The Lessons of ValuJet 592

Subject: The Lessons of ValuJet 592
From: Stuart Burnfield <slb -at- FS -dot- COM -dot- AU>
Date: Thu, 28 May 1998 09:32:27 +0800

Wendy Christensen <christensen -at- CATLAS -dot- MV -dot- COM> said:
> . . . I recommend perusal of "The Lessons of ValuJet 592" in the
> March, 1998, issue of The Atlantic Monthly....touches upon technical
> writing and documentation as among the many vital elements of complex
> systems where failure, or a multiplicity of unpredictably inter-
> related failures, can kill.

> >

I endorse Wendy's recommendation. This is a fascinating piece about
complex systems and the limits of safety procedures. Two snippets that
should particularly interest tech writers:

. . .This required a gang of hard-pressed mechanics to draw
a verbal distinction between canisters that were "expired,"
meaning most of the ones they were removing, and canisters
that were not "expended," meaning many of the same ones,
loaded and ready to fire, on which they were expected to put
nonexistent caps. Also involved were canisters that were
expired and expended, and others that were not expired but
were expended. And then, of course, there was the set of
new replacement canisters, which were both unexpended and
unexpired. If this seems confusing, do not waste your time
trying to figure it out -- the SabreTech mechanics did not,
nor should they have been expected to. The NTSB suggested that
one problem at SabreTech's Miami facility may have been the
presence of Spanish-speaking immigrants on the work force, but
quite obviously the language problem lay on the other side --
with ValuJet and the English-speaking engineers, literalists,
who wrote the orders and technical manuals as if they were
writing to themselves. The real problem, in other words, was


Yes, a mechanic might have found his way past the ValuJet work
card and into the huge MD-80 maintenance manual, to chapter
35-22-01, within which line "h" would have instructed him to
"store or dispose of oxygen generator." By diligently pursuing
his options, the mechanic could have found his way to a
different part of the manual and learned that "all serviceable
and unserviceable (unexpended) oxygen generators (canisters)
are to be stored in an area that ensures that each unit is not
exposed to high temperatures or possible damage." By pondering
the implications of the parentheses he might have deduced that
the "unexpended" canisters were also "unserviceable" canisters
and that because he had no shipping cap, he should perhaps take
such canisters to a safe area and "initiate" them, according to
the procedures described in section 2.D. To initiate an oxygen
generator is of course to fire it off, triggering the chemical
reaction that produces oxygen and leaves a mildly toxic residue
within the canister, which is then classified as hazardous
waste. Section 2.D contains the admonition "An expended oxygen
generator (canister) contains both barium oxide and asbestos
fibers and must be disposed of in accordance with local
regulatory compliances and using authorized procedures." No
wonder the mechanics stuck the old generators in boxes.

Stuart Burnfield "Fun, fun, fun
Functional Software Pty Ltd In the sun, sun, sun. . ."
mailto:slb -at- fs -dot- com -dot- au

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