DEN04IA012

NTSB incident investigation · McDonnell Douglas DC-10-10 · Denver, CO · October 12, 2003

Incident · No injuriesIncident investigationFinal report
Date
October 12, 2003, 07:17 local (13:17 UTC)
Place
Denver, CO
Injuries
7 uninjured
Damage
Minor damage
Phase of flight
Takeoff
Aircraft
N375FEMcDonnell Douglas DC-10-10
Weather
Visual (VMC) · Dawn
Status
Completed · report June 30, 2004
Report
Approved by Office Director
Parties
Denver FAA FSDO
FAA report
20031012026399I
Case key
58212

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

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Probable cause

the manufacturer's improper installation of the inboard slat drive mechanism's lower left hand anti-torque strut, which resulted in the axial migration of the rod-end bearing, the binding of the anti-torque strut, and the subsequent activation of the slat take-off configuration warning horn. Contributing factors include the aborted take-off, the initiation of normal brakes during a high energy stop, and the main landing gear fire.

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/malfunctionTakeoff - roll/run
Material inadequate,improperManufacturerCause
Flight control,slat - malfunctionCause
Aborted takeoffFactor
Warning system(other) - activated
Miscellaneous/otherTakeoff - aborted
Airspeed(v1) - obtainedPilot in command
Remedial action - initiatedPilot in command
Aborted takeoff - performedPilot in commandFactor
Terrain condition - runway
Light condition - dawn
FireTakeoff - aborted
Brakes(normal) - initiatedPilot in commandFactor
Landing gear - fireFactor
Landing gear,tire - melted
Landing gear,tire - deflated

Analysis

According to the captain, during the take-off roll, and shortly after the first officer called out the take-off decision speed (V1,158 knots), the take-off warning horn sounded. At that time, the captain initiated a Rejected Take-Off (RTO). Assured that a stop on the runway was possible, he elected not to apply maximum braking in "hopes that a more gentle brake application might avoid or mitigate any damage to the aircraft and lessen the heat and fire risk." During the RTO, DEN tower contacted the crew and reported smoke in the vicinity of the left main landing gear. Immediately thereafter, the tower reported that fire was coming from the same area. DEN tower initiated a call to alert aircraft rescue and firefighting equipment (ARFF) to the scene. The aircraft came to a stop, on the runway centerline, with approximately 1,800 feet of runway remaining. The crew completed the emergency quick evacuation checklist, and all seven persons aboard egressed via the L1 escape slide. The initial inspection of the airplane revealed that both of the nose landing gear tires, two main landing gear brake lines, all eight main landing gear brake assemblies, and all eight main landing gear tires were damaged during the RTO. Each damaged item was required to be replaced prior to towing the aircraft off the runway. The maintenance manager stated that the nose and main landing gear assemblies had "overheated," during the RTO and that each tire had deflated after the airplane came to rest, because "there was no indication that the tires had skidded." During an examination of the airplane, it was determined that the take-off warning horn was the result of a take-off configuration conflict between the inboard and outboard slats. An inspection of the inboard slat drive mechanism's lower left hand anti-torque strut, revealed that a rod-end bearing had migrated out of the rod-end, and that two washers were missing, which allowed the anti-torque strut to ride on the bolt that attaches the rod-end to the slat drive mechanism.

Factual narrative

History of flight

On October 12, 2003, at 0717 mountain daylight time, a McDonnell Douglas DC-10-10, N375FE, owned by Federal Express Corporation, Memphis, Tennessee, and operating as FedEx flight 840, sustained minor damage during a rejected takeoff at Denver International Airport (DEN), Denver, Colorado. The airline transport certificated captain, airline transport certificated first officer, flight engineer, and four non-revenue passengers were not injured. Visual meteorological conditions prevailed. An instrument flight rules (IFR) flight plan was filed for the scheduled domestic cargo flight being conducted under the provisions of Title 14 CFR Part 121. The flight to Memphis, Tennessee, was originating at the time of the accident.

According to a Federal Express representative, at 0646, flight 840 "blocked out" from the FedEx ramp at DEN for a direct flight to Memphis. The aircraft taxied approximately 6 miles, and at 0717 it was cleared for take-off on runway 16R (16,000 x 200 feet). According to the captain, during the take-off roll, and shortly after the first officer called out the take-off decision speed (V1, 158 knots), the take-off warning horn sounded. At that time, the captain initiated a Rejected Take-Off (RTO). Assured that a stop on the runway was possible, he elected not to apply maximum braking in "hopes that a more gentle brake application might avoid or mitigate any damage to the aircraft and lessen the heat and fire risk." During the RTO, DEN tower contacted flight 840 and reported smoke in the vicinity of the left main landing gear. Immediately thereafter, the tower reported that fire was coming from the same area. DEN tower initiated a call to alert aircraft rescue and firefighting equipment (ARFF) to the scene. The aircraft came to a stop on the runway centerline at the D3 intersection. Approximately 1,800 feet of runway remained. After completing the emergency quick evacuation checklist, all seven persons aboard egressed via the L1 escape slide. At 0725, the tower closed the runway to all operations.

