/

PB96-9104O7

NTSB/AAR-96/07

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT

GROUND SPOILER ACTIVATION IN

VALUJET AIRLINES FLIGHT 558

DOUGLAS DC-9-32, N922VV

NASHVILLE, TENNESSEE

JANUARY 7, 1996

REPORT

FLIGHT/HARD LANDING

6781
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Board Act of 1974 to investigate transportation accidents, determine the probable causes of

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NTSB/AAR-96/07 PB96-9104O7

NATIONAL TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

GROUND SPOILER ACTIVATION IN FLIGHT/HARD LANDING

VALUJET AIRLINES FLIGHT 558

DOUGLAS DC-9-32, N922W

NASHVILLE, TENNESSEE

JANUARY 7,1996

Adopted: December 11, 1996

Notation 6781

Abstract: This report explains the ground spoiler activation in flight and subsequent hard landing

of ValuJet Airlines flight 558, N922VV, a Douglas DC-9-32 at Nashville International Airport,

Nashville, Tennessee. The safety issues discussed in the report include the adequacy of ValuJet’s

operations and maintenance manuals, specifically winter operations nosegear shock strut servicing

procedures; the adequacy of ValuJet’s pilot training/crew resource management training programs;

flightcrew actions/decisionmaking; the role of communications (flightcrew/flight attendants/

operations/dispatch/air traffic control); ValuJet’s flightcrew pay schedule; Federal Aviation

Administration (FAA) oversight of ValuJet; and the adequacy of cockpit voice recorder (CVR)

duration and procedures. Safety recommendations concerning these issues were made to the FAA

and ValuJet Airlines.
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iii

CONTENTS

ABBREVIATIONS .................................................................................................................................................... vi

EXECUTIVE SUMMARY...................................................................................................................................... viii

1. FACTUAL INFORMATION................................................................................................................................ 1

1.1 HISTORY OF FLIGHT ...................................................................................................................................... 1

1.2 INJURIES TO PERSONS ................................................................................................................................. 10

1.3 DAMAGE TO AIRPLANE ............................................................................................................................... 10

1.4 OTHER DAMAGE ......................................................................................................................................... 10

1.5 PERSONNEL INFORMATION.......................................................................................................................... 10

1.5.1 The Captain ......................................................................................................................................... 10

1.5.2 The First Officer .................................................................................................................................. 11

1.5.3 Flight Attendants ................................................................................................................................. 12

1.5.4 FAA Principal Operations Inspector (POI) for ValuJet...................................................................... 12

1.5.5 FAA Principal Maintenance Inspector (PMI) for ValuJet................................................................... 12

1.6 AIRCRAFT INFORMATION............................................................................................................................. 13

1.6.1 Landing Gear System........................................................................................................................... 13

1.6.2 Ground Spoiler System ........................................................................................................................ 15

1.6.3 Pressurization System.......................................................................................................................... 16

1.7 METEOROLOGICAL INFORMATION............................................................................................................... 17

1.8 AIDS TO NAVIGATION.................................................................................................................................. 17

1.9 COMMUNICATIONS...................................................................................................................................... 17

1.10 AIRPORT INFORMATION............................................................................................................................... 18

1.11 FLIGHT RECORDERS .................................................................................................................................... 18

1.11.1 CVR...................................................................................................................................................... 19

1.11.2 FDR ..................................................................................................................................................... 19
iv

1.12 WRECKAGE AND IMPACT INFORMATION ..................................................................................................... 20

1.13 MEDICAL AND PATHOLOGICAL INFORMATION............................................................................................. 20

1.14 FIRE ............................................................................................................................................................ 20

1.15 SURVIVAL ASPECTS..................................................................................................................................... 20

1.16 TESTS AND RESEARCH ................................................................................................................................ 21

1.16.1 Landing Gear System Examination ..................................................................................................... 21

1.17 COMPANY/OPERATIONS INFORMATION....................................................................................................... 21

1.17.1 ValuJet’s Cold Weather/Winter Nosegear Strut Servicing Procedures............................................... 21

1.17.2 ValuJet’s Manuals .............................................................................................................................. 22

1.17.2.1 ValuJet’s QRH and AOM ..........................................................................................................................23

1.17.2.2 ValuJet’s COM...........................................................................................................................................25

1.17.2.2.1 In-flight Irregularity Procedures...........................................................................................................26

1.17.3 ValuJet’s Training Program................................................................................................................ 26

1.17.3.1 CRM Training ............................................................................................................................................28

1.17.4 ValuJet’s Crew Pay Schedule/Criteria ................................................................................................ 28

1.18 ADDITIONAL INFORMATION......................................................................................................................... 29

1.18.1 FAA Oversight ...................................................................................................................................... 29

1.18.2 Postaccident FAA/ValuJet Actions ...................................................................................................... 30

2. ANALYSIS ........................................................................................................................................................... 35

2.1 GENERAL .................................................................................................................................................... 35

2.2 COLD WEATHER/WINTER FLIGHT OPERATIONS .......................................................................................... 35

2.3 FLIGHTCREW ACTIONS/DECISIONMAKING................................................................................................... 36

2.4 VALUJET’S TRAINING PROGRAM................................................................................................................. 38

2.4.1 Crew Resource Management Training ................................................................................................ 39

2.5 VALUJET PAY SCHEDULE............................................................................................................................ 39

2.6 COMMUNICATIONS...................................................................................................................................... 40
v

2.7 CVR ISSUES................................................................................................................................................ 41

2.8 VALUJET ACTIONS/FAA OVERSIGHT.......................................................................................................... 42

3. CONCLUSIONS .................................................................................................................................................. 43

3.1 FINDINGS..................................................................................................................................................... 43

3.2 PROBABLE CAUSE....................................................................................................................................... 44

4. RECOMMENDATIONS..................................................................................................................................... 46

5. APPENDIXES ...................................................................................................................................................... 49

APPENDIX A - INVESTIGATION AND HEARING ........................................................................................... 49

APPENDIX B - COCKPIT VOICE RECORDER TRANSCRIPT ...................................................................... 50

APPENDIX C - VALUJET FLIGHT 558 DIGITAL FLIGHT DATA RECORDER DATA PLOT................. 75

APPENDIX D - AIR TRAFFIC CONTROL TRANSCRIPT AND STATEMENTS.......................................... 76

APPENDIX E - EXCERPTS FROM VALUJET AND DOUGLAS DOCUMENTS/MANUALS .................. 119

APPENDIX F - FAA DOCUMENTS/CORRESPONDENCE ............................................................................ 147
vi

ABBREVIATIONS

agl: above ground level, 7

AIM: Aeronautical Information Manual, 8

AOL: all operator letter, 14

AOM: aircraft operating manual, 1

APU: auxiliary power unit, 1

ARFF: aircraft rescue and fire fighting, 8

ATC: air traffic control, 7

ATIS: automatic terminal information service, 6

ATP: airline transport pilot, 11

CAM: cockpit area microphone, 19

CDL: configuration deviations list, 13

CFR: Code of Federal Regulations, 1

COM: company operating manual, 4

CRM: crew resource management, 11

CVR: cockpit voice recorder, 18

EPR: engine pressure ratio, 20

FAA: Federal Aviation Administration, 2

FAR: Federal Aviation Regulation, 22

FCOM: flightcrew operating manual, 6

FDR: flight data recorder, 18

FSDO: flight standards district office, 13

FSI: Flight Safety International, 24

G: vertical acceleration force, 19

IFR: instrument flight rules, 1

ILS: instrument landing system, 6
vii

IOE: initial operating experience, 24

LOS: line operational simulation, 28

MEL: minimum equipment list, 13

msl: mean sea level, 4

P&W: Pratt & Whitney, 13

PA: public address, 10

PMI: principal maintenance inspector, 12

POI: principal operations inspector, 12

psi: pounds per square inch, 6

QRH: quick reference handbook, 2

SB: service bulletin, 14

SN: serial number, 13

VMC: visual meteorological conditions, 1
viii

EXECUTIVE SUMMARY

About 1620 central standard time, on January 7, 1996, a Douglas Aircraft

Company DC-9-32, N922VV, operated by ValuJet Airlines, Inc., as flight 558, touched down

hard in the approach light area short of runway 2R at the Nashville International Airport in

Nashville, Tennessee. Flight 558 was operating under the provisions of Title 14 Code of Federal

Regulations Part 121, as a scheduled, domestic passenger flight from Atlanta, Georgia, to

Nashville. The flight departed the William B. Hartsfield Atlanta International Airport at

approximately 1540, with five crewmembers and 88 passengers on board. The flight attendant

who occupied the rear cabin jumpseat and four passengers reported minor injuries; no injuries

were reported by the remaining 88 occupants. The airplane sustained substantial damage to the

tail section, nosegear, aft fuselage, flaps, slats, and both engines. Visual meteorological

conditions prevailed for the flight, which operated on an instrument flight rules flight plan.

The National Transportation Safety Board determines that the probable cause of

this accident was the flightcrew’s improper procedures and actions (failing to contact system

operations/dispatch, failing to use all available aircraft and company manuals, and prematurely

resetting the ground control relay circuit breakers) in response to an in-flight abnormality, which

resulted in the inadvertent in-flight activation of the ground spoilers during the final approach to

landing and the airplane’s subsequent increased descent rate and excessively hard ground impact

in the runway approach light area.

Contributing factors in the accident were ValuJet’s failure to incorporate cold

weather nosegear servicing procedures in its operations and maintenance manuals, the

incomplete procedural guidance contained in the ValuJet quick reference handbook, and the

flightcrew’s inadequate knowledge and understanding of the aircraft systems.

The safety issues discussed in this report include the adequacy of ValuJet’s

operations and maintenance manuals, specifically winter operations nosegear shock strut

servicing procedures; the adequacy of ValuJet’s pilot training/crew resource management

training programs; flightcrew actions/decisionmaking; the role of communications

(flightcrew/flight attendants/operations/dispatch/air traffic control); ValuJet’s flightcrew pay

schedule; Federal Aviation Administration oversight of ValuJet; and the adequacy of cockpit

voice recorder duration and procedures.
NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

GROUND SPOILER ACTIVATION IN FLIGHT/HARD LANDING

VALUJET AIRLINES FLIGHT 558, DOUGLAS DC-9-32, N922VV

NASHVILLE INTERNATIONAL AIRPORT

NASHVILLE, TENNESSEE

JANUARY 7, 1996

1. FACTUAL INFORMATION

1.1 History of Flight

About 1620 central standard time,1

 on January 7, 1996, a Douglas Aircraft

Company (Douglas) DC-9-32, N922VV, operated by ValuJet Airlines, Inc., as flight 558,

touched down hard in the approach light area short of runway 2R at the Nashville International

Airport in Nashville, Tennessee. Flight 558 was operating under the provisions of Title 14 Code

of Federal Regulations (CFR) Part 121, as a scheduled, domestic passenger flight from Atlanta,

Georgia, to Nashville. The flight departed the William B. Hartsfield Atlanta International

Airport at approximately 1540, with five crewmembers and 88 passengers on board. The flight

attendant who occupied the rear cabin jumpseat and four passengers reported minor injuries; no

injuries were reported by the remaining 88 occupants. The airplane sustained substantial damage

to the tail section, nosegear, aft fuselage, flaps, slats, and both engines. Visual meteorological

conditions (VMC) prevailed for the flight, which operated on an instrument flight rules (IFR)

flight plan.

The accident occurred on the third leg of the day for the DC-9 flightcrew. The

captain flew the first leg of the day, from Atlanta to Indianapolis, Indiana. According to the

captain, the first leg’s departure from Atlanta was delayed for more than an hour because of

maintenance on the auxiliary power unit (APU) generator and deicing operations. The first

officer performed pilot flying duties for the second leg, which was the return flight from

Indianapolis to Atlanta. The flightcrew described the second leg of the trip sequence as routine.

The captain told investigators that upon arrival in Atlanta after the second leg, he

went to ValuJet system operations to pick up the paperwork for the third leg of the trip sequence.

When the captain returned to the DC-9, he performed the exterior preflight inspection of the

airplane. He stated that this inspection of the airplane was normal, and he did not notice any

landing gear anomalies; specifically, the captain indicated to investigators that the nosegear strut

inflation appeared normal. The ValuJet aircraft operating manual (AOM) states that during the

 

1

 Unless otherwise indicated, all times are central standard time, based on a 24-hour clock.
2

exterior inspection of the airplane, the flightcrew should check the nosegear strut for inflation

and leaks and includes a note indicating that “Normal strut extension is 2 to 6 inches.” 2

While the captain performed the exterior preflight inspection, the first officer,

who performed pilot flying duties for the third leg, completed the weight and balance paperwork

and performed the interior preflight inspection of the airplane. According to the company, flight

558 was originally scheduled to depart Atlanta for Nashville at 1355; however, in part because of

the delays before departure from Atlanta on the first leg of the trip, flight 558 did not leave the

gate at Atlanta until 1525.

The pilots reported that the engine start and taxi from the gate were normal.

Because of the amount of ice and snow they encountered as they taxied to runway 26L, the pilots

were concerned that the aircraft’s surfaces/components would get contaminated during taxi.

At approximately 1539, flight 558 was cleared for takeoff on runway 26L. The

flightcrew stated that the takeoff roll and rotation were normal. The pilots reported that after the

captain announced a positive rate of climb, the first officer requested “...gear up.” The captain

attempted to raise the landing gear lever to the retract position, but the lever would not move

beyond the uplock check position.3

In accordance with the procedures outlined in the Federal Aviation Administration

(FAA)-approved ValuJet quick reference handbook (QRH), Page A-38,4 (see figure 1) entitled

“Unable to Raise Gear Lever,”5

the captain attempted to turn the nosewheel steering wheel

located at his left side. The nosewheel steering tiller did not turn, which confirmed that the

nosewheel steering was centered and locked. According to the QRH, this indicated a

 

2

 Douglas representatives stated that they would not expect flightcrew members to reliably detect

underserviced/underinflated nosegear shock struts during the strut extension examination performed

during their aircraft preflight inspection because the visible indications of such a condition are very

subtle and are dependent on aircraft load conditions. Douglas representatives stated that reliable

detection of underserviced/underinflated nosegear shock struts is accomplished by comparing the strut

pressure and the “X” dimension (amount of visible chrome plate on the piston) with the “strut inflation

curve.” This inspection/comparison is identified as an item “normally accomplished by maintenance.”

3

 Further description of the landing gear lever positions is included in section 1.6.1, “Landing Gear

System.”

4

 Excerpts from the QRH and other ValuJet and Douglas manuals are included in appendix E.

5

 Throughout the ValuJet manuals, the term “landing gear lever” is used instead of the Douglas term

“landing gear handle.”

4

malfunction of the landing gear anti-retraction mechanism.6 The pilots, proceeding in accordance

with the QRH, pushed the landing gear handle release button and raised the landing gear lever

again; this time the landing gear retracted.

The flightcrew retracted the flaps and slats and adjusted the throttles for initial

climb. The captain assumed flying duties and requested that the first officer review the QRH to

verify that all required procedures for raising the gear lever had been accomplished. The first

officer confirmed that they had completed the procedures correctly.

As the DC-9 climbed through 4,000 feet mean sea level (msl), the captain

advanced the throttles to normal climb power and called for the “Climb” checklist. At this point,

the takeoff warning horn sounded,7

 and the first officer noted that the cabin was not pressurizing.

The flightcrew referred to the QRH again and determined that in addition to the landing gear

anti-retract mechanism malfunction, the ground shift mechanism must have malfunctioned.8

Specifically, the ValuJet QRH, page A-38, indicated that if the ground shift mechanism was still

in the ground mode, there would be “No auto-pressurization, and takeoff warning horn will

sound when flaps/slats are retracted.” The QRH further stated, “The ground control relay

electrical circuits can be placed in the flight mode by pulling the Ground Control Relay circuit

breakers (H20 and J20).” The pilots stated that when the first officer pulled the ground control

relay circuit breakers (H20 and J20), the takeoff warning horn silenced, and the cabin began to

pressurize. The flightcrew completed the “Climb” checklist without further incident.

As the DC-9 climbed through 10,000 feet msl, the captain engaged the autopilot

and transferred control of the airplane back to the first officer. According to the pilots, they

discussed the problems they had encountered and considered their options as they continued the

climbout after departure. ValuJet’s company operating manual (COM) states that pilots shall

report all incidents and/or irregularities9

 to company system operations/dispatch at the earliest

opportunity. The pilots indicated that they did not contact ValuJet system operations/

 

6

 According to the ValuJet DC-9 AOM, the “anti-retraction mechanism prevents moving the [landing

gear] lever more than 2 inches out of the DOWN position until the nose gear strut extends, actuating the

ground shift mechanism.”

7

 According to the ValuJet DC-9 AOM, an intermittent warning horn will sound when the aircraft is in

the ground mode, if throttles are advanced at least 2 1/8 inches forward of idle stops, as if for takeoff, and

if the flaps are not set at 5o

 or 15o. The horn will not sound under similar circumstances, if the aircraft is

in flight mode.

8

 For additional information on the ground shift mechanism, see section 1.6.1, “Landing Gear System,”

and figure 2.

9

 On pages 7-7 through 7-9 of the ValuJet COM, reportable incidents/irregularities are listed. Page 7-8

states that any mechanical or communication malfunction should be reported to ValuJet system

operations by radio. These pages are included in appendix E.

6

dispatch about the events that occurred during their departure from Atlanta because they believed

that the ice and snow on the ground in Atlanta might have contaminated the ground shift

mechanism. They stated that they believed that they had resolved the problem, and the airplane

appeared to be flying safely and normally. The pilots also believed that it was safe to continue

the flight to Nashville and said that they planned to have the contract maintenance personnel10 at

Nashville examine the airplane after landing.

The pilots indicated that the flight to Nashville proceeded normally, and during

the en route portion of the flight, they discussed the procedures they should use during the

approach and landing in Nashville. The flightcrew consulted the guidance in the QRH, page A38, “Unable to Raise Gear Lever,” under the subheading “Approach and landing.”11 The pilots

decided to depressurize the cabin during the descent with the automatic pressurization system.

The pilots reported that although the automatic pressurization system appeared to be functioning

normally, they were concerned that there might be a slight “bump” in pressurization after

landing, caused by the venting of cabin pressure after touchdown.12 The pilots decided that they

could preclude such a loss of cabin pressurization after landing by resetting the ground control

relay circuit breakers just before touchdown. They believed that resetting the circuit breakers on

short final approach would also satisfactorily accomplish the third QRH approach and landing

checklist item.13 (Refer to figure 1.)

According to the pilots, as they approached Nashville, they performed the normal

“Descent and Approach” checklist and obtained the current automatic terminal information

service (ATIS) for Nashville. The ATIS reported VMC and surface winds out of the northwest at

12 knots, with gusts to 20 knots, at Nashville. In accordance with the COM, the first officer

elected to fly the instrument landing system (ILS)/transition to visual approach to runway 2R at

 

10

 ValuJet uses contract maintenance facilities for scheduled and unscheduled maintenance away from its

primary maintenance bases in Atlanta and at Dulles International Airport, Washington, D.C. ValuJet’s

contract maintenance organization for Nashville was Northwest Airlines.

11

 The guidance provided in this section of the QRH is quoted in full in section 1.17.2.1 of the narrative.

A copy of page A-38 of the QRH is included in appendix E.

12

 According to the Douglas flightcrew operating manual (FCOM), if the DC-9 automatic pressurization

system was operating normally during the descent and approach, and the differential pressure indicator

indicated zero pounds per square inch (psi) as the aircraft approached the runway, there would be no

pressurization anomaly upon touchdown. Also, the DC-9 has a manual pressurization control, which

may be employed by selecting the manual control position with the cabin pressure controller lever,

located on the right side of the throttle console. This allows the flightcrew to manually position the cabin

outflow valves, located in the lower aft section of the airplane and, thus, manually control cabin

pressurization.

13

 The ValuJet AOM, which provides more detailed procedural guidance than the QRH for abnormal

operations (including “Unable to Raise Gear Lever”), describes the third step under “Approach and

landing” as follows: “Reset Ground Control Relay circuit breakers during taxi [emphasis added] and

verify that circuits are in the ground mode.”
7

an airspeed about 10 knots higher than the calculated approach airspeed to compensate for the

gusty crosswind during the approach and landing.

As the DC-9 descended on the ILS approach, the flightcrew performed the normal

“Before Landing” checklist, which included arming the spoilers, extending the flaps/slats, and

extending the landing gear. The flightcrew stated that the landing gear extended normally, and

flaps were set at 50o (fully extended) for landing.

The first officer told investigators that when the DC-9 was about 100 feet above

ground level (agl), the captain verified a zero psi differential on the cabin differential pressure

gauge and reset the ground control relay circuit breakers. According to the first officer, he noted

that the cabin outflow valve began to move to the full open position, and then he heard the sound

of the ground spoilers deploying as the airplane began to descend at an excessive rate. The first

officer reported that he shouted “ground spoilers!” and attempted to arrest the excessive sink rate

with back pressure on the control column and the addition of full power.14

At approximately 1620, the DC-9 struck the runway approach light area tail first,

followed by main landing gear and nosegear, with engine thrust increasing. The nosewheel tires

and rims separated after ground impact,15 and then the airplane became airborne again. The

captain assumed control of the airplane as it became airborne and established a climb on runway

heading. The first officer raised the flaps to 15o, which positioned the flaps for the climb.

Because of possible impact damage, the flightcrew decided not to retract the flaps/slats any

further and to leave the landing gear extended during the go-around.

As the pilots performed the go-around procedure, the first officer noticed that the

No. 2 (first officer’s) navigation and communication radios were unusable. The captain then

attempted to contact air traffic control (ATC) using the No. 1 (captain’s) communication radio

but was unsuccessful.16 Because the first officer was unable to use the navigation radio to

perform the published missed approach procedure, the pilots agreed that they should remain in

VMC and return to land at Nashville as soon as possible. They planned to land on runway 31

because it was closest to their position and because they knew it was operational from the ATIS

broadcast they had received during their first approach. The pilots indicated to investigators that

they did not have time to brief the flight attendants during the go-around. Because the flightcrew

 

14

 According to the ValuJet AOM, the ground spoilers automatically retract and disarm if the left throttle

is moved forward from the idle position stop.

15

 The flightcrew stated that it was not aware of the damage to the nose landing gear.

16

 Postaccident examination revealed that the No. 1 communication radio switch was in an intermediate

(unpowered) position, which resulted in the No. 1 communication radio’s failure to operate during the

go-around. Additionally, the right DC bus reverse current relay, which provides power to the No. 2

navigation and communication radios, was “open,” which resulted in the No. 2 communication and

navigation radios’ failure to operate during the go-around. The right DC bus reverse current relay is

mounted on the inside of the aft wall of the nose wheel well.
8

was unable to communicate by radio with the Nashville ATC tower, the first officer tuned the

airplane’s transponder to 7700/7600, in accordance with lost communication procedures.17

 

Nashville ATC personnel stated that they observed debris from the DC-9 at the

approach end of runway 2R after the airplane struck the ground during the first landing attempt,

and they were aware that the airplane nosegear was damaged from the impact. Although the air

traffic controllers attempted to advise the flightcrew of the damage, they were unable to

reestablish radio communication with flight 558. At approximately 1623, ATC personnel

contacted the aircraft rescue and fire fighting (ARFF) facility to advise it that they were unable to

communicate with a DC-9 that would probably be returning to land with landing gear problems.18

Meanwhile, the pilots continued the approach to runway 31. The captain was

flying the airplane, while the first officer advised the captain of their relative position to runway

31 and the length of the runway and briefed the approach. The pilots completed the “Before

Landing” checklist, and the first officer extended flaps and slats for landing. The pilots decided

not to arm the spoilers for landing because they planned to manually deploy the ground spoilers

during the landing roll. As they approached the runway, the pilots observed emergency

equipment with flashing lights moving into position near runways 2R and 31. (See figure 3,

“Airport Diagram.”)

At approximately 1628, the airplane touched down on its main landing gear on the

centerline of runway 31. The first officer deployed the ground spoilers manually, and the captain

applied the thrust reversers. Both pilots stated that they heard a loud grinding noise when the

nosegear touched down on the runway centerline. The noise continued throughout the landing

roll, and the airplane began to drift to the left of the runway centerline. The captain corrected for

the left drift with brakes, and the airplane came to a stop about 5,800 feet from the approach end

of runway 31.

When the airplane came to a stop, the flightcrew performed the “After Landing”

checklist and shut down the engines normally. The captain informed the flight attendants and

 

17

 According to the FAA Aeronautical Information Manual (AIM), if radio communications are lost, the

pilot should tune the aircraft transponder to code 7700 to indicate an urgent or distress situation to ATC,

then tune the transponder to code 7600 to indicate a loss of radio communications.

18

 The ATC transcript is included in appendix D.
[

s

s

&

Figure 3—Nashville International Airport Diagram
10

passengers via the public address (PA) system that a flight control malfunction had occurred, that

the airplane was safely stopped with emergency equipment standing by, and that the pilots were

requesting ground transportation from the airplane to the terminal. He instructed the passengers

to remain seated until further advised. The first officer opened the right side cockpit window and

asked the ARFF personnel if any risk was involved in remaining on board the airplane. ARFF

personnel advised the pilots that there was no evidence of fuel leaks, smoke, or fire, and the

airplane appeared to be safe for continued occupancy.

Approximately 20 minutes after the airplane came to a stop, buses arrived to

transport the passengers to the terminal building. The passengers deplaned via the left front

airstair and were bused to the terminal. The pilots secured the airplane and were transported to

the terminal in an emergency response vehicle.

The accident occurred at dusk, at approximately 36o

, 7 minutes, 6 seconds North

latitude and 86o

, 40 minutes, 9 seconds West longitude.

1.2 Injuries to Persons

Injuries Flightcrew Cabin Crew Passengers Other Total

Fatal 0 0 0 0 0

Serious 0 0 0 0 0

Minor 0 1 4 0 5

None 2 2 84 0 88

Total 2 3 88 0 93

1.3 Damage to Airplane

The DC-9 received substantial damage to its tail section, nosegear, aft fuselage,

slats, flaps, and both engines.

1.4 Other Damage

Two runway approach system lights and two runway threshold lights on runway

2R were damaged when the airplane struck terrain on the approach light portion of the runway.

The surface of runway 31 was also damaged.

1.5 Personnel Information

The flightcrew consisted of the captain and the first officer. The trip sequence on

the day of the accident was the first time the captain and first officer had flown together. The

cabin crew consisted of three flight attendants.

1.5.1 The Captain
11

The captain, age 43, was hired by ValuJet in November 1994 as a first officer on

the DC-9 airplane.19 He was upgraded to captain on the DC-9 in December 1995. He held an

airline transport pilot (ATP) certificate, with airplane single-engine and multiengine ratings, and

a DC-9 type rating.

