© 2003 Mark E.
What Really Brought Down Flight 592?
Within days of ValuJet Flight 592’s May 11, 1996, disaster,
the Federal Aviation Administration (FAA) did some very unusual
things. Those things, and others, lead me to believe that:
The oxygen generators did not start the fire; An unapproved
part started the fire, and; The FAA conspired to cover up
ValuJet Flight 592, a McDonnell Douglas DC-9-32, crashed near
Miami and claimed 110 lives. The National Transportation Safety
Board (NTSB), in accident report #DCA96MA054, stated that
fire was initiated by one or more oxygen generators loaded
in the forward cargo compartment. The report implies that
the loose-load oxygen generators, without safety caps installed,
actuated from being jostled around. The oxygen generators
undoubtedly intensified the fire, but consider the possibility
that the oxygen generators did not start the fire.
is evidence strongly suggesting the FAA, immediately after
the accident, suspected a different ignition source and took
steps to cover it up, or at least reduce the impact if that
different source were to become known.
A day or two after the accident, the deputy director of Douglas
Aircraft Company’s spares division gave an assignment to a
staff specialist. The deputy director told the specialist
that the FAA, on or about May 12, 1996, had asked American
Airlines personnel at Dallas-Fort Worth Airport (DFW) how
they procured primary longitudinal trim relays, part number
9207-10296, used on DC-9-32 airplanes.
American Airlines was a maintenance contractor to ValuJet
at DFW. Under Federal Law, that particular aircraft replacement
part, at that time, could be sold for installation on a DC-9-32
only by Douglas Aircraft Company. Records showed that Douglas
Aircraft Company had never sold that part number. The deputy
director instructed the specialist to help the relay manufacturer,
Leach International, convince the FAA the relay sold to the
airline was essentially identical to the relay Douglas Aircraft
Company installed on new aircraft at production. In their
discussion, Leach informed the specialist there was an FAA
mandated maintenance action, an Airworthiness Directive (AD),
applicable to the relay.
|Extract from the NTSB's Alaska 261
91-21-07 SB A27-316 Primary trim
control relays, inspection and periodic replacement.
Note: Overheating of the relays creates potential for
fire in the forward cargo compartment. Failure of a relay
generally results in an inability to command the stabilizer
in one direction using the primary trim system. However,
the failure of a primary trim relay does not, by itself,
disable the alternate trim system.
Airworthiness Directive AD 91-21-07 (and Douglas Aircraft
Company Alert Service Bulletin A27-316, dated January 4, 1991,
incorporated into law by reference in the AD) applied to the
ill-fated DC-9-32. The AD states, “To eliminate overheating
of the primary longitudinal trim relays and the possibility
of fire in the forward cargo compartment, accomplish the following.”
The requirement was to replace the relays prior to the accumulation
of 8,000 flight hours, and thereafter at intervals not to
exceed 8,000 flight hours. Flight 592 had 68,400.7 total flight
hours at the time of the accident according to the accident
report. Were the relays replaced within the period mandated?
Even if the relays were replaced as required, could one “overheat”
in less than 8,000 hours?
The Alert Service Bulletin was even more damning. Its Reason
paragraph states, “Four operators reported six instances of
overheat failure of the primary longitudinal trim contactors
(relays). Contactor failures have resulted in smoke and burning
behind the right side cargo liner at the forward side of the
forward cargo door. In some instances smoke was reported in
the main passenger cabin.”
The Reason statement ends, “In one case an intercostal (metal
aircraft structure) was damaged and required replacement.”
Parentheses are mine.
Leach also told the specialist the FAA was pushing Leach,
immediately after the accident, to obtain FAA Parts Manufacturer
Approval (PMA) on the relay. With PMA Leach could legally
sell the relay directly to airlines. Leach obtained PMA May
29, 1996 (Ref. PMA No. PQ2059NM, dated May 29, 1996). The
FAA granted PMA based on a licensing agreement betweeen Leach
and Douglas Aircraft Company dated May 22, 1996.
Obtaining PMA within 18 days of the accident was a minor miracle.
It was especially noteworthy because Douglas provided the
PMA assistance (license) within 10 working days of the accident,
a process that ordinarily took months. And, the FAA granted
PMA within three working days of Leach’s application.
