Case Study

The Crash of ValuJet Flight 592

Valujet was one of the generation of new discount airlines that sprang up as the result of airline deregulation
in the 1980s. Based in Atlanta, it offered cheap fares to Florida and other popular destinations. Its cost
savings were achieved in part by hiring other companies to perform many of the routine operations that keep
an airline flying. For example, many major airlines perform aircraft maintenance themselves, work that
Valujet hired a company named SabreTech to do. One of the jobs that SabreTech had been hired to perform
for Valujet was the routine task of replacing oxygen-generator canisters in some of its DC-9s. This work was
performed at SabreTech’s facility at Miami International Airport.

The oxygen canisters in the DC-9 are located above the passenger seats and are used to provide
oxygen to the passengers through masks should the cabin pressure somehow be lost. The canisters contain a
core of sodium chlorate, which is activated by a small explosive charge. This small explosion is initiated when
the passenger pulls the oxygen mask toward herself. A chemical reaction within the canister liberates oxygen,
which the passenger breathes through the mask. During use, the surface temperature of the canister can be as
high as 500°F, which is normally not a problem, since the canister is mounted so that it is well ventilated. To
ensure that they will operate properly when needed, the oxygen-generator canisters must be replaced
periodically.

The Valujet maintenance rules made it clear that when the canisters are removed, a bright yellow
safety cap must be installed on them to ensure that the explosive charge is not inadvertently set off.
Unfortunately, SabreTech didn’t have any of these safety caps on hand while they were performing this work.
Instead, tape was applied where the caps should have gone, and the canisters were placed in five cardboard
boxes and left on a shelf in the hangar. However, two of the SabreTech mechanics marked on the paperwork
that the caps had been installed and signed off on the job.

The five boxes of canisters sat on the shelf for several weeks, until a manager instructed a shipping
clerk to clean up the area and get the boxes out of the hangar.

Since the canisters were Valujet property, the shipping clerk prepared the boxes to be shipped back
to Valujet headquarters in Atlanta. He rearranged the canisters, placing some of them end to end in the box,
added some bubble pack on top, and sealed up the boxes. To this load, he also added tires, some of them
mounted on wheels and probably filled with air. A shipping ticket was prepared describing the load as empty
oxygen canisters (even though most of them were full) and tires. The load was delivered to Flight 592.

The Valujet ramp agent accepted the load despite the fact that Valujet was not certified to carry
hazardous wastes such as empty oxygen generators, which contain a toxic residue from the chemical reaction.
The flight’s copilot, Richard Hazen, also looked at the load and the shipping ticket, but apparently didn’t think
that there was a problem with carrying this cargo. Together, the ramp agent and the copilot decided to put
the load in the forward hold, which is underneath and behind the cockpit. The Valujet ground crew placed the
tires fl at on the bottom of the compartment and stacked the five boxes on top of the tires.

What happened to the plane after the cargo hold was loaded was reconstructed from the flight data
recorder and the voice recorder, the “black boxes” that all planes are required to carry. Takeoff of Flight 592
was normal. But six minutes into the flight, there was a beep on the public-address system. At the same time,
there was a sound like a chirp on the voice recorder. The flight data recorder indicated a pulse of pressure
occurring simultaneously with these sounds. Accident investigators think that during either taxi or takeoff,
one of the canisters was jostled and the explosive charge ignited. As the chemical reaction proceeded, the
canister got extremely hot, especially since the canisters were in a box and were not ventilated as they are
when mounted in the airplane. The chirping sound and the accompanying pressure surge were probably
caused by one of the tires in the hold bursting due to the heat. At this
point, the cardboard boxes and the tires were probably on fire. Suddenly, the plane’s instruments started to
indicate an electrical failure, presumably caused by the shorting or melting of some of the wiring that ran
underneath the cabin floor.

As smoke filled the cabin, the pilot, Candalyn Kubek, struggled to regain control of her aircraft.
Desperate radio messages were sent to air-traffic control in Miami, where controllers tried to route the plane
back to Miami and, finally, to a closer airport. The pilots were unable to control the plane. It banked sharply to
the right and dove nose first into the Everglades. All 110 persons aboard were killed.

This case seems to be a perfect example of a systemic accident. There were many small mistakes
made by several people:

• The proper safety caps should have been installed.

• Although the safety caps were not installed on the oxygen canisters, had they been packed properly, this
situation might not have been a problem.

• The ramp agent, who was trained to identify improper and hazardous cargo, should not have let these boxes
on the airplane.

• The copilot, similarly trained, should also have refused to carry this cargo.

• Something that generates such intense heat should not have been put in such close proximity to a tire,
which burns with very acrid and thick smoke.

• The cargo compartment should have had heat and smoke detectors to give the
pilots advanced warning of trouble in the hold.

By themselves, none of these lapses should have led to the crash. However, the convergence of all
these mistakes made the accident inevitable. In the aftermath of this accident, the State of Florida fi led
criminal charges against SabreTech, charging the company with 110 counts of murder, 110 counts of
manslaughter, and various charges related to the improper handling of hazardous materials. Initially, the jury
in the trial found SabreTech guilty of some of the criminal charges. This was the first time a criminal guilty
verdict had been returned against a corporation in the United States. After much legal wrangling, many of
these guilty verdicts were thrown out by an appeals judge. Ultimately, SabreTech agreed to plead no contest
to a single count of mishandling hazardous materials and to make a $500,000 donation to a fund supporting
airline safety causes. This outcome dismayed many of the accident victims’ families. SabreTech is no longer in
business.

Three SabreTech employees also faced criminal charges of making false statements, conspiracy, and
willfully violating hazardous-materials regulations. At least one of them claimed that he was ordered by
supervisors to sign forms allowing the mislabeled canisters to be placed on the airplane. Charges were
dropped against one of the three, and ultimately the other two were found not guilty. Immediately after the
accident, Valujet’s entire fleet was grounded for several months as the FAA investigated the company’s safety
record. Valujet began flying again in 1996, but eventually changed its name to AirTran to try to help lure
business back. As a result of the crash, the FAA began to require airlines to install heat and
smoke detectors in the cargo holds of all airplanes.