A DC9-30 CARRYING PAX WAS DISPATCHED IN NON COMPLIANCE WITH 12 CHEMICAL OXYGEN GENERATORS LOADED IN THE AFT CARGO PIT.
Synopsis
A DC9-30 CARRYING PAX WAS DISPATCHED IN NON COMPLIANCE WITH 12 CHEMICAL OXYGEN GENERATORS LOADED IN THE AFT CARGO PIT.
Narrative
OXYGEN GENERATORS WERE MOVED BY PAX ACFT FROM ZZZ; US; TO ABC; US; ON ACR FLT XYX. DURING THE WK OF JUN/XA-XD/99; IT WAS REALIZED THAT A FULL INVESTIGATION OF PROC AND HANDLING OF OXYGEN GENERATORS AT ACR ZZZ FACILITIES WAS BEING IMPLEMENTED. ON THE DAY OF THE INCIDENT; MY LEAD STOCK CLERK TOLD ME TO COMPLETE HAZMAT PAPERWORK FOR SHIPPING OF THE GENERATORS. DUE TO THE NATURE OF THE HAZMAT ITEM; I DIRECTED IT TO THE SUPVR; WHICH IS ALSO THE HAZMAT INSTRUCTOR FOR ZZZ STORES. THE MOVEMENT DOCUMENTS FROM THE MATERIAL CTL UNIT IN ACR CLRLY STATED PAX ACFT MOVEMENT WITH FLT NUMBERS AND FLT TIMES. THIS SUPVR DIRECTED ME; WITH HIS ASSISTANCE; TO CHK MANUFACTURED DATES ON THE GENERATORS. THE SUPVR APPROVED THE OXYGEN GENERATOR'S DATES AND THAT THEY COULD BE SHIPPED. HE THEN DIRECTED ME TO RETRIEVE AIR TRANSPORT MOVEMENT CONTAINERS MADE FOR OXYGEN GENERATOR MOVEMENT ON AIR TRANSPORTATION AND HOW THEY SHOULD BE PACKAGED FOR MOVEMENT. WITH HIS APPROVAL OF DATES; PACKAGING AND HANDLING; I BELIEVED THE GENERATORS WERE FINE TO SHIP PER FLT DOCUMENTS. FOLLOWING THE DIRECTION OF THIS SUPVR; I RETRIEVED BOXES; REPACKAGED AND PREPARED THE MOVEMENT OF THESE 12 OXYGEN GENERATORS. THE HAZMAT PAPERWORK; CHKOFF LIST; AUTHORIZATIONS AND PLT NOTIFICATIONS WERE WRITTEN FOR MOVEMENT ON THE REQUIRED FLT INSTRUCTED BY MATERIAL CTL UNIT AND MY SUPVR. BEFORE ANY MOVEMENT FROM THE STORES HAZMAT AREA; A SECOND SUPVR WAS NOTIFIED OF THE SHIPMENT. I SHOWED THE SHIPMENT TO THE ON DUTY SUPVR FOR NEXT SHIFT IN ZZZ STORES. THE PAPERWORK AND ROUTING LABELS WERE PRESENTED TO HIM FOR HIS SHIPMENT APPROVAL. THIS SUPVR ALSO APPROVED THE OXYGEN GENERATOR MOVEMENT. I PERSONALLY TOOK THE SHIPMENT TO THE ACFT TO SAFEGUARD ANY PROBS. THE 3 AIR TRANSPORT MOVEMENT CONTAINERS CONTAINING OXYGEN GENERATORS WERE LOADED IN THE AFT CARGO OF THE ACFT. THE CONTAINERS WERE RETRIEVED IN ABC; US; AS THEY CAME OFF THE ACFT. BECAUSE OF THE FIRST SUPVR'S STATEMENTS AND DIRECTIVES; I BELIEVED THESE ITEMS COULD BE TRANSPORTED AS STATED ON THE MOVEMENT DOCUMENTS. AT NO TIME WHILE PACKAGING THE GENERATORS DID I THINK THAT THEY WERE NOT SUPPOSED TO GO BY PAX ACFT. THE FIRST KNOWLEDGE THAT THE OXYGEN GENERATOR MOVEMENT WAS INCORRECT AS DIRECTED AND APPROVED BY MY SUPVR WAS DAYS LATER. A FULL IN-HOUSE INVESTIGATION BEGAN DURING THE JUN/XA-XD/99 WK. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE SUPVR WHO DIRECTED THE GENERATORS BE SHIPPED ON A PAX CARRYING FLT WAS ALSO THE HAZMAT MGMNT SPECIALIST. THE RPTR SAID HE QUESTIONED THIS SUPVR ON THE LEGALITY OF SHIPPING THESE CHEMICAL OXYGEN GENERATORS ON A PAX CARRYING FLT. THE RPTR STATED THE SUPVR DID NOT DISCUSS THIS POINT BUT TOLD THE RPTR TO 'DO IT.' THE RPTR SAID HE OBTAINED 3 CONTAINERS USED FOR SHIPPING THESE GENERATORS AND REMOVED THE SHIPPING INSTRUCTION WARNING LABELS AND LOADED THE GENERATORS. THE RPTR STATED STILL BEING UNSURE OF WHAT HE WAS ORDERED TO DO HE CONSULTED WITH ANOTHER SUPVR AND WAS ASSURED IT WAS OK. THE GENERATORS WERE LOADED ON PAX CARRYING FLT AND DEPARTED. THE RPTR STATED THE COMPANY AND THE FAA WERE ALERTED BY THE DOWN LINE STATION WHO RECEIVED THE GENERATORS AND A COMPANY HEARING WAS HELD. THE RPTR SAID THE COMPANY DISCIPLINARY HEARING FOUND HIM AT FAULT. THE RPTR SAID THE FAA HEARING HAS NOT BEEN HELD AND HAS HAD NO CONTACT WITH THE FAA. RPTR CONTACTED AGAIN ON OCT/XA/99 AT XA00 SAID THE FAA IS ALSO INVESTIGATING AND IS AWARE OF EVERYONE INVOLVED.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.