for shipping reported he had followed. (The field engineer was invited to attend this

demonstration but indicated he was unable to because of a schedule conflict.) The demonstration

was intended to repeat, to the extent possible, the same sequence of steps taken by the field

engineer who purged the accident instrument and prepared it for shipment.93 The DNA

synthesizer used in the demonstration was the same type as that involved in the accident.

For the demonstration, the 15 internal reagent bottles were filled about 25 to 50

percent full with acetonitrile. The two external reagent bottles were likewise filled about 15 to

25 percent full. A 4-liter brown glass bottle for the nonchlorinated wastes was about 65 percent

full of waste. The clear glass bottle for the chlorinated wastes was empty. There were three

external connections: the vent tube, power connection, and the inert gas (helium) hookup. A

31⁄2-inch floppy disk94 with the operating software had been inserted in the disk drive, which is

located at the top rear of the synthesizer.

During the demonstration, the “prime all” cycle was then run three times on each

of the two column positions (see figure A in appendix F). The “prime all” cycle was run a fourth

time on the column 1 position to observe the flow of liquid to the waste bottles and to note the

sequence of the priming function. Liquid was observed flowing into the waste bottles during the

“prime all” cycle, and the menu (a screen on the front of the unit with computer-generated

messages) indicated that every reagent position was primed.

The internal and external reagent bottles were then removed from the synthesizer

and emptied by inverting them until no drops came out. Minute amounts of liquid were observed

in the reagent bottles after the bottles were emptied and shaken. The amount of liquid remaining

in one of the 25 mL reagent bottles was measured in a pipette and found to be approximately

0.005 mL.

The reagent bottles were reinstalled in the synthesizer without further attempts to

remove the minute amounts of remaining residue. The system was then charged with helium to

dry it. This was accomplished by running “prime all” three times on each column position. (The

fluid injectors used for the flushing are pneumatically driven by the inert gas.) During the drying

 93 During initial postaccident interviews, the field engineer initially stated that he followed

PerSeptive’s procedures, as outlined in Service Note 89-006 from memory, and thus those procedures were used as a

guideline during the February 18, 1997, demonstration. However, as discussed above, he later acknowledged that he

had performed 44 additional steps.

94 The disk is required for the instrument to operate and records data regarding the keystrokes and

operations performed on the synthesizer.
137

process liquid was observed dripping into the waste bottles. Upon completion of the “prime all”

cycles, the helium gas (hookup) inlet line was disconnected, and all of the reagent bottles were

loosened to depressurize the system.

After the drying process was complete, minute amounts of liquid were observed in

the internal reagent bottles. Four of the 25 mL reagent bottles had about 0.001 mL of liquid, and

a minute amount of liquid was also observed in at least one of the large reagent bottles.

However, because the large bottles had been removed and sat uncapped for about 15 minutes to

allow any remaining residue to flow to the bottom of each bottle, the residue had evaporated

from the large bottles before measurements could be made.