Safety lapses at United Arab Emirates (UAE) LCC Flydubai and its maintenance, repair and overhaul (MRO) provider, Jordan Aircraft Maintenance Company (Joramco), allowed for unlabeled, active oxygen generators to be shipped in hold cargo on two flights in late 2013, one with 165 passengers and six crew members on board.
Although there were no injuries or aircraft damage as a result of the flights, the UAE’s Air Accident Investigation Sector (AAIS) issued 11 recommendations in its final report on one of the incidents—a December 2013 flight in which a Flydubai 737-800 was ferried from the Amman-based MRO back to its home base in Dubai, carrying six unlabeled, active oxygen generators in cargo. Investigators discovered the other flight, which carried three oxygen generators in cargo, during the course of the investigation.
Chemical oxygen generators, which are integrated into the overhead Passenger Service Units (PSUs) in Flydubai’s Boeing 737-800s for use during cabin-pressure anomalies, were banned from carriage as cargo in passenger aircraft after the May 1996 crash of a ValuJet DC-9 near Miami. The U.S. NTSB determined that active oxygen generators improperly carried in Class D cargo on the aircraft had caused a fire that directly led to the crash.
In its investigation, AAIS inspectors found multiple missed opportunities for the shipping errors to be discovered prior to the flights. Along with a lack of dangerous-goods training for employees, Joramco did not have a Jordanian-approved safety-management system and an associated risk-assessment process in place.
“Had such a system been in use it is likely that the weaknesses in dangerous-goods handling would have been identified,” the AAIS says. Although there had been an informal agreement between Flydubai and Joramco that called for the removed PSUs and oxygen generators to be shipped to Dubai via road, the specification had not been codified in the contract for the work.
In conjunction with the C maintenance check of the 737-800s, Joramco had been removing three sets of economy seats and three PSUs in the front of the aircraft as part of a conversion to a business-class cabin. North Carolina-based Timco holds the supplemental type certificate (STC) for the conversion. The incident aircraft was the ninth 737-800 to undergo the conversion.
“The chemical oxygen generators had not been removed from the PSUs, nor had they been made safe by the installation of safety pin and a safety cap,” the AAIS says in the report. “In the case of each oxygen generator, the firing pin was engaged in the firing mechanism and the activation cable was connected to the pin.” The AAIS says neither the PSUs, nor the oxygen generators or the boxes containing them had been labeled as “dangerous goods.”
Timco’s STC work instructions did not “specifically reference” documentation that would have instructed maintenance technicians to install safety pins and caps into the oxygen generators when the PSUs were removed. AAIS issued three recommendations to the company, including the addition of “permanent” dangerous-goods markings on the oxygen canisters.
The bulk of the recommendations (five) were issued to Flydubai. Included is a call for the carrier to require all maintenance service providers it uses to have a Safety Management System accepted by local regulators and to provide initial and recurrent dangerous-goods training to certain employees.
For its part, Jaramco received two recommendations, including enhanced training for employees. The company voluntarily sent its technicians and stores employees to dangerous-goods training courses before the recommendations were issued.