On June 8, 1995, a Douglas DC-9-32, N908VJ, was being operated by ValuJet Airlines as a scheduled, domestic passenger flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121. Flight 597, destined for Miami, Florida, departed gate C25 at the William B. Hartsfield Atlanta International Airport, Atlanta, Georgia, at 1855, and was cleared for takeoff on runway 27R at 1908. Five crewmembers and 57 passengers were on board.
As flight 597 began its takeoff roll, a "loud bang" was heard by the airplane occupants and air traffic control personnel. The right engine fire warning light illuminated, the flightcrew of a following airplane reported to the ValuJet crew that the right engine was on fire, and the takeoff was rejected. Shrapnel from the right engine penetrated the fuselage and the right engine main fuel line, and a cabin fire erupted. The airplane was stopped on the runway, and the captain
ordered the evacuation of the airplane.
The flight attendant seated in the aft flight attendant jumpseat received serious puncture wounds from shrapnel and thermal injuries. Another flight attendant and five passengers received minor injuries. The pilots, the third flight attendant, and 52 passengers were not injured. The airplane’s fuselage was destroyed.
We determined that the probable cause of this accident was the failure of Turk Hava Yollari maintenance and inspection personnel to perform a proper inspection of a 7th stage high compressor disk, thus allowing the detectable crack to grow to a length at which the disk ruptured, under normal operating conditions, propelling engine fragments into the fuselage; the fragments severed the right engine main fuel line, which resulted in a fire that rapidly engulfed the cabin area. The lack of an adequate recordkeeping system and the failure to use “process sheets” to document the step-by-step overhaul/inspection procedures contributed to the failure to detect the crack and, thus, to the accident.
As a result of this accident investigation, we recommended:
The Federal Aviation Administration:
- Review the Air Agency Certificates and Repair Station Operations Specifications of all repair stations and ensure that the language used in the operations specifications clearly indicates the extent of the repair stations’ authority. (A-96-78)
- Revise 14 CFR Part 145 to require Subpart C foreign repair stations to adhere to the same recordkeeping requirements as domestic repair stations. (A-96-79)
- Revise the applicable regulations and provide specific guidance on the documentation to be used and kept during inspections and overhauls, including “process sheets” or similar detailed documentation for all certificated repair stations. (A-96-80)
- Require that “serviceable tags” be used to return engines and other components to service, that they be in a prescribed format (perhaps in the format of FAA Form 8130-3), and that when there is a change of ownership, and certainly upon importation, the approval for return to service attest to the overall airworthiness of the part and the tag reflect that a complete and thorough review of records, including “process sheets” of the last overhaul, has taken place. In the absence of such records, require an overhaul of the part when there is a change in ownership. (A-96-81)
- Require that all transport-category aircraft manufactured before November 27, 1990, be retrofitted with a public address system capable of operating on an independent power source. (A-96-82)
- Emphasize to principal operations inspectors the importance of thoroughly reviewing flight attendant training programs before approving them and flight attendant manuals before accepting them. (A-96-83)
- Provide guidance on how to implement the requirement that occupants who are more than 24 months old are restrained during takeoffs, landings, and during turbulence. (A-96-84)
- Require that each flight attendant have a cockpit key in his/her possession at all times while on duty. (A-96-85)
- Prohibit the use during any type of replacement, after 1997, of cabin materials in all transport-category airplanes that do not comply with the current fire safety standards contained in 14 CFR 25.853. (A-96-86)
- Amend 14 CFR Part 121 to prohibit, upon a transfer of the aircraft from one certificate holder to another, or by January 1, 2001, whichever occurs first, the operation of airplanes with cabin materials that do not meet the requirements of 14 CFR Part 25.853. (A-96-87)
- Issue an operations bulletin recommending that principal operations inspectors advise their air carriers to disseminate FAA safety guidance on airline passenger attire to their flight attendants. (A-96-88)
- Require all aircraft currently required to be installed with a cockpit voice recorder (CVR) to be retrofitted within 2 years with a CVR installation designed such that an uninterrupted recording from the boom or mask microphones and headphones for each flight crewmember’s position and from an area microphone can be made on dedicated channels of the CVR. A sidetone shall be produced only when the transmitter or interphone is selected, and, in addition, all audio signals received by hand-held microphones shall be recorded on the respective crewmember’s channel when keyed to the “ON” position. (A-96-89)
