# NTSB MIA02FA075: McDonnell Douglas MD-11, N809DE, Charlotte, NC, April 1, 2002 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: March 31, 2002, 19:45 local (Apr 1, 2002, 00:45 UTC) - Place: Charlotte, NC - Coordinates: 35.214168, -80.943054 - Nearby events: https://openairdocs.org/map.md?lat=35.2142&lon=-80.9431&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 5 serious, 11 minor, 229 uninjured - Status: Completed, report April 28, 2004 - Report: Approved by Office Director - Parties: Boeing Commercial Airplane Company, Delta Air Lines, Airline Pilots Association, FAA FSDO - NTSB case key (mKey): 54424 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA02FA075 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54424/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54424 - Page: https://openairdocs.org/ntsb/MIA02FA075 ## Probable cause The failure of the aircraft operator to comply with, in a timely manner, on the No. 2 engine, Boeing Alert Service Bulletin MD11-71A086, resulting in the integrated drive generator feeder cable chaffing through a fire warning loop and failure of the fire warning system due to electrical damage. This resulted in a continuous indication in the cockpit of a No. 2 engine fire, an emergency descent and landing, and injuries to passengers during the subsequent emergency evacuation of the airplane. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, cruise - fire warning system,powerplant - chafed - maintenance,service bulletin/letter - not performed, company maintenance personnel (cause) - fire warning system,powerplant - activated - Forced landing, emergency descent/landing - Miscellaneous/other, emergency landing - evacuation - performed, flightcrew ## Analysis The captain stated he was the pilot flying and the takeoff and climb to the cruise altitude of 33,000 feet was conducted within normal parameters. After level off the relief pilot left the cockpit to begin his rest period. Within a few minutes he observed that the number 2 engine master warning light was illuminated, as well as a level 3 alert on the Engine and Alert Display and a red light on the number 2 fire handle and fuel shutoff lever. The fire bell did not activate. He and the first officer performed the memory and initial action items on the hard card checklists for an engine fire and shutdown the No. 2 engine. In addition, the captain discharged an engine fire bottle. The engine fire light continued to illuminate. The captain then fired a second engine fire bottle. The engine fire light continued to be illuminated. The captain requested that the relief pilot return to the cockpit. He then contacted Air Traffic Control (ATC) and told them that their No. 2 engine was on fire and that they intended to land at the nearest suitable field. ATC responded that Charlotte was 35 miles away with a 10,000 foot runway. He asked for radar vectors and an immediate descent into Charlotte. They were given a lower altitude. The first officer initiated fuel dumping. The relief pilot returned to the cockpit and he asked the relief pilot and the first officer to run the checklists. As they descended the aircraft encountered heavy rain, light hail, and moderate turbulence. In addition, they observed a bright flash to the left of the nose, which might have been a lightning strike. As they completed the descent and approach checklists he told the crew to expect an emergency evacuation upon landing and directed the first officer to so inform the flight attendants. The aircraft was configured for an engine out approach and they reviewed the loss of a second engine procedure. The remainder of the approach, touchdown and landing roll occurred within normal parameters. He brought the airplane to a stop on the runway. The engine fire indication remained illuminated. The relief pilot stated they did not terminate fuel dumping prior to landing. They completed the items on the evacuation checklist. He then ordered an evacuation of the airplane. According to Delta Air Lines representatives, examination of the No. 2 engine by company maintenance personnel found one fire loop chafed through an adjacent cable, an integrated drive generator (IDG) feeder cable, inside the No. 2 engine cowling This allowed a direct 115 volt AC connection between the IDG and the fire detection control unit. The result was an electrical short and complete failure of the detection control unit that was indicated in the cockpit as a fire warning. There was no evidence of fire in the No. 2 engine. Boeing Service Bullettin MD11-71-086 was issued on May 21, 1996. The subject of the service bulletin was "Power Plant - Electrical Harness - Replace/Modify Integrated Drive Generator (IDG) Wire Harness Support Brackets". On May 21, 2001, Boeing elevated the service bulletin to the "Alert" level. Boeing recommended that aircraft operators accomplish the service bulletin within 1 year. According to Delta Air Lines personnel, in November 2001, Delta Air Lines Aircraft Engineering issued a Engineering Order to comply with Alert Service Bulletin MD11-71A086. The Engineering Order stated that all engines should be inspected and modified by November 2002. All three engines on the accident aircraft were