National Transportation Safety Board
Office of Public Affairs
Washington, D.C. - 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.
NTSB Media Contact:
Terry N. Williams
The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.