ALERT
BULLETIN
AB 2017:7/11-1
2/24/2017
1398250
TO:
FAA (AFS-300)
INFO:
FAA (AVP-1, AVP-200, AFS-200, AFS-280, AFS-900, ANM-100, SEA-ACO,
SEA-AEG, AQS-230), A4A, AFA, ALPA, AMFA, APFA, ASAP, ATSG, CAPA,
IAM, ICAO, ICASS, IFALPA, NTSB, PAMA, SWAPA, TWU, BE Aerospace Inc.
FROM: Linda J. Connell, Director
NASA Aviation Safety Reporting System
SUBJ: PBE Explosion During Disposal
We recently received an ASRS report describing a safety concern that may involve your area of operational
responsibility. We do not have sufficient details to assess either the factual accuracy or possible gravity of the
report. It is our policy to relay the reported information to the appropriate authority for evaluation and any
necessary follow-up. We feel you should be aware of the following:
ASRS received a report from a Maintenance Technician describing the explosion of
a PBE unit during disposal. Reporter stated he was removing the PBE from its
packaging when the unit exploded. Debris impacted the Technician, and some
pieces were found over 20 feet away. The reporter expressed concern about the
possibility of an inflight PBE explosion.
ASRS has previously alerted on PBE fire and explosion incidents during disposal in
Alert 2003:79/11-2 and Alert 2004:66/9-3. These alerts are also enclosed.
To properly assess the usefulness of our alert message service, we would appreciate it if
you would take the time to give us your feedback on the value of the information that we
have provided. Please contact Dennis Doyle at (408) 541-2831 or email at
[email protected]
Aviation Safety Reporting System
P.O. Box 189 | Moffett Field, CA | 94035-0189
ACN: 1398250
Time
Date: 201610
Place
Altitude.AGL.Single Value: 0
Aircraft 1
Make Model Name: Boeing Company Undifferentiated or Other Model
Component 1
Aircraft Component: Oxygen System/Portable
Person 1
Function.Maintenance: Technician
ASRS Report Number: 1398250
Events
Anomaly.Ground Event / Encounter: Other / Unknown
Detector.Person: Maintenance
Result.General: Physical Injury / Incapacitation
Narrative 1
Aircraft [was] undergoing a modification after delivery from manufacturer. At the maintenance
facility, a mechanic, while accomplishing [a task] which calls for the removal and replacement of
[Protective] Breathing Equipment (PBE), ie, replacement of BE Aerospace PBE with new model PBE.
During the removal, steps advised to dispose of BE Aerospace PBE models and dispose of it locally.
Following dangerous materials/goods.
The mechanic was opening and removing a BE Aerospace PBE from its packaging after taking it
from the aircraft. He was inside the maintenance facility, and without pulling the cord that turns on
the PBE, he was in the process of spreading open the PBE to dispose of locally. At this stage the
PBE literally exploded in his hands. The mechanic was standing erect, and holding the PBE chest
high. Metal debris from the oxygen canister was fired and found over 20 feet away from the
incident. [Mechanic was injured and required medical attention].
PBE information: Part Number 119003-21.
This style of PBE produced by B/E Aerospace Inc, has been written up before for being difficult to
open, following the same procedures for disposal, however no injury had been reported.
Callback 1
The reporter stated the PBE (Protective Breathing Equipment) that exploded was one that was
originally installed in the aircraft as it came from Boeing. All the PBEs were being replaced with
PBEs from a different manufacturer. The reporter stated that the procedure to dispose of the
original PBE is to activate it prior to disposal. In the process of activating the PBE, it exploded
sending shrapnel up to 20 feet away. The reporter also stated that often in order to open the PBE
aluminum wrapping they had to cut it with a knife, but in this case the Mechanic only had to pull
the cord to activate it when it exploded. The reporter stated that his concern was that this could
just as easily happen to a flight crew member while in flight.
Synopsis
An air carrier maintenance worker reported that while a Mechanic was preparing Protective
Breathing Equipment for disposal, it exploded injuring the Mechanic.
