Causes and Lessons Learned of Value Jet 592 Accident

Introduction

May 11, 1996 will always remain a painful memory in the minds of most people, especially friends and family of those who were on board the Value Jet Flight 592 (Hardy, 2010). It is on this date that the plane crashed into the Everglades in Florida, within a span of ten minutes after taking off from Miami International Airport. The pilot attempted to return to the airport after an uncontrolled fire started in the Class D cargo compartment. The accident generated various opinions over the cause, with different individuals giving their account of the events. Most fingers pointed towards human error as the major cause of the accident which left 110 individuals dead, including 5 crew members. However, the accident was a wakeup call to the air transport service providers, with various companies taking up precautionary measures and developing strategies that would enable them to ensure that the airplanes were mechanically fit to fly and that the safety of every individual on board was guaranteed.

Causes of the Accident

The accident involving Flight 592 was one of the major accidents in the airline industry in the United States. In normal circumstances, if put under good conditions, aircraft could hardly crash unless they are affected by natural conditions such as storms, or individual conditions of the pilots such as seizure. None of these factors was evident in the incident involving Flight 592. It is thus important to consider human involvement and the possibility of such involvement in facilitating the accident. In this vein, it is the James Reasons human performance model that could be effective in the analysis of human involvement in the accident discussed in this paper (Eurocontrol Experimental Centre, 2006).

Through this model, an in-depth evaluation of all levels of management and the employees involved can be conducted in order to note any links with the accident. The model is made up of five components, which include decision-makers, preconditions, management, defenses, and productive. In the model, Reasons maintains that some individuals make poor decisions, which leads to active failures, while other individuals make latent failures. Latent failures take place before the accident and they create room for the active failures to take place (Eurocontrol Experimental Centre, 2006).

On the other hand, active failures are basically the failures of those persons who are involved with the accident. In most cases, the individuals who are involved in the active failures that lead to accidents face most of the blame. As much as it may be their fault, it is always important to consider the preconditions that these individuals were subjected to. In this case, it is important to take a closer look at the pressures that were put on these individuals by the management and attitudes that were held throughout the preparation process.

The management makes the latent failures in most cases, whereby they make faulty decisions that lead to poor decisions by individuals who take instructions from the management, active failures, and thus leading to accidents. Latent failures would in most cases fail to realize the dangers that their decisions could hold. Instead, they always believe that bad decisions can only originate from their subordinates working on the ground. These individuals thus do not seek any self-awareness through mechanisms such as acquiring feedback that would enable them to identify and solve their mistakes (Eurocontrol Experimental Centre, 2006). Thus, in the investigation of Flight accidents, it is important to consider not only the role of the latent failures in the accident but also that of the active failures.

In the case of Flight 592 of Value Jet airlines, it is important to consider the entire company in order to note the role of the latent failures in the accident. After the accident involving Flight 592, the carrier stopped its operations. Most individuals would relate this move to the crash, but in the real sense, it goes beyond one crash as the company had experienced a series of crashes before, on different occasions. After Value Jet flight 592’s accident, the company thought that that was the final red alert to shut down. The company’s services were admired by most people as they offered low prices for their tickets, an aspect, among others, that facilitated rapid growth.

The Federal Aviation Administration (FAA) used Value Jet as an icon to promote aviation with various claims that the airline was safe, an aspect that was contrary to the actual situation on the ground (Eurocontrol Experimental Centre, 2006). The FAA failed to see the other side of such a rapid expansion, which involved poor aircraft maintenance and inadequacy in terms of facilities, an aspect that resulted in outsourcing to other organizations that had questionable reputations. Such factors were major contributors to the in-flight fire that led to the crashing of Value Jet flight 592.

With reference to Reason’s model, the weaknesses of all involved parties in the accidents are examined. At the topmost level in this chain of evaluations is the FAA. Being the highest board in the country in matters to do with aviation, the FAA failed greatly to carry out their responsibilities (Schiavo, 1997). The association was created for the sake of promoting and regulating aviation. However, they developed a conflict of dual existence as per these two responsibilities. It was upon them to develop policies that would enable them to effectively control the operations of the airlines in the country in order to promote their safety, while again they were expected to safeguard the airlines from criticism and opposition in order to promote aviation. Some of the workers in the association failed to serve both purposes and they ended up favoring one side while leaving the other unattended. The FAA failed to regulate the operations of Value Jet an aspect that led to poor management of the Flights.

