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M A R C H 1 9 9 8
T was known from the start that fire took the airplane down. The federal investigation began within hours, with the arrival that evening of a National
Transportation Safety Board team from Washington. The investigators set up shop
in an airport hotel, which they began to refer to as the "command post." The
language is important. As we will see, similar forms of linguistic stiffness,
specifically engineerspeak, ultimately proved to have been involved in the
downing of Flight 592 -- and this is a factor that the NTSB investigators,
because of their own verbal awkwardness, have been unable quite to recognize.
Go to part one of this article.
Go to part three of this article.
The press plays a more difficult role, though one equally important to the public's safety. It has a classically symbiotic relationship with the NTSB, relying on the investigators for information while providing them with their only effective voice. Nonetheless, in the time of crisis immediately after an accident, a tension exists between the two. Working under pressure to get the story out, reporters resent the caution of the investigators and their reluctance to speculate anonymously. Working under pressure to get the story right, investigators, for their part, resent the reporters' incessant demands during the difficult first days of an accident probe -- the recovery of human remains and airplane parts. By the time I got to Miami, nineteen hours after Flight 592 hit the swamp, the two camps had assumed their habitual positions and were passing each other warily in the hotel lobby.
Twenty miles to the northwest, deep in the Everglades, the recovery operation was already under way. The NTSB had set up a staging area -- a "forward ops base," one official called it -- beside the Tamiami Trail, a two-lane highway that traverses the watery grasslands of southern Florida. Within two days this staging area blossomed into a chaotic encampment of excited officials -- local, state, and federal -- with their tents and air-conditioned trailers, their helicopters, their cars and flashing lights. I quit counting the agencies. The NTSB had politely excluded most of them from the actual accident site, which lay seven miles north, along a narrow levee road.
The press was excluded even from the staging area, but was provided with two news conferences a day, during which investigators cautiously doled out tidbits of information. One NTSB official said to me, "We've got to feed them or we'll lose control." But the reporters were well behaved, and if anything a bit overcivilized. Near the staging area they settled into their own little town of television trucks, tents, and lawn chairs. The location gave them good Everglades backdrops and shots of alligators swimming by; the viewing public could not have guessed that they stood so far from the action. They acted impatient, but in truth this was not a bad assignment; at its peak their little town boasted pay phones and pizza delivery.
Maybe it was because of my obvious lack of deadline that the investigators made an exception in my case. They slipped me into the front seat of a Florida Game and Fish helicopter whose pilot, in a fraternal gesture, invited me to take the controls for the run out to the crash site. From the staging area we skimmed north across the swamped grasslands, loosely following the levee road, before swinging wide to circle over the impact zone -- a new pond defined by a ring of turned mud and surrounded by a larger area of grass and water and accident debris. Searchers in white protective suits waded side by side through the muck, piling pieces of people and airplane into flat-bottomed boats. It was hot and unpleasant work performed in a contained little hell, a place that one investigator later described to me as reeking of fuel, earth, and rotting flesh -- the special smell of an airplane accident. We descended onto the levee, about 300 yards away from the crash site, where an American flag and a few tents and trucks constituted the recovery base.
The mood there was quiet and purposeful, with no sign among the workers of the emotional trauma that officials had been worriedly predicting since the operation began. The workers on break sat in the shade of an awning, sipping cold drinks and chatting.
They were policemen and firemen, not heroes but
straightforward guys accustomed to confronting death. Not knowing who I was,
they spoke to me frankly about the gruesome details of their work, and made
indelicate jokes, but they seemed more worried about dehydration than about
"taking the job home" or losing sleep. I relaxed in their company, relieved to
have escaped for a while the expectation of grief. It was, of course, a somber place to be. Human remains lay bagged in a refrigerated truck for later transport to the morgue. A decontamination crew washed down torn and twisted pieces of airplane, none longer than several feet. Investigators tagged the most promising wreckage, to be trucked immediately to a hangar at an outlying Miami airport, where specialists could study it. Farther down the levee I came upon a soiled photograph of a young woman with a small-town face and a head of teased hair. A white-suited crew arrived on an airboat and clambered up the embankment to be washed down. Another crew set off. A boatload of muddy wreckage arrived. The next day the families of the dead came on buses, and laid flowers and cried. Pieces of the airplane kept being hauled up for nearly another month.