The captain’s first-class medical certificate was issued on September 25, 1995,

with no restrictions or limitations. According to company records, the captain completed

ValuJet’s crew resource management (CRM) course on April 14, 1995. The captain’s most

recent proficiency check was completed on December 6, 1995, in the DC-9 airplane in

conjunction with his upgrade to captain. A review of his captain upgrade training records

indicated that the captain flew 25.8 hours of initial operating experience, all under 14 CFR Part

121. Records indicated that at the time of the accident, the captain had accumulated 4,381 total

flight hours, including 1,061 hours in the DC-9, with 26 hours as a DC-9 captain. The captain’s

total flight hours included 3,320 flight hours in military aircraft.

The captain’s written statement indicated that his aviation background began in

the U.S. Navy in 1975, and he was designated a naval aviator in 1976. He indicated that from

1976 to 1978 he was assigned as a standardization flight instructor in the North American T-28.

Between 1978 and 1982, the captain flew the Lockheed P-3 with a patrol squadron.20 In 1982,

the captain left active duty and joined the naval reserve. Between 1982 and 1991, the captain

served with a naval reserve patrol squadron as plane commander, mission commander, and

maintenance check pilot in the Lockheed P-3. The captain left the naval reserve patrol squadron

in August 1991. According to the captain’s résumé, he worked for Lockheed Missiles & Space

Company as a systems/logistics engineer between 1982 and 1993. The captain’s résumé

indicated that he was employed as an associate builder/residential construction when he applied

for employment as a first officer at ValuJet.

The captain had been off duty for 3 days before the day of the accident. On the

day of the accident, he reported for duty at about 0915. He flew two flight legs with the first

officer before the accident flight leg and had accumulated 5 hours 30 minutes of flight time and 7

hours 5 minutes of duty time at the time of the accident.

1.5.2 The First Officer

The first officer, age 42, was hired by ValuJet in October 1995 as a first officer on

the DC-9 airplane. He held an ATP certificate with airplane multiengine land ratings, an

instrument rating, and DC-9, Gulfstream G-1159, Cessna 500, Falcon 10, Falcon 20, and Falcon

50 type ratings. He had commercial pilot privileges for airplane single-engine land and sea.

 

19

 The captain of ValuJet flight 558 was the first officer on ValuJet flight 597, which incurred an

uncontained engine failure/fire on June 8, 1995. The Safety Board investigated the accident and issued

its findings in report NTSB/AAR-96/03.

20

 The North American T-28 is a two-seat, reciprocating engine-powered training aircraft. The Lockheed

P-3 is a Navy antisubmarine patrol airplane equipped with four turbopropeller engines.
12

His first-class medical certificate was issued on June 1, 1995, and contained the

limitation, “Holder must wear corrective lens while flying.” Training records indicate that the

first officer completed ValuJet CRM training in September 1995 with his initial hire training. A

review of the first officer’s initial operating experience training records indicated that he flew 27

hours of initial operating experience, all under 14 CFR Part 121. The first officer’s last

proficiency check was completed on October 11, 1995, in the DC-9 airplane. According to

company records, he had accumulated about 7,707 total flight hours, with 205 hours in the DC-9,

all as first officer.

The first officer reported that he had more than 20 years flight experience, of

which more than 17 years and 5,500 flight hours were in multiengine turbojet aircraft.

The first officer was off duty on January 3 and January 4. On January 5, he

accumulated about 6 hours of flight time and about 8 hours of duty time. On January 6, he

accumulated about 41⁄2 hours of flight time and about 6 hours of duty time. He reported for duty

at about 0915 on the day of the accident. He had accumulated 5 hours 30 minutes of flight time

and 7 hours 5 minutes of duty time at the time of the accident.

1.5.3 Flight Attendants

Two flight attendants occupied the aft-facing double-occupancy jumpseat in the

forward cabin at the time of the accident. The other flight attendant was seated in the forwardfacing rear cabin jumpseat. All three flight attendants had satisfactorily completed ValuJet’s

flight attendant training program.

1.5.4 FAA Principal Operations Inspector (POI) for ValuJet

The POI was hired by the FAA in September 1989 as a geographic air carrier

inspector. He spent approximately 1 year in that position and then transferred to certificate

management in 1990. At various times from 1990 through the time of the accident, he managed

the certificates of five Part 121 air carriers (including ValuJet) and three Part 135 air carriers. He

was the project manager for ValuJet’s certification and then became the POI when ValuJet began

operations in October 1993. In September 1995, the FAA reassigned all non-ValuJet certificate

responsibilities to other inspectors. At the time of the accident, the ValuJet certificate was the

only certificate assigned to the POI.

The POI had more than 32 years of aviation experience at Eastern Airlines before

he was hired by the FAA. He had been hired by Eastern Airlines in December 1956 and worked

as first officer, flight engineer, and captain. He had been a captain on the Convair 330/440, L188

(Lockheed Electra), DC-9, Boeing 727, Boeing 757/767, Airbus A300, and Lockheed L1011.

1.5.5 FAA Principal Maintenance Inspector (PMI) for ValuJet

The PMI was hired by the FAA in August 1989 as the accident investigation and

enforcement program coordinator in the FAA’s Southern Regional Office. In December 1992, he
13

transferred to an aviation safety inspector/quality specialist position in the Atlanta Flight

Standards District Office (FSDO), where he began certificate management duties in December

1993. The PMI was assigned to manage ValuJet’s certificate in December 1994 and held that

assignment until August 1996. Between November 1994 and February 1996, the PMI also

managed a second Part 121 operator.

The PMI had more than 25 years of aviation experience before he was hired by the

FAA. He had been a maintenance officer in the U.S. Air Force from 1964 until 1969, when he

was hired by McDonnell Douglas Aerospace as a manufacturing systems analyst. He owned and

managed a general aviation operation from January 1971 until September 1973, when he entered

the Air Force reserves as a full-time maintenance manager. The PMI remained as an Air Force

reserve maintenance manager until August 1989, when he was hired by the FAA.

1.6 Aircraft Information

N922VV, a DC-9-32, serial number (SN) 47274, was registered to ValuJet

Airlines, Inc. The airplane had been purchased from Douglas and was put into service as part of

ValuJet’s fleet on August 1, 1995. It had previously been operated by Delta Air Lines and Aero

Mexico. The airplane was powered by two Pratt & Whitney (P&W) JT8D-9A turbofan engines.

No pertinent discrepancies were noted in the airplane maintenance logs, the

minimum equipment list (MEL), or configuration deviations list (CDL). The APU generator

malfunction that delayed the aircraft on the first leg of the trip was repaired by maintenance

personnel in Atlanta, and the flightcrew noted no further anomaly. No irregularities were noted

by the ground or flightcrew before flight 558’s departure from Atlanta.

At the time of the accident, flight 558 had an estimated operating weight of

96,489 pounds. The certificated maximum landing weight of this DC-9 was 99,000 pounds.

The center of gravity was at 20 percent mean aerodynamic chord, which was within limits.

1.6.1 Landing Gear System

The DC-9 tricycle landing gear is controlled by a lever on the left side of the first

officer’s instrument panel and is hydraulically actuated by pressure from the right hydraulic

system. The main and nose landing gear consist of dual wheels mounted on shock struts, with

dual brakes mounted on the main landing gear.

The ground shift mechanism, which is actuated by nosegear shock strut

extension/compression, controls whether certain aircraft systems operate in the ground or flight

mode.21 When the nosegear shock strut is compressed by the weight of the aircraft, the ground

shift mechanism causes those aircraft systems to be operated in the ground mode. When the

nosegear shock strut is extended after takeoff, it triggers the ground shift mechanism,

 

21

 Refer to figure 2.
14

electronically shifting the aircraft systems to the flight mode.22 In addition, when the aircraft is

in the flight mode, the ground shift mechanism mechanically centers the nose wheel, locks out

the rudder pedal nose wheel steering function, and releases the gear lever anti-retraction

mechanism.

According to Douglas representatives, when the nosegear shock strut is

underserviced/underinflated, strut extension after liftoff may not be sufficient to activate the

ground shift mechanism to shift the aircraft systems into the flight mode and release the gear

lever anti-retraction mechanism. Douglas representatives indicated that this is a commonly

reported occurrence during cold weather operations. They stated that Douglas had issued

numerous service bulletins (SBs) and all operator letters (AOLs) describing the anomaly and

recommending maintenance procedures to avoid underserviced/underinflated nosegear shock

struts during cold weather operations.23

The landing gear lever has DOWN, UPLATCH CHECK,24 and UP positions.

When the airplane is on the ground, the gear lever is locked in the DOWN position by the antiretraction mechanism. The anti-retraction mechanism can be overridden by use of the landing

gear lever release push-button, which is located on the left side of the first officer’s instrument

panel, beneath the landing gear lever. According to the ValuJet AOM, page 11-2-3, the landing

gear lever release button bypasses the landing gear anti-retraction release mechanism if the

ground shift mechanism malfunctions, allowing the landing gear lever to be moved to the UP

position.

 

22

 According to Douglas, the ground sensing control mechanism provides the mechanical means of

establishing a ground or flight mode of operation for the aircraft. The ground sensing control mechanism

consists of a linkage and a two-way closed circuit cable run that is actuated solely by the nosegear torque

links during strut extension or compression. The landing gear lever anti-retraction mechanism is also

actuated through the ground sensing control mechanism. The Douglas FCOM indicates that being unable

to raise the landing gear handle after liftoff is an indication of a failure in the mechanical portion of the

ground shift mechanism, while lack of cabin pressurization is an indication of a failure in the electrical

portion of the ground shift mechanism.

23

 Douglas representatives reported that when they become aware that an operator has purchased a

Douglas aircraft, the operator is placed on a mailing list and automatically receives all future Douglas

communications, SBs, AOLs, etc., for that aircraft. Douglas records indicate that ValuJet has been on

the DC-9 mailing list since before it began operations in October 1993. Additionally, Douglas records

indicate that on December 16, 1993, ValuJet purchased all back-issued DC-9 aircraft-related Douglas

communications, SBs, AOLs, etc., from Douglas. Douglas records also indicate that on February 7,

1994, ValuJet purchased the complete Douglas DC-9 maintenance manual and the temporary repair

manual with revisions on microfilm.

24

 According to the ValuJet AOM, when the landing gear lever is moved to the UPLATCH CHECK

position, “hydraulic pressure is bypassed in all gear and door hydraulic components. The main gear rests

on the [landing gear] doors and the nose gear is held up by the overcenter linkage.”
15

According to the Douglas DC-9 FCOM, section 2, page 4, under the heading

“LANDING GEAR -- ABNORMAL OPERATION,”25 if the pilots are unable to raise the landing

gear control handle after takeoff, they should do the following:

1. Check nosewheel steering with NORMAL26 force on wheel.

2. If wheel does not turn ... a malfunction of the gear anti-retract mechanism

is indicated. In this event push the gear handle release button and raise the

landing gear handle. Go to step 4.

3. DO NOT RETRACT landing gear if wheel is steerable as there is no

assurance that the nosewheel will center, and remain centered, during

retraction. Limit speed to applicable gear extend limitations. Continue

procedure.

4. If electrical circuits (auto pressurization, takeoff warning after flaps up)

indicate that ground shift is in ground mode, pull ground control relay circuit

breakers to place circuits in flight mode. Insure that airplane is depressurized

prior to landing.

5. On next landing, during rollout (above approximately 30 kts.) momentarily

release brakes and place the anti-skid switch to OFF and operate brakes

manually.

6. Reset ground control relay circuit breakers during taxi and verify that

electrical circuits (auto pressurization, air conditioning, ground blowers) are in

the ground mode.

1.6.2 Ground Spoiler System

The DC-9-32 has four spoiler panels located on the upper surfaces of the wings,

forward of the trailing edge flaps. During airborne operations, the spoiler panels work with the

ailerons automatically, through an aileron/flight spoiler mixer assembly, to help lower the upaileron wing. Additionally, when the speed brake/ground spoiler control lever is pulled aft during

flight, the four spoiler panels extend to function as speed brakes. Maximum spoiler deployment

in flight is approximately 30o

. During ground operation, the four spoiler panels can be extended

to 60o

 to perform the ground spoiler function. Ground spoiler actuation can be accomplished

automatically or manually.

 

25

 Excerpts from the Douglas maintenance manuals and FCOM are included in appendix E.

26

 According to Douglas, “NORMAL” force is considered to be equivalent to the force a pilot would

apply to the nosewheel steering wheel to steer the aircraft during ground operations.
16

According to the Douglas DC-9 FCOM, automatic ground spoiler extension

requires main wheel spin-up or the ground shift mechanism to be in the ground mode. According

to Douglas publications, the flightcrew’s action of arming the spoilers for landing, per the normal

“Before Landing” checklist, was an acceptable technique, provided that the ground control relay

circuit breakers were not reset until after landing. Under these circumstances, with or without the

ground control relay circuit breakers reset, the main wheel spin-up during the landing would

actuate automatic spoiler extension. Douglas representatives stated that another acceptable

option would have been for the pilots not to arm the spoilers before landing and then to manually

extend the spoiler panels using the speed brake/ground spoiler control lever during the landing

roll. However, the Douglas representatives cautioned that had the pilots chosen this technique,

the landing roll would have required more runway than if they had extended the spoilers

automatically.

1.6.3 Pressurization System

According to the ValuJet AOM, the DC-9 pressurization system uses bleed air

from the engine compressor sections to pressurize and air condition the airplane. The desired

pressurization level is maintained by regulating the escape of cabin air through the cabin outflow

valves. Although manual outflow valve control may be selected, the cabin outflow valves are

normally automatically controlled through the cabin pressure control system. The ValuJet AOM

indicates that the automatic cabin pressure controller includes the following controls:

- A BAR CORR control and IN HG window are used to set appropriate

barometric pressure prior to takeoff or descent.

- An ALTITUDE control and an AIRPLANE ALTITUDE window are used

to set the controller prior to takeoff and just prior to establishing descent.

- The RATE INC control is used to adjust cabin vertical speed.

Under normal operations, the cabin will begin to pressurize automatically in

accordance with the controller limits set by the flightcrew when the nosegear strut extends on

takeoff, thereby placing the aircraft systems in the flight mode. Similarly, under normal

circumstances, cabin depressurization occurs automatically in accordance with the controller

limits set by the flightcrew. Automatic depressurization is normally complete upon landing,

when the nosegear strut compresses, and the aircraft systems transition to the ground mode.

Page 13-2-2 of the AOM states the following, in part:

Prior to landing, the ALTITUDE KNOB is used to set the destination airport

altitude in the CABIN ALT window to ensure that the cabin altitude will equal

airport altitude upon landing.

Additionally, the AOM states the following:
17

If the airplane lands with the cabin inadvertently pressurized, the automatic

system, in response to a signal from the ground control relay, will cause the

outflow valves to open and depressurize the aircraft.

In addition to the automatic pressurization system, manual control may be

employed. This is done by moving the cabin pressure controller lever down to

the manual position (which deenergizes the automatic system) and manually

positioning the cabin outflow valves by depressing and rotating the cabin

pressure controller wheel.

1.7 Meteorological Information

VMC prevailed when the airplane departed Atlanta and at the time of the accident.

The William B. Hartsfield Atlanta International Airport hourly weather

observation at 1456 was the following:

sky—ceiling at 2,800 feet; visibility—10 miles, in light snow;

temperature—22 o

F; dew point—14 oF; and wind—290o at 24 knots.

The Nashville International Airport weather observation at 1626 was the

following:

sky—ceiling at 2,400 feet; visibility—5 miles, in light, blowing snow;

temperature—21 o

F; dew point—15 oF; wind—340o at 12 knots, with

gusts to 20 knots; and altimeter setting—30.11 inches of mercury. The

weather was essentially the same as the preceding and subsequent hourly

weather observations, although visibility varied with precipitation intensity

throughout the afternoon.

1.8 Aids to Navigation

There were no known difficulties with external aids to navigation.

1.9 Communications

The pilots indicated that all communication and navigation radios functioned

normally during ground operations at Atlanta and during the flight from Atlanta to Nashville.

There were no known communication difficulties involving the accident airplane before the

initial ground impact. After the airplane came to a stop on runway 31, internal communications

functioned properly, as the pilots were able to make a PA announcement.

The two communication radio control panels are located on the cockpit control

pedestal between the pilots. The communication radio control panels contain the radio frequency

selection knobs and the radio on/off switches. Two of the three audio control panels in the
18

cockpit are also located on the cockpit control pedestal between the pilots. The third audio

control panel is located on the overhead panel for the observer’s position. The audio control

panels permit the pilots to monitor the audio output of the service interphone, communication,

and/or navigation radios, and to select the desired communication radio for transmission.

As the pilots performed the go-around, they noted that the No. 2 communication

and navigation radios, and the No. 1 communication radio on board the airplane were unusable.

Postaccident examination of the aircraft revealed that the No. 1 communication radio on/off

switch was positioned in an intermediate (unpowered) position. Additionally, the right DC bus

reverse current relay, which provides power to the No. 2 communication and navigation radios,

was “open.” Postaccident functional testing revealed that the No. 1 and No. 2 communication

and navigation radios were capable of normal operation. 27

The pilots set the airplane’s transponder to 7700/7600 in accordance with lost

radio communication procedures, and returned to land on runway 31. ValuJet’s manuals did not

contain specific procedural guidance pertaining to lost radio communications. Nashville ATC

made several attempts to advise the flightcrew of the separated nosegear assembly, using tower

frequencies and the emergency broadcast frequency, without success. The flightcrew reported

that they were not aware of the extent of damage to the airplane; specifically, they stated that they

did not know that the nosegear had separated until they heard the scraping noise during the

landing roll on runway 31.

1.10 Airport Information

The Nashville International Airport is located approximately 6 miles southeast of

Nashville, Tennessee, and has an airport elevation of 599 feet. The airport has four runways,

three of which are parallel paved surfaces, oriented north-northeast/south-southwest. The

farthest east of these runways, runway 2R, was the assigned landing runway for flight 558.

Runway 2R is 8,000 feet long and 150 feet wide. The flightcrew used the fourth runway, runway

31, for landing after the go-around. Runway 31 is 11,029 feet long and 150 feet wide. (Refer to

figure 3, “Airport Diagram.”)

Nashville International Airport is fully certificated under 14 CFR Part 139. ARFF

response was not an issue in this accident.

1.11 Flight Recorders

A digital flight data (FDR) and a cockpit voice (CVR) recorder were installed in

the airplane. The FDR was an 11-parameter Loral Fairchild Model F800, SN 6316, recorder.

The CVR was a Fairchild Model A-100A, SN 57863. Both recorders were removed from the

airplane and sent to the Safety Board’s laboratory in Washington, D.C., for readout.

 

27

 For additional information on the unusable radios, see section 2.6, “Communications.”
19

The cases of both recorders were intact and exhibited no evidence of damage or

excessive wear. Aside from loss of FDR data coincident with the airplane’s hard touchdown,

good quality recordings were obtained from both recorders.28

1.11.1 CVR

The CVR recording consisted of four channels: the cockpit area microphone

(CAM), the captain’s position, the first officer’s position, and the passenger cabin’s PA system.

The CAM channel, from which all crewmember conversation was transcribed, was of good

quality. A transcript was prepared of the entire 30-minute, 26-second recording, which started

after the initial ground impact on runway 2R and approximately 2:03 minutes before the aircraft

touched down on runway 31. The transcript ended after the APU was shut down, approximately

28 minutes after the aircraft landed on runway 31. The CVR transcript is contained in appendix

B.

It should be noted that CVR data are recorded on a 30-minute closed loop tape

that records continuously while electrical power is on the airplane and there is power to the CVR.

The electrical power on the accident airplane was shut off approximately 36 minutes after the

hard landing, and the CVR recording did not include documentation of the hard landing event.

About 4 minutes of postimpact/go-around information and all preimpact audio information and

conversation had been recorded over and was unrecoverable.

1.11.2 FDR

The FDR experienced data loss coincident with the highest recorded vertical

acceleration forces (Gs), which occurred during the hard touchdown of the airplane. The Safety

Board’s laboratory retrieved portions of the lost data and developed a composite data set of the

accident landing.

The readout revealed that the airplane's sink rate was between 39 and 47 feet per

second just before runway impact, whereas over the previous 10 seconds, the descent rates were

between 0 and 23 feet per second. About 4 seconds before impact, pitch attitude values increased

from about 0 to a maximum value of 22.8° nose up about the time of impact. Roll attitude values

did not exceed +/-5° throughout the initial impact sequence. During the 2 seconds before impact,

vertical acceleration values increased from 0.677 Gs to the final valid recorded value of 2.854 Gs.

 

28

 The Safety Board generally uses the following criteria to assess the quality of a CVR recording: a

“poor” recording is one in which a transcription is nearly impossible given that a large portion of the

recording is unintelligible; a “fair” recording is one in which a transcription is possible, but the recording

is difficult to understand; a “good” recording is one in which few words are unintelligible; and an

“excellent” recording is very clear and easily transcribed.
20

Engine pressure ratio (EPR) values remained stable throughout the approximate 15 seconds

before touchdown, at 1.39 to 1.41 for the No. 1 engine, and 1.40 to 1.45 for the No. 2 engine,

respectively. After the touchdown, EPR values increased to 1.49 and 1.45, decreased to 1.19 and

1.30 for the next second, and then increased over the next 5 seconds to about 2.20 and 2.13 for the

Nos. 1 and 2 engines, respectively.

A plot of ValuJet flight 558’s FDR data is included as appendix C.

1.12 Wreckage and Impact Information

Debris from the nose landing gear and the runway approach lights was found at

the approach end of runway 2R. The first indications of impact were ground scars in the runway

approach light area, about 90 feet before the runway threshold lights. Two runway threshold

lights and two runway approach lights were damaged.

The airplane came to a stop on runway 31, approximately 10 feet left of the

centerline and about 5,800 feet from the approach end of the runway. Runway 31 exhibited

scrape marks along the runway centerline. The scrape marks started on the runway centerline,

approximately 2,750 feet from the approach end of the runway. The scrape marks continued,

veering slightly left of the centerline, for more than 3,000 feet. The scrape marks stopped where

the airplane’s nosegear strut rested on the pavement. (See section 1.16.1 for details of the

landing gear system examination.)

1.13 Medical and Pathological Information

The CVR transcript and pilot statements indicate that during the minutes after the

airplane came to a stop on the runway, the flight attendant who occupied the rear cabin jumpseat

told the flightcrew that her ribs were sore. Additionally, ValuJet representatives indicate that

four passengers reported “minor strains” as a result of this accident. No other injuries were

reported.

In accordance with ValuJet’s FAA-approved program, the flightcrew provided

postaccident toxicological samples for analysis. The samples were analyzed and found to be

negative for ethanol and other drugs of abuse. Toxicological samples were not requested or

received from the flight attendants.

1.14 Fire

No fire was associated with this accident.

1.15 Survival Aspects

Occupant survivability was not an issue in this accident.
21

1.16 Tests and Research

1.16.1 Landing Gear System Examination

On January 12, 1996, investigators performed a functional landing gear retraction

test and further examination of the landing gear system on the accident airplane. The DC-9 had

been relocated to a heated hangar at Nashville International Airport. Investigators were unable to

place the airplane on jacks to perform a full landing gear retraction test because damage to the

empennage area rendered the rear jack point unusable.

The forward jack point appeared to be safe for use, so the forward portion of the

DC-9 was jacked, and a partial landing gear retraction was performed. This operational test of

the landing gear system did not reveal a ground shift mechanism anomaly. The ground shift

mechanism operated normally, and the nosegear retracted normally during several operational

cycles.

Investigators attempted to simulate the accident approach/landing sequence in the

hangar by pulling the H20 and J20 circuit breakers to put the airplane in the flight mode.

Investigators then performed the “Before Landing” checklist, which included extending the

landing gear and arming the spoilers. When they reset the H20 circuit breaker, they observed that

the cabin pressurization went to the open position. When the J20 circuit breaker was reset, the

ground spoilers deployed.

1.17 Company/Operations Information

1.17.1 ValuJet’s Cold Weather/Winter Nosegear Strut Servicing Procedures

The ValuJet COM and maintenance manual contain FAA-approved sections on

winter operations. The COM winter operations section was approved by ValuJet’s POI on

November 17, 1995. On page 5-10 of the winter operations section, under the heading “MAIN

AND NOSE GEAR STRUTS” the manual states the following:

Due to temperature differences during Winter months, a height change in oleo

shocks is experienced. To eliminate unnecessary raising and lowering of

struts, which contributes to packing damage and leakage, all struts will be

checked in accordance with current instructions for proper heights.29 Unless

an aircraft arrives at a station with a flat strut, no pressure should be added. It

is better for a strut to be low in a cold climate than excessively high in a warm

one.

According to Douglas representatives, several DC-9 operators with aircraft based

in cold climates reported that landing gear anomalies from insufficient air charge in the nosegear

 

29

 The instructions for proper strut inflation heights are outlined for pilots and maintenance personnel in

the ValuJet AOM and maintenance manuals, respectively.
22

shock strut were more frequent during cold weather operations. The Douglas representatives

reported that as a result of these occurrences, most DC-9 operators amended their maintenance

practices for cold weather operations, specifically regarding strut inflation and inspection. Those

airlines typically amended their cold weather servicing procedures to reflect the procedures

recommended in the DC-9 maintenance manual. These procedures are as follows:

A. Nose Gear Strut

 (1) prior to cold weather season:

(a) Change fluid in strut. This prevents seal damage 

caused by water in fluid which changes to ice particles 

during cold weather exposure.

(b) Replace seals as required.

(2) During cold season:

(a) Check strut for servicing requirements every 14 

days.

(b) Wipe exposed chromed surface of piston with 

MIL-H-5606 hydraulic oil daily. 

Investigators reviewed the FAA-approved ValuJet winter operations section of the

maintenance manual in effect at the time of this accident and the winter operations section of the

revised maintenance manual (dated May 6, 1996). Neither document contained nosegear shock

strut servicing procedures that reflected the guidance provided by Douglas.30

1.17.2 ValuJet’s Manuals

The ValuJet QRH, AOM, and COM are required by Federal Aviation Regulations

(FARs) and ValuJet policy to be available to the flightcrew for reference on every flight.

Excerpts from the QRH, AOM, and COM, in addition to those presented below, are contained in

appendix E.

 

30

 According to ValuJet’s winter operations manual, “This publication is in effect whenever required by

cold weather and its contents are ‘Standard Operating Procedures’. Preparation for cold weather will

begin September 1st in order to assure material and support equipment is in place when needed.

