Event Details


Title:Inadvertent In-Flight Slat Deployment, China Eastern Airlines Flight 583, McDonnell Douglas MD-11, B-2171, 950 Nautical Miles South Of Shemya, Alaska, April 6, 1993
Micro summary:The wing slats on this McDonnell Douglas MD-11 were inadvertently deployed in cruise, causing an in-flight upset.
Event Time:1993-04-06 at 0110 HST
File Name:1993-04-06-US.pdf
Publishing Agency:National Transportation Safety Board (NTSB)
Publishing Country:USA
Report number:NTSB-AAR-93-07
Pages:71
Diversion Airport:Eareckson Air Station, Shemya, Alaska (Diversion)
Site of event:950 nm S of Shemya, AK
Latitude/Longitude:N39, E172
Departure:Shanghai Hongquao Airport, Shanghai, China
Destination:Unknown
Airplane Type(s):McDonnell Douglas MD-11
Flight Phase:Cruise
Registration(s):B-2171
Operator(s):China Eastern Airlines
Type of flight:Revenue
Occupants:255
Fatalities:2
Serious Injuries:156
Minor/Non-Injured:97
Other Injuries:0
Diverted to:Eareckson Air Station, Shemya, Alaska (Diversion)
Executive Summary:On April 6, 1993, at 0110 Hawaiian Standard Time, China Eastern Airlines flight 583, a McDonnell Douglas MD- 11, Chinese registration B-2171, a scheduled international passenger flight from Beijing, China, to Los Angeles, California, with an intermediate stop in Shanghai, China, had an inadvertent deployment of the leading edge wing slats while in cruise flight, approximately 950 nautical miles south of Shemya, Alaska. 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 U. S. Air Force Base, Shemya, Alaska. Of the 235 passengers and 20 crewmembers aboard the airplane, 2 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.

The National Transportation Safety Board determines that the probable cause of this accident was 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.

The safety issues in this report focused on the inadequate design of the flap/slat actuation handle on the MD-11 airplane, the inadvertent extension of the leading edge wing slats, the longitudinal stability of the MD-11 during the pitch upset, and the pilot-induced oscillations that can occur during the recovery. Also discussed is the premature deterioration of the seat cushion fire-blocking material and the inability of the material to provide the required seat cushion fire protection on transport-category airplanes.

Safety recommendations concerning these issues were addressed to the Federal Aviation Administration.
Learning Keywords:Operations - Upset - Uncommanded or excessive Pitch
Operations - Upset in-flight (extreme attitudes, stall, spin)
Systems - Flight Controls - Spoilers - Slats - Flaps
Other - Certification

 




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