DOUGLAS MD-10FEDERAL EXPRESS CORP
Raymond, PA, USA · 2008-06-14·N554FE
What happened
NTSB summary, verbatimAccording to the captain, the flight was uneventful until shortly before the airplane entered a holding pattern at FL330. The speed calculated by the flight management system (FMS) was 230 knots, 5 knots above the Vmin speed for the configuration and weight of the airplane. Both pilots expected the FMS to automatically default to the ICAO maximum holding speed of 265 knots, as described in the company flight manual. However, the captain decided to command the FMS to maintain 240 knots to increase the buffer between the holding speed and Vmin. Upon reaching the pattern fix, the airplane automatically banked left to enter holding and the captain noticed that the airspeed was lessening from 240 knots. He expected the airspeed to recover once the turn was completed. He also expected the bank to be limited to 15 degrees, but the autopilot actually commanded 23 degrees. Upon completing the turn, the airspeed was approximately 5 knots below Vmin. The captain expected the airspeed to recover now that the airplane was wings level. However, this did not occur, and when appropriate, the airplane started to automatically turn to the inbound holding heading. The crew then requested and was granted a clearance to descend to FL320 in the holding pattern. The captain then selected level change on the FMS to 320 and he also reduced the autobank controller to 15 degrees, from 23 degrees. During the descending turn, with the airspeed at about 220 knots, the first officer recommended extending the slats. The maximum slat extension speed at that juncture was 270 knots, according to the captain. When the slats extended, the maximum slat extension speed indicator on the airspeed indicator fell to below 220 knots. The captain then immediately ordered the first officer to retract the slats. He stated that at this point the airplane began to buffet, and an autoslat extension alert occurred. The first officer requested a further descent and was cleared to FL290. The captain then selected a level change on the FMS to 290. The buffeting ceased when the airplane was passing approximately FL300 during this descent. The flight landed uneventfully; however, the buffeting had caused substantial damage to both elevators and right horizontal stabilizer that was discovered during a post-flight inspection. According to the flight data recorder data and an analysis of that data by the airplane’s manufacturer, the slats were extended by the flight crew when the airspeed was 205 knots, well below the maximum slat extension speed of 260 knots. However the Mach number at that time was 0.59, well above the 0.51 Mach minimum slat extension speed. The target Mach then became 0.51, and the autothrottles reduced from 100% N1 rpm to about 50% N1 rpm. When the slats were retracted by the flight crew, the autothrottles advanced the thrust back to 100% N1 rpm. However, by the time the engine thrust had recovered, the airspeed had dropped to about 180 knots. The stick shakers activated about 5 seconds later and continued to operate for approximately one minute.
Photographs
1the aircraft, and what the investigators foundProbable cause
the Board's determinationThe flight crew's failure to adequately monitor the airplane's airspeed during the holding pattern, leading to the onset of an aerodynamic stall and subsequent structural damage to the tail from buffet.
Occurrence sequence
1 stepsNTSB coding · CICTT taxonomy- 1 · Enroute-holding (IFR)Aerodynamic stall/spindefining event
Findings
1 causal · 0 contributing- CAUSEPersonnel issues › Action/decision › Info processing/decision › Expectation/assumption — Pilot
Sequence of events
8 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)- SRN 92,228 (about 1 h 40 min after takeoff)holdingp.4Slats L2, R2, L4 and R4 transitioned from Retracted to Transit (Near Retracted) while in about a 15-degree left roll at 33,000 ft, 206 knots computed airspeed, both engine N1 at 98%
- SRN 92,228-92,255holdingp.4Slats moved to Transit (Near Extended), back to Near Retracted, then Retracted; N1 decreased to a minimum of 48% then increased to about 80%; airspeed decreased to 194 knots and continued decreasing
- SRN 92,271holdingp.4At 186 knots both stick shakers transitioned to Warn; engine N1 had increased to about 99%
- SRN 92,283descentp.4Descent from 33,000 ft to 29,000 ft began; airspeed had decreased to a minimum of 176 knots
- SRN 92,283-92,329descentp.4Airspeed fluctuated around 180 knots and the stick shakers cycled to Warn a couple more times; at SRN 92,305 Slat Auto Extend commanded Extend, slats L4/R4 moved to Near Retracted, master caution and Slats Disagree activated; all reverted at SRN 92,318 as airspeed increased; slats back to Retracted at SRN 92,323
- SRN 92,329descentp.4At 30,787 ft and 189 knots the stick shakers ceased and remained off for the rest of the flight
- SRN 92,475cruisep.4Reached 29,000 ft with airspeed increased to 243 knots
- SRN 96,647landingp.4Aircraft landed, about 1 hour 9 minutes later
NTSB analysis
from the final reportAccording to the captain, the flight was uneventful until shortly before the airplane entered a holding pattern at FL330. The speed calculated by the flight management system (FMS) was 230 knots, 5 knots above the Vmin speed for the configuration and weight of the airplane. Both pilots expected the FMS to automatically default to the ICAO maximum holding speed of 265 knots, as described in the company flight manual. However, the captain decided to command the FMS to maintain 240 knots to increase the buffer between the holding speed and Vmin. Upon reaching the pattern fix, the airplane automatically banked left to enter holding and the captain noticed that the airspeed was lessening from 240 knots. He expected the airspeed to recover once the turn was completed. He also expected the bank to be limited to 15 degrees, but the autopilot actually commanded 23 degrees. Upon completing the turn, the airspeed was approximately 5 knots below Vmin. The captain expected the airspeed to recover now that the airplane was wings level. However, this did not occur, and when appropriate, the airplane started to automatically turn to the inbound holding heading. The crew then requested and was granted a clearance to descend to FL320 in the holding pattern. The captain then selected level change on the FMS to 320 and he also reduced the autobank controller to 15 degrees, from 23 degrees. During the descending turn, with the airspeed at about 220 knots, the first officer recommended extending the slats. The maximum slat extension speed at that juncture was 270 knots, according to the captain. When the slats extended, the maximum slat extension speed indicator on the airspeed indicator fell to below 220 knots. The captain then immediately ordered the first officer to retract the slats. He stated that at this point the airplane began to buffet, and an autoslat extension alert occurred. The first officer requested a further descent and was cleared to FL290. The captain then selected a level change on the FMS to 290. The buffeting ceased when the airplane was passing approximately FL300 during this descent. The flight landed uneventfully; however, the buffeting had caused substantial damage to both elevators and right horizontal stabilizer that was discovered during a post-flight inspection. According to the flight data recorder data and an analysis of that data by the airplane’s manufacturer, the slats were extended by the flight crew when the airspeed was 205 knots, well below the maximum slat extension speed of 260 knots. However the Mach number at that time was 0.59, well above the 0.51 Mach minimum slat extension speed. The target Mach then became 0.51, and the autothrottles reduced from 100% N1 rpm to about 50% N1 rpm. When the slats were retracted by the flight crew, the autothrottles advanced the thrust back to 100% N1 rpm. However, by the time the engine thrust had recovered, the airspeed had dropped to about 180 knots. The stick shakers activated about 5 seconds later and continued to operate for approximately one minute.