Previous Alert(s)
ALERT
BULLETIN
TO:
AB 2004:66/9-3
7/26/04
615686
FAA (AFS-200, AFS-300, AFS-900)
INFO: FAA (ASY-300, ANM-100, AEU-100, ADG-1, AAR-440), AASC, ASAP, AFA, ALPA, APA,
APFA, ATA, IAM, IATA, ICAO, ICASS, IFALPA, NBAA, NTSB, PAMA, PFAA, RAA, SWAPA
FROM: Linda J. Connell, Director
NASA Aviation Safety Reporting System
SUBJ: PERSONAL BREATHING EQUIPMENT (PBE) EXPLOSION
We recently received an ASRS report describing a safety concern which may involve your area of
operational responsibility. We do not have sufficient details to assess either the factual accuracy or
possible gravity of the report. It is our policy to relay the reported information to the appropriate
authority for evaluation and any necessary follow-up. We feel you should be aware of the following:
ASRS received a report from a union safety representative reporter who was notified that a
technician was injured while discharging PBE’s per change orders. The reporter claims that
three PBE’s were discharged without any problems. However, the fourth PBE, “...exploded
when the lanyard was pulled.” The reporter also claims that, “...this is the third known
incident involving discharging these impact point devices.” One device, “...exploded in a
shower of sparks...”, after a one to two minute delay. Company engineering has reportedly
issued a bulletin instructing technicians, “...not to discharge these devices but to store them
in a steel drum.”
(Keywords: Personal Breathing Equipment, Explosion)
To properly assess the usefulness of our AB service, we would appreciate it if you would take the
time to give us your feedback on the value of the information that we have provided. Please
contact Michael Jengo at (650) 969-3969 or [email protected].
Aviation Safety Reporting System
625 Ellis Street * Suite 305 * Mountain View * CA * 94043
ACN: 615686
Time
Date : 200404
Day : Wed
Local Time Of Day : 0601 To 1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Altitude.AGL.Single Value : 0
Person / 1
Function.Maintenance : Technician
ASRS Report : 615686
Person / 2
Function.Maintenance : Technician
Function.Other Personnel.Other : Injured Technicion
Person / 3
Function.Maintenance : Technician
Person / 4
Function.Maintenance : Technician
Events
Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Other Anomaly.Other : PBE Explosions
Independent Detector.Other.Other : Person 1
Resolutory Action.None Taken : Detected After The Fact
Consequence.Other : Company Review
Consequence.Other : Maintenance Action
Narrative
EMPLOYEE FOLLOWED GPM ON PBE DISPOSAL. 3 PBE WERE DISCHARGED WITH NO EVENT.
FOURTH PBE EXPLODED WHEN LANYARD WAS PULLED. I WAS INFORMED THAT THIS HAD
HAPPENED THE NIGHT BEFORE, BUT NO ONE WAS HURT. THAT MECHANIC PULLED THE PIN.
THEN AFTER 1 OR 2 MINS THE PBE EXPLODED IN A SHOWER OF SPARKS. CALLBACK
CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT HIS
FUNCTION IS THE UNION SAFETY REPRESENTATIVE AND THE INJURED TECH RPTED THE
DETAILS OF THE PERSONAL BREATHING EQUIPMENT EXPLOSION. THE RPTR STATED THE
TECHNICIAN WAS WORKING AN ENGINEERING CHANGE ORDER TO REMOVE THE DEVICES THAT
HAD A CERTAIN PART NUMBER AND A COLORED LINE DUE TO BAG SEAL LEAKAGE. THE RPTR
STATED THE CHANGE ORDER INSTRUCTED THE TECHNICIAN TO OPEN THE BAG AND
DISCHARGE THE DEVICE PER THE GENERAL PROCS MANUAL. THE RPTR SAID THE MANUAL
REQUIRED THE DEVICE BE DISCHARGED OUTSIDE ON A METAL TABLE AWAY FROM ANY
INFLATABLES. THE RPTR STATED THAT FOUR DEVICES WERE TAKEN TO THE DISCHARGE SITE
WHERE THE TECHNICIAN DISCHARGED THREE DEVICES WITH NO PROB. THE RPTR SAID THE
FORTH DEVICE WAS OPENED, THE LANYARD PULLED AND THE DEVICE EXPLODED LIKE A 12
GAUGE SHOTGUN SHELL. THE RPTR STATED A 45 DEG METAL ELBOW WITH A SHORT TUBE
ATTACHED STRUCK THE TECHNICIAN INCURRING A SEVERE BRUISE. THE RPTR SAID THIS IS
THE THIRD KNOWN INCIDENT INVOLVING DISCHARGING THESE DEVICES. THE RPTR STATED THE
FIRST INCIDENT THE DETAILS WERE NOT CLR ON HOW THE DEVICE REACTED BUT THE SECOND
INCIDENT THE LANYARD WAS PULLED, A DELAY OF ONE TO TWO MINS OCCURRED THEN THE
DEVICE EXPLODED IN A SHOWER OF SPARKS. THE RPTR SAID ENGINEERING HAS JUST
RELEASED A BULLETIN NOT TO DISCHARGE THESE DEVICES BUT TO STORE THEM IN A STEEL
DRUM.
