Hardware Podcasts

ValuJet 592 crashed in 1996 with 110 people aboard. We reconstruct the layered failure and what Perrow's normal accident theory says about why it happened.

Go/No-Go · 27 Mar 2026 · 38m

What this episode covers

Hosts John Brunner and Alex Howe reconstruct the 1996 ValuJet Flight 592 crash, attributing the disaster to a layered failure involving expired chemical oxygen generators lacking safety caps, which ignited in the cargo hold. They analyze William Langewiesche’s account of how SaberTech mechanics, confused by inconsistent labeling of 'expired' versus 'expended' generators and a lack of provided safety caps, packed hazardous items into shipping boxes. The discussion applies Charles Perrow’s normal accident theory and Diane Vaughan’s normalization of deviance to explain how organizational complexity, 'pencil whipping' of paperwork, and systemic complacency created a tightly coupled system where accidents became inevitable.

Most relevant to

large enterprises

Topics

Mentioned

Companies
ValuJet, SaberTech, Air Tran, Southwest, JetBlue, Breeze Airways
Also
William Langewiesche, Charles Perrow, Diane Vaughan, Scott Sagan, American Airlines Flight 191, World Airways Flight 30

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