ValuJet Flight 592 was a regularly scheduled flight from Miami to Atlanta in the United States. On May 11, 1996, the McDonnell Douglas DC-9 operating the route crashed into the Florida Everglades about 10 minutes after departing Miami due to a fire in the cargo compartment. The fire was caused by mislabeled and improperly stored chemical oxygen generators. All 110 people on board were killed.
ValuJet, a low-cost carrier, already had a poor safety record before the crash, and the incident brought widespread attention to the airline's problems. Its fleet was grounded for several months after the crash. When operations resumed, the airline was unable to attract as many customers as it had before the deadly crash. The airline acquired AirTran Airways in 1997 but the lingering damage to the ValuJet brand led its executives to assume the AirTran name. It is the deadliest aviation accident in Florida history .
Background ValuJet Airlines was founded in 1992 and was known for its aggressive cost-cutting measures. Many of the airline's planes were purchased in used condition from other airlines, and little training was provided to workers and contractors who were hired for maintenance and other services. ValuJet quickly developed a reputation for a lackluster safety record. In 1995, the United States military refused the airline's bid to fly its personnel due to safety concerns, and some officials at the Federal Aviation Administration (FAA) wanted the airline grounded.
In 1986, an American Trans Air McDonnell Douglas DC-10 being serviced at Chicago's O'Hare International Airport was destroyed on the ground by a fire caused by chemical oxygen generators. On February 3, 1988, aboard American Airlines Flight 132, a fire began in the cargo hold of the McDonnell Douglas MD-83 while the plane was in flight, caused by hazardous materials (primarily hydrogen peroxide); in that case the crew landed the aircraft safely. After Flight 132, the National Transportation Safety Board (NTSB) recommended to the FAA that all class D cargo holds be fitted with smoke detectors and fire-suppression systems. The FAA declined to implement the recommendation.
Aircraft and crew The aircraft, a DC-9-32 registered N904VJ, was the 496th DC-9 assembled at the Long Beach plant. It was 27 years old and had been previously flown by Delta Air Lines. Its first flight occurred on April 18, 1969, and it was delivered to Delta on May 27, 1969, as N1281L. 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 1993. The aircraft was powered by two Pratt & Whitney JT8D-9A turbofan engines.
The aircraft had suffered a series of incidents in the two years before the crash, including two aborted takeoffs and eight emergency landings. Engine and pressurization errors were the primary issues in several of the incidents. In May 1995, the FAA issued a rewiring directive for all DC-9 cockpits because the wire bundles in the switch panel could cause "fire and uncontrolled smoke throughout the cockpit as a result of chafing and shorting."
In the flight deck were two experienced pilots, Captain Candi Kubeck (35) and First Officer Richard Hazen (52). Kubeck had accumulated 8,928 total flight hours throughout her career (including 2,116 hours on the DC-9) and Hazen had more than 11,800 total flight hours throughout his career, with 2,148 on the DC-9.
Accident On the afternoon of May 11, 1996, Flight 592 left Gate G2 in Miami after a delay of one hour and four minutes because of electrical problems. There were 110 people on board: 105 passengers, mainly from Florida and Georgia, and a crew of two pilots and three flight attendants. At 2:04 p.m. EDT, the DC-9 departed from Runway 9L (now Runway 8R) and began a normal climb.
At 2:10 p.m., the passengers began to smell smoke. At the same time, the pilots heard a loud bang in their headsets and noticed that the plane was losing electrical power. The sag in electrical power and the banging sound were eventually determined to be the result of an explosion of a tire in the cargo hold. 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 (CVR) when the cockpit door was opened. ValuJet's flight-attendant training manual stated that the cockpit door should normally not be opened when smoke or other harmful gases might be present in the cabin. However, by this time the intercom was no longer functional and there was no other way to alert the pilots. The flight data recorder (FDR) indicated a progressive failure of the DC-9's electrical and flight control systems resulting from the spreading fire.
Kubeck and Hazen immediately asked air traffic control to return to Miami 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 when it crashed at 2:13:42 p.m., about ten minutes after takeoff.
