Valu Jet Flight #592 Crash Incident Analysis_Bazeley-Mineta Transportation Institute

11/10/14 DesignStrategy-USA.com 1

ValuJet Flight 592 Transportation as the “cause”

“Improper Transportation of Hazardous Materials”

Roger_Bazeley, 05/04/2004

Slides 1-9 Are Professional Background and can be covered with Brief Comment - Alow for animation 5-8 seconds Per Slide. Slides 10-58 will be best if manually clicked for animation of coment points. Cooments may be made by reading headlines and highlighted sections of Bullet Points.The Pictures and With diagrams make for a show that can be flexible in time spent on each slide. Many are efective with a 5-10 Second pause.Runtime - 15-20 Minutes (58 Slides_ RMB)


ValuJet Flight 592: Aircraft: McDonnell Douglas DC-9-32

Manufactured 1967, 662 produced

2006, 294 DC-9-30 remain in service

2 Pratt & Whitney JT8D-9A Engines

14,500 lbs thrust

115 Passengers

Cruising Speed 570 mph


ValuJet Flight 592: The Incident 5/11/1996

May 11, 1996 at 2:14 EST ValuJet Flight 592 crashed Into the Florida Everglades about 10 Minutes after take-off from Miami Intl. Airport

Cause: In-flight Fire and Impact with Terrain

110 passengers/crew Died on impact

In-flight fire attributed to the Improper handling and transportation of hazardous materials by ValuJet’s maintenance contractor SabreTech

Passenger Oxygen Generators Human Error Factor/FAA Procedures


ValuJet 592: Location of The Crash SiteFlorida Everglades – 12 Miles Northwest of Miami International Airport


ValuJet Flight 592: Hazardous Materials Involvement

FRD CARGO HOLD – Fire Origin


ValuJet Flight 592: Hazardous Materials Involvement

Passenger Oxygen Generator/Mask


ValuJet Flight 592: In-Flight Activity before Impact

Preceding the plane’s impact the CVR recorded the captain stating “fire” and the first officer replying, “uh smoke in the cockpit…smoke in the cabin’.

1411:12, the CVR recorded a flight attendant shouting, “completely on fire.”

1411:26, the north departure controller advised the Miami Center that flight 592 was returning with an emergency.

1411:37, the first officer transmitted that they needed the closest airport.

1411:41, the controller replied,” Critter five ninety two they’re gonna be … standing by for you, you can plan runway one two when able to direct to Dolphin (an electronic navigational aid) now.”

1411:46, the first officer responded that the flight needed radar vectors.


ValuJet 592: In-Flight Activity before Impact

1411:49, the controller instructed flight 592 to turn left heading one four zero, and was acknowledged by the first officer.

1412:45, the controller transmitted, “Critter five ninety two keep the turn around heading uh one two zero.” No response from the flight crew.

The last recorded FDR data showed the aircraft at 7,200 feet MSL, at a speed of 260 KIAS, and on the heading 218 degrees.

1412.48, the FDR stopped recording data, while the planes transponder continued to function recorded by ATC.

The impact occurred at 1413:42.


The Crash Site: Point of ImpactFlorida Everglades – Deep Water Swamp – Bedrock Bottom


Response: Resources

Airport Foam Apparatus

The Miami-Dade Department Airport Fire Rescue Division (MDFR)

Conduct physical search and rescue operations in damaged or collapsed structures and transportation accidents.

Provide EM care at disaster sites for trapped victims and Task Force members.

Carry out reconnaissance duties to assess damage and determine needs, use collected information to provide feedback to all agencies involved.

Provide disaster communications support using state-of-the-art satellite systems.

Conduct hazardous materials survey/evaluations of affected areas.


Response: Recovery & Reconstruction

Collected Fragments Cargo Hold-Mock-up


Response: The NTSB “Go Team”

ValuJet 952 Report

NTSB “Go Team” is a group of investigators; on-call for immediate accident scene assignment

The remoteness of a crash site does not diminish the need to establish NTSB jurisdiction

The Go Team establishes a meeting place/EOC at the nearest location to the crash site

The NTSB safety officer conducts an accident site risk assessment by coordinating with the local Incident Commander

The safety officer or on-scene commander conducted daily briefings

NTSB has the sole responsibility to determine the cause of the accident


IMPACT: On Transportation

ValuJet CEO JORDAN

ValuJet was grounded by the FAA on June 16, 1996

ValuJet never recovered from the crash. In 1997, it merged with AirTran

Over 4,000 ValuJet employees lost jobs

July 1997, FAA indicated 14 ongoing investigation of oxygen generator transport on ailrines since the ValuJet crash , May 1, 1996

2001 FAA mandated fire suppression and detectors in all class D cargo holds

More restrictive technical and hazardous material proceedures and personel training implemented

Cockpit procdures for the use of oxygen masks and smoke goggles-revised FAA guidiance/specifications


IMPACT: On Victims’ Families

ValuJet CEO JORDAN

SabreTech’s fines of $2 million and $9 million in restitution and 110 counts of manslaughter and 110 counts of third degree murder were eliminated by the U.S. 11th Circuit Court of Appeals in 2001.

Florida State prosecutors dropped the murder case against SabreTech, ValuJet’s defunct maintenance contractor, in exchange for a $500,000 donation to aviation causes.

The federal court judge re-sentenced SabreTech to 3 years probation and a $500,000 fine for one count of improperly handling hazardous materials.

The psychological impact upon the victims’ families of these light-weight rulings and penalties exacted on ValuJet and SabreTech remains devastating…

1999 Flight 952, Everglades Memorial dedicated


ValuJet Flight 952: Lessons Learned

Failure of the FAA to adequately monitor ValuJet’s heavy maintenance programs and responsibilities, including ValuJet’s oversight of its contractors/ SabreTech’s repair certificate

Failure to insure that both ValuJet and contract maintenance facility employees were aware of the “no-carry” hazardous materials policy and had received appropriate hazardous materials.

U.S. passenger airlines are now required to have fire suppression and detection systems in specified cargo compartments; oxygen generators are banned as cargo on passenger aircraft

Federal Aviation Administration has hired more inspectors of hazardous materials and revamped its program of airline oversight

Frequent Training employees and contractors on the proper handling, packaging, labeling, and documentation of airline cargo and hazardous materials---FAA needs to be more proactive in implementing improvements generators are banned as cargo on passenger aircraft


ValuJet Flight 952: Conclusion

There was a major breakdown in the human factors performance areas which include:

1.) ValuJet’s management oversight and training

2.) Contractor due diligence in the personnel training of hazardous material regulations and handling procedures

3.) FAA timely implementation of corrective standards and procedures, guidance, oversight and enforcement for commercial airlines transporting and handling hazardous/dangerous cargo materials.

Valu Jet Flight #592 Crash Incident Analysis_Bazeley-Mineta Transportation Institute

Government & Nonprofit

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