ValuJet Flight 592

ValuJet Airlines Flight 592

A ValuJet McDonnell Douglas DC-9-32, similar to the one involved
Accident summary
Date May 11, 1996
Summary In-flight fire caused by improperly stored oxygen generators
Site Everglades, Miami-Dade County, Florida, United States
25°54′47″N 80°34′41″W / 25.91306°N 80.57806°W / 25.91306; -80.57806Coordinates: 25°54′47″N 80°34′41″W / 25.91306°N 80.57806°W / 25.91306; -80.57806
Passengers 105
Crew 5
Fatalities 110 (all)
Survivors 0
Aircraft type McDonnell Douglas DC-9-32
Operator ValuJet Airlines
Registration N904VJ
Flight origin Miami International Airport
Miami, Florida
Destination William B. Hartsfield Atlanta Int'l Airport, Atlanta, Georgia

ValuJet Flight 592 was a regularly scheduled flight from Miami International Airport to Hartsfield-Jackson Atlanta International Airport. On May 11, 1996, the McDonnell-Douglas DC-9 operating the route crashed into the Everglades approximately eleven minutes after taking off from Miami as a result of a fire in the cargo compartment caused by improperly stored cargo, killing all 110 people on board.[1] The airline already had a poor safety record before the crash, and the crash brought widespread attention to the airline's problems. Because of this incident, the airline was grounded for several months after the accident and was forced to acquire another brand (Air Tran) to continue to stay in business.

Background

ValuJet Airlines was founded in 1992 and was known for its cost-cutting measures. All of the airline's planes were purchased used from other airlines, very little training was provided to workers, and contractors were used for maintenance and other services. The company quickly developed a reputation for its lax safety. In 1995, the U.S. military refused ValuJet's bid to fly military personnel because of safety worries, and officials at the FAA wanted the airline to be grounded.

In 1996, an American Trans Air McDonnell-Douglas DC-10 being serviced at Chicago's O'Hare International Airport was destroyed by a fire caused by chemical oxygen generators.[2] In 1988, American Airlines Flight 132 (a McDonnell-Douglas MD-80, the successor airplane to the DC-9) had a similar accident. A fire began in the cargo hold, caused by hazardous materials (primarily hydrogen peroxide), but the crew landed the aircraft safely.[3] After the ValuJet Flight 592 incident, the National Transportation Safety Board (NTSB) recommended to the FAA that all class D cargo holds have smoke detectors and/or fire suppression systems.

Aircraft and crew

The aircraft that crashed, a DC-9,[4] was 27 years old and had been previously owned by Delta Air Lines. Its first flight was April 18, 1969. Delivered to Delta on May 27, 1969, the airframe flew for Delta until the end of 1992, when it was retired and sold back to McDonnell Douglas. McDonnell Douglas then sold the plane to ValuJet in early 1993.

The aircraft had suffered a series of incidents in the two years prior to the crash, including aborted takeoffs and emergency landings.[5]

In the cockpit were two experienced pilots: Captain Candalyn Kubeck (35) and First Officer Richard Hazen (52). The captain had accumulated more than 8,900 hours throughout her career and the first officer had more than 11,800 total flight hours.[6]

Accident

On the afternoon of May 11, 1996, Flight 592 pushed back from gate G2 in Miami after a delay of 1 hour and 4 minutes due to mechanical problems.[1] There were 105 passengers, mainly from Florida and Georgia, on board, as well as a crew of two pilots and three flight attendants, bringing the total number of people on board to 110. At 2:04 pm, 10 minutes before the disaster, the DC-9 took off from runway 9L (now runway 8R) and began a normal climb.

At 2:10 pm, the passengers started to smell smoke. At the same time, the pilots heard a loud bang in their headphones and noticed the plane was losing electrical power. The spike in electrical power and the bang were eventually determined to be the result of a tire in the cargo hold exploding. Seconds later, a flight attendant entered the cockpit and informed the flight crew of a fire in the passenger cabin. Passengers' shouts of "fire, fire, fire" were recorded on the cockpit voice recorder when the cockpit door was opened. Though the ValuJet flight attendant manual stated that the cockpit door should not be opened when smoke or other harmful gases might be present in the cabin, the intercom was disabled and there was no other way to inform the pilots of what was happening. The CDR indicated a progressive failure of the DC-9's electrical and flight control systems due to the spreading fire.

