How Deadly Cargo Got Aboard Valujet Flight

INEXPERIENCE and misunderstanding allowed hazardous devices to move carelessly through an aircraft-maintenance shop and onto the doomed ValuJet flight, where they are believed to have touched off a fire that led to the crash that killed 110 people in May. -----------------------------------------------------------------

MIAMI - On the morning of Monday, March 4, mechanics with SabreTech, an aviation-maintenance outfit, scrambled aboard two McDonnell Douglas MD-80 jetliners in a hangar at Miami International Airport.

Their mission: to refit the aircraft - just arrived from Slovenia where they'd been flown by Adria Airways - then deliver them to their customer, the airplanes' new owner, ValuJet Airlines.

Along with moving the galley and adding an aft lavatory, Work Card 0069 mandated one straightforward yet crucial task: Remove and replace all the right-side cabin chemical oxygen generators. Upon a plane's sudden loss of pressure, these marvelous contraptions, secreted overhead, fire off a chemical reaction to help create emergency air for occupants.

They were highly combustible. Each was capable upon activation of heating to more than 500 degrees.

With a short pull-string and exposed firing pin, each canister was an accident waiting to happen.

The accident in this case would be called ValuJet Flight 592.

What follows is the step-by-step story of how the 144 canisters moved over a period of weeks from the two MD-80s, onto shelves, across workbenches where the oxygen-bearing canisters were removed from their "heat shield" brackets, into cardboard boxes, through a stockroom and eventually into the cargo hold of an Atlanta-bound DC-9 carrying 110 people.

A series of missteps

Federal documents and interviews with people who came into contact with those canisters reveal a series of missteps that resulted in highly volatile, hazardous cargo being placed aboard a passenger plane.

One thing could have prevented the firing pins from accidentally being pulled and the percussion caps setting off the small explosions that released oxygen and incredible bursts of heat, which is what investigators now believe brought down Flight 592: The small yellow safety caps that both Work Card 0069 and the MD-80 maintenance manual say should be placed on the firing pin of any non-expended generator removed from a jet.

Nobody, apparently, had any caps on hand. They could have been purchased at a store near the airport. Total cost: $9.16, including tax.

SabreTech mechanics checking the generators discovered most were outdated. Remove and replace them all, said ValuJet.

On Thursday, March 14, they began. So did the warning signs.

This is scary, thought mechanic John Taber, as he started fiddling with the generators in the MD-80, referred to in reports as N802. This thing could go off on me.

Other mechanics worked nearby. Among them was Eugene Florence, who removed some of the canisters. And Mark Schultz. And Mauro Valenzuela, who took out at least eight of them. Soon, concern gave way to routine.

Taber later told investigators: "I was scared, the first 10, and then after that I got used to them."

He grabbed two cardboard boxes to hold the spent canisters and their brackets, or "inserts." "I marked the boxes `0 generators off aircraft N802' and that was it. I didn't put any labels on the bottles because they were still in the inserts."

On each insert, Taber placed a green tag, SabreTech's symbol for "unserviceable." Where the tag said "Reason for Removal," he put: "Out of date." Other mechanics wrote "out date" or "expired" or "out of date."

Taber said he knew the canisters got hot when they went off. He said he mentioned to his supervisor, Dave Wiles, that the old canisters should be capped for safety. He said Wiles wanted to put caps on the old ones but, Taber said he was told, "the company didn't have any."

"We knew that they could go off or fire," Taber said later. "That's why we stacked them in the boxes. We knew what we had and we were handling them carefully."

Both ValuJet and SabreTech ordered replacement oxygen generators, but neither ordered the shipping caps, which are required by federal law, according to testimony.

Wiles denies that anyone asked him for caps.

First time for crew

Overseeing Taber on N802, along with mechanics Robert Rodriguez and Billy Moss, was Jude Casimir, a SabreTech crew chief.

"We were assigned to remove the generators and we had routine cards, which explained to the guys how to take them out," he said. He was asked if he checked with storage to see if they had any safety caps for the old canisters, one of the steps required in the removal process.

"No, I didn't," he replied. "It's the first time we've handled these. We've never handled any generators at all, as far as I know."

Casimir said he made it clear to the mechanics what to do.

"I specifically told my guys, you know, once we remove them, to use the green company tags which are unserviceable parts, (and to) make sure . . . everything was documented so that we could keep track of them for our aircraft. I had them placed in boxes so they wouldn't get shuffled or mixed up with any other generators."

Procedures to follow

At a nearby worktable, Mauro Valenzuela was attaching green tags to canisters pulled from another plane. Following the instructions on Work Card 0069, he cut the pull string in an attempt to disarm it, then used it to tie the green tag to the bottle. Along the way, mechanics had to sign off each completed step. Item B requires a safety cap be installed if the generator has not been expended.

You have B and a signature there, right? he was asked later by investigators.

"Uh-huh," he replied.

Did you install the cap?

"No."

Why sign B if you didn't do it?

"I don't know. I assumed caps had been put on."

After four days of removing the canisters, the first in a series of missteps had been taken. Canisters without required safety caps were now green-tagged as "unserviceable," but without any label showing them as potentially hazardous.

On some of the canisters, the pull strings were wrapped around the device to prevent the firing pin from being pulled out of the trigger mechanism. On others, mechanics cut the strings.

