AIRCRAFT ACCIDENT REPORT

1 PB97-910406 NTSB/AAR-97/06 DCA96MA054 NATIONALTRANSPORTATIONSAFETYBOARDWASHING TON, 20594 AIRCRAFT ACCIDENT REPORTIN-FLIGHT FIRE AND IMPACT WITH TERRAINVALUJET AIRLINES FLIGHT 592DC-9-32, N904 VJEVERGLADES, NEAR MIAMI, FLORIDAMAY 11,19966704 BThe national transportation safety board is an independent Federal agency dedicated topromoting aviation, railroad, highway, marine, pipeline, and hazardous materials 1967, the agency is mandated by Congress through the Independent SafetyBoard Actof 1974 to investigate transportation accidents, determine the probable causes ofthe accidents, issue safety recommendations, study transportation safety issues, and evaluatethe safety effectiveness of government agencies involved in transportation . The safety Boardmakes public its actions and decisions through ACCIDENT reports, safety studies, specialinvestigation reports, safety recommendations, and statistical about available publications may be obtained by contacting: national transportation safety BoardPublic Inquiries Section, RE-51490 L Enfant Plaza, , 20594(202)314-6551(800)877-6799 safety board publications may be purchased, by individual copy or by subscription, from: national Technical Information Service5285 Port Royal RoadSpringfield, Virginia 22161(703)487-4600 AIRCRAFT ACCIDENT REPORTNTSB/AAR-97/06(PB97-910406) IN-FLIGHT FIRE AND IMPACT WITH TERRAIN VALUJET AIRLINES FLIGHT 592, DC-9-32, N904VJ EVERGLADES, NEAR MIAMI, FLORIDA MAY 11, 1996 Page 54 has bee n updated to corr ec tl y describe type K and type B thermocouples.

2 (4 Jan 00)Original descriptions were CORRECTIONS ARE INCLUDEDIN THIS VERSION OF THE PUBLISHED REPORT :NTSB/AAR-97/06 PB97-910406 national TRANSPORTATIONSAFETY BOARDWASHINGTON, 20594 AIRCRAFT ACCIDENT REPORTIN-FLIGHT FIRE AND IMPACT WITH TERRAINVALUJET AIRLINES, FLIGHT 592DC-9-32, N904 VJEVERGLADES, NEAR MIAMI, FLORIDAMAY 11,1996 Adopted: August 19, 1997 Notation 6704 BAbstract: This REPORT explains the in-flight fire and impact with terrain of ValuJet Airlines flight592, a DC-9-32, N904VJ, in the Everglades near Miami, Florida, on May 11, 1996. Safetyissues discussed in the REPORT include minimization of the hazards posed by fires in class D cargocompartments; equipment, training, and procedures for addressing in-flight smoke and fireaboard air carrier airplanes; guidance for handling of chemical oxygen generators and otherhazardous AIRCRAFT components; SabreTech s and ValuJet s procedures for handling companymaterials and hazardous materials; ValuJet s oversight of its contract heavy maintenancefacilities; the Federal Aviation Administration s (FAA) oversight of ValuJet and ValuJet scontract maintenance facilities; FAA s and the Research and Special Programs Administration s(RSPA) hazardous materials program and undeclared hazardous materials in the mail.

3 AndValuJet s procedures for boarding and accounting for lap children. safety recommendationsconcerning these issues were made to the FAA, RSPA, the Postal Service, and the AirTransport x1. FACTUAL INFORMATION .. History of Flight .. Statements of Chemical Oxygen Generators Carried as Cargo on Flight 592 .. 4 Events Preceding the ACCIDENT .. Description of Chemical Oxygen Guidelines for Removal and Disposition of Oxygen Generators .. Accomplishment of Maintenance Tasks Involving Oxygen Generators .. Mechanic and Inspector Signoffs on Work Role of ValuJet Technical Packaging and Shipping of Oxygen Injuries to Persons .. Damage to the Other Damage .. Personnel Information .. Captain .. First Officer .. Flight Attendants .. Airplane General .. Engines .. Cargo Compartment Information.

4 Federal Regulations .. safety board Recommendations .. DC-9 Ventilation System .. DC-9 Electrical Wiring Maintenance .. Meteorological Information .. Navigational Communications .. Airport Information .. Flight Recorders .. Flight Data Recorder .. Cockpit Voice Recorder .. Wreckage and Impact Information .. General .. Forward Cargo Medical and Pathological Information .. Fire Damage .. Cargo Carried in Forward Cargo Compartment .. Forward Cargo Aft Cargo Compartment .. Survival ValuJet s Procedures for Lap Children .. Onboard Firefighting and Smoke Removal Procedures .. ValuJet s Flight Attendant Manual .. ValuJet s AIRCRAFT Operating Manual .. Douglas AIRCRAFT DC-9 Flightcrew Operating Guidance for Smoke Removal on Other safety board Recommendations on Smoke Removal Procedures .. Smoke Goggle Equipment and Training for Air Carrier Tests and Research.

5 Oxygen Generator Fire Test Conditions and Airplane Flight Performance .. Organizational and Management Information .. General .. ValuJet s AIRCRAFT Maintenance Program .. General .. SabreTech s Procedures for Tagging and Identifying AIRCRAFT Parts .. ValuJet s Maintenance Training Training of SabreTech Employees .. ValuJet s Hazardous Materials Prior Hazardous Materials ValuJet s Oversight of FAA Oversight of Principal Maintenance Inspector (PMI) .. FSDO Staffing Levels .. FAA Inspections of ValuJet .. Regional Aviation safety Inspection Program .. national Aviation safety Inspection Program REPORT .. AFS-300 Summary 120-Day Special Emphasis Consent Order .. FAA Oversight of SabreTech .. Principal Maintenance Inspector .. FAA Special Inspection of SabreTech .. FAA 90-Day safety Review of the FAA s Hazardous Materials Program.

