Testimony of Jim Hall, Chairman National Transportation Safety
before the Committee on Transportation and Infrastructure, Subcommittee on Aviation
House of Representatives, Regarding Issues Raised by the Crash of ValuJet Flight 592
June 25, 1996
Good morning, Chairman Duncan and Members of the Committee. It
has been just over 6 weeks since ValuJet flight 592 crashed into
the Everglades following an in-flight fire, killing all 110 persons
aboard. Since that time, the Federal Aviation Administration has
grounded the airline, and as this morning's hearing shows, many
questions have been raised about ValuJet's operations and the
FAA's oversight of those operations.
The enormous tragedy of the accident, the intense public and news
media scrutiny of the airline and the FAA since then, and perhaps
the perception of mixed signals sent by government officials since
that accident, have combined to raise doubts in the minds of some
Americans about the safety of their airline system.
Before addressing the issues before us today, Mr. Chairman, I'd
like to put this concern in some perspective. I think that, as
Chairman of the National Transportation Safety Board, I am in
a position to do so, because Congress in its wisdom established
the Board 29 years ago to be an independent investigative agency,
to provide impartial analysis of industry and government alike.
Congress intended the Safety Board to take the longer view, to
separate the investigation from the passion of current events,
and direct recommendations to those in the position to affect
improvements in transportation safety, be they in government or
In our 29-year history, we have investigated more than 100,000
aviation accidents and issued over 3,600 aviation-related recommendations,
most of which were directed to the FAA. To its credit, the FAA
has adopted over 80 percent of those recommendations, and over
90 percent of our urgent recommendations.
Over the decades, dedicated government employees at the Safety
Board and the FAA have worked closely together to define the latest
technologies and the most meaningful regulations to ensure that
the American people have the safest transportation system in the
I do not mean to imply that we haven't had our differences with
the FAA over the years. There are a number of safety improvements
that we believe the FAA has not adopted or has taken too long
to adopt, and when that happens we make sure you in Congress and
the American people know about it. Even though we have our disagreements,
the relationship between the FAA and the NTSB has always been
a professional one, and we have nothing but the highest regard
for the efforts of the 48,000 men and women at the FAA who work
every day to fulfill their responsibilities.
That relationship has worked to benefit the American people. In
an industry that has seen traffic grow from 106 million passengers
in 1967, the year the Safety Board opened its doors, to 545 million
passengers last year -- a five-fold increase -- the fatal accident
rate has dropped at the same time almost 75 percent. In 1995,
for example, there was one fatal Part 121 airline accident for
every 4.l million flights.
This remarkable safety record did not happen by chance, but by
the dedicated efforts of thousands of inspectors, air traffic
controllers, investigators, pilots, mechanics and manufacturing
personnel, and through the oversight and policy and budgetary
support provided by you and your colleagues in Congress.
I congratulate you, Mr. Chairman, for holding these timely hearings
to allow the American people to hear what their government is
doing to ensure their safety in the skies.
Eighteen months ago, after a series of fatal accidents, Secretary
Peña convened an airline safety summit here in Washington,
providing a forum for government agencies and the airline industry
to establish heightened safety goals. Several hundred senior government
and airline officials attended the two-day meeting. While I applauded
the decision to hold the summit, I noted in my remarks that absent
from the agenda were certain issues the Safety Board had addressed
over the years, issues like airline management, FAA oversight,
and corporate culture. Without addressing these issues, I felt,
we could never approach the summit's goal of "zero accidents."
Although the aviation industry had taken many of the necessary
steps over the years to prevent most accidents through the systematic
elimination of hazards and the use of technology to overcome human
failures, I questioned the rate of progress in eliminating management
Mr. Chairman, that is a question we must continue to address.
How far have we come to eliminate a management mindset that allows
unsafe practices to flourish at airlines, or go undetected at
I am sorry to say, Mr. Chairman, that while we have not yet determined
what exactly happened aboard flight 592 that fateful day, I would
not be surprised if at the conclusion of this investigation we
find that this accident is the result of previous lessons learned
This hearing has been convened to examine issues raised by the
ValuJet crash, and no issues more directly concern the circumstances
of this accident than the carriage of hazardous materials on aircraft
and fire protection on airliners.
