FLIGHT SAFETY F O U N D AT I O N

Vol. 62 No. 9
Accident PreventionFor Everyone Concerned With the Safety of Flight September 2005

Hard Landing Results in

Destruction of Freighter
Inadequate crosswind-landing technique by the pilot flying and
inadequate monitoring by the pilot not flying were cited in the collapse of
the Boeing MD-10’s right main landing gear on touchdown.

FSF Editorial Staff

About 1226 local time Dec. 18, 2003, a Boeing Canada Dash 8, Fokker F27 and MD-11. She had
MD-10-10F operated by FedEx as Flight 647 veered completed MD-10 differences training in February
off the right side of the runway after the right main 2003. She had been a Dash 8 captain for Mesaba
landing gear collapsed on touchdown at Memphis Airlines before being hired by FedEx in 1996.
(Tennessee, U.S.) International Airport. The first
officer and a nonrevenue passenger received minor “A review of the first officer’s employment, flight
injuries during the evacuation. The captain and four and training records revealed that two of her [Dash
nonrevenue passengers were not injured. The airplane 8] captain proficiency check rides (on April 7 and 13,
was destroyed by the post-impact fire. 1994, while she was employed by Mesaba Airlines)
were unsatisfactory,” the report said. “According to
The U.S. National Transportation Safety Board Mesaba Airlines, the check airman who conducted
(NTSB) said, in its final report, that the probable both proficiency check rides indicated that the
causes of the accident were “the first officer’s failure unsatisfactory results were because of ‘generally
to properly apply crosswind landing techniques to poor airmanship.’”
align the airplane with the runway centerline and to properly
arrest the airplane’s descent rate (flare) before the airplane A U.S. Federal Aviation Administration (FAA) inspector who
touched down; and the captain’s failure to adequately monitor observed the first officer’s check ride on April 13, 1994, required
the first officer’s performance and command or initiate that she be re-examined for her airline transport pilot (ATP)
corrective action during the final approach and landing.” certificate. The first officer completed the re-examination on
May 15, 1994.
The captain, 59, had approximately 21,000 flight hours,
including 2,602 flight hours as an MD-11/MD-10 flight The report said that the first officer failed an MD-11 proficiency
crewmember. He held type ratings in the Cessna Citation 500 check ride on Oct. 26, 1999. After receiving additional training,
and MD-11. (The report said that a pilot with an MD-11 type she completed the check ride on Oct. 29, 1999.
rating is qualified to fly an MD-10 after completing MD-10
differences training. The captain had completed MD-10 “The records also indicated that on Oct. 17, 2001, the first
differences training in October 2000.) He had been a pilot for officer failed another MD-11 proficiency check ride,” the report
Flying Tiger Airlines for 11 years when the company merged said. “After additional training, she satisfactorily completed a
with FedEx in 1989. proficiency check ride on Oct. 19, 2001.”

The first officer, 44, had approximately 15,000 flight hours, The accident occurred on the last day of a scheduled four-day
including 1,918 flight hours as an MD-11/MD-10 flight trip that included a line check of the first officer by the captain,
crewmember. She held type ratings in the de Havilland a FedEx check airman.
 “FedEx required this line check because the first officer was The nonrevenue passengers on the accident flight were off-
a flight crewmember involved in an altitude deviation that duty FedEx pilots. A DC-10 captain occupied the flight deck
occurred shortly after departing [from London,] England, in jump seat; the other passengers — two DC-10 first officers, an
November 2003,” the report said. MD-11 first officer and a DC-10 flight engineer — occupied
courier seats aft of the flight deck.
The altitude deviation occurred when air traffic control (ATC)
told the crew to climb to and maintain Flight Level (FL) 230 The airplane departed from Oakland, California, U.S., at 0832
(approximately 23,000 feet). The first officer and the captain of (Memphis time; 0632 Oakland time).
that flight believed that they had been cleared to FL 330. The
airplane was near FL 260 when ATC told the crew to descend The cockpit voice recorder (CVR) recorded numerous sounds
to FL 230. of the first officer clearing her throat and coughing, and a
conversation between the captain and the jump seat passenger
“As a result of this excursion, the first officer and the captain about the first officer’s health. The conversation, recorded from
[of the altitude-deviation flight] were required to complete a a cockpit area microphone, began about 1056.
company-mandated requalification simulator proficiency check
and a line check,” the report said. “The first officer successfully “She was coughing like crazy the other day,” the captain said.
completed the requalification simulator proficiency check on “I think she’s got pneumonia.”
Nov. 20, 2003.”
“She’s going to make us sick,” the jump seat passenger said.
During the 12 months preceding the accident, the first officer
frequently had been on reserve duty. She had flown about 61 “I think so, too,” the captain said. “It’s a three-leg line check
hours and conducted, as the pilot flying, seven landings — six in [to requalify]. I think she would have [stayed home] if it hadn’t
MD-11s and one in an MD-10 — during the 90 days preceding been [for] so much scrutiny on this line check.”
the accident.
The first officer told investigators that she felt fine during the
FedEx pilots and check airmen told investigators that differences accident flight and was not taking any medication.
in flight characteristics and handling qualities between the two
airplanes are minimal (see “Boeing MD-10-10F”). “She stated that she was not sick, and there is no evidence that
this (the coughing/clearing her throat) adversely affected the
“The significant flight control inputs that are needed when flight or her performance,” the report said.
landing either an MD-11 or MD-10 in strong, gusty crosswind
conditions (such as those encountered during the accident At 1145, the first officer briefed the captain on arrival procedures
flight) would render any subtle differences in handling and approach procedures for Runway 27 and Runway 36L at the
characteristics between the airplane negligible,” the report Memphis airport. The pilots also discussed the use of Runway
said. 36R as a backup.

