# NTSB MIA98LA096: Douglas DC-10-30F, N303FE, Memphis, TN, March 6, 1998 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 6, 1998, 02:00 local (08:00 UTC) - Place: Memphis, TN - Location: 35.0424° N, 89.9767° W: Placed by OpenAirDocs at FREDERICK W SMITH INTL/MEMPHIS (MEM), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=35.0424&lon=-89.9767&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 7 uninjured; on the ground: 1 serious - Status: Completed, report July 13, 1998 - Report: Approved by Office Director - NTSB case key (mKey): 38471 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA98LA096 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38471/pdf - Page: https://openairdocs.org/ntsb/MIA98LA096 ## Probable cause ground personnel (an equipment loader) failed to follow established written procedures (ramp safety policy), resulting in a pressurized entry door being opened before it was fully depressurized, subsequently injurying the equipment loader. The malfunctioning outflow valve was a related factor. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, standing - engine(s) operating - air cond/heating/pressurization,outflow valve - malfunction (contributing factor) - Miscellaneous/other, standing - instructions,written/verbal - not followed, ground personnel (cause) ## Analysis An equipment loader attempted to activate the entry door of an airplane with a presurized cabin, before the airplane rotating beacon was turned off. As the cabin was being depressurized, the door opened, and the equipment loader was knocked off the loader. Company ramp safety policy stated to not approach an arriving aircraft until it had come to a complete stop at its parking position, the engines shut down, the wheels chocked, and the red rotating beacons turned off. Investigation revealed the aircraft had a malfunction of the pressurization outflow valve, while conducting engine shutdown procedures on the parking ramp. ## Factual narrative On March 6, 1998, about 0200 central standard time, a Douglas DC-10-30F, N303FE, registered to Federal Express Corporation, operating as a 14 CFR Part 121 supplemental domestic international cargo flight, experienced a failure of the pressurization outflow valve on the left main cargo door, while conducting engine shutdown procedures on the parking ramp at Memphis International Airport, Memphis, Tennessee. Visual meteorological conditions prevailed and an IFR flight plan was filed. The airplane sustained no damage. The airline transport-rated pilot-in-command, first officer, second officer, and four jump seat riders reported no injuries. The flight originated from San Diego, California, about 3 hours 3 minutes before the accident. The PIC stated he parked the airplane on the FedEx ramp and the crew entry doors would not open, and he suspected the airplane had not fully depressurized. He instructed the second officer to make sure the airplane was depressurized. Before he had the opportunity to run the checklist, they heard a loud bang. The second officer opened the cabin outflow valve and the crew doors opened normally. The PIC exited the airplane and observed a ramp worker was on the ramp injured. The second officer stated he departed the cockpit after the airplane was parked. He disarmed the entry doors and returned to the cockpit to complete the shutdown and termination checklists. While accomplishing this, he was informed that the entry doors would not open, and to check the airplane pressurization. The airplane had not fully depressurized automatically. While manually opening the outflow valve, he heard a bang sound from the rear. He continued with the checklist, and wrote up the pressurization system in the airplane logbook. Upon exiting the airplane he became aware of the accident. The injured equipment loader stated when he approached the airplane, the upper and lower beacons were off. He walked up and released the lever on the door. The door blew and he was knocked off the loader. Ground personnel stated after the airplane was blocked and the airplane engines were shut down, that the ground team proceeded to mate the ground equipment and crew stairs to the airplane. The beacon was still on. Another ground crewmember knocked on the crew door and instructed the flight crew to shut off the beacon. As the ground crewmember was pushing the button, another ground crewmember yelled from the ground to stop. He turned turned around, turned back, looked into the cockpit, heard a loud noise, and observed the equipment loader falling off the loader. Review of Federal Express Corporation, Aircraft Ramp Operations Procedures, R2-85-5 Ramp Safety Policy states, "When driving or operating ground equipment, the operator is responsible for the following:... * Not approaching an arriving aircraft until it has come to a complete stop at its parking position, the engines are shut down and have completed a rundown, the wheels are chocked, and the red rotating beacons are turned off." ## Aircraft - Registration: [N303FE](https://openairdocs.org/aircraft/N303FE), registered now, S/N 46802, built 1973 (OpenAirDocs) - Reported make and model: Douglas DC-10-30F - Registry model: [Mcdonnell Douglas MD-10-30F](https://openairdocs.org/model/mcdonnell-douglas-md-10-30f) (registry code 3024020) (OpenAirDocs) - Registry engine: [GE CF6-50 series](https://openairdocs.org/engine/ge-cf6-50-series) (registry code 30018, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 46802 - Airframe hours: 56241 - Engines: GE CF6-50 turbo fan - Damage: No damage - Flight: Part 121 - Registered owner: Federal Express Corporation - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, March 10, 1998, 201 hours before - Departed: SAN, SAN DIEGO, CA - Destination: MEM - Flight plan: IFR - Airport: MEM, Memphis International ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 3,369 total, 3,369 in this make and model, 204 as pilot in command, 77 in the last 90 days, 12 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 140° at 13 knots, gusting 19 - Visibility: 15 statute miles - Lowest ceiling: 3,800 ft overcast - Temperature: 63 °F, dew point 57 °F - Altimeter: 29.00 inHg - Observed at: MEM ## 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 19980306010419A](https://openairdocs.org/incident/19980306010419A), Mar 6, 1998: Doug DC1030F, Memphis, TN. Arrived at gate not fully depressurized. Ground crew opened cargo door. Blown off lift. Depressure not full open. (.4)an equipment loader attempted to activate… 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.