On May 8, 1996, a stock clerk at a Miami maintenance shop closed up five cardboard boxes sitting on his shipping-room floor. He did not know what was inside them. The next day he gave a colleague a description for a shipping ticket: the tags on the boxes, he said, meant they were empty. The colleague wrote it down: "Oxy Cannisters [sic]-'Empty.'" The sealed boxes sat by the shipping table until the morning of May 11, when a driver carried them to the ValuJet ramp, and within hours they were in the forward cargo hold of Flight 592, climbing out of Miami for Atlanta.
The boxes held about 144 chemical oxygen generators that SabreTech, ValuJet's maintenance contractor, had pulled from two MD-80s it was servicing in Miami, replacing generators past their twelve-year service life. A generator makes emergency oxygen by igniting a sealed core of sodium chlorate with a spring-loaded firing pin; set off, its case can reach 500 degrees Fahrenheit. The manual required a safety cap over that pin on any generator not already fired, before storage. SabreTech's mechanics removed the generators and left the caps off. Work card 0069, part of the maintenance package ValuJet bought from the manufacturer and never altered, omitted the manual's final step: how to store or dispose of a generator still carrying a live charge.
Nobody at the Miami shop had been trained to identify or ship hazardous material by air; that work went through an outside contractor nobody called this time. Most generators carried a green tag reading "Repairable," SabreTech's own form for parts pulled off an airplane. The stock clerk later said he read that word as meaning unserviceable, and unserviceable, to him, meant empty; nobody who had removed the generators told him otherwise. A ramp agent showed the finished ticket to the first officer before loading. Neither discussed the line about the canisters.
About six minutes after takeoff, the crew heard an unexplained sound, and within half a minute passengers were shouting fire. The chemical reaction had likely begun earlier, sometime between loading and the takeoff roll, burning unseen in a hold with no smoke detector and no extinguisher. The compartment was rated Class D, built on the assumption a fire there would exhaust its own air and go out; this one burned on oxygen its own cargo was making. Flight 592 crashed into the Everglades about ten minutes after takeoff; all 110 aboard died. Eight years earlier, a similar fire in a Class D hold on American Airlines Flight 132 had landed safely, and the Safety Board told the FAA to require detection and suppression equipment in every such hold. The FAA refused in 1993 as not worth the cost.
A shipping ticket is not filled out for its own sake. It is the one fact anyone past the loading dock, the ramp agent, the first officer, will ever have about a sealed box, because nobody above that dock opens one to check. When the writer does not know the fact and was never shown how to find out, the paper still reads as settled, and nobody downstream can tell the difference.
Three words on a shipping ticket outweighed a hundred and ten lives, and the man who wrote them did not think he was lying.