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The Crash of ValuJet Flight 592
Abstract:
This report explains human factors that caused Valujet flight 592 to crash into the
Introduction:
James Reason is changing the way we look at aviation safety. His
model of human performance, called Reasons model, evaluates all levels
of management and employees that can be linked to an accident. It consists of five components. They are the decision makers, management, preconditions, productive, and defenses. Some people make poor decisions that result in active failures, other people make latent failures. Latent failures occur long before an accident.[1] Latent failures are failures that set up unfavorable circumstances that allow active failures to occur. Active failures are failures of the people involved with the event or accident.
Active failures leading to an accident are the obvious ones. These people get most of the blame. It may be their fault, but what were the preconditions that these people were faced with? What pressures were put on them by upper management? What attitudes were commonly held? These are some of the questions that Reason’s model attempts to answer.
People who make latent failures usually don’t realize that their bad decisions can be as dangerous as ones made by people taking orders down the line. Another problem with upper management is their inability to frequently see the repercussions of their actions. They don’t get feedback all the time. Some may not even be aware of their mistakes. This is one of the main points that Reasons model makes. Latent failures are equally as critical as active failures. Sometimes the blame needs to be spread a little more evenly.
The Tragedy of Valujet:
When I recall a company called Valujet, all I can think of is tragedy. The carrier ceased to exist not because of a single crash, but because of the unmanageable problems that caused many crashes. Valujet flight 592 was the final red flag to shut the airline down. People admired Valujet for their low ticket prices. The industry loved the rapid growth of the company. The FAA upheld Valujet to “promote” aviation. They cited that it was a safe airline, despite evidence to the contrary. This attitude was destructive, in a way, because of the many oversights on the FAA’s part. We did not want to believe that Valujet was an accident looking for a place to happen. There was, of course, a flipside to the rapid expansion. Shoddy maintenance, combined with inadequate facilities which led to outsourcing to questionable companies, was a result of their rushed growth. This, along with the rest of the dominos, led to the in-flight fire and impact with terrain of Valujet flight 592.
Reason’s model examines weaknesses at all levels. The factors that went into this accident began with the FAA. This was the least recent failure in the chain of events. The FAA is not perfect. In fact, the FAA’s existence is a dual conflict. They were created to regulate and promote aviation. Sometimes there is a fine line between policing the airlines to ensure safety at all costs and protecting the airlines from opposition and criticism. Some workers of the FAA seem oblivious to this. They tend to lean to one side or the other. This may never be resolved. Federal statutes, along with the secretary of transportation, remain as the system of checks and balances for the FAA. But the DOT is the division that intimately knows what the FAA is up to and makes recommendations.
In this accident, the FAA made had previously contributed failures and indecisions. After a string of Valujet accidents in 1995, the FAA dismissed them and insisted they were a safe carrier. Then a planes landing gear collapsed a second time in early ’96, terrifying passengers and crew. Was the FAA going to do anything about this? Again, The FAA said they were safe. It seemed clear that the accidents were going to continue. Considering that the FAA’s inspectors had access to Valujet’s fleets, hangars, training records, log books, and maintenance offices, they were failing to do anything about Valujet. In fact, at one point, the FAA said Valujet was a model that others, including the FAA, should emulate.[2]
The FAA was reluctant to enforce restrictions that might hobble Valujet’s growth. But one of Valujet’s biggest problems was that it was cursed by its own growth. The FAA and DOT are both in charge of ensuring aviation safety. But money and effort are sometimes wasted in department programs. Also, when the FAA does find discrepancies, it can have problems communicating internally. The sense of urgency is often ambiguous in written reports. The FAA’s own inspectors wanted Valujet shut down months before flight 592 went into the
As new Inspector General Mary Schiavo headed the DOT, safety issues in aviation were investigated. The DOT started concentrating more on safety than audits, personnel regulations, etc. What they found were serious gaps in competence. The agency managed aviation as they saw fit. They were obviously too close to the aviation industry to see their own job clearly. This is why the DOT is the FAA’s whistleblower. The DOT’s conclusion was that the FAA had weaknesses in almost all areas of inspecting, supervising, examining, certifying, etc. The FAA was its own worst enemy. It would take the deaths of more than a hundred people aboard Valujet 592 to expose the chronic weaknesses in the FAA.
