ENGG 406 ASSIGNMENT 1

INCIDENT INVESTIGATION AND RISK ANALYSIS - VALUJET AIRLINES FLIGHT 592

DARREN TING ID:1184002

1) Loss with respect to P.E.A.P. Loss Short Term People Environment Assets The incident resulted in 110 deaths Property damage was caused to the crash scene Severe damage was cause to a jet costing $4 million The incident resulted in halted operations due to investigation

Production

Long Term People

Emotional damage was caused to ValuJets family members and airline crew Jet fuel leaked into Everglades causing environmental damage The incident damaged ValuJets reputation The incident significant lowered flight volumes due to public distrust

Environment

Assets Production

2) Incident Incident Activation of one or more oxygen generators due to improper packaging as cargo resulted in the fire Oxygen generators that were exposed to fire which were determined to produce a temperature well over 1000 degrees Fahrenheit once ignited

Contact with substance

Contact with energy

3) Immediate Cause Immediate Cause Substandard Practices Failure to follow established procedures Oxygen generators were improperly carried as cargo SabreTech failed to prepare, package and identify unexpected chemical oxygen generators before presenting to ValuJet Failing to use personal protective equipment Inadequate guidance for pilots about the need to don oxygen masks and smoke goggles immediately after fire did not contribute to emergency situation Substandard Conditions ValuJet ignored recommendations by National Transportation Safety Board to install smoke detectors and fire suppression systems in Class D cargo hold Valujet failed to train their own employees in recognizing oxygen generators as hazardous material ValuJet failed to make contractors and subcontractors aware that ValuJet did not have authority to transport hazardous materials such as oxygen tanks Inadequate or improper protective equipment Smoke goggle equipment requires excessive time effort and attention to don preventing proper emergency protocol to be followed by pilots

Inadequate warning systems

Inadequate training, expertise

4) Basic causes Basic Cause Job Factors SabreTech failed to identify oxygen generators as hazardous material Smoke goggle equipment requires excessive time effort and attention to don which discourages pilots from following proper emergency procedure Valujet failed to train their own employees in recognizing oxygen tanks as hazardous material ValuJet failed to make contractors and subcontractors aware that ValuJet did not have authority to transport hazardous materials A Lack of formal procedure in SabreTechs shipping and receiving department, including handling of hazardous material allowed oxygen tanks to be categorized as ordinary cargo Personal Factors ValuJet took advantage of de-regulated airline industry which led cost concerns to compromise safety ValuJet failed to make contractors and subcontractors aware that ValuJet did not have authority to transport hazardous material There was inadequate guidance for pilots about the need to don oxygen masks and smoke goggles immediately after smoke was discovered

Inadequate leadership/supervision

Inadequate tools and equipment

Inadequate work standards

Improper motivation

Lack of knowledge

5) Lack of control

Lack of Control 1) The competency and training of There is insufficient training that led to a employees failure to ValuJet employees in recognizing oxygen generators that are hazardous material that ValuJet did not have authority on Comprehensive training would have ensured that pilots donned safety equipment when fire is detected 2) Operation and maintenance Proactive maintenance and operation monitoring would have identified the oxygen generators as potential hazardous materials and would have prevented ValuJet from even transporting them Proper risk assessments would have identified oxygen generators as hazardous material. Proper risk assessment would have prompted ValuJet to execute the National Transportation Safety Boards recommendation to install smoke detectors and fire suppression systems in their Class D cargo hold

3) The assessment/analysis and management of risk

4) Management leadership, commitment There was a lack of leadership and and accountability accountability in management to ensure that all employees have comprehensive safety training. This applies to emergency protocol and recognition of hazardous materials ValuJet failed to implement an effective safety and loss management program for its employees and contractors which subsequently led to a complacent work culture ValuJet already had past incidents and was already under Federal government scrutiny. A

lack of initiative in management resulted in a lack of proactive measures being undertaken

5) The competency and integration of contractors

There is a lack of training provided to SabreTech employees to understand potential hazards of hazardous material. A lack of a formal system in SabreTechs shipping and receiving department allowed oxygen generators to be incorrectly regarded as ordinary cargo which should have been identified as hazardous material

6) Reporting, investigating and analyzing incidents and taking follow up action

ValuJet already had an incident the year earlier which wold have indicated flaws in ValuJets safety and risk management programs National Transportation Safety Board had already determined that the probable cause was due to failure of maintenance and inspection ValuJet failed to investigate and learn from past incidents and make corrective measures to prevent future accidents from happening

6) Semi quantitative risk assessment

Event Key Factors Management

Deviations -Cost concerns override safety concerns leading to management neglecting safety recommendations -Lack of proper safety and risk management program for employees and contractors -Lack of training led to hazardous material regarded as ordinary cargo -Lack of formal system in shipping department to identify hazardous material -Personal protective equipment requires too much effort and attention to don -Inadequate guidance for pilots to don safety equipment immediately after fire is detected -ValuJet employees failed to recognize hazardous material

Proba bility 3(H)

Impact

Risk

Controls -Implement National Safety Transportation Board safety recommendations to install fire suppression systems -Establish a comprehensive and ongoing loss and safety management program -Provide comprehensive training for all contractors regarding hazardous material -Establish formal procedures for identification and handling of hazardous material for contractors -Redesign PPE or replace old PPE with new equipment that is simpler and quicker to use -Incorporate and reinforce importance of personal protective equipment in safety training -Provide comprehensive training for all employees regarding hazardous material

Residual Risk 2(M)

3(H)

9(H)

2(M)

3(H)

6(H)

1(L)

Contractor

3(H)

2(M)

6(H)

2(M)

1(L)

3(H)

3(H)

1(L)

Equipment

2(M)

3(H)

6(H)

2(M)

Employees

3(H)

3(H)

9(H)

2(M)

3(H)

3(H)

9(H)

2(M)

Notes: (H)-high, (M)-medium, (L)-low

Figure 1: Consequence Matrix used in semi quantitative risk analysis for ValuJet incident

Figure 2: Risk Matrix used in semi quantitative risk analysis for ValuJet incident