As a technical communications professional, I belong to a large organization called the Society for Technical Communications (STC). At our last monthly meeting, our chapter invited Joseph Devney to speak. Mr. Devney is a noted linguist and technical writing consultant working with large organizations on improving company documentation in order to enhance customer satisfaction and avoid costly litigation.
A large portion of Mr. Devney’s presentation entitled: Unhappy Customers Are Just the Beginning: Potential Costs of Poor or Missing Documentation focused on both the legal consequences and threats to human safety that can result from unacceptable company documentation. One of the highlighted case studies presented during the talk was a horrific 1996 crash of a passenger jet in the Florida Everglades that claimed 110 lives.
On May 11, 1996 at 2:04 pm EST, ValuJet Flight 592 departed from Miami International Airport en route to Atlanta carrying 105 passengers and a flight crew of 5. The aircraft was a 27-year old McDonnell Douglas DC-9-32 operated by ValuJet Airlines (a low cost regional carrier based in Georgia).
At 2:10 pm EST, approximately 6 minutes after takeoff, a loud bang was heard over the headphones of the pilots followed by smoke and a fire in the passenger cabin. After the cabin fire started, the plane immediately began to lose all electrical power. Both pilots requested an immediate return to Miami and began turning the plane around. However, as the fire progressed inside the cargo hold of the aircraft, it is believed that the heat weakened forward floor beams of the passenger cabin eventually collapsed and destroyed the hydraulic flight controls of the aircraft. It is also believed that the flight crew most likely became unconscious from the toxic fumes consuming the cockpit.
At 2:13 pm EST, ValuJet 592 disappeared from radar. The DC-9-32, lacking all necessary flight controls, rolled right and crashed nose first into the Francis S. Taylor Wildlife Management Everglades at a speed of 507 mph (816 km/h) killing all 110 persons on board instantly. When the aircraft made impact, it disintegrated into hundreds of pieces. Recovery efforts at the crash site were hampered by multiple sawgrass injuries, hungry alligators and a lack of roads nearby. Because the crash zone existed in swamplands, pieces of wreckage had to be transported by airboats to distant roads.
The National Transportation Safety Board (NTSB) later concluded that the main cause of the crash was the chemical reaction of several unexpended oxygen generator canisters improperly stored in the forward cargo hold of the aircraft. Oxygen generators are Coke can size canisters installed inside the bulkheads above the passenger seat. When an oxygen mask is released and pulled during a cabin de-pressurization, the oxygen generator unit activates and supplies the passenger with needed oxygen. When activated, chemical oxygen generators also produce a tremendous amount of heat due to a phenomenon known as an exothermic chemical reaction.
Upon further investigation by the NTSB, it was also discovered that the cargo hold of ValuJet 592 was transporting company owned materials (COMAT) in addition to passenger baggage. These items included full and empty oxygen generator canisters, spare aircraft wheels and other spare parts. It comes as no surprise that having these other combustible materials stored on board only fed the fire.
In short, when the boxes containing oxygen canisters were loaded into the cargo hold, they were marked as expended or empty. During the flight, the unexpended canisters rolled around inside the boxes and activated when the release pins came out. As the canisters heated up, they caught fire and burned with intensity as other active canisters released oxygen and fed the fire. Within minutes, the combustible aircraft tires were also burning and contributed to the massive fire that consumed the lower portion of the aircraft fuselage.
In my opinion, there were other unfortunate factors that contributed to the crash of ValuJet 592. The airline was a low budget airline that routinely cut corners and was run by apathetic executives who did not budget properly for safety or training programs. ValuJet was also clearly in violation of Federal Aviation Administration (FAA) rules forbidding the transportation of hazardous materials. Finally, the airline was attempting to save money by hauling aircraft parts aboard passenger flights instead of paying a ground shipping company to properly transport these materials safely.
Above all, however, the single biggest failure that contributed to this tragedy was lack of proper communication between ValuJet and one of its maintenance contractors SabreTech.
Among the ValuJet Airlines documents surrendered to the NTSB was a document labeled as Work Card 0069 (see ValuJet Work Card PowerPoint below). This document explains the procedures for replacing expended oxygen generator canisters. An additional document that was surrendered is a SabreTech shipping ticket (see shipping ticket image below) dated May 10, 1996 that lists the COMAT items loaded into the cargo hold of ValuJet 592 prior to takeoff.
ValuJet Work Card
In my professional opinion as a technical writer, these two documents should never have been released or used. The Work Card is disorganized and contains no illustrations until the end of the document. Figures are called out in the steps but do not appear on the same page. The document also uses some terminology that a person who speaks English as a second language might not understand. The warnings and cautions are all written in upper case and warnings are not placed before the stepped procedures. Procedure steps use letters instead of numbers.
The shipping ticket form is also disorganized and lacks additional columns or rows to accommodate detailed information. It is written by hand instead of generated on a computer and is almost completely illegible. Most importantly, it does not comply with any official FAA standards and contains no warning or danger notices addressing the handling of hazardous materials.
Documents this critical should have been authored by a professional writer who understands writing to a specified audience. Moreover, the documents should have gone through a strenuous signoff loop involving upper management (and the FAA if necessary). The documents should have been edited over and over then tested by the end user(s) for clarity and usability. Only then should documents this critical be released into the document stream. The bottom line is this: any documentation that is not well written or disorganized will not be taken seriously or will be ignored.
The first part of Joseph Devney’s presentation title hits the nail square on the head: Unhappy customers are just the beginning. Indeed, poor or missing documentation could cause much more legal and financial pain later on. In the case of ValuJet 592, it cost 110 human lives, destroyed company assets, and ended the operation of an airline.
ValuJet Airlines (already possessing one of the worst safety records in commercial aviation history) never recovered from the Flight 592 crash. Unable to financially operate on its own, it merged with another regional carrier named AirTran Airways in 1997. On November 17, 1997, the newly merged company retired the ValuJet name and chose to operate as AirTran Airways.
ValuJet 592 Memorial honoring the 110 passengers and crew in the Florida Everglades.