I can vouch for these things because I was the Douglas Aircraft
Company spares specialist. If the primary longitudinal trim
relay did not ignite the oxygen generators, why did the FAA
focus on ensuring that that specific part number relay received
FAA-PMA virtually instantaneously after the crash? There are
other relay part numbers in the AD, but the only part number
the FAA pushed Leach to apply for PMA was 9207-10296 – the
part number of the relays installed in the doomed airplane.
A cursory understanding of the worldwide aircraft replacement
parts business is needed to understand the import of the foregoing.
There is a relatively constant annual turnover of $10B in
that business. Unapproved, bogus, or illegal parts comprise
several billion dollars, or more, of that annual trade. The
FAA has been struggling for years to control it. The last
thing the FAA needed was for 110 deaths to be attributed to
an unapproved part. By ensuring Leach obtained PMA on the
part, the FAA anticipated the question, if it were asked,
“Is the primary longitudinal trim relay FAA approved?” The
FAA could truthfully respond, “Yes it is.” Only a skeptic
would rephrase the question, “Was the relay FAA approved at
the time of the crash?”
There was a powerful champion in the crusade to eliminate
unapproved aircraft parts. The FAA’s parent organization is
the Cabinet level Department of Transportation (DOT). The
Inspector General of DOT when 592 crashed was the young, ambitious,
and zealous Mary Schiavo.
She was outspoken. She declared that virtually all airplanes
were flying with bogus parts installed. She and her team prosecuted
numerous cases involving unapproved parts. Millions of dollars
in fines and years of incarceration were meted out to unapproved
parts miscreants under her leadership.
One of her reports quotes a convicted illegal drug dealer
as saying, “I quit dealing in illegal drugs and got into the
illegal aircraft parts business because there’s more money
to be made and you meet a better class of people,” or words
to that effect. She cited problems at ValuJet months before
the accident, and refused to fly them for safety reasons.
She spoke out about the FAA’s failings. Ms. Schiavo left government
service and “resigned” her post just shy of two months after
the crash of Flight 592. Even though she stated no one pressured
her to resign, the FAA must have been greatly relieved she
was no longer liable to investigate a certain unapproved part.
Additional reasons to suspect the relays started fire aboard
Flight 592 include the following.
*The NTSB assumes the oxygen generators actuated as they rolled
around the cargo compartment when the firing pins struck the
percussion caps. Tests at Douglas Aircraft Company facilities
in Southern California failed to prove the oxygen generators
could self-actuate. With great difficulty, and under conditions
unlikely to be encountered in flight, the oxygen generators
eventually actuated, according to a colleague who participated.
Those tests are not cited in the NTSB report.
*Did the primary longitudinal
trim relay generate sufficient heat to actuate the oxygen
generators? If not directly, did they ignite passenger cargo
in the forward cargo compartment, which in turn ignited the
*The report speculates that the flight crew attempted to reduce
thrust on both engines for emergency descent. The right engine
went to flight idle about six minutes into the flight. The
left engine did not respond to inputs to reduce thrust, resulting
in asymmetric thrust.
There were no right-roll indications in the Flight Data Recorder
heading data. The airplane was in a sideslip condition, most
likely with the left wing down. This would cause the cargo
to shift to the left, supporting the possibility the fire
started, not where heat damage was most pronounced, but to
the right – the location of the longitudinal trim relays.
*In static tests the FAA pulled the pins and actuated the
oxygen generators. Two of the five tests resulted in no fire.
(Ref. NTSB report, pp. 54-55)
*The NTSB’s report cites “…heat damaged wire bundles were
not routed near the breached area of the cargo compartment,
whereas the boxes containing the oxygen generators were loaded
into the area directly beneath the breached area of the cargo
compartment.” (Ref. NTSB accident report, pp 100-101.)
This begs the question, “Were the heat damaged wire bundles
those routed, near the relays, ‘…behind the right side cargo
liner…’ as cited in Alert Service Bulletin A27-316?”
The FAA knew there was an unapproved part on Flight 592, believed
it might have caused the fire, and hoped to cover up that
Is the FAA guilty of aiding and abetting the unapproved aircraft
replacement parts industry?