ValuJet Flight 592

One of the most important things for any company in any industry to do is to market itself. This is how businesses thrive: they get their names out there, they get customers, they make money, and they do it all over again. Finding a niche is what business is all about. The process by which one successfully establishes a unique commercial identity is called branding. The name of a product or company should say a lot about it. Think of the images that different makes and models of cars bring to mind. Names like Explorer, Navigator, Charger, and Cruiser tell you that these are cars that go places. Then you have others like Mustang, Cobra, Jaguar, and Stingray that imply a wild type of animal ferocity just waiting to be unleashed. (I would be much obliged if anyone could tell me what the hell "Touareg" implies, however.)

For the most part, airline companies don't really do that. They have names like American Airlines or Swissair or Air France. They basically describe where they're from and maybe where they go. Others have utterly banal names like United (with what?) or Continental (which one?). One major exception to this was a regional airline that appeared in 1992 called ValuJet. ValuJet primarily serviced the Southeastern United States with a few stops along the eastern seaboard and even Canada. Obviously, the name brings to mind "whoa, hey, I could save a couple of bucks if I went on one of those flights!" And you could: a direct flight from Jacksonville, Florida, to Atlanta, Georgia, would only set you back about $40, minus baggage fees. Two decades ago, nobody could compete with those kinds of rates, and ValuJet rapidly expanded. The company was founded by several high ranking corporate officers of various regional American airlines, but eventually the former president of Delta would sign on, lending more gravitas to the organization. The company's operational pedigree was impeccable. Five years after its inception, though, ValuJet would cease to exist.

ValuJet Flight 592

Flight 592 was ValuJet's regular flight from Miami to Atlanta, where the company was based. The plane itself was a McDonnell-Douglas DC-9, one of the most popular and common medium-sized passenger planes in the world. The DC-9 has multiple configurations, but can generally seat about 100 people. ValuJet's fleet was comprised almost entirely of refurbished DC-9s purchased from other airline companies. The DC-9 flying Flight 592 was nearly 30 years old on May 11, 1996. While this might sound like an advanced age for an aircraft, a plane can theoretically fly indefinitely with the proper maintenance (of course, then we get into a Theseus' boat situation where it's unclear how much of the original plane remains, but I digress). That said, ValuJet still had one of the oldest fleets among American airline companies. This was where the "Valu" part of the name came into play.

On the day of the flight, neither the plane's autopilot nor its intercom system were functional. It was delayed in Miami so maintenance could try to repair them. While workers were able to fix the intercom, the autopilot would have to be serviced at the company's headquarters. Apparently this was not particularly abnormal or worrying. Captain Candalyn Kubeck and First Officer Richard Hazen were accustomed to having to wait for their planes to be serviced. And the trip from Miami to Atlanta would only take about an hour and a half anyway, so manual flight wouldn't be a big deal. So it stood when at shortly after 2:00 in the afternoon, flight 592 took off with 105 passengers and 5 crew members on board. All 110 people would be dead within 10 minutes.

At first, everything went fine. The take off was normal as was the standard vertical climb to the flight's cruising altitude. Six minutes after takeoff, both the pilot and the co-pilot heard a loud thump coming from the rear of the plane. Seconds later, their electrical systems began to fail. A flight attendant came into the cockpit to inform the pilots that smoke was filling the cabin, which could only mean one thing: fire. Kubeck told Hazen to request an immediate return to Miami for an emergency landing, which was granted. Smoke began to fill the cockpit, at which point Hazen requested clearance to land at the closest available airport, which was also granted. Two minutes after that, the plane rolled over onto its right side, went nose down, and began a rapid descent into the Florida Everglades, where it impacted the swamp at over 500 miles per hour.

Investigation

While the Everglades are one of Florida's most beautiful natural features, they are utterly inhospitable to the human race. These wetlands are filled with alligators, snakes, and a veritable galaxy of harmful bacteria just waiting to infect and kill anyone unlucky enough to come into contact with them. Recovering the aircraft would be a daunting challenge for the National Transportation Safety Board. Unfortunately, this was not the NTSB's first investigation that took place in the Everglades. The NTSB had last been out there in 1972 after the crash of Eastern Airlines Flight 401, which had been caused by an insufficiently attentive crew playing with a burnt out light bulb rather than watching their altitude. The NTSB was clearly able to assign blame to the crew for that crash for reasons that should be fairly obvious, but determining the cause of this crash would be more daunting.

Despite the danger inherent to searching through a gator-infested swamp and the extreme violence of the crash, both the cockpit voice recorder (CVR) and the flight data recorder (FDR) were recovered in operational order. Unfortunately, neither of the black boxes revealed much that the NTSB didn't already know. One thing was clear, though: the crew made heroic efforts to salvage the plane, still attempting to control it up until seven seconds before the crash, when they were presumably overtaken by smoke inhalation.

Investigators already knew that there was a bump of some sort shortly after take-off and right before the electrical systems began to fail. By syncing the CVR with the FDR, they could see that the plane's external air pressure readings suddenly spiked at exactly the same time as the unidentified sound. The only thing that would cause such a thing would be an explosion of some type from inside the airplane. Given that neither the wings nor the engines had exploded, a fuel problem was deemed unlikely. Suspicion immediately turned to a bomb of some sort.

Even before September 11, 2001, terrorism was still a big deal (duh). There was much chatter among the relevant government agencies about the possibility of a terrorist attack during or before the 1996 Olympic Games set to happen in Atlanta in July and August. Could the crash of ValuJet Flight 592 have been a prelude to such an attack? The first step was to examine the plane's cargo manifest. While the NTSB was able to account for everything the DC-9 was carrying and rule out the possibility of a bomb, they did discover one unusual piece of cargo: a set of boxes designated COMAT (company materials) listed as containing "oxy canisters (empty)." These packages had been sent from a company called SabreTech which serviced the maintenance needs of ValuJet's fleet. This seemed like an appropriate place to start.

