Ramon Lopez/WASHINGTON DC

The cause of the ValuJet Airlines McDonnell Douglas DC-9-32 crash on 11 May, 1996, was failure by the US aviation-safety system to keep hazardous material off a commercial transport aircraft, according to the US National Transportation Safety Board (NTSB) official accident report. ValuJet, the Federal Aviation Administration and ValuJet's maintenance contractor SabreJet are all seen as contributors to the disaster.

NTSB chairman Jim Hall sums up the report, saying: "The entire system there to protect the public failed-The ValuJet crash resulted from failure up and down the line, from federal regulators, to airline managers in the board room, and to workers on the shop floor."

The fatal accident was caused by an intense fire in the aircraft's Class D cargo compartment, says the report. Class D is the designation for a compartment to which the crew have no firefighting access, and for which the only fire-protection is low- or zero-air supply. The fire originated in oxygen generators illegally loaded as cargo.

The NTSB report lists numerous failures, including:

ValuJet's maintenance-oversight failure in not monitoring SabreTech's standards;

SabreTech's failure to prepare, identify and track correctly the unexpended oxygen-generators before delivering them to ValuJet;

the FAA's failure to implement a 1988 NTSB recommendation that smoke-detectors and fire-suppressors be fitted in Class D cargo holds;

the FAA's failure (cited as contributory) adequately to monitor ValuJet's heavy-maintenance programme and its oversight of SabreTech's work.

The NTSB has recommended that the FAA expedite the proposed directive requiring smoke detectors and fire suppressors in all Class D cargo holds. The rule is promised before the end of 1997 requiring detector retrofit before 2001 for 2,800 US-registered commercial passenger aircraft and 300 freighters - a rule likely to be followed by Europe. The US airline industry, however, is seeking a two year delay because the work could cost some $300 million.

ValuJet continues to argue that SabreTech should be blamed, alleging that the oxygen-generator package that its ramp agent loaded was mislabelled as harmless, legal cargo. SabreTech has responded by saying it has "-admitted its errors-It's now time for ValuJet to accept its responsibilities".

Source: Flight International