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Accident Report Detail

 
In-Flight Fire and Impact With Terrain Valujet Airlines Flight 592 DC-9-32, N904VJ

Executive Summary

On May 11, 1996, at 1413:42 eastern daylight time, a Douglas DC-9-32 crashed into 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. Both pilots, the three flight attendants, and all 105 passengers were killed. Visual meteorological conditions existed in the Miami area at the time of the takeoff. Flight 592, operating under the provisions of 14 CFR Part 121, was on an instrument flight rules flight plan destined for the William B. Hartsfield International Airport, Atlanta, Georgia.

Safety issues discussed in the report include minimization of the hazards posed by fires in class D cargo compartments; equipment, training, and procedures for addressing in-flight smoke and fire aboard air carrier airplanes; guidance for handling of chemical oxygen generators and other hazardous aircraft components; SabreTech's and ValuJet's procedures for handling company materials and hazardous materials; ValuJet's oversight of its contract heavy maintenance facilities; FAA's oversight of ValuJet and ValuJet's contract maintenance facilities; FAA's and the Research and Special Programs Administration's (RSPA) hazardous materials program and undeclared hazardous materials in the U.S. mail; and ValuJet's procedures for boarding and accounting for lap children. Safety recommendations concerning these issues were made to the FAA, RSPA, the U.S. Postal Service, and the Air Transport Association.


Probable Cause

The National Transportation Safety Board determines that the probable causes of the accident, which resulted from a fire in the airplane's class D cargo compartment that was initiated by the actuation of one or more oxygen generators being improperly carried as cargo, were (1) the failure of SabreTech to properly prepare, package, and identify unexpected chemical oxygen generators before presenting them to ValuJet for carriage; (2) the failure of ValuJet to properly oversee its contract maintenance program to ensure compliance with maintenance, maintenance training, and hazardous materials requirements and practices; and (3) the failure of the Federal Aviation Administration (FAA) to require smoke detection and fire suppression systems in class D cargo compartments.

Contributing to the accident was the failure of the FAA to adequately monitor ValuJet's heavy maintenance programs and responsibilities, including ValuJet's oversight of its contractors, and SabreTech's repair station certificate; the failure of the FAA to adequately respond to prior chemical oxygen generator fires with programs to address the potential hazards; and ValuJet's failure to ensure that both ValuJet and contract maintenance facility employees were aware of the carrier's "no-carry" hazardous materials policy and had received appropriate hazardous materials training.


Accident Location: Miami , FL    
Accident Date: 5/11/1996
Accident ID: DCA96MA054

Date Adopted: 8/19/1997
NTSB Number: AAR-97-06
NTIS Number: PB1997-910406