ValuJet Flight 592
A ValuJet McDonnell Douglas DC-9-32, similar to the one involved
|Date||May 11, 1996|
|Summary||Accidental activation of poorly packaged dangerous cargo, leading to in-flight fire and loss of control|
|Site||Everglades, Miami-Dade County, Florida, United States
|Aircraft type||McDonnell Douglas DC-9-32|
|Flight origin||Miami International Airport
|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 ValuJet Airlines McDonnell-Douglas DC-9 operating the route crashed into the Everglades about 11 minutes after taking off from Miami as a result of a fire in the cargo compartment caused by improperly stored cargo. All 110 people on board perished. The airline already had a poor safety record before the crash, and the accident brought widespread attention to the airline's problems. The airline was grounded for several months after the accident. When operations resumed, ValuJet's reputation was so tarnished that it was forced to merge with AirTran Airways and rebrand itself as such to stay in business. To date, the accident remains the deadliest in the history of Florida.
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 1986, an American Trans Air McDonnell Douglas DC-10 being serviced at Chicago's O'Hare International Airport had been destroyed on the ground by a fire caused by chemical oxygen generators. In 1988, American Airlines Flight 132 (operated by a McDonnell-Douglas MD-80) had a similar incident to that which later downed ValuJet Flight 592: a fire began in the cargo hold while the plane was in flight, caused by hazardous materials (primarily hydrogen peroxide), but in that case the crew landed the aircraft safely.
Aircraft and crew
The aircraft that crashed, a DC-9, 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.
In the cockpit were two experienced pilots: Captain Candalyn Kubeck (35) and First Officer Richard Hazen (52). Captain Kubeck had accumulated more than 8,900 hours throughout her career and First Officer Hazen had more than 11,800 total flight hours throughout his career.
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. 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 14:04, 10 minutes before the disaster, the DC-9 took off from runway 9L (now runway 8R) and began a normal climb.
At 14:10, 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 sag 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 no other way was available to inform the pilots of what was happening. The flight data recorder 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 14:13:42. 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 had burned through the floorboards in the cabin, resulting in structural failure and damage to cables underneath the instrument panels. The NTSB report on the accident stated, "the Safety Board cannot rule out the possibility that the flightcrew was incapacitated by smoke or heat in the cockpit during the last 7 seconds of the flight." Interruptions in the cockpit voice recorder occurred on two occasions, one as long as 1 minute 12 seconds. The aircraft hit the water at 14:13:42 Eastern Daylight Time, about 10 minutes after takeoff. The impact site was on the western edge of Florida Water Conservation Area 3B, between two levees, in an area known as the L-67 Pocket.
Kubeck, Hazen, the three flight attendants and all 105 passengers aboard were killed instantly. Recovery of the aircraft and victim remains 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 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:
...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 hitting the swamp and they could see nothing but scattered small debris and part of an engine near the crash site.
|Residences of passengers:||Passengers||Crew||Total|
Notable passengers killed on the flight included:
- San Diego Chargers running back Rodney Culver and his wife
- Songwriter and musician Walter Hyatt
- Del-Marie Walker, primary suspect in the murder of Catherine Holmes in College Park, Georgia.
- Former Miami Hurricanes football offensive lineman Robert Woodus
The oldest person aboard the jet was 84-year-old Conway Hamilton of Miami, and the youngest was four-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. About 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 passenger and crew remains to determine how much exposure they would have had to fumes and smoke from the in-flight fire.
At the end of a fifteen-month investigation, the NTSB 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 expired chemical oxygen generators were placed in the cargo compartment in five boxes marked COMAT (company 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. The cylindrical, tennis-ball-can-sized generators also may have been 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 they were empty oxygen canisters, when in fact they were neither simple oxygen canisters, nor empty. 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 a 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. 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.
The NTSB report placed responsibility for the accident on three parties:
- SabreTech, for improperly packaging and storing hazardous materials
- ValuJet, for not supervising SabreTech
- FAA, for not mandating smoke detection and fire suppression systems in cargo holds as recommended in 1988 after a similar incident
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. Valenzuela is still a fugitive; he was specifically highlighted in the EPA's announcement of a website to search for "environmental fugitives."
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.
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 also 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. 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.
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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 , about 11.9 miles west of Krome Avenue in Miami-Dade County and points to the location of the crash site 11.9 miles to the north-northeast. Students from the American Institute of Architecture designed the memorial, and local contractors, masons, and labor unions built it for free.
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.
The flight number "592" was retired from the use of ValuJet operations. Following the AirTran/ValuJet merger the year after the crash, the flight number "592" was retired from all future AirTran operations, and when AirTran was integrated into Southwest Airlines at the end of 2014, flight number 592 was retired from the SWA system as well.
In popular culture
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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"), 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). It was also referenced in the first CSI: Miami episode ("Golden Parachute") in 2002, as well as a second season episode ("Wannabe") in 2004. The 2009 Law & Order episode ("By Perjury") was also based on the case.
