DCA93MA037

NTSB accident investigation · Mcdonnell Douglas MD-11 · Shemya, AK · April 6, 1993

Accident · FatalClass 1 · MajorFinal report
Date
April 6, 1993, 02:30 local (06:30 UTC)
Place
Shemya, AK
Injuries
2 fatal, 60 serious, 96 minor, 97 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
B2171Mcdonnell Douglas MD-11
Weather
Visual (VMC) · Night/dark
Status
Completed · report December 27, 1994
Report
Approved by Office Director
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
Case key
10974

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The national transportation safety board determines that the probable cause of this accident was the inadequate design of the flap/slat actuation handle by the Douglas aircraft company that allowed the handle to be easily and inadvertently dislodged from the up/ret position, thereby causing extension of the leading edge slats during cruise flight. The captain's attempt to recover from the slat extension, given the reduced longitudinal stability and the associated light control force characteristics of the MD-11 in cruise flight, led to several violent pitch oscillations. Contributing to the violence of the pitch oscillations was the lack of specific MD-11 pilot training in recovery from high altitude upsets, and the influence of the stall warning system on the captain's control responses. Contributing to the severity of the injuries was the lack of seat restraint usage by the occupants.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionCruise - normal
Flt control syst,wing flap control - inadequateCause
Acft/equip,inadequate designManufacturerCause
Flight control,slat - deployed inadvertently
Abrupt maneuverCruise - normal
Aircraft handling - improperPilot in commandCause
Inadequate trainingPilot in commandFactor
Seat belt - not usedPassengerFactor
Altitude deviation,uncontrolledCruise - normal

Analysis

Flight 583 was level at 33,000 feet when the leading edge slats deployed inadvertently. The autopilot disconnected and the captain was manually controlling the airplane when it progressed through several violent pitch oscillations and lost 5,000 feet. The safety board determined that the inadvertent deployment of the slats was the result od an inadequately designed flap/slat handle that allowed the handled to be easily and inadvertenly dislodged from the up/ret position, thereby causing slat extension.

Factual narrative

See NTSB blue cover factual accident report - ntsb/aar- 93/07

Aircraft

Registration
B2171
Reported as
Mcdonnell Douglas MD-11
Category
Airplane
Engine
GE CF6, 61,500 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 129
Operator
China Eastern Airlines
Registered owner
China Eastern Airlines
Airworthiness certificate
Standard, Transport
Departed
Shanghai,China, OF
Destination
LAX · Los Angeles, CA
Flight plan
IFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Certificate
Foreign
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Unknown, Unknown
Seat
Right
Flight hours
8,535 total · 1,341 in this make and model

Weather

Conditions
Visual (VMC) · Night/dark