Upon arriving at SabreTech, the NTSB investigators discovered a series of horrific facts. First, safety standards at SabreTech were abysmal. Second, many employees did not actually know what they were servicing. Finally, the company lacked the basic mandated minimum resources to perform certain types of maintenance procedures, but did them anyway. The issue at hand was clearly the allegedly empty oxygen canisters. It was determined that they were not in fact canisters, but rather oxygen generators. This might sound like an utterly meaningless distinction, but oxygen generators are the mechanical devices that provide oxygen to the masks with which all commercial airliners are equipped in the case of a sudden depressurization in the cabin.

There is a very strict series of rules for the safe handling of these generators: they have to be fitted with special caps that prevent them from accidentally becoming active during any sort of shifting during transportation. The reason for this is that when the masks are deployed, pulling on them causes a lanyard to detach from the generator that activates it through what is basically a small chemical explosion. SabreTech failed to purchase these caps and instead instructed their employees to simply cut the tubing off or put duct tape over the tops of the generators. They were also packaged inappropriately; instead of being placed in the special boxes they typically go in, the oxygen generators were just put in bubble wrap and tossed in a box. Additionally, none of the generators were "empty" at all, they were simply approaching their expiration date. They had come from two older DC-9s that ValuJet had purchased and sent to SabreTech for refurbishing. The employee who filled out the shipping log evidently did not understand the difference between "empty" and "expired" and was also unaware of the difference between a canister and a generator. It is unlikely that either Kubeck or Hazen would have accepted oxygen generators as cargo for their flight if they had been properly denoted as such.

Flight 592 was also carrying other airplane parts in its cargo, most notably a tire. Through testing, the NTSB was fairly easily able to recreate the fire by activating a single oxygen generator in one of the five boxes full of them. The thud sound heard on the CVR was determined to have been the tire bursting after catching fire, which created a chain reaction within the cargo hold. Luggage compartments in almost all airplanes are airtight specifically to prevent a fire from breaking out within one of them; with a constant source of oxygen from the generators, however, the fire was free to grow and spread, which it did. The fire burned so hot that the thermometer in the testing chamber was unable to properly read the temperature. The test had to be quickly aborted when it became clear that the entire building was at risk of being consumed by the resulting inferno.

Amazingly, a very similar incident had occurred back in the 1980s, causing the Federal Aviation Authority to recommend that all cargo holds be equipped with both smoke detection and fire extinguishing technology. It did not, however, legally mandate such a move, which of course a company concerned with keeping its fares cheap would have no reason to institute on its own initiative. Ultimately, the NTSB assigned blame to SabreTech for its poor work standards, ValuJet for not properly supervising its contractors, and the FAA for not addressing a known danger previously. Needless to say, the FAA would later mandate that all cargo holds be upgraded with the safety features mentioned above.

Aftermath

Even though SabreTech received the bulk of the blame for the disaster, ValuJet did not fare much better. Just about any other airline company could have spun the situation by demonstrating that the crash had nothing to do with the skill of its pilots or the quality of its aircraft. Flight 592 was ValuJet's first and only fatal accident. Despite this, its safety record was far from exemplary. ValuJet had the highest rate of failed take-offs and emergency landings among American airline companies at the time.

The year before the crash, ValuJet Flight 597 from Atlanta to Miami had to be evacuated while preparing to take off because of a problem with the fuel line that caused the plane to be engulfed in flames. The cause was immediately known (rust on the engine) because the problem was repeatedly reported, but ValuJet did not provide the funds to repair it. Luckily, all passengers and crew had been able to escape from the plane with their lives, although some suffered serious injuries. As a result, the Department of Defense declined a contract with ValuJet to transport military personnel within the United States and in February of 1996, just three months before the crash of flight 592, the FAA banned the airline from making any further additions to its fleet without prior authorization. A month after the crash, all ValuJet planes were grounded. After the ban was lifted, ticket sales plummeted and the company could not salvage its reputation. It merged with AirTran in 1997 and adopted the smaller company's name.

For its part, SabreTech was destroyed by the accident. The company was fined millions of dollars by the federal government and three of its employees were charged with negligence and conspiracy; two were acquitted, but one fled from prosecution and was convicted in absentia; as of 2013, he is still at large. The state of Florida indicted the company on 110 counts of manslaughter and 110 counts of third degree murder (unintentionally killing someone while committing a nonviolent felony). The company pleaded no contest to the charges and agreed to donate a significant sum of money to two safety charities. It limped along until it went out of business in 1999.

In retrospect, the name "ValuJet" doesn't really send the message the company was likely hoping for. Imagine if we had things like ValuDoc, where you get the finest medical assistance from graduates of the fully accredited Online University of Chechnya or ValuLaw, where you get the best legal representation a $25 retainer can buy. The things that went into providing that "Valu" included outdated equipment, substandard safety practices, abhorrent pay for the staff, a serious lack of accountability (it was not uncommon for contractors to contract out jobs to subcontractors, who would then contract those jobs out to subsubcontractors), and incomplete training. Most people are not aware of AirTran's connection to ValuJet, which is probably a good thing for the company. It is one of the few corporate rebrandings that actually worked. To its credit, AirTran has not had a single fatal accident since Flight 592. Still, I can't help but imagine the reluctance some people might feel about taking a trip with them if they knew the full extent of their company's history.