Aloft

by William Langewiesche

  The timing is not clear. For weeks the five boxes stood on a parts cart beside the airplanes. Eventually a variety of mechanics lugged them over to Sabretech’s shipping and receiving department, where they sat on the floor in the area designated for Valujet property. Several days before the accident, a Sabretech manager told the shipping clerk to clean up the area and get all the boxes off the floor in preparation for an upcoming inspection by Continental Airlines, a potential customer. The boxes were unmarked, and the manager did not ask what was in them.

  The shipping clerk then did what shipping clerks do and prepared to send the oxygen generators home to Valujet headquarters in Atlanta. He redistributed them equally between the five boxes, laying the canisters horizontally end to end and packing bubble wrap on top. After sealing the boxes he applied address labels and Valujet company-material stickers and wrote ‘aircraft parts.’ As part of the load he included two large main tires, mounted on wheels, and a smaller nose tire. The next day, he asked a co-worker, the receiving clerk, to make out a shipping ticket and to write Oxygen Canisters – Empty on it. The receiving clerk wrote Oxy Canisters, and then put Empty between quotation marks, as if he did not believe it. He also listed the tires.

  The cargo stood for another couple of days until May 11, when the company driver had time to deliver them across the airport to Flight 592. There, the Valujet ramp agent accepted the material, though federal regulations forbade him to, even if the generators were empty, because Valujet was not licensed to carry any such officially designated hazardous materials. He discussed the cargo’s weight with the copilot, Richard Hazen, who also should have known better. Together they decided to place the load in the forward hold, where Valujet workers laid one of the big main tires flat, placed the nose tire at the center of it, and stacked the five boxes on top of it around the outer edge, in a loose ring. They leaned the other main tire against a bulkhead. It was an unstable arrangement. No one knows exactly what happened then, but it seems likely that the first oxygen generator ignited during the loading, or during the taxiing or on takeoff, as the airplane climbed skyward.

  Two weeks later and halfway through the recovery of the scorched and shattered parts, a worker finally found the airplane’s cockpit-voice recorder, the second ‘black box’ sought by the investigators. It had recorded normal sounds and conversation up to the same moment – six minutes after takeoff – when the flight data recorder registered a pulse of high pressure. The pulse may have been one of the tires exploding. In the cockpit it sounded like a chirp and a simultaneous beep on the public address system. The captain, Candalyn Kubeck, asked, ‘What was that?’

  Hazen said, ‘I don’t know.’

  They scanned the airplane’s instruments and found sudden indications of electrical failure. It was not the cause but a symptom of the inferno in the hold – the wires and electrical panels were probably melting and burning – but the pilots’ first thought was that the airplane was up to its circuit-breaking tricks again. The recording here is garbled. Candalyn Kubeck appears to have asked, ‘About to lose a bus?’ Then more clearly she said, ‘We’ve got some electrical problem.’

  Hazen said, ‘Yeah. That battery charger’s kickin’ in. Oooh, we gotta—’

  ‘We’re losing everything,’ Kubeck said. ‘We need, we need to go back to Miami.’

  Twenty seconds had passed since the strange chirp in the cockpit. A total electrical failure, though serious, was not in those sunny conditions a life-threatening emergency. But suddenly now there was incoherent shouting from the passenger cabin, and women and men screaming, ‘Fire!’ The shouting continued for thirteen seconds and subsided.

  Kubeck said, ‘To Miami,’ and Hazen put in the call to Jesse Fisher, the air traffic controller who the night before had fed his cat and slept well. When Fisher asked, ‘What kind of problem are you having?’ Kubeck answered off radio, ‘Fire,’ and Hazen transmitted his urgent, ‘Smoke in the cockpit, smoke in the cabin.’

