Washington, DC --The National Transportation Safety Board
today determined the probable cause of the crash on landing
of a FedEx cargo aircraft was the first officer's failure to
properly apply crosswind landing techniques to align the
airplane with the runway centerline and to properly arrest
the airplanes descent rate before the airplane's touchdown.
Additionally, the captain's failure to adequately monitor
the first officer's performance and command or initiate
corrective action during the final approach and landing
contributed to the accident, the Board said.
On December 18, 2003, Federal Express Corporation flight 647
crashed while landing at Memphis International Airport.
Following the crash, the right main landing gear of the Boeing
MD 10 -10F collapsed, and there was a post-crash fire. There
were two crewmen and five nonrevenue FedEx pilots aboard the
airplane. The first officer and one nonrevenue pilot received
minor injuries during the evacuation.
"This accident highlights the need for proper training," said
NTSB Acting Chairman, Mark Rosenker. "If the accident
crewmembers had applied techniques in accordance with their
training, the landing would have been uneventful, he added.
The investigation found that the first officer had
demonstrated unsatisfactory performance during proficiency
checkrides at a previous employer and at Federal Express.
During her career at FedEx, she had two unsatisfactory
proficiency checkrides. Although the first officer's
proficiency checkrides demonstrated deficiencies in multiple
areas, the investigation was unable to directly link her
previous deficiencies to her actions on the day of the
accident. During the accident flight, the captain was serving
as both check airman and pilot in command; he was expected to
continually monitor the first officer's performance while at
the same time being responsible for the overall safe conduct
of the flight.
After the flight 647 accident and as a result of several other
accidents and incidents, the FedEx Flight Operations
Directorate developed its Enhanced Oversight Program (EOP) to
improve air safety through early identification of pilots who
exhibit deficiencies during training or checkrides.
After the Memphis accident plane came to a rest and as the
right wing was on fire, flightcrew and jumpseaters attempted
to evacuate the airplane via the L1 door slide; however, the
slide separated from the airplane during the inflation
sequence. Therefore, everyone aboard the aircraft was forced
to exit the airplane using the cockpit window. During the
evacuation and while persons were still aboard the plane at
least 13 pieces of personal baggage were thrown from the
airplane. FedEx issued additional guidance following this
accidents requiring its pilots involved in an accident to
evacuate in the most expeditious manner possible, without
salvaging their baggage.
As a result of this accident, the Safety Board made the
To the Federal Aviation Administration:
1. Require all Part 121 air carrier operators
to establish programs for flight crewmembers
who have demonstrated performance deficiencies
or experienced failures in the training
environment that would require a review of
their whole performance history at the company
and administer additional oversight and
training to ensure that performance
deficiencies are addressed and corrected.
2. Amend the emergency exit training information
contained in the flight crew and cabin crew
sections in Federal Aviation Administration
Order 8400.10 (Air Transportation Aviation
Inspector's Handbook) to make the emergency
exit door/slide training described in the
flight crew section as comprehensive as the
cabin crew emergency training section of the
principal operations inspector handbook.
3. Verify that all Part 121 operators' emergency
door/slide trainers are configured to
accurately represent the actual airplane exit
door/slide and that their flight crew
emergency exit door/slide training provides
the intended hands-on emergency procedures
training as described in 14 Code of Federal
Regulations Section 121.417, to include
pulling the manual inflation handle.
4. Inform all air traffic control tower
controllers of the circumstances of this
accident, including the need to ensure that
aircraft rescue and firefighting (ARFF)
vehicles are not delayed without good cause
when en route to an emergency and the need to
relay the number of airplanes.
A synopsis of the accident investigation report, including
the findings, probable cause and safety recommendations, can
be found on the "Publications" page of the Board's web site,