— 110 Hansen, McAndrews and Berkeley. History of Aviation Safety in the [U.S.]. 2005.

— 110 NFPA. U.S. Unintentional Fire Death Rates By State.” December 2008, p. 21.

— 110 NTSB. AAR, In-Flight Fire and Impact with Terrain, ValuJet…1997.

— 110 NTSB. “Board Meeting: In-Flight Fire and Impact with Terrain, ValuJet Airlines…”

— 110 NationMaster.com. Encyclopedia, ValuJet Flight 592

— 109 CNN. ValuJet Flight 592. Complete List of Passengers and Crew, May 13, 1996.

— 108 Haine, Edgar A. Disaster in the Air. New York: Cornwall Books, 2000, p. 47.

— 107 Cobb/Primo. “The Crash of ValuJet Flight 592.” Ch. 5, pp. 80-102 in The Plane Truth.

Narrative Information

NTSB Board Meeting Executive Summary: “On May 11, 1996, at 1413:42 eastern daylight time, a Douglas DC-9-32 crashed into the Everglades about 10 minutes after takeoff from Miami International Airport, Miami, Florida. The airplane, N904VJ, was being operated by ValuJet Airlines, Inc., as flight 592. Both pilots, the three flight attendants, and all 105 passengers were killed. Visual meteorological conditions existed in the Miami area at the time of the takeoff. Flight 592, operating under the provisions of 14 CFR Part 121, was on an instrument flight rules flight plan destined for the William B. Hartsfield International Airport, Atlanta, Georgia.

“Probable Cause: The National Transportation Safety Board determines that the probable causes of the accident, which resulted from a fire in the airplane’s class D cargo compartment that was initiated by the actuation of one or more oxygen generators being improperly carried as cargo, were (1) the failure of SabreTech to properly prepare, package, and identify unexpected chemical oxygen generators before presenting them to ValuJet for carriage; (2) the failure of ValuJet to properly oversee its contract maintenance program to ensure compliance with maintenance, maintenance training, and hazardous materials requirements and practices; and (3) the failure of the Federal Aviation Administration (FAA) to require smoke detection and fire suppression systems in class D cargo compartments.

“Contributing to the accident was the failure of the FAA to adequately monitor ValuJet’s heavy maintenance programs and responsibilities, including ValuJet’s oversight of its contractors, and SabreTech’s repair station certificate; the failure of the FAA to adequately respond to prior chemical oxygen generator fires with programs to address the potential hazards; and ValuJet’s failure to ensure that both ValuJet and contract maintenance facility employees were aware of the carrier’s “no-carry” hazardous materials policy and had received appropriate hazardous materials training.

“Safety issues discussed in the report include minimization of the hazards posed by fires in class D cargo compartments; equipment, training, and procedures for addressing in-flight smoke and fire aboard air carrier airplanes; guidance for handling of chemical oxygen generators and other hazardous aircraft components; SabreTech’s and ValuJet’s procedures for handling company materials and hazardous materials; ValuJet’s oversight of its contract heavy maintenance facilities; FAA’s oversight of ValuJet and ValuJet’s contract maintenance facilities; FAA’s and the Research and Special Programs Administration’s (RSPA) hazardous materials program and undeclared hazardous materials in the U.S. mail; and ValuJet’s procedures for boarding and accounting for lap children. Safety recommendations concerning these issues were made to the FAA, RSPA, the U.S. Postal Service, and the Air Transport Association.

Recommendations: “As a result of the investigation of this accident, the National Transportation Safety Board made the following recommendations:

“To the Federal Aviation Administration:

Expedite final rulemaking to require smoke detection and fire suppression systems for all class D cargo compartments. (A-97-56)

Specify, in air carrier operations master minimum equipment lists, that the cockpit-cabin portion of the service interphone system is required to be operating before an airplane can be dispatched. (A-97-57)

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. (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 flightcrew training, or both. (A-97-59)

Require that the smoke goggles currently approved for use by the flightcrews of transport category aircraft be packaged in such a way that they can be easily opened by the flightcrew. (A-97-60)