inspected and modified in accordance with the Engineering Order on March 3, 2002. On March 28, 2002, the No. 2 engine was changed and the engine installed had not been modified by the Engineering Order.The Delta Airlines descent, approach, and before landing checklists dated June 30, 2000, and which were in use at the time of the accident, required the pilots to check the Engine and Alert Display. When fuel dumping is activated, a message is displayed on the Engine and Alert Display. ## Factual narrative HISTORY OF FLIGHT On March 31, 2002, about 1945 eastern standard time, a McDonnell Douglas MD-11, N809DE, registered to Delta Air Lines, Inc., operating as a Title 14 CFR Part 121 scheduled international passenger flight, Delta flight number 12, executed an emergency landing and passenger evacuation at the Charlotte/Douglas International Airport, Charlotte, North Carolina. Instrument meteorological conditions prevailed and an international instrument flight plan was filed. The aircraft received minor damage, and three flightcrew, 11 cabincrew and 215 passengers were not injured. Eleven passengers received minor injuries and five passengers sustained serious injuries. The flight departed Atlanta for London's Gatwick Airport at 1902. The captain stated that he was the pilot flying and also he was acting as a Line Check Airman providing operating experience training to the first officer. This was the first officer's first operating experience segment as an MD-11 first officer. The takeoff and climb to the cruise altitude of 33,000 feet was conducted within normal parameters. After level off the relief pilot left the cockpit to begin his rest period. Within a few minutes he observed that the number 2 engine master warning light was illuminated, as well as a level 3 alert on the EAD (Engine and Alert Display) and a red light on the number 2 fire handle and fuel shutoff lever. The fire bell did not activate. He and the first officer performed the memory and initial action items on the hard card checklists for an engine fire. In addition, the captain discharged an engine fire bottle. The engine fire light continued to illuminate. The captain then fired a second engine fire bottle. The engine fire light continued to be illuminated. The captain requested that the relief pilot return to the cockpit. He then contacted ATC (Air Traffic Control) and told them that their No. 2 engine was on fire and that they intended to land at the nearest suitable field. ATC responded that Charlotte was 35 miles away with a 10,000-foot runway. He asked for radar vectors and an immediate descent into Charlotte. They were given a lower altitude. The relief pilot returned to the cockpit and he asked the relief pilot and the first officer to run the checklists. As they descended the aircraft encountered heavy rain, light hail, and moderate turbulence. In addition, they observed a bright flash to the left of the nose, which might have been a lightning strike. As they completed the descent and approach checklists he told the crew to expect an emergency evacuation upon landing and directed the first officer to so inform the flight attendants. The aircraft was configured for an engine out approach and they reviewed the loss of a second engine procedure. The remainder of the approach, touchdown and landing roll occurred within normal parameters. He brought the airplane to a stop on the runway. The engine fire indication remained illuminated. They completed the items on the evacuation checklist. He then ordered an evacuation of the airplane. The first officer stated that the captain was the flying pilot. The takeoff roll and climbout from Atlanta were conducted within normal parameters. When the aircraft leveled at flight level 330, the relief pilot left the cockpit to begin his rest period. Within a few minutes , he observed a flashing red warning light, a level 3 alert on the EAD and a red light on the No. 2 engine fire handle and fuel shutoff lever. The captain began an immediate descent into Charlotte and requested that the relief pilot return to the cockpit. The first officer began to run the engine fire/severe damage checklist. He stopped to provide the relief pilot access to the cockpit. He then completed the items on the checklist with the assistance of the relief pilot. As they descended the captain called for fuel dump. The first officer accomplished the items on the fuel dump checklist. The aircraft was encountering heavy rain, light hail, and moderate turbulence. There were no strong echoes indicated on weather radar. In addition, they observed a bright flash to the left of the nose. The captain remarked that they had been struck by lightning. The first officer initiated and accomplished the descent checklist after changing the destination and setting up the landing runway in the flight management system. The relief pilot assisted him in the completion of the approach checklist. As they became established on the glideslope for runway 18 at Charlotte, the captain told then to expect an emergency evacuation upon landing and instructed the relief pilot to so inform the flight attendants. The airplane was configured for an engine out approach. While on final approach, the