In-Flight Fire and Impact with Terrain, ValuJet Airlines Flight 592, Dc-9-32, N904VJ, Everglades

271 Pages·1998·5.02 MB·English

PB97-910406
NTSB/AAR-97/06
DCA96MA054
NATIONAL
TRANSPORTATION
SAFETY
BOARD
WASHINGTON, D.C. 20594
AIRCRAFT ACCIDENT REPORT
IN-FLIGHT FIRE AND IMPACT WITH TERRAIN
VALUJET AIRLINES FLIGHT 592
DC-9-32, N904VJ
EVERGLADES, NEAR MIAMI, FLORIDA
MAY 11,1996
6704B
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Establishedin 1967, the agency is mandated by Congress through the Independent Safety
Board Actof 1974 to investigate transportation accidents, determine the probable causes of
the accidents, issue safety recommendations, study transportation safety issues, and evaluate
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THESE CORRECTIONS ARE INCLUDED
IN THIS VERSION OF THE PUBLISHED REPORT:
AIRCRAFT ACCIDENT REPORT
NTSB/AAR-97/06(PB97-910406)
IN-FLIGHT FIRE AND IMPACT WITH TERRAIN
VALUJET AIRLINES FLIGHT 592, DC-9-32, N904VJ
EVERGLADES, NEAR MIAMI, FLORIDA
MAY 11, 1996
• Page 54 has been updated to correctly describe type K and type B thermocouples. (4 Jan 00)
Original descriptions were transposed.

NTSB/AAR-97/06 PB97-910406
NATIONAL TRANSPORTATION
SAFETY BOARD
WASHINGTON, D.C. 20594
AIRCRAFT ACCIDENT REPORT
IN-FLIGHT FIRE AND IMPACT WITH TERRAIN
VALUJET AIRLINES, FLIGHT 592
DC-9-32, N904VJ
EVERGLADES, NEAR MIAMI, FLORIDA
MAY 11,1996
Adopted: August 19, 1997
Notation 6704B
Abstract: This report explains the in-flight fire and impact with terrain of ValuJet Airlines flight
592, a DC-9-32, N904VJ, in the Everglades near Miami, Florida, on May 11, 1996. 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; the Federal Aviation Administration’s (FAA) 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. Safety recommendations
concerning these issues were made to the FAA, RSPA, the U.S. Postal Service, and the Air
Transport Association.