As you know, Mr. Chairman, we recently concluded the recovery
efforts in the Everglades, after an unprecedented month-long search
for wreckage and, on the part of the medical examiner, for the
remains of victims. While our investigation is continuing, some
important facts have emerged.
It appears that about 5 minutes after takeoff, the crew of flight
592 decided to return to Miami after hearing a noise and reporting
smoke in the cabin to air traffic controllers. Wreckage examination
indicates an extremely intense fire in the aircraft, hot enough
to melt seat railings and floor beams.
We know the forward cargo compartment carried oxygen generators
-- perhaps more than 100 -- packed in cardboard, and at least
3 airplane tires. It appears that at least some of the generators
were not empty, as indicated on the shipping documents, and none
were equipped with safety caps.
What actually caused the plane to plunge into the Everglades --
for example, was the crew incapacitated or was the aircraft rendered
uncontrollable? -- is unknown at this time.
But these facts raise the very real possibility that warnings
the airline industry and its regulators received through close
calls in past years went tragically unheeded.
I'd like to recount for you an accident that occurred some 8 years
ago that may have foreshadowed the accident that has brought us
On February 3, 1988, American Airlines flight 132, a DC-9, departed
Dallas/ Fort Worth International Airport for Nashville with a
midcargo compartment loaded with, among other things, a 104-pound
fiber drum of textile treatment chemicals. Undeclared and improperly
packaged hazardous materials inside the fiber drum included 5
gallons of hydrogen peroxide solution and 25 pounds of a sodium
During the flight, a flight attendant and a "deadheading"
first officer notified the pilots of smoke in the passenger cabin.
The passenger cabin floor above the cargo compartment was hot
and soft, and the flight attendants had to move passengers from
the affected area. Fortunately, the aircraft landed and a successful
evacuation was conducted.
The airworthiness of the airplane was threatened by the fire.
Excessive temperatures reached critical flight and engine control
cables, floor beams and the passenger cabin floor. We believe
that the cargo compartment did not meet the intent of the regulations
designed to contain such a fire.
How did we get so close to tragedy? Let me suggest some reasons:
o Because the cargo compartment was not equipped with fire or
smoke detection systems, the cockpit crew had no way of detecting
the threat until smoke and fumes reached the cabin.
o While smoke was detected in the passenger cabin, the cockpit
crew had no means of identifying the location of the fire.
o Further, because the cargo compartment was not equipped with
a fire extinguishing system, so even if they knew there was a
fire, the cockpit crew had no means available to extinguish or
suppress the fire in the cargo compartment.
o Without fire detection or suppression systems, the cockpit crew
could only rely on the adequacy of cargo compartment designs and
construction to control a fire in the cargo compartment.
Mr. Chairman, the passengers and crew of this particular aircraft
were fortunate that day. While no one was seriously injured, the
potential for a catastrophic accident was present. And even this
incident wasn't the first of its kind. Less than 2 years earlier,
an undeclared shipment of 35 percent hydrogen peroxide solution
was shipped in drums with no outside markings to warn about the
presence of hazardous materials. The shipment had travelled from
Florida to Seattle on its way to the Philippines when cargo handlers
found several packages had leaked. This was one of more than 2,000
hazardous materials incident reports involving air transportation
filed with the DOT in the 17 years leading up to the American
Airlines accident in 1988.
It should be noted that the Department of Transportation has the
overall regulatory responsibility over the transportation of hazardous
materials, through its Research and Special Programs Administration,
including the inspection of shippers for compliance with hazardous
materials safety requirements.
But Mr. Chairman, despite Safety Board recommendations to the
FAA to require fire detection systems, and fire extinguishing
systems, and better fire blocking materials in cargo compartments,
the sad fact is that the crew of ValuJet flight 592 had no more
equipment available to warn them of a fire or to fight it than
did the crew of that American Airlines flight 8 years earlier.
Would this have made a difference for the ValuJet flight? We don't
know at this point of our investigation, but we're going to try
to find out. We intend to conduct tests at the FAA's Technical
Center in Atlantic City to determine if the fire started before
takeoff, on takeoff, or later. We might be able to determine if
a detection system would have alerted the crew early enough to
have prevented the tragedy, even without an extinguishing system.
A major issue raised by our investigation involves the precipitating
event on the American Airlines plane and maybe on the ValuJet
plane -- the carriage of hazardous materials on airliners. NTSB
has addressed the issue of undeclared hazardous materials being
transported by air in the past. Thousands of companies and individuals
ship products by air, usually in small quantities.
