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| AVOIDABLE TRAGEDY
AUGUST 19, 1997TRANSCRIPT |
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Many technical and human errors led to the crash of Valujet 592, according to a report by the National Transportation Safety Board (NTSB). The crash has raised questions about the overall safety of air-travel. Kwame Holman reviews the developments to date, and Elizabeth Farnsworth investigates the details with the Chairman of the NTSB, James Hall.
A RealAudio version of of this segment is available.
NewsHour Links:
August 19, 1996:
Kwame Holman reports on the ValuJet crash report.
June 25, 1996:
Kwame Holman reports on the House hearings on the ValuJet crash and the issue of airline safety.
June 19, 1996:
The Federal Aviation Authority has its mandate changed in an effort to improve air safety.
May 26, 1996:
Margaret Warner interviews National Public Radio's Derek Deveron from the Valujet crash site in south Florida.
May 26, 1996:
Experts question the safety of ValuJet and other "off-brand" airlines.
December 26, 1995:
Computer malfunctions continue to plague Chicago O'Hare's air traffic control center.
ELIZABETH FARNSWORTH: Now, for more we're joined by the chairman of the National Transportation Safety Board, whom you just saw, James Hall. Thank you very much for being with us. Let's go through some of these failures up and down the line, as you put it. First of all, how did oxygen canisters which burst into flame get on this airplane? Whose failure was that?
JAMES HALL, Chairman, National Transportation Safety Board: Well, as we mentioned, it's a combination of failures. Obviously, it began with Sabretech's failure to properly prepare--
ELIZABETH FARNSWORTH: Sabretech being the subcontractor of ValuJet--
JAMES HALL: Right.
ELIZABETH FARNSWORTH: --which was doing certain kinds of maintenance.
Oxygen containers probably caused the fatal explosion.
JAMES HALL: They were doing heavy maintenance. They were retrofitting three of the DC-9 aircraft that ValuJet had, and they were responsible for replacing and removing these old oxygen generators. They'd expired.
ELIZABETH FARNSWORTH: Those are the generators that on an airplane, if something happened, the gas mask would pop out and you'd put it over your face.
JAMES HALL: You'd pull it, and it's essentially got a pin like a grenade, so if you pull on it, that is--the oxygen is, they say activated--the generator is activated; the oxygen is released, and flows into the mask. Obviously, when it was supposed to be packaged with a safety cap on it, the work card that had been signed off by Sabretech was supposed to--indicated that that had been done. It had not been done.
ELIZABETH FARNSWORTH: So that was actually falsification there?
JAMES HALL: Well, it was--it would appear to be, yes. And we found then obvious failure at ValuJet--understand any procedures in regard to the transport of hazardous materials--ValuJet had a procedure in place to transport hazardous materials that were called COMAT, company materials, which was in violation of the authority they had from the FAA. They did not have a clear understanding up and down ValuJet what they could and could not do in the transport of hazardous materials, which obviously contributed to the accident, and then of course finally is the Federal Aviation Administration's oversight of both Sabretech and ValuJet, we found to be lacking, not only--well, just extremely lacking up and down the line.
ELIZABETH FARNSWORTH: Well, let's go through the story and we'll get to that. The oxygen generators are on board. Why did they burst into flame? What causes that?
JAMES HALL: Well, we're not sure. Our fire experts feel that they were loaded in boxes, improperly marked, thrown into the cargo compartment, probably on top of a number of tires. That's speculation again, but we know they were not secured. Somewhere during the takeoff roll and the--going out for takeoff and the roll and takeoff, we feel that because the safety caps were not on there that pure oxygen then was dispensed from one of these generators. And any type of friction, small static electricity, spark in that cargo could have ignited a fire. We feel then that the first time the crew was aware of that was when one of the tires exploded and caused an anomaly in the system that gave them notice, and then unfortunately probably the next thing was the fire breaking through the floor of the cabin, where the passengers were located.
Could sprinkling systems prevent future accidents?
ELIZABETH FARNSWORTH: And as we heard in Kwame's report, if there had been fire suppression equipment--in other words, a sprinkling system, is that what you mean, on the plane, perhaps it would have calmed the fire enough so that the crew could have gotten back in time to the airport, is that what your conclusion is?
JAMES HALL: Since 1988, the Safety Board has been recommending that some 3500 Class C cargo holds in this country that are primarily in the narrow-bodied jets should have fire detection and suppression system. You should never permit a fire on an aircraft where the flight crew does not know there is smoke and a problem, and give them a chance to get that plane safely down.
ELIZABETH FARNSWORTH: And am I right, this is where the strongest criticism of the Federal Aviation Administration comes in, because your organization, the NTSB, recommended it; they did not go along with that, so there were none of those systems, is that right?
The aviation industry has been slow to respond.