Synopsis
WHILE WORKING AN ENGINEERING CHANGE ORDER A TECHNICIAN FOLLOWING THE GENERAL
PROCS MANUAL DISCHARGED A PERSONAL BREATHING EQUIPMENT DEVICE AND WAS
INJURED WHEN THE DEVICE EXPLODED.
ALERT
BULLETIN
TO:
AB 2003:79/11-2
10/20/03
583873
FAA (AFS-200, AFS-300, AFS-900)
INFO: FAA (ASY-300, ANM-100, AEU-100, ADG-1, AAR-440), AASC, ASAP, AFA, ALPA,
APA, APFA, ATA, IAM, IATA, ICAO, ICASS, IFALPA, NBAA, NTSB, PAMA, PFAA,
RAA, SWAPA
FROM: Linda J. Connell, Director
NASA Aviation Safety Reporting System
SUBJ: PORTABLE BREATHING EQUIPMENT (PBE) HOOD OXYGEN CANISTER FIRE
We recently received an ASRS report describing a safety concern which may involve your area of
operational responsibility. We do not have sufficient details to assess either the factual accuracy or
possible gravity of the report. It is our policy to relay the reported information to the appropriate
authority for evaluation and any necessary follow-up. We feel you should be aware of the following:
ASRS received a report from a lead technician who experienced a PBE hood fire while
disposing of an expired oxygen canister within the hood. These hoods are placed in a
metal cage and opened up as the canister is discharged. The reporter claims the unit
“...when opened and triggered, broke apart instantly and caught fire inside the hood.” The
technician also claims that these units could be a serious safety issue for maintenance
personnel, flight crews, and cabin crew members. The reporter was aware of one other
similar event while discharging a canister. It emitted sparks and flashes.
(Keywords: Fire, Oxygen Canister)
To properly assess the usefulness of our AB service, we would appreciate it if you would take
the time to give us your feedback on the value of the information that we have provided. Please
contact Michael Jengo at (650) 969-3969 or [email protected].
Aviation Safety Reporting System
625 Ellis Street * Suite 305 * Mountain View * CA * 94043
ACN: 583873
Time
Date : 200305
Day : Wed
Local Time Of Day : 0601 To 1200
Place
Locale Reference.Airport : ZZZ.Airport
State Reference : US
Aircraft / 1
Operator.Common Carrier : Air Carrier
Make Model : Commercial Fixed Wing
Person / 1
ASRS Report : 583873
Events
Resolutory Action.None Taken : Detected After The Fact
Supplementary
Problem Areas : Aircraft
Problem Areas : Company
Problem Areas : Maintenance Human Performance
Page 1
Narrative :
OXYGEN CANISTER BROKE APART AND BURNT WHEN DISCHARGED LOOKS LIKE IT CAUGHT FIRE WHILE
STILL INSTALLED ON PBE HOOD. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO:
THE RPTR STATED THAT DURING THE MAINT CHECKS PORTABLE BREATHING EQUIP KITS THAT ARE OUT
OF DATE AND UNITS THAT ARE NOT HARD OR SEALED CORRECTLY ARE REMOVED. THE RPTR SAID THESE
UNITS OR KITS ARE THEN PLACED IN A METAL CAGE AND OPENED UP NORMALLY AND THE CANISTER
DISCHARGED TO ALLOW THE KITS TO BE SHIPPED BY TRUCK TO A LANDFILL. THE RPTR STATED THIS
PARTICULAR KIT WHEN OPENED AND TRIGGERED BROKE APART INSTANTLY AND CAUGHT FIRE INSIDE
THE HOOD. THE RPTR SAID THIS COULD BE A SERIOUS SAFETY ISSUE NOT ONLY FOR THE PEOPLE
HANDLING THESE UNITS, BUT FLT AND CABIN CREWS. THE RPTR STATED A PERSON USING THIS HOOD IN
AN EMER WOULD BE ENDANGERED. THE RPTR SAID THE UNIT HAD BEEN SENT TO THE COMPANY
ENGINEERING DEPARTMENT FOR EVALUATION. THE RPTR STATED PREVIOUS EXPERIENCE WITH
DISCHARGING THE CANISTERS HAS BEEN ONE THAT EMITTED SPARKS AND FLASHES.
Synopsis :
DURING A CANISTER DISCHARGE OF AN OUT OF DATE COCKPIT PORTABLE BREATHING UNIT THE OXYGEN
CANISTER BROKE APART AND CAUGHT FIRE WHILE IN THE HOOD.
Page 2