A Boeing MD-10-10F aircraft, registration N364FE, had a significant aviation history incident when it crashed on December 18, 2003, in Memphis, Tennessee, during Federal Express Flight 647. The National Transportation Safety Board (NTSB) cited the primary cause of the accident, which this critical analysis paper aims to explore. It aims to evaluate the findings as well. Moreover, it will recognize the root causes that potentially caused the mishap. The NTSB may not address it, yet it remains. Lastly, the paper will suggest actions pilots should take when encountering comparable circumstances.
Primary Cause of the Accident:
According to the findings of the meticulous inquiry by investigators at the National Transportation Safety Board into the unfortunate accident, the cardinal mistake ultimately responsible for the tragic crash of Federal Express Flight 647 was, regrettably, the pilots’ egregious mishandling and mismanagement of the aircraft’s perilous descent toward the runway (Smaili et al., 2019). The investigation found that the pilots permitted the aircraft to descend at speed beyond the suggested maximum, culminating in a rough landing and the consequent buckling of the landing gear.
An essential feature of secure arrivals is upholding correct glide path regulation. The glide path constitutes the dropped course followed by a plane during the concluding approach and landing. Aviators must govern the aircraft’s descent velocity inside specified restrictions to guarantee a seamless and restrained grounding (NTSB, 2003). Nonetheless, regarding Flight 647, the cockpit team did not sustain sufficient glide path command, culminating in a harsh landing.
A severe impact transpires as the craft connects with the ground untowardly or at an erroneous slant (Oh et al., 2020). This variety of alighting surpasses the schematic constraints of the vehicle’s undercarriage, culminating in prospective architectural impairment. Regarding Expedition 647, the adverse touchdown prompted the buckling of the chassis, amplifying the ramifications of the cockpit’s deficient descent regulation.
The subsequent investigation substantiates the inference that the aviators were accountable for the deficient descent regulation. Scrutiny of the voyage statistics recorder and cockpit communication recorder information, complemented by supplementary applicable intelligence, uncovered that the team digressed from recognized conventions and instructions during the arrival segment (Smaili et al., 2019). They sanctioned the drop velocity to surpass the suggested restrictions, signaling an absence of suitable command over the aircraft’s glide path. The swift drop beyond the suggested velocity can bear numerous unfavorable impacts. Primarily, it levies undue anxiety upon the touchdown components, akin to shock absorbers and tires, rendering them more prone to malfunction (NTSB, 2003). Secondarily, it elevates the possibility of impairing the craft skeleton and other crucial configurations, potentially compromising the aggregate security of the craft. Finally, a forceful landing can adversely sway passenger consolation and credence.
The plunge of the undercarriage exhibits the dire repercussions of the aviators’ deficient descent regulation. The undercarriage was devised to endure standard alighting strengths inside fixed margins (Griffin & Walsh, 1992). Nonetheless, because of the forcible touchdown prompted by the aviators’ deeds, the undercarriage surpassed its architectural endurance, culminating in its fall and immobilizing the airliner.
The deduction of the leading investigative committee that the main factor behind the unfortunate event was the deficient glide scope regulation of the aeronautical operators during the descent to the surface is adequately established (Smaili et al., 2019). The substantiation furnished in the examination sturdily affirms this resolution, signaling that the team wandered from conventional practices and permitted the drop speed to surpass secure restraints. Consequently, a firm connection with the ground transpired, conducing to the giving way of the alighting gear.
Agreement with the Findings:
I agree with the NTSB’s findings that the primary cause of the Federal Express Flight 647 accident was the flight crew’s inadequate glide path control during landing. The NTSB presented strong evidence and analysis which strongly supports this conclusion. The flight and cockpit voice recorder data indicate deviations from established procedures and guidelines during the landing phase, revealing valuable insights into the crew’s actions and decision-making (Oh et al., 2020). Recorded data shows the crew did not manage the descent rate within the recommended limits. This discrepancy significantly contributed to the hard landing. The landing gear collapsed later.
Moreover, the NTSB’s findings are consistent with the information accessible about the accident. Examine the wreckage, comprising the landing gear components. The excessive force exerted during the hard landing caused the landing gear to collapse, supporting the conclusion. This physical evidence supports the crew’s inadequate glide path control—the subsequent gear failure. The NTSB possesses extensive expertise in aviation accident investigations and is a reputable organization. They based their findings on a solid foundation created by thoroughly examining the accident forms (NTSB, 2003). They have further strengthened their conclusions with the evidence and data collected. The NTSB conducts a comprehensive and objective analysis. Various aspects, including crew performance, system performance, and environmental factors, are considered. The NTSB’s expertise and the weight of evidence show that the flight crew’s inadequate glide path control during the landing primarily caused the accident. Recognizing and addressing the human factors involved in aviation accidents is crucial. In this case, the crew’s failure to follow established procedures and appropriately manage the descent rate emphasizes the importance of crew training, situational awareness, and decision-making (Griffin & Walsh, 1992). Pilots and aviation professionals can highlight the importance of proper training, adherence to procedures, and effective crew resource management by learning from accidents such as Flight 647
The rationale for the Agreement:
- Flight Crew Performance: The NTSB’s investigation revealed that the crew failed to adhere to established procedures and guidelines during the landing phase. This lack of discipline and attention to detail in managing the aircraft’s glide path clearly indicates crew error. To ensure safe and consistent practices, adherence to standard operating procedures is essential in aviation (Smaili et al., 2019). In this case, the flight crew’s failure to maintain the descent rate within the recommended limits demonstrates a deviation from established procedures, leading to the accident (NTSB, 2003). The crew’s inadequate glide path control highlights a lapse in their performance and decision-making during a critical phase of flight.