Even after a series of accidents involving Flights from the company occurred in 1995, the FAA rallied its support behind the company and encouraged the carrier to continue with its services with claims that it was safe. Early in 1996, the landing gear of one of Value Jet’s planes collapsed, but the FAA still maintained their support for the company. As much as the inspectors from the FAA accessed the training records, fleets, logbooks, hangars, and the maintenance offices of Value Jet, they did not take any action in response to the poor conditions of the planes. As a matter of fact, they sugar-coated the company’s reputation with claims that it was a great example in the airline industry, and that other companies should emulate its operations (Schiavo, 1997).

The FAA failed to enforce restrictions and implement its own policies for the safety of the passengers, and instead, it focused on the growth of the company and the benefits that came with such growth. Poor communication within the FAA, in cases where discrepancies were found, led to casual handling of most of the issues concerning Value Jet, even in cases where they required urgency and utmost attention. An investigation of the FAA by the Department of Transport (DOT) revealed inefficiencies in the association and cases of incompetence. The company experienced rapid growth, moving from two planes to fifty-one planes, only three years after its establishment (Schiavo, 1997).

The second latent failure that could have resulted in the accident of Flight 592 is Value Jet Airline’s management. The management directed their focus towards growth while disregarding other aspects that would improve their services and ensure the safety of the passengers and the crew members. The rapid growth of the company was facilitated by the failure of the company to invest large amounts of capital. The company did not offer special services such as food, printed tickets, or seat reserves on board as it targeted relatively low-income members of the society (Schiavo, 1997). The employees also received poor motivation as they were not offered any discount tickets, yet they earned less income as compared to other companies. The executives were also not given company cars, and they used cheap furniture in their offices.

As much as the company made high profits, the employees in the company were held in low regard, an aspect that can be explained by the low pay they received. This poor motivation could be termed as a precondition of the accident. The employees, starting from the highest level of the executives, developed little interest in the work as it did not offer them the benefits they desired. The managers strained from the development process, and as much as they facilitated the growth, they did not focus on developing a corporate culture that would promote the performance of the employees. The company did not have a well-established operational manual, and the ones that existed for pilots had faults. The payment structure of the pilots offered little motivation as they were only paid for the flights completed (Schiavo, 1997). This structure encouraged most of the pilots to disregard safety in the quest of earning more money. Case in point, some of the pilots preferred to fly even in conditions that required cancellation such as maintenance problems, bad weather, among other problems.

Another cause of the crash of ValuJet’s Flight 592 among other flights that had been involved in accidents earlier is poor maintenance if the fleet. The company’s growth and high demand for flight services came with the development of mechanical problems concerning the fleet. The company had old planes that had been bought from Turkey and thus needed high maintenance. However, maintenance was not regarded highly, and the company proceeded to give the contracts of maintenance to the contractors who bided the lowest. The same contracts were spread among several companies, with emphasis placed on keeping the planes moving in order to earn a profit, and not to ensure that they were at their best conditions before they embarked on journeys (Schiavo, 1997). Prior to the accident involving Flight 592, there had been many accidents and emergency landings than any other company, an indication of poor maintenance of the fleet.

This poor maintenance can also be categorized under active failure. The Flight crashed as a result of a fire that started from the cargo compartment. The oxygen generators from which the fire originated were improperly packed and labeled (NTSB, 1997). SabreTech Company is the first active failure in this case since they were responsible for the preparation of these generators. This company had been given a contract by Value Jet to carry out heavy repairs involving the airplanes.

As a cause of the fire, there was inadvertent activation of one oxygen generator leading to an exothermic reaction. The pilots could either have been distracted by the fire, or they were barred from operating and communicating as a result of smoke in the cockpit. SabreTech did not fully inspect the oxygen generators as they only concentrated on the dates of expiration and gave no consideration to the conditions. The safety mechanisms of the generators should be highly considered. The generators are fitted with safety pins which are pulled out by the pressure exerted by a passenger who reaches out for oxygen. Additionally, a safety cap is installed on each generator to restrict the pin from moving (NTSB, 1997). Some of the generators that were put on board on Flight 592 did not have the safety caps. This lack of safety caps on the generators is what prompted the pins to pull out and cause a fire. The individuals who were preparing the oxygen generators did not have enough training to handle them in the right manner.

