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Valujet Flight 591, the Flight Preceding the Accident Flight on the Same Aircraft, Was Operated by the Accident Crew

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Valujet Flight 591, the Flight Preceding the Accident Flight on the Same Aircraft, Was Operated by the Accident Crew 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 The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. 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 the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (202)314-6551 (800)877-6799 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 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 iii 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 iv 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.....................
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