Much was made of this recovery, which -- prior to the offshore retrieval of TWA's Flight 800 -- the NTSB called the most challenging in its history. It is true that the swamp made the search slow and difficult, and that the violence of the impact meant that meticulous work was required to reconstruct the critical forward cargo hold. However, it is also true that the physical part of the investigation served to confirm what a look at a shipping ticket had already suggested -- that ValuJet Flight 592 burned and crashed not because the airplane failed but, in large part, because the airline did.
To me as a pilot, the most impressive aspect of the investigation was the speed with which it worked through the false pursuit of an electrical fire -- an explanation supported by my own experiences in flight, and all the more plausible here because the ValuJet DC-9 was old and had experienced a variety of electrical failures earlier the same day, including a tripped circuit breaker that had resisted the attentions of a mechanic in Atlanta, and then mysteriously had fixed itself. I was impressed also by the instincts of the reporters, who for all their technical ignorance seized on the news that Flight 592 had been loaded with a potentially dangerous cargo of chemical oxygen generators -- more than a hundred little firebombs that could have caused this accident, and that indeed did.
Flight 592 crashed on a Saturday afternoon. By Sunday the recovery teams were pulling up scorched and soot-stained pieces. On Monday a searcher happened to step on the flight-data recorder, one of two required black boxes meant to help with accident investigations. The NTSB took the recorder to its Washington laboratory and found that a blip in the flight data six minutes after Flight 592's takeoff seemed to indicate a momentary rise in air pressure. Immediately afterward the recorder began to fail intermittently, apparently because of electrical-power interruptions. On Tuesday night, at a press conference at the hotel, Robert Francis, the vice-chairman of the NTSB and the senior official on the scene, announced in a monotone, "There could have been an explosion." A hazardous-materials team would be joining the investigation. The investigation was focusing on the airplane's forward cargo hold, which was located just below and behind the cockpit, and was unequipped with fire detection and extinguishing systems. Routine paperwork indicated that the Miami ground crew had loaded the hold with homeward-bound ValuJet "company material," a witch's brew of three tires -- at least two of them mounted -- and five cardboard boxes of old oxygen generators.
XYGEN generators are safety devices. They are small steel canisters mounted
in airplane ceilings and seatbacks and linked to the flimsy oxygen masks that
dangle in front of passengers when a cabin loses pressurization. To activate
oxygen flow the passenger pulls a lanyard, which slides a retaining pin from a
spring-loaded hammer, which falls on a minute explosive charge, which sparks a
chemical reaction that liberates the oxygen within the sodium-chlorate core.
This reaction produces heat, which may cause the surface temperature of the
canister to rise to 500° Fahrenheit if the canister is mounted correctly in
a ventilated bracket, and much higher if it is sealed in a box with other
canisters, which may themselves be heating up. If there is a good source of
fuel nearby, such as tires and cardboard boxes, the presence of pure oxygen
will cause the canisters to burn ferociously. Was there an explosion on Flight
592? Perhaps. But in any event the airplane was blowtorched into the ground.It is ironic that the airplane's own emergency-oxygen system was different -- a set of simple oxygen tanks, similar to those used in hospitals, that do not emit heat during use. The oxygen generators in Flight 592's forward cargo hold came from three MD-80s, a more modern kind of twin jet, which ValuJet had recently bought and was having refurbished at a hangar across the airport in Miami. As was its practice for most maintenance, ValuJet had hired an outside company to do the job -- in this case a large firm called SabreTech, owned by Sabreliner, of St. Louis, and licensed by the FAA to perform the often critical work. SabreTech, in turn, hired contract mechanics from other companies on an as-needed basis. It later turned out that three fourths of the people on the project were just such temporary outsiders. The vulnerability of American wageworkers could be sensed in their testimony after the accident. They inhabited a world of boss men and sudden firings, with few protections or guarantees for the future. As the ValuJet deadline approached, they worked in shifts, day and night, and sometimes through the weekend as well. It was their contribution to our cheap flying.