JAMES HALL: Yes. Unfortunately, Elizabeth, not only the FAA but the whole aviation industry, there was an incident beginning in 1981, there was a 1988 incident, there have been seven incidents since 1988, in which there have been problems with the transport of oxygen generators, some causing one with Delta Airlines--it was an incident similar to this, the December before this accident. All of that information, unfortunately, never prodded the FAA to take the action that it finally took as a result of the ValuJet accident.
ELIZABETH FARNSWORTH: And do you believe that had there been either a warning system or some kind of a sprinkling system this crash might not have happened?
JAMES HALL: Of course, you can never say with total certainty what, you know, there may be the possibility the system did not work or malfunction for some reason, but clearly the odds are that if there's some protection and suppression system there, this accident would not have happened.
Subcontractors need to be regulated.
ELIZABETH FARNSWORTH: What struck me watching the hearings today is the use of subcontractors, so that you have ValuJet subcontracting to Sabretech its maintenance, but then they were subcontracting to almost independent contractors, it sounded like, even further down the line. How is anybody held accountable under those kinds of circumstances?
JAMES HALL: Well, it's going to be a challenge. You know, Tom Jefferson, our founding father, said the basic responsibility of the government is public safety. And I think the government has got to look at the way society, the economy we live in now works. We have ValuJet here subcontracting this heavy maintenance function. Two of three individuals they had for oversight were contract employees. And over half of the employees at Sabretech that were performing this work were contract employees. And how do you protect the public safety and provide quality assurance on this work is something that was not done in this situation and as a challenge for the FAA in the future.
ELIZABETH FARNSWORTH: In the hearings today you also raised questions about ValuJet's very rapid growth and the FAA's ability to stay on top of an airplane that's growing that rapidly. What did you conclude about that?
JAMES HALL: Well, we concluded--we didn't really get to any specific conclusions. I observed that there was a lot of resources being expended in Washington through inspections and oversight of ValuJet at the time the people that had the basic responsibility were requesting additional staff and did not get any. There was a report issued--
ELIZABETH FARNSWORTH: In other words, they didn't have enough people to do what they needed to do?
JAMES HALL: Exactly. And there was a report issued in February of 1986--I mean, 1996--requesting that ValuJet's certification be reconsidered pinpointing all of these problems that we're now talking about in this accident investigation. And for some reason that never got acted on and got lost in the maze at FAA.
ELIZABETH FARNSWORTH: What's happened since? Has any of this been corrected since? You have recommended that there be fire suppression systems in planes but the FAA's given the companies until 2001 to do it, right?
JAMES HALL: Well, I'm encouraged by Secretary Schlater. He's come in. He says that safety's the North Star that he's going to have while he's the secretary of transportation. The new FAA administrator has--I think she's going to do an outstanding job in terms of safety leadership. The FAA has made changes and has reevaluated and looked at their systems, but--
Will airline safety improve?
ELIZABETH FARNSWORTH: We should say, by the way, we did ask them to come, and their response to the hearings today was to put out a whole list of changes they've made. Do you think those were serious changes?
JAMES HALL: I think they're serious changes, but, again, the thing that I mentioned at the beginning of our hearing today we need to be sure that these are lessons learned and not forgotten. And in Washington, D.C., you have to go through and be sure that all these things are done and followed through and completed--
ELIZABETH FARNSWORTH: Like what?
JAMES HALL: --are they will be forgotten?
ELIZABETH FARNSWORTH: Like what needs to be followed?
JAMES HALL: Like the retrofit of the 3500 cargo holds out there, until their detection and suppression systems and all of those cargo holds our aviation industry won't be as safe as it can be and should be.
ELIZABETH FARNSWORTH: So you want that done right away?
JAMES HALL: We want that done as soon as possible. Obviously, I would compliment Delta Airlines and ValuJet Airlines. They're the two airlines who began movement after the pledge was made by the ATA in December to begin working on this, and Delta Airlines very soon is going to retrofit its first cargo hold.
ELIZABETH FARNSWORTH: Mr. Hall, people watching these hearings today might come away rather frightened because when you hear the testimony about the lack of responsibility and workers signing cards saying that there are safety--safety caps on oxygen generators when they aren't it's scary. What do you say to people who listened to those hearings and got scared?
JAMES HALL: I would hope that anyone that saw those hearings would be reassured by the process that we have in this government on how seriously we take transportation safety. And where there are failures in the system we move to correct them. When you're dealing with human beings, you need training, you need redundancy, you need to be sure the human being is not fatigued, that they know the job they're supposed to do. Most of us work real hard and do the best job we can. But it's the responsibility of the government and the industry to be sure that the individual on the floor knows what they're supposed to do, and that there's a system in place to ensure that that work is done.
ELIZABETH FARNSWORTH: Well, Mr. Hall, thank you for being with us.
JAMES HALL: Thank you, Elizabeth.
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