first officer announced and read the loss of second engine checklist. At 840 feet agl, he initiated and completed the before landing checklist. The captain brought the airplane to a stop on the runway and then called for the emergency evacuation checklist, which the relief pilot read and performed. The captain made a public address announcement and the first officer activated the evacuation horn. The relief pilot stated that he sat on the cockpit jumpseat during the takeoff roll and climbout from Atlanta. When the aircraft leveled at flight level 330, he left the cockpit to begin his rest period. Within a few minutes a flight attendant informed him that the captain had requested that he return to the cockpit immediately. Upon entering the cockpit he observed that the fire handle light for the No. 2 engine was illuminated and that the captain and first officer were in the process of running the engine fire checklist. The captain asked him to run the checklists with the first officer so that he could focus his attention on the operation of the aircraft and communications with ATC. As they completed the checklists the captain began an emergency descent into Charlotte. The engine fire light remained illuminated after completion of checklist items. As they descended, the aircraft encountered heavy rain, light hail, and moderate turbulence. In addition, they observed a bright flash to the left of the nose. The captain remarked that they had been struck by lightning. As they completed the descent and approach checklists and became established on the glideslope for runway 18 at Charlotte, the captain said to expect an emergency evacuation upon landing and directed the relief pilot to so inform the flight attendants. The aircraft was configured for an engine out approach. In addition, the flight crew reviewed the loss of second engine procedure. The remainder of the approach, touchdown and landing roll occurred within normal parameters. The captain brought the airplane to a stop on the runway. They then completed the items on the evacuation checklist. The relief pilot stated in interview with NTSB that they did not terminate the fuel dumping prior to landing. The flight attendant positioned at the 1R door stated that about 10 minute after takeoff the flight attendants were given the 10,000-foot signal, but the seat belt sign was left on due to light turbulence. They began cabin service. A while later the pilots called back and told the flight attendants to take their seats. About 30 seconds later the pilots asked that they send the relief pilot to the cockpit, that they had a problem and needed him right away. The aircraft began descending and they stowed the carts. The aircraft continued the descent at a steep angle. The flight attendant positioned at the 1L door, who was the onboard leader, talked to the pilots and the pilots told her they had a fire in No. 2 engine and would be landing in Charlotte. The pilot also told her to prepare the cabin for an emergency landing and that he did not think they would have to evacuate the aircraft, but to review their emergency procedures. She passed this information to the other flight attendants. They completed the preparation for landing and took t ## Aircraft - Registration: N809DE (not matched to a registry record) - Reported make and model: McDonnell Douglas MD-11 - Category: Airplane - Serial number: 40480 - Airframe hours: 40531 - Engines: Pratt & Whitney PW 4460 60000 lbs thrust turbo jet; Pratt & Whitney PW 4460 60000 lbs thrust turbo jet; Pratt & Whitney PW 4460 60000 lbs thrust turbo jet - Damage: Minor damage - Flight: Part 121 - Registered owner: Delta Air Lines, Inc. - Airworthiness certificate: Standard, Transport - Last inspection: AAIP, February 28, 2002, 20 hours before - Departed: KATL, Atlanta, GA - Destination: ELGW, London - Flight plan: IFR - Airport: KCLT, Charlotte Douglas Internationa, runway 18R, 10,000 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review October 4, 2001; seat: left; flight hours: 20,120 total, 1,647 in this make and model, 191 in the last 90 days, 5 in the last 24 hours - Co-pilot; age 41; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review March 20, 2002; seat: right; flight hours: 8,363 total, 5 in this make and model, 5 in the last 90 days, 5 in the last 24 hours - Co-pilot; age 45; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review February 1, 2002; seat: center; flight hours: 11,500 total, 1,268 in this make and model, 150 in the last 90 days, 7 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night - Wind: 360° at 10 knots - Visibility: 2 statute miles - Lowest ceiling: 300 ft overcast - Temperature: 54 °F, dew point 54 °F - Altimeter: 29.85 inHg - Observed at: CLT ## 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 20020331026589A](https://openairdocs.org/incident/20020331026589A), Mar 31, 2002: Doug MD11, Charlotte, NC, Minor damage. (-23) On March 31, 2002 a mcdonnel Douglas MD-11 was enroute from atlanta, Georgia to london, united kingdom, when the aircraft was forced to make an emergency… ## Docket (25 files) The files NTSB released with the investigation on June 13, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54424. 