Susceptibility normally begins to decrease after April 15th.” Further, the manual states “This reference

applies only to those stations where ValuJet has instituted contracts for deicing of its aircraft and will

eliminate those cities in the most southern portion of the ValuJet route system where a specific winter

procedure is not normally an operational concern.”
23

1.17.2.1 ValuJet’s QRH and AOM

ValuJet’s QRH, which was consulted by the flightcrew, was stamped “FAAapproved,”31 with the POI’s name, and dated September 14, 1995. The QRH contains condensed

guidance for abnormal and emergency procedures.

The instructions in the QRH, on page A-38, under the heading “UNABLE TO

RAISE GEAR LEVER,” subheading “Approach and landing,” state the following:

AIRPLANE..............................................DEPRESSURIZE (PNF)

ANTI-SKID SWITCH (before 30 kts)...........................OFF (PNF)

GROUND CONTROL RELAY C/Bs (if pulled)

 (H20 and J20).................................................RESET (C or FO)

The ValuJet AOM is a two-volume manual that describes the systems and

procedures for the DC-9. Volume 1 contains procedures for normal, emergency, and abnormal

operations; operating limitations; bulletins; flight training; and performance standards/charts.

Volume 2 contains systems descriptions for the DC-9. According to the POI, the AOM is an

“FAA-approved” document.

The instructions listed on pages A-11-2 and A-11-3 of the AOM, under

“UNABLE TO RAISE GEAR LEVER,” “Approach and landing,” state the following:

AIRPLANE..............................................DEPRESSURIZE (PNF)

-- Ensure airplane is depressurized prior to landing.

ANTI-SKID SWITCH (before 30 kts)...........................OFF (PNF)

-- During landing rollout and before 30 kts,

 momentarily release brakes and place Anti-skid

 switch to OFF.

GROUND CONTROL RELAY C/Bs (if pulled)

 (H20 and J20)...................................................RESET (C or FO)

-- Reset Ground Control Relay circuit breakers

 during taxi and verify that circuits are in the

 ground mode.

 

31

 According to the POI, the term “FAA-approved” applied to a document indicates that the FAA has

reviewed the document thoroughly and endorses its contents. The term “FAA-accepted” applied to a

document indicates that the FAA has seen the document and “allows” its use. According to the FAA, the

term “FAA-accepted” does not imply that a thorough review has been accomplished or that the FAA

endorses the contents of the document.
24

The pilots reported that they referred only to the QRH for abnormal procedural

guidance during the flight from Atlanta to Nashville, although the AOM and COM were also

available in the cockpit. The pilots reported that during all simulator training, during initial

operating experience (IOE), and in normal flight operations, ValuJet encouraged them to use the

QRH as their primary source of information for abnormal and emergency procedures. According

to both pilots, although they referred to the AOM during the classroom portion of their initial

training,32 when they transitioned to the simulator portion of the initial training, the only

reference material available to them was the QRH. The first officer stated that when he and his

classmates questioned the absence of the AOM, the Flight Safety International (FSI) simulator

instructors informed them that ValuJet wanted them to use the QRH “like a Bible” for abnormal

procedures. The first officer indicated that he and his classmates stopped their first simulator

session and called the company to get an official determination as to what guidance they should

use for abnormal and emergency procedures during routine flight operations; he stated that

ValuJet management advised them to use the QRH instead of the AOM.

 ValuJet’s chief pilot stated that flightcrews are encouraged to use the QRH as a

handy initial reference manual in the event of an abnormal occurrence but that they are instructed

to then refer to the ValuJet AOM for detailed guidance. On January 8, 1996, the day after the

accident, ValuJet’s director of flight standards and training issued a letter to all ValuJet pilots,

stating the following:

If it becomes necessary to refer to the QRH (Quick Reference Handbook), for

Emergency or Abnormal procedures, please use the appropriate section of the

AOM (Aircraft Operating Manual) in conjunction with the QRH.

On February 22, 1996, ValuJet’s director of flight standards and training issued a

letter to all ValuJet pilots, with reference to first officer approach minimums and QRH removal

from aircraft. According to ValuJet’s chief pilot, the letter was intended to notify the pilots that

the company was raising the first officer approach minimums, removing the QRHs from their

aircraft, and replacing the QRH with a laminated emergency checklist to be used with the AOM.

It stated the following:

Effective immediately, First Officer minimums will be 300’ AGL and 3/4

miles visibility. Additionally, the First Officer minimums in the first 100

hours will be 500’ and 11⁄2 miles visibility.

In the next few days, all of the aircraft should have the new Emergency Check

list on board. If you should encounter an aircraft with the QRH on board,

please...let us know. In this case, remember that the QRH is to be used for

reference only and the Aircraft Operating Manual will have updated

 

32

 Information on ValuJet’s training program is included in section 1.17.3.
25

information. Maintenance in ATL and IAD [have the] Emergency Check List

on hand.

1.17.2.2 ValuJet’s COM

The ValuJet COM is maintained in one binder and contains flight operations

bulletins; information on system operations control, line operations, communication, nonscheduled operations, and reports; aircraft logbook and maintenance procedures; emergency

procedures; weight and balance; and international operations. The COM also contains a portion

of the FAA-approved ValuJet operations specifications and winter operations specifications.

According to the POI, the COM is largely an “FAA-accepted” document; however, the

operations specifications and winter operations sections within the COM are “FAA-approved.”

According to ValuJet, the company expects flightcrews to adhere to the guidance

contained within the company manuals, unless adherence to such guidance would result in the

flightcrew violating the FARs. Page 1-2 of the COM states the following, in part:

The Company Operations Manual is a requirement of Federal Aviation

Regulation 121. Its purpose is to provide guidance to ValuJet personnel in

conducting company operations. The Company Operations Manual contains

only part of the rules and procedures that ValuJet and its employees are

required [emphasis added] to follow. Although this Manual does expand and

clarify many requirements of FAR Part 121 and various other regulations, it

does not, and is not intended to, substitute for the requirements of the FARs or

the contents of the Airman’s Information Manual. (Should a disagreement

arise between the FARs and the Company Operations Manual, the FARs will

always take precedence.)

Additionally, page 1-24 of the COM, under the heading “Duties and

Responsibilities,” subheading “Captain,” states the following, in part:

[The captain shall] Operate his/her aircraft in accordance with all company

directed practices and procedures as well as all applicable rules and

regulations except when, in his/her judgment, it is necessary to deviate from

such procedures to assure continued safety of flight. 

Page 3-17 of the COM, under “CREW MEMBER RESPONSIBILITIES,” with

regard to the first officer flying, states the following:

A captain who has at least 100 hours as P.I.C. [pilot-in-command] in jet

transport aircraft under Part 121 may, at his/her discretion, allow the First

Officer to manipulate the flight controls for takeoffs, approaches and landings

as well as en route phases of flight.
26

The captain, who had 26 hours as a DC-9 captain, told investigators that he was

unaware of the 100-hour limitation listed in the COM. Neither the POI nor ValuJet’s chief pilot

expressed surprise at the fact that the flightcrew failed to abide by COM guidance. In

independent postaccident interviews, both the POI and the chief pilot explained the pilots’

variance from the COM’s 100-hour limitation by citing industry standard operating procedures,

and the pilot’s right to deviate from rules for safety reasons. The POI further stated that the

COM is an FAA-accepted, not FAA-approved, manual.

1.17.2.2.1 In-flight Irregularity Procedures

Page 10-2 of the ValuJet COM, revision 46, under the heading “Reporting,” states

the following, in part:

The Captain shall [emphasis added] report all incidents and/or irregularities to

System Operations by radio or telephone at the earliest opportunity.

On page 10-3, the ValuJet COM further stipulates what pilots should do:

Provide System Operations Control with information concerning the nature

and extent of the malfunction, and its anticipated effect on the management of

the flight.

On page 10-4, the ValuJet COM indicates what dispatcher actions will occur in

response to a reported irregularity:

Systems Operations Control will immediately convene the technical

specialists (maintenance, flight, etc.) who may be of assistance and will relay

to the pilot by radio the recommendations and questions of the technical

group. He/She will then direct activities on the ground to support the course

of action to be undertaken by the pilot.

The ValuJet COM also states that detailed procedures for handling most

mechanical problems are found in the AOM.

1.17.3 ValuJet’s Training Program

FSI provides training to ValuJet pilots in accordance with a syllabus provided by

ValuJet, based on the FAA-approved ValuJet flight operations training manual. Initial pilot

training for ValuJet “new hires” is conducted by FSI at its Airline Learning Center in Miami,

Florida. Subsequent training (e.g., upgrade, recurrent, and CRM) is conducted by FSI at its

Airline Learning Centers in Miami and Atlanta.
27

After the accident, both pilots told investigators that they believed that the training

they received from FSI was deficient, especially in the area of systems. The first officer’s

training records indicate that he underwent six simulator training sessions before he took the DC9 type-rating check ride. The first officer stated that although he successfully completed the

type-rating check ride, he did not believe that six simulator sessions were sufficient to provide

him with a thorough knowledge or understanding of the systems. The captain’s training records

indicate that he underwent 10 simulator training sessions before he took the DC-9 type-rating

check ride. According to FSI personnel, the number of simulator sessions is variable and is

dependent on pilot performance and material coverage.

According to the ValuJet/FSI initial equipment training syllabus,33 the training

program included 13 days of classroom training, 3 days of system integration training in fixedbase simulators, and 6 days of flight training in full-flight simulators. According to the DC-9

initial equipment training syllabus, the classroom modules that addressed the landing gear and

pressurization systems were scheduled for 11⁄2 hours and 3 hours, respectively, and were to be

augmented in system integration and flight training sessions. The lesson plan for the landing

gear module listed the following lesson elements:

1. General description **34

2. Nosewheel steering **

3. Ground shift mechanism

a. Location and purpose

b. Functions

1) Left ground control switch

2) Right ground control switch

c. Ramifications of override

4. Operating limitations **

5. Controls and indicators **

6. Normal procedures **

7. Emergency/Abnormal procedures

a. In-depth coverage of all landing gear-related emergency/abnormal

procedures

Both pilots reported that although they received instruction in “Unable to Raise

Gear Lever” procedures during their initial DC-9 systems simulator training, they did not

continue the procedure beyond landing gear retraction. Neither pilot recalled receiving any

specific instruction about when to reset the ground control relay circuit breakers.

 

33

 Excerpts from the FSI training syllabus are included in appendix E.

34

 Items marked with ** have not been entirely described in the text. The entire lesson plan for the

landing gear module is included in appendix E.
28

According to ValuJet’s chief pilot, FSI has been very responsive to changes and

improvements to the ValuJet training syllabus. FSI and ValuJet personnel reported that since this

accident, the classroom and simulator training regarding “Unable to Raise Gear Lever”

procedures have been enhanced.

1.17.3.1 CRM Training

ValuJet initiated a CRM program in January 1995.35 Pilots who received their

initial training after September 1995 received CRM training with the initial training at the FSI

facility in Miami. Pilots who received their initial training before September 1995 received the

2-day course in CRM at the FSI facility in Atlanta. The first officer of flight 558 received CRM

training with his initial training at FSI in October 1995. Records indicate that the captain of

flight 558 completed the CRM training on April 14, 1995, 8 months before his upgrade to

captain.

According to the POI, ValuJet’s current CRM curriculum does not include

integrated (flightcrew, cabin crew, company, etc.) CRM training or a line operational simulation

(LOS)36 program nor is such training required by FARs.

1.17.4 ValuJet’s Crew Pay Schedule/Criteria

Records indicate that when ValuJet began operations in October 1993, the

company implemented a pay and bonus schedule in which pilots were paid based upon the

number of flight segments flown and received bonus pay at the end of the year based on a share

of the annual company profits. According to the POI, the airline’s pay and bonus schedule has

been controversial since the airline became operational. The POI stated that under the ValuJet

pay schedule in place at the time of the accident, he did not believe that the pilots would have

been compensated for the accident leg of the flight if they had returned to Atlanta rather than

completing the trip to Nashville. However, according to ValuJet’s director of operations and

ValuJet’s chief pilot, the pilots would have received “segment 2”37 pay for the accident leg of the

trip sequence, whether they returned to Atlanta or continued the flight to Nashville. On page 1-

30 of the COM, revision No. 41, under the heading “Compensation,” it states the following:

Flight Operations compensation is based on a segment rate.

 

35

 CRM training was not a required portion of air carrier training programs when ValuJet began its

operation in October 1993. Subsequently, FARs have required Part 121 and 135 air carrier and

commercial operators to provide CRM training for their flightcrews. The CRM training programs must

be incorporated into company training by mid-1997.

36

 LOS is the FAA’s revised terminology for the training that was formerly known as line oriented flight

training (LOFT) and includes special purpose orientation training and line operational evaluation. The

revised definition (FAR Part 142.3) was adopted May 23, 1996, and became effective August 1, 1996.

37

 See excerpt from COM, page 1-30, dated March 15, 1995, under the heading “Compensation,” in

appendix E.
29

Segments will be numbered according to statute mileage length.

*City to City mileages used are those published by the Department of

Transportation, Statute miles, Airport to Airport, Great Circle Route.

Page 1-30 also contains a city to city mileage table for ValuJet’s route structure.38

The table indicates that city to city distances of less than 350 statute miles fall under the

segment 2 pay category. According to ValuJet’s chief pilot, where only one airport identifier is

named under a segment, the mileage listed is from Atlanta to that airport/city. Nashville

International Airport is listed under segment 2. Page 1-30, revision No. 41, dated March 15,

1995, was current at the time of the accident.

The pilots stated that they were not certain whether they would have been

compensated if they had returned to Atlanta, but they indicated that pay was not a factor in their

decisionmaking process. According to the first officer, he had experienced pay discrepancies on

some occasions since he was hired by ValuJet and had successfully negotiated with the company

to receive back pay.

1.18 Additional Information

1.18.1 FAA Oversight

The POI for ValuJet was involved in ValuJet’s certification even before the airline

began operation in October 1993. He was directly involved in FAA approval and acceptance of

ValuJet’s original certification manuals and documents, such as the QRH, AOM, and COM,

including the COM’s winter operations section. The most current revision to the COM winter

operations section at the time of the accident was approved by the POI on November 17, 1995.

Although at the time of the accident he met all FAA qualification and currency requirements for

POI responsibilities,39 he did not meet the FAA’s currency requirements for the DC-9 when he

originally received the ValuJet assignment. Because of this lack of qualification, he referred all

DC-9 system-specific documents and manuals to an FAA inspector who was DC-9 qualified and

current. According to the POI, the other FAA inspector reviewed the original ValuJet QRH

before the POI approved and endorsed it. The applicable FAA Form 8000-3640 indicated that the

ValuJet QRH was approved by the other FAA inspector on October 8, 1993. The FAA form also

indicated that the activity took only 1 hour of the FAA inspector’s time. Records indicate that

subsequent revisions to the QRH were personally reviewed and approved by the POI.

 

38

 See appendix E for excerpts from the COM.

39

 The FAA requires that its POIs be qualified in, and remain current in, at least one of the aircraft types

operated by the operators they oversee. ValuJet operates only Douglas DC-9 aircraft. The POI stated that

it was common to have a more current inspector review an item for approval and that this practice was in

accordance with FAA policy.

40

 A copy of the applicable FAA Form 8000-36 is included in appendix F.
30

The PMI for ValuJet was assigned to his position in December 1994; another

FAA inspector held PMI responsibilities during ValuJet’s original certification and during the

airline’s first year of operation. ValuJet’s original PMI approved the maintenance manual winter

operations section. The PMI at the time of the accident had no experience or familiarity with the

DC-9 aircraft or its systems when he received the responsibility for ValuJet’s certificate;

however, experience in the equipment used by the airline is not an FAA requirement for the PMI

position. The PMI met all FAA qualification requirements for PMI responsibilities when he

received the ValuJet assignment.

During postaccident interviews, the PMI told Safety Board investigators that he

was unaware of the DC-9’s history of problems with underserviced/underinflated nosegear

shock struts causing landing gear and ground shift mechanism anomalies during cold weather.

He further stated that he was unfamiliar with the procedures recommended by Douglas for cold

weather operations and did not have any discussions with ValuJet personnel regarding the

implementation of any cold weather operations procedures. The PMI left the ValuJet certificate

and transferred to the FAA’s Southern Regional Office in late August 1996.

1.18.2 Postaccident FAA/ValuJet Actions

Records indicate that on February 5, 1996, the POI sent a letter to ValuJet’s senior

vice president of operations,41 expressing his concern about recent accidents and incidents42

involving ValuJet flights. The POI wrote that the recent incidents involved flightcrews who were

either new to the air carrier and/or had very little Part 121 experience, and several involved bad

weather. He reported that during his observation of a recent initial training class at FSI in Miami,

he noted that only one pilot in the class had prior Part 121 experience. The POI indicated that

FAA inspectors conducting en route surveillance had found it necessary to counsel captains

during flights to keep them from operating contrary to FARs. The letter continued:

Recent Enroute Surveillance has indicated that due to the rapid expansion of

ValuJet Airlines many of the new Captains have a minimal amount of Part

121 experience. It appears that the Captains are allowing the First Officer to

make the takeoff and/or landing out of response to an unwritten practice of

alternating that function rather than considering the weather and/or their own

need for experience. 

On February 14, 1996, a report summary was prepared by the FAA’s maintenance

aircraft division of the Office of Aviation Flight Standards (AFS-300) as a result of ValuJet’s

accident and incident history and a Department of Transportation (DOT) Office of Inspector

 

41

 Correspondence between the FAA and ValuJet is included in appendix F.

42

 FAA records indicate that from 1994 through September 1996, ValuJet aircraft/flightcrews were

involved in three accidents and nine incidents.
31

General audit of ValuJet.43 The report addressed ValuJet’s accidents and incidents, enforcement

history, national aviation safety inspection program (NASIP) inspection results, and the FAA’s

surveillance activity. The report indicated that ValuJet had a total of 46 violations since 1993, of

which 20 remained open at the time the report was written. The report covered approximately 3

years of data and revealed that, “In all areas analyzed, [ValuJet] was at the advisory and or alert

threshold....”44 The report concluded that the data reviewed “...clearly show some weakness...” in

the FAA’s overall surveillance of ValuJet’s operations, with specific weaknesses noted in the

following areas:

1. Manuals and Procedures....

2. Shop and Facilities....

3. Structural Inspection....

The report recommended the following actions:

1. Consideration should be given to an immediate FAR-121 re-certification

of this airline....

2. The overall surveillance of the air carrier should be increased in FY96.

Special attention should be directed toward manuals and procedures,

structural inspections, the adequacy of the maintenance program, and

shops and facilities....

3. The close out dead line for the NASIP inspection is February 28, 1996.

Every effort should be made to meet this dead line with positive corrective

action.

4. When a violation of the FARs are detected the inspector should consider

past enforcement history before administrative corrective action is offered.

If an air carrier violates the same regulation in a short period of time,

escalating the enforcement action may be appropriate.

On February 16, 1996, the FAA’s Atlanta FSDO issued a letter that announced the

initiation of a special emphasis program at ValuJet to positively identify areas of concern and the

 

43

 This report is included in appendix F.

44

 According to AFS personnel, the terms “advisory” and “alert” are evaluative terms used to describe air

carrier noncompliance with (or potential for deviation from) published safety requirements and

standards, based on data retrieved from the FAA’s Safety Performance Analysis System. “Advisory” and

“alert” correspond to mid- and low-level compliance, respectively. The approximate formula for “large

Part 121 air carrier groups” is as follows:

A = the average number of reported instances of air carrier noncompliance with (or

potential for deviation from) published safety requirements and standards.

1 x A = “advisory”

1.5 x A = “alert”
32

corrective actions necessary to reduce or eliminate the problem areas. The letter stated the

following:

ValuJet is an unconventional carrier when compared to more traditional 121

operators. They are innovators, dedicated to low overhead, leasing rather than

owning, and tightly controlling all expenses. The tight control of expenses

includes training (pilot pays), equipment purchases (used), and maintenance

(all contracted out to geographically diverse low bidders.)

According to the letter, the program would consist of the following four elements:

♦ Supplementing the existing FAA employee assignment to ValuJet.

♦ Special seven day systems (operational observation) review.

♦ Analysis of data collected in more than 375 inspections of all types, over a

period of two years.

♦ Identify and implement corrective actions.

The 120-day special emphasis program was initiated on February 22, 1996. On

February 27, 1996, the POI sent another letter to ValuJet’s senior vice president of operations,

which stated the following, in part:

In the two and a half years that ValuJet Airlines, Inc. has been certificated, the

Federal Aviation Administration has conducted one (1) RASIP and one (1)

NASIP inspection. Additionally, the Department of Defense has conducted

two inspections. None of these inspections have produced any Findings that

would tend to explain the number of recent accidents and incidents that have

occurred.

In an effort to uncover any uncommon denominator that might have been

present in each incident, this office launched a Special Emphasis Program on

February 22, 1996 in which we stepped up FAA surveillance throughout your

route structure. It is still very early in our program and although we are not

prepared to announce any trends at this time based on our surveillance, we

have become aware of certain factors that were present in many case’s that

could have had some influence on the Captains judgment.

The POI’s letter also expressed concern about ValuJet’s pay and bonus policies in

effect during the first few years of the airline’s operations. He indicated that the FAA was

concerned that pay considerations might have influenced the pilots’ decisions with regard to the

safe operation of their flights. The POI requested that ValuJet review its pay policies and

determine to what extent, if at all, the pay policies were affecting the safety of its flights. The

POI also requested a copy of the ValuJet pilot compensation program.

On March 15, 1996, the Atlanta FSDO issued a document that indicated that the

preliminary results of the special emphasis program revealed discrepancies in maintenance
33

inspection programs, MEL management, decisionmaking by cockpit crews, aircrew abnormal

checklist training, and gate agent training. The document also recognized that many corrective

actions had already been implemented by ValuJet, such as the following:

♦ ValuJet hired an Operations Manager to oversee the Dispatch Office.

♦ ValuJet implemented an in-house self audit program under the direction of

ValuJet’s Director of Safety.

♦ ValuJet initiated a standard practice manual system.

The document noted several actions taken by ValuJet as a result of the special

emphasis program. In the operational area, these actions included:

♦ Signed an updated contract for a Cockpit Resource Management Program to

be taught by Flight Safety International. This class was originally to be given

only to new hires, but has now been escalated to encompass all pilots. All will

have been trained by May 15, 1996.

♦ They have started holding Captain’s Seminars. An 8 hour course that will be

given to all upgrading Captains. This will be a retroactive course that will

include all current ValuJet Captains. Training of the latter group should be

completed by June 1, 1996.

♦ First Officer Minimums have been raised to 500’ agl and 1 mile for the first

250 hours at ValuJet. All current First Officers have been increased to 300’

agl and 3/4 miles.

♦ Restrictions have been implemented requiring Captains to make all landings

on

 a. runways of 7,500 feet or less

b. contaminated runways when braking action is reported as less than

good

c. when ice or slush is on the runway

d. during heavy rain

e. when there is any snow accumulation

♦ Implemented double the FAR requirement for minimum time for crew pairing

of new pilots with new Captains.

♦ Beginning on March 10, 1996, three of Flight Safety International’s most

experienced check airmen will conduct comprehensive line checks of

[ValuJet] pilots and flight operations over a 10 day period.

♦ Established a monthly Safety Review, to be published by the Check Airmen’s

Department, covering all incidents involving DC-9’s, as well as any related

incidents or accidents.

♦ Established a monthly publication of a Standards letter from the Check

Airmen’s Department that will include a review of specific procedures and

questions about the DC-9.
34

The document also listed numerous maintenance-related changes implemented by

ValuJet as a result of the special emphasis program’s preliminary findings. 45

After the crash of ValuJet flight 592 in the Florida Everglades on May 10, 1996,

the FAA increased its surveillance of ValuJet. On June 17, 1996, ValuJet suspended revenue

flight operations. On June 18, 1996, ValuJet agreed to surrender its operating certificate to the

FAA and signed a consent order with the FAA stipulating that the FAA would retain ValuJet’s

operating certificate “until such time as the FAA determines that ValuJet is qualified and capable

of exercising the privileges of the holder of an Air Carrier Operating Certificate.”

On August 29, 1996, the FAA returned ValuJet’s air carrier operating certificate,

permitting the company to resume operations if the airline is found to be managerially and

financially fit by the DOT. According to the FAA, ValuJet had 51 aircraft in operation when it

ceased operations in June 1996. On September 30, 1996, ValuJet resumed operations.

 

45

 ValuJet’s actions are listed in full in appendix F.
35

2. ANALYSIS

2.1 General

The flightcrew was certificated, trained and qualified for the flight, and in

compliance with the Federal regulations on flight and duty time. The flight attendants had

completed ValuJet’s FAA-approved flight attendant training program. The airplane was properly

certificated and operated in accordance with applicable Federal regulations. VMC prevailed at

the time of the accident; however, cold weather/winter conditions existed at the time of the

accident.

During their departure from Atlanta, the pilots experienced difficulty raising the

landing gear and had to manually bypass the landing gear anti-retraction system before they could

successfully retract the landing gear. As they continued the climb, the pilots realized that

although the airplane was airborne, the cabin pressurization and takeoff warning systems were

still operating in the ground mode. In accordance with the guidance contained in the QRH, the

pilots pulled the ground control relay circuit breakers and observed that the airplane’s

pressurization and takeoff warning systems began to operate in the flight mode. Because of the

irregularities encountered by the pilots, and because postaccident examination and testing of the

nosegear and its systems revealed no evidence of preimpact mechanical anomaly, the Safety

Board concludes that the nosegear shock strut extension during the initial climbout was

insufficient to actuate the ground shift mechanism, release the landing gear lever anti-retraction

mechanism, and shift the airplanes systems to the flight mode.

It is likely that the nosegear shock strut did not extend far enough to actuate the

ground shift mechanism because it was underserviced/underinflated for the cold/winter weather

conditions. The en route portion of the flight proceeded uneventfully. When the airplane was

about 100 feet above the ground during the approach to Nashville, the pilots reset the ground

control relay circuit breakers, thereby unintentionally shifting the airplane systems from the flight

mode to the ground mode. The ground spoilers subsequently extended in flight, and the airplane

descended suddenly, impacting the ground in the runway approach light area.

2.2 Cold Weather/Winter Flight Operations

During his preflight inspection of the DC-9, the captain of flight 558 observed that

the nosegear shock strut appeared to have normal extension. However, according to Douglas

representatives, visual inspection for proper nosegear strut extension by flightcrew members

cannot be relied upon to detect underserviced/underinflated nosegear struts. The Safety Board

concludes that such preflight visual inspections by flightcrews cannot be relied upon to detect

underserviced/underinflated DC-9 nosegear struts and that more frequent and detailed

maintenance inspections of the DC-9 nosegear shock strut should be included in cold weather

maintenance procedures.