The employees were not even aware of the hazardous practices and materials handling due to poor training. SabreTech Company did not have the correct training material that would correspond with the policies of ValuJet. In addition, Flight 592 had not received any certification to carry any hazardous material. The generators were thus not supposed to be carried as cargo (NTSB, 1997). As much as the company had many employees, the incomplete materials passed across all of them without any one of them pointing out to the mistake. This could be linked to the attitude that had been developed in the company as a result of poor motivation.

Lessons Learnt

After the crash of Value Jet Flight 592, various lessons of importance to aviation were learned in the view of reducing accidents in the future. The FAA developed regulatory measures that required all the cargo compartments, especially those that could not be readily accessed by the flight crew to be fitted with special systems that can detect and suppress fire (Federal Aviation Administration, 2013). This is aimed at minimizing the spreading of fire that starts in the cargo compartments. Strategies have also been set in order to ensure that any hazardous cargo is well checked, and packaged in order for them to be included in cargo on a carrier. All organizations are expected to ensure high maintenance of their airlines with high regards to safety regardless of the organizations that oversee such maintenance or the service providers.

Another lesson learned is the need for some of the procedures of maintenance to be conducted by individuals who have been highly trained for such tasks due to their technicality. It is important for any maintenance service providers to be equipped with their tools, parts, or materials that are used in airplane materials to ensure that they are efficient and that they work properly. It was also learned that those safety strategies that involve passive features rely on the operation of the feature if subjected to particular threats. The best safety strategy is preventing such threats (Federal Aviation Administration, 2013).

Airlines have also recognized the need to refine their training, equipment, and procedures in order to effectively counter in-flight fires. The need to train pilots on how to don oxygen masks immediately after identifying smoke in the cockpit was also learned after the accident. Moreover, most airlines recognized the need to install better smoke goggles in the cockpit.

Strict restrictions were developed for the inclusion of oxygen generators on aircraft (Federal Aviation Administration, 2013). More guidance was provided for dealing with oxygen generators and any other material identified as hazardous. The need for the FAA to develop proper strategies that would ensure that there is proper handling of material in airlines was also identified. The maintenance programs by Value Jet also showed that there is a possibility that any major airline can overlook vital critical maintenance operations, and that there is a need for these airlines to be monitored.

Conclusion

It is evident that the 1996 accident involving Value Jet Flight 592 was caused by human error and negligence. Various parties failed at their levels to play their roles. The FAA failed to effectively regulate the operations of Value Jet including the maintenance, as much as they engaged in promoting the company’s sales through protecting them against critics. The company’s management on its side failed to maintain proper maintenance of its airplanes and motivation of the employees leading to the development of a poor attitude in the country. SabreTech failed to ensure that there was proper maintenance of the oxygen generators. The employees disregarded safety in their quest for money to boost their low pay. However, the accident resulted in various lessons that became of benefits in aviation. The lessons were adopted at all levels, ensuring that all measures were developed and implemented for the safety of the passengers and crew.

References

Eurocontrol Experimental Centre. (2006, October). Revisiting the Swiss Cheese model of accidents. Retrieved November 26, 2013, from Eurocontrol Experimental Centre: http://i3pod.com/wp-content/uploads/2011/04/Revisiting-the-Swiss-Cheese-Modek-EEC-note-2006-13.pdf.

Federal Aviation Administration. (2013). Lessons learned. Retrieved November 26, 2013, from Federal Aviation Administration: http://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=10&LLTypeID=12

Hardy, T. L. (2010). The system safety skeptic: Lessons learned in safety management and Engineering. Bloomington: AuthorHouse.

NTSB. (1997). Aircraft accident report 20594. Washington D.C.: U.S. Government Printing Office.

Schiavo, M. (1997). Flying blind, flying safe. New York: Avon Books.