We will never know everyone at fault in this story. ValuJet gave the order to replace oxygen generators on the MD-80s, most of which had come to the end of their licensed lifetimes. It provided SabreTech with explicit removal procedures and general warnings about the dangers of fire. Over several weeks SabreTech workers extracted the generators and taped or cut off their lanyards before stacking most of them in five cardboard boxes that happened to be lying around the hangar. Apparently they believed that securing the lanyards would keep the generators from being fired inadvertently. What they did not do was place the required plastic safety caps over the firing pins -- a precaution spelled out on the second line of ValuJet's written work order. The problem for SabreTech was that no one had such caps, or cared much about finding them. Ultimately the caps were forgotten or ignored. At the end of the job, in the rush to complete batches of paperwork on all three MD-80s, two mechanics routinely "pencil-whipped" the problem by signing off on the safety-cap line as well as on the others, certifying that the work had been done. SabreTech inspectors and supervisors signed off on the work too, apparently without giving the caps much thought.
The timing is not clear. For weeks the five boxes stood on a parts rack beside the airplanes. Eventually mechanics lugged them over to SabreTech's shipping-and-receiving department, where they sat on the floor in the area designated for ValuJet property. A few days before the accident a SabreTech manager told the shipping clerk to clean up the area and get all the boxes off the floor in preparation for an upcoming inspection by Continental Airlines, a potential customer. The boxes were unmarked, and the manager did not care what was in them.
The shipping clerk then did what shipping clerks do, and prepared to send the oxygen generators home to ValuJet headquarters, in Atlanta. He redistributed them equally among the five boxes, laying the canisters horizontally end to end, and packing bubble wrap on top. After sealing the boxes he applied address labels and ValuJet company-material stickers, and wrote "aircraft parts." As part of the load he included two large main tires and a smaller nose tire -- at least two of which were mounted on wheels. The next day he asked a co-worker, the receiving clerk, to make out a shipping ticket, and to write "oxygen canisters -- empty" on it. The receiving clerk wrote "Oxy Canisters" and then put "Empty" between quotation marks, as if he did not believe it. He also listed the tires.
The cargo stood for another day or two, until May 11, when the SabreTech driver had time to deliver the boxes across the airport to Flight 592. There the ValuJet ramp agent accepted the material, though federal regulations forbade him to, even if the generators were empty, since canisters that have been discharged contain a toxic residue, and ValuJet was not licensed to carry any such officially designated hazardous materials. He discussed the cargo's weight with the copilot, Richard Hazen, who also should have known better. Together they decided to place the load in the forward hold, where ValuJet workers laid one of the big main tires flat, placed the nose tire at the center of it, and stacked the five boxes on top of it around the outer edge, in a loose ring. They leaned the other main tire against a bulkhead. It was an unstable arrangement. No one knows exactly what happened then, but it seems likely that the first oxygen generator ignited during the loading or during taxiing or on takeoff, as the airplane climbed skyward.
Two weeks later and halfway through the recovery of the scorched and shattered parts a worker finally found the airplane's cockpit voice recorder, the second black box sought by the investigators. It had recorded normal sounds and conversation up to the moment -- six minutes after takeoff -- when the flight-data recorder indicated a pulse of high pressure. The pulse may have been one of the tires exploding. In the cockpit it sounded like a chirp and a simultaneous beep on the public-address system. The captain, Candalyn Kubeck, asked, "What was that?"
Hazen said, "I don't know."
They scanned the airplane's instruments and found sudden indications of electrical failure. It was not the cause but a symptom of the inferno in the hold -- the wires and electrical panels were probably melting and burning along with other, more crucial parts of the airplane -- but the pilots' first thought was that the airplane was merely up to its circuit-breaking tricks again. The recording here is garbled. Kubeck seems to have asked, "About to lose a bus?" Then, more clearly, she said, "We've got some electrical problem."
Hazen said, "Yeah. That battery charger's kickin' in. Oooh, we gotta ..."
"We're losing everything," Kubeck said. "We need, we need to go back to Miami."
Twenty seconds had passed since the strange chirp in the cockpit. A total electrical failure, though serious, was not in those sunny conditions a life-threatening emergency. But suddenly there was incoherent shouting from the passenger cabin, and women and men screaming, "Fire!" The shouting continued for thirteen seconds and then subsided.