The Safety Board notes that numerous airlines follow specific maintenance

procedures for cold weather protection and servicing of the nose landing gear, typically following
36

the additional cold weather servicing practices recommended in the DC-9 maintenance manual.

However, ValuJet’s maintenance manual had not been revised or amended in accordance with

the manufacturer’s recommended cold weather nosegear servicing procedures. Although

ValuJet’s route structure involved primarily southern locations that do not normally experience

severe cold weather, ValuJet does operate its airplanes in areas where they can be exposed to

cold weather conditions. The scope and range of jet travel and the unpredictable nature of

weather systems are such that no airline operating in the continental United States can safely

consider its aircraft exempt from any such weather extremes. The Safety Board concludes that

ValuJet Airlines and the FAA should have recognized the possibility of airplanes being exposed

to cold weather conditions and the potential nosegear problems from such exposure, and ValuJet

should have developed cold weather nosegear servicing procedures similar to those in the DC-9

maintenance manual to address these problems.

Accordingly, the Safety Board believes that ValuJet should develop, immediately,

a more extensive and accurate winter operations manual, with corresponding adjustments to

maintenance procedures, to reflect the manufacturer’s cold weather nosegear servicing

procedures. Further, because no airline is exempt from encountering a range of weather

extremes, the Safety Board believes that the FAA should require all airlines to review their

operations and maintenance manuals and, if necessary, adjust or expand these manuals to reflect

the manufacturer’s recommended cold weather nosegear servicing procedures.

2.3 Flightcrew Actions/Decisionmaking

The Safety Board is concerned that several times during the accident trip

sequence, the flightcrew did not adhere to FAA-accepted ValuJet COM guidance. The Safety

Board identified at least three instances during which company procedures clearly were not

followed.

The first instance occurred when the first officer flew the second leg and planned

to fly the third leg of the trip. Although according to the COM, a captain may allow the first

officer to fly the airplane when the captain has at least 100 hours as PIC in jet transport aircraft

under Part 121, at the time of the accident, the captain of flight 558 had only 26 hours as PIC.

Therefore, the captain was not authorized under the COM to allow the first officer to fly the

airplane. The captain told investigators that he was not familiar with the section of the COM

that indicated that he was not supposed to share flying duties with the first officer.

The Safety Board notes that the first officer appeared to be competent and capable

of pilot flying duties, and the weather, although marginal VMC, was above first officer approach

minimums. The Safety Board concludes that although the first officer’s performing pilot flying

duties did not jeopardize the safety of the flight, the captain’s decision to allow the first officer to

act as the flying pilot indicates a lack of awareness and/or regard for the guidelines contained

within the ValuJet COM.

The second instance during which company procedures were not followed was

when the pilots did not notify ValuJet system operations/dispatch that they were unable to raise
37

the landing gear without pushing the landing gear handle release button. Also, they did not

report that they needed to disengage the ground control relay circuit breakers to put the airplane

in flight mode.

The Safety Board concludes that had the pilots adhered to COM procedures and

notified system operations/dispatch of the landing gear irregularity during their departure from

Atlanta, they would probably have received sufficient maintenance advice and guidance from

technical specialists to land uneventfully at either Atlanta or Nashville. According to ValuJet’s

chief pilot, if the pilots had informed system operations/dispatch of the anomaly during their

departure from Atlanta, they probably would have been advised to return to Atlanta to have

company maintenance personnel examine the airplane. The chief pilot indicated that in their

advisory capacity, dispatch and maintenance personnel would have reviewed the appropriate

landing procedures with the flightcrew before they returned to land.

Finally, the flightcrew used only the QRH, without referring to the AOM, to

determine how to address the anomalies that arose. Page A-38 of the QRH lists resetting the

ground control relay circuit breakers under the heading “Approach and landing,” and although

the preceding checklist item, “ANTI-SKID SWITCH (before 30 kts),” is clearly an after-landing

item, the QRH does not include the specific instructions to reset the ground control relay circuit

breakers after landing/during taxi. Thus, had the pilots consulted the AOM for more detailed

guidance, they might have recognized that they should not reset the ground control relay circuit

breakers until after the airplane was on the ground, and the accident might not have occurred.

However, the Safety Board concludes that there was adequate information available on page A38 of the QRH for the flight to have landed uneventfully at Nashville.

The pilots indicated that although it was unwritten, they believed that ValuJet

management had encouraged them to consider the QRH their primary reference source for

abnormal procedures. The use of “unwritten” procedures, combined with a failure to hold

personnel accountable for following published guidance, can erode the importance, and

concomitantly, the value, of the existing guidance. The Safety Board concludes that the

flightcrew’s decisions and actions in this case demonstrate insufficient concern for adherence to

and a lack of company guidance about the guidelines and procedures set forth in the FAAaccepted ValuJet COM and the FAA-approved ValuJet AOM.

The Safety Board is also concerned that neither the POI nor ValuJet’s chief pilot

seemed concerned that the flightcrew failed to abide by COM guidance. Therefore, the Safety

Board believes that the FAA should stress the importance of adherence to the rules, structure, and

guidelines within the revised ValuJet COM to ValuJet management and its employees, to FSI (or

other contracted training organizations used by ValuJet), and to the individuals responsible for

the oversight of ValuJet.

The flightcrew encountered several airplane system anomalies shortly after

departure from Atlanta. Once the airplane was safely airborne and en route from Atlanta to

Nashville, the pilots had sufficient time under relatively low stress and access to adequate

resources to make informed, thoughtful decisions about how to proceed. Had the pilots felt that
38

they needed more time and/or information, they could have requested ATC clearance to enter a

holding pattern while they consulted additional resources. However, the pilots’ statements and

actions indicated that they did not perceive a need for additional time or information to decide

how to deal with the anomalies.

The Safety Board concludes that although the pilots had sufficient time to assess

their circumstances, seek assistance from other resources, review the options available to them,

and make a thoughtful decision, the pilots’ decisions, procedures, and actions resulted in the

inadvertent in-flight activation of the ground spoilers while the airplane was on short final

approach for the runway. The Safety Board determines that the flightcrew’s improper decisions,

procedures, and actions were directly causal to the accident.

2.4 ValuJet’s Training Program

The pilots told Safety Board investigators that they believed that the training they

received from FSI was deficient, especially in the area of aircraft systems. In fact, although both

pilots had recently completed ValuJet/FSI training in the DC-9 and its systems, the pilots

demonstrated that they did not have adequate knowledge or understanding of DC-9-32 systems to

properly diagnose and respond to the abnormal situation when they reset the ground control relay

circuit breakers on short final approach to the runway.

In an attempt to determine whether there were identifiable deficiencies in the

ValuJet/FSI training program, Safety Board investigators examined the FAA-approved ValuJet

flight operations training manual and the FSI ValuJet DC-9 initial equipment training syllabus.

Although the Safety Board did not find any specific discrepancies in the FSI training syllabus, the

syllabus was very general and did not go into detailed description of the material to be covered

by FSI instructors. One possible consequence of the lack of detailed guidance for FSI instructors

to follow is inconsistent application of the existing guidance by FSI instructors. However, as

mentioned previously, according to ValuJet and FSI personnel, ValuJet and FSI have since

revised and improved the training syllabus in response to perceived deficiencies.

The Safety Board also observes that the training syllabus did not contain written

guidance about the ValuJet manuals or other reference materials to be used by FSI instructors in

support of the lesson plans. Again, the pilots of flight 558 used the AOM as the sole reference

manual during their classroom training and then were told that the QRH should be used instead

of the AOM when they transitioned from the classroom to the simulator. The Safety Board notes

that the AOM and QRH were never used at the same time in the training environment, which had

the unfortunate effect of reducing the opportunity for comparison of the instructions contained in

the manuals. Had the manuals been used side by side in classroom training, it might have been

clearer to the pilots that the ground control relay circuit breakers should have been reset after

landing.

The Safety Board concludes that ValuJet’s pilot training, as performed by FSI,

conformed with the FAA’s requirements. However, the Safety Board concludes that the pilots’

actions and statements illustrate that their knowledge or understanding of the aircraft systems and
39

the effects those systems have on each other was inadequate. Although the Safety Board

recognizes and commends ValuJet’s efforts to revise and improve the pilot training syllabus used

by FSI, the Safety Board believes that the FAA should reevaluate ValuJet’s flight operations

training manual and the ValuJet training syllabus used by FSI, and require ValuJet to revise or

expand these documents to include more detailed descriptions and explanation of the DC-9

systems and procedures.

2.4.1 Crew Resource Management Training

 The Safety Board notes that ValuJet initiated a 2-day CRM training course in

January 1995 and that both the captain and first officer of flight 558 had completed this training.

The Safety Board is concerned that the ValuJet CRM course may have only provided an

overview of cockpit resource management, without thoroughly teaching the concept of total,

integrated crew resource management. Pilots who possess an operational awareness of

integrated crew resource management practices would likely understand the value of

communicating with operations/dispatch and flight attendants, and of accessing the more detailed

procedural and systems information available to them in the AOM.

Although the pilots did not brief the flight attendants about the irregularity and its

possible ramifications during the go-around, the pilots indicated that the omission was the result

of the limited time available to them during the go-around. Records indicate that the pilots had

approximately 6 minutes between the hard landing on runway 2R and their touchdown on

runway 31. According to the CVR transcript, approximately 15 seconds before the airplane

touched down on runway 31, the first officer stated “...[we] should’ve braced them in the back.”

The flightcrew’s failure to discuss the irregularity and its possible ramifications with the flight

attendants is further evidence of insufficient adherence to the accepted principles of crew

resource management training.

Although the direct communication and coordination between the captain and first

officer were not an issue in this accident, the Safety Board concludes that the pilots’ failure to

communicate with and utilize some of the other resources available to them (such as the more

detailed written procedural guidance located in the AOM, or in-flight maintenance advice

through ValuJet system operations/dispatch in Atlanta or from contract maintenance personnel in

Nashville) raises questions about the effectiveness of the CRM training provided. Therefore, the

Safety Board believes that ValuJet should clarify for all flightcrews the importance of referencing

all available crew reference documents and consulting with company maintenance personnel

(time permitting) to resolve in-flight abnormalities before committing a flight to landing.

Further, the Safety Board believes that the FAA should require ValuJet to revise

its CRM training curriculum to more clearly reflect modern integrated (flightcrew, cabin crew,

company, etc.) CRM practices (including LOS training) and to combine academic/classroom

training with integrated practical crew simulations.

2.5 ValuJet Pay Schedule
40

During its investigation, the Safety Board received conflicting information about

ValuJet’s pay and bonus schedule. The Safety Board questioned whether the pay and bonus

schedule in use by ValuJet at the time of this accident (on page 1-30 of ValuJet’s COM, dated

March 15, 1995) was a factor in the flightcrew’s decision to continue the flight to its destination,

rather than return to Atlanta after the irregularity. Although the information indicated the basis

for ValuJet’s pilot pay schedule, the COM did not define ValuJet’s application of the pay policy

in the event that a scheduled flight did not reach its intended destination.

Also, the Safety Board is concerned that the individuals interviewed about the pay

schedule held dissimilar views about how the ValuJet pay schedule would have been applied had

the flightcrew elected to return to Atlanta after the irregularity. However, the Safety Board notes

that the documentation it reviewed after the January 7, 1996, accident had not been revised or

changed since March 15, 1995. The change bar on page 1-30 indicates that the change(s)

effected on March 15, 1995, pertained to route structure/city to city mileage. The Safety Board

concludes that ValuJet’s pay schedule was fairly constant in the months preceding the accident.

The Safety Board notes that ValuJet’s pay and bonus schedule has evolved as a

result of adjustments to ValuJet’s route structure and employee feedback, as well as in response

to recent incidents and accidents. According to an August 14, 1996, letter from ValuJet’s vice

president and project manager to the FAA Atlanta FSDO, the most recent revised ValuJet pay

and bonus schedule reflects increased segment pay rates for first- and second-year captains and

first officers, with decreased eligibility for, and reliance upon, annual bonus pay. The Safety

Board recognizes and supports ValuJet’s efforts to provide an improved pay and bonus schedule

for its employees.

2.6 Communications

The pilots indicated that all communication and navigation radios functioned

normally throughout the flight from Atlanta to Nashville; the first anomaly was noted during the

go-around procedure after the airplane touched down hard in the approach light area short of

runway 2R. During the go-around, the pilots noted that the No. 1 (captain’s) communication

radio and the No. 2 (first officer’s) communication and navigation radios were unusable.

Postaccident examination of the aircraft revealed that the No. 1 communication

radio was unusable because the No. 1 communication radio on/off switch was positioned in an

intermediate (unpowered) position. The pilots stated that they did not intentionally place the

No. 1 communication radio switch in the intermediate (unpowered) position nor did they recall

bumping the No. 1 communication radio switch. However, the Safety Board notes that the No. 1

communication radio switch, which is located on the left (captain’s) side of the control pedestal

between the two pilots, might have been inadvertently and unknowingly bumped by either

flightcrew member during the initial ground impact at Nashville or during their performance of

subsequent go-around procedures.

Additionally, postaccident examination revealed that the right DC bus reverse

current relay, which provides power to the No. 2 communication and navigation radios, was
41

“open.” The right DC reverse current relay is mounted on the inside of the aft wall of the nose

wheel well and is not accessible from the cockpit during flight. The Safety Board notes that

during the initial ground impact, the nose landing gear struck the ground with enough force to

separate the nosewheel assemblies from the nosegear strut. It is likely that either the force of the

initial ground impact or an impact of the nose wheel assembly/debris against portions of the

nose wheel well resulted in the “opening” of the right DC reverse current relay.

The Safety Board concludes that there were no preexisting (preimpact)

communication/navigation radio anomalies; rather, the radio difficulties that the flightcrew

encountered during the go-around were, directly or indirectly, the result of the airplane’s impact

with the ground in the approach light area short of runway 2R.

2.7 CVR Issues

The investigation of this accident was complicated by the fact that the 30-minute

closed loop CVR tape did not include documentation of the initial approach to runway 2R, the

hard landing event, or the go-around. Although the flightcrew’s statements and recollections

were detailed and clear, information pertinent to the investigation was unrecoverable because of

the 30-minute tape duration. The Safety Board concludes that had the flightcrew turned off

power to the CVR after the airplane was safely stopped on the ground, investigators would have

had access to valuable documentation of the hard landing and the events leading up to it.

Therefore, the Safety Board believes that the FAA should require all airlines to revise their

procedures to stipulate that flightcrews turn off power to the CVR as part of the engine shutdown

procedure in the event of a reportable incident/accident.

Over the years, the Safety Board has investigated several accidents and incidents

in which pertinent CVR information has been overwritten and lost because of the 30-minute

recording limitation. The Safety Board has recognized the advantages of an extended duration

CVR in certain accidents and especially in incidents. On March 6, 1995, as a result of the

investigation of the Continental Airlines flight 795 accident at LaGuardia Airport on March 2,

1994,46 the Safety Board issued the following safety recommendation to the FAA:

Require, after December 31, 1995, that all newly manufactured cockpit voice

recorders intended for use on airplanes have a minimum recording duration of

2 hours. (A-95-23)

Because the FAA responded that it would address this issue in upcoming

rulemaking, the Safety Board classified this recommendation “Open—Acceptable Response” in

May 1996. As a result of a new recommendation being made in this report, Safety

Recommendation A-95-23 is now classified “Closed—Unacceptable Action/Superseded.”

 

46

 For more detailed information, read Aircraft Accident Report—“Runway Overrun Following Rejected

Takeoff, Continental Airlines Flight 795, McDonnell Douglas MD-82, N18835, LaGuardia Airport,

Flushing, New York, March 2, 1994” (NTSB/AAR-95/01)
42

The Safety Board further concludes that the 30-minute closed loop CVR tape on

board the accident airplane was of inadequate duration to be helpful in the investigation of this

accident, because pertinent impact-related audio information and conversation had been recorded

over and was unrecoverable. Therefore, the Safety Board believes that the FAA should require

that all newly manufactured CVRs intended for use on airplanes have a minimum recording

duration of 2 hours.

2.8 ValuJet Actions/FAA Oversight

The Safety Board notes that there was no indication that the POI recognized that

the manner in which FSI and ValuJet used the ValuJet manuals and handbooks during pilot

training was potentially confusing to the pilots. Although documentation indicates that the POI

occasionally sat in on portions of the FSI/ValuJet ground school, there is no evidence that he ever

audited the entire training class. Additionally, the POI and the original PMI approved the winter

operations portions of ValuJet’s COM and maintenance manual, respectively, when neither

document included cold weather/winter servicing procedures for the nosegear shock strut. The

Safety Board concludes that the FAA’s oversight of ValuJet’s procedures and operations was

inadequate.

The Safety Board notes that according to FAA records, ValuJet made numerous

changes in its training, flight operations, pay and bonus schedule, and maintenance practices,

with increasing frequency and focus on these issues in the months between this accident and the

crash of flight 592. The Safety Board recognizes that the FAA and ValuJet appeared to be trying

to identify the problem areas in the airline and make changes to improve safety in ValuJet’s

operations when flight 592 crashed in the Florida Everglades. The Safety Board will further

analyze and make conclusions with regard to ValuJet’s actions and the FAA’s oversight of

ValuJet, and develop recommendations, as needed, in its report on the flight 592 accident.
43

3. CONCLUSIONS

3.1 Findings

1. The flightcrew was certificated, trained and qualified for the flight, and in

compliance with the Federal regulations on flight and duty time.

2. The airplane was properly certificated and operated in accordance with

applicable Federal regulations.

3. The nosegear shock strut extension during the initial climbout was insufficient

to actuate the ground shift mechanism, shift the airplane systems to the flight mode, and release

the gear lever anti-retraction mechanism.

4. Preflight visual inspections by flightcrews cannot be relied upon to detect

underserviced/underinflated DC-9 nosegear struts, and more frequent and detailed maintenance

inspections of the DC-9 nosegear shock strut should be included in cold weather maintenance

procedures.

5. ValuJet Airlines and the Federal Aviation Administration should have

recognized the possibility of airplanes being exposed to cold weather conditions and the potential

nosegear problems from such exposure, and ValuJet should have developed cold weather

nosegear servicing procedures similar to those in the DC-9 maintenance manual to address these

problems.

6. Although the first officer’s performing pilot flying duties did not jeopardize

the safety of the flight, the captain’s decision to allow the first officer to act as the flying pilot

indicates a lack of awareness and/or regard for the guidelines contained within the ValuJet

company operating manual.

7. Had the pilots adhered to ValuJet’s company operating manual procedures and

notified system operations/dispatch of the landing gear irregularity during their departure from

Atlanta, they would probably have received sufficient maintenance advice and guidance from

technical specialists to land uneventfully at either Atlanta or Nashville.

8. There was adequate information available on page A-38 of the quick reference

handbook for the flight to have landed uneventfully at Nashville

9. The flightcrew’s decisions and actions in this case demonstrate insufficient

concern for adherence to and a lack of company guidance about the guidelines and procedures set

forth in the Federal Aviation Administration (FAA)-accepted ValuJet company operating manual

and the FAA-approved ValuJet aircraft operating manual.
44

10. Although the pilots had sufficient time to assess their circumstances, seek

assistance from other resources, review the options available to them, and make a thoughtful

decision, the pilots’ decisions, procedures, and actions resulted in the inadvertent in-flight

activation of the ground spoilers while the airplane was on short final approach for the runway.

11. ValuJet’s pilot training, as performed by FSI, conformed with the FAA’s

requirements.

12. The pilots’ actions and statements illustrate that their knowledge and

understanding of the aircraft systems and the effects those systems have on each other were

inadequate.

13. The pilots’ failure to communicate with and utilize some of the other

resources available to them (such as the more detailed written procedural guidance located in the

aircraft operating manual, or in-flight maintenance advice through ValuJet system

operations/dispatch in Atlanta or from contract maintenance personnel in Nashville) raises

questions about the effectiveness of the crew resource management training provided.

14. ValuJet’s pay schedule was fairly constant in the months preceding the

accident.

15. There were no preexisting (preimpact) communication/navigation radio

anomalies; rather, the radio difficulties that the flightcrew encountered during the go-around

were, directly or indirectly, the result of the airplane’s impact with the ground in the approach

light area short of runway 2R

16. Had the flightcrew turned off power to the cockpit voice recorder after the

airplane was safely stopped on the ground, investigators would have had access to valuable

documentation of the hard landing, and the events leading up to it.

17. The 30-minute closed loop cockpit voice recorder tape on board the accident

airplane was of inadequate duration to be helpful in the investigation of this accident, because

pertinent impact-related audio information and conversation had been recorded over and was

unrecoverable.

18. The FAA’s oversight of ValuJet’s procedures and operations was inadequate.

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of

this accident was the flightcrew’s improper procedures and actions (failing to contact system

operations/dispatch, failing to use all available aircraft and company manuals, and prematurely

resetting the ground control relay circuit breakers) in response to an in-flight abnormality, which

resulted in the inadvertent in-flight activation of the ground spoilers during the final approach to
45

landing and the airplane’s subsequent increased descent rate and excessively hard ground impact

in the runway approach light area.

Contributing factors in the accident were ValuJet’s failure to incorporate cold

weather nosegear servicing procedures in its operations and maintenance manuals, the

incomplete procedural guidance contained in the ValuJet quick reference handbook, and the

flightcrew’s inadequate knowledge and understanding of the aircraft systems.
46

4. RECOMMENDATIONS

As a result of the investigation of this accident, the National Transportation Safety

Board makes the following recommendations:

--to the Federal Aviation Administration:

Require all airlines to review their operations and maintenance

manuals and, if necessary, adjust or expand these manuals to reflect the

manufacturer’s recommended cold weather nosegear servicing

procedures. (A-96-166)

Stress the importance of adherence to the rules, structure, and

guidelines within the revised ValuJet company operating manual to

ValuJet management and its employees, to Flight Safety International

(or other contracted training organizations used by ValuJet), and to the

individuals responsible for the oversight of ValuJet. (A-96-167)

Reevaluate ValuJet’s flight operations training manual and the ValuJet

training syllabus used by Flight Safety International, and require

ValuJet to revise or expand these documents to include more detailed

descriptions and explanation of the Douglas DC-9 systems and

procedures. (A-96-168)

Require ValuJet to revise its crew resource management (CRM)

training curriculum to more clearly reflect modern integrated

(flightcrew, cabin crew, company, etc.) CRM practices (including line

operational simulation training) and to combine academic/classroom

training with integrated practical crew simulations. (A-96-169)

Require all airlines to revise their procedures to stipulate that

flightcrews turn off power to the cockpit voice recorder as part of the

engine shutdown procedure in the event of a reportable

incident/accident. (A-96-170)

Require that all newly manufactured cockpit voice recorders intended

for use on airplanes have a minimum recording duration of 2 hours.

(A-96-171)

--to ValuJet Airlines :

Develop, immediately, a more extensive and accurate winter

operations manual, with corresponding adjustments to maintenance

procedures, to reflect the manufacturer’s cold weather nosegear

servicing procedures. (A-96-172)
47

Clarify for all flightcrews the importance of referencing all available

crew reference documents and consulting with company maintenance

personnel (time permitting) to resolve in-flight abnormalities before

committing a flight to landing. (A-96-173)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK

Member

December 11, 1996
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5. APPENDIXES

APPENDIX A - INVESTIGATION AND HEARING

1. Investigation

The National Transportation Safety Board was initially notified of this accident

about 1745 on January 7, 1996, by the Federal Aviation Administration’s Southern Region

Communication Center. One investigator from the Safety Board’s Southeast Regional Office

was immediately dispatched to the scene, and CVR and FDR specialists assisted in the

investigation.

Parties to the investigation were the FAA, ValuJet, and the Douglas Aircraft

Company.

2. Public Hearing

No public hearing was held in connection with this accident.
50

APPENDIX B - COCKPIT VOICE RECORDER TRANSCRIPT
51

Transcript of a Fairchild A100A cockpit voice recorder (CVR), s/n 57863,

installed on a DC9-32, N922VV, which was involved in an accident in Nashville,

TN, on January 7, 1996.

LEGEND

CAM Cockpit area microphone voice or sound source

-1 Voice (or position) identified as Captain

-2 Voice (or position) identified as First Officer

-3 Voice identified as Nashville Airport ground personnel

-4 Voice identified as first Flight Attendant

-5 Voice identified as Nashville Airport ground personnel

-6 Voice identified as passenger

-7 Voice identified as passenger

-8 Voice identified as passenger

-? Voice unidentified

PA Aircraft public address system

* Unintelligible word

# Expletive deleted

( ) Questionable text

[ ] Editorial insertion

- Break in continuity
52

On April 26, the first officer made the following comments concerning the

transcript:

1) At 1:06, replace "* *" with "flaps".

2) At 1:20, replace "*" with "sorry".

3) At 2:06, replace CAM-? With CAM-2 and "(idle)" with "manual", respectively.

4) At 2:28, replace CAM-? With CAM-2 and "(braking)?" with "is it braking?",

respectively.

5) At 3:04, replace CAM-2 with CAM-1

6) At 4:20, replace "* * *" with "before you set down".

7) At 5:00, replace CAM with CAM-2.

8) At 6;23, replace CAM-? With CAM-1.

9) At 17:31, replace "wonder what" with "do you want" and "* *" with "an",

respectively.

10) At 18:26, replace "* *" with "ah".

11) At 25:29, replace CAM-? With CAM-2.

12) At 26:50, replace "* * *" with "rolled the".
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0000:00[start of recording]0000:00[start of transcript]0000:02CAM-2 okay we got three green ... okay three zero, that's three

zero over there.

0000:09CAM-2 stand by twenty-five flaps.0000:12CAM-2 do not arm the spoilers.0000:22CAM-2 we (could have) blown tires and everything right now.0000:25CAM-2 see it?0000:25CAM-1 yeah.0000:26CAM-2 let's turn right (in) and go in and land.0000:30CAM-2 this is eleven thousand feet.

0000:40RDO-2 nashville tower critter five (twenty-ei

0000:47CAM-2 there it is right there.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0000:48CAM-1 I see it.0000:48CAM-2 stand by twenty-five.0000:49CAM-1 flaps twenty-five.0000:50CAM [sound of click]0000:52CAM-2 * * * down the runway.0000:58CAM-2 stand by full flaps.0001:00CAM [sound of GPWS - "Glide slope"]0001:02CAM-2 don't worry about that.0001:04CAM-2 stand by full flaps.0001:06CAM-2 *.0001:06CAM-1 * * fifty.0001:07CAM [sound of click]
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0001:08CAM-2 all right landing checks.0001:11CAM-2 watch your V speed one twenty-four * down ... gotta get it

on the runway.