Valujet was an unconventional airline. It was a highly discounted carrier. Being the bare-bones airline that it was, it was initially a huge success story. In just three years it had leapt from two planes on eight routes to fifty-one planes with 320 itineraries.[3] Investors saw gargantuan profits from their stocks.
Valujet was able to offer very low fares by cutting out frills and not investing in large amounts of capital. They targeted students, the elderly, families with children, small business entrepreneurs, and others who wouldn’t normally fly. Their employees were not regarded highly. Pilot captains made $42,000; flight engineers: $28,000; and flight attendants got around $14,000. Passengers
got no meals, no seat reservations, no printed tickets, no city ticket
offices, no airline clubs or frequent flyer programs. Employees got no discount tickets. Executives had no company cars. Corporate offices had cheap furniture. The list goes on. Their fleet consisted of old Turkish Airline planes and used or reconditioned planes from other various sources. Other spare parts were also purchased from
In the barriers to an accident, Valujet shot far more holes in the wall than the FAA. But only because they were not forced to do anything by the FAA. Its growth had strained managers as well as the structure of the company itself. As it was growing too fast for its shoes, it lost organization. Executives have one of the most stressful jobs in the world. Valujet executives could not possibly keep up. More and more problems started arising at the surface.
Right around this time the Department of Defense needed an airline to ferry around its DOD personnel. Valujet bid for this contract. When the DOD examined Valujet closely, they were aghast to see the gaps at every level. They said the mid-level managers lacked a clear sense of duty and responsibility. The supervisors’ jobs were also ill-defined. Maintenance facilities, training, inspections, records, manuals, quality assurance, internal audits, and tool testing all had discrepancies. The result was a loss for the contract. Valujet is not good enough to fly DOD personnel. The report was not publicized. It was deemed for internal use only. But thousands of complacent passengers were allowed to fly. A While later, the FAA held an investigation on Valujet and found the same problems the DOD found months before.
The FAA had flaws in their regulations. In 1988, an American Airlines DC-9 had an in-flight fire in a cargo compartment. The cargo compartment was a class D cargo compartment, the same as Valujet’s DC-9 cargo compartments. As a result of the in-flight fire, the NTSB urged the FAA to rewrite regulations for class D cargo compartments. They urged them to require fire and smoke detection and extinguishing systems for all class D cargo compartments. Also, they recommended that the FAA evaluate certifications for all types of cargo compartments and correct any deficiencies in safety. The FAA did not change its requirements. It had just previously made some adjustments to cargo liner requirements and felt this gave an acceptable level of safety. Requiring compliance with making all class D cargo compartments safer would not meet cost/benefit criteria that the FAA had. Safety was put behind money.
Pilots for Valujet had poor role models for managers. The "corporate culture" was pervasive. Even their operations manuals for pilots had flaws. Pilots were only paid for flights they completed. This was a bad policy because it encouraged pilots to put safety after money. They would choose to fly rather than cancel for weather, maintenance, or other problems. The attitudes at Valujet were dangerous. Pilots from Valujet took off in weather that left pilots from other airlines grounded.
Valujet's maintenance was a nightmare. Its problems were directly proportional to its growth. Its maintenance program had been watered down over time. It spread maintenance to some fifty different contractors at eighteen companies.[5] It had little control over its own maintenance. Its emphasis was on keeping planes in service to maximize profits. This put safety after profits, a seemingly recurrent theme at Valujet. The result was an airline with an accident/incident record fourteen times worse than industry average. Emergency landings became a weekly occurrence. Some examples of poor maintenance are: putting a plane back into service that had a hole in the engine housing and letting it make eight flights, an emergency chute opening inside the cabin and pinning a flight attendant to the wall, an avionics microphone shorting out, a broken weather radar system that was complained about more than thirty times before it was fixed, a cabin rapidly depressurizing at altitude, and duct tape being used for general repairs. Once, a mechanic used a hammer and chisel on an engine part. Later, that engine had to be shut down in flight.[6]
Active Failures:
Aside from all the latent failures, this accident is filled with active failures as well. The accident resulted from a fire in the cargo compartment. The fire came from improperly labeled and packaged aviation oxygen generators. SabreTech was the company that prepared these oxygen generators. They were a maintenance facility which had a contractual relationship with Valujet to perform heavy aircraft repairs. An oxygen generator was inadvertently activated and the exothermic reaction started the fire. This fire either distracted the pilots or filled the cockpit with unmanageable amounts of smoke to the point that they crashed the airplane.