11.0 MB in all. - Survival Factors 6 - Factual Report (item 1, .PDF, 573 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184327&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Factual%20Report%20-Master.PDF - Survival Factors 6 - Attachment A - Safety Briefing Card (item 2, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183385&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%20A%20-%20Safety%20Briefing%20Card-Master.PDF - Survival Factors 6 - Attachment B - Flight Attendant Statements (item 3, .PDF, 711 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183488&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%20B%20-%20Flight%20Attendant%20Statements-Master.PDF - Survival Factors 6 - Attachment C - Air Cruisers Maintenance Manual (item 4, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419297&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%20C%20-%20Air%20Cruisers%20Maintenance%20Manual-Redacted.PDF - Survival Factors 6 - Attachment D - Slide/Raft Maintenance Record (item 5, .PDF, 292 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183388&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%20D%20-%20Slide%2FRaft%20Maintenance%20Record-Master.PDF - Survival Factors 6 - Attachment E - Photograph Cover Sheet (item 6, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183392&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%20E%20-%20Photograph%20Cover%20Sheet-Master.PDF - Survival Factors 6 - Attachment E - Photo 1. Damage to Ceiling (item 7, .PDF, 413 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183393&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%20E%20-%20Photo%201.%20Damage%20to%20Ceiling-Master.PDF - Survival Factors 6 - Attachment F - Aircraft Rescue and Firefighting Report (item 8, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183389&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%20%20F%20-%20Aircraft%20Rescue%20and%20Firefighting%20Report-Master.PDF - Survival Factors 6 - Attachment G - Airport Certification Inspection (item 9, .PDF, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183390&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%20G%20-%20Airport%20Certification%20Inspection-Master.PDF - Flight Data Recorder 10 - Factual Report of Group Chairman (item 10, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40166451&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%2010%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Flight Data Recorder 10 - Attachment 1: Plots (item 11, .PDF, 287 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40166453&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%2010%20-%20Attachment%201%3A%20Plots-Master.PDF - Flight Data Recorder 10 - Attachment 2: Data (item 12, .CSV, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40166454&FileExtension=.csv&FileName=Flight%20Data%20Recorder%2010%20-%20Attachment%202%3A%20Data-Master.csv - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 13, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419298&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Supplement E (item 14, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183851&FileExtension=.PDF&FileName=Supplement%20E-Redacted.PDF - Reports from Federal Agencies - ATC Controller Statements (item 15, .PDF, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419299&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%20-%20ATC%20Controller%20Statements-Redacted.PDF - ATC Information (item 16, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183869&FileExtension=.PDF&FileName=ATC%20Information-Master.PDF - Transcript of Radio Communications (item 17, .PDF, 468 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419300&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - Aircraft Logbook Records (item 18, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419301&FileExtension=.PDF&FileName=Aircraft%20Logbook%20Records-Redacted.PDF - Boeing Service Bulletin MD11-71A086 (item 19, .PDF, 243 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183875&FileExtension=.PDF&FileName=Boeing%20Service%20Bulletin%20MD11-71A086-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 20, .PDF, 365 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419302&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 21, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184004&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Cockpit Voice Recorder 12 - Factual Report of Group Chairman (item 22, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40184391&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 23, .PDF, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419303&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Accident Flight Logbook Pages (item 24, .PDF, 975 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419304&FileExtension=.PDF&FileName=Accident%20Flight%20Logbook%20Pages-Redacted.PDF - Other Pertinent Forms and Reports: Aircraft Normal Checklist (item 25, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40206180&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%3A%20Aircraft%20Normal%20Checklist-Master.PDF From the NTSB's public API. 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