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On 5/11/96, about 1415 eastern daylight time, a McDonnell Douglas DC-9-32 crashed into the everglades swamp shortly after takeoff from Miami International Airport, Miami Florida, the airplane, N904VJ, was operated by ValuJet Airlines, Inc., as ValuJet flight 592. Both pilots, the three flight attendants, and all 105 passengers were killed. Before the accident, the flightcrew reported to air traffic control that it was experiencing smoke in the cabin and cockpit. Visual meteorological conditions existed in the Miami area at the time of the takeoff. The destination of the flight was Hartsfield International Airport, Atlanta, Georgia. Flight 592 was on an instrument flight rules flight plan.
TO THE FEDERAL AVIATION ADMINISTRATION: Specify, in air carrier operations master minimum equipment lists, that the cockpit-cabin portion of the service interphone system is require to be operating before an airplane can be dispatched.
Original recommendation transmittal letter:
Closed - Unacceptable Action
Miami, FL, United States
In-Flight Fire and Impact With Terrain Valujet Airlines Flight 592 DC-9-32, N904VJ
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Safety Recommendation History
ALTHOUGH THE CREW COORDINATION PROCEDURES MANDATED IN THE FAA'S APRIL 28, 1998, HANDBOOK BULLETINS CLARIFY WHAT SHOULD HAVE ALREADY BEEN EXISTING PRACTICES AMONG AIR CARRIERS, THE SAFETY BOARD CONTINUES TO BELIEVE THAT ANY SYSTEM OF PREARRANGED CHIMES, DOOR KNOCKS, AND ONE-WAY (PILOT TO FLIGHT ATTENDANT) COMMUNICATIONS USING THE PASSENGER ADDRESS SYSTEM IS AN INADEQUATE ALTERNATIVE TO A FUNCTIONAL INTERPHONE SYSTEM, ESPECIALLY FOR COPING WITH AN IN-FLIGHT EMERGENCY, SUCH AS A FIRE. CONSEQUENTLY, THE SAFETY BOARD CLASSIFIES SAFETY RECOMMENDATIONS A-97-57 "CLOSED--UNACCEPTABLE ACTION."
Letter Mail Controlled 10/15/98 5:02:19 PM MC# 981252: ON APRIL 28, 1998, THE FAA ISSUED JOINT FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIR TRANSPORTATION (HBAT) 98-18 AND JOINT FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIRWORTHINESS (HBAW) 98-09 "AIR CARRIER MANUAL INSTRUCTIONS CONCERNING MINIMUM EQUIPMENT LIST (MEL) CONDITIONS AND LIMITATIONS." BULLETIN 98-09 DIRECTS AVIATION SAFETY INSPECTORS TO DIRECT THEIR CARRIERS TO INCLUDE ADDITIONAL INSTRUCTIONS THAT CLARIFY ACTIONS TO BE TAKEN IN CASE OF EMERGENCY OR AN ABNORMAL SITUATION CONCERNING MEL CONDITIONS AND LIMITATIONS. THE BULLETIN ALSO DIRECTS AVIATION SAFETY INSPECTORS TO INFORM THEIR CARRIERS THAT, IN PREPARATION FOR THE POSSIBLE BREAKDOWN OF CABIN/FLIGHT DECK COMMUNICATIONS EQUIPMENT, THE PILOT-IN-COMMAND NEEDS TO BRIEF THE FLIGHT CREW, LEAD FLIGHT ATTENDANT, AND/OR CONCERNED FLIGHT ATTENDANTS ABOUT THE ACTIONS TO BE TAKEN IN EMERGENCY OR ABNORMAL SITUATIONS. ON JULY 24, 1998, THE FAA ISSUED MMEL POLICY LETTER 39 REVISION 3, "PUBLIC ADDRESS SYSTEM, CREWMEMBER INTERPHONE AND ALERTING SYSTEMS," WHICH ESTABLISHES A STANDARD MMEL POLICY FOR THE PASSENGER ADDRESS SYSTEM ON PASSENGER AND CARGO AIRPLANES AND A POLICY FOR CREW MEMBER INTERPHONE AND ALERTING SYSTEMS. THE POLICY LETTEER STATES THAT, ON PASSENGER AIRCRAFT, THE PASSENGER ADDRESS SYSTEM MAY BE INOPERATIVE PROVIDED THE FLIGHT DECK/CABIN INTERPHONE SYSTEM AND AURAL ALERTING OPERATE NORMALLY. THE POLICY LETTER ALSO ESTABLISHES A 3-DAY LIMIT FOR REPAIR TO AN INOPERATIVE PASSENGER ADDRESS SYSTEM.
Letter Mail Controlled 7/27/98 3:17:30 PM MC# 980931: In January 1998, the Air Transport Association Master Minimum Equipment List (MMEL) Subcommittee, consisting of representatives from the Federal Aviation Administration (FAA) and industry, met in Atlanta, Georgia. The subcommittee reviewed current methods of cabin and cockpit crew communication in the event of cabin smoke, fire, or fume emergency to determine if alternate procedures for cabin-cockpit communications, such as those in the current DC-9 minimum equipment list (MEL), should be revised. The subcommittee also assessed the most appropriate methods of communication to determine if current airplane flight manuals, flight attendant procedures manuals, and MEL's support those methods. The results of the review are as follows: * The subcommittee reviewed the MEL data for a period of 1 year and 2.47 million departures (30 percent of departures by U.S. carriers). The review revealed that the interphone system was available on 99.5 percent of the departures. Where there were interphone failures, 0.25 percent occurred after departure, and the airplane was dispatched with inoperable interphones on the remaining 0.25 percent of departures. The review also revealed that MEL relief for interphones was invoked 874 times, relief was used for an average of 1.8 days, and over half of the systems placed on relief were repaired in 1 day. The interphone system was usually repaired during scheduled maintenance the night following the failure. * The review of written procedures revealed that a number of carriers did not have adequate written procedures contained in their manuals to handle interphone problems. Based on this review, the FAA and industry agreed that adequate written procedures needed to be included in air carrier operations manuals and flight attendant manuals for inoperative interphone systems. Also a standard interphone proviso needed to be established to be included in MMEL's and MEL's. On April 28, 1998, the FAA issued Joint Flight Standards Handbook Bulletin for Air Transportation 98-18 and Joint Flight Standards Handbook Bulletin for Airworthiness 98-09, Air Carrier Manual Instructions Concerning Minimum Equipment List Conditions and Limitations. The bulletin directs aviation safety inspectors to inform their carriers to include additional instructions to clarify actions to be taken in the case of emergency or abnormal situations concerning the MEL conditions or limitations. The bulletin also directs aviation safety inspectors to inform their carriers of the need for the pilot-in-command to brief the flightcrew, lead flight attendant, and/or concerned flight attendants of the actions to be taken in emergency or abnormal situations in preparation of the possible break down of cabin/flight deck communication equipment. I have enclosed a copy of the bulletin for the Board's information. The FAA is developing a MMEL policy letter to specify what items must be operable (chimes, public address system) for the interphone system to be inoperable. The policy letter will include a requirement for written procedures to be included in the operations manuals and flight attendant manuals. I will keep the Board informed of the FAA's progress on this safety recommendation.
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