Aircraft Accident Report

8 Hard Landing, Gear Collapse Federal Express Flight 647 Boeing MD-10-10F, N364FE Memphis, Tennessee December 18, 2003

〔图〕插图

Aircraft Accident Report

NTSB/AAR-05/01

PB2005-910401

Notation 7632A

Aircraft Accident Report

Hard Landing, Gear Collapse Federal Express Flight 647 Boeing MD-10-10F, N364FE Memphis, Tennessee December 18, 2003

NTSB/AAR-05/01 PB2005-910401 Notation 7632A Adopted May 17, 20

〔图〕3dVsQARD\n National Transportation Safety Board 490 L'Enfant Plaza, S.W. Washington, D.C. 20594

References

Keywords

17, 2, 5, 2 Previous Safety Board Emergency Exit Training

References

°°

°

°

°

Factual Information

5

Aircraft Accident Report

1.2 Injuries to Persons

Table 1. Injury chart.

1.3 Damage to Aircraft

The airplane was destroyed by impact forces and a postcrash fire.

1.4 Other Damage

Several runway edge lights on the right side of runway 36R were damaged.

1.5 Personnel Information

1.5.1 The Captain

The captain, age 59, was hired by Flying Tiger Airlines on July 10, 1978, and became a FedEx employee when the two companies merged on August 7, 1989. He holds an airline transport pilot (ATP) certificate with a multiengine land rating and a flight engineer certificate for turbojet-powered airplanes. The captain's ATP certificate indicated type ratings in the Cessna 500 (issued December 21, 1977) and the MD-11 (issued September 21, 1996). The captain completed initial MD-10 differences training on October 24, 2000.$^{11}$ The captain's most recent Federal Aviation Administration (FAA)

Factual Information

8

Aircraft Accident Report

completed the requalification simulator proficiency check on November 20, 2003, and her mandatory line check was being conducted when the accident occurred. (Table 2 documents the first officer's checkride failures as an airline employee.)

Table 2. First officer checkride failures.

During postaccident interviews, the check airman who conducted the November 20, 2003 simulator proficiency checkride stated that the first officer had to repeat one of the engine failure scenarios and described her flying as “in the average range.” He stated that he counseled the first officer regarding crew resource management and declaring an emergency without first consulting with the captain. The check airman described her performance as average. (This check airman also reported that he had conducted the first officer’s proficiency checkride on October 19, 2001. He stated that, at that time, he considered the first officer a below-average pilot and noted that she was very weak in the areas of procedures and judgment.) For additional information about the first officer’s flight history, see the Operations Group Chairman’s Factual Report in the public docket for this accident.

FAA records indicated no accident or incident history or enforcement action. However, a search of the National Driver Registry database revealed that the first officer's Arizona State driver's license was suspended from November 15, 1998, to February 16, 1999, for a driving under the influence of alcohol conviction. According to FAA records, the first officer reported the suspension of her driver's license to the FAA's Civil Aviation Security Division. In a February 4, 1999, letter, the manager of the FAA's Aeromedical Certification Division advised the first officer, "We have carefully reviewed your letter and your complete medical file, which reveals a previous alcohol-related offense."$^{17}$ The

° °° °

° °°°

°°°

Factual Information

13

Aircraft Accident Report

〔图〕MEMPHIS INTL(MEM)MEMPHIS, TENNESSEECIuoesTENNFEDEXANGX33HUBRAMPVWMFD81Station #33181M9ControlMBTowerM7Accident SiteM6z芝M

Figure 1. MEM airport diagram.

1.10.1 MEM Aircraft Rescue and Firefighting General Information

The Memphis-Shelby County Airport Authority (MSCAA) operates MEM and is responsible for airport operations and establishing and maintaining an emergency plan.

°°

Factual Information

17

Aircraft Accident Report

side of the fuselage, left wing, and the nose and tail sections exhibited minimal impact or fire damage.

〔图〕Fed\n

Figure 2. Photograph of the damage to the right side of the airplane.

The R1 and L1 passenger/emergency exit doors are located aft of the cockpit on the right and left side of the fuselage, respectively. During postaccident examination, the R1 door was closed, its door control handle was in the closed position, and its slide-arming lever was in the armed position. However, the L1 door was found in the full-open position, and the evacuation slide/raft was found deployed and inflated on the ground near the nose of the airplane. The slide/raft remained connected to the airplane by its mooring line.$^{33}$

The L1 emergency door control handle was in the open position. The L1 slide's triangular red manual inflation handle (which is used to inflate the slide/raft if it fails to automatically inflate upon opening) and the rectangular white slide/raft disengage handle (which is located beneath the girt flap assembly and is used to release the slide/raft from the airplane in the event of a water landing) were found on the cabin floor near the R1 door. The manual inflation handle has a red reflective bracket and is stenciled with the word PULL in white lettering; the handle is normally attached by a cable to the inflation

Factual Information

18

Aircraft Accident Report

cylinder. The slide/raft disengage handle is webbed and has the word PULL stenciled in red lettering; it is normally attached by Velcro at the base of the upper girt assembly under the girt cover flap. The slide/raft disengage handle is normally used only during emergency evacuations after a water landing (ditching). (Figure 3 shows FedEx's MD-11/-10 emergency evacuation door trainer, with the girt flap assembly in place. Figure 4 shows FedEx's MD-11/-10 emergency evacuation door trainer, with the girt flap assembly lifted.)$^{34}$ The distance from the accident airplane's L1 doorsill to the ground was 16 feet 10 inches instead of the usual distance of 16 feet 3 inches because of the failed right main landing gear.

〔图〕SLIDE0C17-119/5AIRPLANE DOOR SILL\n

Figure 3. FedEx's MD-11/-10 emergency evacuation door trainer, with the girt flap assembly in place, as it would appear when the door/slide is opened. The arrow indicates the manual inflation handle.

Factual Information

19

Aircraft Accident Report

〔图〕SLIDEICNVHFORAIRPLANE DOOR SILL\n

Figure 4. FedEx's MD-11/-10 emergency evacuation door trainer, with the girt flap assembly lifted. The arrow indicates the slide/raft disengage handle.

The cockpit, its furnishings, and the nonrevenue crewmember cabin area (the area located directly behind the cockpit door and in front of the cargo barrier, including the four courier seats) remained intact and exhibited no fire, smoke, or soot damage. All cockpit and passenger cabin area oxygen masks were stowed, and all cabinets and stowage compartments were intact, with their doors closed. The captain and first officer evacuation tapes$^{35}$ were deployed through their respective open cockpit windows. The lavatory and the cockpit doors were open, and the rigid cargo barrier door, which allows access to the main deck cargo compartment from the passenger cabin area, was found closed and secured by the first firefighters to board the airplane.

1.12.1 Tire and Other Markings on the Runway

Examination of tire markings on runway 36R revealed that the airplane touched down on the left main landing gear first about 564 feet from the approach end of the runway and 9 feet right of the runway centerline. The tire markings showed that the right main landing gear touched down about 613 feet from the approach end of the runway and 45 feet right of the runway centerline.

°

Factual Information

27

Aircraft Accident Report

FedEx Flight 647

〔图〕插图

Figure 5. The airplane's vertical speeds (as identified by the Safety Board's performance study) during the accident landing and the two previous landings, with altitude displayed above.

The Safety Board's study of the FDR pitch data showed no evidence of an increase in the airplane's pitch attitude (flare) before touchdown. By contrast, during the two previous landings recorded by the FDR, the airplane's pitch increased during the seconds before touchdown, reaching nose-up pitch attitudes of more than 7°. Figure 6 shows the pitch attitudes recorded by the FDR during the accident landing and two previous landings.

Factual Information

28

Aircraft Accident Report

〔图〕插图

Figure 6. Pitch attitudes recorded by the FDR during the accident landing and two previous landings. The vertical black line (FDR elapsed time 0 seconds) represents the airplane's touchdown.

Although the FDR pitch data showed no evidence of a flare before the airplane touched down, the FDR elevator position data showed that the elevator moved from about 2.75° to 12.75° airplane nose up almost immediately after the left main landing gear touched down, just as the right main landing gear touched down. The study also revealed that the airplane's longitudinal axis was not aligned with its direction of flight or the runway when it touched down. Rather, the nose of the airplane was aligned on a heading of about 352.6°, about 5.4° left of the runway's magnetic heading of 358° and about 6.5° left of the airplane's ground track of about 359.1°. This information is consistent with the physical evidence noted in section 1.12.2.

1.16.1.2 Wind Derivation

The FDR recorded wind speed and direction every 4 seconds. The Safety Board derived wind speeds and directions for the 4 seconds between the recorded samples by comparing airplane positions (obtained from the airplane performance study acceleration integration) with FDR airspeed (converted to true airspeed) and heading data. The results

°

°°°°

°

°

°

°

°

°

°°

°

64

Aircraft Accident Report

Appendix B

Cockpit Voice Recorder Transcript

The following is a transcript of the Allied Signal model 6022 CVR installed on the accident airplane. Only radio transmissions to and from the accident airplane were transcribed. This CVR transcript reflects excerpts from the 2 hours and 58 seconds recorded before power was lost to the CVR. All times are central standard time based on a 24-hour clock.

LEGEND

CAM Cockpit area microphone voice or sound source

HOT Crew station voice or sound source

CAWS Central Aural Warning System electronic voice

RDO Radio communications transmitted from N364FE, FedEx Flight 647

CTR1 Radio transmission from first Memphis Center controller

CTR2 Radio transmission from second Memphis Center controller

APR1 Radio transmission from first Memphis Approach controller

APR2 Radio transmission from second Memphis Approach controller

TWR Radio transmission from Memphis Tower controller

-1 Voice identified as the Captain

-2 Voice identified as the First Officer

-3 Voice of an unidentified jumpseat passenger

-? Voice unidentified

• Unintelligible word

Expletive

@ Non-pertinent word

( ) Questionable insertion

[ ] Editorial insertion

... Pause or interruption

Note 1: Times are expressed in central standard time (CST).

Note 2: Generally, only radio transmissions to and from the accident aircraft were transcribed.

Note 3: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the words as spoken.

Note 4: A non-pertinent word or phrase, where noted, refers to a name or a word not directly related to the operation, control or condition of the aircraft.

V E R B A T I M

Appendix B

67

INTRA-COCKPIT COMMUNICATION

3 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

69

INTRA-COCKPIT COMMUNICATION

5 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

78

INTRA-COCKPIT COMMUNICATION

14 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

79

INTRA-COCKPIT COMMUNICATION

15 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

08

INTRA-COCKPIT COMMUNICATION

16 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

82

INTRA-COCKPIT COMMUNICATION

18 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

89

INTRA-COCKPIT COMMUNICATION

21 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

98

INTRA-COCKPIT COMMUNICATION

22 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

87

INTRA-COCKPIT COMMUNICATION

23 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

88

INTRA-COCKPIT COMMUNICATION

24 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

1216:11 APR2 FedEx six forty seven heavy reduce speed to one niner zero.

INTRA-COCKPIT COMMUNICATION

25 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

06

INTRA-COCKPIT COMMUNICATION

26 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

91

INTRA-COCKPIT COMMUNICATION

27 of 45 AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

93

INTRA-COCKPIT COMMUNICATION

29 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

95

INTRA-COCKPIT COMMUNICATION

31 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

96

INTRA-COCKPIT COMMUNICATION

32 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

97

INTRA-COCKPIT COMMUNICATION

33 of 45 AIRCRAFT-TO-GROUND COMMUNICATION

INTRA-COCKPIT COMMUNICATION

34 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

66

INTRA-COCKPIT COMMUNICATION

35 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

101

INTRA-COCKPIT COMMUNICATION

37 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

103

INTRA-COCKPIT COMMUNICATION

39 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

104

INTRA-COCKPIT COMMUNICATION

40 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

105

INTRA-COCKPIT COMMUNICATION

41 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

Appendix B

108

INTRA-COCKPIT COMMUNICATION

44 of 45

AIRCRAFT-TO-GROUND COMMUNICATION

INTRA-COCKPIT COMMUNICATION

45 of 45

AIRCRAFT-TO-GROUND COMMUNICATION