On April 6, 1993, at 0110 Hawaiian Standard Time, China Eastern Airlines flight 583, a McDonnell Douglas MD- 1 1, Chinese registration B-2 17 1, a scheduled international passenger flight from Beijing, China, to Los Angeles, California, with an intermediate stop in Shanghai, China, had an inadvertent deployment of the leading edge wing slats while in cruise flight, approximately 950 nautical miles south of Shemya, Alaska. The autopilot disconnected, and the captain was manually controlling the airplane when it progressed through several violent pitch oscillations and lost 5,000 feet of altitude. The captain regained stabilized flight, declared an emergency because of passenger injuries, and diverted to the U. S. Air Force Base, Shemya, Alaska. Of the 235 passengers and 20 crewmembers aboard the airplane, 2 passengers were fatally injured, and 149 passengers and 7 crewmembers received various injuries. The airplane did not receive external structural damage, but the passenger cabin was substantially damaged.
We determined that the probable cause of this accident was the inadequate design of the flaplslat actuation handle by the Douglas Aircraft Company that allowed the handle to be easily and inadvertently dislodged from the UPJRET position, thereby causing extension of the leading edge slats during cruise flight. The captain's attempt to recover from the slat extension, given the reduced longitudinal stability and the associated light control force characteristics of the MD-11 in cruise flight, led to several violent pitch oscillations.
Contributing to the violence of the pitch oscillations was the lack of specific MD-11 pilot training in recovery from high altitude upsets, and the influence of the stall warning system on the captain's control responses.
Contributing to the severity of the injuries was the lack of seat restraint usage by the occupants.
As a result of the investigation of this accident, We made the following safety recommendations: -To the Federal Aviation Administration:
- Require Douglas Aircraft Company to provide data needed to upgrade MD-11 training simulators to accurately represent the aircraft's longitudinal stability and control characteristics for high altitude cruise flight; and to develop specific guidance and simulator scenarios to train pilots in optimum techniques for the recovery from high altitude upsets, including those accompanied by stall warning.(A-93-143)
- Require operators to provide specific training for the recovery from high altitude upsets, including those accompanied by stall warning. (A-93-144)
- Establish high altitude stall margins for MD- 1 1 airplanes in order to limit the effects of high altitude pitch upsets. (A-93- 145)
- Evaluate the dynamics of the MD-11 stall warning system to ensure that the "on" and "off' logic are consistent with providing the pilot timely information. (A-93-146)
- Conduct a thorough review of the MD-11 high altitude cruise longitudinal stability and control characteristics, stall warning margins, and stall buffet susceptibility to ensure that pilot responses to routine pitch attitude upsets do not result in hazardous pitch oscillations, structural damage, or any other condition that could lead to unsafe flight. (A-93-147)
- Require that fire-blocking materials identified as Testori 0200-316 and 0206-100 be replaced with new materials that meet the fire retardant requirements of 14 CFR 25.853. (A-93- 148)
- Amend 14 CFR 25.853 to include a requirement to test the fire- retardant properties of fire blocking materials after they have been subjected to in-service wear. (A-93-149)
- Conduct research upon the effects of actual in-service wear on the continued airworthiness of fire-blocking materials. Based on the findings, require periodic actual in-service tests of fire-blocking materials to verify compliance with the requirements of 14 CFR 25.853. (A-93-150)
- Inform other certification authorities of the findings regarding the deterioration of the fire-blocking materials noted in this accident investigation with the view toward replacing them, as required. (A-93-15 1)
- Direct principal maintenance inspectors to inform operators of the need to periodically inspect fire-blocking materials for wear and damage and to replace defective materials. (A-93-1 52)
- Issue an Airworthiness Directive requiring the operators of MD-1 Is to install an interim flaplslat handle system or device to prevent the inadvertent deployment of the wing leading edge slats, when such a system or device becomes available. (A-93-8 1)
- Issue an Air Carrier Operations Bulletin to Principal Operations Inspectors to verify that MD-11 operators have advised flightcrews of the potential for an inadvertent in-flight slat extension if contact is made with the flaplslat handle. (A-93-82)
- Require an expeditious installation of a redesigned flaplslat actuating system, when it becomes available for retrofit, that will prevent uncornrnanded and inadvertent deployment of the leading edge wing slats on MD-11 airplanes. (A-93-83)