Kubeck said, "To Miami," and Hazen put in the call to Jesse Fisher, the air-traffic controller. When Fisher asked, "What kind of problem are you having?" Kubeck answered, off-radio, "Fire," and Hazen transmitted his urgent "Smoke in the cockpit. Smoke in the cabin."
Investigators now presume that the smoke was black and thick, and perhaps poisonous. The recorder picked up the sound of the cockpit door opening, and the voice of the chief flight attendant, who said, "Okay, we need oxygen. We can't get oxygen back there." Did she mean that the airplane's cabin masks had not dropped, or that they had dropped but were not working? If the smoke was poisonous, the masks might not have helped much, since by design they mix cabin air into the oxygen flow. The pilots were equipped with better, isolating-type masks and with goggles, but may not have had time to put them on. Only a minute had passed since the first strange chirp. Now the voice recorder captured the sound of renewed shouting from the cabin. In the cockpit the flight attendant said, "Completely on fire."
The recording was of little use to the NTSB's technical investigation, but because it showed that the passengers had died in agony, it added emotional weight to a political reaction that was already spreading beyond the details of the accident and that had begun to call the entire airline industry into question. The public, it seemed, would not be placated this time by standard reassurances and the discovery of a culprit or two. The press and the NTSB had put aside their on-site antagonism and had joined forces in a natural coalition with Congress. The questioning was motivated not by an immediate fear of unsafe skies (despite the warnings of Mary Schiavo, a federal whistle-blower who claimed special insight) but rather by a more nuanced suspicion that competition in the open sky had gone too far, and that the FAA, the agency charged with protecting the flying public, had fallen into the hands of industry insiders.
HE FAA's administrator then was a onetime airline boss named David Hinson -- the
sort of glib and self-assured executive who does well in closed circles of
like-minded men. Now, however, he would have to address a diverse and skeptical
audience. The day after the ValuJet accident he had flown to Miami and made the
incredible assertion that ValuJet was a safe airline -- when for 110 people lying
dead in a nearby swamp it very obviously was not. He also said, "I would fly on
it," as if he believed that he had to reassure a nation of children. It was an
insulting performance, and it was taken as evidence of the FAA's isolation and
of its betrayal of the public's trust.After a good night's sleep Hinson might have tried to repair the damage. Instead he appeared two days later at a Senate hearing in Washington sounding like an unrepentant Prussian: "We have a very professional, highly dedicated, organized, and efficient inspector work force that do their job day in and day out. And when we say an airline is safe to fly, it is safe to fly. There is no gray area."
His colleagues must have winced. Aviation safety is nothing but a gray area, and the regulation of it is an indirect process of negotiation and maneuver. Consider the size of the airline business, the scale of the sky, and the loneliness of an airplane in flight. The FAA can affect safety by establishing standards and enforcing them through inspections and paperwork, but it cannot throw the switches or turn the wrenches, or in this case supervise the disposal of old oxygen generators. Safety is ultimately in the hands of the operators, the mechanics and pilots and their managers, because it involves a blizzard of small judgments. Hinson might have admitted this reality to the American public, which is certainly capable of understanding such subtleties, but instead, inexplicably, he chose to link the FAA's reputation to that of ValuJet. This placed the agency in an impossible position. Whether for incompetence or for cronyism, the FAA would now inevitably be blamed.
Within days it came out that certain inspectors at the FAA had been worried about ValuJet for some time and had described their concerns in their reports. Their consensus was that the airline was expanding too fast (from two to fifty-two airplanes over its two-and-a-half-year life) and that it had neither the procedures nor the people in place to maintain standards of safety. The FAA tried to keep pace, but because of its other commitments -- including countering the threat of terrorism -- it could assign only three inspectors to the airline. At the time of the accident they had run 1,471 routine checks on the operation and made two additional eleven-day inspections, in 1994 and 1995. This level of scrutiny was about normal. But by early 1996 concern had grown within the FAA about the disproportionate number of infractions committed by ValuJet and the string of small bang-ups it had had. The agency began to move more aggressively. An aircraft-maintenance group found such serious problems in both the FAA's surveillance and the airline's operations that it wrote an internal report recommending that ValuJet be "recertified" immediately -- meaning that it be grounded and started all over again. The report was apparently sent to Washington, where for reasons that remain unexplained it lay buried until after the accident. Meanwhile, on February 22, 1996, headquarters launched a 120-day "special emphasis" inspection, a preliminary report on which was issued after the first week. This suggested a wide range of problems. The special-emphasis inspection was ongoing when, on May 11, Flight 592 went down.
