AviationWeek piece on FedEx crash
Um, How was this first officer hired by FedEx with two, yes 2 failed checkrides in his past???
FedEx Crash Highlights Need to Correct Performance Deficiencies
05/22/2005 12:31:36 PM
By Frances Fiorino
LESSONS LEARNED
The crash of FedEx Flight 647 could lead to wider establishment of Part 121 programs to detect and correct pilot performance deficiencies, and to enhanced emergency evacuation training for flight crews.
These are among several recommendations issued by the NTSB last week at its final hearing on the Dec. 18, 2003, accident involving a FedEx MD-10-10F (N364FE). The safety board found flight crew actions as probable cause of the hard landing on Runway 36R at Memphis (Tenn.) International Airport that injured two of the seven people on board.
THE BOARD REVIEWED the series of events leading to the accident. The first officer, the pilot flying, was undergoing a check ride; the captain acted as check airman as well as pilot in command. Five other FedEx nonrevenue pilots were on Flight 647 that was en route from Metropolitan Oakland (Calif.) airport.
Climb, cruise and descent were normal and the approach to the Memphis runway was stable through about 200 ft. AGL, according to the NTSB. Winds were from 320 deg. at 21 kt. gusting to 26. A wind shear alert sounded at about 1,500 ft., but the board ruled out wind shear as a factor. The MD-10's autopilot was turned off at 700 ft. AGL. The landing conditions were within the capabilities of the flight crew, who were all trained and practiced in crosswind techniques, according to the NTSB.
However, investigators found the first officer failed to properly apply crosswind landing techniques to align the aircraft with the Runway 36R centerline and failed to flare by applying back pressure on the control column to arrest descent. (According to the board, FedEx pilots are trained to align aircraft with the centerline no less than 200 ft. AGL to prevent drift from centerline, and to apply back pressure on the control column at 30 ft. AGL to initiate the flare.)
As a result, the aircraft touched down "extremely hard" to the right of centerline while still in a crab (aircraft nose pointed into the wind). On touchdown, the outer cylinder fractured, the right main landing gear collapsed and the MD-10 veered off the right side of the runway (see photo). NTSB data show that at touchdown the left gear descent rate was 12.5 fps.; right gear, 14.4 fps., in excess of the design limit of 10 fps. The vertical and lateral loads coincided, according to the board. Fire then erupted on the right side of the aircraft destroying the right wing and parts of the right fuselage.
Evacuation, however, was impeded by crewmembers attempting to retrieve personal belongings before exiting. According to the NTSB, most of the pilots on board exposed themselves to unnecessary risk by doing so. In addition, the pilot who opened the L1 emergency exit mistakenly pulled both manual inflation and slide-release handles, which resulted in separating the slide from the doorsill. He said he pulled the manual inflation handle only. Both handles were found on the cabin floor.
Rescue vehicles were hampered in reaching the accident aircraft because ground controllers did not give them priority over nonemergency airport traffic.
NTSB investigators studied other operational factors, and concluded that cargo loading was not a factor; neither was fatigue, although the flight crew was on the last leg of a four-day trip.
They also examined crew records. The NTSB noted that the first officer, who was employed by FedEx since 1996, had two previous unsatisfactory proficiency check rides with the company, although in areas unrelated to performance on the day of the accident. Flight 647's first officer also had two captain proficiency check ride failures with a previous employer as well as an FAA reexamination.
AS FOR FLIGHT 647'S captain, the board found that he failed to provide adequate oversight of the first officer's performance and failed to take any corrective action--such as commanding a go-around or taking the flight controls--that could have prevented the accident.
As a result of the probe, the NTSB is asking that the FAA require Part 121 operators to establish programs for flight crew who have demonstrated performance deficiencies or failures in the training environment. The programs would require a review of performance history as well as provide oversight and training to remedy the problems.
The board also recommended that all Part 121 emergency door slide trainers are configured to represent the actual aircraft exit door. Finding FedEx hands-on training "inadequate," the board recommended that hands-on procedures training as described in Part 121.417 include pulling the manual inflation handle. Further, the board is requesting that air traffic controllers be made aware of this accident to ensure that rescue vehicles are not delayed getting to the scene of an accident or incident.