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Federal Express 647

Accident Case Study

This accident would make a good case study for airline hiring practices. The first officer had a track record of busted checkrides with all the red flag buzz words including a phrase that should have kept her from getting an interview in the first place: "poor airmanship." But I will leave that to others.


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Photo: Aircraft wreckage, from NTSB AAR 0501, figure 2.

Click photo for a larger image

Accident Report

  • Date: December 18, 2003
  • Time: 1226 CST
  • Type: Boeing MD-10-10F
  • Operator: Federal Express Corporation
  • Registration: N364FE
  • Fatalities: 0 of 2 crew, 0 of 5 passengers
  • Aircraft Fate: Destroyed
  • Phase: Landing
  • Airports: Metropolitan Oakland International Airport, Oakland, CA (Departure) ; Memphis International Airport, Memphis, TN (Arrival)

Narrative

[NTSB AAR-05/01, ¶1.7.1] MEM weather at 1225, wind from 320° at 21 knots, with gusts to 26 knots; visibility 10 sm; a broken layer of clouds at 4,500 feet; temperature 11° C [Celsius]; dew point -1° C; altimeter setting 30.09 inches Hg [mercury]; pressure altitude 180 feet; and relative humidity 46 percent. Remarks: peak wind 330° at 26 knots occurred at 1220.

[NTSB AAR-05/01, ¶2.2] Both pilots stated that the landing flare was normal, including proper alignment with the runway centerline and compensation for wind conditions below 200 feet. The captain indicated that he thought they experienced a "strong gust" of wind during the landing, and both pilots described the landing as firm but otherwise normal. However, FDR evidence and physical evidence, including tire markings on the runway, indicated that the airplane touched down with both main landing gear assemblies and the nose gear well right of the runway centerline on a heading about 5.6° left of the runway heading.

[NTSB AAR-05/01, ¶1.12.1] 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.

[NTSB AAR-05/01, ¶1.12.2] The right main landing gear collapsed during the landing roll, and the outer cylinder fractured into six pieces.

[NTSB AAR-05/01, ¶1.12] The airplane came to rest in the grass about 155 feet right of the runway 36R centerline and 5,979 feet from the approach end of the runway. The airplane was aligned on a magnetic heading of about 070° and in a slight (about 20°) right-wing-down attitude. The right main landing gear assembly collapsed, and the airplane was supported by its nose landing gear, left main landing gear, and the lower surface of the right wing.

Analysis

[NTSB AAR-05/01, ¶1.5.2]

  • The first officer, age 44, was hired by FedEx on February 21, 1996, from Mesaba Airlines, where she had been employed as a DeHaviland DHC-8 captain. She holds an ATP certificate (issued March 21, 1991) with a multiengine land rating and a flight engineer certificate for turbojet-powered airplanes. The first officer's ATP certificate indicated type ratings in the DHC-8 (issued September 21, 1992), Fokker F-27 (issued November 11, 1995), and MD-11 (issued October 22, 1998). FedEx records indicated that the first officer completed initial MD-10 differences training on February 10, 2003. The first officer's most recent FAA first-class airman medical certificate was issued on July 25, 2003, with a restriction that the holder must wear corrective lenses.
  • Placing a pilot with such limited experience in large aircraft at the controls of a very large airplane is unfair to the operator, the pilot, and to the public.

  • The first officer estimated that she had flown about 15,000 total flight hours. FedEx records indicated that, at the time of the accident, the first officer had accumulated about 1,918 flight hours as an MD-11/-10 flight crewmember, including about 61 flight hours and 7 landings in the 90 days preceding the accident. Between February 2003 (when she completed the MD-10 differences training) and the accident flight, the first officer accumulated about 25.6 flight hours and 2 landings in the MD-10.13 The first officer's most recent recurrent MD-11/-10 line check was completed on April 18, 2001; her most recent MD-11/-10 simulator proficiency check was completed on November 20, 2003; and her most recent ground training was completed on November 28, 2003.
  • 13,000 hours of flight time in smaller aircraft will go far in cementing small aircraft procedures into a pilot. One of the problems with the airline scheduling system is such a pilot will be faced with years of reserve duty with very few landings. Though the first officer had 15,000 hours of total time, she was relatively inexperienced when it came to handling and landing large jets.

  • A review of the first officer's employment, flight, and training records revealed that two of her DHC-8 captain proficiency checkrides (on April 7 and 13, 1994, while she was employed by Mesaba Airlines) were unsatisfactory. According to Mesaba Airlines, the check airman who conducted both proficiency checkrides indicated that the unsatisfactory results were because of "generally poor airmanship."" As a result of the first officer's unsatisfactory performance during the April 13 checkride, the FAA inspector who observed that checkride required her to be reexamined for her ATP certificate by an FAA check airman under the provisions of 49 CFR, Chapter 447, Section 44609 (currently codified as Section 44709).14 On May 15, 1994, the first officer satisfactorily completed the reexamination.
  • I am a bit surprised that FedEx would hire a pilot with the words "poor airmanship" documented.