6 Staff .. FAA Programs to Address Undeclared Hazardous Materials .. Hazardous Materials Transported as Company Materials (COMAT) .. Hazardous Materials Shipped from Maintenance RSPA s Hazardous Materials Program .. Enforcement Approvals Program .. Additional Other Air Carriers Handling of Chemical Oxygen Generators .. Incidents Involving Chemical Oxygen Hazardous Waste Occupational safety and Health Administration (OSHA) Requirements .. Postal Service .. Hazardous Materials Incidents in the Mail on AIRCRAFT .. General .. Propagation and Detection of Fire .. Acceptance of the COMAT Shipment .. Flightcrew Decisions and Flightcrew Performance Before the Flightcrew Decisions and Actions During the Crew s Use of Emergency Procedures and Equipment .. Emergency Procedures for Smoke Removal .. Guidance for the Removal and Disposition of Chemical Oxygen Adequacy of Information on Routine Work Card 0069.

7 Lack of Hazardous Materials Labels on the Removed Generators .. Lack of safety Use of Improper Parts Tag .. Lack of Communication About Items Left in Shipping and Stores SabreTech s Preparation of the COMAT Human Factors in the Maintenance Environment .. Guidance and Procedures for Transporting Hazardous ValuJet s Oversight of Subcontractor Maintenance Facilities .. FAA s Oversight of Adequacy of FAA s Hazardous Materials Undeclared Hazardous Materials .. RSPA s Program for Approving Explosives for transportation .. ValuJet s Procedures for Boarding and Accounting for Lap Children .. 1313. CONCLUSIONS .. Probable 1374. RECOMMENDATIONS .. 1385. APPENDIXES .. 143 APPENDIX A investigation AND HEARING .. 143 APPENDIX B COCKPIT VOICE RECORDER 144 APPENDIX C SHIPPING TICKET FOR THE COMPANY MATERIAL .. 176 APPENDIX D WORK CARD 0069.

8 177 APPENDIX E EXCERPTS FROM AIRCRAFT MAINTENANCE SERVICESAGREEMENT .. 183 APPENDIX F PART III OF APPENDIX F TO 14 CFR PART 189ixAPPENDIX G VALUJET DC-9 EMERGENCY PROCEDURES .. 191 APPENDIX H 1995 NASIP INSPECTION REPORT 192 APPENDIX I FEBRUARY 14, 1996, AFS-300 213 APPENDIX J ATTACHMENT 1 OF CONSENT ORDER .. 222 APPENDIX K EXCERPTS FROM TITLE 49 CFR PART 175 .. 230xEXECUTIVE SUMMARYOn May 11, 1996, at 1413:42 eastern daylight time, a Douglas DC-9-32 crashedinto the Everglades about 10 minutes after takeoff from Miami International Airport, Miami,Florida. The airplane, N904VJ, was being operated by ValuJet Airlines, Inc., as flight 592. Bothpilots, the three flight attendants, and all 105 passengers were killed. Visual meteorologicalconditions existed in the Miami area at the time of the takeoff.

9 Flight 592, operating under theprovisions of 14 CFR Part 121, was on an instrument flight rules flight plan destined for theWilliam B. Hartsfield International Airport, Atlanta, Georgia. ! " # $ % " # & ' ( $ ) * +& + *++ ( ! ,- *++ ( " # & " # & $ *++ ( ' $ " # to ensure that both ValuJet and contract maintenance facilityemployees were aware of the carrier s no-carry hazardous materials policy and had receivedappropriate hazardous materials training, safety issues discussed in the REPORT include minimization of the hazards posed byfires in class D cargo compartments; equipment, training, and procedures for addressing in-flightsmoke and fire aboard air carrier airplanes; guidance for handling of chemical oxygen generatorsand other hazardous AIRCRAFT components; SabreTech s and ValuJet s procedures for handlingcompany materials and hazardous materials; ValuJet s oversight of its contract heavymaintenance facilities; FAA s oversight of ValuJet and ValuJet s contract maintenance facilities.)))

10 FAA s and the Research and Special Programs Administration s (RSPA) hazardous materialsprogram and undeclared hazardous materials in the mail; and ValuJet s procedures forboarding and accounting for lap children. safety recommendations concerning these issues weremade to the FAA, RSPA, the Postal Service, and the Air Transport transportation safety BOARDWASHINGTON, 20594 AIRCRAFT ACCIDENT REPORTIN-FLIGHT FIRE AND IMPACT WITH TERRAINVALUJET AIRLINES, FLIGHT 592, DC-9-32, N904VJ,EVERGLADES, NEAR MIAMI, FLORIDA, MAY 11, 19961. FACTUAL of FlightOn May 11, 1996, at 1413:42 eastern daylight time,1 a Douglas DC-9-32 crashedinto the Everglades about 10 minutes after takeoff from Miami International Airport (MIA),Miami, Florida. The airplane, N904VJ, was being operated by ValuJet Airlines, Inc., asflight 592. Both pilots, the three flight attendants, and all 105 passengers2 were killed.