ValuJet Flight 592 crash investigation
ValuJet Flight 592 was a tragic aviation disaster that occurred on May 11, 1996, shortly after takeoff from Miami, en route to Atlanta. The flight, carrying 105 passengers and 5 crew members, crashed into the Florida Everglades, resulting in no survivors. The investigation revealed that the fire, likely caused by improperly stored oxygen generators, spread rapidly, leading to the loss of control of the aircraft. This incident highlighted significant deficiencies in both ValuJet's operations and maintenance practices, particularly its subcontractor, SabreTech. The National Transportation Safety Board (NTSB) later criticized the Federal Aviation Administration (FAA) for not enforcing safety recommendations, which ultimately led to a shift in the FAA's focus from promotion of the industry to prioritizing safety.
In the aftermath, ValuJet was grounded and subsequently merged with another airline, rebranding as AirTran Airways. The incident prompted changes in regulations regarding the transport of hazardous materials in aircraft, and it fueled ongoing discussions about the relationship between airline companies and regulatory bodies. The fallout from the crash extended to legal repercussions for individuals involved in maintenance operations, with one mechanic fleeing charges related to the incident. Overall, the ValuJet Flight 592 crash remains a pivotal event in aviation safety history, emphasizing the importance of stringent oversight and regulatory reform.
ValuJet Flight 592 crash investigation
DATE: Airliner crashed on May 11, 1996
THE EVENT: On May 11, 1996, ValuJet Flight 592, en route from Miami International Airport to Hartsfield International Airport in Atlanta, Georgia, crashed minutes after takeoff. The plane dived into the Florida Everglades, complicating the investigation into the causes of the crash as well as recovery of the remains of the passengers and crew.
SIGNIFICANCE: The forensic investigation into the crash of ValuJet Flight 592 focused on causes and effects. The ultimate impact of the disaster was a shift in the Federal Aviation Administration’s mandate from “promotion” to “safety” in the civil aviation industry.
ValuJet was one of several discount airlines created during the reconfiguration of the passenger airline industry following the bankruptcy of such major carriers as Pan American World Airways, Eastern Airlines, and several others. On May 11, 1996, one of ValuJet’s DC-9-32 aircraft was carrying 105 passengers and 5 crew members. Within minutes of takeoff, the copilot requested clearance from the control tower for the plane to return to Miami because of fire and smoke in the passenger cabin and cockpit. Soon after, however, the plane plunged into the Everglades, reportedly at an angle of some 75 degrees. The Miami-Dade County Department began search-and-rescue operations in the dangerous alligator- and snake-infested terrain, which was also covered with flammable aviation fuel, only to determine that there were no survivors.
Candalyn Kubeck, the first American female chief pilot to die in an accident, was in command of Flight 592. The plane, which was built in 1969, had been found to have several violations during ValuJet’s two and one-half years of operations, but it had never been grounded.
The Investigation
The plane’s flight data recorder, which measured eleven types of aircraft movement and control settings, was recovered on May 13. The voice recorder, or “black box,” was retrieved on May 15. The cockpit tape had recorded a brief, unidentified sound some six minutes after takeoff and indicated that the crew had been informed of fire and smoke conditions in the passenger cabin about twenty-two seconds later. Eleven seconds after that, the copilot requested clearance to return to Miami, but the plane crashed four minutes later, barely 20 miles west of the airport.
The search for human remains and wreckage ended on June 10. Some 75 percent of the aircraft was recovered, and the Metro-Dade County medical officer reported that by then the remains of 36 of the 110 crash victims had been identified.
The radio message of fire and smoke on board was confirmed by the state of the wreckage. Suspicions focused on the nature of the cargo stored in the plane’s forward hold, which included more than one hundred oxygen generators, the safety devices used in aircraft to provide oxygen to passengers when cabin pressure is lost. The investigators concluded that a chemical reaction inside one or more of the generators had ignited and in turn set fire to three aircraft tires also stored in the hold; from that point, the fire spread quickly. It was not clear, however, whether these conditions compromised the plane’s controls first or whether the conflagration had disabled the crew.
The investigators also discovered that ValuJet, in the interest of keeping expenses down, had farmed out maintenance and loading operations to a subcontractor: SabreTech, based in Phoenix, Arizona. It was also found that ValuJet had exercised very little supervision over this subcontractor. The oxygen generators had not been properly packed, lacked safety caps, and were incorrectly labeled as empty rather than as hazardous cargo as they should have been, given that the chemical reaction that creates oxygen in such generators can also create heat of up to 500 degrees Fahrenheit. The fire that occurred on the plane was further evidenced by the fact that the recovered debris included a scorched seat frame, two heat-damaged oxygen generators, and a partially burned aircraft tire.
