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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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April 6, 1993 · Mcdonnell Douglas MD-11 · B2171

Shemya, AK

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
April 6, 1993
Injury Outcomes
158 injuries (2 fatalities, 60 serious injuries, 96 minor injuries), 97 uninjured
Location
Shemya, AK
Aircraft
Mcdonnell Douglas MD-11
Tail Number
B2171
Operator
China Eastern Airlines
Injuries
Fatal
Aircraft Damage
Minor
NTSB Number
DCA93MA037

FLIGHT 583 WAS LEVEL AT 33,000 FEET WHEN THE LEADING EDGE SLATS DEPLOYED INADVERTENTLY. THE AUTOPILOT DISCONNECTED AND THE CAPTAIN WAS MANUALLY CONTROLLING THE AIRPLANE WHEN IT PROGRESSED THROUGH SEVERAL VIOLENT PITCH OSCILLATIONS AND LOST 5,000 FEET. THE SAFETY BOARD DETERMINED THAT THE INADVERTENT DEPLOYMENT OF THE SLATS WAS THE RESULT OD AN INADEQUATELY DESIGNED FLAP/SLAT HANDLE THAT ALLOWED THE HANDLED TO BE EASILY AND INADVERTENLY DISLODGED FROM THE UP/RET POSITION, THEREBY CAUSING SLAT EXTENSION.

NTSB Probable Cause

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.

Full Narrative

SEE NTSB BLUE COVER FACTUAL ACCIDENT REPORT - NTSB/AAR- 93/07

Flight

Event TypeAccident
Event Time22:30 AKDT
Nearest Airport0nm N
Runway0
Runway Width0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftMcdonnell Douglas MD-11
Tail NumberB2171
Aircraft CategoryAir
DamageMinor
OperatorChina Eastern Airlines
Operating RulePart 129
Engines3
Engine TypeTurbofan
Engine DetailsGe · CF6 · Turbofan · 61500
Seats350

People & Injuries

Injury Summary158 injuries (2 fatalities, 60 serious injuries, 96 minor injuries), 97 uninjured
Fatal2
Serious60
Minor96
Uninjured97
Total255
Crew 1Age 42 · Unknown

Conditions

ConditionsVMC
LightDark Night
WindCalm
CeilingNone
Temperature / Dew Point0 C / 0 C
Altimeter0

Appendix: Source Data