NTSB on FedEx DC-10.
 

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
following recommendations:

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,
www.ntsb.gov.

From the factual docket....RH gear touchdown was at approximately 870 FPM with a 6 degree crab. Elevator did not move prior to touchdown.

Interesting sidenote....in this case, the RH gear failed - broke off right at the schraeder valve area. In the MD-11 accidents (EWR, Hong Kong), the wing box failed.

Memphis newspaper report:

Pilots blamed in FedEx crash
Safety investigators cite faulty landing in '03 incident

By Hilary Roxe
Associated Press
May 18, 2005

WASHINGTON -- The pilot of a FedEx cargo jet that caught fire after landing
at Memphis International Airport in December 2003 was largely responsible
for the accident, the National Transportation Safety Board said Tuesday.

The board also found that the flight captain, who was evaluating the pilot,
failed to adequately monitor and correct her landing.

The pilot, First Officer Robyn S. Sclair, didn't do enough to account for
gusty winds and sufficiently slow the plane as it approached the airport.
She brought down the Boeing MD10 slightly to the right of the runway's
center line.

The faulty landing overtaxed the right main landing gear, causing it to
collapse, and the plane caught fire after it veered off the runway,
investigators said.

Besides the two pilots, five FedEx pilots were riding to Memphis as
passengers. All seven escaped through cockpit windows after a passenger
inadvertently released an inflatable escape slide from the side of the
aircraft.

Two people, including Sclair, were injured.

Sclair was undergoing a company-mandated evaluation from Capt. Richard W.
Redditt after deviating from an assigned altitude over England a month
earlier. NTSB reports showed she received two unsatisfactory ratings on MD11
aircraft in 1999 and 2001. Those scores went up after she received more
training.

But Sclair's story led the board to recommend creating oversight and
training programs for crew members who showed deficiencies or experienced
failures in training environments.

"If you took a look at the person as a whole, you may find a pattern that .
. . this person may have some deficiencies that can be, in fact, improved
and be corrected before they get into a situation like we've seen here,"
said Mark Rosenker, acting NTSB chairman.

Investigators also found crew members hadn't received adequate training on
how to handle exit slides. The board recommended providing more hands-on
learning and ensuring training equipment matches the slides used on actual
planes.

"All of the training programs highlighted have been updated since the
accident," said FedEx spokeswoman Kristin Krause.

Krause said Redditt has retired and Sclair is on leave from the company.

Capt. Gary Janelli, a representative of the Air Line Pilots Association,
said the report should have given more weight to wind conditions and
Sclair's lack of recent MD10 training.

"She had conducted only three landings in an MD10 in last seven months, and
the most recent was two days prior," said Janelli, a FedEx MD11 pilot based
in Anchorage, Alaska.

All her other landings had been in MD11s.

Although the MD11 and MD10 are the same type of aircraft, "they handle
differently," Janelli said.

While FedEx's initial training includes time in MD10s and MD11s, there is
"no required follow-on training in the MD10," he said.

"The handling characteristics are different enough that we would like to see
training in both airplanes," Janelli said.

The plane was flying from Oakland, Calif., on the last leg of a four-day
trip. Fatigue was ruled out as a factor in the accident, as was the weather,
though wind shear advisories were in effect that day.

Investigators said it was not clear how the fire started, but flames
consumed the right wing and charred the side of the plane.

The pilots/jumpseaters threw the bags out while waiting to go out the only available exit. The video shows that the fire was quite intense - no one would have delayed egress just to save bags. Imagine how long it took 7 normally-abled people to shinny down a 25 foot rope.

And the only slide on the non-burning side was unuseable due to wind and the roll angle of the fuselage. The jumpseaters pulled the disconnect handle in a desperate attempt to get a normal deployment.

Shouldn't this be amended to read that the primary fault lay with the Captain for insufficient monitoring, and the FOs sh!t landing listed under 'additionally'? Isn't that why Capts get paid more - responsibility?

