This presentation reviews voluntary safety reports received by NASA's Aviation Safety Reporting System pertaining to Hazardous Materials

Hooey, Becky

Moya, Jorge

Perez, Richard

English

NASA Technical Reports Server

Fall 2019
NASA ASRS: Reports of 
HazMat Incidents
InfoShare – Ground Operations                      Bellevue, WA
Becky Hooey, PhD
ASRS Program Director
NASA  Ames Research Center
Becky.L.Hooey@nasa.gov
https://ntrs.nasa.gov/search.jsp?R=20200000340 2020-03-11T13:30:55+00:00Z
ASRS Government /Industry Partnership
 FAA provides funding to NASA 
for ASRS operations and 
report processing
- AVP:  ASRS operations
- ASH: HazMat report processing
 NASA manages ASRS 
operations and provides 
research and analysis 
capabilities
 The Aviation Community 
provides support through 
advocacy for reporting, 
feedback, and 
communications 
2AVP = Accident Investigation and Prevention
ASH = Security and Hazardous Materials Safety
ASRS Principles
VOLUNTARY PARTICIPATION
Aviation personnel voluntarily submit reports concerning events related to 
safety for the purpose of system alerting, understanding and learning
CONFIDENTIALITY PROTECTION
Protection of identity is provided by NASA through de-identification of 
persons, companies, and any other identifying information
INDEPENDENT
Necessary for trust building and unbiased dissemination of safety 
information
NON-PUNITIVE
FAA will not use, nor will NASA provide, any report submitted for inclusion 
under ASRS guidelines or information derived therein for use in any 
disciplinary or other adverse action (14 CFR 91.25 & AC 00-46E)3
Monthly Intake
January 1981 – August 2019
ASRS Report Volume Profile
 Over 43 years of 
confidential safety 
reporting
 ASRS receives over 
8,887 reports per 
month, or 431 per 
working day
 Current intake 
estimate for 2019 is 
over 108,000
1981 2019
Incident Reporter Distribution
September 2018 – August 2019
n = 105,690
We want your safety reports!
Individual reports can be submitted directly to ASRS at: 
http://asrs.arc.nasa.gov
or
ASAP programs can use our 
secure electronic transmission protocol
Report source:
• Direct to ASRS - 16% 
• ASAP - 84%
Aviation Safety Reporting System
ASRS Report Processing Flow
ASAP 
Transfer
ASRS 
Website or 
Mail
http://asrs.arc.nasa.gov
ASRS Safety Products
These products and services fulfill the program’s 
mission to disseminate safety data
ALERT 
MESSAGES
QUICK 
RESPONSES
ASRS 
DATABASE
CALLBACK 
NEWSLETTER
SPECIAL 
STUDIES
Safety information 
issued to 
organizations in 
positions of authority 
for evaluation and 
possible corrective 
actions.
Rapid data analysis by 
ASRS staff on safety 
issues with immediate 
operational importance 
generally limited to 
government agencies.
The public ASRS 
Database Online and 
data available in 
Database Report Sets 
or Search Requests 
full filled by ASRS 
staff.
Monthly newsletter 
with a lessons learned 
format, available via 
website and email.
Studies/Research 
conducted on safety 
topics of interest in 
cooperation with 
aviation organizations.
7
Alerts and FAA telecons
 ASRS has issued 129 total alerts from Sep 1, 2018 
to Aug 31, 2019
 Hazmat Alert Examples (2013 – 2019)
•Dispatching Aircraft with Cell Phones Lost in Cabin
•Hazardous Material Improperly Boarded
•Dangerous Goods Labels Covered By USPS Stickers
•Lithium Battery Shipment via U.S. Mail on Passenger Aircraft
•Li-Ion Battery Shipment Packaging
•E-Cigarette Cabin Fire Hazard
•Hazmat Procedure
•Lithium Battery Shipping and Fire Suppression Equipment
9https://asrs.arc.nasa.gov/publications/callback/cb_476.html
ASRS Monthly 
Publication
CALLBACK
Hazardous Materials 
Special Study  
Fullform processing of all 
HazMat-related reports
April 2018 – Current
Report Processing funded by FAA Security and Hazardous Materials Safety (ASH)
10
CAST Safety Enhancements (SE117, SE121, SE125, SE126, SE129, SE130, SE131)
HazMat Special Study 
April 2018 – August 2019
422 reports identified as “HazMat” since April 2018
11
HazMat Secondary Coding Effort
Jan 2019 – June 2019
ASRS Expert Analysts coded 144 records (from Jan to 
June 2019) utilizing a Supplemental Question Set which 
included the following questions:
• What was the HazMat Class Type and Description if available?
• Where was the HazMat located?
• Who first detected the HazMat issue/event?
• When was the HazMat issue/event identified?
• What were the HazMat Reported issues?
• What was the reported result or impact of the HazMat Issue?
• What factors contributed to the HazMat issue/event?
12
Class 4: Flammable Solids 
0
Class 2: Gases 
2
Class 1: Explosives                
0
Class 7: Radioactive Material 
1
Class 5: Oxidizing Substances, 
Organic Peroxides  0
Class 6: Toxic Substances and 
Infectious Substances  4
Class 8: Corrosives 
1
Each record may contain more than one HazMat type.
A total of 69 records were coded as Not Stated/Unknown/Other 
What was the HazMat Class Type and Description if available?
Class 3: Flammable Liquids 
4
Class 9: Miscellaneous Hazardous 
Materials  69
Dry Ice 
17
Lithium Ion Batteries 
41
Batteries – Unspecified 
8
Dry Cell Batteries
2
Unspecified 
1
13
HazMat Records – Secondary Coding
Reports Received Jan 2019 - June 2019
n=144 records
HazMat Records – Secondary Coding
Reports Received Jan 2019 - June 2019 
n=144 records 15
HazMat Records – Secondary Coding
Reports Received Jan 2019 - June 2019 (n = 144 records)
n=144 records
