ValuJet Flight 592 crash
ValuJet Flight 592, which crashed on May 11, 1996, shortly after takeoff from Miami, was a tragic event that resulted in the loss of all 110 people on board. The flight experienced smoke and fire conditions in the cabin, leading the crew to request a return to the airport, but the aircraft ultimately plunged into a swamp. Investigations revealed that the fire was likely caused by improperly stored chemical oxygen generators in the cargo hold, which ignited and possibly compromised the aircraft's controls. ValuJet's rapid expansion, outsourcing of operations, and inadequate oversight played significant roles in the circumstances leading up to the crash. The National Transportation Safety Board (NTSB) criticized both ValuJet and the Federal Aviation Administration (FAA) for their failures in safety regulation and oversight. In the wake of the accident, regulations regarding the transport of oxygen generators were tightened, and ValuJet later rebranded as AirTran. The incident highlighted serious deficiencies in airline safety standards and regulatory practices, prompting discussions about the relationship between the airline industry and government oversight.
ValuJet Flight 592 crash
The Event Atlanta-bound flight crashes near Miami, killing 110
Date May 11, 1996
Place Some twenty miles west of Miami International Airport in the Florida Everglades
When the DC-9-32 twin-engine aircraft hit the water and mud of the swamp, a lengthy investigation was begun to determine the cause of death of all aboard—two pilots, three flight attendants, and 105 passengers. Additionally, contributing factors were acknowledged, new safety regulations issued, and a few people in the private and public sectors lost their jobs. Suspended for a while, ValuJet returned to the air, eventually under a new identity.
ValuJet was one of the discount airlines created during the reconfiguration of the airline industry following the bankruptcy of such major carriers as Pan American World Airways (Pan Am) and Eastern Air Lines. Candalyn Kubeck, the first female chief pilot to die in an air crash, had Richard Hazen as her flight officer. Within minutes after takeoff, at eleven thousand feet, the copilot requested clearance from the control tower to return to Miami given the fire and smoke conditions in the passenger cabin and cockpit. As the plane was turning around, it plunged into the swamp, breaking up as it hit the surface. The Miami-Dade County Police Department began its search and rescue operations in the dangerous alligator- and snake-infested terrain, now covered with flammable aviation fuel and debris, only to determine that there were no survivors.
The Investigation
The crash was described as a “systems accident” born of the confusion that lies within the complex organizations through which an airline system is managed. Once in a while, several bad, minor choices, none of them lethal by itself, come together in synergistic fashion and cause a tragedy such as that of Flight 592.
The plane’s flight data recorder, which measured eleven types of aircraft movement and control settings, was recovered on May 13. The cockpit voice recorder was retrieved on May 15. Its tape had included a brief, unidentified sound some six minutes after takeoff and indicated that the crew had been informed of smoke and fire conditions in the passenger cabin. Eleven seconds thereafter, the plane requested clearance to return to the airport but crashed four minutes later.
The search for human remains and wreckage ended on June 10. By then, 36 of the 110 crash victims had been identified. The wreckage confirmed the smoke and fire on board. The investigation focused on the nature of the cargo stored in the plane’s forward hold, just below and behind the cockpit. Indeed, 119 chemical oxygen generators had been loaded there. Ironically, these small firebombs are in fact safety devices to provide passengers with the vital gas when an aircraft loses pressurization. The investigators concluded that a chemical reaction inside one or more of these generators had ignited and in turn set fire to at least one of three aircraft tires also stored in the hold. It was not clear, however, whether these conditions had compromised the plane’s controls first or whether the conflagration had disabled the crew, now unable to fly the plane.
The investigation also discovered that ValuJet, during its spectacular expansion from two to fifty-two aircraft over two and a half years, in the interest of keeping expenses low to make such growth possible, had farmed out loading and maintenance operations to a subcontractor, SabreTech, owned by Sabreliner of St. Louis and licensed by the Federal Aviation Administration (FAA). Both ValuJet and the FAA, as it turned out, had exercised very little supervision over SabreTech, which hired many underpaid casual workers in order to be competitive. The oxygen generators had not been properly packed, lacked the mandatory plastic safety caps over their firing pins, and were mislabeled as being empty rather than as hazardous cargo since the chemical reaction that creates oxygen can also generate heat well over 500, even 1,000 degrees Fahrenheit—which is what had happened.
The investigation uncovered “serious deficiencies” in the airline’s operations—inappropriate repairs, improper documentation, and ignoring FAA safety directives. ValuJet resumed flights several months later, eventually changing its designation to AirTran. In December, 2001, SabreTech faced 220 charges of murder and manslaughter involving the 110 crash victims. It was allowed to donate to charity by way of compensation.
Final NTSB Report
The final report of the National Transportation Safety Board (NTSB) of August 19, 1997, criticized the FAA for failing to enforce its ten-year-old recommendation that smoke detectors and fire suppression systems be installed in all cargo holds. Underlying it all was the cozy relationship between the airline on one hand and those at the FAA and its supervisory U.S. Department of Transportation (DOT) responsible for the public’s safety on the other. This is a general problem because often the government regulators themselves come from the industry that they are also supposed to control.
Then there is politics. The airline industry is a significant financial contributor to the campaigns of various congressional representatives and senators who sit on key civil aviation committees. Accordingly, here, too, there is considerable reciprocal back-scratching. Thus, even crusaders among the regulators (such as federal whistle-blower Mary Schiavo, former inspector general of the DOT) were voices crying in the wilderness when charging that crucial negative reports on ValuJet’s earlier violations had been suppressed.
Impact
On May 23, 1996, all passenger planes were forbidden to carry the kind of oxygen generators suspected of causing the crash (empty generators were exempted from the ban). After Schiavo resigned her job in July, 1996, and went public with her complaints, Congress reworded the dual mandate with which the FAA had been entrusted. It now called for safety first and foremost.
Bibliography
Cobb, Roger W., and David M. Primo. The Plane Truth: Airline Crashes, the Media, and Transportation Policy. Washington, D.C.: The Brookings Institution, 2003. Includes a good account of ValuJet Flight 592.
Langewiesche, William. “The Lessons of ValuJet 592.” The Atlantic Monthly, March, 1998, 81-98. A former working pilot tries to demonstrate that this was a case of “systems failure” lying beyond the reach of conventional solutions.
Matthews, Rick A., and David Kauzlarich. “The Crash of ValuJet Flight 592.” In State-Corporate Crime: Wrongdoing at the Intersection of Business and Government, edited by Raymond J. Michalowski and Ronald C. Kramer. New Brunswick, N.J.: Rutgers University Press, 2006. Stresses the mutually reinforcing interaction between the private sector (ValuJet and SabreTech) and the benign tolerance of government (the FAA) in the accident.