Boeing MD-10-10F, N364FEMemphis, TennesseeDecember 18, 2003

Aircraft Accident ReportNTSB/AAR-05/01PB2005-910401Notation 7632A

National TransportationSafety Board

Washington, D.C.

Aircraft Accident Report

Hard Landing, Gear Collapse

Federal Express Flight 647

Boeing MD-10-10F, N364FE

Memphis, Tennessee

December 18, 2003

NTSB/AAR-05/01

PB2005-910401 National Transportation Safety Board

Notation 7632A 490 LíEnfant Plaza, S.W.

Adopted May 17, 2005 Washington, D.C. 20594

E PLUR IBUS UNUM

NATIONAL TRA S PORTATION

B OAR D

SAFE T Y

N
National Transportation Safety Board. 2005. Hard Landing, Gear Collapse, Federal Express

Flight 647, Boeing MD-10-10F, N364FE, Memphis, Tennessee, December 18, 2003. Aircraft Accident

Report NTSB/AAR-05/01. Washington, DC.

Abstract: This report explains the accident involving Federal Express flight 647, a Boeing MD-10-10F,

N364FE, which crashed while landing at Memphis International Airport (MEM), Memphis, Tennessee.

Safety issues in this report focus on flight crew performance, emergency evacuations, MEM air traffic

control and aircraft rescue and firefighting issues, and flight data recorder reliability.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2005-910401 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Aircraft Accident Report

Contents

Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.5.1.1 The Captain’s 72-Hour History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.5.2 The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.5.2.1 The First Officer’s 72-Hour History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.5.2.2 The First Officer’s Landing History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.7.1 Weather for Memphis International Airport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.7.2 Massachusetts Institute of Technology/Lincoln Laboratory Study . . . . . . . . . . . . . 11

1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.10.1 MEM Aircraft Rescue and Firefighting General Information . . . . . . . . . . . . . . . . 13

1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.11.2.1 FDR Recording of Aileron Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.12 Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.12.1 Tire and Other Markings on the Runway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.12.2 Landing Gear Assemblies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.12.3 Cargo and Shipping Containers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

1.12.4 Postaccident Examination of the Emergency Evacuation Slides . . . . . . . . . . . . . . 21

1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.15.1 Nonrevenue FedEx Pilot’s Activation of the L1 Door/Slide . . . . . . . . . . . . . . . . . 22

1.15.2 Emergency Evacuation Videotape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

1.15.3 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

1.15.3.1 RMFD Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

1.15.3.2 Postaccident Federal Aviation Administration Actions . . . . . . . . . . . . . . . . . . . 25

1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.16.1 Airplane Performance Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
iv Aircraft Accident Report

1.16.1.1 Safety Board’s Airplane Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.16.1.2 Wind Derivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

1.16.1.3 Boeing’s Airplane Landing Energy Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

1.16.2 Metallurgical Examination of the Right Main Landing Gear Assembly . . . . . . . . 29

1.16.3 Flight Simulator Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1.17 Operational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.17.1 FedEx General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.17.2 FedEx Crew Training, Guidance, and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.17.2.1 FedEx’s Missed Approach/Go-Around Policy . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.17.2.2 FedEx Crosswind Landing Guidance and Procedures . . . . . . . . . . . . . . . . . . . . 32

1.17.2.2.1 Crewmember Descriptions of the Accident Approach and Landing . . . . . . 32

1.17.2.3 FedEx Windshear Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

1.17.2.4 FedEx Emergency Evacuation Procedures and Guidance . . . . . . . . . . . . . . . . . 34

1.17.2.5 FedEx Emergency Evacuation Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1.17.2.5.1 Regulatory Requirements and Federal Aviation 

Administration Oversight of Emergency Training . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

1.17.2.5.2 Previous Safety Board Emergency Exit Training 

Device Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

1.17.3 FedEx Enhanced Oversight Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

1.17.4 Federal Aviation Administration and Department of 

Defense Oversight of FedEx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

1.18.1 MD-11/-10 Flight Characteristics and Differences . . . . . . . . . . . . . . . . . . . . . . . . . 40

1.18.2 Previous Safety Board Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.2 The Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

2.3 Failure of the Right Main Landing Gear Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

2.4 Flight Crew Performance—Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

2.5 Survival Factors Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

2.5.1 Emergency Exit Door/Slide Operation and Training . . . . . . . . . . . . . . . . . . . . . . . 51

2.5.2 Cockpit Window Emergency Evacuation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . 53

2.6 Memphis ATCT Actions and Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

2.7 FDR Aileron Update Rate Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

4. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

4.1 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

4.2 Previously Issued Recommendation Reiterated in This Report . . . . . . . . . . . . . . . . . . 61

5. Appendixes

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Contents
v Aircraft Accident Report

Figures

1. MEM airport diagram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2. Photograph of the damage to the right side of the airplane.. . . . . . . . . . . . . . . . . . . . . . . . . 17

3. FedExís MD-11/-10 emergency evacuation door trainer, with 

the girt flap assembly in place, as it would appear when the 

door/slide is opened. The arrow indicates the manual inflation handle . . . . . . . . . . . . . . . . 18

4. FedExís MD-11/-10 emergency evacuation door trainer, with the 

girt flap assembly lifted. The arrow indicates the slide/raft disengage handle . . . . . . . . . . . 19

5. The airplaneís vertical speeds (as identified by the Safety 

Boardís performance study) during the accident landing and the two 

previous landings, with altitude displayed above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

6. Pitch attitudes recorded by the FDR during the accident landing 

and two previous landings. The vertical black line (FDR elapsed time 

0 seconds) represents the airplaneís touchdown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
vi Aircraft Accident Report

Abbreviations

AC advisory circular

ADC air data computer

AFFF aqueous film forming foam

AFS autoflight system 

agl above ground level

AIRMET airmenís meteorological information

ALPA Air Line Pilots Association

ARFF aircraft rescue and firefighting 

ASOS automated surface observation system 

ATC air traffic control 

ATCT air traffic control tower 

ATIS automatic terminal information service

ATP airline transport pilot

C Celsius

CAWS central aural warning system

c.g. center of gravity

CFR Code of Federal Regulations

CVR cockpit voice recorder 

EOP enhanced oversight program

FAA Federal Aviation Administration 

FCC flight control computer 

FCIF flight crew information file

FDR flight data recorder

FL flight level

FMS flight management system
Abbreviations vii Aircraft Accident Report

FOM flight operations manual

fpm feet per minute

Fps feet per second

FSB Flight Standardization Board

ft-lb foot-pound

Hg mercury 

IND Indianapolis International Airport

IRS inertial reference system

ITU initial, transition, or upgrade training

ILS instrument landing system 

MAC mean aerodynamic chord

MEM Memphis International Airport

MFD Memphis Fire Department

MIT Massachusetts Institute of Technology

ms millisecond

MSCAA Memphis/Shelby County Airport Authority

msl mean sea level 

OAK Metropolitan Oakland International Airport

POI principal operations inspector

P/N part number

PRIA Pilot Records Improvement Act

PST Pacific standard time

RMFD Rural/Metro Fire Department

sm statute miles

S/N serial number

WAGS windshear alert and guidance system

WME wind measuring equipment
viii Aircraft Accident Report

Executive Summary

On December 18, 2003, about 1226 central standard time, Federal Express

Corporation (FedEx) flight 647, a Boeing MD-10-10F (MD-10), N364FE, crashed while

landing at Memphis International Airport (MEM), Memphis, Tennessee. The right main

landing gear collapsed after touchdown on runway 36R, and the airplane veered off the

right side of the runway. After the gear collapsed, a fire developed on the right side of the

airplane. Of the two flight crewmembers and five nonrevenue FedEx pilots on board the

airplane, the first officer and one nonrevenue pilot received minor injuries during the

evacuation. The postcrash fire destroyed the airplaneís right wing and portions of the right

side of the fuselage. Flight 647 departed from Metropolitan Oakland International Airport

(OAK), Oakland, California, about 0832 (0632 Pacific standard time) and was operating

under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument

flight rules flight plan. 

The National Transportation Safety Board determines that the probable causes of

the accident were 1) the first officerís failure to properly apply crosswind landing

techniques to align the airplane with the runway centerline and to properly arrest the

airplaneís descent rate (flare) before the airplane touched down; and 2) the captainís

failure to adequately monitor the first officerís performance and command or initiate

corrective action during the final approach and landing.

The safety issues in this report focus on flight crew performance, emergency

evacuations, MEM air traffic control and aircraft rescue and firefighting issues, and flight

data recorder reliability. 
1 Aircraft Accident Report

1. Factual Information

1.1 History of Flight

On December 18, 2003, about 1226 central standard time,1 Federal Express

Corporation (FedEx) flight 647, a Boeing MD-10-10F (MD-10),2 N364FE, crashed while

landing at Memphis International Airport (MEM), Memphis, Tennessee. The right main

landing gear collapsed after touchdown on runway 36R, and the airplane veered off the

right side of the runway. After the gear collapsed, a fire developed on the right side of the

airplane. Of the two flight crewmembers and five nonrevenue FedEx pilots3 on board the

airplane, the first officer and one nonrevenue pilot received minor injuries during the

evacuation. The postcrash fire destroyed the airplaneís right wing and portions of the right

side of the fuselage. Flight 647 departed from Metropolitan Oakland International Airport

(OAK), Oakland, California, about 0832 (0632 Pacific standard time) and was operating

under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument

flight rules flight plan.

The accident occurred on the last day of the flight crewís 4-day, 3-leg trip during

which the captain of the flight, a company check airman, was conducting a line check for

the first officer.4

 The first leg of the trip departed MEM about 2100 on December 15,

2003, and arrived at Indianapolis International Airport (IND), Indianapolis, Indiana, about

2215 (2315 eastern standard time). The captain was the flying pilot for that leg. The

second leg of the trip departed IND about 1431 (1531 eastern standard time) on December

16 and arrived at OAK about 1850 (1650 Pacific standard time). The first officer was the

flying pilot for that leg.

The captain and first officer remained in Oakland on December 17, with no flight

duties assigned, then reported for duty on December 18 before the accident flightís

scheduled departure time of 0810 (0610 Pacific standard time). The airplaneís departure to

MEM was delayed until 0832 because of a package sorting issue that was later resolved.

The first officer was the flying pilot, and the captain performed the nonflying pilot and

line check airman duties. 

1 Unless otherwise indicated, all times are central standard time based on a 24-hour clock.

2 An MD-10 is a DC-10 that has been retrofitted with an advanced-technology flight deck. According

to Boeing, the retrofit allows for a two-person flight crew (instead of three), weight savings, increased

reliability, and commonality with the MD-11 fleet. FedEx received delivery of its first MD-10s on May 9,

2000.

3 The five off-duty, nonrevenue FedEx flight crewmembers included a DC-10 captain, who occupied

the jumpseat in the cockpit, two DC-10 first officers, an MD-11 first officer, and a DC-10 flight engineer

who occupied the courier seats located in the cabin directly aft of the cockpit.

4 FedEx required this line check because the first officer was a flight crewmember involved in an

altitude deviation that occurred shortly after departing Stanstead, England, in November 2003. For

additional information regarding this incident, see section 1.5.2. 
Factual Information 2 Aircraft Accident Report

According to postaccident interviews, cockpit voice recorder (CVR)5 and flight

data recorder (FDR) evidence, and air traffic control (ATC) records, the climb and cruise

phases of the flight were routine and uneventful. As the airplane approached MEM, the

captain and first officer discussed procedures and runway options and planned for the

arrival at MEM. About 1145:40, the first officer briefed the captain on arrival and

approach procedures for runways 27 (the primary landing runway option) and 36L (the

secondary landing runway option). According to the CVR, about 1156:39, the captain

stated, ìI need to see a stable approach at a thousand feet. If for some reason weíre not

stable go aroundÖall right?î The first officer responded, ìyep no problem there.î 

The captain obtained the current MEM automatic terminal information service

(ATIS) information and, about 1200:34, stated that the winds were out of ìthree

twentyÖsixteen gusts to twenty-two, soÖitís more favorable to the three sixes.î About

1202:08, the first officer stated, ìI just think we should start putting out slats about twenty

miles on the other sideÖbecause IímÖstill fairly unfamiliar with Memphis, so I wanna

get configured a bit earlier for that.î The captain responded, ìdo what you want,î and

provided additional information about normal arrival operations, addressing typical

stepdown and traffic pattern procedures, altitudes, airspeeds, and the probability of an

early turn into MEM. The first officer acknowledged the information and requested the

in-range checklist. About 1203:22, the captain stated, ìyouíre driving and you stay

focused on that and make me do whatever you need done.î The first officer stated, ìokay.î 

About 1204:46, the captain stated, ìtwo ninety is the default descent speed. Which

is just fine. Thatís whatís in there.î About 1205:22, the captain continued the in-range

checklist, confirming altimeter settings with the first officer. About 1205:37, Memphis Air

Route Traffic Control Center advised the pilots to contact MEM approach control. About

1206:00, the captain announced that the in-range checklist was complete, then contacted

MEM approach control. The MEM approach controller advised the pilots to expect to land

on runway 36L and informed them that ATIS information Zulu was current. The approach

controller cleared flight 647 to descend to and maintain 8,000 feet mean sea level (msl).6

The captain acknowledged the clearance and repeated ìthree six leftî to the first officer. 

 About 1209:12, the captain advised the first officer that the winds were out of

ìthree twenty at sixteen gusts to twenty two. Ten miles [visibility]. Itís still saying wind

shear.î The first officer responded, ìgoodness.î About 1210:46, the captain stated, ìI

donít see any other TCAS [traffic alert and collision avoidance system] targetsÖWe may

be the lead dog coming in here.î About 1211:24, the MEM approach controller instructed

the pilots to reduce the airplaneís airspeed to 210 knots and then descend to and maintain

6,000 feet. Shortly after the captain acknowledged these instructions, the first officer

asked him to confirm the clearance, and the captain repeated the instructions. The first

officer repeated the airspeed restriction and asked the captain to extend the slats. 

5 The CVR recorded the last 2 hours 58 seconds of cockpit communications before the accident. See

appendix B for a partial transcript of the CVR recording. 

6 Unless otherwise indicated, altitudes are reported as msl. 
Factual Information 3 Aircraft Accident Report

About 1212:11, the captain stated, ìthereís BOWEN [a navigational

intersection]Öone seventy five is the heading out of BOWEN.î The CVR recorded the

first officer as she responded, ìoh, thank you.î About 1212:42, the captain stated,

ìFREAZ [a navigational intersection] is out there fourteen miles from touchdown.î About

1213:14, the captain stated, ìairportís right there,î and the first officer responded, ìyep.î 

About 1213:18, the MEM approach controller advised the pilots to contact MEM

approach control on a different frequency. About 30 seconds later, the captain contacted

MEM approach control on the new frequency and advised the controllers that flight 647

was level at 6,000 feet. About 1214:15, the first officer requested 15° of flaps. About

1214:33, MEM approach control cleared the pilots to descend to and maintain 5,000 feet

and turn 10° right. Afterward, the MEM approach controller advised the pilots that they

should expect to land on runway 36R instead of 36L, as previously instructed. 

About 1215:39, the captain told the first officer, ìthree six rightís in the fix page

and itís in theÖFMS [flight management system],î and the first officer thanked him.

About 1216:11, the MEM approach controller instructed the pilots to reduce the airplaneís

airspeed to 190 knots, and the captain acknowledged this instruction. The first officer

called for the approach checklist about 1218:10, and the captain responded, ìapproach

check. Briefingís complete to three six right. The altimeter is three zero one zero.î As the

captain finished speaking, the MEM approach controller instructed the pilots to turn left to

a heading of 020° and intercept the localizer7

 for runway 36R. The captain acknowledged

the instruction, and the pilots continued the approach checklist, completing it about

1218:58.

About 1219:00, the captain stated that the localizer was ìaliveî8 and that they were

18 miles from touchdown. About 10 seconds later, the MEM approach controller told the

pilots to reduce the airplaneís airspeed to 170 knots and cautioned them about possible

wake turbulence from an Airbus airplane that was about 6 1/2 miles ahead of the flight

647 airplane. The captain acknowledged the speed reduction and stated that he was

looking for the Airbus airplane. About 1219:24, the first officer stated, ìflaps twenty two

please,î and the CVR then recorded the sound of two clicks. About 1219:28, the captain

stated, ìI got an Airbus right thereÖand another one out there looksÖabout level with

us.î About 20 seconds later, the MEM approach controller cleared flight 647 to descend to

and maintain 2,000 feet. About 1220:20, the captain advised the first officer that they had

intercepted the localizer, adding, ìweíre not yet cleared for the approach.î The first officer

responded, ìthatís noted.î 

About 1221:00, the pilots told the MEM approach controller that they saw the

airport. The approach controller then stated, ìFedEx six forty seven heavy cleared visual

7 The localizer is the component of an instrument landing system (ILS) that provides lateral course

guidance to pilots during approach and landing. When a pilot dials the ILS frequency for a runway into the

airplaneís navigation equipment, that equipment receives and displays directional guidance from ILS

components on the ground, including the localizer and the glideslope (vertical guidance). 

8 Pilots commonly use the term ìaliveî to indicate the localizer or glideslope needle movement that

occurs as the airplane nears the localizer course. 
Factual Information 4 Aircraft Accident Report

approach runway three six right, maintain a hundred and seventy knots until MAGEE [a

navigational intersection] and you can contact tower now.î The captain acknowledged the

clearance and switched to the MEM air traffic control tower (ATCT) frequency. About

1221:53, the MEM local controller stated, ìFedEx six forty seven heavy, Memphis tower,

number two following a heavy Airbus two mile final caution wake turbulence runway

three six right. Gain and loss of ten [knots] short final runway three six right, cleared to

land.î 

About 1222:31, the captain stated, ìhow ëbout four extra knots. I donít like to add

extra speed, but you know, three or four knots can make a lot of differenceÖif youíre

bumpiní around back and forth.î The first officer responded, ìgood enoughÖletís go with

ah landing gear down. Before landing checklist, pleaseÖglideslopeís alive.î The captain

responded, ìSpoilers are armed. The gearís downÖand three green. Flaps are twenty two.