Kubeck and Hazen immediately asked air traffic control for a return to Miami due to the increasing smoke in the cockpit and cabin, and were given instructions for a return to the airport. One minute later, Hazen requested the nearest available airport. Kubeck began to turn the plane left in preparation for the return to Miami.

Flight 592 disappeared from radar at 2:13:42 pm. Eyewitnesses nearby watched as the plane banked sharply, rolled onto its side and nosedived into the Francis S. Taylor Wildlife Management Area in the Everglades, a few miles west of Miami, at a speed in excess of 507 miles per hour (816 km/h). Kubeck lost control of the plane less than 10 seconds before impact. Examination of debris suggested that the fire burned through the floorboards in the cabin, resulting in structural failure and damage to cables underneath the instrument panels. It is possible that the crew was incapacitated by smoke and heat during the last seven seconds of the flight.[7] There were interruptions in the cockpit voice recorder on two occasions, one as long as 1 minute 12 seconds.[8] The aircraft impacted the swamp at 1413:40 Eastern Standard time, 31 minutes and 19 seconds into the flight.

Kubeck, Hazen, the three flight attendants, and all 105 passengers aboard were killed instantly. 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 mile (400 m) away from the crash scene, and the location of the crash itself was a deep-water swamp with a floor made out of solid limestone. The DC-9 was destroyed on impact, with no large pieces of the fuselage remaining. Sawgrass, alligators, and risk of bacterial infection from cuts plagued searchers involved in the recovery effort.

Two witnesses, fishing nearby, testified according to the NTSB report:[9]

...that they saw a low-flying airplane in a steep right bank. According to these witnesses, as

the right bank angle increased, the nose of the airplane dropped and continued downward. The

airplane struck the ground in a nearly vertical attitude.

They reported seeing no external damage to the DC-9 or any sign of fire or smoke other than the engine exhaust. A group of sightseers in a small private plane also witnessed the crash and provided a nearly identical account, stating that Flight 592 seemed to "disappear" after impacting the swamp and they could see nothing but scattered small debris and part of an engine near the crash site.

Victims

Residences of passengers:[10]PassengersCrewTotal
 United States1055110
Total1055110
Names of victims at memorial

Notable passengers killed on the flight included:[10]

The oldest person aboard the jet was 84-year-old Conway Hamilton of Miami, and the youngest was 4-year-old Daniel Darbor of Atlanta.

Recovery of the passengers and crew took several weeks and little in the way of intact human remains were found due to the sheer violence of the impact, immersion in swamp water, and scavenging wildlife. Approximately 68 of the 110 persons aboard the plane were identified, in some cases from examining jawbones and at least one individual from a single tooth. A piece of torn flesh was proven to belong to First Officer Hazen, but Captain Kubeck's remains were never found. Due to the above-mentioned factors, it was not possible to perform toxicology tests on the passengers' and crew's remains to determine how much exposure they would have had to fumes and smoke from the in-flight fire.

Investigation

The NTSB investigation[1] eventually determined that the fire that downed Flight 592 began in a cargo compartment below the passenger cabin. The cargo compartment was a Class D design, in which fire suppression is accomplished by sealing off the hold from outside air. Any fire in such an airtight compartment would quickly exhaust all available oxygen and then burn itself out. As the fire suppression is accomplished without any intervention by the crew, such holds are not equipped with smoke detectors. However, the NTSB determined that just before takeoff, over 100[14] expired chemical oxygen generators were placed in the cargo compartment in five boxes marked COMAT (Company-Owned MATerial) by ValuJet's maintenance contractor, SabreTech, in contravention of FAA regulations forbidding the transport of hazardous materials in aircraft cargo holds. Failure to cover the generators' firing pins with the prescribed plastic caps made an accidental activation much more likely. The investigation revealed that rather than covering the firing pins, the SabreTech workers simply duct-taped the cords around the cans, or cut them, and used tape to stick the ends down. It is also possible that the cylindrical, tennis-ball-can-sized generators were loaded on board in the mistaken belief that they were just empty canisters, thus being certified as safe to transport in an aircraft cargo compartment. SabreTech employees indicated on the cargo manifest that the "oxy canisters" were "empty" instead of being expired oxygen generators. ValuJet employees interpreted this to mean that they were empty oxygen canisters, when in fact they were neither simple oxygen canisters, nor empty.[15] A worker then loosely packed the oxygen canisters in several cardboard boxes with a layer of bubble wrap.