0001:17CAM-2 skid is on.0001:20CAM-2 * before landing, no smoking signals, ignition .. switching,

gear is three green, flaps are four fifty, spoilers are forwardand de-act ... there's the crash trucks.

0001:45CAM-2 a little high.0001:48CAM-2 this is (a little more) runway ... should've braced them in the

back.

0001:54CAM-2 I think we'll be all right .. get it on the runway and stop with

reversers.

0002:03CAM [sound of thump, similar to that of touchdown]0002:06CAM-? (idle).0002:07CAM [sound of momentary grind]0002:08CAM [sound of grinding starts]
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0002:11CAM-? *.0002:28CAM-? (braking)?0002:30CAM-? yeah.0002:53CAM-2 okay reversers.0003:00CAM [sound of grinding stops]0003:01CAM-2 good it's over.0003:02CAM [sound of passenger cabin applause]0003:04CAM-2 #.0003:07CAM-? [sound of exhale]0003:08CAM-2 engine shutdown.0003:09CAM-1 yeah shut 'em.0003:10CAM-2 be prepared to abandon the airplane.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0003:13CAM-1 whoo wee.0003:15CAM-2 after landing.0003:16PA-3 ladies and gentlemen please remain seated with your seat

belts securely fastened ... please do not remove your seatbelts.

0003:18CAM-2 anti-skid .. off.. flaps and slats.0003:22CAM-1 (what is this?)0003:23CAM-2 do you wanna pick them up?0003:24CAM-1 yeah.0003:24CAM-2 we're sitting mighty low, we must have blown all the tires.0003:25PA-3 ladies and gentleman please do not remove your seat belts.

please stay seated with your seat belts securely fastened.

0003:32PA-1 ladies and gentlemen we had a ah flight control malfunction

... we've been able to get the aircraft on the ground andstop here on the runway.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0003:38CAM-2 please be seated.0003:38PA-1 please be seated.0003:46CAM-2 let's see we got the APU up and running .. let's go ahead

and shut the engine down ... what do you think?

0003:50CAM-1 yeah.0003:53CAM-2 # #.0004:00CAM-2 you shut 'em down Steve?0004:00CAM-1 yeah.0004:03CAM [sound similar to engine spooldown]0004:05CAM [sound similar to power interruption to CVR]0004:09CAM-3 you lost your nose wheel.0004:10CAM-2 lost the nose wheel?0004:13CAM-2 we lost the nose wheel.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0004:18CAM-2 on the runway or ... ?0004:20CAM-3 well right now it's back on the other runway over there .. you

didn't have it * * * it was already off.

0004:26CAM-2 okay.0004:28CAM-2 we lost the nose wheel.0004:30CAM-1 felt like it.0004:33CAM-2 well, what do we do .. do we abandon?0004:37CAM-1 yeah, we gotta get the people off.0004:43CAM-2 well, you feel like writin’ a whole lot?0004:45CAM-1 yeah, guess we're gonna have to ... ah, see if they can get

us some transportation for the passengers.

0004:50CAM-2 yeah.0005:00CAM [sound of whistle]0005:01CAM-2 can you call transportation for our passengers * ?
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0005:04CAM [sound of five knocks]0005:05CAM-3 pardon?0005:05CAM-2 can we get transportation set up for our passengers?0005:07CAM-3 * * * the nose wheel's gone, you're just sittin' down on the

axle now.

0005:11CAM-2 on the axle?0005:12CAM-3 yeah.0005:13CAM-2 okay.0005:14CAM-3 yeah we'll get * * * *.0005:16CAM-2 thank you .. you might want to see if northwest has a tug

they can lift the nose gear up and get us towed.

0005:27CAM-2 (or one of those) delta tugs ... we lost the nose wheel.0005:30PA-1 ladies and gentlemen we're going to have to sit here ‘till we

get some busses out here to transport us over to theterminal ... please stay in your seats, I'll go ahead and turnthe seat belt sign off at this time.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0005:43CAM-2 * * all checklists need to be run.0005:45CAM [sound of several clicks]0005:47CAM-? oh #.0005:51CAM-2 (engines) .. lights ... spoilers, APU is cranked and (armed)

with the air off.

0005:56CAM [sound of several clicks]0006:15CAM-2 you wanna get outta the airplane or what?0006:20CAM-2 lower the ah rear air air stairs?0006:23CAM-? [sound of sigh]0006:25CAM-2 the pressure * * * (out).0006:27CAM-1 you sure?0006:28CAM-2 (naw), I I just pulled the window open.0006:30CAM-4 that was * *.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0006:31CAM-2 you all know how to lower the aft air stairs ... the aft air

stairs ... I'll tell you what, our radios don't work .. if we couldjust get a northwest maintenance person or valujetmaintenance -

0006:42CAM-3 [mostly unintelligible and intermittent]0006:45PA-4 ladies and gentleman, the captain did requested you to stay

in your seat, he just did turn the seat belt sign off well theseat belt sign is off but you do need to stay in your seatsplease ... return to your seats.

0006:50CAM-2 I don't know how the ah main ah stairs will work with the

nose wheel so down low.

0006:54CAM-1 I don't know either.0006:56CAM-2 I think it's better to go out the ah rear end.0006:57CAM-1 yeah, go out the back.0007:01CAM-2 let's go ahead and unlock this door.0007:02CAM-1 yeah.0007:11CAM-? (shake it again.)
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0007:15CAM-1 we're gonna have to go out the back ... out the back.0007:18CAM-4 we are.0007:18CAM-2 but there's no big rush right now.0007:20CAM-1 there's no big rush .. we're gonna get some busses to get

over here, ah -

0007:22CAM-4 okay, do you know that the floor, the floor board is * up, I -0007:26CAM-5 (can people walk over it?)0007:27CAM-4 I haven't been back there, * * *.0007:28CAM-2 was it the center section?0007:29CAM-? yeah, above the * *.0007:30CAM-2 yeah, that's the main gear, yeah.0007:33CAM-4 what what happened?0007:35CAM-2 the ground spoilers deployed.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0007:35CAM-1 we .. the ground spoilers deployed just before we hit.0007:38CAM-4 the what now.0007:38CAM-1 these.0007:39CAM-4 yeah.0007:40CAM-1 okay .. they deployed0007:41CAM-2 they went out in the air.0007:43CAM-1 and ah -0007:44CAM-4 I think my ribs are broken.0007:47CAM-2 is anybody hurt in the back?0007:48CAM-5 um ... no, um the people would just really like to know

what's going on.

0007:53CAM-1 okay.0007:55CAM-5 I'm sorry -
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0007:55CAM-1 that's all right.0007:56CAM-2 if we knew we could tell 'em.0007:58PA-1 ladies and gentleman, as soon as we get some ground

transportation we'll be able to get off the aircraft .. it's prettycold outside, we're gonna have to stay here until we getsome busses to depart you up to the terminal ... thank youfor your patience.

0008:07CAM-4 so it was the airplane that something went wrong with,

right?

0008:09CAM-2 yeah, the ground spoilers came up in flight .. that's why we

just “school” ... sunk right out of sight.

0008:16CAM-? ah.0008:20CAM-4 my ribs are hurting so bad.0008:21CAM-1 yeah.0008:22CAM-? * * *.0008:22CAM-4 my side is sore.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0008:23CAM-5 I think we did well ... I mean you guys did a great job.0008:25CAM-2 well we lost both radios.0008:28CAM-4 are your nerves shot yet Steve?0008:29CAM-1 no they're not shot yet.0008:35CAM-2 let's see ... terminating checklist?0008:37CAM-1 yeah.0008:38CAM [sound of female chuckle]0008:39CAM-4 what is that your contact?0008:40CAM-5 no, it was my eye (dripping) ... now my eyelid's really (fried

in shrimp).

0008:44CAM-2 * ... transponder stand by ... fire warning, don't have to do all

that.

0008:56CAM-2 I want to get out of this thing and take a look, make sure

we're not leaking fuel.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0008:59CAM-1 go ahead.0009:00CAM-2 * * * the after air stairs ... I can try the ah main door.0009:15CAM-2 is everybody okay?0009:18CAM-2 okay ... * * we're trying to get the busses out here to get you

off * terminal.

0009:38CAM-1 that's my jacket ... * *.0009:59CAM-3 we got (stairs) problem.0010:00CAM-2 okay ... we leaking any fuel?0010:06CAM [several minutes of mostly unintelligible and intermittent

background conversation between cam-2 and ground crewconcerning aft air stair operation]

0012:07CAM-4 so what was it that happened, Bob.0012:09CAM-2 the ground spoilers that deploy when you land, when you

touch down they come up automatically, they came up inflight, right over the approach lights ... the airplane just sunkout of sight.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0012:21CAM-? [mostly unintelligible and intermittent]0012:25CAM-2 we hit really hard ... the airplane is damaged, there's no

nose wheel on it ... there's no tire on the nose wheel.

0012:34CAM-4 * * * did we land with no tires?0012:35CAM-2 yeah .. *.0012:36CAM-4 I knew we did, I knew (it hurt bad), that's what I told her I

said oh my God, I said * the (spoilers) and landing gear.

0012:41CAM-2 * nose wheel.0012:45CAM [start of mostly unintelligible and intermittent background

conversation]

0016:07CAM-1 about how long before we get some transportation, you

think?

0016:10CAM-3 [unintelligible]0016:17PA-1 ladies and gentleman, the ground transportation is on its

way and as soon as it gets here we will be able to de-plane.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0016:23CAM [continuation of mostly unintelligible and intermittent

background conversation]

0017:29CAM-1 let's sit down and make some notes.0017:31CAM-2 yup .... wonder what to tell the people in the back, * *

explanation *.

0017:57CAM-1 gear down, * * * *.0018:04CAM-1 about where did you notice this -0018:09CAM-2 oh I didn't even see it, I knew what it was when we started

sinking out of sight.

0018:13CAM-6 should be about five more minutes * * *.0018:14CAM-? okay.0018:17PA-1 ladies and gentlemen, in about five more minutes we should

have a bus here to take us up to the terminal .. thank youfor your patience.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0018:26CAM-2 I knew what it was * * as soon as you pushed it in I said

there goes the cabin, it started to open up, it got a groundsignal is what it got, gave this * a signal to deploy when youpushed it in. This is misleading. It tells you to reset 'em butyou reset them probably after you're on the ground but itdoesn't say that.

0019:12CAM-2 did you try the nose steering though after it didn't - ?0019:13CAM-1 yeah yeah did try -0019:15CAM-2 so we retracted.0019:37CAM-2 did you notice if we had four lights when reversing?0019:42CAM-1 I don't even remember.0019:50CAM-2 we lost oil quantity in the right engine.0020:08CAM [sound of power interruption to CVR]0020:12CAM-1 you reached over and stowed these on go around, huh?0020:14CAM-4 yeah.0020:14CAM-6 captain, somebody here looking for you.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0020:15CAM-1 alright.0020:17CAM [start of mostly unintelligible and intermittent background

conversation]

0020:56CAM-2 it's not working, it's not working here.0021:25CAM-1 yeah yeah it's on.0021:30CAM-2 that's electric * that's not hydraulic.0021:34CAM-1 * * raise it.0022:03CAM-2 is it coming out now?0022:04CAM-1 yeah.0023:05PA-1 okay ladies and gentlemen, the busses have arrived here

and if you would, very carefully, we're ready to depart theaircraft .. please get your bags and take your bags with you.

0023:25CAM-1 eighty-six or eighty-five?0023:27CAM-? eighty-six.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0023:50CAM-2 are the stairs locked, got the rails up?0023:53CAM-1 yeah the rails are up.0023:55CAM [start of mostly unintelligible and intermittent passenger

background conversation during passenger de-planing]

0025:22CAM-2 engine and wing anti-ice off.0025:29CAM-? D.C. busses off?0025:39CAM-2 don't have any oil ... right CSD low.0025:45CAM [unintelligible]0026:07CAM-2 so you didn't feel any movement on the - so you raised the

gear pushed the button and raised the gear, we read thechecklist -

0026:12CAM-1 soon as I did that, the second time over here ....0026:14CAM [start of mostly unintelligible and intermittent passenger

background conversation during passenger de-planing]

0026:50CAM-2 I * * * fire trucks anyway, in case we had to evacuate.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0027:07CAM-2 hey you okay ... you just, it's just nerves right now okay ..

you're gonna be shaking all over like a leaf in a fewminutes, okay.

0027:37CAM-7 little more airspeed on approach.0027:40CAM-2 that wasn't it.0027:50CAM-8 okay guys, you all did a great job, thank you.0027:52CAM-1,2 thank you.0027:56CAM-2 get out that video camera and film that nose wheel.0028:01CAM [sound of several power interruptions to the CVR]0028:24CAM-2 when everybody's off should we shut this APU down?0028:26CAM-1 (yeah.)0028:27CAM-? * *.0028:36CAM-4 we had a lot of way before we really had to stop though,

didn't we?
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICA

TIME and TIME andSOURCE CONTENT SOURCE CONTENT0028:39CAM-1 hmmm?0028:42CAM-4 or should we have stopped * *.0028:54CAM-2 it was eleven thousand feet, what did we have left, four

thousand?

0029:01CAM-2 used almost seven thousand.0029:15CAM-2 * * *.0029:33CAM-2 we got enough vans?0029:57CAM-9 we got we we caught the brunt of it back there in the back.0030:02CAM-1 we did de-pressurize, right?0030:02CAM-2 yeah, well, it was working normal, the pressurization .. I

mean we set the cabin down it came down it was down tosea level .. and then when you pushed the breakers in, theoutflow valve went to full open which de-pressurized theairplane but at the same time -

0030:26[end of recording]0030:26[end of transcript]

76

APPENDIX D - AIR TRAFFIC CONTROL TRANSCRIPT AND STATEMENTS
Q

77

Memorandum

U.S. Department

of Transportation

Federal Aviation

Administration

Subject: INFO RMATION: Transcript; Date: February 6, 1996

Reference Aircraft Accident; VJA558;

Nashville, TN; January 7, 1996

Reply to

From: Manager, Nashville ATCT, BNA-2 Attn of:

TO: This transcript covers the Nashville ATCT Departure Radar West Control

position for the time period from January 7, 1996, 2201 UTC

to January 7, 1996,2230 UTC.

Agencies Making Transmissions Abbreviations

Nashville ATCT, Departure Radar West

Nashville ATCT, Local Control One

Memphis ARTCC

Valujet 558

Beechjet 445CC

Eagleflight 533

Southwest 1364

United 1417

American 1323

Northwest 1470

Cessna Citation 72WE

Cessna Centurion 210RG

PAT505 (Military)

USAir 1578

Southwest 1263

Bonanza 25466

Cherokee Archer 2070M

DRW

LC1

VJA558

N445CC

EGF533

SWA1364

UAL1417

AAL1323

NWA1470

N72WE

N21ORG

PAT505

USA1578

SWA1263

N25466

N2070M

I hereby certify that the following is a true transcription of the recorded conversations pertaining to

the subject aircraft accident involving VJA558.

Dianne P. Reid

Quality Assurance and Training Specialist

February 6, 1996
78

BNA-ATCT-079

VJA558

Page 2 of 25

2201

2201:17

2201:20

2201:31

2201:38

2201:41

2201:44

2201:47

N445CC

DRW

N445CC

DRW

N445CC

DRW

DRW

2201:51 ZME

2202:00 DRW

*(and) nashville beechjet four four five charlie charlie

beechjet four four five charlie charlie nashville

approach expect vectors for the i 1s runway three

one approach descend and maintain six thousand

advise when you have arrival information charlie

*(ok) we have charlie down to six thousand expect

thirty one and apparently uh we lost frequency

with the last controller

roger dld you pickup the new frequency over the vortac

no sir we looked up on the uh on the arrival

roger

nashville nashville seventy three I’ve got four

forty five charlie charIie and he’s descending

alright thank you very much (unintelligible)

beechjet four four five charlie charlie turn left

heading two zero zero descend at pilot’s

discretion maintain three thousand and it’ll be

vectors for i 1s runway two right be vectors for

ils runway two right approach braking action was

reported fair by seven thirty seven
79

BNA-ATCT-079

VJA558

Page 3 of 25

2202:16

2202:23

2202:28

2202:47

2202:53

2202;59

2203:05

2203:09

2203:14

2203:30

2203:49

2203:53

N445CC

EGF533

DRW

DRW

N445CC

DRW

EGF535

DRW

EGF677

SWA1364

DRW

SWA1364

o k uh two hundred degrees on the heading three

thousand and two right now

departure eagleflight five thirty three is in a

right turn to zero nine zero

eaglefight five thirty three nashville departure

radar contact

beechjet five charlie charlie amend altitude

descend and maintain six thousand fly heading two

three zero

two thirty at six thousand charlie charlie

eagleflight five thirty three climb and maintain

five thousand turn right heading of one five zero

five zero and up to five five thirty three

eagleflight six seventy seven contact memphis

center one three two point one so long

one thirty two point one eagle six seventy seven we’ll see you later

south thirteen sixty four with you out of sixteen

hundred climbing to five thousand

*(southwest) thirteen sixty four nashville were

you checking in

affirmative out of twenty six hundred for five thousand
80

BNA-ATCT-079

VJA558

Page 3 of 25

2202:16

2202:23

2202:28

2202:47

2202:53

2202:59

2203:05

2203:09

2203:14

2203:30

2203:49

2203:53

N445CC

EGF533

DRW

DRW

N445CC

DRW

EGF535

DRW

EGF677

SWA1364

DRW

SWA1364

o k uh two hundred degrees on the heading three

thousand and two right now

departure eagleflight five thirty three is in a

right turn to zero nine zero

eagleflight five thirty three nashville departure

radar contact

beechjet five charlie charlie amend altitude

descend and maintain six thousand fly heading two

three zero

two thirty at six thousand charlie charlie

eagleflight five thirty three climb and maintain

five thousand turn right heading of one five zero

five zero and up to five five thirty three

eagleflight six seventy seven contact memphis

renter one three two point one so long

one thirty two point one eagle six seventy seven we’ll see you later

south thirteen sixty four with you out of sixteen

hundred climbing to five thousand

*(southwest) thirteen sixty four nashville were

you checking in

affirmative out of twenty six hundred for five thousand
81

BNA-ATCT-079

VJA558

Page 4 of25

2203:57

2204:06

2204:57

2205:05

2205:08

2205:09

2205:16

2205:20

2205:26

2205:32

2205:42

DRW southwest thirteen sixty four nashville departure

radar contact climb and maintain seven thousand

turn left headiig of two six zero

SWA1364 southwest thirteen sixty four seven thousand left heading two

six zero

UAL1417 united fourteen seventeen uh with you uh out of uh eighteen

hundred for five thousand

DRW is that united fourteen seventeen

UAL1417 affirmative

DRW united fourteen seventeen nashville departure

radar contact climb and maintain one five fifteen

thousand

UAL1417 cleared to one five thousand united uh fourteen

seventeen

DRW southwest thirteen sixty four traffic twelve

thirty two miles northwest bound eight thousand

centurion

SW1364 southwest thirteen sixty four *(that traffic

passed us)

DRW eagleflight five thirty three when you’re able

direct rome climb and maintain one five thousand

EGF533 o k was that one five thousand for five thirty

three
82

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VJA558

Page 5 of 25

2205:44

2205:50

2205:53

2206:00

2206:04

2206:08

2206:08

2206:13

2206:16

2206:19

2206:23

DRW eagle five thirty three affirmative climb and

maintain one five thousand direct rome

EGF533 direct rome (unintelligible) one five thousand

five thirty three

DRW united fourteen seventeen turn left heading uh

three six zero when you’re able direct

(unintelligible) is it walnut ridge

UAL1417 uh left turn uh uh three sixty and uh we’d like to

go direct Louisville

DRW I’m sorry direct Louisville for united fourteen

seventeen

UAL1417 (unintelligible)

DRW southwest thirteen sixty four climb and maintain

one five thousand direct walnut ridge for you when

you’re able

SW1364 thirteen sixty four one five thusand walnut ridge

when able

VJA558 critter five fifty eight with you one zero uh one

two thousand (unintelligible)

AAL1323 thirteen twenty three twenty five hundred for five

DRW critter five fifty eight turn left heading two

eight zero descend and maintain five thousand

vectors i 1 s runway two right
83

BNA-ATCT-079

VJA558

Page 6 of25

2206:31 VJA558 eight zero down to five thousand expect two right

critter five fifty eight

2206:35 DRW eagle flight five thirty three turn left heading

of one two zero vector around traffic

2206:40 EGF533 two zero five thirty three

2206:40 DRW five charlie charlie descend and maintain three

thousand

2206:45 445CC three thousand five charlie charlie

2206:49 DRW american thirteen twenty three nashville departure

radar contact climb and maintain one five thousand

turn left heading two six zero

2206:57 AAL1323 left two six zero climb to one five thousand

american thirteen twenty three

2207:02 DRW southwest thirteen sixty four contact memphis

center on one two five point eight five so long

2207:09 SWA1364 thirteen sixty four twenty five eight five good

day

2207:46 NWA1470 nashville approach northwest fourteen seventy ten

thousand with delta.
84

BNA-ATCT-079

VJA558

Page 6 of 25

2206:31 VJA558 eight zero down to five thousand expect two right

critter five fifty eight

2206:35 DRW eagle flight five thirty three turn left heading

of one two zero vector around traffic

2206:40 EGF533 two zero five thirty three

2206:40 DRW five charlie charlie descend and maintain three

thousand

2206:45 445CC three thousand five charlie charlie

2206:49 DRW american thirteen twenty three nashville departure

radar contact climb and maintain one five thousand

turn left heading two six zero

2206:57 AAL1323 left two six zero climb to one five thousand

american thirteen twenty three

2207:02 DRW southwest thirteen sixty four contact memphis

center on one two five point eight five so long

2207:09 SWA1 364 thirteen sixty four twenty five eight five good

day

2207:46 NWA1470 nashville approach northwest fourteen seventy ten

thousand with delta.
85

BNA-ATCT-079

VJA558

Page 7 of 25

2207:51 DRW northwest fourteen seventy nashville approach

roger expect vectors i 1s runway two right

braking action reported good by a uh seven thirty

seven correction braking action reported fair by a

seven thirty seven

2208:03 NWA1470 *(o k) copy northwest fourteen seventy

2208:06 DRW beechjet five charlie charlie turn right heading

two niner zero braking action reported fair by a

seven thirty seven

2208:11 N445CC right turn (unintelligible) braking action fair thank you sir

2208:15 NWA1470 and approach northwest fourteen seventy

2208:19 DRW united fourteen seventeen contact memphis center

one three three point eight five

2208:23 UAL1417 thirty three eight five united fourteen seventeen

good day

2208:27 DRW northwest fourteen seventy fly heading one three

zero descend at pilot’s discretion maintain five

thousand go head

2208:32 NWA1470 okay uh one thirty heading uh down to five

thousand uh you’re winds still at three twenty at

uh fourteen

2208:38 DRW critter five fifty eight turn right heading of

three one zero
86

BNA-ATCT-079

VJA558

Page 8 of 25

2208:41

2208:43

2208:5 1

2208:53

2209

2209:02

2209:06

2209:10

2209:13

2209:17

2209:23

2209:24

VJA558

DRW

EGF533

DRW

N445CC

DRW

NWA1470

DRW

NWA1470

LC1

DRW

three one zero critter five fifty eight

eagle flight five thirty three you can proceed

direct rome when you’re able contact memphis

center on one two six point seven five

twenty six seventy five direct rome five thirty

three

beechjet five charlie charlie you’re seven miles

from skaggs turn right heading thru five zero

maintain three thousand until established on the

localizer cleared i 1s runway two right approach

three live zero three thousand cleared uh for the

i 1s two right approach

northwest fourteen seventy the winds are three

three zero at one three

yes sir I'd like to request runway three one

united fourteen seventy expect vectors i ls

runway three one approach

ah northwest fourteen seventy roger

local

northwest won’t take two right he wants thirty one

because of the wind
87

BNA-ATCT-079

VJA558

Page 9 of 25

2209:27 LC 1

2209:27 DRW

2209:28 LC 1

2209:44 DRW

2209:51

2209:55

2010

2010:01

2010:04

2010:10

2011

2011:27

2011:29

2011:32

2011:34

that’s fine

s k

d g

american thirteen twenty three uh turn left

heading of two four zero join jay forty six

AAL1323 left two four zero join jay forty six american

thirteen twenty three

DRW american thirteen twenty three contact memphis

center on one two five point eight five so long

AAL1323 twenty five eighty five *(american thirteen twenty

three)

DRW beechjet five charlie charlie contact tower on one

one eight point six

445CC one one eight point six charlie charlie good day

DRW critter five fifty eight descend and maintain

three thousand

VJA558 three thousand critter five fifty eight

ZME nashville shelby on the three

DRW nashville
88

BNA-ATCT-079

VJA558

Page 10 of 25

2011:35

2011:40

2011:40

2012

2012:06

2012:13

2012:25

2012:28

2012:41

2012:45

2012:55

2012:59

2213:02

DRW

ZME

N72WE

DRW

N72WE

DRW

DRW

NWA1470

DRW

NWA1470

DRW

that two whiskey echo I turned him inside that

eagle jet there he’s heading uh three four zero

your control

thank you b r

(unintelligible)

nashville approach citation seven two whiskey echo

citation seven two whiskey echo nashville approach

expect an i 1s approach runway two right at nashville

braking action reported fair by a seven thirty seven and

uh you say you have information delta

that’s affirmative sir and uh that was expect uh

two right

affirmative

northwest uh fourteen seventy turn left heading

one one zero

left heading one one zero northwest fourteen

seventy

and northwest fourteen seventy descend and

maintain four thousand

out of four thousand northwest fourteen seventy

critter five fifty eight turn ten degrees right
89

BNA-ATCT-079

VJA558

Page 11 of 25

2213:04

2213:10

2213:13

2213:26

2213:33

2213:41

2213:46

22

22

3 ;48

3:52

2213:57

2214

2214:05

2214:10

2214:21

VJM58

DRW

VJA558

DRW

NWA1470

DRW

N72WE

DRW

N72WE

DRW

N72WE

DRW

DRW

turn ten degrees right critter five fifty eight

(unintelligible) make that heading three four zero

four zero critter five fifty eight

northwest uh fourteen seventy you’re (unintelligible) you’re

number two for the airport I’ve got a uh d c nine inbound

runway two right I'll be (unintelligible) about ten mile final

*(o k) copy northwest fourteen seventy

seven two whiskey echo center gave you a three

four zero heading is that correct

thats correct sir (unintelligible)

o k you can expect three forty heading for awhile

that will be vectors to the final approach course

o k sir maintain three forty for now then seven uh

seven two whiskey echo

if you need something else let me know

uh whiskey echo roger

centurion two one zero romeo golf contact memphis

center one three three point eight five

centurion two one zero romeo golf contact memphis

center one three three point eight five
90

BNA-ATCT-079

VJA558

Page 12 of 25

2214:27

2214:35

2214:39

2214:40

2214:41

2214:44

2214:47

2214:48

2214:59

2215:10

2215:17

2215:20

N2 1ORG

DRW

VJA558

DRW

DRW

NWA1470

DRW

DRW

VJA558

DRW

VJA558

DRW

three three eight five four romeo golf

critter five fifty eight whats your ah speed now

speed now two thirty

thank you

northwest fourteen seventy reduce speed to two one

zero

and reduce to two one zero for northwest fourteen

seventy

thank you

critter five five eight is uh five miles from skaggs turn right

heading three five zero maintain three thousand until established

on the localizer cleared i 1s approach runway two right speed one

seven zero or greater til skaggs please.

