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NTSB blames airline, contractor and FAA for ValuJet crash

'Failures all up and down the line'

In this story: August 19, 1997
Web posted at: 11:55 p.m. EDT

WASHINGTON (CNN) -- Investigators said Tuesday the ValuJet crash that killed 110 people last year was the result of failures by the airline, its maintenance contractor and the Federal Aviation Administration, and could have been avoided.

In a report on the May 11, 1996, crash in the Florida Everglades, the National Transportation Safety Board concluded that the ValuJet DC-9 probably would not have crashed if the plane had been fitted with fire detection and suppression gear.

CNN's Kathleen Koch reports
icon 2 min. 17 sec. VXtreme video
oxygen generator

"The ValuJet accident resulted from failures all up and down the line -- from federal regulators to airline executives in the boardroom to workers on the shop room floor," NTSB Chairman Jim Hall said at the conclusion of a daylong hearing.

The NTSB concluded that the crash was caused by a fire in the cargo hold fueled by oxygen-generating canisters which had been improperly handled and labeled by SabreTech Corp., the maintenance contractor for ValuJet.

In a statement after the hearing, ValuJet charged once again that Sabretech knew the canisters were dangerous and purposely mislabeled them.

SabreTech responded angrily. "That's just bunk," said SabreTech legal counsel Kenneth Quinn, "and it's irresponsible of ValuJet to put out information they know to be false."

But the NTSB also criticized ValuJet's failure to oversee its contract maintenance program.

FAA chided for ignoring 1988 recommendation

The NTSB also added fuel to a simmering feud with the FAA by chiding it for not carrying out a 1988 NTSB recommendation to require airlines to install smoke alarms and fire suppression systems in cargo holds.

The FAA finally acted on the recommendation after the ValuJet crash, but has given the airlines until 2001 to retrofit their planes. Hall believes it should be done more quickly, and the board recommended Tuesday that the plan be expedited.

"All of us owe it to the American people to do it just as fast as we possibly and responsibly can," he said after the hearing.

In an unusually lengthy list of 47 "findings" stemming from its probe of the crash, the board concluded that a fire suppression system, used in conjunction with an alarm system, would probably have given the crew time to turn around and land safely.

Smoke alarm would have alerted crew

"A suppression system would have either extinguished or delayed fire development giving the crew more time to safely land and evacuate the aircraft," the report says.

The board found that loss of control was most likely the result of flight control failure from the extreme heat and structural collapse. But it admitted that it could not rule out the possibility that the flight crew was incapacitated by smoke or heat in the cockpit during the final seconds.

Chief investigator Gregory Feith said many of the 25 oxygen generators found at the accident site bore internal and external evidence of fire and heat damage. Aviation safety sources say they believe the fire may have started before the ValuJet plane took off, and that a smoke alarm could have warned the crew.

Another change the NTSB wants the FAA to institute quickly is to require that phones between the cabin and cockpit work. They didn't on Flight 592, and flight attendants had to open the cockpit door to tell the crew there was a fire, allowing smoke in the cockpit.

Hall directs remarks to victims' families

reccommendations graphic

Other NTSB recommendations include:

  • Label oxygen canisters as dangerous;

  • Make sure that maintenance facilities get better training to identify, handle and dispose of hazardous materials;

  • Beef up FAA oversight of maintenance;

  • Ensure contract maintenance shops get the same FAA inspections as in-house maintenance facilities.

The ValuJet crash has already led to changes at the FAA, including closer scrutiny of new carriers and banning oxygen generators in the cargo holds of passenger aircraft. The generators are considered safe when located above passengers as a source of emergency oxygen if depressurization occurs during flight.

Hall directed some of his remarks to the crash victims' relatives, about 70 of whom traveled to Washington to attend the hearing.

"We have done everything in our power to see that an accident like this never happens again," he said.

But the families are not satisfied.

Said Lee Hamilton Sawyer, the daughter of one of the crash victims: "Not until the changes are made and we see things implemented on planes will we have a sense of closure..."

Correspondent Kathleen Koch and Reuters contributed to this report.

ValuJet Special Section

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