Evaluate the cockpit emergency vision technology and take action as appropriate. (A-97-61)

Evaluate and support appropriate research, including the National Aeronautics and Space Administration research program, to develop technologies and methods for enhancing passenger respiratory protection from toxic atmospheres that result from in-flight and post-crash fires involving transport-category airplanes. (A-97-62)

Evaluate the usefulness and effectiveness of the Douglas DC-9 procedures involving the partial opening of cabin doors and similar procedures adopted by some operators of other transport-category airplanes for evacuating cabin smoke or fumes and, based on that evaluation, determine whether these or other procedures should be included in all manufacturers’ airplane flight manuals and air carrier operating manuals. (A-97-63)

Require airplane manufacturers to amend company maintenance manuals for airplanes that use chemical oxygen generators to indicate that generators that have exceeded their service life should not be transported unless they have been actuated and their oxidizer core has been depleted. (A-97-64)

Require that routine work cards used during maintenance of Part 121 aircraft (a) provide, for those work cards that call for the removal of any component containing hazardous materials, instructions for disposal of the hazardous materials or a direct reference to the maintenance manual provision containing those instructions and (b) include an inspector’s signature block on any work card that calls for handling a component containing hazardous materials. (A-97-65)

Require manufactures to affix a warning label to chemical oxygen generators to effectively communicate the dangers posed by unexpended generators and to communicate that unexpended generators are hazardous materials; then require that aircraft manufactures instruct all operators of aircraft using chemical oxygen generators of the need to verify the presence of (or affix) such labels on chemical oxygen generators currently in their possession (A-97-66)

Require all air carriers to develop and implement programs to ensure that other aircraft components that are hazardous are properly identified and that effective procedures are established to safely handle those components after that are removed from aircraft. (A-97-67)

Evaluate and enhance its oversight techniques to more effectively identify and address improper maintenance activities, especially false entries. (A-97-68)

Review the adequacy of current industry practice and, if warranted, require that Part 121 air carriers and Part 145 repair facilities performing maintenance for air carriers develop and implement a system requiring items delivered to shipping and receiving and stores areas of the facility to be properly identified and classified as hazardous or nonhazardous, and procedures for tracking the handling and disposition of hazardous materials. (A-97-69)

Include, in its development and approval of air carrier maintenance procedures and programs, explicit consideration of human factors issues, including training, procedures development, redundancy, supervision, and the work environment, to improve the performance of personnel and their adherence to procedures. (A-97-70)

Review the issue of personnel fatigue in aviation maintenance; then establish duty time limitations consistent with the current state of scientific knowledge for personnel who perform maintenance on air carrier aircraft. (A-97-71)

Issue guidance to air carriers on procedures for transporting hazardous aircraft components consistent with Research and Special Programs Administration requirements for the transportation of air carrier company materials; then require principal operations inspectors to review and amend, as necessary, air carrier manuals to ensure that air carrier procedures are consistent with this guidance. (A-97-72)

Require air carriers to ensure that maintenance facility personnel, including mechanics, shipping, receiving, and stores personnel, at air carrier-operated or subcontractor facilities, are provided initial and recurrent training in hazardous materials recognition, and in proper labeling, packaging, and shipment procedures with respect to the specific items of hazardous materials that are handled by the air carrier’s maintenance functions. (A-97-73)

Ensure that Part 121 air carriers’ maintenance functions receive the same level of Federal Aviation Administration surveillance, regardless of whether those functions are performed in house or by a contract maintenance facility. (A-97-74)

Review the volume and nature of the work requirements of principal maintenance inspectors assigned to Part 145 repair stations that perform maintenance for Part 121 air carriers, and ensure that these inspectors have adequate time and resources to perform surveillance. (A-97-75)

Develop, in cooperation with the U.S. Postal Service and the Air Transport Association, programs to educate passengers, shippers and postal customers about the dangers of transporting undeclared hazardous materials aboard aircraft and about the need to properly identify and package hazardous materials before offering them for air transportation. The programs should focus on passenger baggage, air cargo, and mail offered by U.S. Postal Service customers. (A-97-76)

