Professional Ethics HSS 201

Air Disaster in ValuJet Flight 592

Presented By:
Nikita Mangla
Shweta Jha
Batch : S5

About the Case:

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 with the speed of about 550 miles per hour.
The airplane was being operated by ValuJet Airlines, as
flight 592.
Both pilots, the three flight attendants, and all 105
passengers were killed.

Accident:

There were 105 passengers, mainly from Florida and

Georgia, on board, as well as a crew of two pilots and three
flight attendants, bringing the total number of people on
board to 110.
At 2:10 pm, the passengers started to smell smoke. At the
same time, the pilots heard a loud bang in their headphones
and noticed the plane was losing electrical power.
The spike in electrical power and the bang were eventually
determined to be the result of a tire in the cargo hold
exploding.
Seconds later, a flight attendant entered the cockpit and
informed the flight crew of a fire in the passenger cabin.
Passengers' shouts of "fire, fire, fire" were recorded on the
cockpit voice recorder when the cockpit door was opened.

Flight 592 disappeared from radar at 2:13:42 pm.

The NTSB report on the accident stated that "the Safety
Board cannot rule out the possibility that the flight crew was
incapacitated by smoke or heat in the cockpit during the last
7 seconds of the flight.
And All this happened because 5 boxes of improperly
secured canister of chemical oxygen generators were kept
in the cargo compartment of ValuJet Flight 592. SabreTech
did not cover and secure the firing pins on the generators.

Investigation:

The NTSB investigation eventually determined that the fire that downed
Flight 592 began in a cargo compartment below the passenger cabin.
The cargo compartment was a Class D design, in which fire suppression
is accomplished by sealing off the hold from outside air. Any fire in such
an airtight compartment would quickly exhaust all available oxygen and
then burn itself out.
Chemical oxygen generators, when activated, produce oxygen for
passengers if the plane suffers an explosive decompression. As a
byproduct of the exothermic chemical reaction, they also produce a great
quantity of heat. These two factors together were sufficient not only to
start an accidental fire, but also to produce enough oxygen to keep the
fire burning.
Laboratory testing showed that canisters of the same type could heat
nearby materials up to 500 F (260 C), enough to ignite a smoldering
fire.

The fire began to move inside the

plane from the cargo and towards
the cockpit.

The plane crashed vertically with the speed of about 550 miles per hour
in to the everglades

Lets us see through a small video,

what really happened on May 11,
1996

Legacy:

On the third anniversary of the accident, in 1999, a memorial was

dedicated to the victims in the Everglades. The memorial, consisting of
110 concrete pillars, is located just north of Tamiami Trail about 11.9
miles west of Krome Avenue in Miami-Dade County and points to the
location of the crash site eight miles to the north.

Organizational results:

Temporarily grounded by safety questions, ValueJet

eventually resumed flying. The investigation
showed it outsourced many jobs and operated with
one of the oldest fleets in the industry, buying
planes many airlines no longer wanted.
It merged with a fellow low-cost carrier, AirTran, and
even though it was the larger airline, it took the
AirTran name, wiping from the skies the tainted
name of ValuJet.
In 2011, AirTran was taken over by Southwest
Airlines.

Overarching messages by
the organization:
ValuJet: We pay the lowest wages
We are in a business where we take
the lives of the people.
Southwest: There are absolutely no words to
state our grieves and our sorrows over this
tragedy.

Lessons Learned:

1. Do the work before crisis occurs.

2. Be responsive, informed and sympathetic.
3. Know when things arent working and flexible.
4. Failure of the FAA(Federal Aviation Administration) to
adequately monitor ValuJets heavy maintenance
programs and responsibilities.
5. Failure to insure that both ValuJet and contract
maintenance facility employees were aware of the no
carry hazardous materials policy.
6. Frequent Training employees and contractors on the
proper handling, packaging, labelling and
documentation of airline cargo and hazardous material.