ASN Aircraft accident McDonnell Douglas MD-11 B-2171 Shemya, AK

Home » Database » 1993

Status:	Accident investigation report completed and information captured
Date:	Tuesday 6 April 1993
Time:	01:10 HST
Type:	McDonnell Douglas MD-11
Operator:	China Eastern Airlines
Registration:	B-2171
MSN:	48495/461
First flight:	1991
Total airframe hrs:	4810
Cycles:	1571
Engines:	3 Pratt & Whitney PW4460
Crew:	Fatalities: 0 / Occupants: 20
Passengers:	Fatalities: 2 / Occupants: 235
Total:	Fatalities: 2 / Occupants: 255
Aircraft damage:	Minor
Aircraft fate:	Repaired
Location:	1760 km (1100 mls) S of Shemya, AK ( United States of America)
Phase:	En route (ENR)
Nature:	International Scheduled Passenger
Departure airport:	Shanghai-Hongqiao Airport (SHA/ZSSS), China
Destination airport:	Los Angeles International Airport, CA (LAX/KLAX), United States of America
Flightnumber:	583

Narrative:
China Eastern flight 583 had an inadvertent deployment of the leading edge wing slats while in cruise flight. The autopilot disconnected, and the captain was manually controlling the airplane when it progressed through several violent pitch oscillations and lost 5,000 feet of altitude. The captain regained stabilized flight, declared an emergency because of passenger injuries, and diverted to the US Air Force Base, Shemya, Alaska. Two passengers were fatally injured, and 149 passengers and 7 crewmembers received various injuries. The airplane did not receive external structural damage, but the passenger cabin was substantially damaged.

Probable Cause:

PROBABLE CAUSE: "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."

Accident investigation:

Investigating agency:	NTSB
Status:	Investigation completed
Duration:	204 days (7 months)
Accident number:	NTSB/AAR-93/07
Download report:	Final report

Classification:

Forced landing on runway

Sources:

» Air Safety Week 1 November 1993 (p. 1-3)
» Air Safety Week 19 April 93 (1,2)
» Air Safety Week 31 May 1993 (p. 1,2)
» Air Safety Week 12 April 1993 (p. 1,2)
» NTSB/AAR-93/07