  Investigators now presume that the smoke was black and thick and perhaps poisonous. The recorder picked up the sound of the cockpit door opening and the voice of the chief flight attendant who said, ‘Okay, we need oxygen, we can’t get oxygen back there.’ Did she mean that people could not breathe, or that the airplane’s cabin masks had not dropped, or that they had dropped and were not working? We will never know. But if the smoke was poisonous, the masks might not have helped much anyway, since by design they mix cabin air into the oxygen flow. The pilots were equipped with better isolating-type masks and with goggles but may not have had the time to put them on. Only a minute had passed since the first strange chirp. Now just before it failed, the voice recorder captured the sound of renewed shouting from the cabin. In the cockpit the flight attendant said, ‘Completely on fire.’

  The recording was of little use to the NTSB’s technical investigation, but because it showed that the passengers had died in agony, it added emotional weight to a political reaction that was already spreading beyond the details of the accident and that had begun to call the entire airline industry into question. The public, it seemed, would not be placated this time by standard reassurances and the discovery of a culprit or two. The press and the NTSB had set aside their on-site antagonism and had joined forces in a natural coalition with Congress. The questioning was motivated not by the immediate fear of unsafe skies (despite the warnings of Mary Schiavo, a federal whistle-blower who stepped forward to claim special insight) but rather by a more nuanced suspicion that competition in the open sky had gone too far and that the FAA, the agency charged with protecting the flying public, had fallen into the hands of industry insiders.

  The FAA’s administrator then was a one-time airline boss named David Hinson, the sort of glib and self-assured executive who does well in closed circles of like-minded men. Now, however, he would have to address a diverse and skeptical audience. The day after the Valujet accident he had flown to Miami and made the incredible assertion that Valujet was a safe airline – when for 110 people lying dead in a nearby swamp it very obviously was not. He also said, ‘I would fly on it,’ as if he believed he had to reassure a nation of children. It was an insulting performance, and it was taken as further evidence of the FAA’s isolation and its betrayal of the public’s trust.

  After a good night’s sleep Hinson might have tried to repair the damage. Instead he appeared two days later at a Senate hearing in Washington sounding like an unrepentant Prussian: ‘We have a very professional, highly dedicated, organized, and efficient work force that do their job day in and day out. And when we say an airline is safe to fly, it is safe to fly. There is no gray area.’

  His colleagues must have winced. Aviation safety is nothing but a gray area, and the regulation of it is an indirect process involving negotiation and maneuver. The FAA can affect safety by establishing standards and enforcing them through inspections and paperwork, but it cannot throw the switches in the cockpits or turn the wrenches in the hangars, or in this case supervise the disposal of old oxygen generators. Safety is ultimately in the hands of the operators, the pilots and mechanics and their managers, because it involves a blizzard of small judgments. Hinson might have admitted this, but instead, inexplicably, he chose to link the FAA’s reputation to that of Valujet. This placed the agency in an impossible position. It would now inevitably be found to blame.

  Within days evidence emerged that certain inspectors at the FAA had been worried about Valujet for years and had included their concerns in their reports. Their consensus was that the airline was expanding too fast (from two to fifty-two airplanes over two and a half years) and that it had neither the procedures nor the people in place to maintain standards of safety. The FAA tried to keep pace, but because of its other commitments – including countering the threat of terrorism – it could assign a crew of only three furiously overloaded inspectors to the entire airline. At the time of the accident they had run 1,471 routine checks on Valujet operations, and 2 additional eleven-day inspections in bo
th 1994 and 1995. Despite the burden it placed on the individual inspectors, this level of scrutiny was, at least on paper, about normal for an airline of this size. But by early 1996, concern had grown within the FAA about the airline’s disproportionate number of infractions and its string of small bang-ups. The agency began to move more aggressively. An aircraft maintenance group found such serious problems in both the FAA’s field-level surveillance and the airline’s operations that it wrote an internal report recommending that Valujet be ‘recertified’ immediately – meaning that it be grounded and started all over again. The report was sent to Washington, where for unexplained reasons it lay buried until after the accident. Meanwhile, on February 22, 1996, headquarters launched a 120-day ‘special emphasis’ inspection, which after the first week issued a preliminary report suggesting a wide range of problems. The special emphasis inspection was ongoing when, on May 11, Flight 592 went down.