CONTENTS
EXECUTIVE SUMMARY...........................................................................................................x
1. FACTUAL INFORMATION...................................................................................................1
1.1 History of Flight....................................................................................................................1
1.1.1 Statements of Witnesses.................................................................................................4
1.1.2 Chemical Oxygen Generators Carried as Cargo on Flight 592—..................................4
Events Preceding the Accident................................................................................................4
1.1.2.1 Description of Chemical Oxygen Generators..........................................................6
1.1.2.2 Guidelines for Removal and Disposition of Oxygen Generators..........................10
1.1.2.3 Accomplishment of Maintenance Tasks Involving Oxygen Generators...............13
1.1.2.4 Mechanic and Inspector Signoffs on Work Cards.................................................14
1.1.2.5 Role of ValuJet Technical Representatives...........................................................17
1.1.2.6 Packaging and Shipping of Oxygen Generators....................................................17
1.2 Injuries to Persons...............................................................................................................20
1.3 Damage to the Airplane.......................................................................................................20
1.4 Other Damage.....................................................................................................................20
1.5 Personnel Information.........................................................................................................21
1.5.1 Captain.........................................................................................................................21
1.5.2 First Officer..................................................................................................................22
1.5.3 Flight Attendants..........................................................................................................23
1.6 Airplane Information...........................................................................................................24
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1.6.1 General.........................................................................................................................24
1.6.2 Engines.........................................................................................................................24
1.6.3 Cargo Compartment Information.................................................................................24
1.6.3.1 Federal Regulations...............................................................................................26
1.6.3.2 Safety Board Recommendations...........................................................................27
1.6.4 DC-9 Ventilation System.............................................................................................34
1.6.5 DC-9 Electrical Wiring System....................................................................................34
1.6.6 Maintenance.................................................................................................................36
1.7 Meteorological Information................................................................................................37
1.8 Navigational Aids................................................................................................................38
1.9 Communications.................................................................................................................38
1.10 Airport Information...........................................................................................................38
1.11 Flight Recorders................................................................................................................38
1.11.1 Flight Data Recorder..................................................................................................38
1.11.2 Cockpit Voice Recorder.............................................................................................39
1.12 Wreckage and Impact Information....................................................................................39
1.12.1 General.......................................................................................................................39
1.12.2 Forward Cargo Compartment.....................................................................................41
1.13 Medical and Pathological Information..............................................................................43
1.14 Fire Damage......................................................................................................................44
1.14.1 Cargo Carried in Forward Cargo Compartment.........................................................44
1.14.2 Forward Cargo Compartment.....................................................................................45
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1.14.3 Aft Cargo Compartment.............................................................................................46
1.14.4 Fuselage......................................................................................................................46
1.15 Survival Aspects................................................................................................................47
1.15.1 ValuJet’s Procedures for Lap Children......................................................................47
1.15.2 Onboard Firefighting and Smoke Removal Procedures.............................................48
1.15.2.1 ValuJet’s Flight Attendant Manual.....................................................................48
1.15.2.2 ValuJet’s Aircraft Operating Manual..................................................................48
1.15.2.3 Douglas Aircraft DC-9 Flightcrew Operating Manual........................................49
1.15.2.4 Guidance for Smoke Removal on Other Airplanes.............................................50
1.15.2.5 Safety Board Recommendations on Smoke Removal Procedures......................51
1.15.3 Smoke Goggle Equipment and Training for Air Carrier Pilots..................................51
1.16 Tests and Research............................................................................................................53
1.16.1 Oxygen Generator Fire Tests......................................................................................53
1.16.1.1 Test Conditions and Results................................................................................54
1.16.2 Airplane Flight Performance......................................................................................55
1.17 Organizational and Management Information..................................................................58
1.17.1 General.......................................................................................................................58
1.17.2 ValuJet’s Aircraft Maintenance Program...................................................................60
1.17.2.1 General................................................................................................................60
1.17.2.2 SabreTech............................................................................................................61
1.17.2.3 SabreTech’s Procedures for Tagging and Identifying Aircraft Parts..................63
1.17.3 ValuJet’s Maintenance Training Program..................................................................64
v
1.17.4 Training of SabreTech Employees.............................................................................65
1.17.5 ValuJet’s Hazardous Materials Policy........................................................................66
1.17.5.1 Prior Hazardous Materials Incident.....................................................................70
1.17.6 ValuJet’s Oversight of SabreTech..............................................................................70
1.17.7 FAA Oversight of ValuJet..........................................................................................72
1.17.7.1 Principal Maintenance Inspector (PMI)..............................................................72
1.17.7.2 FSDO Staffing Levels.........................................................................................73
1.17.7.3 FAA Inspections of ValuJet................................................................................74
1.17.7.3.1 Regional Aviation Safety Inspection Program.........................................................74
1.17.7.3.2 National Aviation Safety Inspection Program Report.............................................74
1.17.7.3.3 AFS-300 Summary Report........................................................................................75
1.17.7.3.4 120-Day Special Emphasis Inspection......................................................................76
1.17.7.3.5 Consent Order...........................................................................................................78
1.17.8 FAA Oversight of SabreTech.....................................................................................80
1.17.8.1 Principal Maintenance Inspector.........................................................................80
1.17.8.2 FAA Special Inspection of SabreTech................................................................81
1.17.9 FAA 90-Day Safety Review of the FAA....................................................................82
1.17.10 FAA’s Hazardous Materials Program......................................................................85
1.17.10.1 Staff...................................................................................................................86
1.17.10.2 FAA Programs to Address Undeclared Hazardous Materials...........................87
1.17.10.3 Hazardous Materials Transported as Company Materials (COMAT)..............89
1.17.10.4 Hazardous Materials Shipped from Maintenance Facilities..............................90
1.17.11 RSPA’s Hazardous Materials Program....................................................................90
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