Vliegtuigongeval op 06 APR 1993 met McDonnell Douglas MD-11 B-2171

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Accident

Last updated: 18 June 2013

Status:	Definitief
Datum:	06 APR 1993
Tijd:	01:10 HST
Type:	McDonnell Douglas MD-11
Luchtvaartmaatschappij:	China Eastern Airlines
Registratie:	B-2171
Constructienummer:	48495/461
Bouwjaar:
Aantal vlieguren:	4810
Aantal vluchten:	1571
Bemanning:	slachtoffers: 0 / inzittenden: 20
Passagiers:	slachtoffers: 2 / inzittenden: 235
Totaal:	slachtoffers: 2 / inzittenden: 255
Schade:	Licht
Gevolgen:	Repaired
Plaats:	1760 km (1100 mijl) S of Shemya, AK (Verenigde Staten)
Fase:	Kruisvlucht (ENR)
Soort vlucht:	Internationale lijnvlucht
Vliegveld van vertrek:	Shanghai-Hongqiao Airport (SHA/ZSSS), China
Vliegveld van aankomst:	Los Angeles International Airport, CA (LAX/KLAX), Verenigde Staten
Vluchtnummer:	583

Beschrijving:
China Eastern flight 583 had an inadverterent 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: "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."

Bronnen:
» Air Safety Week 1.11.1993 (p. 1-3)
» Air Safety Week 19.04.93 (1,2)
» Air Safety Week 31.05.1993 (p. 1,2)
» Air Safety Week 12.4.1993 (p. 1,2)
» NTSB/AAR-93/07

Veiligheidsmaatregelen

NTSB issued 10 Safety Recommendations

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 AD's and Safety Recommendations

Foto's

Kaart

Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Shanghai-Hongqiao Airport en Los Angeles International Airport, CA bedraagt 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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