  As this record of official concern emerged, the questions changed from why Hinson had insisted on calling Valujet ‘safe’ after the accident to why he had not shut down the airline before the accident. Trapped by his earlier simplistic formulations, he could provide no convincing answer. The press and Congress jeered. The FAA now launched an exhaustive thirty-day review of Valujet, the most concentrated airline inspection in U.S. aviation history, assigning sixty inspectors to perform in one month the equivalent of four years’ work. Lewis Jordan, the founder and president of Valujet, complained that Hinson was playing to the mob and conducting a witch hunt that no airline could withstand. Jordan had been trying shamelessly to shift the blame for the deaths onto his own cut-rate contractor, Sabretech, and he received little sympathy now. But he was right about the witch hunt. Even when Valujet did things right under the pressure of the inspection, the results were compared to earlier statistics to demonstrate that when the inspectors were not present Valujet normally did things wrong. Five weeks after the accident, it was a surprise to no one when Valujet was indefinitely grounded.

  Here now was the proof that the FAA had earlier neglected its duties. The agency’s chief regulator, Anthony Broderick, was the first to lose his job. Broderick was an expert technocrat, disliked by safety crusaders because of his cautious approach to regulation and respected by aviation insiders for the same reason. Hinson pushed him out in front, knowing that he was a man of integrity and would accept responsibility for the FAA’s poor performance. But if Hinson thought that he himself could escape with this sacrifice, he was wrong. Broderick’s airline friends now joined the critics in disgust, and the jeering grew so loud that Hinson was forced from office.

  In that sense the system worked. One year after the accident it was possible to conclude that the tragedy had perhaps had some positive consequences – primarily because the NTSB had done an even better job than usual, not only of pinpointing the source and history of the fire but of recognizing some of its larger implications. With a well-timed series of press feedings and public hearings, the accident team had kept the difficult organizational issues alive and had managed to stretch the soul-searching through the end of the year and beyond. By shaking up the FAA, the team had reminded the agency of its original responsibilities – prodding it perhaps into a renewed commitment to inspections and a resolution to impose greater responsibility on the airlines for their actions, including the performance of outside shops.

  For the airlines, the investigation served as a necessary reminder of the possible consequences of cost cutting and complacency. Among airline executives smart enough to notice, it may also have served as a warning about the public’s growing distrust of their motivations and about widespread anger with the whole business – anger that may have as much to do with the way passengers are handled as with their fears of dying. However you wanted to read it, the Valujet turmoil marked the limits of the public’s tolerance. The airlines were cowed, and they submitted eagerly to the banning of oxygen generators as cargo on passenger flights. Having lost their friend Broderick, they then rushed ahead of the FAA with a $400 million promise (not yet fulfilled) to install fire detectors and extinguishers in all cargo holds. As it had before, the discussion of hidden cargo hazards ran up against the practical difficulties of inspection. Nonetheless, after the accident the ground crews could be counted on for a while to watch what they loaded into airplanes and what they took out and threw away.

  And the guilty companies? They were sued, of course, and lost money. After firing the two mechanics who had fraudulently signed the work orders, Sabretech tried to put its house in order. Nonetheless, its customers fled and did not return. The Miami operation dropped from 650 to 135 employees and in January 1997 was forced to close its doors. Soon afterward, as the result of a three-month FAA investigation, Sabretech’s new Orlando facility was forced to close as well. Valujet survived its grounding and under intense FAA scrutiny returned to the sky toward the end of 1996, with a reduced and standardized fleet of DC-9s. Because of continuing public worries it changed its name to Airtran, and for a while it was probably the safest airline in the country. What then explains the feeling, particular to this case, that so little has in reality been achieved?

