Chemistry of Fire Page 18

  Passengers rushed the exits, but the openings were not wide enough, and people jammed against them. The fire began to consume the plane. The overhead bins caught fire, and flaming debris began falling. Fire trucks were racing down the runway, their emergency lights revolving in the oncoming Georgia night. Within seconds, the entire Douglas DC-9 aircraft was destroyed. It is nothing short of a miracle that everyone got out, even a two-year-old child and the injured flight attendant.

  Like ValuJet Flight 592, that DC-9 had been purchased from Türk Hava Yolları (THY), known in English as Turkish Airlines. The NTSB found that THY mechanics didn’t understand English and ignored the usual instructions for detecting and treating fatigue cracks in critical engine components. A disk that holds the turbine fan blades had developed a 1.5-inch fatigue crack, which is gigantic in metallurgical terms. It was certainly big enough to have been detected if anyone had bothered to look. When it let loose, fragments of metal and whole fan blades shot out at supersonic speeds in an explosive disintegration. THY has a history of catastrophic failures. By failing to close a cargo door properly (the instructions were in English), it helped to send a DC-10 and 346 people to their deaths in a forest outside of Paris in 1974.

  It might be comforting to tell ourselves that ValuJet was the world’s worst airline, that it bought the airplanes that even Turkey didn’t want. But the same thing could happen on any airline. It already has.

  It happened to Midwest Express Flight 105, a DC-9, on September 6, 1985; to United Airlines Flight 232, a DC-10, on July 19, 1989; and to Delta Airlines Flight 1288, an MD-88, on July 6, 1996. All three of those aircraft experienced catastrophic engine failures. All three were manufactured by McDonnell Douglas, one of the most famous names in American aviation. General Electric made and inspected the engines. All had critical flaws, which were easy to detect through ordinary engineering tests. These incidents and accidents were the background against which the FAA and ValuJet conspired to conceal dire flaws in the airline’s operation, which led to the crash in the swamp.

  That Wednesday, investigators poring over records at ValuJet headquarters in Atlanta found a cargo manifest that listed oxygen generators as cargo on Flight 592. This jolted the investigators with a deep sense of dread and foreboding. They had seen it time and again. Those sodium chlorate “candles” are like hand grenades. You pull the pin, and sodium chlorate mixes with iron powder, producing oxygen and a lot of heat (as well as table salt and rust as by-products).

  The candles are standard equipment on many airliners, used to supply emergency oxygen to passengers. They are lighter and cheaper than conventional bottles of compressed oxygen. But they’re tricky to use and easy to set off accidentally. As anyone who took chemistry in high school ought to know, oxygen and a lot of heat will burn anything, even steel. In five separate incidents prior to the crash, chlorate candles had burst into flames. In some cases, they had nearly brought down other airplanes. One candle burst into flames on the Mir space station and nearly killed everyone on board.

  I interviewed an NTSB lead investigator, Greg Feith, who had become something of a media star, since he was the only thing the TV crews could film. He was young, articulate, and good looking, and he had the bearing of an athlete. One female reporter had asked him during a briefing, “Greg, how do you feel getting all this attention? How does it feel to be the Mud Stud?” And Feith had ducked his head shyly and demurred, but the moniker had stuck.

  Feith described a test he had performed to see how hot the candles could get when they were stacked together in a cardboard box, as they had been on this flight. They had reached a temperature of two thousand degrees. As soon as the investigators saw chlorate candles listed on the cargo manifest, they felt that kind of certainty that comes from long experience.

  Ronald Reagan issued Executive Order 12,291, which requires the FAA to conduct a cost-benefit analysis before it can force airlines to enact any safety measure. The FAA first established the going price for a human life: $1.5 million at the time. It calculates how much it would cost not to improve safety by comparing fatalities (number of bodies times $1.5 million) with the actual cost of the safety improvement. Nothing has to be done if it’s not cost-effective.

  Today the FAA still allows chlorate candles to be used on airliners and flown as cargo. As you fly around the country, they fly around in your seat back or beneath your seat in the cargo hold.