At 1156, the captain told the first officer, “I need to see a stable
Boeing MD-10-10F approach at a thousand feet. If, for some reason, we’re not
stable, go around. All right?”
The Boeing Co. converted 60 McDonnell Douglas DC-10-10s
to MD-10-10F freighters for Federal Express Corp. (FedEx).
The conversion included retrofit of an advanced-technology The first officer said, “Yep. No problem there.”
flight deck that accommodates two flight crewmembers and
provides commonality with the FedEx MD-11 fleet. Boeing
The captain said, “But we don’t have … a lot of gas, so … be
delivered the first MD-10-10F to FedEx in 2000.
stable.”
Introduced in 1970, the DC-10-10 was the first model in the
DC-10 series of long-range, high-capacity transport airplanes
and was designed to be flown by three flight crewmembers.
“Got it,” the first officer said. “Here we go.”
The airplane is powered by three General Electric CF6-6D
or CF6-6D1 turbofan engines, each rated at 40,000 pounds During descent, the captain listened to the automatic terminal
(18,144 kilograms) thrust. information service (ATIS) broadcast, which said that winds
The MD-11, a derivative of the DC-10, has a digital flight were from 320 degrees at 16 knots with gusts to 22 knots,
deck designed for two pilots, winglets and a redesigned visibility was about 10 statute miles (16 kilometers), a broken
tail incorporating fuel-trim tanks. The airplane is powered ceiling was at 4,300 feet and wind shear advisories were in
by three Pratt & Whitney PW4460 turbofan engines, each
rated at 60,000 pounds (27,216 kilograms) thrust.♦ effect for the airport.

Sources: U.S. National Transportation Safety Board and Jane’s All the The captain repeated the wind information and told the first officer
World’s Aircraft that the winds were more favorable to a landing on Runway 36L
or Runway 36R than to a landing on Runway 27.

2 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • SEPTEMBER 2005

 The first officer said that she was “still fairly unfamiliar with The captain told the first officer that MAGEE was 5.5 nautical
Memphis” and wanted to configure the airplane for approach miles (10.2 kilometers) ahead.
earlier than normal.
The tower controller cleared the crew to land and told them
The captain said, “Do what you want.” He then briefed the that they were no. 2 to land, following the Airbus on a two-
first officer about typical approach-and-landing procedures at nautical-mile (four-kilometer) final to Runway 36R. The
the airport. controller issued a wake-turbulence advisory for the Airbus
and a wind shear alert: “Gain and loss of ten [knots] short final
Soon after conducting the “In Range” checklist, the crew was runway three six right.”
told by Memphis Approach Control that they should expect
clearance to land on Runway 36L. The controller told the crew At 1222, the captain said, “How about four extra knots? I don’t like
to descend to 8,000 feet. to add extra speed; but, you know, three or four knots can make a
lot of difference if you’re bumping around back and forth.”
At 1211, the controller told the crew to reduce airspeed to 210
knots and to descend to 6,000 feet. Soon thereafter, the first officer The first officer said, “Good enough. Let’s go with landing
called “two ten [knots]” and told the captain to extend the slats. gear down [and] ‘Before Landing’ checklist, please. Glideslope
The airplane was in level flight at 6,000 feet at 1214 when the [indicators are] alive.”
first officer called for 15 degrees of flap.
The captain said, “Spoilers are armed. The gear is down, and
The controller told the crew to descend to 5,000 feet and to three green. Flaps are twenty-two. Flaps to go. … There’s
expect clearance to land on Runway 36R, which was 9,000 feet MAGEE.”
(2,745 meters) long and 150 feet (46 meters) wide. The captain
programmed the flight management system for an approach and Soon after the first officer called for 35 degrees of flap at 1223,
landing on Runway 36R. the airplane’s central aural warning system (CAWS) issued
a “tail wind shear” alert. The airplane was 1,460 feet above
The crew was conducting the “Approach” checklist at ground level (AGL).
1216, when the controller told them to reduce airspeed to
190 knots, to turn left to a heading of 020 degrees and to The pilots told investigators that they continued the approach
intercept the instrument landing system (ILS) localizer for because they observed no airspeed excursions during the brief
Runway 36R. CAWS wind shear alert.