...presumably when the Capt tw@tted her one after they got out.....!

16B

16blades - no. I would say that the primary cause WAS the FO's "landing" because if she hadn't screwed it up there would have been no crash and the Captain's (lack of) monitoring would have been irrelevant.

OK, he screwed up because he let her go too far - but she crashed it, not him.

Moggiee I believe that you are in danger of confusing primary cause with the desire to seek blame (a normal human failing). The NTSB usually restricts their findings to the most probable cause, but in this instance there is more than one.

Few accidents have a sole cause; there are usually a collection of circumstances that when they come together the accident is inevitable. Many of the circumstances are beyond the apparent ‘probable cause’.

We do not know what guidance the management pilots provided to the Captain re training/assessment; was the Captain experienced in judging how far to let a First Officer progress, was he a fully 'qualified' trainer (experience of a training establishment), or was he ‘promoted’ to a training role (the NTSB concluded that the crew met the requirements – but are they good enough?).

Alternatively the Captain may have been providing every opportunity for the First Officer to succeed, enabling the benefit of a confidence boosting landing in difficult conditions (another human frailty of wishing to help others).

In hind sight, which always clarifies judgement, it may have been prudent for management to limit the First Officers flying to one aircraft type (active oversight required).

I don’t know of the extent of the differences between the DC10 and MD11, but the latter with FBW controls has some history of problems on approach and landing (the NTSB conclude that this was not a factor – how).

Then there could be the simulators, how accurate are they? Does simulator training provide adequate experience in the conditions of the accident, or is the time just used for the flight check - to get/keep a ‘ticket’.

The weather was not a factor (by itself), but in combination with the previous factors, the margins of safe flight could be eroded; then with just one further issue an incident or an accident results (if a bit more drift had been removed - or the gear had not broken, would it have been an accident?).

This accident, like many before it, follows the classic James Reason model of Active and Latent failures, and thus the need to defend in depth (Swiss Cheese model).

Good point about simulator recurrent training. A significant amount of scheduled simulator training is spent on LOFT exercises with its accent on warm and fuzzy CRM, deep and meaningful crew discussions on MEL's, and highly unlikely multiple scenarios dreamed up by the training department.

Yet accidents continue to occur because pilots land too fast and long on short wet runways, fail to react fast enough to GPWS pull up warnings, and stuff up gusty crosswind landings. Surely this is where accent on simulator training should be. I am amazed to read that many operators do not allow first officers to practice aborted take-offs, on the flimsy basis that only the captain will carry out an abort. Incapacitation of the captain during the take off run is obviously not considered.

On how many occasions during a precious 3-monthly sim check is a pilot allowed the opportunity to practice 35 knot crosswind landings until he or she is totally competent? By practice, I mean not just one lousy go, but several landings set up by the simulator instructor from say 1000 ft on final. Same with GPWS pull up practice from a glass mountain until fully competent. Speed brake extension in descent followed by a GPWS pull-up can change the mechanics of the pull-up actions. Does one see real dual instruction on this manoeuvre? Not on your nelly.

LOFT is fine as long as the whole period is not wasted on getting from A to B with countless Shakespearian scenarios where the actors are the crew and the flight deck is the stage. Down to earth practical flying skills training is where the simulator comes in on its own - if only trainers will realise it.

safetypee - apologies if I did not make myself 100% clear.

I was not arguing that the FO was the SOLE cause, just that the ration of primary to additional was reversed compared to the opinion of 16 blades.

However, just my opinion, of course.

What I don't get is the fact that the MD-10 and the MD-11 are two completely different airframes. The MD-10 is a glorified DC-10 cockpit. I would like some clarification on this, but I think the cockpit layout is the only difference. every thing else about the airframe is different. In days past, we were able to be qualified on 2 or 3 different planes simultaniously, but those days are gone, and for good reason I think. I hated keeping my BMEP's different from EPR's and I could never find those damn mixture levers on the DC-8.