  • According to FedEx training records, the first officer completed DC-10 flight engineer training on April 17, 1996. She began MD-11 first officer transition training on August 31, 1998, and received her MD-11 type rating on October 22, 1998. The records also indicated that, on October 26, 1999, the first officer failed her MD-11 proficiency checkride; deficiencies were noted in the areas of engine-out takeoff, nonprecision approach, and engine fire/failure/restart. The records further indicated that, after additional training, she satisfactorily completed a proficiency checkride on October 29, 1999. The records also indicated that, on October 17, 2001, the first officer failed another MD-11 proficiency checkride; deficiencies were noted in the areas of powerplant failure, nonprecision approach, missed approach procedures,15 one/two engine-out landing, and command judgment. The records further indicated that, after additional training, she satisfactorily completed a proficiency checkride on October 19, 2001.

[NTSB AAR-05/01, ¶1.17.2.2]

  • FedEx's MD-11/-10 flight manual (page 7-1-6-2) states the following regarding crosswind landings:
  • Crosswind landings are accomplished by flying the final approach in a wings level attitude with a crab into the wind. At approximately 200' agl, align the fuselage with the runway by smoothly applying rudder and maintain runway centerline by lowering the upwind wing. In high crosswinds, consideration should be given to commencing the align maneuver prior to 200'. The align maneuver shall be established by 100' agl.

  • The flight manual also stated that, to ensure that the airplane is in the correct landing attitude and airspeed at touchdown, pilots should smoothly increase back pressure on the control column as the airplane descends through 30 feet agl, bringing the nose of the airplane up an additional 2° to 2.5° above its approach pitch attitude (resulting in about a 7° to 7.5° nose-up pitch attitude). The flight manual further stated that this pitch attitude should be established by 10 feet agl and that, subsequently, a constant pitch attitude should be maintained to touchdown.
  • The FOM listed the following guidelines for acceptable landing performance:

    • Airspeed +/- 5 knots of the target speed on final
    • Touchdown to occur in the touchdown zone
    • Touchdown close to or on the centerline
  • On page 1-1-0-9, the FedEx MD-11/-10 FOM indicated that the maximum crosswind landing limitation is 31 knots. The manual also stated that pilots landing in crosswinds should adjust their approach airspeed by adding a wind additive of the greater of the following (not to exceed 20 knots):
    • 5 knots
    • 1/2 the steady wind in excess of 20 knots
    • gust factor

[NTSB AAR-05/01, ¶2.2]

  • FedEx's MD-11/-10 crosswind landing procedures dictate that, as the airplane descends through about 200 feet, the pilot should begin to apply control wheel and rudder inputs to align the longitudinal axis of the airplane with the runway centerline. This alignment procedure places the airplane in a sideslip, allowing the airplane to maintain the desired ground track and longitudinal alignment despite the crosswind conditions, as long as aileron and rudder control inputs are appropriate for those conditions. Then, as the airplane descends through about 30 feet, the procedures indicate that the pilot should smoothly increase back pressure on the control column to increase the airplane's pitch attitude (flare) to about 7° as appropriate for landing.
  • A series of simulations performed using the accident FDR data to backdrive an MD-11/-10 flight simulator indicated that the airplane maintained a stable condition, tracking along the runway centerline with an appropriate wind correction angle as it descended through 200 feet. The FDR evidence further indicated that the first officer began to apply left aileron and right rudder to align the airplane with the runway centerline about 160 feet (this became visually apparent in the simulator about 140 feet). However, the data and the simulations showed that these normal crosswind landing control inputs were only momentary; as the airplane descended below 100 feet, the aileron and rudder control inputs were neutralized and remained neutral until the airplane touched down. The simulations showed that, as a result of the neutralized flight control inputs, the airplane began to drift to the right and continued to drift to the right, with a 5° to 6° left crab angle, until it touched down.

[NTSB AAR-05/01, ¶3.1]

  • The first officer did not properly apply control wheel and rudder inputs to align the airplane with the runway centerline or apply appropriate back pressure on the control column to arrest the airplane's rate of descent before touchdown; as a result, the airplane touched down extremely hard while still in a crab.
  • The captain, who was conducting a line check of the first officer, did not adequately monitor the first officer's performance during the final stages of the approach and landing at Memphis and failed to take or initiate corrective action to prevent the accident.
  • The excessive vertical and lateral forces on the right main landing gear during the landing exceeded those that the gear was designed to withstand and resulted in the fracture of the outer cylinder and the collapse of the right main landing gear.

Probable Cause

[NTSB AAR-05/01, ¶3.2.] The National Transportation Safety Board determines that the probable causes of the accident were 1) the first officer's failure to properly apply crosswind landing techniques to align the airplane with the runway centerline and to properly arrest the airplane's descent rate (flare) before the airplane touched down; and 2) the captain's failure to adequately monitor the first officer's performance and command or initiate corrective action during the final approach and landing.

See Also:

References

NTSB Aircraft Accident Report, AAR-05/01, Federal Express Flight 647, Boeing MD-10-10F, N364FE, Memphis, Tennessee, December 18, 2003

Revision: 20150118
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