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NTSB Public Meeting of July 25, 2000 Abstract of Final Report (Subject to Editing) Aviation Accident Report Crash During Landing Federal Express, Inc., Flight 14, McDonnell Douglas MD-11, N611FE Newark International
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 NTSB Public Meeting of July 25, 2000 Abstract of Final Report (Subject to Editing) Aviation Accident Report Crash During Landing Federal Express, Inc., Flight 14, McDonnell Douglas MD-11, N611FE Newark International

This is an abstract from the Safety Board's report and does not include the Board's rationale for the conclusions and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions, probable cause, and recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients and investigation parties as soon as possible. The following information is subject to further review and editing.

SUMMARY

On July 31, 1997, about 0132 eastern daylight time, a McDonnell Douglas MD-11, N611FE, operated by Federal Express, Inc., (FedEx) as flight 14, crashed while landing on runway 22R at Newark International Airport, Newark, New Jersey (EWR). The regularly scheduled cargo flight originated in Singapore on July 30 with intermediate stops in Penang, Malaysia; Taipei, Taiwan; and Anchorage, Alaska. The flight from Anchorage International Airport to EWR was conducted on an instrument flight rules flight plan and operated under the provisions of 14 Code of Federal Regulations Part 121. On board were the captain and first officer, who had taken over the flight in Anchorage for the final leg to EWR, one jumpseat passenger, and two cabin passengers. All five received minor injuries in the crash and during subsequent egress through a cockpit window. The airplane was destroyed by impact and a postcrash fire.

CONCLUSIONS

1. There was no preexisting damage or degradation to the airplane structure, systems, or components that contributed to this accident.

2. The airplane's approach before the landing flare was stabilized.

3. The captain's execution of the beginning of the flare maneuver was normal and not a factor in the accident.

4. The accident airplane performed normally in response to the captain's flight control inputs until after the second touchdown.

5. The captain was concerned about the airplane's touchdown location on runway 22R and intended to take measures during the landing to achieve an early touchdown and minimize the length of the rollout on the runway after touchdown.

6. The captain's nose-down elevator input beginning at 17 feet radio altitude was not consistent with Federal Express guidance for landing the MD-11.

7. The captain's nose-down elevator input at 17 feet radio altitude (2 seconds before the first touchdown) was consistent with an attempt to control the point of touchdown given his concerns about the runway length.

8. The captain made a nearly full nose-up elevator input and a large throttle increase to compensate for the increased sink rate caused by his previous nose-down input.

9. The captain's full nose-down elevator control input at the time of the first touchdown was consistent with his continued concerns to avoid a long landing and his desire to avoid a tailstrike.

10. The captain's overcontrol of the elevator during the landing and his failure to execute a go-around from a destabilized flare were causal to the accident.

11. The captain's control inputs during the flare and bounce were not consistent with landing procedures and techniques outlined in the Federal Express MD-11 pilot training procedures, McDonnell Douglas flight crew operating manual, or with Federal Express' MD-11 tailstrike awareness and high sink rate and bounce recovery training.

12. The captain had no previously documented skill deficiencies that contributed to this accident.

13. Air carrier pilots' performance would be improved by additional guidance and training in landing techniques.

14. The crew's calculation error in determining the runway length required for landing influenced the captain's subsequent actions during final approach and landing by creating a sense of urgency to touchdown early and initiate maximum braking immediately.

15. Some flight crewmembers may lack proficiency in the operation of airport performance laptop computers, or similar airplane performance computing devices, and confusion about calculated landing distances may result in potentially hazardous miscalculations of available runway distances after touchdown.

16. The inoperative left landing light did not impede the captain's ability to land the airplane.

17. The MD-11's tendency to pitch up at ground spoiler deployment did not contribute to the accident.

18. The handling changes incorporated in the MD-11 flight control computer-908 software upgrade will provide valuable improvements in safety during MD-11 landings.

19. With the information that is currently available from the flight data recorder, it may be impossible to distinguish the control inputs of the MD-11 flight control computer-908 longitudinal stability augmentation system from the pilots' control inputs.

20. The MD-11's throttle resolver angle-driven spoiler knockdown feature did not contribute to this accident.

21. Additional basic research to identify undesirable landing phase combinations and to compare the overall qualitative and quantitative stability and control characteristics of widely used, large transport-category airplanes is needed to improve certification criteria and reduce the incidence of potentially catastrophic landing accidents.

22. The energy transmitted into the right main landing gear during the second touchdown was 3.2 times greater than the MD-11's maximum certificated energy and was sufficient to fully compress (bottom) the right main landing gear strut and cause structural failure of the right wing rear spar./P>

23. The structural failure of the right wing rear spar resulted in the rupture of the right wing fuel tanks and fire.

24. The failure modes and effects for vertically fused and overdesigned landing gear designs may have been inadequately researched to identify whether, under overload conditions, one design might provide a safer break-up sequence for the airplane than the other design.