I landed that day in Memphis,45 minutes prior and I chose the east west runway to land on because it favored the winds a lot more than the north/south runways even though it was considerably shorter.

I know most of us want to work for a company that will give their pilots extra training if they need it. We would all like to be able to go to the sim without fearing for our job. I think FEDEX is that kind of company. But, how far should the company go? When is enough enough? Its a tough position, and monday morning quarterbacking sure is easy!

Huck made some good points. The crew and jumpseaters had everything going against them that day. It was the worst possible scenario for egress except for haveing no way out.

Do the FARs still not require six approaches and landings in a given six-month period? How can only six approaches landings create proficiency, especially in an artificial environment (the sim.)? At another major airline, due to the fact that there are no line FOs who are type-rated by the company to fly in both seats (only using "real" Captains for the left seat...despite a number of pilots who flew years as widebody FO or in the larger, long-range military transports as PIC), some FOs there rarely "fly" a leg, so to speak, and so they must requal in the wonderful simulator sometime each year. The type rating of only Captains was not a, eh..., company decision.

At another airline, the lack of hand-flying led to a near-tragedy in SFO when engine vibration and a compressor stall (?) on a 747-400 made it very difficult to read the (engine) EICAS indications. The plane, loaded with fuel and passengers for an Asian city, barely cleared a large hill. Despite some yaw, initially only aileron was used INSTEAD or rudder.

Ignition Override Can you point me to any reports covering the 747-400 incident you mention since it has lead to new regulation ("Sustained Engine Imbalance") and I would like to find out a bit about the background?

This is at least the third MD-11 that has fallen to pieces on landing ..... couldn't be anything to do with the aircraft could it????

Safetypee

The MD-11 does not have FBW controls. It has an LSAS system with input to the pitch control via the a/p but there are no direct FBW controls. The main difference is the DC-10/MD-10 has that lovely great horizontal stabilizer, the MD-11's is vastly smaller in size.

Huck.

It wasn't the bags they were desperately trying to get out the burning hull, it was the catering. It's in the contract so have it they must!;)

Offa,
it was not an MD-11, it was a MD-10 (DC-10) Entirely different deal

RebelD;
it was a United Airlines 747-400 that barely missed the hill off the end of the 28's in SFO

So you've worked with pilots then, have you?

RebelDJ: True, it was United. I usually avoid stating the name of the company involved (even foreign names), but there are few secrets in the aviation community, except among the novices and outsiders.

Type in "NTSB/GOV" and on the first page of the NTSB aviation website, you see the menu. The second topic on the list should say "monthly incidents/accidents", or such. Some of the info I read was probably in "Aviation Week & ST". Either our company flight ops or pilot union magazine probably covered it also.

Maybe it is not so strange that many accidents in foreign countries result in neither "educational" nor informative facts being sent to, or available to the NTSB, despite the fact that many of the aircraft involved were produced and certificated by another branch of the DOT (Dept. of Transportation).

Maybe the NTSB receives it but does not bother to publish it? This is unlikely. If pilots and investigators could read more accident reports from each country, it could lead to improvements in safety. But then, most politicians (and their appointed puppets on very tight strings) seem to want to cover up any problems at home-a major incentive to suppress the release of safety data (:\), but helps hide certain facts from the US State Department. This department can strongly influence the DOT regarding prohibition of various airlines from operating to the US. Both awkward politics and inadequate documentation "allegedly" prevent certain airlines from flying to US airports. "Allegedly" is a very important word.

Off-topic here, but this might be news to many in the US airline industry: another interesting fact about control of the so-called "deregulated" US airline industry. The PBGC, which will soon help make up some of the missing cash from private retirement pension shortcomings, and is being crippled by the US airline industry, is run by the Secretaries of Commerce, Labor and whichever third Secretary, Finance?

Guess who loans chunks of US government money to US airlines via the ATSB (Air Transport Stabilization Board)? TWO of these same THREE people on the PBGC!! :E

Is there some conflict of interest here? Maybe just a BIT?:suspect: