ABSTRACT
Investigators focused on the actions of maintenance technicians and those of shipping and receiving personnel, who committed the bulk of the errors that led to the accident, to identify potential error antecedents. The common elements relate simply to the antecedents, the antecedents relate simply and logically to the errors, and the errors relate directly to the accident. Investigators identified three organizations whose policies and practices either caused or contributed to the accident. One was SabreTech, whose personnel committed the errors that led to loading the chemical oxygen generators aboard the accident flight. The second was ValuJet, the company that had contracted with SabreTech to perform its maintenance, and was responsible for ensuring that SabreTech performed the maintenance properly. The third was the FAA, the regulator that approved the maintenance procedures, and was required to ensure that both ValuJet and SabreTech complied with them.