Chemical oxygen generators, when activated, produce oxygen for passengers if the plane suffers an explosive decompression. As a byproduct of the exothermic chemical reaction, they also produce a great quantity of heat. These two factors together were sufficient not only to start an accidental fire, but also to produce enough oxygen to keep the fire burning. The fire risk was made much worse by the presence of combustible aircraft wheels in the hold. Two main tires (one not mounted) and a nose tire and wheel were also included in the list of material shipped as COMAT. NTSB investigators theorized that when the plane experienced a slight jolt while taxiing on the runway, an oxygen generator activated, producing oxygen and heat. Over time, as the DC-9 was taxiing to its takeoff position the surface of the activated generator got hotter and hotter. Soon, the heat ignited the cardboard box and bubble wrap, allowing the fire to start.

Laboratory testing showed that canisters of the same type could heat nearby materials up to 500 °F (260 °C), enough to ignite a smoldering fire. The oxygen from the generators fed the resulting fire in the cargo hold without any need for outside air, defeating the airtight fire suppression design. A pop and jolt heard on the cockpit voice recording and correlated with a brief and dramatic spike in the altimeter reading in the flight data recording were attributed to the sudden cabin pressure change caused by a semi-inflated aircraft wheel in the cargo hold getting so hot that it exploded.[15] Investigators also determined that in this process, the fire began to destroy control cables that ran to the back of the DC-9, which explained why the pilots began losing control 3 and 1/2 minutes before the plane crashed.

Smoke detectors in the cargo holds can alert the flight crew of a fire long before the problem becomes apparent in the cabin, and a fire suppression system buys valuable time to land the plane safely. In February 1998, the FAA issued revised standards requiring all Class D cargo holds to be converted by early 2001 to Class C or E; these types of holds have additional fire detection and suppression equipment.[15][16]

Culpability

The NTSB report placed responsibility for the accident on three parties:

In 1997, a federal grand jury indicted SabreTech for mishandling hazardous materials, failing to train its employees in proper handling of hazardous materials, 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. Two years later, having been found guilty on the mishandling hazardous materials and improper training charges, SabreTech was fined $2 million and ordered to pay $9 million in restitution. Gonzalez and Florence were acquitted on all charges, while Valenzuela failed to appear and was indicted in absentia for contempt of court.[17] Valenzuela is still a fugitive; he was specifically highlighted in the EPA's announcement of a website to search for "environmental fugitives."[18]

In 2001, the United States 11th Circuit Court of Appeals reversed the SabreTech guilty verdict in part. In so doing, the panel concluded that federal law at the time of the crash could not support a conviction for mishandling hazardous materials and that the government did not prove that SabreTech intended to cause harm. The panel did, however, uphold the conviction for improper training, and on remand, the District Court sentenced SabreTech 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. SabreTech settled the state charges by agreeing to plead no contest to a state charge of mishandling hazardous waste and to donate $500,000 to an aviation safety group and a Miami-Dade County charity.

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, but Saberliner Corporation is still operating.

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, the company merged with AirTran Airways. Although ValuJet was the nominal survivor, the ValuJet name was so tarnished by this time that it was scrapped in favor of the AirTran name. In 2006, AirTran did not make any major announcements on the crash's 10th anniversary out of respect for the victims' families.[19]

Many families of the Flight 592 victims were outraged that ValuJet was not prosecuted, given the airline's poor safety record. ValuJet's accident rate was not only one of the highest in the low-fare sector, but 14 times higher than those of the mainline airlines. In the aftermath of the crash, an internal FAA memo surfaced questioning whether ValuJet should have been allowed to stay in the air.[5] The victims' families also point to statements made by ValuJet officials immediately after the crash that appeared to indicate the company knew the generators were on the plane, and in fact had ordered them returned to Atlanta rather than properly disposed of in Miami.[20]

Legacy

Everglades memorial

On the third anniversary of the accident, in 1999, a memorial was dedicated to the victims in the Everglades. The memorial, consisting of 110 concrete pillars, is located just north of Tamiami Trail at 25°45′42.61″N 80°40′19.30″W / 25.7618361°N 80.6720278°W / 25.7618361; -80.6720278 about 11.9 miles west of Krome Avenue in Miami-Dade County and points to the location of the crash site eight miles to the north.