Meanwhile, the deadline set by ValuJet for completing all the work was rapidly approaching: April 24 for N802 and April 30 for N803. The penalty SabreTech faced for blowing it: $2,500 per plane per day.

The old canisters ended up stacked in cartons placed on parts-storage racks near the aircraft being modified. There they stayed for several weeks.

When it came time to open the boxes and begin disassembling the canisters from the heat-shield brackets, Taber noticed something. As many as four canisters had gone off in the box, and several of the plastic brackets had melted together from the heat.

Casimir: "I told them to . . . be a little more careful, as far as handling them. We had no idea that that would happen."

First signs of trouble

Next, the boxes of canisters were moved to a storage area to be held until the on-site ValuJet representative decided where they should go next.

At one point, while the boxes rested on racks near the plane, a ValuJet technical representative, Richard D'Arcy, walked by.

He had worked with similar canisters during a stint at McDonnell Douglas in the early 1990s. In fact, he had been burned once when a canister accidentally discharged in his hands.

"I said (to the mechanics), `You know, if you set those off they can burn you?' and they were like, `Yeah, we've set a few off' and they showed me the ones that they set off."

Taber said later that he'd set one off "to see what would happen."

D'Arcy said he warned SabreTech employees on several occasions and asked that they be disposed of.

However, during interviews, none of the SabreTech employees could recall having had such a conversation with a ValueJet representative.

Boxes in a holding area

The five cardboard boxes had been taken to the ValuJet property-holding area in the rear of the SabreTech shipping department. Still, no caps were installed.

On May 10, the day before the ValuJet crash, employees scrambled to clean up the work area because a potential customer, Continental Airlines, was coming through to inspect SabreTech's facility. Stock clerk Andrew Salas spotted the boxes, which had been sitting in the back of shipping/receiving about five days.

He saw one thing: green tags, signifying "unserviceable." And all things unserviceable, he figured, go back to Atlanta.

He prepared the boxes, along with some jet wheel assemblies, for return to ValuJet's storage facility in Atlanta. He'd never shipped oxygen canisters before, but decided they should go back, even without specifically being told to do so by a ValuJet rep. Salas' reason: "To make the place presentable, because we had an inspection and it was those (boxes) and the wheels that had to go back to their owner."

Salas lined the top of each box with bubble wrap but was unable to line the sides of the box because the space was too tight. "We taped them shut," he said, with about "10 to 20" canisters laying on top of each other inside each box.

Asked later whether he knew the contents were hazardous, Salas, who had never had any training in shipping hazardous materials by air, replied: "I do now."

Salas said he saw the green tags that the mechanics had earlier attached to the generators. He said he had fellow stock clerk Carlos Alberto Diaz fill out the shipping ticket because he was too busy. Then he signed off on it.

Salas told Diaz what content description to write on the ticket: OXY Canisters and on the following line: "empty"

Later, investigators questioned Salas on the three words he used:

OXY? "Well, that stands for oxygen," Salas told investigators.

Canister? "I really wasn't sure what these things were and my closest idea of a name would be canister since that's what they looked like."

Empty? "`Empty' because (with the) green, unserviceable tag . . . that's what I believed they were. Out of service."

Asked about training, Salas said there was a blue book in the storeroom that had information about hazardous materials. He hadn't read it.

Guillermo Giral, SabreTech's director of logistics, said a subcontractor in Miami usually handles the disposal of hazardous materials for SabreTech. And he said while there was no hazardous-materials training program in place last spring, "we were waiting for a . . . program to be set up by ValuJet."

On Saturday, May 11, ValuJet Flight 592 was scheduled to depart for Atlanta at 1:45 p.m. Salas told Mitch Perez, a SabreTech stock clerk/driver working overtime, to take the five boxes and the tires over to 592.

At the plane, he approached ValuJet ramp agent Christopher Rankissoon.

Perez: "I told him we were shipping these things out, whenever he can get them on, go ahead. If you can get them on now, fine. If you can get them on later fine, there is no rush.

"He said, `Put it in the baggage cart over there and then we'll go in and check the weight on the stuff and I'll load it on the next plane.' "

Rankissoon took the paperwork to the co-pilot and asked whether the plane could take the last-minute load. The two looked out the cockpit window at the five boxes on the tarmac below. Weight was discussed.

"I said the only place I've got room is in front," said Rankissoon. "He says, `No problem.' "

As the 105 passengers and five crew members of 592 settled in a few feet above his head, Rankissoon loaded the tires into the forward cargo bay, shoving them in behind passenger luggage. Then the boxes were run up the belt loader to the cargo hold. The boxes were loaded between the tires and the door.

He heard a `clink'

Dennis Segarra, a ValuJet baggage handler, was inside the cargo hold, stacking the boxes. "I heard a clink," he said later. He did not know which box the noise came from. But he knew it was the sound of metal striking metal.

And then the door was shut.

The plane taxied to the runway. At 2 p.m., the ValuJet aircraft - nicknamed "Critter" by the nation's air-traffic controllers because of the grinning cartoon airliner of the fuselage - was cleared for take-off.

"Critter 592 contact departure," the controller said at 2:04 p.m. as the jet thundered skyward. "Good day."

And the reply from 592: "Good day, sir."