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.
We determined the probable causes of the accident, which resulted from a fire in the airplane's class D cargo compartment was the initiated by the actuation of one or more oxygen generatetors being improperly carried as cargo, were:
- the failure of SabreTech to properly prepare, package, and identify unexpended chemical oxygen generators before presenting them to ValueJet for carriage;
- the failure of ValueJet to properly oversee its contract maintenance program to ensure compliance with maintenance, maintenance training and hazardous materials requirements and practices; and
- the failure of the Federal Avaition Administration 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 ValuJets heavy maintenance programs and responsibilities, including ValueJet's oversight of its contractors, and SabreTech's repair station certificate; the failure of the FAA to adquately respond to prior chemical oxygen generator fires with programs to address the potential hazard; and ValueJets failure to ensure taht both ValueJet and contract maintenance facility were aware of the carrier's 'no-carry" hazardous materials policy and had received appropriate hazardous materials traing.
As a result of the investigation, we issued recommendations to the Federal Aviation Administration, to the Research and Special Programs Administration, to the U.S. Postal Service: and to the Air Transport Association.