  That Friday after the stock market closed, with ValuJet’s stock down nearly 30 percent, the airline announced that it would cut daily flights from 320 to 160 in the interest of safety. In fact, that was not quite the truth. The FAA had finally stepped in and made them do it. But the FAA had known for at least a year that ValuJet was just an airline looking for a place to crash. And the FAA had done nothing.

  Saturday, as investigators looked deeper into ValuJet’s records, the whole operation began to seem like a house of cards. ValuJet was the fastest-growing airline in US history, but it had an accident rate fourteen times worse than any other airline’s. It bought below-standard airplanes, and its pilots were catch-ascatch-can. Six months before the crash, ValuJet had tried to get a Department of Defense contract to carry DOD personnel but had been turned down with a scathing report on its lax safety and maintenance and its chaotic management. In fact, ValuJet had no maintenance. It was all done by others in a haphazard outsourcing scheme to save money. During 1994, ValuJet made fifteen emergency landings. During 1995, it made fifty-seven. In the first half of 1996, the rate of emergency landings had exploded to one nearly every other day. Its fleet was falling apart. In fact, ValuJet did not have a director of maintenance, a crucial function at any airline, someone who knows at all times where each jet is and what its condition is. Even so, immediately after the crash, Department of Transportation Secretary Federico Peña, went on television and said, “I have flown ValuJet. ValuJet is a safe airline, as is our entire aviation system.” But Peña knew nothing about aviation. He was a political appointee, the former mayor of Denver, and a friend of Bill Clinton’s. Anyway, he wasn’t quite telling the whole truth.

  Anthony Broderick, FAA associate administrator for regulation and certification, said, “We found no significant safety deficiencies.” He was simply lying. The FAA had found huge deficiencies in safety and had ignored them. Mary Schiavo, the maverick inspector general of the US Department of Transportation (DOT), had been writing a caustic column for Newsweek about that very subject when Flight 592 crashed.

  Meanwhile, passengers continued to defy common sense and buy the tickets. And ValuJet continued to fly.

  On Sunday, May 19, a searcher found burned seat-rails from the first-class cabin, more evidence of a fire in the cargo hold that had burned up through the floor. The grim, exhausting search continued with saw grass matted down from a week’s work and white-clad men on airboats standing off some distance, observing with rifles, like prison trustees. An Air Force reservist employed in the search found a wallet with five new hundred-dollar bills in it. There was a lot of money scattered throughout the swamp. People were on vacation.

  Meanwhile the Mass Disaster Identification Team, a group of South Florida dentists, gathered to try to identify people by dental records. Its first job was to collect dental records for all the victims on the passenger list and put the data into a computer. “Someone will bring us a tooth or maybe two teeth or part of a jaw, and we’ll see if we can make a match,” said Dr. William Silver, head of the team. But at that point no identifications had been made. There were only two other sure ways of identifying someone: by fingerprint or a tattoo.

  That same day, an investigator, cleaning mud out of a burned tire, found part of an exploded sodium chlorate oxygen generator embedded in the rubber, further evidence of how the fire had started.

  The political furor raged around this scene, moving out from Washington in ripples. Senator Trent Lott said, “They [the FAA] did not as aggressively pursue problems at ValuJet as they should have.” FAA administrator David Hins
on countered, “Our inspector workforce did exactly what they are supposed to do.” Which turned out to be another calculated lie. By June, FAA spot checks of ValuJet planes were so alarming that he had to recant, saying “serious deficiencies” existed. “Yes,” he added, “we bear some responsibilities in this case.” Associate Administrator Broderick said, “There are a number of things that show ineffective control and procedures.”

  Ten days after the crash, the crucial cockpit voice recorder had not yet been found. But then a homicide detective named Jimenez stopped in the swamp, exhausted and covered with sweat, and said a prayer, asking God for help. A moment later he stepped on the crushed and punctured device in a few feet of water. It was quickly packed in an Igloo cooler filled with swamp water so that the tape inside would not dry out and crack. It was immediately shipped to Washington for analysis.

  In Washington, Greg Feith and the others listened to the tape from the cockpit voice recorder and came to understand that the crew of Flight 592 never had a chance. The time between Captain Kubeck’s first indication that anything was wrong and her total incapacitation was a matter of seconds. At twenty-nine minutes and twenty-three seconds into the tape, she said, “We got some electrical problem.” At twenty-nine minutes and thrity-one seconds, the cockpit voice recorder captured the screams of passengers. Feith told me later, “Children were crying, it was terrible.” At twenty-nine mintutes and thirty-five seconds, the captain herself was screaming, “We’re on fire! We’re on fire!” Then the screams from the children subsided as they were overcome and mercifully put to sleep by toxic fumes from burning cabin furnishings. Then Feith heard nothing but the sound of rushing air as the plane accelerated into the Everglades.

  After a week and a half of searching, there were still few significant body parts to send to the medical examiner’s office. The only entire victim was the so-called lap child. A woman had held her infant in her lap for takeoff, and that baby had been small and compact enough to be thrown clear in the disintegration. Everything else—everyone else—was bits of flesh. Thumbs. Arms. “Oh, there were one or two torsos,” a fire department searcher told me, “but not much else. No heads. At least not yet. It’s probably all down there. In the Pit.” But it wasn’t. It wasn’t down there at all.

  In March, FAA inspectors had written a memo that expressed concern about “a significant decrease in experience level of new pilots being hired by ValuJet as well as other positions such as mechanics, dispatchers, etc.” and “continuous changes of key management personnel.”

  I spoke to a pilot who had flown with the first officer of Flight 592, whose name was Richard Hazen. Hazen, not Captain Kubeck, had been flying the plane when it crashed. The pilot I spoke to said that Hazen had not been competent to fly large jet aircraft and that everyone who worked with him had known it. He said Hazen was so bad that “I would not leave the cockpit to go to the bathroom when Dick was at the controls.” Hazen had no scan. That is to say, he fixed his gaze on a single instrument instead of moving it from place to place to keep tabs on every system, as a pilot is supposed to. “I warned him on a flight into the Bay Area that the controllers wanted us at 180 knots because the separation between planes was at a minimum. He gave me 180 knots, but he couldn’t hold his altitude or heading. He just fixed on the airspeed. I found that by calling out each instrument, I could get him to look around, but when I stopped, he stopped, too.” Once, attempting to make a turn, Hazen rolled inadvertently into a dangerously steep sixty-degree bank because he was fixated on his heading. He did not notice how steep his turn had become until it was pointed out to him. Early on it was suggested that if Hazen was flying when the fire broke out, and the captain told him to turn back to the airfield, he could have flown into the swamp by making such an error, especially with the added stress and confusion of smoke in the cockpit and an emergency underway. Probably he was just overcome by smoke.

  Whether or not Hazen’s qualifications had any direct bearing on the ValuJet crash, they point to a rather loose system. If Hazen had gotten through, what else had ValuJet failed to notice? Evidently, quite a lot.

  A pilot is ultimately responsible for his flight. Hazen and Captain Kubeck were obliged to read the cargo manifest and ensure that there was no hazardous material on board. That was their job. An NTSB official, however, said that the manifest may have simply read, “co-mat,” meaning company materials, something belonging to the company. The crew may have accepted that and looked no further. They were on a tight schedule. They didn’t have time to poke around.

  The hangar was quiet. The floor was spotless, illuminated by fluorescent lights high overhead among the steel rafters. The windows, even the little ones in the steel doors, had been sealed roughly by plastic sheeting, giving the outside light an eerie quality. The first thing we noticed when we entered the hangar at Tamiami Airport, a few miles from the crash site, was the smell. When one of the reporters asked why it smelled like a morgue, he was asked, “Why do you think it smells like a morgue?” It was typical of relations with the press at the site. I asked one official, being escorted by the FAA, what office he was with and was told, “I don’t think that’s any of your business.” And he walked away. The pathological secretiveness of the FAA is one cause of its troubles. I once flew with a stunt pilot who had a sign in the back of his plane where the passenger could see it. It said:

  Check List

  Sit down.

  Strap in.

  Shut up.

  Hold on.

  Which seemed to sum up the philosophy of the FAA and the airlines when it comes to passengers on scheduled airliners.

  The FAA had good reason for wanting to keep secrets. It had inspected ValuJet five thousand times in three years but had failed to file a single report against the airline. Everything was done through discreet, convivial agreements between Lewis Jordan, ValuJet’s president, and FAA officials, who didn’t want to upset the new airline in its astounding success.

  On the floor of the hangar where investigators were reconstructing the jet, only 4 percent of the airplane had been found. The hammered and mutilated primer-green sculpture was laid out on red and green plastic tarps behind a yellow band of police crime-scene tape. There were heaps of wire as big as raspberry brambles. There were spherical fire bottles from the engines and scuba-looking oxygen bottles for the oxygen masks. (The DC-9 did not use the sodium chlorate candles in its own cabins. It had merely been transporting them.) Swamp grass still clung to those ragged parts. The sodden blue and white ring binders, big as telephone books, were flopped open to the emergency procedures the pilots would have used in their last moments. Orange life vests were scattered here and there. A couple of exploded yellow plastic escape slides lay crumped and muddy, and enormous tires had been chewed up like wads of black gum. Searchers had found an engine: it looked like a crushed beer keg. Landing gear struts had been disfigured by forces we could scarcely imagine.

  Greg Feith showed reporters soot stains on a piece of metal, indicating that there had been a fire. This was not news, merely more evidence to feed the investigation and a hungry press.

  From across the huge hangar, a somber group of men who looked like university professors watched us as we inspected the collected wreckage. Arms folded, they sat near a large ventilating fan at a makeshift table of plywood and cinder blocks, which held a microfilm reader and reels of film of images of the thousands of parts that go into making a McDonnell Douglas DC-9. They would find a part, painstakingly identify it, and put it in place until the jigsaw made some sort of sense. They would, that is, if they could find enough of the airplane to accomplish the task. The rest of the plane, we were told, was down in the Pit. “We have 90 percent of an airplane that’s unaccountable,” said an NTSB spokesman. “We believe we know where it is.”

  Gradually, clues were pieced together. A company named SabreTech was overhauling a ValuJet plane at Miami and had removed the oxygen generators from the seat backs, where they were installed to provide oxygen to p
assengers in an emergency decompression. The canisters were tossed in boxes and set aside. No one knew what to do with them. Someone called ValuJet and was told, sure, send them back. If there had been a head of maintenance at ValuJet, he would have said, “Don’t you know those things can burn?”

  Three aircraft tires had been thrown on the floor of the cargo hold. The cardboard boxes containing the sodium chlorate candles had been tossed in on top of the tires. As in the other five incidents where chlorate candles had caused fires, the ones on ValuJet Flight 592 had been packed without safety caps or pins installed to prevent them from going off. One of the candles had been set off, probably by jostling as the plane taxied out to take off for Atlanta. The burning canister ignited other canisters, and the whole chain reaction probably reached nearly two thousand degrees, burning the tires and then sending smoke and flames up through the cabin floor beneath the feet of passengers.

  The NTSB had been recommending that airlines install smoke detectors and sprinkler systems in cargo holds for decades. It is commonplace for there to be items in the cargo hold that are caustic, flammable, even explosive or radioactive. A simple smoke detector would have saved those on Flight 592. The fire probably started before takeoff, but in any event, the plane crashed after being aloft only six minutes. With a fire warning, the crew would have either evacuated on the ground or turned immediately back to Miami. According to a report from the House Committee on Transportation, the NTSB’s recommendation for smoke detectors was “rejected by the FAA because they believed the gain in safety would not justify the cost of requiring all aircraft to install such systems.”

  As the days went by down in the Everglades, I was left with a lot of time to think and do some investigating of my own. One thing I discovered was that Transportation Secretary Federico Peña’s statement in the wake of the crash that “I have flown ValuJet” had a compelling history. Peña had flown ValuJet in late February. How exactly had the transportation secretary happened to be flying ValuJet slightly more than two months before the crash?