Flaps to go.î About 1223:38, the first officer requested 35° of flaps, and the captain

acknowledged and complied with this request. About 1223:52, the CVR recorded a single

central aural warning system (CAWS) ìtailwind shearî alert.9

 The captain stated, ìokay,

itís all right,î and the first officer stated, ìgoodness.î 

About 1224:27, the CVR recorded the CAWS callout ìone thousandî as the

airplane descended through 1,000 feet above ground level (agl). The captain then stated,

ìvisual. Stable. We got a nine thousand foot runwayÖand we land at a hundred and forty

six. A pretty good headwind oughta work out okay.î About 1224:52, the first officer

stated, ìautopilotís coming off.î About 1225:02, the captain stated, ìchecklist is complete.

Youíre cleared to land,î and the first officer responded, ìthanks.î Between about 1225:08

and about 1225:52, the CVR recorded the CAWS altitude alerts for 500, 100, 50, 40, 30,

20, and 10 feet agl followed by the sounds of touchdown about 1225:53. About 1225:56,

the first officer stated, ìwow,î and the CVR recorded the sound of increasing background

noise, similar to increased engine rpm, and the sound of rumbling that was increasing in

volume. 

About 14 seconds after touchdown (about 1226:07), the FDR data showed a lateral

load factor of about 1.0 G10 as the right wing suddenly moved about 6° lower. About the

same time, the CAWS ìlanding gearî alert began to sound, which repeated until the end of

the recording. About 1226:25, the captain stated, ìhere we go,î and the airplane began to

veer off the right side of the runway. As the airplane veered to the right and came to a stop,

a fire developed on the right side of the airplane. About 1226:30, the airplane came to rest

in the grass on the right side of the runway. The accident occurred during the hours of

daylight. The CVR recording ended when the pilots shut down the engines (thus stopping

electrical power to the CVR) about 1226:41. For additional information regarding the

airplaneís performance and motions during the approach and landing, see section 1.16.

9 During postaccident interviews, the pilots reported that they decided to continue the approach

because the windshear alert was brief and they observed no airspeed excursions during the alert. No other

windshear alerts were generated during the remainder of the flight. For information regarding FedExís

windshear procedures, see section 1.17.2.3 

10 One G is equivalent to the acceleration caused by the earthís gravity (32.174 feet/second2

). 
Factual Information 5 Aircraft Accident Report

1.2 Injuries to Persons

Table 1. Injury chart.

1.3 Damage to Aircraft

The airplane was destroyed by impact forces and a postcrash fire. 

1.4 Other Damage

Several runway edge lights on the right side of runway 36R were damaged. 

1.5 Personnel Information

1.5.1 The Captain 

The captain, age 59, was hired by Flying Tiger Airlines on July 10, 1978, and

became a FedEx employee when the two companies merged on August 7, 1989. He holds

an airline transport pilot (ATP) certificate with a multiengine land rating and a flight

engineer certificate for turbojet-powered airplanes. The captainís ATP certificate

indicated type ratings in the Cessna 500 (issued December 21, 1977) and the MD-11

(issued September 21, 1996). The captain completed initial MD-10 differences training on

October 24, 2000.11 The captainís most recent Federal Aviation Administration (FAA)

Injuries Flight Crew Cabin Crew Passengers Other Total

Fatal 0 0 0 00

Serious 0 0 0 00

Minor 1 0 1 02

None 1 0 4 05

Total 2 0 5 0 7

11 A pilot with an MD-11 type rating is qualified to fly the MD-10 if that pilot completes the required

differences training. Initial MD-10 differences training at FedEx was incorporated in the 3-week,

line-oriented flight training curriculum that was conducted after successful completion of the training and

flight tests required for an MD-11 type rating. The MD-10 initial differences training consisted of 8 hours

per crewmember in the MD-10 simulator, 6 hours of ground school, and 2 hours of computer-based training.

For additional information on differences between the MD-11 and MD-10, see section 1.18.1. 
Factual Information 6 Aircraft Accident Report

first-class airman medical certificate was issued on December 4, 2003, with a restriction

that the holder must wear corrective lenses. 

The captain estimated that he had flown about 21,000 total flight hours. FedEx

records indicated that, at the time of the accident, the captain had accumulated about

2,602 flight hours as an MD-11/-10 flight crewmember, including about 123 hours and

11 landings in the 90 days preceding the accident. On October 12, 2000, the captain

received FAA check airman authorization to conduct line checks at FedEx. According to

FedEx training records, the captainís most recent recurrent ground training was completed

on September 18, 2003; his most recent MD-11/-10 proficiency check was completed on

September 19, 2003; and his most recent MD-11/-10 line check was completed on

December 8, 2003.12 FAA records indicated no accident or incident history or enforcement

action, and a search of the National Driver Registry database indicated no record of

driverís license suspension or revocation.

1.5.1.1 The Captainís 72-Hour History

The captain stated that he felt well rested when he arrived at MEM about 1900 on

December 15, 2003, for the flight to IND. He stated that, on December 16, they departed

IND about midday and arrived at OAK after dark. He indicated that, on December 17,

when no trip segment was scheduled, he spent the day in Oakland and met the first officer

and two other FedEx pilots for dinner about 1720 Pacific standard time that evening. The

captain stated that he returned to the hotel about 1930 Pacific standard time. According to

the captain, he felt well rested when he and the first officer were picked up for duty from

their hotel about 0440 Pacific standard time on the morning of December 18. 

1.5.2 The First Officer 

The first officer, age 44, was hired by FedEx on February 21, 1996, from Mesaba

Airlines, where she had been employed as a DeHaviland DHC-8 captain. She holds an

ATP certificate (issued March 21, 1991) with a multiengine land rating and a flight

engineer certificate for turbojet-powered airplanes. The first officerís ATP certificate

indicated type ratings in the DHC-8 (issued September 21, 1992), Fokker F-27 (issued

November 11, 1995), and MD-11 (issued October 22, 1998). FedEx records indicated that

the first officer completed initial MD-10 differences training on February 10, 2003. The

first officerís most recent FAA first-class airman medical certificate was issued on

July 25, 2003, with a restriction that the holder must wear corrective lenses. 

The first officer estimated that she had flown about 15,000 total flight hours.

FedEx records indicated that, at the time of the accident, the first officer had accumulated

about 1,918 flight hours as an MD-11/-10 flight crewmember, including about 61 flight

hours and 7 landings in the 90 days preceding the accident. Between February 2003 (when

she completed the MD-10 differences training) and the accident flight, the first officer

12 All FedEx flight crewmembers receive flight simulator training every 6 months. In addition, captains

receive an annual line check; first officers do not receive an annual line check. 
Factual Information 7 Aircraft Accident Report

accumulated about 25.6 flight hours and 2 landings in the MD-10.13 The first officerís

most recent recurrent MD-11/-10 line check was completed on April 18, 2001; her most

recent MD-11/-10 simulator proficiency check was completed on November 20, 2003;

and her most recent ground training was completed on November 28, 2003. 

A review of the first officerís employment, flight, and training records revealed

that two of her DHC-8 captain proficiency checkrides (on April 7 and 13, 1994, while she

was employed by Mesaba Airlines) were unsatisfactory. According to Mesaba Airlines,

the check airman who conducted both proficiency checkrides indicated that the

unsatisfactory results were because of ìgenerally poor airmanship.î As a result of the first

officerís unsatisfactory performance during the April 13 checkride, the FAA inspector

who observed that checkride required her to be reexamined for her ATP certificate by an

FAA check airman under the provisions of 49 CFR, Chapter 447, Section 44609

(currently codified as Section 44709).14 On May 15, 1994, the first officer satisfactorily

completed the reexamination. 

According to FedEx training records, the first officer completed DC-10 flight

engineer training on April 17, 1996. She began MD-11 first officer transition training on

August 31, 1998, and received her MD-11 type rating on October 22, 1998. The records

also indicated that, on October 26, 1999, the first officer failed her MD-11 proficiency

checkride; deficiencies were noted in the areas of engine-out takeoff, nonprecision

approach, and engine fire/failure/restart. The records further indicated that, after

additional training, she satisfactorily completed a proficiency checkride on October 29,

1999. The records also indicated that, on October 17, 2001, the first officer failed another

MD-11 proficiency checkride; deficiencies were noted in the areas of powerplant failure,

nonprecision approach, missed approach procedures,15 one/two engine-out landing, and

command judgment. The records further indicated that, after additional training, she

satisfactorily completed a proficiency checkride on October 19, 2001. 

As previously mentioned, the captain was conducting a line check of the first

officer because an airplane she was piloting in early November 2003 was involved in an

altitude deviation. The first officer stated that, when the altitude deviation occurred, ATC

had cleared the flight to flight level (FL) 23016 during the climbout, but she and the captain

believed that they heard the ATC controller clear the flight to FL 330. As the airplane

neared FL 260, ATC advised the flight to return to FL 230. As a result of this excursion,

the first officer and the captain were required to complete a company-mandated

requalification simulator proficiency check and a line check. The first officer successfully

13 The first officerís previous MD-10 landings occurred on April 21, 2003, and December 16, 2003. 

14 Section 44709 authorizes the FAA to reexamine any pilot at any time. The objective of the

reexamination is to determine if a pilot is qualified to exercise the privileges of a particular certificate or

rating. 

15 Deficiencies noted during a missed approach might include failure to maintain the headings and/or

altitudes described in the missed approach procedure. For additional information regarding FedExís missed

approach/go-around policies, see section 1.17.2.1. 

16 Flight level 230 is an altitude of 23,000 feet msl, based on an altimeter setting of 29.92 inches of

Mercury (Hg).
Factual Information 8 Aircraft Accident Report

completed the requalification simulator proficiency check on November 20, 2003, and her

mandatory line check was being conducted when the accident occurred. (Table 2

documents the first officerís checkride failures as an airline employee.) 

Table 2. First officer checkride failures.

During postaccident interviews, the check airman who conducted the

November 20, 2003 simulator proficiency checkride stated that the first officer had to

repeat one of the engine failure scenarios and described her flying as ìin the average

range.î He stated that he counseled the first officer regarding crew resource management

and declaring an emergency without first consulting with the captain. The check airman

described her performance as average. (This check airman also reported that he had

conducted the first officerís proficiency checkride on October 19, 2001. He stated that, at

that time, he considered the first officer a below-average pilot and noted that she was very

weak in the areas of procedures and judgment.) For additional information about the first

officerís flight history, see the Operations Group Chairmanís Factual Report in the public

docket for this accident. 

FAA records indicated no accident or incident history or enforcement action.

However, a search of the National Driver Registry database revealed that the first officerís

Arizona State driverís license was suspended from November 15, 1998, to February 16,

1999, for a driving under the influence of alcohol conviction. According to FAA records,

the first officer reported the suspension of her driverís license to the FAAís Civil Aviation

Security Division. In a February 4, 1999, letter, the manager of the FAAís Aeromedical

Certification Division advised the first officer, ìWe have carefully reviewed your letter

and your complete medical file, which reveals a previous alcohol-related offense.î17 The

Checkride failures Checkride date/result Retest date/result Retest date/result

DHC-8 captain 

proficiency 

checkride

April 7, 1994/failed, 

ìgenerally poor 

airmanshipî cited.

April 13, 1994/failed. 

Reexamination for 

ATP certificate 

required by the FAA 

observer.

May 15, 

1994/satisfactorily 

completed the 

reexamination for ATP 

certificate. 

MD-11 first officer 

proficiency 

checkride

October 26, 1999/failed, 

deficiencies noted in the 

areas of engine-out 

takeoff, nonprecision 

approach, and engine 

fire/failure/restart.

October 29, 

1999/satisfactorily 

completed proficiency 

checkride.

MD-11 first officer 

proficiency 

checkride

October 17, 2001/failed, 

deficiencies noted in the 

areas of powerplant 

failure, nonprecision 

approach, missed 

approach procedures, 

one/two engine-out 

landing, and command 

judgment.

October 29, 

1999/satisfactorily 

completed proficiency 

checkride.
Factual Information 9 Aircraft Accident Report

manager indicated that the FAA would review the first officerís ability to hold a medical

certificate and asked her to submit additional information, including an evaluation from a

substance abuse specialist. In a March 2, 1999, letter, the manager wrote, ìI have reviewed

the information submitted by you in support of your request for an airman medical

certificate. The medical evidence reveals a history of substance abuse (two alcohol-related

offenses)ÖI have determined, however, that you may be granted authorization for special

issuance of a first-class airman medical certificate under 14 CFR 67.401. The certificate

you hold is valid until the normal date of expiration.î The first officer completed the

special issuance authorization period that ended on May 31, 2000, with no further

alcohol-related offenses and satisfactory first-class medical examinations. The first

officerís medical certificate was not revoked during this period. 

1.5.2.1 The First Officerís 72-Hour History

The first officer stated that she arrived in Memphis about midday on December 15,

2003, took a nap at the hotel, and felt well rested when she reported for duty at MEM. She

indicated that, after arriving at IND, she checked into the hotel and went to bed about

0230. The first officer stated that on December 16, she slept until about 1300 and was

picked up for the flight to OAK about 1445. She indicated that she felt well rested for the

flight. She stated that she and the captain worked well together during the flight and that

he provided positive feedback several times. 

According to the first officer, after she checked into the hotel in Oakland, she went

to a bookstore and then out for dinner. She stated that she returned to the hotel about 2200

Pacific standard time and went to bed. The first officer stated that, on December 17 (when

no trip segment was scheduled), she spent a leisurely day in Oakland and met the captain

and two other FedEx pilots for dinner that evening. She stated that, after dinner, she

returned to the hotel and went to bed about 2100 Pacific standard time. 

The first officer stated that she felt fine when she awoke about 0345 Pacific

standard time on the morning of December 18. Although the CVR recorded numerous

sounds ìsimilar to throat clearingî and ìsimilar to coughingî on the first officerís channel

and a discussion between the captain and the cockpit jumpseat occupant about the first

officerís health on the cockpit area microphone (CAM) channel, the first officer stated that

she felt fine during the accident flight and was not taking any medication. 

1.5.2.2 The First Officerís Landing History

As previously stated, review of FedEx records indicated that the first officer had

flown about 61 hours and made 7 landings (6 in the MD-11, 1 in the MD-10) during the

90 days preceding the accident. The Safety Boardís review of the weather conditions for

landings performed by the first officer between August and December 2003 indicated that

she had encountered a variety of wind conditions during that time.18

17 FAA airman medical records showed that the first officer had been previously charged with an

alcohol-related traffic offense in 1993 and was later convicted of reckless driving; her driverís license was

not suspended or revoked in association with the 1993 offense.
Factual Information 10 Aircraft Accident Report

The investigation revealed that, during the 12 months preceding the accident, the

first officer had frequently flown as a ìreserve first officer,î providing relief for assigned

flight crewmembers during required en route rest periods. According to several pilots who

were interviewed after the accident, ìreserveî pilots typically made fewer landings than

assigned flight crewmembers.19

1.6 Airplane Information

The accident airplane, N364FE, an MD-10-10F series airplane, was equipped with

three General Electric CF6-6D engines. According to FedEx records, the accident airplane

had about 65,375 total hours of operation at the time of the accident. 

According to the dispatch documents for the accident flight, the airplaneís takeoff

weight was 408,302 pounds, and its takeoff center of gravity (c.g.) was 16.3 percent mean

aerodynamic chord (MAC).20 The airplaneís estimated landing weight was

358,450 pounds, including about 110,600 pounds of cargo and about 20,300 pounds of

fuel. The dispatch documents indicated that the airplaneís maximum landing weight was

375,000 pounds. According to the documents and postaccident examination, no hazardous

cargo was on board the airplane.21

1.7 Meteorological Information

1.7.1 Weather for Memphis International Airport 

MEM is equipped with an automated surface observing system (ASOS),22 which

continuously measures wind speed and direction,23 visibility, precipitation and

obstructions to vision, cloud height and sky cover, temperature, dew point, and altimeter

setting. A review of the weather observations revealed that the sustained winds 15 to

20 minutes before and after the accident were consistently from the northwest at 17 to

23 knots. The following conditions were recorded by the ASOS about the time of the

accident: 

18 For additional information, see the Operations Group Chairman Factual Report Addendum 2. 

19 Federal regulations require pilots to perform three takeoffs and landings within a 90-day period to

maintain currency. FedEx pilots who are unable to maintain landing currency through their normal flight

line duties could satisfy the 90-day requirement in the simulator. 

20 According to Boeing, the airplaneís takeoff c.g. limits were between 15.4 and 30.3 percent MAC. 

21 For additional information about the airplaneís cargo, see section 1.12.3. 

22 The ASOS is located about 1.6 sm northwest of the accident location at an elevation of about

330 feet. 

23 The ASOS station samples wind direction and speed every 5 seconds and records a 2-minute average

wind direction and speed every minute. For additional information, see the Meteorology Group Chairmanís

Factual Report in the public docket for this accident. 
Factual Information 11 Aircraft Accident Report

MEM weather at 1225, wind from 320° at 21 knots, with gusts to 26 knots;

visibility 10 sm; a broken layer of clouds at 4,500 feet; temperature 11° C

[Celsius]; dew point -1° C; altimeter setting 30.09 inches Hg [mercury]; pressure

altitude 180 feet; and relative humidity 46 percent. Remarks: peak wind 330° at

26 knots occurred at 1220.

MEM weather at 1230, wind from 310° at 23 knots, with gusts to 28 knots;

visibility 10 sm; a broken layer of clouds at 4,500 feet; temperature 10° C; dew

point -1° C; altimeter setting 30.09 inches Hg; pressure altitude 180 feet; and

relative humidity 46 percent. Remarks: peak wind 320° at 28 knots occurred at

1229; aircraft mishap.

Wind measuring equipment (WME)24 located at MEM provided additional

information about the wind speed and direction on the day of the accident. A WME sensor

was located about 1 sm northwest of the accident site and was positioned at 80 feet agl.

Data from the sensor indicated numerous oscillations in the sustained wind speed between

1200 and 1245, including several gusts. The sustained wind speed increased from about

14 knots at 1224:53 to about 23 knots at 1226:45. The data showed that between 1200 and

1245, a maximum gust of 29 knots was recorded. 

The MEM 1153 ATIS broadcast (identified as ATIS information Zulu) reported

that winds were from 320° at 16 knots with gusts to 22 knots, visibility was about 10 sm,

clouds were broken at 4,300 feet, temperature was 10° C, dew point was 0° C, and

altimeter setting was 30.10 inches Hg. The ATIS also noted that windshear advisories

were in effect at MEM. In addition, about 1010, the National Weather Service issued an

AIRMET,25 advising pilots of ìoccasional moderate turbulence below 8,000 feet due to

gusty northerly windsî for an area that included MEM. 

FedEx dispatchers provided the pilots with preflight weather information that

indicated turbulence below 8,000 feet and strong northerly/northwesterly winds aloft and

at the surface. 

1.7.2 Massachusetts Institute of Technology/Lincoln Laboratory 

Study 

At the Safety Boardís request, the Weather Sensing Group at the Massachusetts

Institute of Technology (MIT)/Lincoln Laboratory reviewed data from the MEM terminal

Doppler weather radar and integrated terminal weather system terminal winds. On

February 2, 2004, Massachusetts Institute of Technology/Lincoln Laboratory staff issued

a report that summarized its findings. According to the report, although the winds at MEM

were gusting out of the northwest, the data showed no evidence of horizontal windshear or

other hazardous conditions near the runway at the time of the accident.26 The study was

24 The WME was formerly part of a low level wind shear alert system at MEM.

25 AIRMET is an abbreviation for airmenís meteorological information. AIRMETs are issued to alert

pilots to weather phenomena that are of operational interest and/or are potentially hazardous, including

moderate turbulence.
Factual Information 12 Aircraft Accident Report

not able to definitively determine the presence or magnitude of small-scale turbulence at

or near the surface. The report noted a pattern of buoyancy waves27 aloft that might have

been responsible for the CAWS tail windshear warning recorded by the accident

airplaneís CVR. However, the report also pointed out that less than 15 knots of windshear

was associated with these waves and that this amount of windshear ìshould not negatively

impact the operation of the aircraft.î 

1.8 Aids to Navigation

No problems with any navigational aids were reported.

1.9 Communications

No communications problems were reported between the pilots and any of the air

traffic controllers who handled the flight.

1.10 Airport Information

MEM is located about 3 miles south of Memphis, Tennessee. The official airport

elevation is 341 feet. The airport was certificated under 14 CFR Part 139 as an Index D

airport.

The airport has four runways: runway 9/27 is an east/west runway located on the

northern section of the airport, and runways 18R/36L, 18C/36C, and 18L/36R are three

parallel north/south runways that are located on the southern section of the airport.

Runway 18L/36R (the accident airplane landed on runway 36R) is 9,000 feet long and 150

feet wide and is located on the east side of the airport. (Figure 1 is a diagram of MEM.)

Runway 36R is accessible by numerous taxiways that run perpendicular, parallel, and

angular to it.

26 The Safety Board also derived wind information from recorded FDR data. For additional information, 

see section 1.16.1.2.

27 The report described buoyancy waves as parcels of air that oscillate, rising and falling between

slightly above the boundary layer to near the surface. Buoyancy waves, which often occur in a gusting wind

environment, may have existed from just above the ground to about 4,800 feet agl at the time of the accident. 
Factual Information 13 Aircraft Accident Report

Figure 1. MEM airport diagram.

1.10.1 MEM Aircraft Rescue and Firefighting General Information

The Memphis-Shelby County Airport Authority (MSCAA) operates MEM and is

responsible for airport operations and establishing and maintaining an emergency plan.
Factual Information 14 Aircraft Accident Report

According to a November 1, 2000, letter of agreement between the FAA, City of Memphis

Fire Department (MFD), and the airport authority, titled, ìAirport Emergency

Procedures,î airport rescue and firefighting (ARFF) services at MEM are provided by

MFD personnel. MFD operates the fire station at MEM (fire station no. 33) in accordance

with 14 CFR 139.319. The fire station is located near the ATCT between runways

18R/36L and 18C/36C. The fire station provides ARFF services for the airport 24 hours a

day/7 days a week with a staff of 30 firefighters, at least 18 of whom are present at all

times. As required for airports certificated under Part 139, the airport authority conducts

annual ARFF tabletop exercises and triennial full-scale ARFF drills. MEM records

indicated that the most recent tabletop exercise occurred April 8 and 9, 2003, and that the

most recent triennial full-scale drill occurred in April 2002.

Three MFD station no. 33 ARFF vehicles responded to the accident site.28 In

addition, two ARFF trucks owned and operated by the Rural/Metro Fire Department

(RMFD) responded to the accident.29 RMFD is contracted by FedEx to provide

emergency medical and fire response services for its operations and is based on the FedEx

ramp on the north side of the airport. It is staffed 24 hours a day/7 days a week and often

participates in MEM airport emergency drills and exercises. The letter of agreement

between the FAA, MSCAA, and MFD indicated that if an alert II and/or III30 emergency

occurred, the crash telephone at RMFD would automatically activate; however, there was

no formal agreement between the airport authority, RMFD, and MFD that described

RMFD responsibilities and involvement in emergency situations. 

During postaccident interviews, MFD and RMFD personnel indicated that the two

fire companies had a good working relationship and conducted periodic coordination

exercises.31 They stated that RMFD had an ìunwrittenî agreement with MFD to assist

MFD with all alert II and III ARFF activities (not only those involving FedEx airplanes).

Further, RMFD personnel have observed MEM annual tabletop training exercises and

substituted for MFD when MFD personnel were involved in off-airport exercises during

the triennial full-scale drills in April 2002. 

28 Each of the three MFD vehicles was capable of holding 3,000 gallons of water, 420 gallons of

aqueous film forming foam (AFFF), and 500 pounds of Purple K (a dry chemical agent commonly used by

ARFF).

29 One of the RMFD vehicles was capable of holding 97 gallons of water, 3 gallons of foam, and

500 pounds of Purple K. The other RMFD vehicle was capable of holding 1,500 gallons of water and

210 gallons of AFFF. For a complete list of responding vehicles, see the Survival Factors Group Chairman

factual report in the docket for this accident.

30 According to MSCAA, an alert II occurs when an airplane is experiencing difficulty and a potential

emergency situation exists requiring emergency equipment to respond to an appropriate standby position on

the airport. An alert III occurs when an aircraft accident has occurred and emergency equipment is needed at

the scene to commence firefighting or rescue operations. This accident resulted in an alert III.

31 MFD personnel stated that the periodic coordination exercises conducted with RMFD often involved

familiarization with FedEx airplane systems and structures (for example, battery location, auxiliary power

unit shutdown procedures, emergency exit door/slide operation, etc.).
Factual Information 15 Aircraft Accident Report

1.11 Flight Recorders

1.11.1 Cockpit Voice Recorder

The accident airplane was equipped with an AlliedSignal model 6022 CVR, serial

number (S/N) 1656. The CVR did not appear to have any heat or structural damage, and

the audio data were successfully downloaded from the solid-state memory. Of the CVRís

four channels of audio data, three channels (those that recorded information through the

radio/intercom audio panels at the captain and first officer positions and the CAM)

contained good to excellent quality32 audio information; the fourth channel (which was not

required by Federal regulations) did not contain any useful audio information. 

The recording began at 1025:43 and ended at 1226:41 after the pilots shut down

the engines. The downloaded audio data were saved in two separate data files: a

two-channel recording of the last 2 hours of CVR information and a four-channel

recording of the last 30 minutes of CVR information. A partial transcript was prepared of

selected excerpts of the 2-hour, 58-second CVR recording (including the last 30 minutes),

as shown in appendix B. 

1.11.2 Flight Data Recorder

The accident airplane was equipped with a solid-state Honeywell model FDR,

S/N 08411 that recorded about 450 parameters of airplane flight information in a digital

format using solid-state flash memory. The FDR was recovered in good condition, and

about 27 hours of data were successfully downloaded. The recorded parameters included

radio altitude; indicated and ground airspeeds; magnetic heading; control column, control

wheel, and rudder pedal positions; aileron, elevator, and rudder surface positions; trailingand leading-edge flap and slat positions on both wings; vertical, lateral, and longitudinal

accelerations; pitch and roll attitudes; wind direction and speed; predictive windshear

warning and alert; and head and tail windshears. 

1.11.2.1 FDR Recording of Aileron Positions

During its investigation, the Safety Board observed that, although the FDR

sampled each aileron position four times per second (more frequently than required by

14 CFR 121.344, appendix M), the aileron position data were not being updated from the

data source at the rate required by the regulation. The Boardís flight data study showed

that, as a result of the inadequate update rate, the data for all four ailerons (inboard and

outboard on the right and left wings) showed inaccurate repeated values. For example,

examination of 5-second spans of plotted aileron data revealed that they contained six sets

of data in which a recorded value was repeated three times, followed by one set of data in

which a recorded value was repeated twice. According to the Boardís study, this reflects

32 The Safety Board rates the quality of the CVR recordings according to a five-category scale:

excellent, good, fair, poor, and unusable. See appendix B for a description of these ratings. 
Factual Information 16 Aircraft Accident Report

an approximate update rate of once per 700 milliseconds (ms) instead of the

once-per-500-ms rate that is required by Federal regulation. 

The Safety Board has found similar problems regarding FDR data update rates

with other airplane FDR systems and, as a result, issued two safety recommendations to

the FAA on May 16, 2003, recommending the following: 

Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, Canadair

Challenger CL-600, and Fairchild Dornier 328-300 airplanes be modified with a

digital flight data recorder system that meets the sampling rate, range, and

accuracy requirements specified in 14 Code of Federal Regulations 121.344,

Appendix M. (A-03-015) 

Survey all aircraft required by Federal regulation to have a flight data recorder to

ensure that the data recorded meets the rate, range, and accuracy requirements

specified in 14 Code of Federal Regulations 121.344, Appendix M. (A-03-016)

In an August 11, 2003, letter, the FAA indicated that it was working with the

airplane manufacturers and airworthiness authorities involved to address the issues

discussed in Safety Recommendation A-03-015 and that it would take appropriate action

to correct any deficiencies. With regard to Safety Recommendation A-03-016, the FAA

stated that it would ask all airplane manufacturers not addressed in Safety

Recommendation A-03-015 to provide FDR design criteria information for obtaining data

in accordance with 14 CFR 121.344, Appendix M requirements. Upon review of the

design criteria, the FAA would identify necessary changes to bring any affected airplanes

into compliance. On the basis of the FAAís response and pending additional action, on

January 28, 2004, the Safety Board classified Safety Recommendation A-03-015 ìOpenó

Acceptable Responseî and Safety Recommendation A-03-016 ìOpenóAcceptable

Alternate Response.î 

1.12 Wreckage Information

The airplane came to rest in the grass about 155 feet right of the runway 36R

centerline and 5,979 feet from the approach end of the runway. The airplane was aligned

on a magnetic heading of about 070° and in a slight (about 20°) right-wing-down attitude.

The right main landing gear assembly collapsed, and the airplane was supported by its

nose landing gear, left main landing gear, and the lower surface of the right wing. The

fuselage remained largely intact, but the right wing and the fuselage immediately adjacent

to it exhibited substantial impact and fire damage. The right side of the fuselage also

exhibited impact damage (including punctures and metal buckling) and extensive fire and

heat damage (including paint blistering and some areas of burn-through). The right wing,

slats, flaps, and ailerons showed evidence of substantial impact, fire and heat damage, and

the right engine was separated from the wing at its wing-to-pylon attachments. Soot

deposits were observed on portions of the lower fuselage and most of the right side of the

fuselage. (Figure 2 is a photograph of the damage to the right side of the airplane.) The left
Factual Information 17 Aircraft Accident Report

side of the fuselage, left wing, and the nose and tail sections exhibited minimal impact or

fire damage. 

Figure 2. Photograph of the damage to the right side of the airplane. 

The R1 and L1 passenger/emergency exit doors are located aft of the cockpit on

the right and left side of the fuselage, respectively. During postaccident examination, the

R1 door was closed, its door control handle was in the closed position, and its

slide-arming lever was in the armed position. However, the L1 door was found in the

full-open position, and the evacuation slide/raft was found deployed and inflated on the

ground near the nose of the airplane. The slide/raft remained connected to the airplane by

its mooring line.33

The L1 emergency door control handle was in the open position. The L1 slideís

triangular red manual inflation handle (which is used to inflate the slide/raft if it fails to

automatically inflate upon opening) and the rectangular white slide/raft disengage handle

(which is located beneath the girt flap assembly and is used to release the slide/raft from

the airplane in the event of a water landing) were found on the cabin floor near the R1

door. The manual inflation handle has a red reflective bracket and is stenciled with the

word PULL in white lettering; the handle is normally attached by a cable to the inflation

33 The slide/raft mooring line is intended to keep the slide/raft near the airplane after it is released from

the girt following an emergency water landing. 
Factual Information 18 Aircraft Accident Report

cylinder. The slide/raft disengage handle is webbed and has the word PULL stenciled in

red lettering; it is normally attached by Velcro at the base of the upper girt assembly under

the girt cover flap. The slide/raft disengage handle is normally used only during

emergency evacuations after a water landing (ditching). (Figure 3 shows FedExís

MD-11/-10 emergency evacuation door trainer, with the girt flap assembly in place.

Figure 4 shows FedExís MD-11/-10 emergency evacuation door trainer, with the girt flap

assembly lifted.)34 The distance from the accident airplaneís L1 doorsill to the ground was

16 feet 10 inches instead of the usual distance of 16 feet 3 inches because of the failed

right main landing gear. 

Figure 3. FedExís MD-11/-10 emergency evacuation door trainer, with the girt flap 

assembly in place, as it would appear when the door/slide is opened. The arrow 

indicates the manual inflation handle. 

34 For additional information regarding the L1 emergency evacuation door and slide/raft, see 

section 1.12.4.
Factual Information 19 Aircraft Accident Report

Figure 4. FedExís MD-11/-10 emergency evacuation door trainer, with the 

girt flap assembly lifted. The arrow indicates the slide/raft disengage handle.

The cockpit, its furnishings, and the nonrevenue crewmember cabin area (the area

located directly behind the cockpit door and in front of the cargo barrier, including the

four courier seats) remained intact and exhibited no fire, smoke, or soot damage. All

cockpit and passenger cabin area oxygen masks were stowed, and all cabinets and stowage

compartments were intact, with their doors closed. The captain and first officer evacuation

tapes35 were deployed through their respective open cockpit windows. The lavatory and

the cockpit doors were open, and the rigid cargo barrier door, which allows access to the

main deck cargo compartment from the passenger cabin area, was found closed and

secured by the first firefighters to board the airplane. 

1.12.1 Tire and Other Markings on the Runway

Examination of tire markings on runway 36R revealed that the airplane touched

down on the left main landing gear first about 564 feet from the approach end of the

runway and 9 feet right of the runway centerline. The tire markings showed that the right

main landing gear touched down about 613 feet from the approach end of the runway and

45 feet right of the runway centerline. 

35 The two cockpit evacuation tapes are thin (about 1 inch by 3/16 inch) ribbons of reinforced synthetic

material that are located in compartments above the cockpit sliding windows. These tapes are intended to

allow crewmembers to descend to the ground if the L1 and R1 emergency exit slides are not useable during

an emergency evacuation. 
Factual Information 20 Aircraft Accident Report

The tire marks made by the forward tires on the left and right main landing gear

assemblies were offset and misaligned from the tire marks made by the aft tires on those

assemblies. On the basis of the relative positions of the tire marks on the runway, the

Safety Board calculated that the airplane was yawed about 5.4° nose left of the runway

heading when it touched down on the runway. (This yaw angle is consistent with the

results of the Boardís performance study, which is discussed in section 1.16.1.1.) The

Board also calculated that the cockpit was about 20 feet right of the runway centerline

when the airplane touched down. 

The tracks from the forward and aft inboard tires on the right main landing gear

assembly disappeared about 43 feet after they touched down. A large, sprayed fluid stain

(about 8 feet in diameter) was located on the runway where the forward and aft inboard

tire tracks disappeared. At the Safety Boardís request, Boeing analyzed samples of the

sprayed fluid; this analysis revealed that the substance was Military Specification 5606

hydraulic fluid, which is commonly used in landing gear shock struts. Also, the tracks

from the forward and aft inboard tires reappeared about 10 feet farther down the runway.

The markings on the runway indicated that the right main landing gear assembly moved to

the left and then back to the right. 

The first evidence of airframe contact with the runway was observed about

2,891 feet from the touchdown point. Scrapes from the right outboard flap/hinge were

observed, along with evidence of the right main landing gear assembly collapse, about

12 feet farther down the runway. Evidence of fire and soot was observed on the runway

and ground from about 2,999 feet north of the touchdown point to the airplane wreckage,

and gouges in the runway from contact with the right engine began about 3,085 feet from

the touchdown point. 

1.12.2 Landing Gear Assemblies

The nose and left main landing gear assemblies were found down, locked, and

undamaged, with their struts and tires pressurized. No problems were noted with the

assembliesí wheels, tires, or brakes. The right main landing gear collapsed during the

landing roll, and the outer cylinder fractured into six pieces. The upper end of the outer

cylinder and a portion of the midsection remained attached to the airframe landing gear

attachment fitting by the forward and aft trunnion bolts. The lower end of the right main

landing gear cylinder remained attached to the piston assembly by the shock strut torque

links. 

Pieces of debris from the right main landing gear assembly were found along the

runway from the initial touchdown point to the airplane wreckage location. The debris

nearest the initial touchdown point (which was 564 feet from the approach end of the

runway) was recovered about 378 feet from the touchdown point and was identified as the

right main landing gear shock strut main chamber pressurization valve. Other debris from

the right main landing gear was recovered along the next several hundred feet of the

runway. Other right main landing gear assembly components, including the piston, lower

end of the outer cylinder, truck beam, fore and aft axles, and associated wheels, tires
Factual Information 21 Aircraft Accident Report

(except the no. 3 tire), and brake assemblies, were located about 3,686 feet from the

touchdown point and in the grass about 115 feet right of the runway centerline. The no. 3

tire (the forward inboard tire on the right main landing gear) was located in the grass about

450 feet from the right main landing gear assembly. 

1.12.3 Cargo and Shipping Containers 

All cargo containers were found securely locked in place inside the accident

airplane, and the containersí positions were consistent with those recorded on FedExís

weight and balance manifest for the accident flight. All shipping containers were found

securely locked in place, and the cargo locks showed no apparent damage. The only

evidence of damage to the shipping containers (or the cargo within, when inspected), was

from firefighting operations (for example, snozzle36 penetration of the fuselage) or

postfire activities (for example, removal of the jammed forward cargo door). 

1.12.4 Postaccident Examination of the Emergency Evacuation 

Slides

Examination of the L1 emergency evacuation slide/raft (Pacific Inflatables part

number [P/N] 5WD230100-101) at the accident site revealed that the slideís rigidity

beams were inflated, with no evidence of damage to the slide material. The survival kit

and the inflation bottle were attached to the slide/raft, and the inflation bottleís gauge

indicated that the bottle was fully discharged. The L1 slide girt assembly was intact but

had separated from the girt bar flap assembly at the L1 doorsill. The R1 emergency

evacuation slide/raft (also Pacific Inflatables P/N 5WD230100-101) was not deployed. 

The L1 and R1 emergency evacuation slides were transported to the

manufacturerís facility for further examination. Examination of the R1 evacuation

slide/raft confirmed that it had not been activated. When the R1 slide/raft was unfolded on

the manufacturerís shop floor and inflated, it operated normally. 

Examination of the L1 emergency evacuation slide/raft at the manufacturerís

facility confirmed that the L1 slide/raft girt assembly, the snaps that secure the girt

assembly to the girt, the Velcro that secures the slide/raft disengage handle, and the girt

loops were intact. The girt loops were relaced, the slide/raft disengage handle was secured

to the Velcro patch, and the cover flap was reattached to the girt. There was normal slack

in the girt bar flap when it was snapped to the girt, and there was no damage to the

assembly. 

Examination of the L1 inflation cylinder gauge confirmed that the cylinder was

fully discharged. The manual inflation cylinder was removed from the L1 slide/raft and

the inflation valve was removed from the cylinder to test the valve pull force required to

activate the valve. Examination of the L1 slideís inflation cylinder valve showed that

36 The snozzle is a piercing nozzle on the fire truck that is used to penetrate an airplaneís fuselage and 

dispense AFFF to extinguish fire inside the cabin or cargo area. 
Factual Information 22 Aircraft Accident Report

7 pounds of pull force was required to activate the valve when the inflation cylinder was

pressurized, which was within the specified inflation valve pull force of 5 to 20 pounds.

The manual inflation cable measured 14 inches, in accordance with the cable length

design specifications. 

1.13 Medical and Pathological Information

In accordance with Federal requirements, urine samples were obtained from the

captain and the first officer and were examined by an independent laboratory. The samples

tested negative for drugs of abuse.37 Breath alcohol tests of the captain and first officer

taken about 4 hours after the accident were negative. 

1.14 Fire

A fuel-fed fire occurred after impact. According to the MFD alert report, MFD

personnel were advised of the accident about 1226 and arrived at the accident site about

1228. The report indicated that the ìmain body of fireî was under control within 10 to

15 minutes of MFDís arrival at the site and that the fire was completely extinguished by

1322. 

1.15 Survival Aspects

The captain exited the cockpit through the right-side cockpit window exit, and the

first officer and the five nonrevenue FedEx pilots who occupied the cockpit jumpseat and

rear courier seats exited through the left-side cockpit window exit. Two occupants

received medical treatment for their injuries: (1) the first officer sustained friction burns to

both hands while sliding down the evacuation tape, and (2) the cockpit jumpseat occupant

sustained minor injuries when he landed on his right shoulder after he let go of the

evacuation tape. Two other occupants later reported that they received minor injuries to

their hands while using the evacuation tapes. No other injuries were reported. 

1.15.1 Nonrevenue FedEx Pilotís Activation of the L1 Door/Slide 

As the postaccident fire developed on the right side of the airplane, one of the

nonrevenue FedEx pilots opened the L1 emergency evacuation door and pulled the

manual inflation handle on the evacuation slide/raft.38 However, the slide/raft separated

from the airplane, and the airplane occupants exited through the cockpit window exits.39

37 The postaccident analyses tested for amphetamines, phencyclidine, and metabolites of marijuana,

cocaine, and opiates. 

38 When the cabin door is opened in the emergency mode, the evacuation slide/raft unfolds out of the

airplane and should inflate automatically; however, if the slide does not automatically inflate, a crewmember

can cause it to inflate by pulling the manual inflation handle. Pulling the manual inflation handle while the

slide/raft is inflating automatically does not interfere with the inflation process. 
Factual Information 23 Aircraft Accident Report

During postaccident interviews, the nonrevenue FedEx pilot who opened the L1

door stated that, when the airplane came to a stop, he and the other three FedEx pilots who

occupied the courier seats aft of the cockpit unbuckled their seatbelts, stood up, and saw

white smoke starting to turn gray outside the R1 exit door. He stated that the cockpit door

opened, and he heard the captain ask the air traffic controller if there was a fire; the

controller confirmed that he saw smoke and fire coming from the airplane. The

nonrevenue FedEx pilot stated that, because he was closest to the L1 door and observed no

smoke on that side, he opened that door with the captainís permission. He stated that,

when he lifted the emergency exit handle, the L1 door pneumatically opened upward, and

the slide/raft deployed. However, the nonrevenue FedEx pilot reported that, when he

noted that the slide/raft was angled straight down and had not yet inflated, he pulled the

manual inflation handle. He stated that the slide/raft inflated, separated from the doorsill,

and disappeared under the airplane. 

The nonrevenue FedEx pilot estimated that about 10 seconds elapsed from the

time the L1 door opened until he pulled the slideís manual inflation handle.40 As

previously discussed, both the L1 door manual inflation and slide/raft disengage handles

were found on the cabin floor near the R1 door. The nonrevenue FedEx pilot stated that he

did not pull any other handle on the L1 emergency evacuation slide/raft. He stated that the

slide deployment on the accident airplane was the first actual deployment he had

experienced. 

1.15.2 Emergency Evacuation Videotape

Safety Board investigators obtained a videotape made by a bystander that showed

the burning airplane and the evacuation process. Review of this videotape showed that the

captain evacuated the airplane first, using the right cockpit window evacuation tape, about

57 seconds after the recording began.41 The second crewmember to evacuate the airplane

(the cockpit jumpseat nonrevenue FedEx pilot) exited using the left cockpit window

evacuation tape about 15 seconds later. During the next 65 seconds, the videotape showed

eight objects being thrown from the airplane. The third crewmember to evacuate the

airplane (one of the courier seat nonrevenue FedEx pilots) exited the airplane using the

left cockpit window evacuation tape about 138 seconds after the recording began. The

videotape showed that, during the next 27 seconds, another five objects were thrown from

the airplane. The last four crewmembers evacuated the airplane using the left cockpit

window evacuation tape between about 165 seconds and 209 seconds after the recording

began; the entire evacuation took about 152 seconds. 

During postaccident interviews, some of the nonrevenue FedEx pilots who had

been seated on the courier seats in the cabin indicated that they threw bags out the L1 door

39 For additional information on the use of the emergency slide, see section 1.17.2.5.

40 According to the slide/raft manufacturer, in accordance with FAA requirements, automatic slide

inflation should take no longer than 6 seconds.

41 During a postaccident interview, the bystanderís son stated that his father began filming about

2 minutes after the airplane came to a stop in the grass. 
Factual Information 24 Aircraft Accident Report

and the left cockpit window while they were waiting to exit the airplane through the left

cockpit window. The airplane occupants indicated that many of the bags contained

international passports (which the pilots needed for international FedEx flight segments),

as well as clothing, uniforms, and holiday presents.42 During postaccident documentation

of the airplane, investigators found no occupantsí bags remaining. 

1.15.3 Emergency Response 

MFD fire station no. 33 and MEM ATCT records showed that, about 1226:44,

MEM ATCT personnel made the initial notification of the accident via the primary crash

phone in the tower. This notification automatically activated crash alarms at the MFD fire

station, MFD dispatch (located in downtown Memphis), the MEM airport

communications operator (located in the lower level of the airport terminal), the

Tennessee Air National Guard, and the RMFD. 

According to the transcript of ATC communications on the local control

frequency, about 1227:56, the accident captain advised the local controller that there were

seven people aboard the airplane.43 According to MEM ATCT personnel, this information

was repeated aloud within the tower but was not relayed to ARFF responders. However,

as previously discussed, the airplane occupants successfully evacuated through the cockpit

windows without ARFF assistance. 

Two MFD station no. 33 ARFF vehicles were the first ARFF vehicle responders to

reach the airplane and immediately began to fight the fire on the right side of the airplane.

After the first MFD firefighting units arrived at the accident site, a command site was

established west of the accident airplane, and firefighting and first aid efforts were

initiated. A few minutes later, when the two RMFD vehicles arrived,44 the on-scene

commander instructed one of them to take up a position on the left side of the airplane and

to use its snozzle45 to apply firefighting agents in the airplaneís main cargo compartment.

The MFD action report stated that the main body of the fire was under control within 10 to

15 minutes after MFD firefighting units arrived at the site and was completely

extinguished by about 1322. According to the MFD station no. 33 action report, all of the

airplane occupants who were in need of on-scene medical treatment had received it and,

by 1402, had been transported to local medical facilities for further examination and

treatment as necessary. 

42 For information regarding FedExís emergency evacuation procedures, see section 1.17.2.4.

43 During postaccident interviews, FedEx personnel indicated that they sometimes transport as many as

27 occupants on their wide body ìcargoî airplanes. 

44 For additional information about this delay, see section 1.15.3.1.

45 According to the snozzle manufacturer, this was the first time the snozzle was used in firefighting

after an accident. Postaccident interviews indicated that it worked effectively. 
Factual Information 25 Aircraft Accident Report

1.15.3.1 RMFD Emergency Response

The ARFF vehicles that were dispatched to the accident site by RMFD arrived

several minutes after the MFD fire station no. 33 ARFF vehicles. According to the

transcript of ATC communications on the ground control frequency, about 1228:08,

RMFD ARFF personnel requested permission to travel to the accident site, and the MEM

ground controller advised them to hold short of runway 27 because of landing traffic. A

review of recorded radar data showed that, at that time, the arriving airplane was about

2.5 miles east of the end of runway 27. The ATC transcript showed that the ground

controller began to brief a relief ground controller about 1228:58, and the briefing

continued until about 1231:06.46 During this time (about 1229:28), the arriving airplane

touched down. About 1230:04 (during the briefing), the relief ground controller asked the

ground controller, ìwant that fire vehicle out there too?î and, about 1230:06, the ground

controller cleared the RMFD vehicles to cross runway 27. About 1231:20, the relief

ground controller cleared the RMFD vehicles to proceed to the accident site. 

According to postaccident interviews with MEM ATCT personnel, RMFD ARFF

vehicles normally operate on the FedEx ramp, which is not part of the airportís movement

area; therefore, it is not typically under the ATCTís control. The ATCT controllers

indicated that the RMFD vehicles were not considered primary emergency responders.

The November 1, 2000, letter of agreement between MEM ATCT, the airport authority,

and MFD fire station no. 33 addressing airport emergency procedures did not specify

response procedures for the RMFD, but it noted that the airport crash phone rings at the

FedEx (RMFD) fire station. The ATC controllers indicated that RMFD personnel were

considered a secondary source for ARFF services, or unofficial ìmutual aid,î although no

formal mutual aid agreement was in effect.

1.15.3.2 Postaccident Federal Aviation Administration Actions

On March 1, 2004, the FAA issued a notice to all airport operators, ARFF

management, and FAA airport certification safety inspectors (CertAlert No. 04-01). This

notice described the circumstances of this accident and stated the following: 

Arriving ARFF units were surprised to see 7 personnel egress the aircraft. A

briefing with the cargo operator after the accident revealed that on its MD-10

aircraft, there could be as many as 27 personnel on board, at any time.

Additionally, in some configurations, personnel are located in the rear of the

fuselage section. This is usually used during livestock transportation with the

handlers in the rear, but may occur for other reasons. 

If, after the accident, the crew was unable to advise ARFF of the total personnel

on board, some passengers could be trapped based on an assumption of expected

and limited crew. 

46 According to MEM ATCT personnel, the ground controller was being relieved so he could

participate in postaccident activities as described in FAA Order 8020.11B, Aircraft Accident and Incident

Notification, Investigation, and Reporting.
Factual Information 26 Aircraft Accident Report

The FAA suggests that airport operators and/or ARFF crews contact their cargo

operators and explore avenues to determine the number of personnel that could

possibly be expected on a particular aircraft. If possible, pre-plan with cargo

operations for a way to obtain personnel manifests for incoming flights. At the

minimum, expect that there could be a far greater number of personnel aboard

than expected. 

1.16 Tests and Research

1.16.1 Airplane Performance Studies

1.16.1.1 Safety Boardís Airplane Performance Study 

The Safety Board conducted an airplane performance study, which used the pitch,

bank, heading, and acceleration data recorded by the FDR to determine the load factors at

the right main landing gear during the landing. This airplane performance study also

integrated the FDR acceleration data with ground evidence (tire tracks and markings on

the runway surface) to create an integrated flightpath and ground path for the accident

airplane. The Boardís study showed that, during the 20 seconds before touchdown, the

airplaneís descent rate was 12.5 feet per second (fps) with +/- 2.5-fps oscillations. At

1225:52.1, the airplaneís left main landing gear touched down at a rate of about 12.5 fps;

about 0.25 second later, the right main landing gear touched down at a rate of about

14.5 fps. By contrast, the Boardís study identified vertical speeds of less than 6 fps at

touchdown during the airplaneís two previous landings. Figure 5 shows the airplaneís

vertical speeds (as identified by the Safety Boardís performance study) during the

accident landing and the two previous landings, with altitude displayed above. 

The MD-10-10F design criteria require that the airplaneís landing gear and

associated structure must be capable of absorbing energy equivalent to a 10 fps vertical

speed (descent rate) when landing at the airplaneís maximum design landing weight of

375,000 pounds (in accordance with the landing design limits imposed by

14 CFR 25.47347 through 25.487).48 In addition, in accordance with Section 25.723, the

main landing gear is designed to be capable of absorbing reserve energy that is equivalent

to a maximum airplane descent rate of 12 fps (720 feet per minute [fpm]) when landing at

the maximum airplane design landing weight. According to the Boardís study, the right

main landing gear was subject to a peak longitudinal load factor of about -0.18 G, a peak

lateral load factor of about 0.38 G, and a peak vertical load factor of about 2.27 Gs during

the landing.49

47 Title 14 CFR 25.473, ìLanding Load Conditions and Assumptions,î states that the airplane is

assumed to contact the ground with a limit descent velocity of 10 fps at the design landing weight (the

maximum weight for landing conditions at maximum descent velocity). 

48 The accident airplaneís estimated landing weight was 358,450 pounds. Landing energy calculations

accounted for the differences between the design maximum and actual landing weights.

49 Landing gear certification criteria address energy absorption/rate of descent; there are no published G

limits for landing gear certification. 
Factual Information 27 Aircraft Accident Report

Figure 5. The airplaneís vertical speeds (as identified by the Safety 

Boardís performance study) during the accident landing and the two 

previous landings, with altitude displayed above. 

The Safety Boardís study of the FDR pitch data showed no evidence of an increase

in the airplaneís pitch attitude (flare) before touchdown. By contrast, during the two

previous landings recorded by the FDR, the airplaneís pitch increased during the seconds

before touchdown, reaching nose-up pitch attitudes of more than 7°. Figure 6 shows the

pitch attitudes recorded by the FDR during the accident landing and two previous

landings. 
Factual Information 28 Aircraft Accident Report

Figure 6. Pitch attitudes recorded by the FDR during the accident landing 

and two previous landings. The vertical black line (FDR elapsed time 

0 seconds) represents the airplaneís touchdown. 

Although the FDR pitch data showed no evidence of a flare before the airplane

touched down, the FDR elevator position data showed that the elevator moved from about

2.75° to 12.75° airplane nose up almost immediately after the left main landing gear

touched down, just as the right main landing gear touched down. The study also revealed

that the airplaneís longitudinal axis was not aligned with its direction of flight or the

runway when it touched down. Rather, the nose of the airplane was aligned on a heading

of about 352.6°, about 5.4° left of the runwayís magnetic heading of 358° and about 6.5°

left of the airplaneís ground track of about 359.1°. This information is consistent with the

physical evidence noted in section 1.12.2. 

1.16.1.2 Wind Derivation

The FDR recorded wind speed and direction every 4 seconds. The Safety Board

derived wind speeds and directions for the 4 seconds between the recorded samples by

comparing airplane positions (obtained from the airplane performance study acceleration

integration) with FDR airspeed (converted to true airspeed) and heading data. The results
Factual Information 29 Aircraft Accident Report

showed a left quartering headwind that ranged in speed between about 25 and 35 knots,

with an average speed of about 30 knots and shifts in direction (from about 300o to 330°)

between about 1225:10 and about 1225:42. Beginning about 1225:42, as the first officer

began to align the airplane for landing, the derived wind speed decreased to about

20 knots. However, the wind derivation method assumed the airplane had zero sideslip,

and, when the first officer maneuvered the flight controls to align with the runway, the

airplane transitioned into a sideslip. This compromised the validity of the derived wind

speeds during that portion of the approach; however, subsequent calculations that

corrected for the sideslip indicated that the winds did not diminish significantly during the

landing. 

1.16.1.3 Boeingís Airplane Landing Energy Analysis

Boeing also conducted an airplane performance study (which produced results

consistent with the Safety Boardís performance study) and used those results to conduct a

landing energy analysis.50 The landing energy analysis showed that the total energy

dissipated to the left main landing gear during the landing was 473,478 foot-pounds

(ft-lb), and the energy dissipated to the right main landing gear during the landing was

563,478 ft-lb. According to 14 CFR 25.723(2)(b), ìShock Absorption Tests,î the

MD-10-10F main landing gear design requirement for reserve energy dissipation is

838,509 ft-lb total, or about 419,255 ft-lb each to the left and right main landing gear

assemblies (assuming equal energy dissipation at each main landing gear assembly).

Boeingís calculations showed that the total energy dissipated to the right main landing

gear during the landing was about 34 percent greater than the design reserve energy

requirement and about 19 percent greater than the energy dissipated to the left main

landing gear. 

1.16.2 Metallurgical Examination of the Right Main Landing Gear 

Assembly 

The Safety Board visually examined portions of the accident airplaneís right main

landing gear assembly, including six sections of the fractured outer cylinder, at its

materials laboratory. The visual examination of all of the fracture surfaces showed rough

features with chevron markings consistent with tensile overstress. The chevron markings

emanated from the shock strut chamber check valve hole located on the aft side of the

cylinder just below the lower brace link. 

Measurements of the check valve hole at the inboard origin area met Boeingís

specifications, and the cylinder wall thickness at the failure plane met Boeingís thickness

requirements, except for localized areas where it was greater than the requirements.

Examination of the origin area revealed that the fracture initiated from both sides of the

check valve hole inner diameter surface about 0.235 to 0.245 inch from the cylinderís

50 The landing gear external ground loads associated with Boeingís reserve energy analysis included

only vertical and drag loads applied to the landing gear; they did not include the additional effects of lateral

or torsional loads that would be imposed on landing gear at touchdown in a sideslip. 
Factual Information 30 Aircraft Accident Report

inner surface. No evidence of preexisting fatigue was found. The check valve threads

(only present near the outer diameter surface of the hole, which is not near the origin area)

were relatively undamaged. 

Examination of the unthreaded surface of the check valve hole from which the

fracture initiated revealed significant circumferential tool marks and the presence of

metallic deposits. Scanning electron microscope examination revealed that the fracture

initiated at the base of the tool marks, which had a maximum depth of about 0.0015 inch.

The area exhibited no evidence of fatigue or brittle zones. 

Energy dispersive spectroscopy analysis of the cylinder base metal showed that the

composition was consistent with the specified 300M steel. Hardness tests revealed that the

fractured cylinder had a hardness consistent with applicable specifications. 

1.16.3 Flight Simulator Study 

The Safety Board used an MD-11 flight simulator that was backdriven51 based on

the accident airplaneís FDR data to reconstruct the airplaneís motions and the views from

the cockpit during the approach and landing at MEM. All cockpit instrumentation and

systems were operational, and the control wheel and rudder pedals moved as required to

replicate the FDR. The simulator was programmed to provide a daytime visual scene of an

airport with landing runway features similar to runway 36 at MEM and ground texture

cues. The full-motion flight simulation was repeated several times to allow investigators

to observe the internal and external cues available during the simulation. After the flight

simulations, investigators (including representatives from FedEx and the Air Line Pilots

Association [ALPA]) agreed on the following observations: 

ï It appeared that the control wheel approached full travel to the left and right

several times during the approach. 

ï As the airplane descended through about 130 to 140 feet, it appeared to

momentarily align with the runway centerline; however, control wheel and

rudder inputs initiated during this alignment maneuver were not maintained,

and the airplaneís nose moved slightly left (back into the wind) as the airplane

drifted to the right. This drift was evident from both pilot seats in the simulator

and became markedly visible as the airplane descended through about 60 feet

agl.

51 To backdrive the flight simulator, investigators used data recorded by the FDR rather than a pilot

input to drive the visual and motion systems of the simulator.
Factual Information 31 Aircraft Accident Report

ï When the airplane touched down, the control wheel and rudder pedals were

close to their neutral positions, and it did not appear as if the pilots attempted to

increase control column back pressure (to ìflareî the airplane) before landing.

(According to FedEx procedures, the pilots should have initiated the flare as

the airplane descended through 30 feet agl.) The airplane was in a left ìcrabî52

and right of the runway centerline when it touched down. 

Investigators also determined that it would have been possible to conduct a

successful go-around if initiated at various points during the approach and landing.53

1.17 Operational and Management Information

1.17.1 FedEx General Information

FedEx was incorporated in June 1971 and, in April 1973, began operating

14 corporate-type jet airplanes from the airlineís hub at MEM. After the deregulation of

the air cargo industry in 1977, FedEx began to expand, acquiring more and larger

airplanes (including Boeing 727s and McDonnell Douglas DC-10s) and using multiple

airports for its operations. In recent years, FedEx has added various models of Boeing,

Airbus, Fokker, ATR, and Cessna airplanes to its fleet, including McDonnell Douglas

MD-11s/-10s and Airbus A300s and A310s. At the time of the accident, FedEx operated a

fleet of 624 airplanes with about 4,200 pilots. 

1.17.2 FedEx Crew Training, Guidance, and Procedures

1.17.2.1 FedExís Missed Approach/Go-Around Policy

According to chapter 6 of FedExís flight operations manual (FOM), ìthe decision

to execute a go-around is both prudent and encouraged anytime the outcome of an

approach or landing becomes uncertain. FedEx considers the use of the go-around under

such conditions as an indication of good judgment and cockpit discipline on the part of the

flightcrew.î Further, chapter 6 of the FOM states the following, in part:

The decision a pilot must make before descending below the minimum altitude for

the approach is not a commitment to landÖ

The operational decision to continue an approach using visual means must be

based on information the pilot accumulates throughout the approach. Since many

variables are involved, the final decision to commit to a landing is the captainís

and is primarily a judgment based on all relevant factors. 

52 The term ìcrabî refers to ìthe maneuvering of an aircraft partially into a crosswind to compensate for

drift.î

53 For additional information, see the Operations Group Chairman Factual Report, Addendum 5 in the

docket for this accident.
Factual Information 32 Aircraft Accident Report

1.17.2.2 FedEx Crosswind Landing Guidance and Procedures

FedExís MD-11/-10 flight manual (page 7-1-6-2) states the following regarding

crosswind landings: 

Crosswind landings are accomplished by flying the final approach in a wings level

attitude with a crab into the wind. At approximately 200í agl, align the fuselage

with the runway by smoothly applying rudder and maintain runway centerline by

lowering the upwind wing. In high crosswinds, consideration should be given to

commencing the align maneuver prior to 200í. The align maneuver shall be

established by 100í agl. 

The flight manual also stated that, to ensure that the airplane is in the correct

landing attitude and airspeed at touchdown, pilots should smoothly increase back pressure

on the control column as the airplane descends through 30 feet agl, bringing the nose of

the airplane up an additional 2° to 2.5° above its approach pitch attitude (resulting in about

a 7° to 7.5° nose-up pitch attitude). The flight manual further stated that this pitch attitude

should be established by 10 feet agl and that, subsequently, a constant pitch attitude

should be maintained to touchdown. 

The FOM listed the following guidelines for acceptable landing performance: 

ï Airspeed +/- 5 knots of the target speed on final 

ï Touchdown to occur in the touchdown zone

ï Touchdown close to or on the centerline 

On page 1-1-0-9, the FedEX MD-11/-10 FOM indicated that the maximum

crosswind landing limitation is 31 knots. The manual also stated that pilots landing in

crosswinds should adjust their approach airspeed by adding a wind additive of the greater

of the following (not to exceed 20 knots): 

ï 5 knots 

ï 1/2 the steady wind in excess of 20 knots 

ï gust factor 

1.17.2.2.1 Crewmember Descriptions of the Accident Approach and 

Landing

During postaccident interviews, the captain told investigators that he was satisfied

with the first officerís flying techniques during the entire approach. He stated that the

airplane was fully configured (landing gear extended, 35° of flaps) for the approach before

the first officer disengaged the autopilot about 800 to 900 feet agl and that the

autothrottles remained engaged throughout the approach. The captain stated that the first

officer made the wind corrections necessary to keep the airplane tracking the extended

runway centerline and maintained a proper glidepath during the approach. He indicated
Factual Information 33 Aircraft Accident Report

that he did not observe anything ìout of limitsî during the approach and that he did not

have to make corrective comments or control inputs. 

The captain stated that, at 50 feet agl, the throttles automatically moved toward

idle and that, about 30 feet agl, the first officer began to flare, increasing back pressure on

the control column. He reported that the airplane landed on the runway centerline and in

the touchdown zone, with the left and right main landing gear tires touching down at the

same time and the nose gear lowering ìnormally.î 

The first officer stated that she maintained a wind correction angle of about 10°

left of the runway heading and an approach airspeed of 149 knots until the airplane

descended through about 200 feet agl. She reported that she then began to align the

airplaneís longitudinal axis with the runway centerline and initiated the flare about 30 feet

agl. She stated that she did not perceive a need to adjust the throttles after the autothrottles

moved them to idle. Both pilots indicated that the airplane touched down firmly and did

not bounce. 

According to FDR data, the airplane maintained about a 5° nose-up pitch attitude

from about 1,500 feet agl until it touched down. No increase in pitch to dissipate airspeed

and attain the proper landing attitude was observed in the FDR data as the airplane neared

the runway. 

1.17.2.3 FedEx Windshear Guidance

FedExís MD-11/-10 flight manual defines windshear as ìa rapid change in wind

direction and/or velocity that results in airspeed changes greater than 15 knots or vertical

speed changes greater than 500 fpm. Such conditions can be caused by convective

conditions, frontal systems, and/or low altitude jet streams.î According to the flight

manual, pages 8-3A-4-1 and 8-3A-4-2, the MD-11 windshear alert and guidance system

(WAGS)54 is available from 1,500 to 50 feet radar altitude during the landing approach. 

When the WAGS detects windshear, it generates an aural tail or head windshear

announcement and illuminates a red or yellow WINDSHEAR annunciation in the upper

left corner of the pilotsí primary flight display, indicating decreasing or increasing

airplane performance, respectively. If the windshear condition continues, the WAGS

provides flight director or autopilot pitch guidance for an optimal flightpath through the

windshear. When windshear conditions no longer exist, all windshear annunciations

cease; however, the system continues to provide pitch and flightpath guidance until safe

flight conditions are again achieved. 

FedExís MD-11/-10 flight manual recommended that pilots use standard operating

techniques and procedures to prevent a ìdangerous flight path situation from developing if

inadvertent windshear is encountered.î The manual recommended that pilots know the

54 The WAGS is part of the autoflight system (AFS) and receives information from the central air data

computer (ADC), inertial reference system (IRS), FMS, and other components of the AFS. When the central

ADCs and IRSs provide data that indicate an adverse wind condition, the WAGS provides windshear alerts

on the electronic instrument system and through the CAWS.
Factual Information 34 Aircraft Accident Report

go-around decision criteria parameters and be prepared to execute an immediate

go-around if those parameters are exceeded. Additionally, the manual stated that the

nonflying pilot should closely monitor the vertical flightpath instruments, including

vertical speed, altimeters, and glideslope displacement, and call out any deviations from

normal. The flight manual also suggested that pilots take precautions ìwhenever

probability of windshear exists but avoidance action is not considered necessary.î For the

approach and landing, these recommended precautions included achieving a stabilized

approach no later than 1,000 feet agl, using 35° of flaps, and increasing approach

airspeeds by up to 20 knots. 

1.17.2.4 FedEx Emergency Evacuation Procedures and Guidance

According to the emergency evacuation guidance contained on page 2-13A-2-4 of

FedExís MD-11/-10 flight manual, after the airplane has stopped, the pilots should do the

following: 

ï Verify that the outflow valve is open; 

ï Set the parking brake; 

ï Move the fuel levers to the off position; 

ï Command the evacuation; 

ï Move the engine fire handles to the down/discharge position; 

ï Pull/rotate the auxiliary power unit fire handle; and 

ï Unlock the cockpit door.55

Postaccident examination of the cockpit and review of the CVR indicated that the flight

crew had successfully performed all items except those that were hindered by airplane

damage.

On January 15, 2004, FedEx issued Flight Crew Information File (FCIF) 04-0020

(Vital), titled, ìEmergency Evacuation Guidance,î which stated, in part, the following: 

Emergency evacuations are potentially one of the more time-sensitive events in

aviation. Each aircraft [flight manual] addresses the emergency evacuation

procedures for that aircraft. This FCIF provides general policy concerning

emergency evacuations. 

When the captain declares an emergency evacuation, the crew will follow the

[flight manual] procedures and the captain will designate the evacuation route. In

the event the captain is incapacitated, the crew chain of command will dictate who

designates the route. 

55 The flight manual further specified that the pilots should unlock the cockpit door ìto allow

courier/cabin jumpseaters and/or emergency/security personnel access to the cockpit.î
Factual Information 35 Aircraft Accident Report

During an emergency evacuation each crewmember and jumpseater will evacuate

in the most expeditious manner possible. No one will take an unnecessary risk by

taking time to salvage personal articles. Once out of the aircraft, the crew and

jumpseaters should proceed to a safe place away from the aircraft. If possible, the

first officer (2-man crew) or second officer (3-man crew) will carry a copy of the

Notification of Dangerous Goods to give to the emergency responders. 

On January 22, 2004, FedEx issued FCIF 04-0034 (Vital), which stated, in part,

the following: 

This FCIF is to remind each crew member that they must be thoroughly familiar

with their aircraftísÖemergency evacuation procedures. This includes:

1. How to deploy the escape slide

2. If appropriate, how to detach the escape slide for use as a raft

3. How to escape through the cockpit windows

The Jumpseat Certification guide has good information on evacuation, but if you

have jumpseaters (even other crew members), you must brief them on how to

perform an evacuation. If you are jumpseating, you should learn how to perform

an evacuation from the aircraft. 

1.17.2.5 FedEx Emergency Evacuation Training 

The Safety Boardís investigation revealed that FedExís classroom training

included a PowerPoint presentation that showed operation of the emergency exit

door/slide in the emergency and manual modes. The classroom training also included a

videotape showing the deployment of the emergency evacuation slide/raft and a close-up

view of the girt flap assembly, including the manual inflation and slide/raft disengage

handles. The classroom training emphasized that the slide/raft disengage handle is only to

be used during an emergency water landing (ditching) operation. According to FedEx

records, the captain, first officer, cockpit jumpseat occupant, and four courier seat

occupants had completed FedEx MD-11/-10 emergency evacuation training during initial

and subsequent recurrent training, as required. 

FedExís MD-11/-10 emergency exit door/slide trainer was used for emergency

training and hands-on drills at its Memphis facility during initial and recurrent training for

MD-10, MD-11, and DC-10 crewmembers.56 The trainerís emergency slide/raft was

permanently inflated and deployed and was attached to a pipe on the exterior of the trainer

door (just below the doorsill). At the time of the accident, the door trainer did not include

a girt bar flap assembly as would be found on an airplane. This assembly would have

contained the manual inflation handle, the slide/raft disengage handle and the girt bar.57

However, after the accident, FedEx installed a new girt bar flap assembly at the top of the

slide/raft near the MEM trainer doorsill, with a manual inflation handle and a girt cover

56 FedEx also used an emergency exit door/slide trainer at its facility in Anchorage, Alaska, for

recurrent training for Anchorage-based MD-10, MD-11, and DC-10 crewmembers.
Factual Information 36 Aircraft Accident Report

flap that could be lifted to reveal a slide/raft disengage handle.58 According to FedEx

personnel, the company also modified its procedures to require crewmembers to pull, or

simulate pulling, the manual inflation handle during training sessions. 

1.17.2.5.1 Regulatory Requirements and Federal Aviation Administration 

Oversight of Emergency Training

Emergency exit door/slide training devices are used extensively for flight and

cabin crew emergency training in the aviation industry. The FAA principal operations

inspector (POI) assigned to an operator is responsible for examination and approval of

these devices. According to the guidance contained in FAA Order 8400.10, Air Transport

Aviation Inspectorís Handbook, POIs are to ensure that an operatorís emergency exit

door/slide training device(s) accurately represents the operation of the doors, slides, rafts,

and other equipment that a crewmember might encounter on an airplane. 

The handbookís specific guidance for flight crewmember emergency exit

training59 states that the emergency exit door training device should be designed so that

students have the ability to do the following:

1. Experience the actual operation (open and close) of each exit in the normal

and emergency modes; 

2. Receive instruction on slide/raft deployment, transfer from one door to

another, and detachment from the aircraft (or training device) of each type of

slide/raft (if applicable); and 

3. Actually use the slide/raft (this requirement needs to be accomplished only once,

during initial new hire or equipment training). 

More detailed guidance is contained in the cabin crewmember (flight attendant)

emergency exit training section of FAA Order 8400.10,60 which advises POIs to ensure

that an operatorís emergency exit door/slide training device(s): 

1. Accurately represents the position and operation of the handles and hardware

of the actual aircraft door; 

2. Simulates both the normal and emergency modes; 

57 According to a FedEx training representative, the original girt bar flap assembly was removed from

the door/slide trainer when FedEx installed a new slide/raft to the trainer. A FedEx training manager stated

that the girt bar assembly was not reattached because of concerns that it might cause a tripping hazard for

crewmembers during training. (FedExís Anchorage trainer does not have a girt bar assembly but does have a

red manual inflation handle at the base of the door.) 

58 This new installation did not have a girt bar; rather, a plastic pipe attached the inflated evacuation

slide/raft to the trainer door sill. 

59 For additional information, see FAA Order 8400.10, Air Transportation Inspectorís Handbook,

volume 3, chapter 2, section 4.

60 FedEx is a cargo operator and does not employ cabin crew/flight attendants; however, the guidance

contained in this handbook pertains to flight or cabin crewmembers attempting an emergency evacuation.

For additional information, see FAA Order 8400.10, Air Transportation Inspectorís Handbook, volume 3,

chapter 14, section 6.
Factual Information 37 Aircraft Accident Report

3. Incorporates the actions required to operate the exit in the same manner as the

actual door in both the normal and emergency modes of operation; 

4. Requires representative forces to open the door in the emergency mode; and 

5. Is equipped with a manual inflation handle, if applicable. The training program should

address the fact that the inflation handle may not always be in the same location on

similar aircraft. 

The POI handbook further dictates that during each emergency drill, flight

attendants should satisfactorily demonstrate the following: 

1. During an emergency exit drill students must operate each type of emergency

exit in the normal and emergency modes, including the actions and forces

required for deployment of the emergency evacuation slides.

2. Ability to open exit properly by assuming correct body/protective position; to use

door controls correctly; to ensure door is in open and locked position; to use manual

slide inflation system to accomplish or ensure slide/raft inflation. 

According to 14 CFR 121.417(c)(2)(i)(A), air carrier crewmembers (pilots and

flight attendants) are required to perform a drill (emphasis added) and operate the

equipment for ìeach type of emergency exit in the normal and emergency modes,

including the actions and forces required in the deployment of the emergency evacuation

slides.î Also, Section 121.417(c)(2)(ii)(c) requires all crewmembers to observe (emphasis

added) the ìdeployment, inflation, and detachment from the airplane (or training device)

of each type of slide/raft pack.î 

As a result of issues identified during the Safety Boardís investigation of the

accident involving AirTran flight 356,61 the Board asked the FAA to provide a ìlegal

interpretationî of Section 121.417. The FAA provided a copy of a November 21, 2003,

internal memorandum to ìclarify crewmember training requirements on the B717 tailcone

door and emergency evacuation slides.î The memorandum stated that each flight

attendant and pilot ìmust operate each type of emergency equipment in the normal and

emergency modes including the actions and forces necessary in the deployment of the

evacuation slidesî during recurrent training. In addition, on December 2, 2004, the Board

requested a legal interpretation of Section 121.417 specifically pertaining to hands-on

training (to include pulling the manual inflation handle, as would be required in an

emergency situation if the slide/raft did not inflate automatically when the door is opened)

for all flight and cabin crewmembers. 

The FAA responded in an internal memorandum dated December 23, 2004, which

stated that the legal interpretation includes ìhands-onî use of the manual inflation handle

during the proficiency drill. (The Safety Board notes that, in July 1992, the FAA issued a

bulletin advising its POIs that they were responsible for approving the training device and

ensuring that the device is equipped with a manual inflation handle.) 

61 For additional information on this accident, see the Safety Boardís public docket for accident

NYC03FA067. 
Factual Information 38 Aircraft Accident Report

During postaccident interviews, the POI assigned to FedExís certificate stated that

the FAA approved FedExís MD-11/-10 emergency door/slide training device and

materials when the company first implemented them. He stated that typically FedEx

management would notify the FAA of any changes or ìenhancementsî to approved

training devices, and the FAA program managers for that fleet would then inspect and

approve those changes. Additionally, the FedEx POI stated that the MD-11/-10 program

managers had the opportunity to conduct surveillance of the door training devices during

their observation of crewmember emergency exit proficiency checks; he estimated that

they observe 15 to 20 proficiency checks each year. He stated that his interpretation of

Section 121.417 was that FedEx crewmembers do not need to perform ìhands-onî

training of the slide/raftís manual inflation handle. 

1.17.2.5.2 Previous Safety Board Emergency Exit Training Device 

Recommendation

During the investigation of the February 19, 1996, accident involving Continental

Airlines flight 1943,62 Safety Board investigators found that the aft flight attendant was

unable to properly access the tailcone exit. Further investigation revealed that, because of

differences between the tailcone emergency exit on the airplane and the tailcone

emergency exit trainer, Continental flight attendants were unable to gain hands-on

experience with the potential difficulties created by the interference of the aft jumpseat

restraint system. As a result, on November 15, 1995, the Board issued Safety

Recommendation A-97-10 asking the FAA to do the following:

Amend Flight Standards Handbook Bulletin 96-02, ìGuidelines for Crewmember

Training on Aircraft Tailcones and Approval of Tailcone Training Devices,î to

include a requirement that if any portion of a restraint system is attached to the

tailcone access plug door in the aircraft [that] might interfere with the opening of

the door, the plug door training device must be equipped with the entire restraint

system. 

In a May 9, 1997, letter, the FAA stated that it responded to Safety

Recommendation A-97-10 by issuing Flight Standards Handbook Bulletin 97-07,

ìAmendment to Guidelines for Crewmember Training on Aircraft Tailcones and

Approval of Tailcone Training Devices.î The amended bulletin emphasized that if any

portion of a restraint system is attached to the tailcone access plug door in the aircraft that

might interfere with the opening of the door, the plug door training device must be

equipped with the entire restraint system. In a March 10, 1998, letter, the Safety Board

classified Safety Recommendation A-97-10 ìClosedóAcceptable Action.î 

62 For more information, see National Transportation Safety Board, Wheels-Up Landing, Continental

Airlines Flight 1943, Douglas DC-9, N10556, Houston, Texas, February 19, 1996. Aircraft Accident Report

NTSB/AAR-97/01. (Washington, DC: NTSB, 1997).
Factual Information 39 Aircraft Accident Report

1.17.3 FedEx Enhanced Oversight Program

As a result of a series of accidents and incidents (including the July 26, 2002,

FedEx flight 1478 accident in Tallahassee, Florida),63 the companyís flight operations

directorate implemented a project intended to identify technical and operational

modifications that would improve air safety. On the basis of the projectís findings, the

company developed an enhanced oversight program (EOP) to identify and track pilots

with deficiencies noted during training or required checkrides. (The Safety Board notes

that, at the time of this writing, this program is unique in the aviation industry.) The EOP

was finalized in late 2003 and was formally implemented in January 2004. 

In a May 19, 2004, e-mail memorandum, FedExís system chief pilot advised

company personnel that the EOP was intended as ìa self-defense program to better direct

assets already being used. This is a tool to improve our safety and performance.î The

memorandum indicated that pilots who were assigned to the EOP would be scheduled for

two line checks annually, which would be scheduled between their 6-month recurrent

simulator training sessions,64 thus providing management and training personnel with an

opportunity to evaluate those pilotsí proficiency every 90 days.65 FedExís system chief

pilot estimated that about 215 pilots (out of about 4,200 total FedEx pilots) were in the

EOP in late 2004. Of the 215 pilots, about 87 were MD-11/-10 pilots. (The EOP was not in

effect until after the flight 647 accident happened, and both pilots have been in a

non-flying status with FedEx since the accident. Therefore, neither pilot has been eligible

to be listed in the EOP. ) 

According to an October 1, 2004, FedEx memorandum, the company had

developed an EOP board of directors, which consisted of a system chief pilot as the

chairman and the directors of flight operations, flight safety, flight standards, and flight

training, to implement and oversee the EOP. The memorandum indicated that the board of

directors meets monthly to review recent events, discuss pilot cases, and update the list of

pilots in the EOP. The memorandum stated that the board of directors would maintain a

database with which they would track EOP information and that the EOP would include

any pilot who has one of the following documented training deficiencies: 

ï An UNSAT [unsatisfactory] training/evaluation within the preceding

12 months. 

ï Requiring [50 percent more training than the norm] in any phase of initial,

transition, or upgrade training (ITU) in the preceding 12 months. 

63 For more information, see National Transportation Safety Board, Collision With Trees on Final

Approach, Federal Express Flight 1478, Boeing 727-232, N497FE, Tallahassee, Florida, July 26, 2002,

Aircraft Accident Report NTSB/AAR-04/02. (Washington, DC: NTSB, 2004).

64 All flight crewmembers normally receive flight simulator training every 6 months. In addition,

captains would normally receive an annual line check; first officers do not normally receive an annual line

check. 

65 In addition, the companyís Flight Standards Division personnel routinely conduct random line checks

of FedEx flight crewmembers. 
Factual Information 40 Aircraft Accident Report

ï Requiring extra training in more than one phase of ITU training in the

preceding 12 months. 

1.17.4 Federal Aviation Administration and Department of 

Defense Oversight of FedEx

 The FAA flight standards district office in Memphis was responsible for oversight

of the FedEx air carrier certificate. Four full-time inspectors were assigned to provide

operational oversight of the airline: a POI, an assistant POI, an aircrew program manager,

and an assistant aircrew program manager. Records indicated that the inspectors were

tasked with 276 surveillance activities at FedEx from October 1, 2003, to September 30,

2004, including cockpit en route inspections, manual procedures, flight crew training

records, dispatch procedures, check airmen observations, line check observations,

simulator procedures, and training program effectiveness. At the time of the accident, 64

of the 276 surveillance activities had been completed. 

The FAA also conducted three special inspections at FedEx since 1995. In

August 1995, the FAA conducted a National Aviation Safety Inspection Program

inspection. In April 1998, the FAA conducted an Office Safety Inspection Program

inspection. In January 2000, the FAA conducted a Regional Aviation Safety Inspection

Program inspection. All operational deficiencies found during these special inspections

were corrected and closed as satisfactory by the FAA. 

In addition, personnel from the Department of Defense Air Carrier and Analysis

Office conducted a biennial survey at FedEx from January 28 to February 1, 2002. All

inspected operational areas were found to meet or exceed standards. No operational

deficiencies were noted in the Department of Defense report. 

1.18 Additional Information

1.18.1 MD-11/-10 Flight Characteristics and Differences

As previously mentioned, the MD-10 is basically a DC-10 that has been modified

with an advanced-technology flight deck and allows for MD-11/-10 commonality, so a

pilot with an MD-11 type rating is qualified to fly the MD-10 if that pilot has completed

the required differences training. Before it approved the common training and checking

programs proposed by FedEx and Boeing, the FAA conducted extensive tests to evaluate

system differences between the MD-11 and MD-10 and to validate the proposed training

and checking programs.66

66 The tests were conducted as outlined in FAA Advisory Circular (AC) 120-53. The only training

program evaluated involved initial and transition training and type rating in the MD-11 with differences

training for the MD-10. The FAAís Flight Standardization Board (FSB) report indicated that evaluations of

MD-10 initial or transition training ìmay be evaluated at a later date.î
Factual Information 41 Aircraft Accident Report

According to the FAAís resultant Flight Standardization Board (FSB) report, dated

May 9, 2000, the FAA conducted a two-stage series of tests. First, the FAA conducted a

handling qualities comparison test to evaluate the effect of the MD-11 flight control

computer (FCC)-908 software load in eliminating handling differences with the MD-10

during takeoff and landing.67 Upon successful completion of the handling qualities

comparison test, the FAA conducted tests to evaluate system differences and to validate

the training programs proposed by FedEx and Boeing.68

According to the FSB report, the FAAís evaluation indicated that the MD-10 and

MD-11 airplanesí handling qualities and systems were similar enough to warrant the same

type rating. The FSB report further stated ìtakeoffs and landings performed in one variant

are equivalent to those performed in other variantsî and that as long as the MD-11

FCC-908 or later software was installed, a pilot could receive credit for 90-day takeoff and

landing currency in either airplane (or a combination of both airplanes). With regard to

mixed-fleet flight crews, the FSB stated ìIf crews fly MD-10 and MD-11 variants in a

mixed-fleet, it is desirable but not mandatory for proficiency checks to alternate each six

months for [captains], and annually for first officers.î 

During postaccident interviews, FedEx pilots and check airmen indicated that the

differences in flight characteristics and handling were minimal. One check airman said he

treated the airplanes as the same and taught the same techniques in each type. He stated

that both airplanes were very automated but that you still had to ìfly the airplane.î

Another check airman stated that he observed some differences between the MD-11 and

MD-10 during landing (for example, he reported that he guards the autothrottles and does

not let the throttles retard on the MD-10 during the flare and touchdown) but added that

ìyou could land the MD-10 like an MD-11 and it would still be a safe landing.î 

1.18.2 Previous Safety Board Actions 

During the late 1980s and early 1990s, the Safety Board issued three safety

recommendations69 to the FAA, suggesting it require commercial operators to review

available pilot flight, training, performance, and disciplinary records. Additionally, during

67 According to AC 120-53, the handling qualities comparison test consisted of ìselected Part 61 or

Part 121 pilot certification flight check maneuvers administered in the comparisonÖaircraftÖwhile using a

crew trained and experienced only in the base aircraft. Acceptable crew performance in completion of

designated maneuvers, without differences training, establishes that the variant and base aircraft are

sufficiently alike in handling characteristics to permit assignment.î

68 According to AC 120-53, these tests also ìfully assess particular difference areas, examine

implications of mixed fleet flying, assess special circumstances such as MEL [minimum equipment list]

effects, and evaluate the effects of crew errors potentially related to the differences.î These tests are

conducted in a ìrealistic line flight environment that includes typical weather, routes, airports, ATC, and

other factors [that] are characteristic of those that the aircraft will be operated in.î

69 Safety Recommendation A-88-141 was issued on November 3, 1988, and was classified ìClosedó

Unacceptable Action/Superceded on November 21, 1990. Safety Recommendation A-90-141 was issued on

November 21, 1990, (superceding A-88-141) and was classified ìClosedóUnacceptable Actionî on

October 20, 1992. Safety Recommendation A-93-014 was issued on February 19, 1993, and was classified

ìClosedóUnacceptable Actionî on February 22, 1994. 
Factual Information 42 Aircraft Accident Report

the investigation of the December 13, 1994, accident involving American Eagle

flight 3379,70 Safety Board investigators again found deficiencies in an operatorís

procedures for evaluating applicant pilotsí experience, skills, and abilities. As a result, on

November 15, 1995, the Board issued Safety Recommendations A-95-116 through -119,

which asked the FAA to do the following: 

Require all airlines operating under 14 CFR Parts 121 and 135 and independent

facilities that train pilots for the airlines to maintain pertinent standardized

information on the quality of pilot performance in activities that assess skills,

abilities, knowledge, and judgment during training, check flights, initial operating

experience, and line checks and to use this information in quality assurance of

individual performance and of the training programs. (A-95-116)

Require all airlines operating under 14 CFR Parts 121 and 135 and independent

facilities that train pilots for the airlines to provide such information to the FAA

for incorporation into a storage and retrieval system. (A-95-117)

Maintain a storage and retrieval system that contains pertinent standardized

information on the quality of 14 CFR Part 121 and 135 airline pilot performance

during training. (A-95-118) 

Require all airlines operating under 14 CFR Parts 121 and 135 to obtain

information from the FAAís storage and retrieval system that contains pertinent

standardized pilot training and performance information for the purpose of

evaluating applicants for pilot positions during the pilot selection and hiring

process. The system should have appropriate privacy protections, should require

the permission of the applicant before release of the information, and should

provide for sufficient access to the records by an applicant to ensure accuracy of

the records. (A-95-119)

In a February 11, 1997, letter, the FAA stated that it responded to Safety

Recommendations A-95-117 through -119 by working with Congress on legislation that

would require that pertinent pilot training records be provided to potential employers by

previous employers. The FAAís efforts resulted in the Pilot Records Improvement Act

(PRIA) of 1996,71 which required that any company hiring a pilot for air transportation

request and receive records from any aviation carrier, company, organization, or person

that had employed a pilot applicant during the previous 5 years. 

70 For more information, see National Transportation Safety Board, Uncontrolled Collision with

Terrain, Flagship Airlines, Inc., dba American Eagle Flight 3379, BAe Jetstream 3201, N918AE,

Morrisville, North Carolina, December 13, 1994, Aircraft Accident Report NTSB/AAR-95/07

(Washington, DC: NTSB, 1995).

71 The authority and reference for the PRIA are found in Public Law 104-264, section 502, which is

codified in 49 United States Code section 44703 (h), (i), and (j), and in FAA AC 120-68C. The PRIA

became effective on February 7, 1997. The PRIA states, in part, ìan air carrier that receives the records of an

individualÖmay use such records only to assess the qualifications of the individual in deciding whether or

not to hire the individual as a pilot. The air carrier shall take such actions as may be necessary to protect the

privacy of the pilot and the confidentiality of the records, including ensuring that information contained in

the records is not divulged to any individual that is not directly involved in the hiring decision.î
Factual Information 43 Aircraft Accident Report

Specifically, the PRIA required all 14 CFR Part 121, 125, and 135 air carriers to

obtain training proficiency checks, airplane and route qualifications, and release from

employment records from previous employers of pilot applicants before allowing an

applicant to begin service as a pilot. The PRIA also required all air carriers to obtain from

the FAA a pilot applicantís current medical certification and airman certification and any

record of closed enforcement actions. The PRIA did not state that air carriers were

required to obtain FAA airman records documenting failed flight checks for certificates

and ratings. The FAA stated that the PRIA eliminated the need for a storage and retrieval

system for pilot training records. In a June 2, 1997, letter, the Safety Board classified

Safety Recommendations A-95-117 through -119 ìClosedóAcceptable Alternate

Action.î72

As a result of its investigation of the July 13, 2003, accident involving an Air

Sunshine Cessna 402,73 the Safety Board issued two safety recommendations (A-05-01

and -02) regarding the importance of obtaining and using all pertinent pilot performance

information in hiring decisions. Although there are no similarities between the Air

Sunshine and FedEx Memphis accidents, the concept of the importance of having

available and using all pertinent information to evaluate a pilotís capabilities applies to

both. Safety Recommendations A-05-01 and -02 asked the FAA to do the following:

Require all Part 121 and 135 air carriers to obtain any notices of disapproval for

flight checks for certificates and ratings for all pilot applicants and evaluate this

information before making a hiring decision. (A-05-01)

Conduct a study to determine whether the number of flight checks a pilot can fail

should be limited and whether the existing system of providing additional training

after a notice of disapproval is adequate for pilots who have failed multiple flight

checks. On the basis of the findings of the study, establish a flight check failure

limit and modify the recheck training requirements, if necessary. (A-05-02)

72 In an April 17, 1998, letter, the FAA stated that the PRIA, along with the requirements of

14 CFR 121.683 and 135.63, addressed most of the concerns in Safety Recommendation A-95-116. The

FAA added that the air carrier training requirements contained in 14 CFR Parts 121 and 135 and the

advanced qualification program were predicated on training to proficiency and, therefore, should certify

pilot proficiency. Further, the FAA stated that much of the information included in the recommendation was

already available to prospective employers. The FAA concluded by stating, ìthe inclusion of subjective

evaluations in the permanent record by individual instructors, check airmen or FAA inspectors may have the

net effect of making the training event a punitive experience rather than one where individuals can learn

from mistakes.î In a January 3, 2000, letter, the Safety Board classified Safety Recommendation A-95-116

ìClosedóReconsidered.î 

73 For more information on this accident, see National Transportation Safety Board, In-flight Engine

Failure and Subsequent Ditching, Air Sunshine, Inc., Flight 527, Cessna 402C, N314AB, About 7.35

Nautical Miles West-Northwest of Treasure Cay Airport, Treasure Cay, Great Abaco Island, Bahamas, July

13, 2003, Aircraft Accident Report NTSB/AAR-04/03 (Washington, DC: NTSB, 2004).
44 Aircraft Accident Report

2. Analysis

2.1 General

The captain and first officer were properly certificated and qualified in accordance

with, and had received the training and rest time prescribed by, Federal regulations and

company requirements. The flight crewmembers possessed valid and current medical

certificates appropriate for Part 121 flight operations. 

Based on the available evidence, fatigue was not a factor in this accident. Although

the CVR recorded the first officer coughing and clearing her throat numerous times, she

stated that she was not sick, and there is no evidence that this (the coughing/clearing her

throat) adversely affected the flight or her performance. 

The accident airplane was properly certificated and maintained and was equipped

and dispatched in accordance with applicable regulations and industry practices. There

was no evidence of any preexisting powerplant, system, or structural failure. 

Cargo loading for the accident flight was routine; no cargo loading anomalies were

observed, and the airplane was operating within the prescribed weight and c.g. limits. No

hazardous materials were on board the airplane. The accident airplaneís cargo and its

loading were not factors in the accident. 

FedEx records indicated that the flight crewmembers had received the requisite

initial, transition, and MD-11/-10 differences training. The Safety Boardís review of the

FAAís FSB report describing its evaluation of MD-11 and MD-10 handling

characteristics and numerous postaccident MD-11/-10 flight crew interviews revealed

only very subtle differences in flight handling characteristics during the landing phase

between the two airplanes. The Safety Board notes that changes in handling characteristics

resulting from differences in weight and balance can be much more significant than any

differences that could be attributed to MD-11/-10 aerodynamic factors. Further, the

significant flight control inputs that are needed when landing either an MD-11 or MD-10

in strong, gusty crosswind conditions (such as those encountered during the accident

flight) would render any subtle differences in handling characteristics between the

airplanes negligible. In any event, the FDR data show that the first officer momentarily

applied flight control inputs to align the airplane with the runway as the airplane

descended between about 200 and 160 feet agl; however, she did not maintain those inputs

as the airplane neared the runway. In the absence of the necessary and significant flight

control inputs during the crosswind landing, any possible differences in handling

characteristics between the MD-11 and MD-10 would not be a factor for the pilot.

Therefore, the Safety Board concludes that differences between the MD-11 and MD-10

handling characteristics during the landing phase were not an issue in this accident. 
Analysis 45 Aircraft Accident Report

ATC was not a factor in the accident; however, in other circumstances, the ground

controllerís delay clearing RMFD ARFF vehicles to the accident site might have had more

serious consequences. For additional information, see section 2.6.

The pilots were provided with weather forecasts, including AIRMET information,

that indicated turbulence below 8,000 feet and strong northerly/northwesterly winds aloft

and at the surface. Postaccident pilot and passenger statements and MEM airport surface

weather information about the time of the accident indicated that the winds were strong

and gusty out of the northwest; however, crew comments recorded by the CVR suggested

that the pilots were not overly concerned about the weather conditions. Several airplanes

landed without incident in similar conditions during the minutes before and after the

accident. The winds identified in the Safety Boardís performance study indicated that the

existing weather conditions might have been responsible for the small airspeed gains and

losses and the CAWS tail windshear alert experienced by the accident flight; however,

there was no evidence of horizontal windshear significant enough to adversely affect the

operation of the airplane. Additionally, a meteorological study conducted by MIT at the

Boardís request was consistent with the results of the Boardís study. Therefore, the

atmospheric conditions encountered during the approach and landing were within the

performance capabilities of the airplane; there was no evidence of significant windshear.

The remainder of this analysis discusses the accident sequence, including flight

crew performance, as well as emergency evacuation and MEM ATCT and ARFF issues.

2.2 The Accident Sequence 

Postaccident interviews with the pilots and examination of the CVR and FDR data

indicated that the en route portion of the accident flight from OAK to MEM was routine

and that the pilots engaged in normal duties and discussions as the airplane neared MEM.

Although they encountered turbulence and gusty crosswind conditions during the descent,

both pilots reported that the approach to runway 36R was routine. A CAWS tail windshear

alert sounded as the airplane descended through about 1,460 feet agl during the approach.

The pilots indicated that because the alert was brief (1 to 2 seconds) and because the

airplane remained in a stabilized approach, they determined that a go-around was not

necessary and continued the approach. This decision was appropriate and consistent with

FedExís windshear policies. 

FedExís MD-11/-10 crosswind landing procedures dictate that, as the airplane

descends through about 200 feet, the pilot should begin to apply control wheel and rudder

inputs to align the longitudinal axis of the airplane with the runway centerline. This

alignment procedure places the airplane in a sideslip, allowing the airplane to maintain the

desired ground track and longitudinal alignment despite the crosswind conditions, as long

as aileron and rudder control inputs are appropriate for those conditions. Then, as the

airplane descends through about 30 feet, the procedures indicate that the pilot should

smoothly increase back pressure on the control column to increase the airplaneís pitch

attitude (flare) to about 7° as appropriate for landing. Throughout final approach and
Analysis 46 Aircraft Accident Report

landing, the airspeed should remain within +/-5 knots of the target airspeed. Following

these procedures would result in an airplane that is aligned with and centered on the

runway centerline in about an appropriate landing pitch attitude and a proper descent rate

and airspeed when it touched down. 

During postaccident interviews, the captain and first officer described the landing

and indicated that it was performed in accordance with FedExís crosswind landing

procedures. Both pilots stated that the landing flare was normal, including proper

alignment with the runway centerline and compensation for wind conditions below

200 feet. The captain indicated that he thought they experienced a ìstrong gustî of wind

during the landing, and both pilots described the landing as firm but otherwise normal.

However, FDR evidence and physical evidence, including tire markings on the runway,

indicated that the airplane touched down with both main landing gear assemblies and the

nose gear well right of the runway centerline on a heading about 5.6° left of the runway

heading. The evidence indicated that the airplaneís left main landing gear touched down

first about 500 feet from the approach end of the runway, and about 9 feet right of the

runway centerline. The evidence further indicated that, almost immediately thereafter, the

right main landing gear touched down about 45 feet right of the runway centerline about

49 feet further down the runway. 

A series of simulations performed using the accident FDR data to backdrive an

MD-11/-10 flight simulator indicated that the airplane maintained a stable condition,

tracking along the runway centerline with an appropriate wind correction angle as it

descended through 200 feet. The FDR evidence further indicated that the first officer

began to apply left aileron and right rudder to align the airplane with the runway centerline

about 160 feet (this became visually apparent in the simulator about 140 feet). However,

the data and the simulations showed that these normal crosswind landing control inputs

were only momentary; as the airplane descended below 100 feet, the aileron and rudder

control inputs were neutralized and remained neutral until the airplane touched down. The

simulations showed that, as a result of the neutralized flight control inputs, the airplane

began to drift to the right and continued to drift to the right, with a 5° to 6° left crab angle,

until it touched down. The winds at the time of the accident would have required a pilotís

constant attention, significant flight control inputs along both the roll (control wheel) and

yaw axes (rudder pedal), and continuous modulation of those inputs. Although the pilots

received a windshear alert earlier in the approach, there was no evidence of a significant

decrease in wind speed or change in wind direction that might have prompted the first

officer to neutralize her crosswind-correcting flight control inputs as the airplane neared

the runway. 

The FDR data and the Safety Boardís performance study showed that after the

airplane descended through about 1,500 feet, its pitch attitude, descent rate, and airspeed

remained fairly constant until touchdown (about 5° nose up, 720 fpm [about 12.5 fps], and

149 knots, respectively). However, according to FedExís crosswind landing procedures, a

pilot should begin to increase back pressure on the control column as the airplane

descends through about 30 feet to increase pitch attitude and arrest the airplaneís descent

rate, dissipate airspeed, and bring the airplane into the correct landing attitude.
Analysis 47 Aircraft Accident Report

Nevertheless, the accident airplaneís FDR data showed that the first officer did not

increase the airplaneís pitch attitude to arrest the airplaneís rate of descent. 

Therefore, on the basis of physical and FDR evidence, the Safety Board concludes

that the first officer did not properly apply control wheel and rudder inputs to align the

airplane with the runway centerline or apply appropriate back pressure on the control

column to arrest the airplaneís rate of descent before touchdown; as a result, the airplane

touched down extremely hard while still in a crab. 

Although the first officer had sufficient visual cues and time to recognize and

correct for the deteriorating approach to landing (either by reapplying wind correction

inputs and increasing back pressure on the control column to arrest the airplaneís rate of

descent before touchdown or by performing a go-around), she did not do either.74 (The

Safety Board notes that FedEx policy states that ìthe decision to execute a go-around is

both prudent and encouraged anytime the outcome of an approach or landing becomes

uncertain;î it is unlikely that either pilot would have hesitated to perform a go-around in

an effort to avoid a possible reprisal.) Because there are no reasonable explanations for the

first officerís failure to take corrective action during the late stages of the approach, and

because of her history of poor performance, the Safety Board examined methods that

identify pilots who may require additional oversight or training to ensure consistent

operational performance. For additional information, see section 2.4.

 Although the first officer was the flying pilot and did not apply proper flight

control inputs during the final moments of the approach, the captain, who was also a check

airman, was responsible for monitoring her performance (especially because he was

conducting a line check of the first officer during the accident flight) and ensuring the

safety of the flight. According to the CVR transcript, as the airplane approached MEM,

the captain provided the first officer with information and advice appropriate for the flight

and consistent with his role as a line check airman. However, the CVR did not record any

comments by either pilot after the airplane descended through 200 feet during the

approach. During postaccident interviews, the captain told investigators that he did not

perceive any reason to comment or advise the first officer during that stage of the

approach and landing. However, the FDR data (as displayed to investigators through the

flight simulator sessions) showed that the first officer neutralized her wind-compensating

flight control inputs as the airplane descended through about 100 feet and that the airplane

subsequently began to drift to the right of the runway centerline. Although it may have

been difficult for the captain, as the nonflying pilot, to immediately recognize that the first

officer had neutralized her flight control inputs, the Boardís flight simulation sessions

showed that as the airplaneís drift to the right continued uncorrected, the drift became

markedly notable from both pilotsí seats as the airplane descended through about 60 feet. 

The Safety Board understands that a line check airman must balance the need to

keep the flight safe with the potential for students to learn from their mistakes; however, in

74 The first officer did move the control column slightly aft immediately before the airplane touched

down; however, the input was too late to affect the airplaneís pitch attitude and descent rate before

touchdown.
Analysis 48 Aircraft Accident Report

this case, the captain allowed the airplane to deviate from established and recognizable

performance standards at the most critical stage of the approach, without comment or

correction. The captain had sufficient time to observe and react to the airplaneís drift and

the first officerís failure to arrest the airplaneís rate of descent as it neared the runway. The

investigators (including representatives from FedEx and ALPA) who observed the

simulations reported that there were clear indications that aspects of the approach needed

correcting and that the captain should have taken corrective actions when these indications

became apparent.75 Therefore, the Safety Board concludes that the captain, who was

conducting a line check of the first officer, did not adequately monitor the first officerís

performance during the final stages of the approach and landing at MEM and failed to take

or initiate corrective action to prevent the accident. 

2.3 Failure of the Right Main Landing Gear Assembly

The Safety Boardís metallurgical examination of portions of the right main

landing gear assembly showed that the landing gear outer cylinder failed in overstress

initiating at the shock strut chamber check valve hole surface. The fracture initiated at the

base of several circumferential tool marks, which were up to 0.0015 inch deep. The

Boardís metallurgical examination indicated that these tool marks were not significant

enough to have caused fatigue cracking at the tool mark location during the life of the

landing gear. Aside from these tool marks, no significant deviations from drawing

requirements were found.76

The MD-10-10F landing gear and associated structure were designed to absorb

energy equivalent to a limit vertical speed (descent rate) of 10 fps (about 600 fpm) when

landing at the airplaneís maximum design landing weight (consistent with the landing

design limits imposed by Sections 25.473 through 25.487). In addition, in accordance with

Section 25.723, the MD-10-10F main landing gear is designed to be capable of absorbing

reserve energy that is equivalent to a maximum airplane descent rate of 12 fps (about

720 fpm) when landing at the maximum airplane design landing weight. However, during

the accident landing, the left main landing gear touched down at a rate of about 12.5 fps

(about 750 fpm) and the right main landing gear touched down at a rate of about 14.4 fps

(about 864 fpm). As previously mentioned, airplane performance studies conducted by

Boeing indicated that the energy dissipated at the right main landing gear during landing

was about 34 percent greater than the reserve energy that the landing gear was designed to

withstand and about 19 percent greater than the energy dissipated at the left main landing

gear.77 In addition, the analyses revealed that peak lateral loads coincided with the

excessive vertical loads. Therefore, the Safety Board concludes that the excessive vertical

75 The captain should have verbally prompted flight control actions, commanded a go-around, or taken

control of the airplane for a go-around or landing. 

76 Nickel deposits were found on the shock strut chamber pressurization/check valve hole surface,

which is unusual but not considered contributory to the event.

77 The landing gear external ground loads associated with Boeingís reserve energy analysis included

only vertical and drag loads applied to the landing gear; they did not include the additional effects of lateral

or torsional loads that might be imposed on landing gear at touchdown. 
Analysis 49 Aircraft Accident Report

and lateral forces on the right main landing gear during the landing exceeded those that the

gear was designed to withstand and resulted in the fracture of the outer cylinder and the

collapse of the right main landing gear. The tool marks at the shock strut chamber check

valve hole created a preferred site for initiation of the crack; however, the damage was too

small to have caused the event if normal landing loads were involved.

2.4 Flight Crew PerformanceóOversight

The Safety Boardís review of FedExís pilot training procedures and oversight at

the time of the accident revealed that, consistent with other operators in the aviation

industry, it focused on a pilotís performance on the day of the checkride with little or no

review of that pilotís performance on checkrides months or years earlier.78 The Board is

concerned that this single-event focus does not allow a carrier to monitor changes or

patterns in a pilotís performance history that could provide significant information about

the competency of a pilot. For example, in this case, the first officerís repeated

substandard performances on checkrides were addressed as singular events that did not

require further evaluation or monitoring after the checkride was satisfactorily completed.

Yet, postaccident review of the first officerís training history and postaccident interviews

suggested a pattern of below-standard performance.

In January 2004, as a result of a series of operational accidents and incidents

involving FedEx flights, FedEx implemented an enhanced oversight program (EOP) to

identify and track pilots who have demonstrated performance deficiencies or failures in

the training environment. The EOP provides identified pilots with additional oversight

(two additional line checks annually for first officers and one additional line check

annually for captains),79 thus providing FedEx management and training personnel with

an opportunity to evaluate those pilotsí proficiency and performance every 90 days.

Additionally, the EOP board, which is made up of company training and flight standards

directors, meets monthly to review recent events and discuss identified pilotsí case

histories. This increased level of monitoring a pilotís performance helps the company

determine if deficient performance demonstrated during a checkride is indicative of the

pilotís overall performance. If FedExís EOP had been in effect when the first officer failed

her checkrides in 1999 and/or 2001, she would certainly have received additional

company scrutiny and training.

According to FedEx representatives, the EOP was intended ìas a tool to improve

our safety and performanceî and to allow FedEx training personnel to better focus its

training efforts. The company believed that review of a pilotís performance history during

checkrides may provide valuable information about the skills and capabilities of that pilot.

A pattern of failures and/or inconsistent performance would indicate performance

deficiencies that could adversely affect the safety of flight. The EOP allows FedEx

78 Typically, when a pilot fails a checkride, only the failed items are reviewed during the recheck.

79 As previously indicated, FedEx flight crewmembers normally receive simulator training every

6 months. In addition, captains would normally receive an annual line check; FedEx first officers normally

do not receive annual line checks. 
Analysis 50 Aircraft Accident Report

training and management personnel to work with pilots to identify the reasons for the

deficiencies and better focus the companyís resources (oversight, training, etc.) to

improve safety. The Safety Board notes that at the time of this writing, FedEx is the only

Part 121 air carrier operator that has implemented this type of proactive program.

Over the years, the Safety Board has repeatedly noted the value of using

information regarding a pilotís past performance to assess that pilotís current and future

performance and overall abilities. For example, as a result of three accidents in the late

1980s/early 1990s, the Board issued three safety recommendations that asked the FAA to

require air carriers to conduct substantive background checks of prospective pilots before

they are hired. Subsequently, as a result of the December 13, 1994, accident involving

American Eagle flight 3379, the Board issued four additional pilot-performance and

training-documentation-related safety recommendations. In response to these

recommendations, in 1996, the Pilot Records Improvement Act (PRIA) was enacted. In

addition, as a result of the July 13, 2003, accident involving an Air Sunshine Cessna 402,

the Board issued two more safety recommendations addressing pilot performance,

checkride failures, and record-keeping. 

These actions, including the PRIA, address a companyís responsibility to review a

pilotís history of performance when evaluating the candidate for hire. However, the PRIA

does not allow use of these preemployment records after a pilot is hired. Additionally,

despite the availability of their own postemployment pilot performance and training

information, operators have not traditionally used this information to conduct ongoing

pilot evaluations. Pilot oversight programs similar in concept to FedExís EOP would

allow operators to extend the important concept behind the PRIA (gathering all the

available information to make informed decisions) to the ongoing evaluation and

oversight of pilots in their employment. 

On the basis of the value of using information regarding a pilotís past performance

to assess that pilotís current and future performance and overall abilities, the Safety Board

concludes that a proactive program, similar in concept to FedExís EOP, in which flight

crewmembers who have demonstrated performance deficiencies or experienced training

failures are identified and given additional oversight and training would be beneficial to

flight safety. Therefore, the Safety Board believes that the FAA should require all 14 CFR

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. 
Analysis 51 Aircraft Accident Report

2.5 Survival Factors Issues

2.5.1 Emergency Exit Door/Slide Operation and Training

All seven FedEx pilots on board the accident airplane had received FedExís

MD-11/-10 emergency exit door/slide training, which consisted of initial and annual

recurrent training.80 FedEx conducted initial and subsequent biennial recurrent training

sessions on its MD-11/-10 emergency exit door/slide trainers, with alternating biennial

recurrent training presented in a classroom video presentation. The emergency slide/raft

on the door trainer was permanently inflated and deployed, and FedEx crewmembers were

required to use the slide during their initial training. 

The Safety Boardís review of FedExís MD-11/-10 emergency exit door/slide

trainer at its training facility in Memphis revealed significant differences between the

trainer and the L1 emergency exit door/slide that the courier seat nonrevenue FedEx pilot

operated during the accident evacuation.81 Most significantly, there was no girt bar flap

assembly (and, thus, no manual inflation or disengage handles) installed on FedExís

MD-11/-10 emergency exit door/slide trainer82 at MEM. FedExís door trainer

configuration eliminated an opportunity for FedEx crewmembers to become familiar with

the location and appearance of these handles, which would have helped them identify the

handles under emergency conditions. Additionally, the door trainer did not reinforce the

amount of time involved in inflating the slide/raft (6 seconds) because the slide/raft on the

trainer door was already inflated and deployed when the training crewmember opened the

trainer door. 

Further, at the time of the accident, FedExís emergency exit training program did

not require crewmembers to simulate pulling a manual inflation handle during the training

sessions.83 All of the FedEx pilots on the accident airplane observed a video presentation

showing the use of the manual inflation handle during training every year (which helps

provide crewmembers with knowledge about door operation); however, this method of

training does not adequately provide crewmembers with the skills required to operate the

door/slide. For example, without hands-on training on a door trainer equipped with a

manual inflation handle, it would be difficult for crewmembers to gain experience with the

specific physical steps associated with opening the door and use of the manual inflation

handle. Direct hands-on experience is beneficial in the development of the skills and habit

80 Federal regulations regarding crewmember emergency training (Section 121.417) state that flight and

cabin crewmembers must perform emergency exit drills ìin the normal and emergency modes, including the

actions and forces required in the deployment of the emergency evacuation slidesî during initial training and

during biennial recurrent training.

81 The Safety Board notes that the R1 emergency exit door/slide was not usable because of the fire and

smoke on the right side of the airplane.

82 FedEx had MD-11/-10 emergency exit door/slide trainers at MEM and Anchorage, Alaska. 

83 As previously indicated, FedEx has since modified its procedures and requires crewmembers to pull,

or simulate pulling, the manual inflation handle.
Analysis 52 Aircraft Accident Report

patterns a crewmember needs to open the door and use the handle during emergency

conditions. 

In addition, although the manual inflation and disengage handles are located near

each other, they are separated by the girt bar flap, which must be lifted to access the

disengage handle. Use of the disengage handle causes the slide/raft to separate from the

airplane, which would not be desirable in this case (use of the disengage handle normally

occurs only during emergency evacuations after water landings). Therefore, the Safety

Board concludes that the nonrevenue FedEx pilot who opened the L1 emergency exit

mistakenly pulled both the manual inflation and slide/raft disengage handles because he

was not sufficiently familiar with their location and operation, thus separating the

slide/raft from the L1 doorsill. 

Although the FAA confirmed in a November 2003 memorandum that the flight

and cabin crewmember emergency exit training requirements should be equivalent, the

guidance contained in FAA Order 8400.10, Air Transportation Aviation Inspectorís

Handbook, includes a more detailed description of the emergency exit training

requirements for cabin crew than for flight crew, including the requirement to pull the

manual inflation handle. During postaccident interviews, the FAA POI assigned to FedEx

stated that his interpretation of this regulation was that flight crews did not have to pull the

manual inflation handle during training. However, in a December 2004 memo, the FAA

confirmed that 14 CFR 121.417 requires both flight and cabin crews to pull the manual

inflation handle during training. 

The Safety Board concludes that the guidance contained in the flight crew

emergency training section of FAA Order 8400.10, Air Transportation Aviation

Inspectorís Handbook, is not adequate for POIs to use in ensuring that emergency exit

door/slide training for flight crewmembers is as comprehensive as that which cabin

crewmembers receive and is as comprehensive as intended by the regulation. Therefore,

the Safety Board believes that the FAA should amend the emergency exit training

information contained in the flight crew and cabin crew sections in FAA Order 8400.10,

Air Transportation Aviation Inspectorís 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 POI handbook. 

The Safety Board further concludes that FedExís inadequate hands-on emergency

procedures training and the differences between the trainer and the door/slide installation

on the accident airplane contributed to the unintentional release of the slide/raft. Further,

the Safety Board is concerned that pilots flying for other Part 121 operators may not be

receiving the proper emergency exit training (since it is possible that other POIs may also

have erroneously interpreted the regulations). Therefore, the Safety Board believes that

the FAA should verify that all 14 CFR Part 121 operatorsí 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 CFR 121.417, to include pulling the manual

inflation handle.
Analysis 53 Aircraft Accident Report

2.5.2 Cockpit Window Emergency Evacuation Issues

Because neither the L1 nor the R1 door could be used for the evacuation (the L1

slide/raft was inadvertently disconnected and there was fire on the right side of the

airplane), the occupants evacuated through the captain and first officer sliding cockpit side

windows and used the evacuation tapes. The two escape tapesóthin (about 1 inch by

3/16 inch) ribbons of reinforced synthetic materialóare located in compartments above

these cockpit windows and are intended to allow crewmembers to descend to the ground if

the L1 and R1 emergency exit slides are not usable during an emergency evacuation. 

Evaluation of a witness-provided videotape of the emergency evacuation showed

that about 152 seconds passed between the time that the first and last occupant exited the

burning airplane. During this time, the crewmembers did not evacuate the airplane in an

uninterrupted flow. Although the captain and cockpit jumpseat nonrevenue pilot

evacuated relatively quickly, the videotape showed delays between subsequent evacuating

crewmembers. During these delays, the escape ropes were available but unused, and

several pieces of baggage were thrown from the airplane. The elapsed time between

successive crewmembers exiting the airplane was as much as 63 seconds. During

postaccident interviews, several crewmembers reported that they were offloading bags

while they waited in line to exit the airplane through the cockpit exits. During subsequent

documentation of the cockpit, jumpseat, and cargo compartments, investigators found no

crewmember baggage. It is evident that the delays were the result of the offloading of

crewmembersí personal bags84 and not because they were waiting for other crewmembers

to exit or had difficulty using the cockpit egress system. The Safety Board concludes that

most of the FedEx pilots on board the accident airplane showed poor judgment and

exposed themselves to unnecessary risk when they delayed their evacuation from a

burning airplane to salvage personal items. 

After the accident, FedEx issued a bulletin to crewmembers that stated, ìDuring an

emergency evacuation each crewmember and jumpseater will evacuate in the most

expeditious manner possible. No one will take an unnecessary risk by taking time to

salvage personal articles.î This bulletin articulated a policy similar to the policy that

passenger-carrying air carriers have expressed to passengers for years. 

2.6 Memphis ATCT Actions and Issues

Although the MEM ATCT controllers were not a factor in this accident or the

effectiveness of the emergency response, the Safety Board notes that in different accident

circumstances, some MEM ATCT controller actions might have had more serious

consequences. For example, after the accident, the MEM ground controller held the

RMFD ARFF vehicles, which were responding to the accident from FedExís ramp on the

north side of the airport, short of runway 27 because of landing traffic. This delay was

84 During postaccident interviews, several occupants indicated that they salvaged the bags because they

contained items they needed for their job (for example, passports, clothes, and uniforms). Additionally,

some occupants reported that some bags contained holiday gifts.
Analysis 54 Aircraft Accident Report

exacerbated when the controller did not clear the RMFD vehicles to cross runway 27

immediately after the landing airplane was clear of the intersection.85 The ground

controller subsequently cleared two airplanes to cross after the landing airplane and before

he cleared the RMFD vehicles to the accident site. The RMFD vehicles were delayed by

almost 2 minutes after the initial request to cross the runway. It should be noted that the

MEM ground controller did immediately clear all MFD vehicles to the accident site. 

Although RMFD is staffed 24 hours a day/7 days a week and has routinely

participated in MEM airport emergency drill exercises, there was no formal mutual aid

agreement between MSCAA and RMFD addressing RMFD responsibilities and

involvement in emergency situations. However, RMFD vehicles operated routinely on the

airport, and the ground controller was not unaccustomed to handling those vehicles.

Therefore, the Safety Board questions the MEM ground controllerís decision to delay the

RMFD ARFF vehiclesí response to a burning airplane on the airport. The Safety Board

considers it important that controllers give priority to all ARFF vehicles assisting in

fire-related emergencies on the airport even if some ARFF vehicles are not officially

incorporated into the airportís emergency plan. Any traffic conflict that the controller

perceived between the landing airplane and the RMFD ARFF vehicles should have been

resolved (possibly by delaying the airplaneís landing) so that the RMFD ARFF could

proceed to the accident scene without delay. Although RMFD ARFF vehicles were not a

required component of MEM emergency responses, the availability of such support was a

benefit that should have been utilized optimally. 

Additionally, the Safety Board noted that, after the accident captain advised MEM

ATCT controllers of the number of people on board the airplane, the local controller

announced this information to others in the tower cab, but neither he nor the ground

controller relayed this information to ARFF personnel. The evacuation was in progress

when the ARFF responders arrived, and this information would have assisted them in

accounting for all occupants, if needed. In this case, because none of the occupants were

incapacitated, the only result was that the ARFF responders reported being surprised to

see more people evacuating the airplane than they had expected. However, in other

circumstances, this lack of pertinent information could have resulted in delayed rescue

efforts. When ARFF responders arrive at an accident site involving a passenger-carrying

flight, they would expect occupants in the cabin, whereas with a cargo flight they may not.

In such a case, if the flight crew was incapacitated and unable to advise ARFF personnel

of additional occupants on board the airplane, ARFF personnel might assume that only the

primary crewmembers were aboard the cargo flight, thereby endangering anyone

remaining on board and unable to self-evacuate. 

The Safety Board concludes that the RMFD ARFF response vehicles were

unnecessarily delayed in providing ARFF assistance because the MEM ATCT ground

controller did not give them priority over other nonemergency airport traffic; under other

circumstances, this could have adversely affected ARFF efforts. The Safety Board further

concludes that ATCT controllers should recognize the importance of relaying all available

85 The Safety Board notes that during this delay the ground controller was briefing a relief ground

controller so the ground controller could participate in postaccident activities. 
Analysis 55 Aircraft Accident Report

pertinent information, including airplane occupant information, to ARFF personnel to

assist them in ARFF efforts and decision-making. Therefore, the Safety Board believes

that the FAA should inform all ATCT controllers of the circumstances of this accident,

including the need to ensure that ARFF vehicles are not delayed without good cause when

en route to an emergency and the need to relay the number of airplane occupants to ARFF

responders. Further, the Safety Board believes that the FAA should, in cooperation with

the MSCAA and MFD, modify the November 1, 2001, letter of agreement, titled, ìAirport

Emergency Procedures,î to fully describe the protocol to be used for emergency

responses, including RMFD ARFF equipment and personnel. 

2.7 FDR Aileron Update Rate Issues

During its investigation of this accident, the Safety Board observed that the

FDR-recorded aileron position data was not being updated at the rate required by Federal

regulations. The Boardís flight data study showed that the data for all four ailerons

(inboard and outboard on the right and left wings) were being sampled once per 250 ms,

more frequently than required by Federal regulations, but were only being updated at a

rate of about once per 700 ms instead of once per 500 ms. The Safety Board has

previously issued two related safety recommendations, recommending the following to

the FAA:

Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, Canadair

Challenger CL-600, and Fairchild Dornier 328-300 airplanes be modified with a

digital flight data recorder system that meets the sampling rate, range, and

accuracy requirements specified in 14 Code of Federal Regulations 121.344,

Appendix M. (A-03-015) 

Survey all aircraft required by Federal regulation to have a flight data recorder to

ensure that the data recorded meets the rate, range, and accuracy requirements

specified in 14 Code of Federal Regulations 121.344, Appendix M. (A-03-016)

In an August 11, 2003, letter, the FAA indicated that it was working with the

airplane manufacturers and airworthiness authorities involved to address the issues

discussed in Safety Recommendation A-03-015 and that it would take appropriate action

to correct any deficiencies. With regard to Safety Recommendation A-03-016, the FAA

stated that it would ask all airplane manufacturers not addressed in Safety

Recommendation A-03-015 to provide FDR design criteria information for obtaining data

in accordance with Section 121.344, Appendix M requirements. Upon review of the

design criteria, the FAA would identify necessary changes to bring any affected airplanes

into compliance. On the basis of the FAAís subsequent response and pending additional

action, on January 28, 2004, the Safety Board classified Safety

Recommendation A-03-015 ìOpenóAcceptable Responseî and Safety Recommendation

A-03-016 ìOpenóAcceptable Alternate Response.î 

The FAA is continuing its efforts to assess the FDR design criteria of all airplanes

that are required to comply with the parameter requirements specified in Section 121.344,
Analysis 56 Aircraft Accident Report

Appendix M. This investigation further demonstrates that FDR sampling problems exist in

large, older airplanes (the MD-10 is a DC-10 that has been retrofitted with an

advanced-technology flight deck) as well as newly designed, small regional jets.86 The

discovery of improper FDR sampling/update rates in the MD-10 confirms that this issue is

likely as widespread as originally believed. 

Because in some circumstances, inadequate and/or inaccurate recorded aileron

position could adversely affect the Safety Boardís ability to identify and address the

related safety issues involved in an accident, possibly allowing an unsafe condition to go

unrecognized, the Safety Board concludes that the required recorded FDR data on the

MD-10 should meet the rate, range, and accuracy requirements specified in

14 CFR 121.344, Appendix M. Therefore, the Safety Board reiterates Safety

Recommendation A-03-016. 

86 Safety Recommendations A-03-015 and -016 were issued as a result of improper FDR 

sampling/update rates observed in newly designed, small regional jets. 
57 Aircraft Accident Report

3. Conclusions

3.1 Findings 

1. The captain and first officer were properly certificated and qualified in accordance

with, and had received the training and rest time prescribed by, Federal regulations

and company requirements. The flight crewmembers possessed valid and current

medical certificates appropriate for 14 Code of Federal Regulations Part 121 flight

operations. 

2. Based on the available evidence, fatigue was not a factor in this accident. Although

the cockpit voice recorder recorded the first officer coughing and clearing her throat

numerous times, she stated that she was not sick, and there is no evidence that this

(the coughing/clearing her throat) adversely affected the flight or her performance. 

3. The accident airplane was properly certificated and maintained and was equipped and

dispatched in accordance with applicable regulations and industry practices. There

was no evidence of any preexisting powerplant, system, or structural failure. 

4. The accident airplaneís cargo and its loading were not factors in the accident. 

5. Differences between the MD-11 and MD-10 handling characteristics during the

landing phase were not an issue in this accident. 

6. Air traffic control was not a factor in the accident. 

7. The atmospheric conditions encountered during the approach and landing were within

the performance capabilities of the airplane; there was no evidence of significant

windshear. 

8. The first officer did not properly apply control wheel and rudder inputs to align the

airplane with the runway centerline or apply appropriate back pressure on the control

column to arrest the airplaneís rate of descent before touchdown; as a result, the

airplane touched down extremely hard while still in a crab. 

9. The captain, who was conducting a line check of the first officer, did not adequately

monitor the first officerís performance during the final stages of the approach and

landing at Memphis and failed to take or initiate corrective action to prevent the

accident. 

10. The excessive vertical and lateral forces on the right main landing gear during the

landing exceeded those that the gear was designed to withstand and resulted in the

fracture of the outer cylinder and the collapse of the right main landing gear. 
Conclusions 58 Aircraft Accident Report

11. A proactive program, similar in concept to FedExís enhanced oversight program, in

which flight crewmembers who have demonstrated performance deficiencies or

experienced training failures are identified and given additional oversight and training

would be beneficial to flight safety.

12. The nonrevenue FedEx pilot who opened the L1 emergency exit mistakenly pulled

both the manual inflation and slide/raft disengage handles because he was not

sufficiently familiar with their operation, thus separating the slide/raft from the L1

doorsill. 

13. The guidance contained in the flight crew emergency training section of Federal

Aviation Administration Order 8400.10, Air Transportation Aviation Inspectorís

Handbook, is not adequate for principal operations inspectors to use in ensuring that

emergency exit door/slide training for flight crewmembers is as comprehensive as

that which cabin crewmembers receive and is as comprehensive as intended by the

regulation. 

14. FedExís inadequate hands-on emergency procedures training and the differences

between the trainer and the door/slide installation on the accident airplane contributed

to the unintentional release of the slide/raft. 

15. Most of the FedEx pilots on board the accident airplane showed poor judgment and

exposed themselves to unnecessary risk when they delayed their evacuation from a

burning airplane to salvage personal items. 

16. The Rural/Metro Fire Department aircraft rescue and firefighting (ARFF) response

vehicles were unnecessarily delayed in providing ARFF assistance because the

Memphis air traffic control tower ground controller did not give them priority over

other nonemergency airport traffic; under other circumstances, this could have

adversely affected ARFF efforts. 

17. Air traffic control tower controllers should recognize the importance of relaying all

available pertinent information, including airplane occupant information, to aircraft

rescue and firefighting (ARFF) personnel to assist them in ARFF efforts and

decision-making. 

18. The required recorded flight data recorder data on the MD-10 should meet the rate,

range, and accuracy requirements specified in 14 Code of Federal

Regulations 121.344, Appendix M. 
Conclusions 59 Aircraft Accident Report

3.2 Probable Cause

The National Transportation Safety Board determines that the probable causes of

the accident were 1) the first officerís failure to properly apply crosswind landing

techniques to align the airplane with the runway centerline and to properly arrest the

airplaneís descent rate (flare) before the airplane touched down; and 2) the captainís

failure to adequately monitor the first officerís performance and command or initiate

corrective action during the final approach and landing. 
60 Aircraft Accident Report

4. Recommendations

4.1 New Recommendations

As a result of the investigation of the FedEx flight 647 accident, the National

Transportation Safety Board makes the following recommendations to the Federal

Aviation Administration:

Require all 14 Code of Federal Regulations 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.

(A-05-014)

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 Inspectorís 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. (A-05-015)

Verify that all 14 Code of Federal Regulations (CFR) Part 121 operatorsí

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 CFR 121.417, to include pulling the manual

inflation handle. (A-05-016)

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 airplane occupants to

ARFF responders. (A-05-017)

In cooperation with the Memphis/Shelby County Airport Authority and

Memphis Fire Department, modify the November 1, 2001, letter of

agreement, titled, ìAirport Emergency Procedures,î to fully describe the

protocol to be used for emergency responses, including Rural/Metro Fire

Department aircraft rescue and firefighting equipment and personnel.

(A-05-018)
Recommendations 61 Aircraft Accident Report

4.2 Previously Issued Recommendation Reiterated in 

This Report

The Safety Board reiterates the following recommendation to the Federal Aviation

Administration:

Survey all aircraft required by Federal regulation to have a flight data

recorder to ensure that the data recorded meets the rate, range, and

accuracy requirements specified in 14 Code of Federal

Regulations 121.344, Appendix M. (A-03-016)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER 

Acting Chairman

RICHARD F. HEALING

Member

ELLEN ENGLEMAN CONNERS

Member

DEBORAH A. P. HERSMAN

Member

Adopted: May 17, 2005

63 Aircraft Accident Report

5. Appendixes

Appendix A

Investigation 

The National Transportation Safety Board was initially notified of this accident on

December 18, 2003. A go-team was assembled in Washington, DC, and traveled to the

accident scene. No Board Member traveled to the accident site. 

The following investigative groups were formed during the course of this

investigation: Airworthiness (Structures, Systems, and Powerplants), Air Traffic Control,

Meteorology, Operations/Human Performance, Airport/Survival Factors, Airplane

Performance, Flight Data Recorder, and Cockpit Voice Recorder. 

Parties to the investigation were the Federal Aviation Administration, the Boeing

Commercial Airplane Group, FedEx Express, Air Line Pilots Association, and the

Memphis/Shelby County Airport Authority. 

Public Hearing 

No public hearing was held for this accident.
64 Aircraft Accident Report

Appendix B

Cockpit Voice Recorder Transcript

The following is a transcript of the Allied Signal model 6022 CVR installed on the

accident airplane. Only radio transmissions to and from the accident airplane were

transcribed. This CVR transcript reflects excerpts from the 2 hours and 58 seconds

recorded before power was lost to the CVR. All times are central standard time based on a

24-hour clock.

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