At 1219, the captain told the first officer that the localizer The report said that no other wind shear alerts were generated
course-deviation indicators were “alive” (i.e., beginning during the remainder of the flight and that a review by the
to center) and that the airplane was 18 nautical miles (33 Massachusetts Institute of Technology Lincoln Laboratory of
kilometers) from touchdown. flight data recorder (FDR) data, Doppler weather radar data
and terminal-winds data indicated that there was no horizontal
The controller told the crew to reduce airspeed to 170 knots and wind shear or other hazardous wind conditions near the runway
issued a wake-turbulence advisory for an Airbus airplane that when the accident occurred.
was 6.5 nautical miles (12.0 kilometers) ahead on the approach.
The captain told the controller that they were looking for the The Lincoln Laboratory review indicated that the tail wind shear
Airbus. warning issued by the CAWS at 1223 likely was generated by
buoyancy waves — “parcels of air that oscillate, rising and falling
The first officer called for 22 degrees of flap. The captain said, between slightly above the boundary layer to near the surface,”
“Flaps twenty-two. I got an Airbus right here and another one the report said. “Buoyancy waves, which often occur in a gusting
out there [that] looks like [it is] about level with us.” wind environment, may have existed from just above the ground
to about 4,800 feet AGL at the time of the accident.”
The controller told the crew to descend to 2,000 feet.
The report said that less than 15 knots of wind shear was
At 1220, the captain told the first officer that the airplane was associated with the buoyancy waves and that the wind shear was
established on the localizer course. “We’re not yet cleared for not significant. The crew’s decision to continue the approach
the approach,” he said. was “appropriate and consistent with FedEx’s wind shear
policies,” the report said.
At 1221, the captain told the controller that they had the airport
in sight. The controller cleared the crew to conduct a visual After the CAWS called out 1,000 feet radio altitude at 1224:27,
approach to Runway 36R and told them to maintain 170 knots the captain told the first officer that the approach was stable.
until crossing the MAGEE intersection and to establish radio “We have a nine-thousand-foot runway,” he said. “And we land
communication with the airport control tower. at a hundred and forty-six.”

FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • SEPTEMBER 2005 3

 At 1224:52, the first officer told the captain that she was Tire marks on the runway indicated that the airplane was yawed
disengaging the autopilot. The first officer did not disengage about 5.4 degrees left of the runway heading and that the flight deck
the autothrottles. was about 20 feet (six meters) right of the runway centerline when
the airplane touched down on the left main landing gear about 564
At 1225:02, the captain said, “Checklist is complete. You’re feet (172 meters) from the approach end of the runway.
cleared to land.”
The report said that the landing gear on the MD-10-10
Studies conducted in a flight simulator after the accident at maximum landing weight (375,000 pounds [170,100
indicated that the control wheel neared full travel to the left kilograms]) were designed to absorb energy generated by a
and right several times during the approach, and that the first touchdown with a descent rate of 10 feet per second (600 feet
officer applied left aileron and right rudder to align the fuselage per minute).
with the runway centerline when the airplane was 140 feet
AGL to 130 feet AGL. “In addition, … the main landing gear is designed to be capable
of absorbing reserve energy that is equivalent to a maximum
“These normal crosswind landing control inputs were only airplane descent rate of 12 feet per second (720 feet per minute)
momentary,” the report said. “As the airplane descended below when landing at the maximum airplane design landing weight,”
100 feet [AGL], the aileron and rudder control inputs were the report said.
neutralized and remained neutral until the airplane touched
down.” The descent rate was 14.5 feet per second (870 feet per minute)
when the right main landing gear touched down about 613 feet
Weather conditions recorded by the automated surface (187 meters) from the approach end of the runway and 45 feet
observing system (ASOS) at the time included winds from (14 meters) right of the runway centerline.
320 degrees at 21 knots with gusts to 26 knots. The airplane
began to drift right after the first officer neutralized the flight “The excessive vertical [forces] and lateral forces on the right
controls. The report said that the flight simulator studies main landing gear during the landing exceeded those that the
showed that the drift was “markedly notable from both pilots’ gear was designed to withstand and resulted in the fracture of
seats as the airplane descended through about 60 feet.” the outer cylinder and the collapse of the right main landing
gear,” the report said.
Investigators estimated that the airplane’s landing weight
was 358,450 pounds (162,593 kilograms), including about The airframe struck the runway about 2,891 feet (882 meters)
110,600 pounds (50,168 kilograms) of cargo — none of which from the touchdown point. As the airplane began to veer off the
was hazardous material — and about 20,300 pounds (9,208 side of the runway at 1226:25, the captain said, “Here we go.”
kilograms) of fuel.
At 1226:30, the airplane came to a stop in the grass about 155
The airplane’s descent rate during the 20 seconds preceding feet (47 meters) right of Runway 36R and 5,979 feet (1,824
touchdown and during the touchdown at 1225:53 was 12.5 feet meters) from the approach end of the runway.
per second (750 feet per minute). FDR data indicated that the
airplane’s pitch attitude was not increased before touchdown “The right main landing gear assembly collapsed, and the airplane
(i.e., the airplane was not flared for landing). was supported by its nose landing gear, left main landing gear
and the lower surface of the right wing,” the report said.
“The first officer did not properly apply control wheel
[inputs] and rudder inputs to align the airplane with the The captain told the controller that seven people were aboard the
runway centerline or apply appropriate back pressure on the airplane. The report said that although control tower personnel
control column to arrest the airplane’s rate of descent before alerted aircraft rescue and fire fighting (ARFF) personnel about
touchdown,” the report said. “As a result, the airplane touched the accident, they did not tell them the number of people aboard
down extremely hard while still in a crab.” the airplane.

The report said that investigators (including representatives of “Controllers should recognize the importance of relaying all
FedEx and the Air Line Pilots Association, International) who available pertinent information, including airplane-occupant
viewed the flight simulator studies said that “there were clear information, to [ARFF] personnel to assist them in ARFF efforts
indications that aspects of the approach needed correcting and and decision making,” the report said.
that the captain should have taken corrective actions when
these indications became apparent.” All the occupants exited the airplane through flight deck
window exits. The report said that several occupants “showed
The report said, “The captain should have verbally prompted poor judgment and exposed themselves to unnecessary risk”
flight control actions, commanded a go-around or taken control when they delayed their evacuation while throwing personal
of the airplane for a go-around or landing.” baggage from the burning airplane.

4 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • SEPTEMBER 2005

 (FARs) Part 121.417 requires cabin crewmembers and flight
crewmembers to pull the manual inflation handle during
training.

ARFF personnel in three vehicles operated by the Memphis

Fire Department (MFD) for the airport authority (the Memphis–
Shelby County Airport Authority) responded to the accident.
The MFD station was west of, and near the end of, Runway
36C. The MFD ARFF personnel arrived at the accident site
about 1228.

ARFF personnel in two vehicles operated by the Rural/Metro

Fire Department (RMFD) for FedEx also responded. The
RMFD station was in the FedEx complex at the extreme
The left side of the fuselage and the left wing received minimal northern end of the airport. Airport tower controllers told
damage by the impact and fire. (Photo: U.S. National Transportation investigators that RMFD ARFF vehicles normally operate
Safety Board) within the FedEx complex and were not considered as primary
emergency responders. The report said that a letter of agreement
The first officer received friction burns to both hands while sliding among FAA, the airport authority and MFD did not specify
down the evacuation tape (a thin ribbon of reinforced synthetic emergency-response procedures for RMFD ARFF personnel.
material deployed through the flight deck window). The jump seat
passenger received a shoulder injury when he fell to the ground At 1228, the RMFD ARFF personnel requested clearance from
after relinquishing his grip on the evacuation tape. the ground controller to proceed from the FedEx complex to
the accident site and were told to hold short of Runway 27
Before exiting through the flight deck window, one passenger because of landing traffic. (Runway 09/27 is north of the three
opened the left front (L1) door. He told investigators that the parallel 18/36 runways.) The report said that the delay was
slide/raft deployed but did not inflate, and that when he pulled not necessary.
the manual inflation handle, the slide/raft inflated, separated
from the L1 doorsill and dropped beneath the airplane. The “A review of recorded radar data showed that, at that time, the
report said that the passenger mistakenly had pulled both the arriving airplane was about 2.5 [nautical] miles [4.6 kilometers)
manual inflation handle and the slide/raft disengage handle. east of the end of Runway 27,” the report said.