A problem we noted with the FAA's cargo compartment fire protection
research and testing is that the FAA did not consider the effects
of hazardous materials involvement on the capability of a cargo
compartment to contain an in-flight fire. In certificating Class
D compartments like those found on the American and ValuJet aircraft,
the FAA assumes that a fire will be snuffed out when the available
oxygen is consumed. This is negated, however, when you have an
oxidizer in the compartment, as we did on the American Airlines
flight, and as it appears we did on ValuJet.
That is why on May 31, 1996 the Safety Board issued urgent safety
recommendations to the FAA to evaluate airline practices, including
training, for accepting passenger baggage and freight shipments
and for identifying undeclared or unauthorized shipments of hazardous
materials, and require air carriers to revise their procedures
as necessary. Because of the presence of oxidizing materials in
some previous accidents, as well as this one, the Board urged
the RSPA and the FAA to prohibit the transportation of oxidizers
and oxidizing materials in cargo compartments that do not have
fire or smoke detection systems.
We know of at least two other incidents in recent years that involved
fires associated with chemical oxygen generators that were shipped
by air. So far, it appears that neither shipment of oxygen generators
was declared to be a hazardous material.
Certainly, there are several actions we have recommended that
can be accomplished quite easily:
o Public education is necessary to address the potential for unintentionally
offering hazardous materials.
o Carrier personnel must be trained to recognize potential hazardous
materials shipments when they see them or to ask the right questions.
o And airlines can improve the appearance, content and location
of notices that are posted to warn passengers and shippers about
hazardous materials restrictions and special shipping requirements.
Notices that are not read are not effective.
The DOT's program to regulate the transportation of hazardous
materials by air, and its regulations to protect aircraft and
occupants from the effects of fires on airliners will be major
focus areas in our ValuJet investigation.
A relevant focus of today's hearing, Mr. Chairman, is whether
there are systemic problems with the oversight of airline operations
and maintenance, particularly in those segments that are outsourcing
to contractors. I'd like to briefly review some recommendations
on this subject that the NTSB has made in the past.
The Safety Board first addressed the issue of FAA oversight of
contract maintenance operations 20 years ago. In 1976, a DC-6
operated by Mercer Airlines crashed in Van Nuys, California following
the failure of a propeller blade that had been improperly repaired
by a contracted repair station. The Board learned that neither
the airline nor the FAA District Office responsible for surveillance
of the repair station was aware that overhauls were not being
accomplished according to the current manual.
As a result, the Board recommended that the FAA remind airlines
of their responsibility for ensuring the adequacy of the maintenance
of their aircraft and components, even if the maintenance is contracted
to outside repair stations. We also recommended that the FAA review
its surveillance procedures for certificated repair stations to
make sure they maintain and use complete and correct maintenance
We addressed the issue of contract maintenance again in 1982,
following the Air Florida Boeing 737 accident during a snow storm
here in Washington. Air Florida's maintenance at National Airport
was performed by another carrier. The Board's examination of the
deicing procedures used for the flight disclosed that there had
been little communication between the carriers regarding these
procedures and that contractor maintenance personnel had only
limited familiarity with the 737 aircraft. We concluded that there
should have been more complete discussions between Air Florida
and the contractor regarding procedures to be applied during B-737
maintenance so that respective responsibilities were understood.
Let me quote from our recommendation letter of 14 years ago: "The
Safety Board believes that the FAA should be more attentive to
contract maintenance agreements between air carriers or with other
contractors to assure that all personnel are adequately trained
for the aircraft involved and fully aware of their individual
responsibilities in the conduct of maintenance."
At least two major accidents prompted Safety Board recommendations
on maintenance practices by the airlines and on the FAA's so-called
"white gloves" inspections conducted under its National
Aviation Safety Improvement Program, or NASIP.
On April 28, 1988, a flight attendant was killed and 8 others
received serious injuries when an Aloha Airlines Boeing 737 experienced
an explosive decompression at 24,000 feet and 18 feet of fuselage
skin and structure ripped off during an inter-island flight in
The accident was a wake-up call for both the industry and the
government, prompting an intensive evaluation of maintenance programs
for so-called "aging aircraft." The FAA had conducted
a NASIP inspection on Aloha Airlines the previous December. Let
me again read a portion of our report, which resonates today in
light of recent events:
"Technically, as stated by the FAA, if an airline complies
with the regulations, it is 'safe.' However, many regulations
are subjective in nature and are subject to interpretation. Consequently,
even with several significant negative findings by a NASIP team,
as was the case with Aloha Airlines, the airline was allowed to
continue operations without making immediate changes and without
having to set deadlines for completion on recommended actions."