- Impact of Hard Landing: The impact of the hard landing exceeding the design limitations of the landing gear further substantiates the role of the crew’s inadequate glide path control as the primary cause. The landing gear is designed to withstand normal landing forces, but structural integrity can be compromised when those forces are exceeded (Oh et al., 2020). In the case of Flight 647, the hard landing caused excessive stress on the landing gear components, surpassing their design limits and resulting in the collapse of the landing gear. This indicates a direct cause-and-effect relationship between the crew’s actions and the subsequent failure of the landing gear.
Agreeing with the NTSB’s findings is strongly justified due to the impact on the landing gear from the hard landing and the flight crew’s failure to follow established procedures. The NTSB conducted evidence and analysis, including examining flight data recorders, cockpit voice recorders, and physical evidence from the accident site (Smaili et al., 2019). They concluded that the crew’s inadequate glide path control caused the accident.
While the NTSB primarily focused on the inadequate glide path control, several underlying factors may have contributed to the accident:
- Fatigue and Crew Resource Management:Fatigue could have significantly impacted the crew’s performance as a crucial underlying factor. Impaired cognitive abilities, decision-making, and reaction times due to fatigue can increase the likelihood of errors. The crew’s judgment and performance during the landing may have been influenced by fatigue, which is worth considering despite its non-explicit mention as a factor in the NTSB report (NTSB, 2003). Long duty hours or circadian rhythm disruptions could have compromised the crew’s ability to manage the descent rate effectively due to fatigue.
- Training and Simulator Programs:Another important aspect related to the underlying factors is crew resource management (CRM). CRM encompasses effective communication, coordination, and decision-making among the flight crew. Inadequate CRM can lead to misunderstandings, misinterpretations, and errors in managing critical flight parameters (NTSB, 2003). Misunderstandings, misinterpretations, and errors in managing critical flight parameters can result from insufficient CRM. The crew’s ability to accurately assess and manage the descent rate in Flight 647 could have been influenced by issues related to CRM, such as ineffective communication or decision-making. The NTSB report does not specifically address CRM deficiencies (Wiegmann & Shappell, 2020). These factors could have influenced the crew’s inadequate glide path control.
Moreover, the investigation did not consider any possible inadequacies in the training or simulator programs that could have caused the crew’s insufficient management of glide path control. Evaluating the adequacy of training programs in preparing pilots to handle abnormal situations during landing is crucial (Oh et al., 2020). Situational awareness, decision-making, and the ability to manage descent rates effectively are skills that should be emphasized and practiced during pilot training. Pilots can develop the necessary competencies to handle challenging landing scenarios by ensuring that training programs address these areas comprehensively.
Recommended Actions for Pilots:
Based on the analysis of this accident case study, pilots facing similar situations should consider the following actions:
- Adherence to Standard Operating Procedures (SOPs): Pilots must strictly adhere to established SOPs during all flight phases, especially critical phases such as landing. This includes closely monitoring descent rates and following recommended glide path parameters.
- Situational Awareness and Decision-making: Pilots should continuously assess their situational awareness and make informed decisions based on available information (Wiegmann & Shappell, 2020). This includes recognizing and addressing abnormal flight parameters promptly.
- Effective Crew Resource Management: Proper communication, coordination, and division of tasks within the flight crew are vital in managing challenging situations (Wiegmann & Shappell, 2020). Pilots should actively use effective crew resource management techniques to enhance operational safety.
The critical analysis of the Federal Express Flight 647 accident highlights the primary cause, as cited by the NTSB: inadequate glide path control during landing. This analysis supports the NTSB’s findings while identifying underlying factors, such as fatigue and crew resource management issues (NTSB, 2003). while the NTSB primarily focused on the flight crew’s inadequate glide path control as the primary cause of the accident, it is essential to consider underlying factors that may have contributed to the crew’s performance during the landing phase. Factors such as fatigue and CRM issues could have influenced the crew’s ability to manage the descent rate effectively. Additionally, deficiencies in training and simulator programs may have affected the crew’s inadequate glide path control. By addressing these underlying factors, the aviation industry can further improve safety measures and enhance pilot training to prevent similar accidents in the future.
Griffin, P. J., & Walsh, J. T. (1992). Book reviews: The holy bible containing the Old and new testaments: New revised standard version. Nashville: Thomas Nelson, 1990. Biblical Theology Bulletin: Journal of Bible and Culture, 22(1), 34–37. https://doi.org/10.1177/014610799202200106
National Transportation Safety Board. (2003). HARD LANDING, GEAR COLLAPSE FEDERAL EXPRESS FLIGHT 647 BOEING MD-10-10F, N364FE MEMPHIS, National Transportation Safety Board Washington, D.C.
Oh, S., Kim, S., & Yoon, Y. (2020). An analysis of runway accident precursors based on latent class model. KSCE Journal of Civil Engineering, 24(9), 2784–2793. https://doi.org/10.1007/s12205-020-2395-x
Smaili, M. H., Breeman, J., Lombaerts, T. J., Mulder, J. A., Chu, Q. P., & Stroosma, O. (2019). Intelligent flight control systems evaluation for loss-of-control recovery and prevention. Journal of Guidance, Control, and Dynamics, 40(4), 890–904. https://doi.org/10.2514/1.g001756
Wiegmann, D. A., & Shappell, S. A. (2020). Aviation case studies using HFACS. A Human Error Approach to Aviation Accident Analysis, 72–98. https://doi.org/10.4324/9781315263878-4