(unintelligible) three five zero three thousand til established cleared

for approach critter five fifty eight

and critter five fifty eight traffic eleven o’clock and four miles is a

northwest d c nine at four thousand inbound for runway three one

five fifty eight (unintelligible) he should be above us in the clouds

(unintelligible) above you
91

BNA-ATCT-079

VJA558

Page 13 of25

2215:23

2215:27

2215:31

2215:35

2215:37

2215:38

2215:39

2215:47

2215:55

2216:00

2216:10

2216:11

2216:15

DRW

N72WE

DRE

N72WE

DRW

N72WE

DRW

DRW

NWA1470

DRW

LC1

DRW

LC1

seven two whiskey echo descend and maintain three

thousand

roger out of one zero thousand for three thousand

whiskey echo

and uh citation seven two whiskey echo thats at

your discretion

o k sir its three thousand at pilots discretion

(unintelligible)

*(echo)

affirmative

northwest fourteen seventy there’s a d c nine uh just uh

off your uh right side just going behind three thousand

now inbound for two right

and we’re in the clouds northwest fourteen seventy

I’ll have lower for you just a moment

local

ten south on northwest fourteen seventy I guess

they filled you in he’s three one

yeah
92

BNA-ATCT-079

VJA558

Page 14 of 25

2216:15

2216:16

2216:16

2216:22

2216:27

2216:47

2216:51

2216:53

2216:56

2217

2217:21

2217:25

2217:30

DRW o k here he comes

LC 1 d g

DRW br

DRW northwest fourteen seventy turn left heading zero

eight zero

NWA1470 turning zero eight zero northwest fourteen

seventy

DRW critter five fifty eight contact nashville tower

one two eight point one five

VJA558 two eight on five critter five fifty eight

switching

DRW northwest fourteen seventy descend and maintain

three thousand

NWA1470 *(down to) three thousand northwest fourteen

seventy

PAT505 departure pat five zero fives with you out of

fifteen hundred for four thousand

DRW pat five zero five nashville departure radar

contact climb and maintain one five thousand

PAT505 up to one five thousand pat five zero five thanks
93

BNA-ATCT-079

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Page 15 of 25

2217:36 DRW northwest fourteen seventy continue descent to

maintain two thousand six hundred

2217:40 NWA1470 down to two thousand six hundred northwest

fourteen seventy

2217:48 DRW and northwest fourteen seventy turn left heading

three three zero you’re uh five miles from ayers

maintain two thousand six hundred until establish

on the localizer cleared for i 1s approach runway

three one

2218:00 NWA1470 a left turn heading three three zero two thousand

six hundred til establish (unintelligible) northwest

fourteen seventy

2218:01 USA1578 good afternoon nashville approach u s air fifteen

seventy eight *(thirteen five for) one zero thousand

with delta

2218:07 DRW us air fifteen seventy eight nashville approach expect

an i 1s approach runway two right braking action reported

fair by a seven thirty seven

2218:15 USA1578 is thirty one available for fifteen seventy eight

2218:17 DRW uh well they want they’re trying to get it uh

plowed right now I’ll let you know as you get

closer

2218:22 USA1578 *(ok) we’ll expect two right and if three

one comes available we’d like that thanks
94

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Page 16 of 25

2218:51

2218:54

2219

2219:05

2219:10

2219:21

2219:24

2219:31

2219:42

2219:53

2219:59

2220

2220:02

2220:09

DRW

PAT505

DRW

N72WE

SWA1 263

DRW

SWA1263

DRW

SWA1263

SWA1263

DRW

NWA1470

pat five zero five proceed on course

five zero five on course thanks

citation seven seven two whiskey echo turn left

heading three one zero

left three one zero uh two whiskey echo

roger southwest twelve sixty three one point four

for five thousand

southwest twelve sixty three nashville departure

radar contact climb and maintain one five thousand

*(climb maintain) one five thousand southwest

twelve sixty three

southwest twelve sixty three uh leaving three thousand

uh five or (intelligible) six hundredturn left heading

three six zero to join jay thirty nine

three thousand six hundred turn left to heading

three six zero uh join jay

(unintelligible)

northwest fif uh fourteen seventy you’re gonna

join about a mile from ayers contact the tower one

one eight point six

(unintelligible) mile from ayers uh eighteen six

for tower for northwest fourteen seventy
95

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Page 17 of 25

2220:35

2220:39

2221

2221:38

2221:39

2221:41

2221:47

2221:56

2221:57

2221:58

2222:00

2222:03

2222:04

DRW

USA1578

DRW

LC 1

DRW

DRW

N72WE

LC1

DRW

LC1

DRW

LC1

u s air fifteen seventy eight descend and maintain

six thousand

leaving one zero thousand for six thousand us air

fifteen seventy eight

go around

ah it’s a whole lot more serious than that we’ll

call you back

o k

*(november) seven two whiskey echo they just

closed runway two right so uh turn right heading

uh one one zero I’ll try to take you to three one

*(o k) right one one zero (unintelligible) whiskey echo

knocked the antenna off

can I use three one

uh I wouldn’t do anything right now this guy lost

his nose wheel

yeah

uh he’s got no tires on the nose gear he came up

short of the runway hit the tail and I can’t talk to him
96

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2222:11 DRW

2222:11 LC 1

2222:18 DRW

2222:19 LC 1

2222:20 DRW

2222:24 LC 1

2222:25 DRW

2222:28 DRW

o k

uh I don’t know what he’s goma do pat so just the

altitude is apparently good he may have knocked the

antenna off the airplane I can’t talk to him

o k

so stay out of his way

alright but I’ve got a couple of inbounds can I

use three one still

thirty one’s good but I don’t know what critters

gonna do

o k

critter five fifty eight (unintelligible) approach

2222:59 DRW seven two whiskey echo turn left heading

(unintelligible) zero niner zero

2223:02 N72WE left zero niner zero on uh whiskey echo

2223:09 DRW the uh localizer frequency for three one is one

hundred nine point seven

2223:14 N72WE one zero nine point seven thank you whiskey echo

2223:19 DRW anything on critter yet
97

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Page 19 of 25

2223:21

2223:23

2223:23

2223:24

2223:24

2223:26

2223:31

2223:46

2224

2224:01

2224:06

2224:11

2224:15

2224:17

LC 1

DRW

LC 1

DRW

LC 1

DRW

USA1578

DRW

DRW

SW1263

DRW

USA1578

DRW

I can’t get him I can’t get him on guard either

o k

so watch him

I’m watching him

alright

us air fifteen seventy (unintelligible) runway

three one now fly heading one niner zero

one nine zero for runway three one us air fifteen

seventy eight ✷(thank you sir)

southwest twelve sixty three contact memphis

center on ah one three three point eight five

southwest twelve sixty three contact memphis

center one two one three three point eight five

(unintelligible) three three eight five southwest

twelve sixty three

us air fifteen seventy reduce your speed to one

seven zero

one seventy us air fifteen seventy eight

pat five zero five contact memphis center one two

five point eight five
98

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Page 20 of25

2224:21

2225

2225:12

2225:15

2225:22

2225:28

2225:30

2225:37

2225:41

2225:48

2225:49

2226

2226:03

PAT505

DRW

N72WE

DRW

USA1578

DRW

N25466

DRW

N25466

DRW

N72WE

one two five eight five pat five zero five good

day

(unintelligible) seven two whiskey echo uh expect

vectors to the final approach course there is a uh

emergency inbound

seven two whiskey echo roger

us air fifteen seventy eight turn right heading

one three zero correction uh turn left heading one

three zero

one three zero us air fifteen seventy eight

affirmative

nashville approach bonanza two five four six six

level at nine thousand

bonanza two five four four uh four six six

nashville altimeter three zero one four

zero one four

and uh seven two whiskey echo and us air fifteen

seventy eight looks like uh it looks like the uh

three one might be closed in just a moment here

let me know if you have any uh different airport

to go to

whiskey echo roger
99

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Page 21 of25

2226:06

2226:09

2226:17

2226:22

2226:24

2226:28

2226:50

2226:55

2227

2227:01

2227:13

2227:17

USA1578

DRW

DRW

N72WE

DRW

N72WE

DRW

USA1578

DRW

USA1578

DRW

ah what uh you’re saying the whole airport’s gonna

be closed

I got I got the feeling it will be two right just

closed and (unintelligible) emergency is landing

three one

seven two whiskey echo turn right heading uh one

two zero

right one two zero whiskey echo

I’ll just vector you back around in a moment

O k thank you

us air fifteen seventy eight do you have an alternate

airport you want to go to or do you just want to try

to hold for a while

uh we’d like to uh try to hold for a little while how long

do they uh claim the emergency is gonna take to clear up

well uh (unintelligible) I’ll try to explain it to you just a

moment but uh turn your turn right to uh I’m gonna hold

you uh over dobbs if you don’t mind (unintelligible) two

left at dobbs can you do that

hold over dobbs o k we’ll have to get that set up

uh yeah we can do that

o k uh turn uh to your right (unintelligible)

heading two seven zero and when able direct dobbs
100

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Page 22 of 25

2227:22

2227:27

2227:31

2227:32

2227:39

2227:42

2227:50

2227:53

2227:55

2228:10

USA1578

DRW

N72WE

DRW

N72WE

DRW

N72WE

DRW

DRW

USA1578

*(ok) two seven zero and when ready direct dobbs u

s air uh fifteen seventy eight

seven two whiskey echo you you want to try to hold

also

yes sir we do

alright turn right to a heading of three one zero at three

thousand you want to hold uh at dobbs also if you’re

gonna dial that in

o k that 'll be fine uh right three one and hold

at dobbs

affirmative when able direct dobbs I’ll just hold you there

and peel you back out to go over to uh runway uh three

one or to whatever runway opens up again

o k sir three one zero uh and then direct dobbs to

hold

affirmative

us air fifteen seventy eight when you get to dobbs hold

south west of dobbs on the two left final approach course

at six thousand legs at your discretion right as left turns

and expect further clearance at uh let’s make it two three

zero zero now is two two two eight

o k understand uh once we get to dobbs hold uh southwest

on the uh two left final approach course right or left turns

our choice ten mile legs o k
101

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Page 23 of 25

2228:20

2228:20

2228:23

2228:39

2228:55

2228:55

2229

2229:18

2229:38

2229:42

2229:46

2230

2230:04

DRW

USA1578

DRW

DRW

USA1578

N72WE

DRW

N72WE

N2070M

DRW

affirmative

and (unintelligible) approach at twenty three

hundred

affirmative

and uh looks and right now the uh aircraft just touched down

and uh lost the nose wheels two right and they’re gonna inspect

it and they just they just landed on on runway three one so three

one is closed and the right is closed well all the tunways are closed right

now so I’ll try to figure out what going to open up first and take ya'll

over there

*(thanks)

*(whiskey echo)

uh seven two whiskey echo when reaching dobbs hold southwest

of dobbs on the two left uh localizer and uh maintain three thousand

left or right turns approved legs at your discretion expect further

clearance at uh two three three two three zero five the time now is

two two two niner

seven two whiskey echo roger

nashville archer two zero seven zero mike at eight

thousand

archer two zero seven zero mike nashville approach

altimeter three zero one four

west arrival three uh two line
102

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Page 24 of 25

2230:10

2230:1 I

2230:14

2230:16

2230:18

2230:19

2230:21

2230:23

2230:26

2230:28

2230:29

2230:31

2230:32

2230:34

DRW

DRW

ZME

DRW

DRW

DRW

DRW

DRW

nashville

yes I understand you’ve got one disabled on the

runway

uh we have no open runways right now

none at all they’re all closed

everyone of them yes

o k we’ll hold everything else outside your

airspace

also I’ve got (unintelligible) overflights but no

arrivals

o k you’ve got no arrivals which one was it

uh it was critter five fifty eight

critter o k

they’ll call you and let you know what happened

pretty soon

thank you

right now I can’t I don’t have the time

r j
103

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Page 25 of25

2230:34 DRW b r 

End of Transcript

✵This portion of the rerecording is not entirely clear, but this represents the best interpretation possible

under the circumstances.
104

Q

U.S. Department

of Transportation

Federal Aviation

Administration

Memorandum

Subject: INFORMATION: Transcript; Date: February 6, 1996

Reference Aircraft Accident; VJA558;

Nashville, TN; January 7, 1996

Reply to

From: Manager, Nashville ATCT, BNA-2 Attn of:

To: This transcript covers the Nashville ATCT Local Control One

position for the time period from January 7, 1996, 2212 UTC

to January 7, 1996, 2230 UTC.

Agencies Making Transmissions

Nashville ATCT, Local Control One

Nashville ATCT, Departure Radar West

Valujet 558

Beechjet 445CC

PAT505 (Military)

Southwest 1263

Northwest 1470

Abbreviations

LC 1

DRW

VJA558

N445CC

PAT505

SWA1263

NWA1470

I hereby certify that the following is a true transcription of the recorded conversations pertaining to

the subject aircraft accident involving VJA558.

D?%%ie~ Q

Quality Assurance and Training Specialist

February 6, 1996

2212

2213:00 N445CC wind check please

2213:02 LC 1 wind three three zero at one four
105

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Page 2 of6

2213:28

2213:32

2213:33

2214

2214:17

2214:21

2215

2215:33

2215:35

2215:40

2216

2216:10

2216:11

2216:15

2216:15

2216:16

2216:16

2217

2217:01

LC 1

N445CC

LC 1

LC 1

N445CC

PAT505

LC 1

PAT505

LC 1

DRW

LC1

DRW

LC1

DRW

LC1

o k thanks uh still out of the northwest about three hundred thirty

affirm

O k thanks

beechjet five charlie charlie turn lefi when able to contact ground

point niner

charlie charlie

tower pat five zero five is ready to go two right

pat five zero five nashville tower turn left heading two eight zero

runway two right cleared for takeoff

left two eight zero cleared for takeoff pat five zero five

local

ten south on northwest fourteen seventy I guess they filled you in

he’s three one

yeah

o k here he comes

d g

b r 

pat five zero five contact departure good day
106

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Page 3 of 6

2217:04

2217:05

2217:11

2217:18

2217:21

2217:24

2218

2219

2219:10

2219:14

2219:17

2219:25

2219:35

2219:37

PAT505

LC 1

SWA1263

VJA558

LC 1

VJA558

LC 1

SW1263

LC1

VJA558

VJA558

LC 1

five zero five good day

southwest twelve sixty three nashville tower fly the nashville eight

departure runway two right cleared for takeoff

nashville eight departure cleared for takeoff southwest twelve sixty

three

(unintelligible) critter five fifty eight is with you uh for a i l s 

runway two right

critter five fifty eight nashville tower runway two right clear to land

cleared to land two right critter five fifty eight

southwest twelve sixty three contact departure good day

good day southwest twelve sixty three

critter five fifty eight a beechjet reported the braking action poor at

the approach end of the runway and then uh becoming fair down

field

five fifty eight roger

*(is) this nashville minnesota

say again
107

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Page 4 of 6

2219:38

2219:40

2219:42

2220

2220:18

2220:37

2221

2221:05

2221:09

2221:13

2221:17

2221:32

2221:35

2221:38

2221:39

2221:41

VJA558

LC 1

VJA558

NW1470

LC 1

NW1470

LC 1

NWA1470

LC 1

LC 1

NWA1470

DRW

LC 1

DRW

is this minnesota

I still didn’t hear ya

disregard

nashville tower northwest fourteen seventy is eight miles out for the

i 1 s three one

critter five fifty eight you’ve lost the uh two wheels off the nose

gear

*(Nashville) tower northwest fourteen seventy six miIes out i 1 s

thirty one

northwest fourteen seventy nashville tower continue

fourteen seventy continue

critter five fifty eight uh did you copy

northwest fourteen seventy runway three one cleared to land

(unintelligible) northwest fourteen seventy

go around

uh it’s a whole lot more serious than that we’ll call you back

o k
108

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Page 5 of 6

2221:46

2221:57

2221:58

2222:00

2222:03

2222:04

2222:11

2222:11

2222:18

2222:19

2222:20

2222:24

2222:25

LC1

LC 1

DRW

LC 1

DRW

LC1

DRW

LC1

DRW

LC1

DRW

LC 1

DRW

critter five fifty eight tower

knocked the antenna off

can I use three one then

uh I wouldn’t do anything right now this guy lost his nose wheel

yeah

uh he’s got no tires on the nose gear he came up short of the

runway hit the tail and I can’t talk to him

o k

uh I don’t know what he’s gonna do pat so just the altitude is

apparently good he may have knocked the antenna off the airplane I

can’t talk to him

o k

so stay out of his way

all right but I’ve got a couple of inbounds can I use three one still

yeah thirty one’s good but I don’t know what critters gonna do

o k
109

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Page 6 of6

2222:29

2223

2223:19

2223:21

2223:23

2223:23

2223:24

2223:24

2223:45

2223:57

2224

2224:01

2225

2225:51

2226

2227

2228

2229

2230

LC 1

DRW

LC1

DRW

LC 1

DRW

LC 1

LCI

LC1

NWA1470

LC1

critter five fifty eight nashville tower

anything on critter yet

I can’t get him I can’t get him on guard either

o k

so watch him

I’m watching him

all right

critter five fifty eight nashville tower

northwest fourteen seventy turn right when able to contact ground

point niner

turn right ground point nine northwest fourteen seventy

critter five fifty eight if you hear the tower you have no wheels

negative wheels on the nose stint

End of Transcript

* This portion of the rerecording is not entirely clear, but this represents the best interpretation

possible under the circumstances.
110

BNA-ATCT-079

VJA558

PERSONNEL STATEMENTS

FEDERAL AVIATION ADMINISTRATION

NASHVILLE ATCT

January 7, 1996

The following is a report concerning the accident involving VJA558 at the Nashville

Airport, January 7, 1996 at 2227 UTC.

My name is Robert F. Snuck (SK). I am employed as an Air Traffic Control Specialist by

the Federal Aviation Administration at the Nashville Air Traffic Control Tower, Nashville,

Tennessee.

During the period 2000 UTC to 0500 UTC, January 7, 1996, I was on duty in the

Nashville, TN ATCT. I was working the Departure Radar West position, from 2038 UTC

to 2211 UTC.

While working the Departure Radar West position, VJA558 checked-in at one two

thousand. VJA558 was turned to a two hundred eighty degree heading and descended to

5,000 feet and told to expect vectors for the ILS approach runway 2R. All arrival were to

go to runway 2R for snow removal on runway 31 per watch supervisor, unless otherwise

coordinated. The two hundred eighty degree heading was issued to vector VJA 558 away

from EGF533. EGF533 was turned to a one hundred twenty degree heading. When these

aircraft were not a factor for each other, VJA558 was turned to a three hundred ten

degree heading and EGF533 was turned direct Rome Vortac. I was relieved on the

position by Pat Brown.

Robert F. Snuck
111

BNA-ATCT-079

VJA558

PERSONNEL STATEMENTS

FEDERAL AVIATION ADMINISTRATION

NASHVILLE ATCT

January 7, 1996

The following is a report concerning the accident involving VJA558 at the Nashville

Airport, January 7, 1996 at 2227 UTC.

My name is Patrick E. Brown (BR). I am employed as an Air Traffic Control Specialist by

the Federal Aviation Administration at the Nashville Air Traffic Control Tower, Nashville,

Tennessee.

During the period 1830 UTC to 0330 UTC, January 7, 1996, I was on duty in the

Nashville, TN ATCT. I was working the Departure Radar West position, from 2212 UTC

to 2241 UTC.

I assumed Departure Radar West at 22122. All radar positions were combined to

Departure Radar West at this time. VJA558, DC9, was twenty-five miles southeast of the

Nashville Airport. I issued information for landing runway 2R At fifteen southeast, I

turned the aircraft to heading three four zero for vectors to the final approach. At

approximately 22152, I cleared VJA558 for the ILS approach to runway 2R At 22162, I

instructed VJA558 to contact the tower. At approximately 22232, I saw VJA558’s radar

tag appear northeast bound off of runway 2R I called Local Control One to see if the

DC9 had a go-around. Local Control One told me to standby because there was a

problem. VJA558 made a right turn southeast bound at one thousand two hundred feet.

Local Control One called back to report runway 2R closed due to debris on the runway. I

then observed VJA558 turning to a straight-into runway31, with no radio contact with

Departure radar West. VJA558’s radar tag went into coast track.

I reserve the right to make any changes to this document if further information is

available.

%273

Patrick E. Brown
112

BNA-ATCT-079

VJA558

PERSONNEL STATEMENTS

FEDERAL AVIATION ADMINISTRATION

NASHVILLE ATCT

January 7, 1996

The following is a report concerning the accident involving VJA558 at the

Nashville Airport, January 7, 1996 at 2227 UTC.

My name is Douglas A. Geary (DG). I am employed as an Air Traffic

Control Specialist by the Federal Aviation Administration at the Nashville Air

Traffic Control Tower, Nashville, Tennessee.

During the period 1830 UTC to 0330 UTC, January 7, 1996, I was on duty in

the Nashville, TN ATCT, I was working the Local Control One position,

from 2131 UTC to 2234 UTC.

VJA558 reported on my frequency on an 8-mile final, ILS approach to

Runway 2R. I cleared him to land on initial contact. On a two-mile final, I

relayed a braking action report from the preceding arrival. The crew of

VJA558 acknowledged the report and then asked something that I didn’t

understand. I had him repeat the question, but again I didn’t understand, so

he told me to disregard. When the aircraft was about 400 feet short of the

threshold, I observed the aircraft sink in an increasing nose-up/taildown

attitude and impact the ground with the tail about two hundred and fifty feet

short of the runway. The nose of the aircraft then impacted the ground, and I

observed the two nose-wheels and other debris sliding down the runway. The

aircraft commenced a go-around and there was a brief discharge of white

vapor from an engine. As VJA558 climbed straight-out, I attempted to

inform him of the observed damaged to the nose gear, but there was no

response. I eventually lost sight of the aircraft

About three miles north-northeast of the airport, I observed the aircraft, on the

BRITE, make a descending right turn. During the next 5 minutes, I made

several attempts on both tower frequencies and Emergency frequency, 121.5,

to inform the aircraft of the nose-gear damage. The crew never responded,
113

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Page 2 of 2

however, they did squawk seven-six-zero-zero about three miles northeast of

the airport. The aircraft continued the right turn back to the airport and I

again got the aircraft in sight about two miles east of the airport as he turned

right-based to final for runway 31. I was still relaying damage reports to the

crew, but they continued the approach. The aircraft landed on Runway 31

and slid to rest on the nose strut about 400 feet northwest of runway 2L.
114

BNA-ATCT-079

VJA558

PERSONNEL STATEMENTS

FEDERAL AVIATION ADMINISTRATION

NASHVILLE ATCT

January 7, 1996

The following is a report concerning the accident involving VJA558 at the Nashville

Airport, January 7, 1996 at 2227 UTC.

My name is James D. Brooks (DW). I am empIoyed as a Supervisory Air Traffic Control

Specialist by the Federal Aviation Administration at the Nashville Air Traffic Control

Tower, Nashville, Tennessee.

During the period 1830 UTC to 0330 UTC, January 7, 1996, I was on duty in the

Nashville, TN ATCT. I was working the Cab Supervisor position from 1900 UTC to

0217 UTC.

I was about to take my dinner break when someone in the tower shouted “Look at

Critter”. When I looked up, I saw VJA558 in a nose-high attitude as the tail of the aircraft

hit the ground short of the runway 2R threshold. The nose then impacted the runway with

what appeared as tremendous force and debris from the nose commenced to falling off as

the aircraft commenced a go-around. I called the fire station giving them an Alert II on

VJA558, DC9, who lost two wheels and no further information available.

The aircraft made a right turn northeast of the airport, then turned toward runway 31,

while squawking seven-six-zero-zero. I took the light gun and tried flashing red to the

aircraft with no response. The aircraft landed on runway 31 sliding down the runway on

the nose strut until it came to rest.

./k“Q#iz4’ . ,’

-/” James D. Brooks
115

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VJA558

PERSONNEL STATEMENTS

FEDERAL AVIATION ADMINISTRATION

NASHVILLE ATCT

January 7, 1996

The following is a report concerning the accident involving VJA558 at the Nashville

Airport, January 7, 1996 at 2227 UTC.

My name is John M. Cowan (MC). I am employed as a Supervisory Air Traffic Control

Specialist by the Federal Aviation Administration at the Nashville Air Traffic Control

Tower, Nashville, Tennessee.

During the period 1800 UTC to 0230 UTC, January 7, 1996, I was on duty in the

Nashville, TN ATCT. I was working as the TRACON Supervisor, from 1841 UTC to

0221 UTC.

At approximately 2221Z, I was advised by the tower cab supervisor that VJA558 had

sustained damage during an attempted landing on runway 2R and had departed. I then

proceeded to the closest radar scope and observed VJA558 approximately 4 miles

northeast of the Nashville Airport. VJA558 circled to land runway 31.