Instruct principal operations inspectors to review their air carriers’ procedures for manifesting passengers, including lap children, and ensure that those procedures result in a retrievable record of each passenger’s name. (A-97-77)

“To the Research and Special Programs Administration:

Develop records for all approvals previously issued by the Bureau of Explosives and transferred to the Research and Special Programs Administration and ensure all records, including designs, testing, and packaging requirements are available to inspectors to help them determine that products transported under those approvals can be done safely and in accordance with the requirements of its approval. (A-97-78)

“To the U.S. Postal Service:

Develop, in cooperation with the Federal Aviation Administration and the Air Transport Association, programs to educate passengers, shippers and postal customers about the dangers of transporting undeclared hazardous materials aboard aircraft and about the need to properly identify and package hazardous materials before offering them for air transportation. The programs should focus on passenger baggage, air cargo, and mail offered by U.S. Postal Service customers. (A-97-79)

Develop a program for U.S. Postal Service employees to help them identify undeclared hazardous materials being offered for transportation. (A-97-80)

Continue to seek civil enforcement authority when undeclared hazardous materials shipments are identified in transportation. (A-97-81)

“To the Air Transport Association:

Develop, in cooperation with the U.S. Postal Service and the Federal Aviation Administration, programs to educate passengers, shippers and postal customers about the dangers of transporting undeclared hazardous materials aboard aircraft and about the need to properly identify and package hazardous materials before offering them for air transportation. The programs should focus on passenger baggage, air cargo, and mail offered by U.S. Postal Service customers. (A-97-82)

(NTSB. “Board Meeting: In-Flight Fire and Impact with Terrain, ValuJet Airlines Flight 592, DC-9-32, N904VJ Everglades, Miami, Florida, May 11, 1996.” News & Events, 8-19-1997.)

CNN: “It was a Saturday afternoon, another day in the short but successful life of ValuJet, a three-year-old discount airline; an afternoon in which more than 100 people in Miami — some on their way somewhere for Mother’s Day visits — boarded ValuJet Flight 592 bound for Atlanta…” (CNN.com. ValuJet Flight 592, 1996)

Cobb and Primo: “This book grew out of our interest in the politics of the aviation industry and the uses of blame to deflect responsibility when an event with unfortunate consequences occurs. The 1996 crashes of ValuJet flight 592 and TWA flight 800 were of special interest because they highlighted the importance that the media play in aviation safety. The ValuJet crash was used as a symbol of low-cost carriers trading off safety for profits, and the company was forced to reinvent itself under another name….” (Preface, p. ix.)

“The Federal Aviation Act of 1958 authorized the creation of the Federal Aviation Agency, an independent regulatory unit. In 1966 the agency was stripped of its independent status, renamed the Federal Aviation Administration, and subsumed under DOT [Dept. of Transportation]. It was given two conflicting objectives (sometimes referred to as a dual mandate). One is safety concerns and regulation. The other is the promotion of the airline business. The first implies oversight of the airline industry, with demands for changes in safety policy. The latter implies a laissez-faire approach, in which airlines would largely be responsible for regulating themselves. The FAA worked closely with the individual airlines, and often promotion concerns trumped safety regulation. The position was altered, at least symbolically, after a series of accidents in the late 1990s. In 1996, in the wake of the ValuJet flight 592 crash, Congress changed the dual mandate of the agency and emphasized safety over the promotion of aviation….” (Chapter 2, “After the Crash,” p. 16.)

“In the past decade,[1] problems [in air transportation system] have mushroomed. The FAA has been so slow in responding to changing safety needs that it has been called the tombstone agency (meaning that change comes about only when people die)….” (Chap. 2, “After the Crash,” p.17.)

NationMaster.com: “….The 27 year old DC-9 aircraft on this route…previously owned by Delta Air Lines took off after a delay of 1 hour and 4 minutes at 2:04 pm and began a normal climb, however at 2:10 p.m. asked air traffic control for a return to Miami due to smoke in the cockpit and cabin. Captain Candi Kubeck and First Officer Richard Hazen were given instructions for a return to the airport. Seconds later, shouts of “fire, fire, fire, fire” were recorded on the plane’s cockpit voice recorder coming from the cabin. A flight attendant opened the cockpit door and informed the flight crew that the cabin was on fire, even though the ValuJet flight attendant manual stated that the cockpit door should not be opened when smoke or other harmful gases may be present in the cabin. The plane’s interior was completely on fire.

