ValuJet Flight 592

Introduction

On 11 May 1996, ValuJet Flight 592 that took off

from Miami Airport to Atlanta happens to crash in

Florida after 10 minutes. The crash happens at 13:42

on daylight killing two pilots, three flight attendance

and 105 passengers.

Chronology of Events

ValuJet contracted out a maintenance job on 3

of its air plains to SabreTech, a maintenance

firm based at Miami airport.

• one of the jobs was to replace the chemical

oxygen generators on board, at the end of

their licensed lifetime.

Chronology of Events

The Valujet maintenance rules made it clear

that when the canisters are removed, a

bright yellow safety cap must be installed

on them to ensure that the explosive charge

is not inadvertently set off.

Chronology of Events

Unfortunately Sabre Tech stacked in

unmarked cardboard boxes but without

required safety caps over their firing pins

(the caps were not available)

Chronology of Events

• nevertheless, SabreTech mechanics signed

paperwork certifying that they had capped the

generators (among many other things)

• supervisors also signed off on the work

What and how are the code of ethics violated by

the people involved in the case?

Engineers shall not affix their signatures to any plan or documents dealing with subject matter in which they lack competence, nor to any plan or document not prepared under their direction or control.

Engineers shall hold paramount the safety, health and welfare of the public.

It has made it clear when the canisters are removed; a bright yellow safety cap must be installed on them to ensure that the explosive charge is not inadvertently set off. But, The SabreTech workers don’t follow the rules causes a death of 110 people in total

The maintenance supervisor of SabreTech make a false statements. They indicated that the cargo were empty but it is actually were fill in with canisters that is not empty.

The ramp agent, who was trained to identify improper and hazardous cargo, should not have let the box that contains the canister into the cargo.

Use ethical theories (utilitarianism, and right ethics or virtue ethics) learnt to analyze the case. Consider all possible elements that are affected in the case i.e mankind, environment, and society?

Utilitarianism

In Valujet Flight 592 case, the safety cap must be install when the canisters are removed to make sure the explosive charge is not set off. But, Sabre Tech did not have these safety caps. Sabre Tech has broken the rule of utilitarianism when they do not install the safety caps.

Right ethics theory

The cargo compartment should have had heat and smoke detectors to give the pilots danced warning of trouble in the hold. This will reduce the risk and protect the human right. They should not consider the benefit of the company only, but is the benefit of the public and human.

Virtue Ethics

The proficiency virtues define that mastery and being well-prepared of one profession. The most comprehensive virtues in this case is professionalism.

The ValuJet workers accepted the cargo and put the load in the airplane, but they did not think that was a problem with carrying this cargo because has the dangerous material. This show that they did not act like professional even they had trained before and they also unable to remove or preventing the harm to the persons in the ValuJet flight 592 airplanes.

Analyze the factual, conceptual and moral issues in the case. Apply either the line-drawing technique to find a solution for the case. Justify the use of your chosen technique.

Factual issues definition is different from facts. Factual issues defined as unknown facts and the question about the facts while facts is a known facts.

For this ValuJet case study, the factual issues is

when the canister is remove from the ValuJet a bright yellow safety cap must be installed on them. The Safety Board concludes, if the safety caps have been installed, the generators would not activate and the accident can be prevent .

Other than that, the accident also occurs due to out of date oxygen generator canister. They told that there is no smoke, strange engine noise when the airplane is going to crash down

Conceptual issue

By referring to ValuJet case study, safety cap must be installed after removed the canister.

Besides that, ValuJet crash also contribute FAA (Federal Aviation Administration) demand that heat and smoke detectors in the cargo need to be installed in order to avoid the accident from happen again. It is suspicious that FAA comes out with that kind of rule due to the accident because the rule should have been implementing before the crash in order to avoid the accident.

Moral issue

The example of moral issues in this case study is when the shipping clerk has a good intention to deliver the box contained unused canister to the ValuJet headquarters in Atlanta. He should send the canisters back to the main office. He should checked the canisters first and make sure that it is really empty before he prepared a shipping ticket that declared the load is empty. Instead of using the airplanes, maybe he should use some others transportation that suitable for the canister to avoid some chemical reaction from happens.

Line drawing technique

1. SabreTech did not install safety caps on the chemical oxygen generator when the canisters are removed.

2. The canisters were placed in five cardboard boxes and left on a shelf in the hanger.

3. Two SabreTech mechanics marked on the paperwork that the caps had been installed and signed off on the job.

4. A shipping ticket was prepared describing the load as empty oxygen canisters (even though most of them were full) and tires

5. The ValuJet ramp agent accepted the load despite the fact that ValuJet was not certified to carry hazardous wastes.

6. The flight’s co-pilot, Richard Hazen, also looked at the load and the shipping ticket, but apparently didn’t think that was a problem with carrying this cargo.

7. The ValuJet ground crew placed the tires flat on the bottom of the compartment and stacks the five boxes on the top of the tires

8. FAA began require airlines to install heat and smoke detectors in the cargo holds of all planes

Line drawing technique is preferred as the solution because it is simple from the other method of problem solving technique. By doing that, it is easy to determine whether the problem is more to the positive or negative paradigm, in order to determine if the problem can be solved or not.

What should the people involved (engineers , management, local authority, government) have done differently?

Engineers

Sabretech maintenance contractor should be aware that

the oxygen generator canister is safety enough to get

on board.

Otherwise, Sabretech maintenance contractor should have informed their management that their company does not have any bright yellow safety cap.

Other than that, they can note on the paperwork that the canisters are not installed with the cap and make sure that the plane is not signed of yet.

The ramp agent also should check the cargo properly in order to avoid the airplanes from carrying the dangerous cargo. This is because the ValuJet lead ramp agent and flight crew were trained to reject shipments marked with hazardous materials labels. Moreover, the ValuJet is not allowed to carry dangerous wastes.

Management ValuJet company management should not ask the

shipping clerk to handle the dangerous wastes because the shipping clerk does not know the oxygen canister is empty or full.

The management should hired expertise to handle the waste of the canister instead of asking the clerk.

Other than that, They also can install the heat and smoke detector to have given the crew time to turn around and land safely because it have either extinguished or delayed fire development.

Other than that, they also can do a monthly check to all these airlines company in order to make sure that they still maintaining a good service to public.

Local Authority

Federal Aviation Administration (FAA) failed to require smoke detection in class D cargo The FAA finally acted on the recommendation after the ValuJet crashed and caused 110 passengers killed including the crew.

all the people involved should take responsibilities while doing their works as it involves the public. This is because even the slightest mistake will give a huge impact to the public and the workers. The accident can be prevents by cooperation from all organization in the beginning of their travel. After completing the case study, the organization involved such as Federal Aviation Administration (FAA) decided to install smoke detectors in the cargo holds. Meanwhile, the SabreTech Company faced criminal charges for making false statement,

REFERENCES

[1] en.wikipedia.org/wiki/ValuJet_Flight_592

[2] www.enotes.com/topic/ValuJet_Flight_592

[3] (2000). In-Flight Fire And Impact With Terrain

Valujet Airlines Flight 592 Dc-9-32, N904vj Everglades, Near Miami, Florida May 11,1996: 1-271