~2z-

(/i John M. Cowan
116

m ,,

,1


119

APPENDIX E - EXCERPTS FROM VALUJET AND DOUGLAS

DOCUMENTS/MANUALS

0800-1200

1200-1300

1300-1700

0800-1200

1200-1300

1300-1700

0800-1200

1200-1300

1300-1700

0800-1200

1200-1300

1300-1700

VALUJET AIRLINES

SYLLABUS

GROUND TRAINING DAY 1

Basic Indoctrination

Operator Specific Subjects

LUNCH

Operator Specific Subjects

GROUND TRAINING DAY 2

Operator Specific Subjects

LUNCH

Operator Specific Subjects

GROUND TRAINING DAY 3

Operator Specific Subjects

LUNCH

Operator Specific Subjects

GROUND TRAINING DAY 4

Airman Specific Subjects

LUNCH

Airman Specific Subjects

September 14, 1993 Syllabus -1
120

VALUJET AIRLINES

0800-1200

1200-1300

1300-1700

0800-1200

1200-1300

1300-1700

0800-1200

1200-1300

1300-1500

1500-1700

GROUND TRAINING DAY 5

Airman Specific Subjects

LUNCH

Airman Specific Subjects

GROUND TRAINING DAY 6

General Emergency

Emergency Equipment and Drills

LUNCH

Emergency Equipment snd Drills

GROUND TRAINING DAY 7

Aircraft Systems

Aircraft Description

LUNCH

Aircraft Description

APU

September 14, 1993 Syllabus -2
121

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VALUJET AIRLINES

0800-1100

1100-1200

1200-1300

1300-1700

0s00-1200

1200-1300

1300-1500

1500-1700

0800-0930

0930-1200

1200-1300

1300-1700

GROUND TRAINING DAY 8

Fuel System

Fire Protection System

LUNCH

Powerplant

GROUND TRAINING DAY 9

Electrical System

LUNCH

Electrical System

Hydraulics

GROUND TRAINING DAY 10

Landing Gear

Brakes

LUNCH

Flight Controls

September 14, 1993 Syllabus – 3
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VALUJET AIRLINES

0800-1100

1100-1200

1200-1300

1300-1500

1500-1700

0800-0930

0930-1200

1200-1300

1300-1500

1500-1700

0800-1200

1200-1300

1300-1700

GROUND TRAINING DAY 11

Heating & Cooling

Pressurization System

LUNCH

Pressurization System

Ice & Rain Protection System

GROUND TRAINING DAY 12

Oxygen System

Emergency Equipment

LUNCH

Communications

Instruments

GROUND TRAINING DAY 13

Navigation

LUNCH

Automatic Flight

September 14, 1993 Syllabus -4
123

FlightSafety htmdiomi

0600-0700

0700-1115

1115-1200

1200-1300

1300-1500

0600-0700

0700-1115

1115-1200

1200-1300

1300-1500

0600-0700

0700-1115

1115-1200

1200-1300

1300-1500

VALUJET AIRLINES

GROUND TRAINING DAY 14

System Integration

Briefing

Fixed-Base Simulator

MEAL

Post-Briefing/Review

Performance

GROUND TRAINING DAY 15

Briefing

Fixed-Base Simulator

MEAL

Post-Briefing/Review

Performance

GROUND TRAINING DAY 16

Briefing

Fixed-Base Simulator

Post-Briefing/Review

Performance
124

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GROUND TRAINING DAY 17

Equipment Examination (Oral)

September 14, 1993 Syllabus -6
125

VALUJET AIRLINES

0600-0700

0700-1115

1115-1215

0600-0700

0700-1115

1115-1215

0600-0700

0700-1115

1115-1215

0300-0700

1115-1215

FLIGHT TRAINING DAY 1

Briefing

FulI-Flight Simulator

Post-Briefing/Review

FLIGHT TRAINING DAY 2

Briefing

Full-Flight Simulator

Post-Briefing/Review

FLIGHT TRAINING DAY 3

Briefing

Full-Flight Simulator

Post-Briefing/Review

FLIGHT TRAINING DAY 4

Briefing

Full-Flight Simulator

Post-Briefing/Review
126

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FLIGHT TRAINING DAY 5

0600-0700 Briefing

0700-1115 Full-Flight Simulator

1115-1215 Post-Briefing/Review

FLIGHT TRAINING DAY 6

0600-0700 Briefing

0700-1115 Full-Flight Simulator

1115-1215 Post-Briefing/Review

FLIGHT TRAINING EVALUATION

0600-0700 Briefing

0700-1115 Full-Flight Simulator

1115-1215 Post-Briefing/Review

September 14, 1993 Syllabus – 8
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LESSON NAME:

Landing Gear

TIME:

1.5 Hours

LESSON OBJECTIVES:

With the use of the DC-9 Pilot Manual, checklists, transparencies, cockpit systems simulator,

appropriate handouts, and class notes, the pilot will be able to:

1.

2.

3.

4.

5.

Locate, identify, and state the function of all panels, controls, switches, lights, and

indicators involving landing gear, and state their proper use.

State procedure for preflighting landing gear system.

Knowledgeably discuss all landing gear system limitations.

Knowledgeably discuss normal procedures for proper management of landing gear

system for all phases of operation.

Knowledgeably discuss and locate all systems-related emergency/abnormal checklist procedures.

July 16, 1993 Landing Gear– 1
128

VALUJET AIRLINES

LESSON ELEMENTS:

I. Aircraft Systems Modules

A. Landing Gear Module

1. General Description

a. Mechanically-actuated hydraulically -operated tricycle gear

(1) Number and size of tires, speed rating, inflation pressure, etc

b. Landing gear controls and hydraulic pressure sources

(1) Hydraulic systems interaction in all modes of gear operation

(2) Gear handle

(3) Gear handle release button (handle override)

(4) Emergency gear extension lever

(a) Free-fall capability

c. HOW locked down and how held up

d. Gear doors

(1) Normal operation, main and nose gear doors

(2) Procedure for opening on ground

(3) Open main gear doors will drag ground

e. Spray deflectors on main gear; spray deflector or chine tires on nose gear

f. Tail bumper assembly

2. Nosewheel Steering

a. Controlled by steering wheel (t80 degrees) or redder pedals (*15 degrees)

b. Two hydraulic steering cylinders

(1) One pressurized by each hydraulic system

(2) One alone can provide nose gear steering at slight steering angle loss

(3) Shimmy dampers in neutral position

c. Manually operated bypass for towing

3. Ground shift mechanism

a. Location and purpose

b. Functions

1) Left ground control switch

2) Right ground control switch

c. Ramifications of override

July 16, 1993 Langing Gear- 2
129

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4. Operating Limitations

a. Cover all limitations, including gear extension/retraction speeds

b. Discuss landing with main gear doors open

5. Controls and Indicators

a. Include emergency gear extension lever, main gear visual position viewer, and nose gear visual lock indicator

6. Normal Procedures

a. Discuss all landing gear-related normal procedures

7. Emergency /Abnormal Procedures

a. In-depth coverage of all landing gear-related emergency/abnormal procedures

July 16, 1993 Landing Gear- 3
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VALUJET AIRLINES

EQUIPMENT.

1. Overhead projector

2. White or black board

3. DC-9 Pilot Manual

4. Cockpit procedures trainer

5. Checklist

INSTRUCTOR ACTIONS:

1. Introduce the lesson and state the lesson objectives.

2. Overview the lesson elements and provide motivation.

3. Present the lesson.

4. Conclude the presentation with a review of the lesson objectives by asking oral

questions.

STUDENT ACTIONS:

1. Listen, take notes, and ask questions.

2. Answer oral questions

3. Operator systems in CPT when required.

COMPLETION STANDARDS

The pilot must demonstrate adequate knowledge of the DC-9 aircraft systems, limitations, and performance by satisfactorily completing an Equipment Examination (Oral) normally

administered at the end of the Ground Training Curriculum Segment. The Equipment

Examination is administered by either the FAA or a Check Airman, as required.

July 16, 1993 Landing Gear- 4
131

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SYSTEM INTEGRATION PERIOD #3

DURATION:

Briefing: 20

c m : 4:0

Debrief: 2:0

BRIEFING:

1. Brief the objectives and the completion standards.

2.

3.

Brief initial conditions, aircraft status and load, and departure and arrival airport

weather.

Brief each procedure and maneuver that is to be accomplished in the lesson. Emphasize

4.

5.

the checklist and procedures to be used.

Brief performance data computation.

Brief abnormal/emergency procedures for hydraulics, landing gear and brakes, controls, and pressurization systems.

OBJECTIVES:

With the use of the aircraft checklist, weight & balance data, performance data

performance and planning manual, takeoff weights manual and the CPT, the crewmember

will be able to practice and demonstrate the following:

1. Accomplish all checklist and flow patterns in a proficient manner.

2. Abnormal/emergency procedures for systems covered in briefing.

3. As appropriate, abnormals and emergency procedures previously covered.

4. State all emergency procedure recall items.

flight

card.

P _’. _-t. .,n .M -
132

Cockpit Preflight Events:

1. As previously covered.

Engine Start and Taxi Events:

1. Abnormal start procedures not previously practiced.

2. Hydraulic and electrical system abnormals.

Takeoff Events:

L

2.

3.

Climb

1.

2.

As previously covered.

Engine failure on takeoff.

Landing gear retraction abnormals.

Events:

Normal procedures

Hydraulic, landing gear, and flight control systems abnormals.

Cruise Events

1. Engine and electrical system abnormals not previously practiced.

2. Hydraulic and flight control system abnormals.

3. Pressurization system abnormals.

Descent Events:

1. Normal pressurization.

2. Landing data, including abnormal conditions.

3. Descent checklist and procedures.

Approach and Landing Events:

1. Approach checklist and procedures.

2. Gear extension abnormals.

3. Before landing-final checklist.

4. Required callouts.

After Landing Events:

L After landing checklist.

2. Parking checklist and procedures.

3. Terminating checklist and procedures.

September 12. 1995 Svct.m. 7=+. -.*;-” ~. -
133

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SYSTEM INTEGRATION PERIOD #3

EQUIPMENT

1. Cockpit Systems Training Device

2. White or Blackboard & chalk

3. Checklist and Performance Data Cards

4. Weight & Balance Template and Forms

5. Performance & PIanning Manual or Data

6. Takeoff and Landing Weights Manuals or Data as appropriate.

INSTRUCTOR ACTIONS:

1. Introduce the lesson and state the lesson objectives.

2 Overview the lesson elements and provide motivation.

3. Provide assistance as required to help crewmember integrate the system training

with procedures.

STUDENT ACTIONS:

1. Complete all Weight & Balance and performance problems.

2. practice all procedures and checklist responses.

3. Commit to memory all required recall items.

4. Take notes and ask questions.

COMPLETION STANDARDS:

The pilot must demonstrate adequate knowledge of the DC-9 systems; the ability to perform

normal procedures within the required limitations; and familiarity with all checklist

procedures and proper responses by satisfactorily completing an Equipment Examination

(Oral) normally administered at the end of the Ground Training Curriculum Segment. The

Equipment Examination is administered by either the FAA or a Check Airman, as required.
PAGE: A-1 1-2

DATE: 3/13/95 VALUJET

REVISION: 8 ABNORMAL PROCEDURES

AIRCRAFT OPERATING MANUAL - DC-9

UNABLE TO RAISE GEAR LEVER

NOTE

Indicates possible malfunction of ground shift.

NOSE STEERING WHEEL.....................OPERATE (C)

- Attempt to turn nose steering wheel using

normal force.

If steering wheel does NOT turn and centering

indices are aligned:

Indicates a malfunction of the anti–retraction mechanism.

lf desired, retract landing gear:

GEAR HANDLE RELEASE BUTTON. . . . . . . . . .PUSH (PNF) - Bypasses anti-retraction mechanism.

GEAR LEVER. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . UP (PNF) - Press release button and place lever UP to retract

the gear.

If steering wheel turns:

DO NOT RETRACT THE GEAR

Indicates ground shift mechanism is still in the ground

mode.

No auto-presaurization, and takeoff warning horn will

sound when flaps/slats are retracted.

VALUJET PAGE: A-11-.3

DATE: 3/13/95

ABNORMAL PROCEDURES REVISION: 8

AIRCRAFT OPERATING MANUAL - DC-9

Approach and landing:

If landing gear was not retracted prior to landing,

ground spoilers must be operated manually.

AIRPLANE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. REPRESSURIZE (PNF)

- Ensure airplane is repressurized prior to

landing.

ANTI-SKID SWITCH (before 30kits ) . . . . . . . . . . . . . OFF (PNF)

- During landing rollout and prior to 30 kts,

momentarily release brakes and place Anti-skid

switch to OFF.

GROUND CONTROL RELAY C/Bs (if pulled)

(H2O and J20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESET (C or FO)

- Reset Ground Control Relay circuit breakers

during taxi and verify that circuits are in the

ground mode.

The ground control relay electrical circuits can be

placed in the flight mode by pulling the Ground Control
135

VALUJET

QUICK REFERENCE HANDBOOK

PILOT MANUAL - DC-9

UNABLE TO RAISE GEAR LEVER

NOSE STEERING WHEEL . . . . . . . . . . . . . . . . . . . . . . . .. OPERATE (c)

If steering wheel does NOT turn and centering

indices are aligned:

Indicates a malfunction of the anti-retraction

mechanism.

If desired, retract landing gear:

GEAR HANDLE RELEASE BUTTON ............. PUSH (PNF)

GEAR LEVER.................................UP (PNF)

If steering wheel turns:

DO NOT RETRACT THE GEAR

Indicates ground shift mechanism is still in the ground

mode.

No auto-pressurization, and takeoff warning horn will

sound when flaps/slats are retracted.

The ground control relay electrical circuits can be placed

in the flight mode by pulling the Ground Control Relay

circuit breakers (H20 and J20).

Do not exceed VLE (300 kts/M.70).

Approach and landing:

If landing gear was not retracted prior to landing,

ground spoilers must be operated manually.

AIRPLANE................................DEPRESSURIZE (PNF)

ANTI-SKID SWITCH (before 30 kts).................OFF (PNF)

GROUND CONTROL RELAY C/Bs (if pulled)

(H20 and J20).................................RESET (C or FO)
136

VALUJET Page: 10-2

Date: 9/20/95

COMPANY OPERATIONS MANUAL Revision: 46

pilot, he/she shall declare an emergency and take any

action that he/she considers necessary under the

circumstances.

3. Whenever a pilot-in-comnand or dispatcher exercises

emergency authority, he/she shall keep the

appropriate ATC facility and System Operations

Control fully informed of the progress of the

flight. The person declaring the emergency shall

send a written report of any deviation, through

Flight Operations, to the Administrator. A

dispatcher shall send his/her report within 10 days

after the date of the emergency, and a pilot-incommand shall send his/her report within 10 days

after returning to his/her home base.

4. Regulations do not intend that a situation or

condition must become critical before emergency

authority is exercised. The Captain will make an

evaluation of the factors and information available

to him, and if he/she then believes an emergency

exists or will be created, will take the action

he/she deems necessary. ValuJet System Operations

Control Is responsible to provide advice and

information to assist the Captain during the

emergency; however, the Captain’s decision is final.

D.

1. The Captain shall report all incidents and/or

irregularities to System Operations Control by radio

or telephone at the earliest opportunity.

2. In addition to the above, the Captain must notify the

Chief Pilot and/or Vice President - Flight Operations

by telephone or teletype immediately after landing

and submit a written report immediately upon his/her

return to home base.

B

The following should be considered emergency conditions:

1. Indication of fire on board the airplane.

2. Failure or malfunction of aircraft or any component

which interferes with the continued safe operation.

3. Priority handling requested of ATC by the P.I.C.

4. Inability to establish definite position.

5. Flight more than twenty minutes overdue and not heard

from at terminal, intermediate station, or other

check point.
137

VALUJET Page: 3-17

Date: 10/10/94

COMPANY OPERATIONS MANUAL Revision: 35

3.3

A.

B.

C.

D.

ME~

Flvina~ L“ft S“a$

Except as may be authorized by the Chief Pilot, all

flight officers will perform their duties from their

normal seats. Designated Check Airmen are authorized to

occupy a pilot seat in conjunction with required initial

or annual enroute checks.

Pr PIV*

1.

2.

3.

A captain who has at least 100 hours as P.I.C. in jet

transport aircraft under Part 121 may, at his/her

discretion, allow the First Officer to manipulate the

flight controls for takeoffs, approaches and landings

as well as enroute phases of flight.

A First Officer who has not met the 100 hour minimum

requirement shall not be paired with a Captain who

also has not met the requirement.

Before take-off, the Captain shall satisfy

himself/herself that the First Officer (and AC if

applicable) clearly understands the duties he/she is

to perform. Also, the Captain should also ensure

that the First Officer fully understands the

procedures to be flown for both take-off and landing.

Should any crewmember become incapacitated and unable to

perform his/her prescribed function, the sequence of

command shall be as follows:

1. Captain

2. First Officer

3. Position One Flight Attendant

4. Flight Attendants, in order of seniority.

Should the Captain become incapacitated, the First

Officer should remain in the right seat for landing.

Uew R~ct=

In today’s cockpit environment, the technical skills

that Flight Crewmembers possess to fly an aircraft from

point A to point B need to be supplemented with “Human

Factors” skills. Crews must effectively utilize all the

resources available, that includes other Crew members.

CRM is the blend of technical and human skills required

to support the safe and efficient operation of our

aircraft.
138

VALUJET BULLETIN # 148

PILOT READ FILE January 8, 1996

To: All Pilots

From: Director Flight Standards and TrainingPD

Re: QRH

If it becomes necessary to refer to the QRH( Quick Reference Handbook), for Emergency

or Abnormals procedures, Please use the appropriate section of the AOM(Aircraft

Operating Manual) in conjunction. with the QRH.
139

TECH. PUBS. VALUJET Fax:770-907-5035 Jul 25 ’96 13:50 P. 02

VALUJET BULLETIN # 153

PILOT READ FILE February 22,1996

To: All Pilots

From: Director Flight Standards and Training

Re: First Officer Minimums/ QRH removal from aircraft

Effective immediately, First Officer minimums will be 300’ AGL and 3/4 miles visibility.

Additionally, the First Officer minimums in the first 100 hours will be 500’ AGL and 1 %

miles visibility.

In the next few days, all of the aircraft should have the new Emergency Check list on

board. If you should encounter a aircraft with the QRH on board, please give this office a

call at 770-907-5421 and let us know. In this case, remember that the QRH is to be used for

reference only and the Aircraft Operating Manual will have updated information.

Maintenance in ATL and IAD Emergency Cheek List on hand.
140

(c)

(d)

DOUGLAS AIRCRAFT CO., INC.

DC-9

MAINTENANCE MANUAL

TEMPORARY

REVISION

If ice was found on the wing upper surface, recheck the

wing by using suitable means after deicing/anti-icing, to

ensure that all deposits of ice have been removed.

CAUTION: IN SOME CASES PRESENCE OF ICE CAN ONLY BE

DETERMINED BY TOUCH.

Fuselage areas in front of the cockpit windows must be

free of snow and ice. This is also-valid for all air

inlet and outlet openings of the APU and air-conditioning

as well as their adjacent areas.

(2) Functional test of flight controls.

(a) Should an aircraft have an extreme ice or snow cover, a

flight control check should be considered according to the

type of aircraft. This check should be performed after

deicing.

(3) Check of engine inlets, probes, and fan blades.

(a ) Engines that have been subjected to strong snowfall and/or

freezing rain during freezing temperatures and strong

winds have to be checked for possible accumulation of snow

and/or ice in the inlet area prior to startup.

(b) Under freezing fog conditions a check of the rearside of

the fan blades for ice build-up is recommended.

(c) In case of fan blade icing, hot air shall be used to melt

the ice.

12. Additional Cold Weather Servicing Requirements

A. Nose Gear Strut

( 1 ) Prior to cold weather season:

(a) Change fluid in strut. This prevents seal damage caused

by water in fluid which changes to ice particles during

cold weather exposure.

(b) Replace seals as required.

(2) During cold season:

(a) Check strut for servicing requirements every 14 days.

(b) Wipe exposed chromed surface of piston with MIL-H-5606

hydraulic oil daily.

12-53-0
141

DOUGLAS AIRCRAFT CO., INC.

DC-9

MAINTENANCE MANUAL

B. Water and Lavatory Servicing

TEMPORARY

REVISION

(1)

( 2 )

When cabin is heated after a prolonged cold soak, plumbing

below floor level can be considerably colder, and lines may

freeze when water is added. To prevent this, do not service

systems until the cabin has reached 70°F (21°C) and area

below floor has been checked to ensure that warm air has

been circulated. In general,with an outside temperature of

32°F (O°C),a minimum of two hours heating the cabin at 70°F

(21°C) will be required to ensure the below-floor plumbing

will not freeze.

If aircraft has been parked in freezing temperatures for two

hours or longer between flights, maintain heat on aircraft,

and leave lavatory doors open and toilet seats raised to

allow a more even distribution of cabin temperature.

c. Towing Operations - These precautions should be taken to

prevent deflation of nose gear strut and tires:

(1) All pushouts and towing operations need to be performed

smoothly. A jerky start will place enough force on nose

gear to cause strut to start leaking.

( 2 ) Sharp turns are to be avoided, since too much weight will be

placed on outside tire, and could cause seal between tire

and rim to break with subsequent tire leakage.

(3) After snow removal, a frozen ridge may remain next to tire.

Unless aircraft is pushed straight back, tire may contact

ridge. This also could cause tire and rim seal to break

with subsequent loss of tire pressure.

D. Batteries - Maintain an external electrical power supply on

aircraft to keep batteries charged. If this is not practical,

make certain that an external power supply is connected to

aircraft to at least three hours prior to using battery (such

as, an APU start). Failure to do so may shorten battery life.

E. Doors - Perform the following prior to start of cold weather

season:

(1) Check all door linkages, hinges, etc., for wear and

alignment.

(2) Check doors for proper gap between door skin and doorjamb.

Failure to do so may result in difficulties in opening

doors, especially during cold weather operations where a

reduced gap may increase incidence of water freezing between

door skin and doorjamb.

elm974614 P.*

.-

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ha”*# . . U,k.h

Sep 1/81

145

EXPORT AUTHORITY: L.uENSE GTDR

A O L FLIGHr

ALL OPERATORS LETTER

OPEI?AIIONS

%

McOO””.11 OO”g,~ Co,..ard, on (M DC) mo~,.t~v ,,Q,,, ~. ,“O . . ...” ,,. ,n,o, md, on a,..,..

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January 24, 199 6

FO-AOL-9-057

FO-AOL-90-003 .,

To: All DC-9, C-9, MD-80, & MD-90 Operators

Subject: DOUGLAS FCOM ABNORMAL PROCEDURE, "UNABLE TO

RAISE LANDING GEAR HANDLE AFTER TAKEOFF”

Applicable to: All DC-9, C-9, MD-80, & MD-90 Aircraft

ATA Chapter No. : 32-00, Landing Gear

Reason: To remind operators of the

understanding and adhering

procedures .

importance of

to established

During a recent DC-9 hard landing accident investigation it was

determined that ground spoilers were deployed on short final with

insufficient altitude remaining t o recover from the resulting

high sink rate. The aircraft struck approach lights just short

of the runway and a hard landing followed. The captain executed

a go-around, and returned for a second landing.

Further investigation revealed that upon departure from the

originating airport the landing gear handle could not be raised.

The crew initiated the appropriate abnormal procedure and

determined that the ground shift mechanism was still in the

“ground” mode. Per this procedure, the landing gear was raised,

and the GROUND CONTROL RELAY circuit breakers were pulled to

place the aircraft systems into the “air” mode. During approach

to the destination airport, the aircraft was configured for

landing and the spoilers were armed for automatic deployment upon

touchdown. After consulting the operator’s “Quick Reference

Handbook”, the flight crew elected to reset the circuit breakers

while the aircraft was on short final. As a consequence of

resetting the breakers, the aircraft was returned to the “ground”

mode, resulting in the automatic deployment of the armed spoilers

and the subsequent hard landing.

NOTE : The subject Douglas procedure and the operator’s “Aircraft

Operating Manual” call for the circuit breakers to be reset

during post-landing taxi.

‘ld.”h.t W-r-t<-rv Dint.oner Ser7ic.g, DOuqlas Aircraft COmDany
146

JUL-25-1936 12:21 FRO M GM FLT OPS 00LIGLFIS RIRCFT T O 012023826819 P.0 2

WIN JET

Volume2 lssue2 JUNE 1996

by

Bill Steelhammer

Senior Accident Investigator

A DOUGLAS FLIGHT CREW

OPERATING MANUAL

ABNORMAL PROCEDURE

During the accident investigation of a recent

DC-9 hard landing, it was determined that the

ground spoilers were deployed on short final.

This resulted in a high sink rate from which

them was insufficient altitude to recover. The

aircraft struck the runway approach lights, and

made a hard landing on the runway from which

a missed approach was executed to an uneventful landing.

Upon subsequent investigation it was revealed

that after takeoff the gear handle could not be

raised. The flight crew initiated the appropriate

abnormal procedure and determined that the

ground shift mechanism was still in the

"GROUND" mode. This abnormal procedure

required that after gear retraction the aircraft be

put into the “flight” mode by pulling both

GROUND CONTROL RELAY C/Bs.

During approach to the destination airport, the

aircraft was configured for landing and the

spoilers armed for automatic deployment at

touchdown. The crew then referred to the Operators Quick Reference Handbook and chose to

reset the C/Bs while the aircraft was on short

final. This action immediately returned the aircraft to the "GROUND" mode, resulting in the

automatic extension of the ground spoilers and

the subsequent near disaster.

NOTE: The subject Douglas procedure

and the operator’s "Aircraft Operating Manual" call for the C/Bs to

be reset during taxi.

Normally, automatic spoiler extension requires

one of two conditions to be met:

1 . Main wheel spinup, or

2. Ground shift mechanism in the

"GROUND" mode.

This accident occurred when the second condition was fulfilled on short final.

In this instance, arming the spoilers for landing

is acceptable, provided the C/Bs are not reset

until after landing. During landing, main wheel

spinup will normally actuate autospoiler extension even though the "GROUND" CONTROL

RELAY" C/Bs are pulled. Alternatively, it

would be acceptable NOT to arm the spoilers

prior to landing, but manually extend them after

touchdown, provided the associated landing

distance penalty is applied (add 470 feet to

landing distance on a dry runway or 540 feet on

a wet runway).
147

APPENDIX F - FAA DOCUMENTS/CORRESPONDENCE
PROGRAM TRACKING AND REPORTING SUBSYSTEM DATA SHEET

ECTION I —- - - - I SECTION IV - COMMENT SECTION (~lmlt.rl)

~--- ‘u Record 10

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(UPIE)

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migmtoc Airman Grf a: ——— Imn *@Other

Ircrsft Reg w N

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Dc/~rturo Point:~7~ Arriv.! Point: Flight #

WIigs!ion d (12):

i

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149

GEORGIA FLIGHT STANDARDS DISTRICT OFFICE

1701 COLUMBIA AVENUE - CAMPUS BUILDING

COLLEGE PARK, GEORGIA 30337

February 5, 1996

Mr. Richard Hillman

Senior Vice President Operations

ValuJet Airlines, Inc.

1800 Phoenix Boulevard

Suite 226

Atlanta, GA 30349

Recent incidents that have occurred during line operations on ValuJet Airlines plus

observations made by FAA Inspectors conducting Enroute Surveillance and my own

observations whiIe observing new hire pilot training in Miami, have brought to light what

appears to be an area of possible concern:

1. In three of the recent incidents/accidents involving ValuJet aircraft, each

occured during bad weather and the pilot at the controls was the First Officer. In several

cases the Captain was either new and/or had very little Part 121 experience.

