Case Study 1 : ValuJet Flight 592

Nor Syazwani Binti Mohd Said (B020810070), Nur Asyrani Bt Mohd Asari (B020810266), Nur Azfarina Bt Anuar (B020810015), Nur Fatehah Binti Othman (B020910127),Siti Sahhiada Ashikin Binti Mohd Yasim (B020910031), Wan Mohd Farhan Bin Wan Masri (B020910188), Yong Ching Kiong (B020810135)

Department of Telecommunication, Faculty of Electronic and Computer Engineering University of Technical Malaysia Melaka Karung Berkunci 1200, 75450 Ayer Keroh, Melaka

Abstract - In this paper a case study about the Valujet Flight 582 accident has been discussed and presented. I. INTRODUCTION On 11 May 1996, ValuJet Flight 592 that took off from Miami Airport to Atlanta happens to crash in Florida Everglades after took off after 10 minutes. The crash happens at 1413:42 on daylight killing two pilots, three flight attendance and 105 passengers. The cause of accidents is resulted from a fore on the airplanes class D cargo compartment that was initiated by the actuation of one or more oxygen generators being improperly carried as cargo. The situation worsened as the fire started melting the control cable underneath the cabin floor. The fire damaged the planes electrical system. A few seconds later, a flight attendant entered the cockpit and advised the flight crew of a fire in the passengers cabin [1].Though the ValuJet flight attendant manual stated that the cockpit door should not be opened when smoke or other harmful gases might be present in the cabin, the intercom was disabled and there was no other way to inform the pilots of what was happening [1]. The pilot failed to control the plane and thus the plane crashed. Figure 1: ValuJet 592 There are several factors that caused the accident to happen. Investigation revealed that the chemical oxygen generators were responsible for the fire in the forward cargo compartment of the DC-9. The fire came from improperly labeled and package aviation oxygen generators. The company that involved with replacing the oxygen generator canister is SabreTech. SabreTech didnt have any of these safety caps on hand while they were performing this work. Instead, tape was applied where the caps should have gone, and the canisters were placed in five cardboard boxes and left shelf in the hangar. However, two of the SabreTech mechanics marked on the paperwork that the caps had been installed and signed off on the job.

Engineers shall not affix their signatures to Figure 2: Oxygen Canister Chemical oxygen generators, produce oxygen when activated. As a product of chemical reaction, it also produces a heat. These two is enough not only to start an accidental fire, but also to produce enough oxygen to keep the fire burning [1]. The fire risk was made much worsen due to the presence of combustible aircraft wheels in the hold. National Transportation Safety Board (NTSB) investigators theorized that when the plane experienced a slight jolt while taxiing on the runway, an oxygen generator unintentionally activated, producing oxygen and heat. The oxygen from the generators has resulted fire in the cargo hold [2]. The Federal Aviation Administration (FAA) is then issued a standard that requires all Class D cargo hold converts to Class C or E where this types of hold have additional fire detection and suppression equipment. 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. Rather than fitting firing pins on the canisters, the SabreTech workers simply duct taped the cords around the cans, or cut them, and used tape to stick the ends down. 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 workers dont follow the rules causes a death of 110 people in total. Engineers shall hold paramount the safety, health and welfare of the public. 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. The flights copilot should also refuse to carry the cargo as that cargo contains hazardous waste. Engineers shall avoid deceptive act such as the maintenance supervisor of SabreTech Figure 3: Crash of the flight ValuJet 592 make a false statements. They indicated that the cargo were empty but it is actually were fill in with canisters that is not empty. II. CONTENT b) What guidance might one (or more) of the a) What and how is (are) the code of ethics violated by the people involved (engineers, management, local authority, government) in the case? engineering society codes of ethics provide in handling happening? or preventing the event from

There are two engineering society codes of ethics that can be use as guidance in order to handling and preventing the event from happening. Firstly, the IEEE (Institute of Electrical and Electronic Engineering) code of ethics. From IEEE code of ethics, first guidance that provide in handling and preventing the event from happening is to maintain and improve technical competence and to undertake technological tasks to others only if qualified by training or experience, or after full disclosure of pertinent limitations. In the case of ValuJet Flight 592, the main cause of the accident is the fire that began in a cargo compartment. The cargo compartment was a Class D design where the fire suppression is accomplished by sealing off the hold from outside air. As the fire suppression is accomplished without any intervention by the crew, such holds are not equipped with smoke detectors. This is the main problem because with smoke detectors, it can alert the flight crew of the fire and they can buys valuable time to land the plane safely. So, in order to preventing the same accident happened again FAA (Federal Aviation Administration) issued revised standards requiring all Class D cargo holds to be converted by early 2001 to Class C or E where they have additional fire detection and suppression equipment. The second code of ethics that can be used as guidance to handling and preventing the accident is NSPE (National Society of Professional Engineering). One of its guidance is engineers shall