As this record of official concern emerged, the question changed from why Hinson had insisted on calling ValuJet "safe" after the accident to why he had not shut down the airline before the accident. Trapped by his own simplistic formulations, he could provide no convincing answer. The press and Congress were sharply critical. The FAA launched an exhaustive thirty-day review of ValuJet, perhaps the most concentrated airline inspection in history, assigning sixty inspectors to perform in one month the equivalent of four years' work. Lewis Jordan, a founder and the president of ValuJet, complained that Hinson was, in effect, conducting a witch hunt that no airline could withstand. Jordan had been trying shamelessly to shift the blame for the deaths onto his own contractor, SabreTech, and he received little sympathy now. No one was surprised when ValuJet was grounded indefinitely five weeks after the accident.
Here now was proof that the FAA had earlier neglected its duties. The agency's chief regulator, Anthony Broderick, was the first to lose his job. Broderick was an expert technocrat, disliked by safety crusaders because of his conservative approach to instituting and applying regulations, and respected by aviation insiders for the same reason. Hinson let him take the fall: Broderick was a man of integrity and would accept responsibility for the FAA's poor performance. But if Hinson thought that he himself could escape with this sacrifice, he was wrong. Broderick's airline friends now joined the critics in disgust. Hinson announced his upcoming resignation.
In a sense, the system worked. The tragedy did have some positive consequences -- primarily because the NTSB did an even better job than usual, not only pinpointing the source and history of the fire but also recognizing some of its larger implications. With a well-timed series of press feedings and public hearings the accident team kept the difficult organizational issues alive and managed to stretch the soul-searching through the end of the year and beyond. By shaking up the FAA, the team reminded the agency of its mandate to oversee the safety of the airlines -- perhaps prodding the FAA into a renewed commitment to inspections and a resolution to hold airlines responsible for their actions and for the performance of outside shops.
For the airlines, the investigation served as a necessary reminder of the possible consequences of cost-cutting and complacency. Among airline executives smart enough to notice, it may also have served as a warning about the public's growing distrust of their motives and about widespread anger with the whole industry -- anger that may have as much to do with the way passengers are handled as with their fears of dying. However one wants to read it, the ValuJet turmoil marked the limits of the public's tolerance. The airlines were cowed, and they submitted eagerly to the banning of oxygen generators as cargo on passenger flights. They then rushed ahead of the FAA with a $400 million promise (not yet fulfilled) to install fire detectors and extinguishers in all cargo holds. The desire to find hidden hazards runs up against the practical difficulties of inspecting cargo. Nonetheless, ground crews can be counted on for a while to watch what they load into airplanes and what they take out and throw away.
And the guilty companies? They lost money and were sued, of course. After firing the two mechanics who had falsely signed the work orders, SabreTech tried to put its house in order. Nonetheless, its customers fled and did not return. The Miami operation shrank from 650 to 135 employees, and in January of last year was forced to close its doors. Soon afterward, as the result of a two-month FAA investigation, SabreTech's new Orlando facility was forced to close as well. ValuJet survived its grounding, and under intense FAA scrutiny returned to the sky later in 1996, with a reduced and standardized fleet of DC-9s; it ultimately changed its name to AirTran. For a while it was probably the safest airline in the country. What, then, explains the feeling, particular to this case, that so little has in reality been achieved?
The online version of this article appears in three parts. Click here to go to part one. Click here to go to part three.
William Langewiesche is a contributing editor of The Atlantic and the author of Sahara Unveiled (1996). His article in this issue will appear in his book Inside the Sky: A Meditation on Flight, to be published this spring by Pantheon Books.
Illustrations by Philippe Weisbecker
Copyright © 1998 by The Atlantic Monthly Company. All rights reserved.
The Atlantic Monthly; March 1998; The Lessons of ValuJet 592; Volume 281, No. 3; pages 81 - 98.
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