ValuJet Airlines

ValuJet Flight 592 crashed into the Everglades, killing 110 people, when improperly packaged oxygen generators ignited in the cargo hold. The FAA had documented serious safety concerns about ValuJet's rapid expansion but delayed grounding the airline due to political pressure.

Decision context

Whether the FAA should have grounded ValuJet based on its own inspectors' findings of systemic safety deficiencies before the crash, and whether outsourced maintenance oversight was adequate.

Decision anatomy

Red = risk factor present · Green = protective factor present

Biases present in the decision

★ Primary driver · Severity estimated from bias type and decision outcome

Toxic combinations

Reference class base rates

Lessons learned

• Status quo bias in FAA oversight: regulatory action against airlines is culturally difficult because the FAA sees its role as promoting aviation
• Outsourced maintenance to lowest-cost providers without adequate oversight created systematic safety gaps
• Hindsight: FAA inspectors had documented the exact risks months before the crash, but the system had no mechanism to force action

Source: NTSB Report AAR-97/06, ValuJet Airlines Flight 592 (1997) (NTSB Report)

Workflows that fire on decisions like ValuJet Airlines’s

The same Recognition-Rigor Framework that documents this case audits memos in the same shape — before the outcome forces the lesson.

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