FAA Failure Cited in ValuJet Crash Report

The National Transportation Safety Board on Tuesday blamed the Federal Aviation Administration, ValuJet Airlines and a maintenance contractor for last year’s fiery crash in the Florida Everglades that killed 110 people.

“The ValuJet accident resulted from failures all up and down the line, from federal regulators to airline executives in the boardroom to workers on the shop room floor,” NTSB Chairman Jim Hall said as his agency handed down its verdict.

NTSB investigators say that a cargo hold fire spread rapidly through the plane shortly after takeoff from Miami International Airport on May 11, 1996. The DC-9, which had no fire-detection or fire-suppression systems in the hold, plummeted nose-first into the swamp, killing everyone on board.

The most stinging criticism in the report was directed at the FAA, the agency responsible for drawing up and enforcing the regulations governing the aviation industry.

“Had the FAA required fire/smoke-detection and/or fire-extinguishment systems in [the DC-9’s] cargo compartments, as the safety board recommended in 1988, ValuJet Flight 592 would likely not have crashed,” the report says.

The board said that even if the intensity of the fire had been so great that a suppression system could not have snuffed it out entirely, the system “would have delayed the spread of the fire, and in conjunction with an early warning, it would likely have provided time to land the airplane safely.”

In an initial draft drawn up by its staff, the NTSB listed shortcomings of the FAA and SabreTech Inc.--a firm that did much of the maintenance work for the then-troubled airline--as the probable causes of the crash. ValuJet’s failings were listed only as “contributing factors.”

But at the suggestion of board member John Goglia during Tuesday’s public meeting, ValuJet was added to the list of principal culprits. It was a decision that drew applause from families of the crash victims.

Federal regulations state that the owner-operators of airliners are responsible for the proper maintenance of those aircraft, Goglia pointed out.

“It doesn’t matter who accomplishes that work,” he said. “They [the airline] must ensure that the airplane is airworthy.”

In tracing the causes of the accident, investigators found that 144 oxygen generators removed from another ValuJet airplane by SabreTech in early 1996 were crated in Florida for shipment to ValuJet’s home base in Atlanta.

In normal use, the generators--each of them a canister about the size and shape of a beer can--are installed in the ceiling above the passenger compartment. When activated, chemicals in the canisters react to produce oxygen for masks that can be used by passengers in the event of sudden and unexpected decompression at high altitudes.

The reaction generates a lot of heat--as much as 500 degrees Fahrenheit. But when installed in the ceiling, the canisters are shielded and insulated.

On Flight 592, the 144 crated canisters--many of which still contained the highly reactive chemicals--were being carried as cargo, stacked atop two large, inflated airplane tires also being carried as freight.

SabreTech officials say the outdated canisters had been incorrectly tagged as repairable, and a stock clerk compounded the error by mistakenly directing a shipping clerk to label them as “empty.”

The NTSB says the canisters in the hold were neither shielded nor insulated and lacked safety caps--required under federal shipping rules--that could have prevented their activation. Canisters containing the chemicals are classified as hazardous materials, and ValuJet was not authorized to carry hazardous cargo.

Somehow, either before or shortly after the DC-9 took off on a scheduled flight to Atlanta, at least one of the canisters tumbled from its box, detonating a built-in percussion cap that set off the oxygen-generating reaction. The first reaction apparently triggered others, flooding the hold with oxygen, heated by the chemical reactions.

In this oxygen-rich, superheated atmosphere, the tires in the hold burst into flames, and the fire spread rapidly upward into the passenger compartment and cockpit above the hold.

A cockpit monitor recovered from the wreckage recorded passengers’ shouts of “Fire! Fire! Fire!” as the pilots struggled in a vain attempt to fly the blazing, smoke-filled jetliner back to the airport in Miami. Whether the cockpit crew was overcome by the smoke before the fire crippled the control systems is not known.

Radar data show that the plane plunged 6,000 feet in about 30 seconds, leveling off momentarily before arcing down into the swamp.

In the final report adopted Tuesday, the board listed the probable causes of the crash as:

* The failure of SabreTech to properly prepare, package, identify and track unexpended chemical oxygen generators to ValuJet for carriage.

* The failure of ValuJet to properly oversee its contract maintenance program to ensure compliance with maintenance, maintenance-training and hazardous-materials requirements.

* The failure of the FAA to require smoke-detection and fire-suppression systems in the cargo holds of passenger planes.

Contributing factors listed by the board included the FAA’s failure to monitor ValuJet’s contract maintenance program, the failure of the FAA to develop programs to address the potential hazards posed by oxygen generators, and ValuJet’s failure to assure that maintenance personnel were trained properly.

The NTSB issued 32 recommendations, calling upon the FAA to expedite the process of developing rules requiring smoke-detection and fire-suppression systems in the holds of passenger planes, develop better maintenance accountability and find improved methods of safeguarding the transportation of hazardous materials.

The FAA responded to the NTSB report late Tuesday, promising “a careful review of the board’s findings and recommendations.” The FAA said it already has made “substantial progress” in many of the areas identified by the board.

Adopting a less-conciliatory tone, ValuJet and SabreTech responded by attacking each other.

ValuJet said SabreTech had “failed to fulfill its legal and moral obligations.”

SabreTech said ValuJet “has been in a permanent state of denial for 15 months over its critical, multiple failures.”

Since the accident, SabreTech has cut back many of its operations. ValuJet, grounded temporarily by the FAA because of maintenance problems that plagued the no-frills airline long before the crash, was permitted to resume operations last October.