Follow-up / safety actions

NTSB issued 13 Safety Recommendations

Issued: 29-JUN-1993	To: FAA	A-93-81
ISSUE AN AIRWORTHINESS DIRECTIVE REQUIRING THE OPERATORS OF MD-11S TO INSTALL AN INTERIM FLAP/SLAT HANDLE SYSTEM OR DEVICE TO PREVENT THE INADVERTENT DEPLOYMENT OF WING LEADING EDGE SLATS, WHEN SUCH A SYSTEM OR DEVICE BECOMES AVAILABLE. (Closed - Acceptable Action)
Issued: 29-JUN-1993	To: FAA	A-93-82
ISSUE AN AIR CARRIER OPERATIONS BULLETIN TO PRINCIPAL OPERATIONS INSPECTORS TO VERIFY MD-11 OPERATORS HAVE ADVISED FLIGHTCREW OF THE POTENTIAL FOR AN INAVERTENT IN-FLIGHT SLAT EXTENSION IF CONTACT IS MADE WITH THE FLAP/SLAT HANDLE. (Closed - Acceptable Action)
Issued: 29-JUN-1993	To: FAA	A-93-83
REQUIRE AN EXPEDITIOUS INSTALLATION OF A REDESIGNED FLAP/SLAT ACTUATING SYSTEM, WHEN IT BECOMES AVAILABLE FOR RETROFIT, THAT WILL PREVENT UNCOMMANDED AND INADVERTENT DELOPYMENT OF THE LEADING EDGE SLATS ON MD-11 AIRPLANES. (Closed - Acceptable Action)
Issued: 10-NOV-1993	To: FAA	A-93-143
REQUIRE DOUGLAS AIRCRAFT COMPANY TO PROVIDE DATA NEEDED TO UPGRADE MD-11 TRAINING SIMULATORS TO ACCURATELY REPRESENT THE AIRCRAFT\'S LONGITUDINAL STABILITY AND CONTROL CHARACTERISTICS FOR HIGHT ALTITUDE CRUISE FLIGHT; AND TO DEVELOP SPECIFIC GUIDANCE AND SIMULATOR SCENARIOS TO TRAIN PILOTS IN OPTIMUM TECHNIQUES FOR THE RECOVERY FROM HIGH ALTITUDE UPSETS, INCLUDING THOSE ACCOMPANIED BY STALL WARNING. (Closed - Acceptable Action)
Issued: 10-NOV-1993	To: FAA	A-93-144
REQUIRE OPERATORS TO PROVIDE SPECIFIC TRAINING FOR THE RECOVERY FROM HIGH ALTITUDE UPSETS, INCLUDING THOSE ACCOMPANIED BY STALL WARNING. (Closed - Acceptable Action)
Issued: 10-NOV-1993	To: FAA	A-93-145
ESTABLISH HIGH ALTITUDE STALL MARGINS FOR MD-11 AIRPLANES IN ORDER TO LIMIT THE EFFECTS OF HIGH ALTITUDE PITCH UPSETS. (Closed - Acceptable Action)
Issued: 10-NOV-1993	To: FAA	A-93-146
EVALUATE THE DYNAMICS OF THE MD-11 STALL WARNING SYSTEM TO ENSURE THAT THE "ON" AND "OFF" LOGIC ARE CONSISTENT WITH PROVIDING THE PILOT TIMELY INFORMATION. (Closed - Acceptable Action)
Issued: 10-NOV-1993	To: FAA	A-93-147
CONDUCT A THOROUGH REVIEW OF THE MD-11 HIGH ALTITUDE CRUISE LONGITUDINAL STABILITY AND CONTROL CHARACTERISTICS, STALL WARNING MARGINS, AND STALL BUFFET SUSCEPTIBILITY TO ENSURE THAT PILOT RESPONSES TO ROUTINE PITCH ATTITUDE UPSETS DO NOT RESULT IN HAZARDOUS PITCH OSCILLATIONS, STRUCTURAL DAMAGE, OR ANY OTHER CONDITION THAT COULD LEAD TO UNSAFE FLIGHT. (Closed - Acceptable Action)
Issued: 10-NOV-1993	To: FAA	A-93-148
REQUIRE THAT FIRE-BLOCKING MATERIALS IDENTIFIED AS TESTORI 0200-316 AND 0206-100 BE REPLACED WITH NEW MATERIALS THAT MEET THE FIRE RETARDANT REQUIREMENTS OF 14 CFR 25.853. (Closed - Acceptable Action)
Issued: 10-NOV-1993	To: FAA	A-93-149
AMEND 14 CFR 25.853 TO INCLUDE A REQUIREMENT TO TEST THE FIRE-RETARDANT PROPERTIES OF FIRE BLOCKING MATERIALS AFTER THEY HAVE BEEN SUBJECTED TO IN-SERVICE WEAR. (Closed - Acceptable Action)
Issued: 10-NOV-1993	To: FAA	A-93-150
CONDUCT RESEARCH UPON THE EFFECTS OF ACTUAL IN-SERVICE WEAR ON THE CONTINUED AIRWORTHINESS OF FIRE-BLOCKING MATERIALS. BASED ON THE FINDINGS, REQUIRE PERIODIC ACTUAL IN-SERVICE TESTS OF FIRE-BLOCKING MATERIALS TO VERIFY COMPLIANCE WITH THE REQUIREMENTS OF 14 CFR 25-853. (Closed - Acceptable Action)
Issued: 10-NOV-1993	To: FAA	A-93-151
INFORM OTHER CERTIFICATION AUTHORITIES OF THE FINDINGS REGARDING THE DETERIORATION OF THE FIRE-BLOCKING MATERIALS NOTED IN THIS ACCIDENT INVESTIGATION WITH THE VIEW TOWARD REPLACING THEM, AS REQUIRED. (Closed - Acceptable Action)
Issued: 10-NOV-1993	To: FAA	A-93-152
DIRECT PRINCIPAL MAINTENANCE INSPECTORS TO INFORM OPERATORS OF THE NEED TO PERIODICALLY INSPECT FIRE-BLOCKING MATERIALS FOR WEAR AND DAMAGE AND TO REPLACE DEFECTIVE MATERIALS. (Closed - Acceptable Action)

Show all...

Photos

accident date: 06-04-1993
type: McDonnell Douglas MD-11
registration: B-2171

Map

This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Shanghai-Hongqiao Airport to Los Angeles International Airport, CA as the crow flies is 10376 km (6485 miles).

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

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