# NTSB DCA04MA082: Boeing MD-11, N601FE, Memphis, TN, September 19, 2004 - Type: NTSB accident investigation - Classification: Accident · No injuries · Major investigation · Final report - Date: September 19, 2004, 12:43 local (17:43 UTC) - Place: Memphis, TN - Coordinates: 35.14957, -90.050544 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.1496&lon=-90.0505&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report March 28, 2006 - Report: Approved by Office Director - NTSB office: Major Investigations Division - Parties: AAI-100 - NTSB case key (mKey): 60155 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA04MA082 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60155/pdf - Page: https://openairdocs.org/ntsb/DCA04MA082 ## Probable cause The pilot's over-rotation during a go-around maneuver initiated because of a bounced landing. The go-around maneuver was initiated at a low speed and high pitch angle, and after reverse thrust was selected, contrary to Boeing and FedEx training guidance. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Hard landing, landing - flare/touchdown - recovery from bounced landing - improper, flightcrew (cause) ## Analysis The approach to landing was normal, and the crew stated that the touchdown was firm but not categorized as a hard landing. The airplane pitched up and bounced after touchdown and the captain became concerned that the airplane would porpoise. The speed had decreased to 107 knots, and reverse thrust had been initiated. The captain elected to conduct a go-around maneuver, and rotated the airplane to a nose high attitude of about 12 degrees prior to achieving sufficient airspeed and a positive rate of climb. The rear fuselage of the airplane contacted the runway for about 3,000 to 4,000 feet causing substantial damage to the airframe. The airplane lifted off, and the crew completed a second landing on runway 36R without further incident. Boeing training material and FedEx guidance states that "after reverse thrust is initiated, a full stop landing must be made. Do not attempt a go-around." Additionally, the FedEx tailstrike awareness training states that "the [pilot flying] must not exceed 10 degrees of pitch or retract the landing gear until the aircraft is safely airborne with a positive rate of climb." ## Factual narrative HISTORY OF FLIGHT On September 19, 2004, at 1243 central daylight time, a Boeing McDonnell Douglas MD-11F, N601FE, operating as FedEx (FDX) flight 859, experienced a tail strike during a go-around maneuver from runway 09 at Memphis International Airport (MEM). The crew was executing a Category III autoland procedure for proficiency. Neither of the 2 crewmembers was injured. The airplane sustained substantial damage to the underside of the rear fuselage and the aft pressure bulkhead. Flight 859 was operating on an instrument flight rules flight plan under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a regularly scheduled cargo flight from Oakland, California (OAK) to MEM. Visual meteorological conditions prevailed at the time of the accident. Flight 859 departed OAK at about 0721 Pacific daylight time. According to the flight crew, the flight was uneventful until the landing on runway 9 at MEM. Memphis air traffic control (ATC) provided radar vectors to a 14 to 15 mile final approach to runway 9. The pilots reported that the approach was stable and nominal. The calculated landing weight for the airplane was 370,000 pounds, with a calculated approach speed of 142 knots indicated. The captain took over flying responsibility for the airplane at about 300 feet above the runway, and he reported that the autoland system was working normally. Flight Data Recorder information showed the airplane was at an airspeed of 142 knots, there was less than ½ dot deflection on the glideslope indicator, the flaps were set at 50 degrees, and the airplane was at a pitch attitude of about 3 degrees airplane nose up. The captain said everything appeared normal when the airplane entered the flare maneuver. Prior to touchdown, the airplane drifted slightly right of the centerline, touching down about 20 feet to the right of centerline. The captain said that the airplane touched down firmly, but not what he would consider a hard landing. After touchdown, he perceived that the airplane pitched further up, instead of pitching down as he expected. He applied forward pressure to the control column to bring the nose down, the sink rate rapidly increased and there was "a second touchdown." He was concerned that the airplane would begin to porpoise and felt it would be safer to go around. FDR data indicated that the airplane remained centered on the ILS localizer and glideslope beams during the approach, with the nose pointed to the left of the runway heading in order to compensate for a 10 knot left crosswind. As the airplane yawed to the right to align the nose with the runway heading just prior to touchdown, performance calculations indicate it drifted to the right and touched down about 30 feet to the right of centerline. With the autopilot still engaged, the airplane bounced slightly, eventually reaching a radio altitude of 3 feet; about 3 seconds after the first touchdown. As the airplane ascended through a radio altitude of about 1 foot during the bounce, the autopilot disconnect warning was recorded on the CVR. According to the FDR, following the autopilot disconnect the control column moved aft to 7 degrees, while the pitch angle decreased from 7 to 4 degrees before starting to increase. At this time the thrust reversers were "unlocked," indicating flight crew selection of reversers. The airplane touched down for the second time about 4.2 seconds after the first touchdown. The spoilers briefly deployed, in conjunction with aileron movement, then retracted concurrently with the go-around maneuver. Almost immediately after the second touchdown, the captain called for maximum power and initiated the go-around maneuver. The FDR indicated that the airplane pitched up steadily until reaching a pitch attitude of about 12 degrees, and the speed decayed to 107 knots. The captain said that he applied aft control column pressure to raise the nose; the airplane did not pitch up to this attitude on its own. About seven seconds after the go-around call, the power