“Flight 592 disappeared from radar at 2:14 p.m. It crashed in Browns Farm Wildlife Management area in the Everglades, a few miles west of Miami….Recovery of the aircraft and victims was made extremely difficult by the location of the crash. The nearest road of any kind was more than a quarter of a mile…away from the crash scene, and the location of the crash itself was summarized as deep-water swamp with a bedrock base. The DC-9 shattered on impact with the bedrock, leaving very few large portions of the plane intact. Sawgrass, alligators, and risk of bacterial infection from cuts plagued searchers involved in the recovery effort….

“It was determined that the fire was caused by the firing of expired chemical oxygen generators placed in the cargo compartment in five boxes marked COMAT (company-owned material) by ValuJet’s maintenance contractor, SabreTech. The generators should not have been shipped in this manner in the first place, since they were hazardous materials. Making the matter worse was the fact that the firing pins for the generators were not properly protected with plastic sleeves to prevent an unintended firing of the generator, and that the canisters were not empty as had been indicated on the cargo manifest.

“Chemical oxygen generators, when fired, produce oxygen. As a byproduct of the chemical reaction, they also produce a great quantity of heat. These two together were sufficient to not only start an accidental fire, but also produce the oxygen to keep the fire burning at an extremely high temperature, made much worse by the presence of readily combustible aircraft wheels in the hold. When the plane experienced a slight jolt while taxiing on the runway, an oxygen canister fired and started to produce oxygen and heat of more than 500° F (260° C). The oxygen from the generators fueled the resulting fire in the cargo hold of the plane. ValuJet was blamed for improper oversight of SabreTech and the FAA was faulted for failing to properly monitor ValuJet. A pop and jolt traced in the air traffic control tape was attributed to a semi-inflated aircraft wheel exploding in the high temperature fire. Two main tires and wheels, a nose tire and wheel was also included in the COMAT.

“The cylindrical, tennis ball can-sized generators were loaded on board in the mistaken belief that their manufacturers, SabreTech, had carried out proper procedures for dealing with unfired canisters (the company workers claimed that the canisters were either “empty” or they had been dealt with properly, when in fact more than half of them were full and not correctly made safe). Had that been the case, the canisters would have posed no serious threat.

“It is believed that even with the generators in the cargo hold, the plane could have been saved. In 1988 American Airlines Flight 132 a MD-80 suffered from a similar accident. A cargo hold fire caused by hazardous materials started, but fortunately the aircraft landed safely. After this incident, the NTSB recommended to the FAA that all class D cargo holds have smoke detectors and/or fire suppression systems. However, it was never mandated.

“If there had been smoke detectors, the crew would have seen warnings that there was a fire and evacuated the plane, thus aborting the take-off. If there had been a fire-suppression system, the fire would have been extinguished and the flight would have continued without incident. It wasn’t until 2001 that suppression systems and smoke detectors have been mandated in all class D holds….

“In 1997, a federal grand jury charged SabreTech with mishandling hazardous materials, failing to train its employees on proper handling of hazardous materials, criminal conspiracy and making false statements. SabreTech’s maintenance supervisor, Daniel Gonzalez, and two mechanics who worked on the plane, Eugene Florence and Mauro Valenzuela, were charged with conspiracy and making false statements. In 1999, SabreTech was found guilty of mishandling hazardous materials and improper training. It was fined $2 million and ordered to pay $9 million in restitution. Gonzalez and Florence were acquitted on all charges; Valenzuela failed to appear, and is currently missing.

