Torqued: Are We Doomed To Repeat Past Mistakes?

 - July 5, 2016, 9:56 AM

May 11 marked the 20-year anniversary of the ValuJet crash. For those who are too young to remember ValuJet, it was one of the many low-cost start-ups that sprang up in the years after deregulation encouraged new entrants into the airline business. Most started and failed. While safety concerns surrounded many of these low-cost carriers, the crash of ValuJet Flight 592 into the Everglades 10 minutes after takeoff from Miami International Airport shined a bright light on some of those safety issues.  

The ValuJet crash is personal for me; I was the Board Member who chaired the NTSB public hearing for that accident. As many of you know, the NTSB holds public hearings on major accidents, those that have significant public interest or where significant safety issues may be involved. ValuJet was a major accident that not only had tremendous public interest but also raised many safety concerns, particularly with regard to the safety of so-called “low cost” carriers, a concern that continues to this day. At the public hearing, testimony is taken from experts in various relevant fields so a complete and accurate factual record can be developed.  That record then becomes the basis for the NTSB’s probable cause and contributing cause determinations and the recommendations it makes to the government and the industry to prevent future accidents.

The hearing also serves as a way to provide answers to the families and friends of the victims who want to know what happened and why. While testimony is taken from many experts, the public usually doesn’t hear from the friends and families of the victims, many of whom bear silent witness to the proceedings. As the Board Member chairing the hearing, I did get to know some of the family members of the victims of that awful tragedy. And around each anniversary, even this many years later, I still get calls and messages from them. Their grief may be less raw today, but the pain and memories of that day remain. For some, more than anything, they want their loved ones not to have died in vain. We owe it to them to make sure the lessons of ValuJet are not forgotten.

The Takeaway from the Crash

As with the anniversary of other aviation tragedies, this has been a time for me to reflect on what went wrong with ValuJet and what lessons we need to remember as an industry lest we are doomed to repeat the same mistakes. For sure, we don’t always learn the first time; I have investigated many an accident where the mistakes of the past were not learned, with tragic consequences. Sometimes it seems that with the passage of time, we forget the lessons even when they are written in blood. With the ValuJet anniversary and with questions being raised almost daily it seems on two low-cost carriers, I thought reviewing those lessons from the past would be worthwhile.

So what are the lessons? The probable and contributing causes of the accident–the result of a fire in the cargo hold that started from one or more improperly carried oxygen generators–were many. The probable causes were determined by the NTSB to be: failure of a maintenance contractor to properly package and identify the oxygen generators that started the fire; the failure of ValuJet to properly oversee the maintenance contractor; and the FAA’s failure to require smoke-detection and fire-suppression systems in the cargo hold. Contributing causes included the FAA’s failure to adequately monitor ValuJet’s heavy maintenance program, including oversight of its contractors, the agency’s failure to properly address prior oxygen generator fires and ValuJet’s failure to properly train its employees and contractors on its no-hazmat-carry policy.

But the lessons that I want to focus on are how to prevent an airline from becoming like ValuJet, not up to the task of overseeing its own maintenance contractors. And how to ensure that the FAA has the resources to oversee today’s low-cost airlines.

A lot of ValuJet’s problems both before and leading up to the accident involved rapid growth beyond the ability of its infrastructure to handle and oversee that growth. In addition, ValuJet chose to fly a varied fleet, which added to the complexity of the operation. To keep its initial costs low, ValuJet bought older, cheaper aircraft. But older aircraft tend to have more maintenance problems and higher costs of operation, in addition to being less fuel efficient. More maintenance problems meant more use of outsourced maintenance providers and required ValuJet to have the infrastructure to support a higher level of oversight of these maintenance providers to ensure compliance with its maintenance manual. For those of you not familiar with airline maintenance requirements, a repair station performing maintenance for an airline must comply with that air carrier’s maintenance manual. And, no matter who actually performs the maintenance, the air carrier is always responsible for the adequacy of that work. In other words, it can outsource the work but not the regulatory responsibility.

In the aftermath of ValuJet–of course, there were plenty of clues to problems before the crash but nothing focuses the FAA like a major airplane disaster–the FAA analyzed what had gone wrong with ValuJet’s certification and growth and put in place recommendations to prevent it from occurring in the future. It’s not clear that it continues to adhere to its own recommendations but they were good ones back in 1996 and they remain good ones today.

Those recommendations were included in the NTSB’s accident report for Flight 592.  Three that bear remembering are:

  • Ensure that all air carriers have adequate resources and infrastructure to support outsourcing and operation of a varied fleet mix.
  • Increase DOT and FAA scrutiny of these factors in determining an air carrier’s initial and continuing qualifications to operate.
  • Ensure that Flight Standards resources and training are adequate to meet safety requirements.

Every airline, low cost or otherwise, needs to have the resources and infrastructure necessary to run its operation, considering its schedule, fleet mix, employees and maintenance contractors. If it doesn’t have those, there is a problem. If the airline won’t address the problem itself, the FAA has to step in and ensure public safety, not wait for another ValuJet tragedy.

At the same time, the FAA needs to ensure that it has the resources and staffing to oversee carriers that it has regulatory responsibility for. As safety management systems become the norm, the best carriers will hopefully require less hands-on oversight by the FAA. But in the meanwhile, the FAA needs to put its resources to ensure public safety isn’t compromised by an unwillingness to heed the lessons of the past.