About 1620 central standard time, on January 7, 1996, a Douglas Aircraft Company DC-9-32, N922VV, operated by ValuJet Airlines, Inc., as flight 558, touched down hard in the approach light area short of runway 2R at the Nashville International Airport in Nashville, Tennessee. Flight 558 was operating under the provisions of Title 14 Code of Federal Regulations Part 121, as a scheduled, domestic passenger flight from Atlanta, Georgia, to Nashville.
The flight departed the William B. Hartsfield Atlanta International Airport at approximately 1540, with five crewmembers and 88 passengers on board. The flight attendant who occupied the rear cabin jumpseat and four passengers reported minor injuries; no injuries were reported by the remaining 88 occupants. The airplane sustained substantial damage to the tail section, nosegear, aft fuselage, flaps, slats, and both engines. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.
The safety issues discussed in this report include the adequacy of ValuJet's operations and maintenance manuals, specifically winter operations nosegear shock strut servicing procedures; the adequacy of ValuJet's pilot training/crew resource management training programs; flightcrew actions/decisionmaking; the role of communications (flightcrew/flight attendants/operations/dispatch/air traffic control); ValuJet's flightcrew pay schedule; Federal Aviation Administration oversight of ValuJet; and the adequacy of cockpit voice recorder duration and procedures.
We determined that the probable cause of
this accident was the flightcrew’s improper procedures and actions (failing to contact system
operations/dispatch, failing to use all available aircraft and company manuals, and prematurely
resetting the ground control relay circuit breakers) in response to an in-flight abnormality, which
resulted in the inadvertent in-flight activation of the ground spoilers during the final approach to
landing and the airplane’s subsequent increased descent rate and excessively hard ground impact
in the runway approach light area.
Contributing factors in the accident were ValuJet’s failure to incorporate cold
weather nosegear servicing procedures in its operations and maintenance manuals, the
incomplete procedural guidance contained in the ValuJet quick reference handbook, and the
flightcrew’s inadequate knowledge and understanding of the aircraft systems.
As a result of the investigation of this accident, we made the following recommendations:
to the Federal Aviation Administration:
- Require all airlines to review their operations and maintenance manuals and, if necessary, adjust or expand these manuals to reflect the manufacturer’s recommended cold weather nosegear servicing procedures. (A-96-166)
- Stress the importance of adherence to the rules, structure, and guidelines within the revised ValuJet company operating manual to ValuJet management and its employees, to Flight Safety International (or other contracted training organizations used by ValuJet), and to theindividuals responsible for the oversight of ValuJet. (A-96-167)
- Reevaluate ValuJet’s flight operations training manual and the ValuJet training syllabus used by Flight Safety International, and require ValuJet to revise or expand these documents to include more detailed descriptions and explanation of the Douglas DC-9 systems and procedures. (A-96-168)
- Require ValuJet to revise its crew resource management (CRM) training curriculum to more clearly reflect modern integrated (flightcrew, cabin crew, company, etc.) CRM practices (including line operational simulation training) and to combine academic/classroom training with integrated practical crew simulations. (A-96-169)
- Require all airlines to revise their procedures to stipulate that flightcrews turn off power to the cockpit voice recorder as part of the engine shutdown procedure in the event of a reportable incident/accident. (A-96-170)
- Require that all newly manufactured cockpit voice recorders intended for use on airplanes have a minimum recording duration of 2 hours. (A-96-171)
To ValuJet Airlines:
- Develop, immediately, a more extensive and accurate winter operations manual, with corresponding adjustments to maintenance procedures, to reflect the manufacturer’s cold weather nosegear servicing procedures. (A-96-172)
- Clarify for all flightcrews the importance of referencing all available crew reference documents and consulting with company maintenance personnel (time permitting) to resolve in-flight abnormalities before committing a flight to landing. (A-96-173)