hold paramount the safety, health and welfare of the public. In the ValuJet Flight 592 case, the engineers shall design the cargo that have fire detection and smoke detectors in order to prevent the accident from happening and affects the public. The flight crew also must prioritize the safety of passenger instead of packaging of hazardous product inside the same airplane. c) Use ethical theories (utilitarianism, duty and right ethics and/or virtue ethics) learnt to analyze the case. Consider all possible elements that are affected in the case i.e mankind, environment, and society. 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. They should respect the human right. Human right is not to be injured, be informed abou the risks and safety of ones surrounding environment or product. This is referring to the right ethic theory. Furthermore, the cargo compartment should have had heat and smoke detectors to give the pilots advanced 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. According to the virtue ethic theory, it emphasizes character more than right and rules. The most comprehensive virtue is responsible professionalism.

In the categories of virtue, the public-spirited virtues and proficiency virtues are suitable to analyze these problems in this case study. The public-spirited virtues are define as the professional should conduct call for beneficence, which is preventing or removing harm to others and promoting public safety, health and welfare. 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. This shows that they did not sacrificing time, talent and money to their professional societies or local communities. The proficiency virtues define that mastery and being well-prepared of one profession. The Sabre Tech agent and the ValuJet workers are unable alert to danger and careful attention to detail. The canisters provide the chemical reaction. This dangerous container was accepted and put on the airplane. This show that they did not alert to the danger and also not sensitive and attention to the detail of the canisters. Besides that, the tires should not put in because it will burns with very acrid and thick smoke. d) Analyze the factual, conceptual and moral issues in the case. Apply either the line-drawing technique or the flow charting 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. When the canister is removed, a bright yellow safety cap must

be installed on them to ensure that the explosive charge is not accidently turn off. The Safety Board concludes that the installation of safety caps would not prevent the oxygen generators from being transported on flight 592. But, if the safety caps have been installed, the generators would not activate and the accident can be prevent [3]. 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 and debris in the air when the airplane is going to crash down to Everglades Park. Next is the conceptual issue. Conceptual issue explained about the issue having to do with the meaning or scope of a term or concept. By referring to ValuJet case study, safety cap must be installed after removed the canister. Instead, tape was applied where the caps should have gone, and the canisters were placed in five cardboard boxes and left on a shelf in the hangar. 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. This action can be classified as irrelevant to apply in this case. FAA should have response to the main cause that is oxygen generator canister. Moral issue arise when decision have to be make about valuable thing. 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. Instead of throwing it, he should send the canisters back to the main office. But he also should not pack it with some tires that mounted on wheel with it. 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 is preferred as the solution because it is simple from the other method of problem solving technique. It is easy to understand by looking to the factor of the case in the line of paradigm. 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.

apparently didnt 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.

e) What should the people involved (engineers, management, local authority, government) have done differently? There are many people and organization involved in this crash disaster such as the Sabretech Company who is assign for maintenances for the plane, ValuJet Company itself, Federal Aviation Administration (FAA) and National Transportation Safety Board (NTSB). Engineers: Sabretech maintenance contractor should be aware that the oxygen generator canister is safety enough to get on board. The Sabretech maintenance contractor failed to cover the firing pins for the generator with the prescribed plastic safety caps results the oxygen to be activated when the plane jolt while taxiing on the runaway. They just simply duct taped the canister rather than recovering the firing pin with safety cap. Otherwise, Sabretech maintenance contractor should have informed their management that their company does not have any bright yellow safety cap to use as a warning sign for the canisters. 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

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 flights co-pilot, Richard Hazen, also looked at the load and the shipping ticket, but

the ValuJet lead ramp agent and flight crew were trained to reject shipments marked with hazardous materials labels and be alert to the potential hazards of undeclared hazardous materials [1]. 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 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. Government: The State of Florida should also file a suit to the Valujet Company claiming that they also should take responsibilities on what had happen. It is because their management had order the shipping clerk to clean up the wastes.

can install the heat and smoke detector to their own airplanes to avoid this accident from happen again. Local Authority: Federal Aviation Administration (FAA) failed to require smoke detection and fire suppression systems in class D cargo compartments recommended by NTSB was one of the cause. The FAA finally acted on the recommendation after the ValuJet crashed and caused 110 passengers killed including the crew. From the probe of the crash, the board concluded that a fire suppression system used in conjunction with an alarm system would probably 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, conspiracy, and willfully violating hazardous-materials regulations.

REFERENCES III. CONCLUSION The case study reveals that the crash of the flight 592 was due to improper maintenance of the oxygen generator canisters place in the cabin with hazardous condition. The problem begins when a yellow safety cap not been installed during performing the work. This failure is the main cause resulting the smoke and fire filled in the cabin and the pilot lose control on the ValuJet causing the plane to crash into Everglades. Regarding to this situation, the blame cannot be put in one organization only because all the people involved should take responsibilities [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: 1271.