The Federal Aviation Administration (FAA) shut down ValuJet on June 17, 1996, for an indefinite period after an intensive thirty-day investigation had uncovered “serious deficiencies” in the airline’s operations. These deficiencies included failure to perform repairs properly, failure to document repairs, flying aircraft known to have serious maintenance problems, and ignoring FAA safety directives. ValuJet was required to pay two million dollars as part of the cost of having its fleet reinspected. When ValuJet resumed operations several months later, it had merged with another company and was known as AirTran Airways. In December, 2001, SabreTech faced 220 charges of and involving the 110 victims of ValuJet Flight 592. The case was settled out of court, with SabreTech pleading no contest and agreeing to donate one-half million dollars to charity.
Final NTSB Report
All of these and other matters contributing to the tragedy were brought out in the report of the National Transportation Safety Board (NTSB) of August 19, 1997. In the report, the NTSB criticized the FAA for failing to enforce its ten-year-old recommendation that smoke detectors and fire suppression systems be installed in all aircraft cargo holds. The NTSB also expressed doubt whether ValuJet’s maintenance chief at the time of the crash, David Gentry, was properly qualified for his position and criticized ValuJet’s lack of supervision over SabreTech.
Underlying the problems noted by the NTSB was the cozy relationship between the airline industry and the FAA as well as the US Department of Transportation (DOT) as a whole, which is responsible for the public’s transportation safety. This is a general problem because often those responsible for overseeing airline industry matters themselves come from the ranks of the industry; this built-in conflict of interest makes the authorities sympathetic to the problems of the airlines in a highly competitive environment and thus unwilling to treat the airlines too harshly.
Politics also played a role. The airline industry is a significant financial contributor to the campaigns of many US senators and members of Congress who sit on important committees dealing with civil aviation, a situation that leads to considerable reciprocal back-scratching. Thus, even crusaders among the regulators (such as Mary Schiavo, former inspector general of the US Department of Transportation) were largely ignored when they charged that crucial negative reports on ValuJet’s earlier violations preceding the crash of Flight 592 had been suppressed so that the flying public would not be alarmed.
Consequences
On May 23, 1996, all passenger planes were forbidden to carry the kind of generator suspected of causing the ValuJet crash (although empty generators were exempted from the ban). Schiavo resigned from the Department of Transportation in July 1996 and went public with her complaints. In part as a result of the crash of Flight 592, the US Congress reworded the dual mandate with which the Federal Aviation Administration had originally been entrusted, namely, to promote civil aviation and ensure its safety. The FAA mandate became to promote safety as a priority but also to encourage the development of civil aviation.
In 1999, Mauro Ociel Valenzuela-Reyes, a mechanic working for SabreTech, was facing criminal charges connected to the crash. Reyes was accused of improperly placing the oxygen generators in the cargo hold without their safety caps. However, prior to his trial, Reyes fled. In 2018, the Federal Bureau of Investigation (FBI) in Miami issued a $10,000 reward for information leading to his capture. As of 2024, Reyes had not been apprehended. Law enforcement agencies speculated that he may be living under an assumed name in South America.
Bibliography
Calder, Simon. No Frills: The Truth Behind the Low-Cost Revolution in the Skies. London: Virgin Books, 2002.
Cobb, Roger W., and David M. Primo. The Plane Truth: Airline Crashes, the Media, and Transportation Policy. Washington, D.C.: Brookings Institution, 2003.
Fallows, James. Free Flight: From Airline Hell to a New Age of Travel. New York: PublicAffairs, 2001.
Krause, Shari Stamford. Aircraft Safety: Accident Investigations, Analyses, and Applications. 2d ed. New York: McGraw-Hill, 2003.
"Mauro Ociel Valenzuela-Reyes Wanted in Connection With ValuJet Airline Crash." Fugitive Watch, 11 July 2024, fugitive.com/mauro-ociel-valenzuela-reyes-wanted-in-connection-with-valujet-airline-crash/#google‗vignette. Accessed 16 Aug. 2024.
"New Reward for Fugitive in 1996 ValuJet Crash." Federal Bureau of Investigation, 5 Apr. 2018, www.fbi.gov/news/stories/new-reward-for-fugitive-in-1996-valujet-crash-040518. Accessed 16 Aug. 2024.
Schiavo, Mary, with Sabra Chartrand. Flying Blind, Flying Safe. New York: Avon Books, 1997.