- Asiana Airlines Flight 991
- Eastern Air Lines Flight 401 – a 1972 accident in which an aircraft crashed into the Florida Everglades not far from where Flight 592 crashed
- List of accidents and incidents involving commercial aircraft
- Nigeria Airways Flight 2120 – crash resulting from an inflight fire triggered by a faulty tire
- Northwest Airlines Flight 705 – another airliner that crashed in the Everglades in February 1963
- Swissair Flight 111 – 1998 crash resulting from an inflight fire caused by faulty wiring
- UPS Airlines Flight 6 – crash resulting from an inflight fire caused by burning Li-Ion batteries in the cargo hold
- ""NTSB Report AAR97-06"" (PDF). Retrieved 22 July 2017.
- Matthews, Rick A.; Kauzlarich, David (1 August 2000). "The Crash of Valujet Flight 592: A Case Study in State-Corporate Crime". Sociological Focus. 33 (3): 281–298. doi:10.1080/00380237.2000.10571171. ISSN 0038-0237.
- Ranter, Harro. "ASN Aircraft accident McDonnell Douglas DC-10-40 N184AT Chicago-O'Hare International Airport, IL (ORD)". aviation-safety.net. Retrieved 22 July 2017.
- "Safety Recommendation A-88-123". National Transportation Safety Board. National Transportation Safety Board. Retrieved 23 January 2016.
- "Aviation Photo #0029996: McDonnell Douglas DC-9-32 - Valujet". Airliners.net. Retrieved 22 July 2017.
- Lawrence, Neal (Autumn 1998). "Danger in the Skies". Midwest Today.
- 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, DC 20594: National Transportation Safety Board. p. 107. Retrieved 24 January 2016.
- 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, DC 20594: National Transportation Safety Board. p. 174. Retrieved 24 January 2016.
- Davis, Steve; Ogden, John C. (1994-01-01). Everglades: The Ecosystem and Its Restoration. CRC Press. ISBN 9780963403025.
- 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, DC 20594: National Transportation Safety Board. p. 4. Retrieved 24 January 2016.
- "Complete list of passengers and crew." CNN. Retrieved on December 23, 2008.
- "Police Believe Killer Died in ValuJet Crash". Los Angeles Times. Reuters. 2 March 1997. Archived from the original on 30 October 2017. Retrieved 30 October 2017.
- "Indicted in 1996 ValuJet Crash, Airline Mechanic Still on EPA's Most-Wanted List". New York Times. Retrieved 24 January 2016.
- Mayday, "Fire in the Hold", season 12 episode 2
- "Revised Standards for Cargo or Baggage Compartments in Transport Category Airplanes". Federal Register. 17 February 1998. Retrieved 2008-10-23.
- "Mechanic in SabreTech Case Indicted for Contempt of Court". USDOT. October 13, 1999. Archived from the original on September 17, 2008.
- "12/10/2008: Wanted: Environmental Fugitives/ Federal government launches first-ever environmental crimes fugitive web site". Environmental Protection Agency. Retrieved 2010-02-10.
- Fishman, Donald A. (1 September 1999). "ValuJet flight 592: Crisis Communication Theory Blended and Extended". Communication Quarterly. 47 (4): 345–375. doi:10.1080/01463379909385567. ISSN 0146-3373.
- Huettel, Steve (May 11, 2006). "10 years after tragedy, AirTran flies on". St. Petersburg Times. Archived from the original on October 12, 2012.
- "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 January 13, 2007.
- "Crash Memorial Moving, Welcome". Retrieved 22 July 2017.
- Herrera, Chabeli (2013-06-04). "Gold pendant found at site of Everglades plane crashes". Miami Herald. Retrieved 2013-10-01.
- Langewiesche, William (March 1, 1998). "The Lessons of Valujet 592". The Atlantic. – Langewiesche presents a case that the ValuJet crash is an example of a "system accident," including the overly formal labeling and safety information on the oxygen 'canisters' (which actually were oxygen generators).
- Larson, Eric (May 20, 1996). "Death in the Everglades". TIME. (Subscription required for access to full article.)
- Flight 592 special report (CNN)
- NTSB brief report
- NTSB full report (PDF)
- Valenzuela's post on US EPA's Fugitive Site
- Audio transcript of the Air Traffic Control conversations
- "Valujet: The Crash of Flight 592 – The Accident". CNN. 1997. Archived from the original on August 16, 2000.
- Tester, Hank. "ValuJet Crash Remembered 15 Years Later" (Archive). NBC Miami. Wednesday May 11, 2011.
- "Valujet 592's Last Flight". The New York Times. November 19, 1996. – Transcript of the Valujet 592 flight recorder.
- Memorial location on Google Maps
- ValuJet Flight 592 Memorial
- Bragg, Rick (December 7, 1999). "Contractor Found Guilty in Trial on ValuJet Crash". The New York Times.
- Reed, Dan; Jones, Charisse (September 28, 2010). "Low-fare king Southwest to buy AirTran for $1.4 billion". USA Today.
- Photo of the plane after being retired by Delta and bought by Valujet
- Photo of the plane while in service with Valujet
- "Passenger list and gallery". flight592.com. Archived from the original on June 14, 2007.