On September 11, 1991, Continental Express flight 2574, an Embraer
120, broke up in flight and crashed near Eagle Lake, Texas, killing
all 14 persons aboard. Our investigation revealed that bolts had
been removed from the horizontal stabilizer during maintenance
the night before the accident and, following a shift change, the
bolts were not replaced. The plane crashed on its second flight
of the day.
In our probable cause finding, we cited the failure of airline
maintenance and inspection personnel to adhere to proper maintenance
and quality assurance procedures. The failure of FAA surveillance
to detect and verify compliance with approved procedures was cited
as a contributing factor.
Following the accident, the FAA conducted a NASIP of Continental
Express' maintenance program. It found very few safety deficiencies,
and complimented the airline on its internal evaluation system.
In our report, we expressed our concern that the NASIP did not
find deficiencies in shift turnover procedures and other matters
relevant to the accident, and recommended that the agency improve
its NASIP procedures.
Some months after Eagle Lake, the same airline had a similar incident
when a plane was forced to return to the airport after bolts had
been removed from a wing panel. Incredibly, even a fatal accident
and an FAA NASIP inspection weren't enough to overcome what appears
to have been corporate culture.
The ValuJet tragedy has shone a spotlight on an evolution that has occurred in segments of the airline industry. The Board has traditionally been expressing its concerns about airlines carrying out their own maintenance programs properly. Now, we are looking at what some have dubbed a "virtual airline" -- one that provides transportation but conducts none of its own maintenance or training. As part of our investigation of this tragic accident, we will analyze how carriers that outsource these services are ensuring the safety of their operations. We also will analyze the effectiveness of the FAA and its NASIP program to ensure compliance with safe practices.
And this brings me to an important observation. Last week, the
FAA announced that it would now require airlines to demonstrate
the regulatory compliance of each of their major contract maintenance
programs and facilities. The implication is that airlines have
not had to do that until now. If this is true, Mr. Chairman, then
we don't just have a ValuJet problem here, we may possibly have
an FAA problem.
Our investigation of the ValuJet accident and the announcements
made by the FAA last week have raised many questions that the
Safety Board is sure to pursue in the coming months:
o Was ValuJet properly ensuring that their contractors were complying
with their operating specifications, and was the FAA assuring
itself that ValuJet was doing this?
o Is the FAA appropriately structured and staffed to verify that
the airline was fulfilling its responsibilities?
o How did ValuJet's manuals, which have been found by the FAA
to have deficiencies get to be approved or accepted.
o What is it that the FAA really does when approving programs
of start-up airlines in the beginning? And how do they try to
handle an airline's rapidly expanding fleet?
o Was the FAA prepared for the large-scale outsourcing that ValuJet
presented? I think some of the FAA's actions last week show that
they now believe they were not.
In conclusion, Mr. Chairman, the ValuJet accident has brought
to the forefront the on-going issue of the need for stronger rules
protecting airline passengers from fire dangers aboard airliners,
including rules governing the acceptance and carriage of hazardous
We will be examining in our investigation the adequacy of federal
standards and requirements for procedures and training of air
carrier personnel and shippers in the identification, packaging
and handling of hazardous materials; the adequacy of federal surveillance
of those procedures and training; and the adequacy of federal
standards for airliner fire-worthiness, with particular emphasis
on cargo compartments and other unoccupied areas not protected
by smoke/fire detection and extinguishing systems.
This investigation also raises serious concerns about the FAA's
ability to assure that airlines comply with Federal safety regulations,
particularly those that outsource much of their training and maintenance.
We will look at the adequacy of the FAA's initial certification
of new entrant carriers, and the adequacy of surveillance and
oversight of those carriers during start-up and during periods
of rapid growth. Did the FAA devote the resources necessary to
oversee such an operation, and did ValuJet have the management
structure to ensure that its contractors complied with its operating
This will be an exhaustive investigation, Mr. Chairman, because
these are complex issues that must be resolved.