on all three engines began increasing, and the flaps began retracting from the 50 degree position. The airplane accelerated in the approximately 12 degree nose up attitude until about 15 seconds after the go-around call, when it reached an airspeed of 115 knots and achieved a positive rate of climb. About 3,650 feet of available runway remained. Witnesses reported that the rear fuselage of the airplane scraped the runway for about 3,000 to 4,000 feet and produced a great deal of sparks. The crew then maneuvered the airplane to a landing on runway 36R without further incident. Boeing documentation states that the airplane's aft body would strike the runway surface at a pitch attitude of about 10 degrees with main gear struts compressed, or about 13 degrees with the main gear struts extended. INJURIES TO PERSONS The 2 crewmembers were uninjured. DAMAGE TO AIRPLANE During the tailstrike, three skin sections were abraded over an area of at least 12 feet by 3 feet. A significant portion of the skin was abraded completely away. Five longerons exhibited abrasion damage as well as numerous shear clips and eight aft fuselage frames. The aft drain mast was fractured and the left aft tail cone hinge was damaged. The damaged area extended from the unpressurized portion of the fuselage across the aft pressure bulkhead to a point about 2 feet forward of the bulk cargo door. The T-cap on the pressure bulkhead exhibited some abrasion damage and there was a ½ inch buckle in the bulkhead web above the point of contact. The listed damage was considered substantial under 49 CFR, Part 830. OTHER DAMAGE None. PERSONNEL INFORMATION The captain, age 46, was hired by FedEx on July 18, 1988. He held a Federal Aviation Administration (FAA) airline transport pilot (ATP) certificate with a multiengine land rating and a flight engineer certificate for turbojet-powered airplanes. The captain's ATP certificate indicated type ratings in the MD-11 and DC-10 (issued December 20, 2003). According to company records, at the time of the accident he had 6,390 hours total time; with 235 hours in the MD-11, all as Captain. The captain's most recent FAA first-class airman medical certificate was issued on July 23, 2004, with a restriction that the holder must wear corrective lenses. The captain had no history of failures or re-tests for FAA pilot and flight engineer certificates and ratings. He completed an MD-11 proficiency check on June 8, 2004, and completed MD-11 tailstrike awareness training on December 9, 2003 The First Officer, age 43, was hired by FedEx on May 16, 1994. He held an FAA ATP certificate with a multiengine land rating and a flight engineer certificate for turbojet-powered airplanes. The First Officer's ATP certificate indicated a type rating in the MD-11 (issued April 18, 2004). According to company records he had 3,723 hours total time, with 133 in the MD-11. The First Officer's most recent FAA first-class airman medical certificate was issued on August 18, 2004, with no restrictions. He completed an MD-11 proficiency check on April 18, 2004, and completed MD-11 tailstrike awareness training on March 26, 2004. A review of FAA records indicated that on May 6, 1994, the first officer was issued a notice of disapproval of application for a Military Competency written test. He subsequently passed the test on July 5, 1994, and was issued a Temporary Airman Certificate for a Commercial Pilot Certificate, Airplane Multiengine Land and Instrument Airplane. AIRCRAFT INFORMATION N601FE, an MD-11F, serial number 48401, was the first production MD-11. It was delivered new to Federal Express on June 27, 1991. The airplane had previously been involved in an incident involving a flight control malfunction on approach to Subic Bay, Philippines, on June 16, 2002 (NTSB # DCA02MA042). METEOROLOGICAL INFORMATION The Memphis aviation su ## Aircraft - Registration: [N601FE](https://openairdocs.org/aircraft/N601FE), registered now, S/N 48401, built 1991 (OpenAirDocs) - Reported make and model: Boeing MD-11 - Registry model: [Mcdonnell Douglas MD-11F](https://openairdocs.org/model/mcdonnell-douglas-md-11f) (registry code 3023600) (OpenAirDocs) - Registry engine: [GE CF6-80 series](https://openairdocs.org/engine/ge-cf6-80-series) (registry code 30025, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 48401 - Engines: General Electric CF-6 62000 lbs thrust turbo fan; General Electric CF-6 62000 lbs thrust turbo fan; General Electric CF-6 62000 lbs thrust turbo fan - Damage: Substantial damage - Flight: Part 121 - Registered owner: Federal Express Corp - Airworthiness certificate: Standard, Transport - Departed: KOAK, Oakland, CA - Destination: KMEM, Memphis, TN - Flight plan: IFR - Airport: KMEM, Memphis International, runway 9, 8,946 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: none; airline transport, flight engineer; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review June 1, 2004; seat: left; flight hours: 6,390 total, 235 in this make and model, 97 in the last 90 days, 45 in the last 30 days, 4 in the last 24 hours - Co-pilot; age 43; injuries: none; flight engineer, airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review June 1, 2004; seat: right; flight hours: 3,723 total, 133 in this make and model, 69 in the last 90 days, 18 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 10 knots, gusting 14 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 43 °F - Altimeter: 30.17 inHg - Observed at: KMEM ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20040919034489A](https://openairdocs.org/incident/20040919034489A), Sep 19, 2004: Doug MD11F, Memphis, TN, Substantial damage. (-23) During approach to runway 09 kmem at approximately 1743 CDT, September 19, 2004, fdx flight 859, an MD-11, N601FE rejected the landing attempt and… ## Other investigations on N601FE (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB DCA02MA042](https://openairdocs.org/ntsb/DCA02MA042), Jun 2, 2002: McDonnell Douglas MD-11F (N601FE), Subic Bay, Philippines, substantial damage. Probable cause: The failure of the lower outboard nut and bolt assembly of the left inboard flap's outboard hinge that resulted from stress corrosion cracking and fatigue. Factors contributing to the accident were… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.