“This verdict was largely thrown out by the United States 11^th Circuit Curt of Appeals in 2001. It found that federal law at the time of the crash did not support a conviction for mishandling hazardous materials and added that SabreTech had no intention to cause any harm. However, it did uphold the conviction for improper training, and SabreTech was later sentenced to a $500,000 fine, three years’ probation and no restitution. Just before the federal trial, a Florida grand jury indicted SabreTech on 110 counts of manslaughter and 110 counts of third-degree murder; one for each person who died in the crash. However, in 2001 SabreTech settled the charges out of court. It pleaded no contest to a state charge of mishandling hazardous waste and agreed to donate $500,000 to an aviation safety group and a Miami-Dade County charity. The United States Court of Appeals for the Eleventh Circuit is a federal court with appellate jurisdiction over the following United States district courts: Northern, Middle, and Southern Districts of Alabama Northern, Middle, and Southern Districts of Florida Northern, Middle, and Southern Districts of Georgia These districts were originally part… In both criminal and civil trials in the United States, a plea of nolo contendere means that the defendant neither admits nor disputes the charge….

“SabreTech was the first American aviation company to be criminally prosecuted for its role in an American airline crash. The company, a subsidiary of St. Louis-based Sabreliner Corporation, went out of business in 1999. Nickname: Gateway City, Gateway to the West, or Mound City Location in the state of Missouri Coordinates: Country United States State Missouri County Independent City Mayor Francis G. Slay (D) Area – City 66. …

“ValuJet was grounded by the FAA on June 16, 1996. It was allowed to resume flying again on September 30, but never recovered from the crash. In 1997, it merged with AirTran. Although ValuJet was the nominal survivor, the ValuJet name was so tarnished by this time that it decided to take the AirTran name. It mentions almost nothing of its past as ValuJet….

“Many families of the Flight 592 victims were outraged that ValuJet/AirTran was not prosecuted, given ValuJet’s poor safety record. ValuJet had a higher accident rate than the 10 largest airlines, leading the FAA to take the unprecedented step of barring it from buying more planes or adding more cities without permission. The agency had seriously considered grounding the airline. The victims’ families also point to statements made by ValuJet officials immediately after the crash that appeared to indicate ValuJet knew the generators were on the plane, and in fact had ordered them returned to Atlanta rather than properly disposed.” (NationMaster.com. Encyclopedia, ValuJet Flight 592.)

Sources

CNN. “ValuJet Flight 592, 1996.” Accessed 12/20/2008 at: http://www.cnn.com/US/valujet.592/

Cobb, Roger W. and David M. Primo. “The Crash of ValuJet Flight 592.” Chapter 5, pp. 80-102, in The Plane Truth: Airline Crashes, the Media, and Transportation Policy. Brookings Institution Press, 2003.

Haine, Edgar A. Disaster in the Air. New York: Cornwall Books, 2000, 394 pages.

Hansen, Mark, Carolyn McAndrews, Emily Berkeley. History of Aviation Safety in the United States. Berkeley, CA: University of California at Berkeley, Institute of Transportation Studies, Research Report NR-2005-001, The National Center of Excellence for Aviation Operations Research, March 2005, 78 pages. Accessed at: http://www.nextor.org/pubs/NR-2005-001.pdf

National Fire Protection Association (John Hall, Jr.). U.S. Unintentional Fire Death Rates by State. Quincy, MA: NFPA, 31 pages, December 2008.

National Transportation Safety Board. Aircraft Accident Report. 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: NTSB, 8-19-1997, 271 pages. Accessed at: http://www.ntsb.gov/publictn/1997/AAR9706.pdf

National Transportation Safety Board. “Board Meeting: In-Flight Fire and Impact with Terrain, ValuJet Airlines Flight 592, DC-9-32, N904VJ Everglades, Miami, Florida, May 11, 1996.” Washington, DC: NTSB News & Events, 8-19-1997. Accessed 2-3-2016 at: http://www.ntsb.gov/news/events/Pages/In-Flight_Fire_and_Impact_with_Terrain_ValuJet_Airlines_Flight_592_DC-9-32_N904VJ_Everglades_Miami_Florida_May_11_1996.aspx

NationMaster.com. Encyclopedia. “ValuJet Flight 592.” Accessed 12-20-2008 at: http://www.nationmaster.com/encyclopedia/ValuJet-Flight-592

[1] Book published in 2003.

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