Valujet requested that SabreTech inspect the oxygen generators prior to the flight. So SabreTech did. But they inspected the expiration dates only. They did not check the condition of the generators. The generators were to go to two other Valujet planes. The generators have a few safety mechanisms built in. The retaining pin has the job of initiating the reaction, sort of like a grenade. It’s made so that a few pounds of pressure will pull it out. Additionally, a safety cap surrounds the retaining pin, resisting movement of the pin.[7] On the cargo that was boarded on flight 592, some oxygen generators had no safety caps. The McDonnell-Douglas maintenance manual stated that if an oxygen generator has not been expended, the safety cap must be installed around the firing pin.
Valujet had problems with the effectiveness of their training programs. All the books for training were OK, it was just the training itself that was ineffective. The maintenance crew that put the oxygen generators together didn’t prepare it right. Valujet employees were commonly not aware of their own hazardous materials requirements and practices. SabreTech employees had no hazardous materials training for Valujet’s policies. The carrier was not certified to carry any hazardous materials. The oxygen generators were not even supposed to be transported as cargo.[8] The company materials had passed by many employees without anyone noticing something wrong about sending oxygen generators on a flight with passengers. Even the first officer signed it off. Maybe somewhere down the line someone knew this was breaking company rules but dismissed it because the general attitudes of the company were lax. Valujet was infamously known for pencil-whipping and cutting corners.
Future Safety:
There were some vital lessons learned in human factors that sprawled from the crash of Valujet 592. The FAA doesn’t start fixing major problems until people start dying. Since the accident, the FAA has got the ball rolling on its rulemaking of requiring class D cargo compartments to have smoke/fire detection and suppression systems. The airlines have looked at the minimization of the hazards posed by fires in cargo compartments. Carriers have since refined their equipment, training, and procedures for addressing in-flight fires. Airline pilots are being trained to know the need to don oxygen masks at the first indication of smoke in the cockpit. Also, better smoke goggles are being installed in the cockpit. They are packaged so that they are easier to open.
Oxygen generators are not allowed on unapproved aircraft. More guidance was disbursed for handling oxygen generators and other hazardous aircraft components. The FAA looked into airlines’ procedures for handling company materials and hazardous materials. Valujet’s contract maintenance programs showed us that it is entirely possible for a major airline to overlook critical maintenance operations. The FAA improved safety issues such as their programs for hazardous materials. The United States Postal Service was recommended to improve safety in undeclared hazardous mail.
We were made aware of the safety issues of in-flight fires, such as the hazards of toxic atmospheres in the cabin. Respiratory protection in the cabin could be enhanced to save many lives in the near future. The effectiveness of current procedures to clear smoke from the cabin is being researched. One method is to partially open one or more cabin doors. Oxygen
generators are starting to carry different labels that more effectively
communicate the nature and danger of unexpended generators. The future looks brighter than the past for aviation safety.
Bibliography
Burt Chesterfield, James Reason’s Model,
Mary Schiavo, Flying Blind, Flying Safe,
Wall Street Journal,
NTSB, Aircraft Accident Report 20594, 1997,
[1] Burt Chesterfield, James Reason’s Model,
[2] Mary Schiavo, Flying Blind, Flying Safe,
[3] Mary Schiavo, Flying Blind, Flying Safe,
[4] Wall Street Journal,
[5] Mary Schiavo, Flying Blind, Flying Safe,
[6] Mary Schiavo, Flying Blind, Flying Safe,
[7] NTSB, Aircraft Accident Report 20594, page 7, 1997,
[8] NTSB, Aircraft Accident Report 20594, page x, 1997,