25. Current manufacturer guidance for hard landing identification and operator maintenance readouts and analysis of flight data recorder data following suspected hard landings may not be adequate to identify landings in which structural damage occurred.

26. Risks to firefighters and the surrounding community were minimized substantially because the incident commander assumed that hazardous materials were on board and acted accordingly.

27. The Newark accident demonstrates that air carriers transporting hazardous materials continue to need a means to quickly retrieve and provide consolidated, specific information to emergency responders about the identity of all hazardous materials on an airplane.

PROBABLE CAUSE

The National Transportation Safety Board determines that the probable cause of this accident was the captain's overcontrol of the airplane during the landing and his failure to execute a go-around from a destabilized flare. Contributing to the accident was the captain's concern with touching down early to ensure adequate stopping distance.

SAFETY RECOMMENDATIONS

-- To the Federal Aviation Administration:

1. Convene a joint government-industry task force composed, at a minimum, of representatives of manufacturers, operators, pilot labor organizations, and the Federal Aviation Administration to develop, within 1 year, a training tool to do the following:

Include information about factors that can contribute to structural failures involving the landing gear, wings, and fuselage, such as design sink rate limits; roll angle limits; control inputs' roll rate; pitch rate; single-gear landings; the effect of decreased lift; and structural loading consequences of bottoming landing gear struts and tires; (A-00-XX)

Provide a syllabus for simulator training on the execution of stabilized approaches to the landing flare, the identification of unstabilized landing flares, and recovery from these situations, including proper high sink rate recovery techniques during flare to landing, techniques for avoiding and recovering from overcontrol in pitch before touchdown, and techniques for avoiding overcontrol and premature derotation during a bounced landing; and (A-00-XX)

Promote an orientation toward a proactive go-around. (A-00-XX)

2. Require principal operations inspectors assigned to Part 121 carriers that use auxiliary performance computers to review and ensure the adequacy of training and procedures regarding the use of this equipment and the interpretation of the data generated, including landing distance data. (A-00-XX)

3. Require the installation, within one year, of the MD-11 flight control computer-908 software upgrade on all MD-11 airplanes. (A-00-XX)

4. Require, on all MD-11s equipped with the flight control computer-908 software, the retrofit of digital flight data recorder systems with all additional parameters required to precisely identify and differentiate between pilot and longitudinal stability augmentation system (LSAS) elevator control activity, including control column force, inertial reference unit pitch rate, LSAS command signals, elevator positions, and automatic ground spoiler command signals. (A-00-XX)

5. Review and, if appropriate, revise the DC-10 and MD-11 throttle resolver angle (TRA)-driven ground spoiler knockdown feature to ensure that it does not prevent ground spoiler deployment at moderate TRAs that could be associated with sink rate and airspeed corrections during the landing phase. (A-00-XX)

6. Require DC-10 and MD-11 operators to provide their pilots with information and training regarding the ground spoiler knockdown feature and its effects on landing characteristics and performance. (A-00-XX)

7. Sponsor a National Aeronautics and Space Administration (NASA) study of the stability and control characteristics of widely used, large transport-category airplanes to:

Identify undesirable characteristics that may develop during the landing phase in the presence of adverse combinations of pilot control inputs, airplane center of gravity position, atmospheric conditions, and other factors; and

Compare overall qualitative and quantitative stability and control characteristics on an objective basis. The study should include analyses of DC-10 and MD-11 landing accidents and any other landing incidents and accidents deemed pertinent by NASA. (A-00-XX)

8. Based on the results of the study recommended in Safety Recommendation A-00-XX [7], implement improved certification criteria for transport-category airplane designs that will reduce the incidence of landing accidents. (A-00-XX)

9. Conduct a study to determine if landing gear vertical overload fusing offers a higher level of safety than when the gear is overdesigned. If fusing offers a higher level of safety, the Federal Aviation Administration should revise 14 Code of Federal Regulations Part 25 to require vertical overload fusing of landing gear. (A-00-XX)

10. Require manufacturers of 14 Code of Federal Regulations Part 23 and Part 25 airplanes and Part 121 operators to revise their hard landing inspection and reporting criteria to account for all factors that can contribute to structural damage. The Federal Aviation Administration (FAA) should also instruct FAA principal maintenance and operations inspectors assigned to Part 121 operators to ensure that these changes have been made to operator maintenance manuals and Flight Operations Quality Assurance exceedence monitoring programs. (A-00-XX)

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Contact: NTSB Media Relations
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