The ValuJet crash should never have happened.
That's the underlying message of a week-long government hearing in Miami, where the National Transportation Safety Board is publicly reviewing the chain of events that led to last May's crash of Flight 592.
While the hearing has unveiled the full horror of the last fiery minutes of Flight 592, it has also highlighted the lessons that have been learned - which may help to improve aviation safety in the future. Moreover, it has served to dramatize, and perhaps intensify, long-standing tensions between the NTSB and the Federal Aviation Administration.
The FAA came under heavy criticism after the ValuJet crash for lax oversight of the low-cost, start-up carrier. Now, that criticism is increasing because many believe the ValuJet accident could have been prevented if the FAA had followed a NTSB recommendation. Back in 1988, the agency recommended that fire-detection devices be placed in cargo holds of aircraft - an action the FAA decided not to implement until last week.
"We certainly believe that if there were fire-detection devices in the cargo hold, it would have allowed the crew the time to get back to Miami," said NTSB member John Goglia, who is presiding over the hearings in Miami. "It appears it took a highly visible event to move the issue."
The NTSB suspects that oxygen generators stowed in the cargo hold, without proper caps, caused a fire that downed the DC-9 in Florida's Everglades, killing all 110 people aboard.
But the FAA and some aviation experts say the agency has acted appropriately. Charged with the dichotomous responsibilities of promoting air travel and regulating air safety, the FAA is required by Congress to complete a cost-benefit analysis before implementing any NTSB recommendation. In the case of requiring fire alarms in cargo holds, the FAA crunched the numbers and said its analysis "didn't support rulemaking." The measure would have cost the airline industry $350 million to implement.
But last Thursday, the FAA revised its position, indicating in a statement that it intends to mandate the fire-detection devices.
"This time, the numbers supported rulemaking," says Alison Duquette, FAA spokeswoman.
The difference, she says, is that the number crunchers were able to come up with a "very accurate figure of what retrofitting aircraft with these systems would cost," and that the FAA's parent organization, the Department of Transportation, placed a new figure on the value of human life. Back in 1988, the value placed on a human life was $1 million. In 1994, the DOT raised that value to $2.7 million.
"We take [NTSB] recommendations very seriously," says Ms. Duquette. The FAA implements the NTSB's "urgent" recommendations 90 percent of the time, she says, and complies with others 85 percent of the time.
"The FAA can't mandate something because the NTSB recommends it," says Aaron Gellman at Northwestern University in Illinois. "It has to make economic sense. The NTSB has a very different mandate than the FAA. That's why they're separate."
The FAA is also criticized for the time it takes to implement changes, and many say that recommendations are often modified so they don't do as much good as they might.
"It's not just whether [the FAA] adopts the NTSB recommendations, but the length of time it allows airlines to comply," says John Strong, co-author of the book "Why Airplanes Crash," and business professor at William and Mary College in Williamsburg, Va.
He cites as an example speculation over whether the recent midair collision over India could happen in the US. Many experts say it couldn't, because the FAA implemented an NTSB recommendation that all US air carriers be equipped with the Traffic Alert and Collision Avoidance System (TCAS), a form of radar in the cockpit that alerts pilots to other air traffic in the vicinity. The NTSB recommended the action after a 1986 accident, but the FAA didn't require TCAS to be installed until 1994. And then, Dr. Strong points out, the recommendation was modified: It was mandated for all passenger carriers, but not for most jet freighters.
But not all NTSB recommendations make economic or practical sense, says Clint Oster, another co-author of "Why Airplanes Crash."
He cites the recommendation that cabin materials be changed to eliminate toxic smoke in cases of fire. "In a world without carry-on baggage, where people didn't wear wool clothes" that emit the same types of toxic smoke, that requirement would make sense, Dr. Oster says. But it's not clear whether such a requirement saves lives, he says.
While the FAA is directly in the line of fire over the crash, the NTSB inquiry has also pointed to mistakes made by ValuJet and one of its maintenance contractors. The NTSB has determined that oxygen canisters were improperly loaded into a Flight 592 cargo hold. The canisters, which qualify as hazardous material and are suspected of causing the blaze, were improperly labeled and lacked protective caps that prevent them from activating during transport.
The NTSB investigation also included a report on the FAA's hazardous materials program. It found that almost half of the FAA's 600 haz-mat inspectors perform no on-site inspections, relying instead on paperwork provided by the airlines.