Eyewitnesses 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 . According to the NTSB's report, two witnesses fishing nearby testified 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 nor 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 that they could see nothing but scattered small debris, part of an engine and a large pool of jet fuel near the crash site.
Examination of debris suggested that the fire had burned through the floorboards in the cabin, resulting in structural failure and damage to the hydraulic cables underneath the instrument panels. This likely rendered the plane uncontrollable; the flight data recorder showed Kubeck lost control of the plane less than 10 seconds before impact. The NTSB report on the accident stated that "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 of which was one minute and 12 seconds in length. The aircraft hit the water at 2:13:42 p.m. EDT, about 10 minutes after takeoff. The impact site was on the eastern edge of Florida Water Conservation Area 3B, between two levees, in an area known as the L-67 Pocket.
All on board were killed in the crash. Recovery of the aircraft and victims was severely complicated by the location of the crash. The nearest road of any kind was more than a quarter of a mile (400 m) away from the crash scene, and the location of the crash itself was a deep-water marsh with a floor of solid limestone. The aircraft 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.
Victims ResidenciesPassengersCrewTotal United States 99 5 104 United Kingdom 2 2 Bahamas 2 2 Unspecified 2 2 Total 105 5 110
Notable passengers killed on the flight included: San Diego Chargers running back Rodney Culver Songwriter and musician Walter Hyatt DelMarie Walker, 38, the prime suspect in a murder in Georgia
Recovery of the passengers and crew took several weeks, and very few intact human remains were found given the sheer violence of the impact, immersion in swamp water and scavenging by wildlife. About 68 of the 110 victims 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 Hazen, but Kubeck's remains were never found. Because of the adverse conditions, performing toxicology tests on the human remains to determine their exposure to fumes and smoke from the in-flight fire was not possible.
Investigation At the end of a 15-month investigation, the National Transportation Safety Board (NTSB) determined that the fire had developed in a cargo compartment below the passenger cabin. The cargo compartment was of a Class D design, in which fire suppression is accomplished by sealing the hold from outside air. Any fire in such an airtight compartment would quickly exhaust all available oxidizers and then extinguish itself. As the fire suppression can be accomplished without any intervention by the crew, such holds are not equipped with smoke detectors.
The NTSB determined that just before takeoff, 144 expired chemical oxygen generators, each slightly larger than the size of a tennis-ball can, had been placed in the cargo compartment in five boxes marked COMAT (company material) by ValuJet's maintenance contractor SabreTech. This violated Federal Aviation Administration (FAA) regulations forbidding the transport of hazardous materials in passenger-aircraft cargo holds. Failure to cover the generators' firing pins with the prescribed plastic caps made accidental activation much more likely. The investigation revealed that rather than covering the pins, maintenance personnel simply cut the cords attached to the pins or applied duct tape around the cans, and consumer-grade adhesive tape was also used to secure the ends. SabreTech employees indicated on the cargo manifest that the "oxy canisters", which were loosely packed in boxes that were each sealed with tape and bubble wrap, were "empty." ValuJet workers then loaded the boxes in the cargo hold in the mistaken belief that the devices were simply empty canisters that would be safe and legal to transport on a passenger aircraft.
Chemical oxygen generators, when activated, produce oxygen for passengers if the plane suffers a decompression. However, they also produce a great quantity of heat because of the exothermic nature of the chemical reaction involved. Therefore, not only could the heat and generated oxygen start a fire, but the oxygen could also keep the fire burning.
Investigators determined that one of the oxygen generators was likely triggered when the plane experienced a slight jolt while taxiing. As the aircraft taxied and took off, the generator began releasing heat that caused other canisters to activate. Each activation created more heat, which rapidly caused all of the generators to activate. The intense heat ignited a fire in the other materials in the cargo hold. The fire was worsened by the presence of two main aircraft tires, one of them mounted on a main wheel, and a nose tire and wheel that were also included in the list of materials shipped as COMAT.