DCA96MA054

NTSB accident investigation · Douglas DC-9-32 · Miami, FL · May 11, 1996

Accident · FatalClass 1 · MajorFinal report
Date
May 11, 1996, 14:13 local (18:13 UTC)
Place
Miami, FL
Injuries
110 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N904VJDouglas DC-9-32
Weather
Visual (VMC) · Day
Status
Completed · report March 31, 1998
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19960511010159A
Case key
11009

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

which resulted from a fire in the airplane's class D cargo compartment that was initiated by the actuation of one or more oxygen generators being improperly carried as cargo, were (1) the failure of SabreTech to properly prepare, package, and identify unexpended chemical oxygen generators before presenting them to ValuJet for carriage; (2) the failure of ValuJet to properly oversee its contract maintenance program to ensure compliance with maintenance, maintenance training, and hazardous materials requirements and practices; and (3) the failure of the Federal Aviation Administration (FAA) to require smoke detection and fire suppression systems in class D cargo compartments. Contributing to the accident was the failure of the FAA to adequately monitor ValuJet's heavy maintenance programs and responsibilities, including ValuJet's oversight of its contractors, and SabreTech's repair station certificate; the failure of the FAA to adequately respond to prior chemical oxygen generator fires with programs to address the potential hazards; and ValuJet's failure to ensure that both ValuJet and contract maintenance facility employees were aware of the carrier's 'no-carry' hazardous materials policy and had received appropriate hazardous materials training. (NTSB Report AAR-97/06)

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

FireClimb
Hazardous material - improperCause
Procedure inadequateOther personCause
Cargo/baggage - improperCause
Maintenance - inadequateCompany/operator managementCause
Smoke detector(s) - not installedCause
Fire extinguisher,cargo - not installedCause
Insufficient standards/requirementsFaa(organization)Cause
Fuselage,cargo compartment - fire
Loss of control - in flightDescent
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The airplane crashed into the Everglades about 10 minutes after takeoff from Miami International Airport. Safety issues discussed in the Board's 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; FAA's 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. (See NTSB Report AAR-97/06)

Factual narrative

Please refer to the National Transportation Safety Board Aircraft Accident Report, NTSB/AAR-97/06, DCA96MA054, for information about this accident.

Aircraft

Registration
N904VJ
Reported as
Douglas DC-9-32
Category
Airplane
Serial number
47377
Airframe hours
2,864
Engine
P&W JT8D-9A, turbo fan
Damage
Destroyed
Fire
In-Flight
Flight
Part 121
Operator
Valujet Airlines Inc
Registered owner
Valujet Airlines Inc
Airworthiness certificate
Standard, Transport
Departed
MIA · Miami, FL
Destination
ATL · Atlanta, GA
Flight plan
IFR
Airport
MIA · Miami Intl

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
35
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
8,928 total · 2,116 in this make and model · 188 in the last 90 days
Role
Co-pilot
Age
52
Injuries
Fatal
Certificates
Airline transport, Flight engineer
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Right

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 8 knots
Visibility
12 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 61 °F
Observed at
MIA, 18 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.