2. Inspectors conducting enroute surveillance have found it necessary to council

Captains in order to keep them from operating contrary to FAR’s and in each case they

have been relatively new Captains who had very little experience in Part 121 operations.

3. The new hire class that is currently in training in Miami appears to have only

one pilot with prior 121 experience.

4. Recent Enroute Surveillance has indicated that due to the rapid expansion of

ValuJet Airlines many of the new Captains have a minimal amount of Part 121 experience.

It appears that the Captains are allowing the First Officer to make the takeoff and/or

landing out of response to an unwritten practice of alternating that function rather than

considering the weather and/or their own need for experience.
150

There is no doubt that our concerns parallel your own and that you are conducting your

own evaluation of the reasons for these events.

Please give this matter your immediate attention and provide this office with your

evaluation and actions that you will be taking. Please respond to this letter by March 5,

1996.

Sincerely,

C:* ~~~cd ~

Robert E. Bruce

Principal Operations Inspector

Bruce:br:02-05-96:h:lowtime
151

VALUJET

VJ6A465W

ALANTA, GA.

2/14/96

Report prepared by

AFS-300
152

This report summary addresses ValuJet Airline’s accident/ incidents, enforcement history,

NASIP Inspections, and the FAA's surveillance activity. Airworthiness concerns

following two (2) recent accidents and a DOT Office of Inspector General (OIG) audit of

the air carrier are the catalyst of this analysis.

Valujet was originally certified as a domestic air carrier (121) on October 21,1993. Their

certificate number is VJ6A465W. ValuJet will be addressed as VJ6A throughout the

remainder of this report.

Their principal base of operations is Atlanta, Ga. Additionally, they operate two (2)

maintenance facilities at the Hartfield Airport, Atlanta, Ga. and Dulles Airport, Va.

General Information:

VJ6A has an adequate management staff that consists of:

CEO

General Manager

Vice President of Maintenance

Director of Maintenance

Chief Pilot

Director of Operations

Chief Inspector

Director of Aircraft Programs

Director of Technical Services,

Director of Safety

The VP of Maintenance, Director of Technical Services, Director of Aircraft Programs,

Chief Inspector, and Director of Safety are recent additions to the management staff.

VJ6A principal inspectors consider ail individuals well qualified for their positions.

VJ6A’S Certificate is managed by the ATL-FSDO, College Park, Ga. The Principal FAA

Inspectors are:

PMI David J. Harper

POI Robert E. Bruce

PAI David L. Frantz

VJ6A employs approx. 142 captains, 17 check airman, 4 designated inspectors, 170 pilots,

450 flight attendants, 156 A&P mechanics, 137 ground personnel, and numerous other

staff and service personnel.

The primary training location for pilots, flight attendants, and mechanics is Atlanta, Ga.
153

VJ6A operates 34 DC-9-30 series aircraft and uses contract maintenance facilities for

scheduled and unscheduled maintenance away from their main base in Atlanta and the

sub-base at Dulles.

Contract Maintenance Organizations:

1. AMR Combs

2. Signature Flight Services

3. Lane Aviation

4. AMR and NWAA

5. Jet Center

6. USAIR

7. David Yocum

8. North West

9. Signature Flight Support

10. North West

11. Continental

12. Continental

13. Rick Aviation

14. Northwest

15. Jet South

16. AMR

17. Northwest

Windsor Lock Ct.

Boston, Ms.

Columbus, Oh

Dallas, Tx.

Fort Lauderdale, Fl.

Oakland, Ca.

Kansas City, Mo.

Orlando, Fl.

Chicago, IL.

Memphis, Tn.

New Orleans, La.

West Palm Beach, Fl.

Newport news, Va.

Philadelphia, Pa.

Fort Myers Fl.

Savannah, Ga.

Tampa, Fl.

The company phone number is (404) 907-2580.

ACCIDENT/INCIDENT:

Accident History:

1. July 5, 1994 aircraft encountered moderate chop at cruise. One (1) cabin crew

member suffered multiple leg fractures no fatalities. The NTSB investigated and

determined probable cause as severe turbulence over flight area.

2. June 8, 1995 aircraft experienced a uncontained turbine failure during takeoff

roll at Atlanta’s Hartsfield Airport, Ga. Five (5) passengers and one (1) cabin crew

member were injured no fatalities. The NTSB is investigating, with no probable cause

reported.

3. January 71996 during an attempted landing at Nashville, Tn. the aircraft

sustained damage to the nose landing gear. The aircraft departed the runway, circled and

landed with no nose landing gear. NTSB is investigating, with no probable cause

reported. No fatalities or injuries reported.

2
154

Incident History:

VJ6A had a total of nine (9) incidents since 1994 with the last one occurring in December

1995.

VIOLATION HISTORY: .— —.

~~ -

\

VJ6A has a tot, e 1993 with 20 violation ~~operL Approx.

Six (6) of thfioIatibns were mainte&~~s violated are; 43.9,43.13,

121.363, 12~*7, and 121.369. No accidents were related to any of these violations.

AII maintenance related violation were closed with administrative action (letter of

correction). In an analysis of the enforcement action it was noted that a violation of FAR

121.363 occurred two (2) times in less than one (1) year and both closed with letters of

correction.

FAA Order 2150.3A specifically states that the letter of corrections sole purpose is to

correct conditions which are in violation of the FARs. With the second violation of FAR

121.363 occurring within one (1) of the first violation it appears that the corrective action

was not adequate.

NASIP

I

A NASIP was performed at VJ6A in September 1995 A total 58 findings were noted.

The category are: L

I. 17 Category A

2. 17 Category B

3. 24 Category C

43 of the 58 findings were maintenance related. While the inspection was completed five

months ago, 43 findings have not been closed.

The significant maintenance related NASIP findings are

/

Manuals and Procedures:

t

1. Eleven findings were noted with the document that outlines the continued

analysis and surveillance program (CAS). The significant findings include

Problems with CAS forms numbering system

CAS does not address engine trend monitoring

Maintenance Manual conflicts with CAS document

CAS program not accepted by the FAA

3
155

✦ CAS does not outline audit function

✦ CAS does not address emergency response

✦ CAS reference a reliability program however, VJ6A has none

2. Fifteen findings were noted with the General Maintenance ManuaI (GMM) and

related documents. The significant findings include

✦ GMM conflicts with FAR requirements in several areas

✦ Fuel Manual not adequate several important items omitted

✦ GMM has conflicting chapters . ✦ GMM does not establish guidelines for RII training

✦ Winter Ops. Manual reference incorrect information on de-icing fluids

✦ Maintenance Check Manual not current in Maint. Planning Dept.

Records Systems:

3. Two findings were noted with the records system they are

✦ No engine rendition monitoring records

✦ CAS reported a maintenance problem, however, no records were found

correcting problem

Maintenance Facilities:

4. Nine findings were noted in the area of Maintenance Facilities. The significant

findings include:

✦ Parts found in bins without records

✦ Parts not identified IAW GMM

✦ A system not outlined in the GMM used to track returned parts to stock

✦ Part scrapping procedure not addressed in GMM

Ramps and Spots:

5. Four findings were noted in the area of ramps and spots. The significant

findings include: 

✦ MEL procedure not followed

✦ Performing maintenance without adequate facilities

✦ Performing maintenance with unapproved procedures

4
156

FAA SURVEILLANT HISTORY:

The following is an analysis of two (2) years of VJ6A’s surveillance activities. The data

was obtained from the NationalPTRS. 22 air carrier specific inspection items were

analyzed. They are identified by the surveillance codes as they appear in the PTRS

Manual.

A reference table is provided below the histogram that identifies the PTRS Code with the

actual inspection function. Example; Number 27 on the chart is a ramp inspection that

was accomplished 226 times in two (2) years.

The histogram clearly shows that the most accomplished inspection is the ramp inspection

PTRS Code 3627 and the least accomplished is the structural inspection PTRS Code

3646.

FTRS DATA FOR FY 94 & 9S

220

200

180

160

140

120

100

80

60

40

20

0

12222223333333 3344444 4

S 15676902345678 901267 9

Reference:

19. = Main Base

21. = Line Station

25. = Air Operators Special Inspection

26. = Manuals and Procedures

27. = Ramps

28. = Spo t

29. = En Route

30. = En Route Cabin

32. = Shop/Facility

33. =Training Records

34. = Aircraft Records

35. = Continuing Analysis

3619= 003

3621 = 036

3625 = 015

3626 = 006

3627 = 226

3628 = 046

3629 = 141

3630 = 006

3632 = 005

3633 = 006

3634 = 031

3635 = 005
157

36. = Reliability Program

37. = Inspection Program

38. = Fuel Facility

39. = Approved Weight& Balance

40. = Contract Maintenance Facility

41. =

Maintenance Support Facility

42. = Technical Manuals

46. = Structural Inspection

47. = Structural spot

49. = Airworthiness Directives

3636 = 002

3637 = 009

3638 = 020

3639 = 003

3640 = 015

3641 = 002

3642 = 005

3646 = 000

3647 = 003

3649 = 003

A total of 588 inspection items were recorded by the certificate management office and

geographic inspectors during the work program years of FY 94 and 95.

Of the 588 inspections 359 were satisfactory, eight (8) were not accomplished eight (8)

were canceled “X-out”, 207 recorded some discrepancy, and six (6) resulted in

enforcement action.

36 percent of all inspection accomplished in two (2) years recorded some findings.

It was noted that surveillance code 3636 reliability program inspection was recorded

two (2) times with a total of 10 inspector hours charged to an air carrier that does not

have a reliability program.

When comparing the NASIP findings with surveillance activities, we clearly see that areas

receiving the least attention during the inspection year make up the majority of the

maintenance related NASIP tidings.

In addition to the PTRS information a report was run on the Safety Performance Analysis

System (SPAS) for VJ6A The report analyzed the following areas:

Records and Procedures

Airworthiness Surveillance

Aircraft Records

The report covered approx. three years of data. In all areas analyzed, VJ6A was at the

advisory and or alert threshold in the majority of the months studied.

Additionally, an independent regional aviation safety specialist analyzed VJ6A inspection

and surveillance data with virtually the same results and conclusions as this report. This

additional sources further validates our hypothesis.

6
158

This report addressed VJ6A’S accident/incident, enforcement history, NASIP Inspection

and the FAA’s surveillance activity. The data reviewed, clearly show some weakness in

the FAA’s surveillance.

The PTRS data analysis revealed that some critical surveillance activities did not receive

much attention. They are as follows

1. Manuals and Procedures PTRS Code 3626 six (6) inspection

2. Shop and Facilities PTRS Code 3632 five (5) inspection

3. Structural Inspection PTRS Code 3646 zero (0) inspections

Although some may argue that six (6) inspections of manuals and procedures is sufficient

in two (2) years, you need only look to the recent NASIP Inspection findings to see why

more inspections should have been done. 35 of the inspection findings were in the

manuals and procedures and shop and facilities area Additionally, the SPAS data for

procedures indicate that increased surveillance is warranted. 20 times between December

1993 and January 1996 VJ6A was at the advisory and or alert threshold.

The PTRS data also indicated that no structural inspections were accomplished on VJ6A's

aircraft in two (2) years. With a supplemental inspection document (SID) required by AD

87-14-07 to ensure continued structural integrity of an aging fleet of DC-9 aircraft,

AFS 300 believes this critical inspection was severely overlooked.

The findings closet date for the September 1995 NASIP inspection is February 28,1996

RECOMMENDATIONS:

Based on VJ6A’S history, The NASIP Inspection NTSB and OIG investigations, and

Surveillance AFS-300 can recommend the following actions:

/

L Consideration should be given to an irnmd:ate FAR-121 re-certification of this

airfine. his recommendation~based on such h-o-~ related issues as ti~absence

L

of adequate po. i= and procedures for the maintenance ersonnel o f Ow.

Additionally, th \

sence o . nd monit ring ~ and the possibtity of a

continuous airworthin - es

reliability.based procedures without a reliability program. ~\

d

2. The overall surveillance of the air carrier should be increased in FY96. Special

attention should be directed toward manuals and procedures, structural inspections, the
159

adequacy of the maintenance program, and shops and facilities. Additionally, the PMI

should consider accomplishing two (2) main base inspections every year.

3. The close out deadline for the NASIP inspection is February 28, 1996. Every

effort should be made to meet this dead line with positive corrective action.

4. When a violation of the FARs are detected the inspector should consider past

enforcement history before administrative corrective action is offered. if an air carrier

violates the same regulation in a short period of time, escalating the enforcement action

may be appropriate.

This report was compiled from information obtained from the national database and

VJ6A’s NASIP Inspection Report. A physical inspection of the maintenance manual was

not conducted by AFS-330

8
160

Memorandum

Atlanta FSDO

Campus Building, Suite 2-11O

1701 Columbia Avenue

College Park, GA 30337-2748

ACTION:

Program

Manager,

Manager,

ValuJet Special Emphasis Date: February 16, 1996

ATL FSDO A&m?O? Spillner:

(404) 305-7200

File:1380-6

Flight Standards Division,

ASO-200

The ATL FSDO will be implementing a special emphasis

program for ValuJet Airlines, for a 120-day period,

beginning February 20, 1996. The program will consist of

four elements. A copy of the plan for the special emphasis

program is attached.

The Atlanta FSDO has directed all available air carrier

inspectors to this special emphasis program. The program

will have a significant impact on the office’s ability to

meet our mission requirement outside of ValuJet.

Attachment two describes the impact on the office.

In addition,we are requesting your assistance in obtaining

two qualified air carrier inspectors, preferably with a DC9 background to assist the POI during the 120-day special

emphasis program for ValuJet.

Charles A. Spillner

2 Attachments

cc: ASO-250/ASO-290

zO”d
161

ATLANTA FSDO

ValuJet Special Emphasis Program

ValuJet has experienced several accidents and incidents during the past year. After

considerable analysis these occurrences do not appear to be related and the traditional

inspection programs (NASIP, RASIP) have not been the key to unlock the reasons for

the occurrences. Some other concerns of the ATL FSDO are:

a. ValuJet is an unconventional carrier when compared to moretraditional 121

operators. They are innovators, dedicated to low overhead leasing rather thanowning

and tightly controlling all expenses, The tight control of expenses includes training (pilot

pays), equipment purchases (d), and maintenance (all contracted out to geographically

diverse low bidders).

b. An inordinate amount of time that the principal inspectors are having to direct

towards answering Congressional, NTSB, DOTIG, DOD, GAO inquiries and FAA safety

and consumer hotline issues.

c. An increase in unfavorable geographic reports concerning maintenance

discrepancies found by FAA inspectors during revenue operations.

d. A significant decrease in experience level of new pilots being hired by ValuJet

es well as other positions such as mechanics, dispatchers, etc.

c. Continuous changes of key management personnel.

f. The ATL FSDO's management will divert critically scarce resources from other

carrier assignments to support this effort.

In order to capture a macro view of ValuJet, the ATL FSDO will initiate a special

emphasis program beginning February 20, 1996. The program will be conducted for a

120-day period and will consist of four elements. The first element will be to

supplement the current ValuJet assignment with additional inspectors. The second

element will be to conduct a systems review by placing emphasis on the observations of

ValuJet personnel in an operational environment Record inspections will be limited to

those records that are being used by ValuJet personnelforthe functionbeingobserved or

to validate a function that bas been observed. Geographical offices will be used to the

maximum extent possible to assist the review. They will be provided an updated

newsletter outlining our areas of concern.

EO. d
162

A separate team will be formed that will be dedicated solely to ValuJet. The team will

be headed by George Uhrin. George is an experienced supervisor and has a good

working knowledge of theValuJet assignment. The makeup of the other team members

is as follows:

Maintenance: Five qualified air carrier inspectors will be assigned to assist the PMI.

Avionics: The PAI will be relieved of all other assignments.

Operations: The POI and APOI will be relieved of their flight test duties. Two

geographic PPM’s will be assigned to the ValuJet assignment; however, most of their

time will be devoted to flight test duties. No other qualified air carrier operations

inspectors are available within the FSDO. The ATL FSDO is requesting the assistance of

two air carrier operations inspectors for a 120-day detail to the ValuJet assignment

Beginning on Thursday, February 22, 1996, the ATL FSDO will conduct a systems

review by placing emphasis on the observation of Valujet personnel in an operational

environment. Additional emphasis will be placed on an evaluation of ValuJet's

accident/incident program and continuing analysis and surveillance program (CAS). The

review will continue for a seven-day period. Record inspections wiIl be limited to those

records that are being used by Valujet personnel for the function being observed or to

validate a function that has been observed. Geographic offices will be used to the

maximum extent possible to assist the review.

We will plan on expending the majority of inspectors’ time in the field. The principals

will remain in the FSDO and track all the data received from the field inspectors.

Adjustment will be made during this program based on the data they have received.

The results of this review coupled with information from previous inspections should

provide the FSDO with the data needed for a systems analysis of the entire ValuJet

operation. The attachments one and two describe the emphasis to be placed in the areas

of operations and airworthiness during this review.

Once the data is collected, the ATL FSDO will complete an analysis and prepare a report

of the findings and recommendations

Once the corrective actions have been identified, the ATL FSDO will take immediate

actions to implement those corrective actions

PO. d
163

ATTACHMENT ONE

OPERATIONS

 Emphasis will be placed on en route inspections. Inspectors will be assigned to

stay with the airplanes all day and report back into the FSDO periodically with

their findings.

Passenger service personnel (gate agents):

● Observation of boarding procedures

● Carry-on luggage

● Hazardous material

● General knowledge of company procedures

● The experience level of the number one flight attendant and how long with

Valujet

● Observe number 2 flight attendant and exit row seating briefing

● Observe safety equipment inspection

● Coordinate with agent on closing cabin door and arming slide

● Coordinate with pilots/front end crew

● Crew Ordination

● Is the PIC in command?

● Accuracy of load manifest

● Are maintenance discrepancies being recorded as they occur?

● Are discrepancies that the flight attendants give the pilots dealt with correctly?

● Validate training

Training:

● Observe as much training as our resources permit

● . ..for standardization

● . ..for compliance with their approved training program
164

●

●

●

●

●

●

●

Maintenance stations, spares, qualifications of people, tools, equipment How

write-ups are handled and if they are properly evaluated and corrected.

Are they following all procedures completely? What is supervision?

Review aircraft records (checks, routine maintenance) and verify all the way

back. (for compliance with procedures, data, records completion, etc.). If

certified repair station, look at certified repair station work order package.

Visit contract facilities and check proper ratings, facilities, data, equipment, etc.

Do they have and use ValuJet manual procedures? Are they properly trained,

certificated, and authorized?

Does ValuJet have evaluations of contract facilities and are they done in person

in accordance with their procedures? Is the person conducting them qualified?

What are the turn-around times at contractors; are there any contract or informal

deadlines, etc.?

See if there is a push to move airplanes.

Spare Parts Management:

● Look at spare parts. Are they properly tagged? Track tags for verification all the

way back. How do they integrate into their operation?

En Route, Ramp and Spot Inspections:

● En routes with emphasis on write-ups, carryovers, MEL items. how and when

items are written up, general rendition of aircraft.

%“d
165

● Are pilots aware of deferred items and do they handle them properly?

● See if there is a push to move airplanes.

Training:

● Are maintenance people in ValuJet qualified end following procedures Do they

have 121 background and experience in the job they are doing?

● Are people properly trained? Review training, curriculums, classes, etc.

Continuing Analysis and Surveillance:

● Review aircraft records looking for trends, types of failures; are they being

written upon legs into maintenance facilities, and being deferred and fixed at the

same maintenance facilities? What is the length of time involved to get them

fixed?


168

March 15, 1996

ATLANTA FSDO

ValuJet Special Emphasis Program

Background:

ValuJet has experienced several accidents and incidents during the past year. After

considerable analysis these occurrences do not appear to be related and the traditional

inspection programs (NASIP,RASP) have not been the key to unlock the reasons for the

occurrences. Some other concerns of the ATL FSDO are:

a. ValuJet is an unconventional carrier when compared to more traditional

121 operators. They are innovators, dedicated to low overhead, leasing rather than

owning and tightly controlling all expenses. The tight control of expenses includes

training (pilot pays), equipment purchases (used), and maintenance (all contracted out to

geographically diverse low bidders).

b. An inordinate amount of time that the principal inspectors are having to

direct towards answering Congressional, NTSB, DOTIG, DOD, GAO inquiries and FAA

safety and consumer hotline issues.

c. An increase in unfavorable geographic reports concerning maintenance

discrepancies found by FAA inspectors during revenue operations.

d. A significant decrease in experience level of new pilots being hired by

ValuJet as well as other positions such as mechanics, dispatchers, etc.

e. Continuous changes of key management persomel.

f. The ATL FSDO’S management will divert critically scarce resources from

other carrier assignments to support this effort.

In order to capture a macro view of VaIuJet, the ATL FSDO initiated a special emphasis

program on February 20, 1996. The program will be conducted for a 120-day period and

will consist of four elements. The following is a summary of the four elements of the

program:

Element 1. Supplementing the Current ValueJet Assignment: Several inspectors have

been reassigned to the ValuJet assignment. There are now 13 employees dedicated to

ValuJet as follows: Supervisor Inspector, Aviation Safety Assistant, POI, PMI, PAI, 4

ACOI’s and 4 ACMI’s. See attachment one.
169

Element 2. Special Emphasis Review: The ATL FSDO conducted a seven day systems

review (2/22-2/29/96) by placing emphasis on the observation of ValuJet personnel in an

operational environment. Geographic offices participated in the review.

Element 3. Analysis: The ATL FSDO is currently conducting an analysis of the data

and will prepare a report of the findings and recommendations. Over 375 inspections were

conducted to include art inspection of each of their 43 operational aircraft. Preliminary

results, in addition to receiving positive comments, show discrepancies in maintenance

inspection programs, MEL management, decision making by cockpit crews, aircrew

abnormal checklist training, and gate agent training.

Element 4. Implement Corrective Actions: Once the corrective actions have been

identified, the ATL FSDO will take immediate actions to implement those corrective

actions. Many corrective actions have all ready been implemented by ValuJet. We

consider these actions to be positive for aviation safety. Attachment 2 and 3 contain a

summary of ValuJet’s actions.
170

VALUJET SPECIAL EMPHASIS PROGRAM

February 20 through June 14, 1996

VALUJET CERTIFICATE MANAGEMENT TEAM

D

Bob Bruce

POI

David Dees

AFOI

r

~dley Boone

APm

t

D

Jerry Fradenburg

ACiY I

1 mvid Harper

WI

1Beocis Wright

ACXI

D

tirk Meola

A~I

E

Ron Rudd

AnGlenn White

AQ41

+ Royce kva”,hn

PM

At Cachmenc 1
171

VALUJET OPERATIONAL ACTIONS

1. Recent Improvements to ValuJet’s Operational Posture.

* They have hired an Operations Manager to oversee the Dispatch Office so that

Mr. Joe Reeves could devote his full time to Dispatch Planning.

* They have implemented an In-House Self Audit Program under the direction of

Mr. Lloyd Prince, Director of Safety.

* Agreed to hold the following Monthly Meetings with this Office.

a. Third Thursday. . . . . . . . ..Operations Meeting (attending members are the

Chief Pilot, Director of Operations, Director of Training, Sr. VP Ops).

b. Check Airman meetings w/FAA for standardization of training/checks.

* Initiated a Standard Practice Manual System which is currently under review.

* Developed an agents Training course that will require all agents to be trained in

ATL after receiving initial training at their home station.

2. Actions Taken as a result of the Special Emphasis Program.

* Signed an updated contract for a Cockpit Resource Management Program to be

taught by Flight Safety International This class was originally to be given

only to new hires, but has now been escalated to encompass all pilots. All

will have been trained by May 15, 1996.

* They have started holding Captain’s Siminars.. An 8 hour course that will be

given to all upgrading Captains. This will be a retroactive course that will

include all current ValuJet Captains. Training of the latter group should be

completed by June 1, 1996.

* First Officer Minimums have been raised to 500’AGL and 1 mile for the first

250 hours at ValuJet All current First Officers have been increased to

300’ AGL and 3/4 miles.

* Restrictions have been implemented requiring Captains to make all landings on

a. runways of 7,500 feet or less.

b. Contaminated runways when braking action is reported as less

than good.

c. Ice or slush is on the runway.

d During heavy rain.

c. There is any snow accumulation.

Attachment 2
172

* Implemented double the FAR requirement for minimum time for crew pairing of

new pilots with new Captains.

* Beginning on March 10, 1996, three of Flight Safety International’s most

experienced check airmen will conduct comprehensive line checks of VJ6A

pilots and flight operations over a 10 day period. (They are VJ Check

Airmen under contract from Flight Safety).

* Established a monthly Safety Review, to be published by the Check Airmen’s

Department, covering all incidents involving DC-9’s, as well as any related

incidents or accidents.

* Established as monthly publication of a Standards letter from the Check

Airmen’s Department that will include a review of specific procedures and

questions about the DC-9.

Bruce:reb:03-15-96 :h:VJ6ASEP

Attachment 2 (cent)
173

VALUJET MAINTENANCE ACTIONS

1. Recent Improvements to VJ’S Maintenance Organization.

* Hiring of two fill-time auditors to review aircraft records.

* Becoming a member of Coordinating Agency for Supplier Evaluation (C.A.S.E.).

* Implementation of annual Technical procedures audits to evaluate seven distinct

elements of the headquarters maintenance organization.

* More intensive follow-up of Quality Assurance (QA) audit findings by monitoring

the corrective actions to address discrepancies.

* Significant improvements in tool calibration and stores procedures.

* Strengthening the initial and recurrent training program for Required Inspection

Items (RII) Inspectors.

2. Actions taken from the Special Emphasis Inspection.

* Reviewing maintenance work cards for N, A, B, and R Checks.

* Additional training to maintenance personnel who perform N, A, B, and R Checks.

* Strengthen their recurrent training program for mechanics by developing a

mandatory course to address General Maintenance Manual (GMM) procedures and

policies, FAR requirements and other general subjects.

* Hiring of two additional auditors to monitor maintenance contractors, and to review

maintenance records.

* Hiring of four additional inspectors to oversee maintenance of N, A, and B Checks

at ATL and IAD.

* Creation of a Technical Support group within line maintenance.

The Technical Support group will be headed by one of ValuJet’s most

experienced maintenance managers and will be staffed by other highly qualified

and experienced maintenance personnel. The group will be stationed in ATL

and AID,yet be readily available for consultation with or travel to outstation

maintenance facilities.

Attachment 3
174

✵ Agreed to hold the following Monthly Meetings with this Office.

Attending members are the Vice President of Maintenance, Director of

Maintenance, Director of Quality Assurance, Chief Inspector, Principal

Maintenance Inspector, and Principal Avionics Inspector.