According to a FedEx field line maintenance manager, the initial inspection of the airplane revealed that both of the nose landing gear tires, two main landing gear brake lines, all eight main landing gear brake assemblies, and all eight main landing gear tires were damaged during the RTO. Each damaged item was required to be replaced prior to towing the aircraft off the runway. The maintenance manager stated that the nose and main landing gear assemblies had overheated, during the RTO. He stated that each tire must have deflated after the airplane came to rest, because "there was no indication that the tires had skidded." Each wheel on the left main landing gear assembly (number 1, 2, 5, and 6), was "welded" to its brake assembly. Between each "welded" tire and brake assembly was also an axial spacer that is normally reused during tire replacement. Due to the lack of replacement parts being on hand, replacement tires, brake lines, and spacers were flown in from other locations. The damaged items were replaced and the airplane was towed to the FedEx ramp. The runway was cleared and reopened at 0038 the following morning.

Test and research

According to Flight Data Recorder (FDR) information, during the take-off roll and subsequent RTO, the right outboard (ROB) slats went from take-off (TO) to landing (LAND) configuration at 156 knots and returned to TO configuration at 152 knots. During this same time, the left outboard (LOB) slats went from TO to LAND configuration at 164 knots and returned to TO configuration at 162 knots.

According to a FedEx systems engineer, this condition would result in the activation of the "take-off warning horn because the slats are no longer in take-off configuration." During an examination of the airplane, it was determined that the take-off warning horn was the result of a take-off configuration conflict between the inboard and outboard slats. An inspection of the lower left hand anti-torque strut (p/n ARH0518-1, IPC 27-83-05-01 item 534), revealed that it had separated from its attachment point on the inboard slat drive mechanism. Upon further inspection, it was noted that a rod-end bearing (p/n MS21232-9), had migrated out of the rod-end (p/n ARH0514-1), and that the two required washers (p/n S2431218-9S20G, CPN 5711588), were missing. This allowed the anti-torque strut to ride on the bolt that attaches the rod-end to the slat drive mechanism. An initial inspection of the bearing revealed that the bearing had migrated out of the rod-end under "axial loads" and that the bearing was "never staked." Further examination revealed that whether the bearing was properly staked or not, the bearing migrated out of the rod-end because the washers were not properly installed. There had been no prior repair or maintenance history pertaining to this component and this was the first time the strut had been removed from the airplane.

On October 20, 2003, a FedEx maintenance engineer examined the left and right wheel and brake assemblies. He stated that the left main landing gear brakes appeared to have been exposed to higher heat, due to a "high energy stop," which caused the wheels and brakes to fuse together. Although several tires received heat damage due to the "hot brakes and tire rims contacting the [tire] side walls," the general observation was that the tires had deflated after the airplane came to a stop. The left main landing gear brakes (number 5 and 6), and the aft inboard and outboard brake hoses were damaged by excessive heat. He stated that the tires did not exhibit any signs of "skid-thru" or damage due to rolling while flat. Although there was extensive heat damage to the wheel and brake assemblies, no wheel or brake deficiencies were noted.

Additional information

According to the captain, FedEx flight 840 was originally a non-stop flight from Oakland, California, to Memphis, Tennessee. During the flight, the captain was directed to divert to Denver to pick up additional freight. The additional freight and fuel resulted in a calculated take-off gross weight of approximately 404,900 pounds, and a landing-limited operational maximum take-off gross weight of approximately 406,700 pounds. The captain said that he anticipated a departure on runway 17R until he noticed that the airplane had been over fueled by approximately 400 pounds. Due to the extra fuel and the reports of wind shear from DEN tower, he elected to taxi to runway 16R to taxi off the over-fuel weight and take advantage of the longer runway.

On November 18, 2003, FedEx issued a Fleet Campaign Directive (FCD), 8-27-040 A, which required the inspection of the inboard slat drive mechanism and the lower left and right hand anti-torque struts for the proper washer installation and staking of the rod-end bearing. The FCD required the inspection of all DC-10, MD-10, and MD-11 aircraft.

According to Douglas Aircraft Company (DAC) CMM 27-83-14, the rod-end bearing (p/n MS21232-9), is to be staked in the rod-end per Douglas Process Specifications (DPS) 1.33-2.

Aircraft

Registration
N375FE
Reported as
McDonnell Douglas DC-10-10
Category
Airplane
Serial number
46613
Airframe hours
76,360
Engines
General Electric CF6-6D, 40,000 lbs thrust, turbo jetGeneral Electric CF6-6D, 40,000 lbs thrust, turbo jetGeneral Electric CF6-6D, 40,000 lbs thrust, turbo jet
Damage
Minor damage
Fire
On-Ground
Flight
Part 121
Registered owner
Federal Express Corporation
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 11, 2003 · 1,067 hours before
Departed
DEN · Denver, CO
Destination
MEM · Memphis, TN
Flight plan
IFR
Airport
DEN · Denver International, runway 17R, 16,000 × 200 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
48
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
July 20, 2003
Seat
Left
Flight hours
3,298 total · 2,615 as pilot in command · 162 in the last 90 days · 56 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dawn
Wind
221° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 19 °F
Altimeter
30.03 inHg
Observed at
KDEN

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N375FE · 1

Matched to the same aircraft by N-number and date.