The report said that the hands-on emergency-procedures After the arriving airplane landed, the ground controller cleared
training provided to flight crewmembers by FedEx was the crews of two other airplanes to taxi the airplanes across the
inadequate. The emergency exit door/slide device used during runway. The controller then cleared the RMFD ARFF personnel
initial training and recurrent training did not have a manual to taxi across the runway and proceed to the accident site. The
inflation handle or a manual disengage handle. Pilots observed report said that RMFD ARFF personnel arrived at the accident
a video presentation on the use of the manual inflation handle, site several minutes after the MFD ARFF personnel.
but “this method of training does not adequately provide
crewmembers with the skills required to operate the door/ The main body of fire was under control within 10 minutes to
slide,” the report said. 15 minutes of the arrival of the MFD ARFF personnel and was
extinguished completely by 1322.
The report said that the guidance on flight crew emergency-
procedures training provided by FAA to its principal operations The report said that in January 2004, FedEx implemented an
inspectors (POIs) was inadequate. enhanced oversight program (EOP) to identify pilots who have
demonstrated performance deficiencies during training and to
“The guidance, contained in FAA Order 8400.10, Air conduct additional oversight of the pilots, including two annual
Transportation Aviation Inspector’s Handbook, includes a line checks of first officers and an additional annual line check
more detailed description of the emergency exit–training of captains. (Normally, captains receive one annual line check;
requirements for cabin crew than for flight crew, including first officers do not receive an annual line check.)
the requirement to pull the manual inflation handle,” the
report said. “Additionally, the EOP board, which is made up of company
training and flight standards directors, meets monthly to
The POI assigned to FedEx told investigators that he interpreted review recent events and discuss identified pilots’ case
the handbook guidance to mean that flight crewmembers histories,” the report said. “This increased level of monitoring
were not required to pull the manual inflation handle during a pilot’s performance helps the company determine if deficient
training. The report said that U.S. Federal Aviation Regulations performance demonstrated during a check ride is indicative of

FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • SEPTEMBER 2005 5

 the pilot’s overall performance. If FedEx’s EOP had been in the actual airplane exit-door/slide and that their flight
effect when the first officer failed her check rides in 1999 and/or crew emergency exit door/slide training provides the
2001, she would certainly have received additional company intended hands-on emergency-procedures training as
scrutiny and training.” described in [Part] 121.417, to include pulling the manual
inflation handle. (A-05-016);
At the time the accident report was adopted (May 2005), FedEx
was the only FARs Part 121 air carrier that had an EOP or a • “Inform all [ATC] control tower controllers of the
similar proactive program. circumstances of this accident, including the need to
ensure that [ARFF] vehicles are not delayed without
Based on the findings of the accident investigation, NTSB made good cause when en route to an emergency and the
the following recommendations to FAA: need to relay the number of airplane occupants to ARFF
responders. (A-05-017); [and,]
• “Require all [FARs] Part 121 air carrier operators to establish
programs for flight crewmembers who have demonstrated • “In cooperation with the Memphis/Shelby County
performance deficiencies or experienced failures in the Airport Authority and [MFD], modify the Nov. 1,
training environment that would require a review of their 2001, letter of agreement titled ‘Airport Emergency
whole performance history at the company and administer Procedures’ to fully describe the protocol to be used
additional oversight and training to ensure that performance for emergency responses, including [RMFD ARFF]
deficiencies are address and corrected. (A-05-014); equipment and personnel. (A-05-018).”

• “Amend the emergency exit–training information [At press time, FAA had not responded to the
contained in the flight crew and cabin crew sections in recommendations.]♦
[FAA] Order 8400.10 … to make the emergency exit–
door/slide training described in the flight crew section [FSF editorial note: This article, except where noted, is based
as comprehensive as the cabin crew emergency-training on U.S. National Transportation Safety Board Aircraft Accident
section of the [POI] handbook. (A-05-015); Report NTSB/AAR-05/01, Hard Landing, Gear Collapse,
Federal Express Flight 647, Boeing MD-10-10F, N364FE,
• “Verify that all [FARs] Part 121 operator’s emergency Memphis, Tennessee, December 18, 2003. The 109-page report
door/slide trainers are configured to accurately represent contains illustrations and appendixes.]

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