  Charles Perrow came unintentionally to his theories about ‘normal accidents’ after studying the failings of large organizations. His point is not that some technologies are riskier than others, which is obvious, but that the control and operation of some of the riskiest technologies like nuclear power generation and some chemical manufacturing require organizations so complex that serious failures are virtually guaranteed to occur. Those failures will occasionally combine in unforeseeable ways, and if they induce further failures in an operating environment of tightly interrelated processes, the failures will spin out of control, defeating all interventions. The resulting accidents are inevitable, Perrow observes, because they emerge from the very heart of the ventures. You cannot eliminate one without killing the other.

  Perrow’s insight has the power of an authentic observation. It tends to impose its logic across pre-existing ideological lines and in unanticipated ways. Perrow himself has run up against it: He is a moralist with an urge to blame elites for the failings of their organizations, and in examining some of the more notorious modern cases he has drawn back from what his own theory coolly suggests – that good and evil were not ultimately at play.

  I went to see Perrow one rainy day in New Haven and suggested to him that his observations could be used to excuse the bad decisions of big business. He stood up and began pacing his brick-walled office, exclaiming that this of course was not what he had intended. I pursued the subject. After a while he seemed delighted to claim that I had stumped him.

  At sixty-two, Perrow is a burly and disheveled man with a fleshy face and the dust of old rebellions about him. He is affable, excitable, physically restless, strong, and no doubt a bit reckless. I got the impression that his students must enjoy him. As a teacher he is at his best as a generalist, heated and irrepressible, spinning off new ideas, acknowledging his errors, and confidently moving on. He is also a storyteller, and accidents are his passion; even in print he wanders into their unimportant details and loses track of his larger subjects. During our conversation about Valujet he diverged into an irrelevant description of a barge collision and then apologized with a self-deprecating smile, calling himself ‘an accident maven.’

  Beneath his affability, however, I saw a seriousness in his eyes and in the unexpected soberings of his facial expressions. I won’t link this directly to his professional contemplation of catastrophe, because like most of us Perrow must deal with horror in the abstract; his sudden soberings may be related simply to his intelligence or his age. Nonetheless, I got the impression that he rarely loses sight of the human suffering contained within his musings. When a reporter from the New York Times called, fishing for a quote on an accident, Perrow grew angry and hung up on him abruptly, after snapping, ‘The people I talk to are graduate students. The New York Times lacks the sophistication.’ I thought th
is was unfair, since the New York Times had just proved itself with that phone call. Perrow is precisely the man who can explain why the-news-that’s-fit-to-print is so regularly the news of disaster.

  In fact it seemed to me, sitting in his office, that Perrow had just hung up on one of his natural allies. His natural opponents are people like me – at least in the general sense. Pilots are safety practitioners, steeped in a can-do attitude toward survival, fluent in the language of collective learning, confident in their own skills, trained to ‘fly the airplane’ to the end. My secret emotion at the Valujet crash site was not compassion or sadness but annoyance with the dead crew. So what if they had a fire, I thought – they still should not have lost control. If that reaction seems too severe, for an active pilot it is nonetheless probably healthy. As a child of the sky, before I first soloed, I was taken aside by my pilot-father, who rather than talking about the risks that lay ahead simply said, ‘If you are crossing the street at a crosswalk, and some drunk driver runs you over, then it is your own fault for being there in the first place.’ And I understood even then that he was right. Pilots have to take their fate firmly into their own hands. Airplanes speak to them through their controls, but they remain inanimate machines and mindlessly unforgiving. I took a job with a great Texas airman named Fritz Kahl, who upon seeing ‘God Is My Copilot’ stenciled below a pilot’s window once remarked to me, ‘Any son of a bitch who needs God to fly beside him oughta stay on the goddamned ground.’ And he was right, too. Pilots are not paid to wonder.

  The basis for such an attitude is the idea that man-made accidents must by definition lie within human control. The strongest proponents of this approach are a group of Berkeley professors – notably the political scientist Todd La Porte – who study ‘high-reliability organizations,’ meaning those with good track records at handling apparently risky technologies – aircraft carriers, air traffic control centers, certain power companies. They search for elements which might explain the high levels of safety already achieved and which might be extended to produce perfect safety.