*Categories are not mutually exclusive.
What were the reported HazMat issues?
n=144 records
HazMat Records – Secondary Coding
Reports Received Jan 2019 - June 2019
Issue Type Description* Count
Documentation
(59)
Documentation Error 24
Missing Documentation 23
Crew Not Notified 7
Incomplete Documentation 5
Loading
(69)
Loading Configuration Issue 50
Hazmat Placement and Tie Down 12
Loading Compatibility Issue 6
Loading Segregation Issue 1
Packaging
(17)
Labeling/Marking Issues 9
Packaging Issue 8
Other
(45)
Other 26
Non-Removal of Lithium Batteries 17
Chain of Hazmat Custody Obligations 2
HazMat Records – Secondary Coding
Reports Received Jan 2019 - June 2019
*Categories are not mutually exclusive.
n=144 records
65 records were coded as None Reported.
HazMat Records – Secondary Coding
Reports Received Jan 2019 - June 2019
What factors contributed to the HazMat Event?
 Inadequate Training
 Confusing, Inadequate, Non-Existent Procedures
 Communication Breakdown
19
 Smart Bag Batteries
Captain Reported: “Shortly after deplaning, one of the ramp 
agents informed me that one of the gate-checked bags he 
just removed from our aircraft was a smart bag, and the 
battery had not been removed.. As I and the flight crew have 
preflight duties to perform, we are unable to directly 
supervise the ramp/gate agents as they receive the gate 
checked bags. The only way to ensure that this does not 
happen again is to retrain the ground operation [crew] on 
how to handle smart bags, as well as periodic monitoring…”. 
(ACN 1629428)
HazMat Handling: Training Issues
HazMat Handling: Training Issues
 Flight Attendant Reported: The current CBT [Computer 
Based Training] has a slide that reads in part "... Spare lithium 
batteries are any rechargeable batteries that are not installed 
in an electronic device." Does this mean that when an FA 
commutes, and our bag is checked (or gate checked) that it is 
ok if our work tablet remains in the checked bag as the battery 
is installed inside? Or does this mean that it is not-ok? And it 
would not qualify to remain in the check bag? I am asking as 
a result of my recent interaction with the Flight Attendant 
Official social media group. The clarity provided does not line 
up with what is in the Continuing Qualification …
 Suggestions: Enhance the clarity of text on [company website] 
and applicable FA [Flight Attendant] manual guidance. (ACN 
1621660)
• SMART BAGS: “When a Ramp Service Employee (RSE) identifies a 
smart bag there is no process that informs the RSE if the bag was 
inspected, who inspected the bag and if powered by lithium was the 
lithium battery removed.” (ACN 1654030) 
• LITHIUM BATTERY STOWAGE: “I think a universal procedure 
between different work groups to identify and understand the proper 
stowage of lithium batteries would help to prevent this confusion and 
misunderstanding.” (ACN 1634785) 
• SCOOTER AND WHEELCHAIRS: “[Airline] must immediately 
establish procedures monitored by FAA oversight to deal with the 
handling of electric scooters and wheelchairs … a form should be 
created in triplicate that notifies the [pilots] of their presence and that 
the ground staff has properly verified their power source is approved 
to be carried aboard our aircraft.” (ACN 1609809) 
HazMat Handling: Procedural Issues
22
• DRY ICE: “Dry ice must be loaded in a separate compartment from 
live animals regardless of the origin of the shipment. There is an 
acceptance process when customers have dry ice in their check-in 
luggage. That process has several failures that may contribute to 
safety failures as follows:
1. Lack of customer awareness of the safety concern may prevent 
customers from being forthright in an effort to avoid having the luggage 
restricted.
2. The acceptance process at the ticket counter does not coincide with 
hazardous material acceptance so requirements may fall through the 
cracks. (i.e., packaging may not have the correct ventilation).
3. The acceptance does not have a [code] so ramp employees do NOT 
have knowledge of dry ice through the scanning process.
4. The special handling tag may come off the bag so this awareness tool 
may fail.” (ACN 1681383)
HazMat Handling: Procedural Issues
Captain reported: “…I was given a Dangerous Goods (DG) summary showing 
"miscellaneous hazmat" loaded on aircraft. I was curious to know exactly what 
the miscellaneous hazmat was, and called Dispatch for clarification. … 
Dispatch was busy working several issues with other flights so I offered to call 
dangerous goods hot-line. 
Dangerous Goods Specialist was unable to give further description of shipment. 
When I asked what drill code “XL" represented, Dangerous Goods Specialist 
said "You'll have to look that up in your pilot manual" and was unable to provide 
any further assistance.
I called Dispatch back as well as Station Operations trying to find out what exactly 
the hazardous material shipment was ... At some point in this process, it was 
decided, not by me, that the shipment would be pulled from the aircraft.”
(ACN 1655095) 
HazMat Communication Breakdown
24
https://asrs.arc.nasa.gov/
Aviation Safety Reporting System
CONTACT INFO
Becky Hooey, PhD 
NASA ASRS Program Director
Becky.L.Hooey@nasa.gov
(408) 541-2827
Jorge Moya
NASA ASRS Research Coordinator 
Jorge.B.Moya@nasa.gov
(408) 541-2816


NASA ASRS: Reports of HazMat Incidents

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