Students from the American Institute of Architecture Students designed the memorial and local contractors, masons and labor unions built it for free.[21]

In a June 4, 2013 Miami Herald article, a local resident stated that while slogging through the sawgrass several months earlier he found a partially melted gold pendant in the same area, which is thought possibly to be from either the ValuJet crash or the crash of Eastern Air Lines Flight 401, which had occurred about 2 miles (3.2 km) from the ValuJet crash site.[22]

In popular culture

COPS happened to be taping with the Miami-Dade Police Department when the accident occurred. As a result, season 9, episode 12, aired featuring some of the first 911 calls and the initial investigations into the accident. Three National Geographic shows, Why Planes Crash ("Fire In The Sky"), Seconds From Disaster ("Florida Swamp Air Crash"), and Mayday ("Fire in the Hold"),[15] covered the crash. It was also featured in the last episode of the four-part Travel Channel series Probable Cause: Air Crash Investigations (Acceptable Risk).

See also

References

  1. 1 2 3 "NTSB Report AAR97-06"
  2. ↑ Candiotti, Susan (15 November 1996). "ValuJet 592 Crash to Be Blamed on Oxygen Canisters". CNN. Cable News Network. Retrieved 6 May 2014.
  3. ↑ "Safety Recommendation A-88-123". National Transportation Safety Board. National Transportation Safety Board. Retrieved 23 January 2016.
  4. ↑ N904VJ
  5. 1 2 Lawrence, Neal (Autumn 1998). "Danger in the Skies". Midwest Today. Retrieved June 2013.
  6. ↑ http://www.ntsb.gov/doclib/reports/1997/aar9706.pdf
  7. ↑ NTSB. "AIRCRAFT ACCIDENT REPORT IN-FLIGHT FIRE AND IMPACT WITH TERRAIN VALUJET AIRLINES FLIGHT 592" (PDF). National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594: National Transportation Safety Board. p. 107. Retrieved 24 January 2016.
  8. ↑ NTSB. "AIRCRAFT ACCIDENT REPORT IN-FLIGHT FIRE AND IMPACT WITH TERRAIN VALUJET AIRLINES FLIGHT 592" (PDF). National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594: National Transportation Safety Board. p. 174. Retrieved 24 January 2016.
  9. ↑ NTSB. "AIRCRAFT ACCIDENT REPORT IN-FLIGHT FIRE AND IMPACT WITH TERRAIN VALUJET AIRLINES FLIGHT 592" (PDF). National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594: National Transportation Safety Board. p. 4. Retrieved 24 January 2016.
  10. 1 2 3 "Complete list of passengers and crew." CNN. Retrieved on December 23, 2008.
  11. ↑ "Murderer died in Valujet crash". Reuters, February 27, 1997, St. Petersburg Times, page 5A, Column 1. . Retrieved December 10, 2008.
  12. ↑ "Atlanta News, Sports, Atlanta Weather, Business News | ajc.com". Nl.newsbank.com. 1 March 1997. Retrieved 2010-02-10.
  13. ↑ "Police Believe Killer Died in ValuJet Crash". Los Angeles Times, March 2, 1997, Los Angeles Times, LA Times On-line Collections. . Retrieved March 20, 2013.
  14. ↑ "Indicted in 1996 ValuJet Crash, Airline Mechanic Still on EPA's Most-Wanted List". New York Times. Retrieved 24 January 2016.
  15. 1 2 3 4 Mayday, "Fire in the Hold", season 12 episode 2
  16. ↑ "Revised Standards for Cargo or Baggage Compartments in Transport Category Airplanes". Federal Register. 17 February 1998. Retrieved 2008-10-23.
  17. ↑ "Mechanic in SabreTech Case Indicted for Contempt of Court". USDOT. October 13, 1999. Archived from the original on September 17, 2008. Retrieved June 2013.
  18. ↑ "12/10/2008: Wanted: Environmental Fugitives/ Federal government launches first-ever environmental crimes fugitive web site". Environmental Protection Agency. Retrieved 2010-02-10.
  19. ↑ Huettel, Steve (May 11, 2006). "10 years after tragedy, AirTran flies on". St. Petersburg Times. Archived from the original on October 12, 2012. Retrieved June 2013.
  20. ↑ "US Attorneys' Office Ignores Critical Evidence in the Valujet Crash: Valujet admitted oxygen generators were to be returned". flight592.com. July 12, 1999. Archived from the original on November 31, 2007. Check date values in: |archive-date= (help)
  21. ↑ http://articles.sun-sentinel.com/1999-05-13/news/9905120786_1_crash-site-plane-airline-tragedy
  22. ↑ Herrera, Chabeli (2013-06-04). "Gold pendant found at site of Everglades plane crashes". Miami Herald. Retrieved 2013-10-01.

Further reading

External links

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