National Transportation
Safety Board
Washington, D.C. 20594
PRSRT STD
OFFICIAL BUSINESS
Postage & Fees Paid
Penalty for Private Use, $300
NTSB
Permit No. G-200
Hard Landing, Gear Collapse
Federal Express Flight 647
Boeing MD-10-10F, N364FE
Memphis, Tennessee
December 18, 2003
Aircraft Accident Report
NTSB/AAR-05/01
PB2005-910401
Notation 7632A
National
National
Transportation
Transportation
Safety Board
Safety Board
Washington, D.C.
Washington, D.C.

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Aircraft Accident Report
Hard Landing, Gear Collapse
Federal Express Flight 647
Boeing MD-10-10F, N364FE
Memphis, Tennessee
December 18, 2003
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NTSB/AAR-05/01
Y B OARD
PB2005-910401
National Transportation Safety Board
Notation 7632A
490 L’Enfant Plaza, S.W.
Adopted May 17, 2005
Washington, D.C. 20594

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National Transportation Safety Board. 2005. Hard Landing, Gear Collapse, Federal Express
Flight 647, Boeing MD-10-10F, N364FE, Memphis, Tennessee, December 18, 2003. Aircraft Accident
Report NTSB/AAR-05/01. Washington, DC.
Abstract: This report explains the accident involving Federal Express flight 647, a Boeing MD-10-10F,
N364FE, which crashed while landing at Memphis International Airport (MEM), Memphis, Tennessee.
Safety issues in this report focus on flight crew performance, emergency evacuations, MEM air traffic
control and aircraft rescue and firefighting issues, and flight data recorder reliability.
The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,
pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board
Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study
transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board
makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and
statistical reviews.
Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also
may be obtained from the Web site or by contacting:
National Transportation Safety Board
Public Inquiries Section, RE-51
490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
(800) 877-6799 or (202) 314-6551
Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To
purchase this publication, order report number PB2005-910401 from:
National Technical Information Service
5285 Port Royal Road
Springfield, Virginia 22161
(800) 553-6847 or (703) 605-6000
The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports
related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

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iii
Aircraft Accident Report
Contents
Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1
History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2
Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.3
Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.4
Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.5
Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.5.1
The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.5.1.1
The Captain’s 72-Hour History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.5.2
The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.5.2.1
The First Officer’s 72-Hour History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.5.2.2
The First Officer’s Landing History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.6
Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.7
Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.7.1
Weather for Memphis International Airport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.7.2
Massachusetts Institute of Technology/Lincoln Laboratory Study . . . . . . . . . . . . . 11
1.8
Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.9
Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.10.1 MEM Aircraft Rescue and Firefighting General Information . . . . . . . . . . . . . . . . 13
1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.11.2.1 FDR Recording of Aileron Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.12 Wreckage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.12.1 Tire and Other Markings on the Runway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.12.2 Landing Gear Assemblies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.12.3 Cargo and Shipping Containers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.12.4 Postaccident Examination of the Emergency Evacuation Slides . . . . . . . . . . . . . . 21
1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.15.1 Nonrevenue FedEx Pilot’s Activation of the L1 Door/Slide . . . . . . . . . . . . . . . . . 22
1.15.2 Emergency Evacuation Videotape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
1.15.3 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
1.15.3.1 RMFD Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
1.15.3.2 Postaccident Federal Aviation Administration Actions . . . . . . . . . . . . . . . . . . . 25
1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1.16.1 Airplane Performance Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

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Contents
iv
Aircraft Accident Report
1.16.1.1 Safety Board’s Airplane Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1.16.1.2 Wind Derivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
1.16.1.3 Boeing’s Airplane Landing Energy Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
1.16.2 Metallurgical Examination of the Right Main Landing Gear Assembly . . . . . . . . 29
1.16.3 Flight Simulator Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
1.17 Operational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
1.17.1 FedEx General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
1.17.2 FedEx Crew Training, Guidance, and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 31
1.17.2.1 FedEx’s Missed Approach/Go-Around Policy . . . . . . . . . . . . . . . . . . . . . . . . . . 31
1.17.2.2 FedEx Crosswind Landing Guidance and Procedures . . . . . . . . . . . . . . . . . . . . 32
1.17.2.2.1 Crewmember Descriptions of the Accident Approach and Landing . . . . . . 32
1.17.2.3 FedEx Windshear Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
1.17.2.4 FedEx Emergency Evacuation Procedures and Guidance . . . . . . . . . . . . . . . . . 34
1.17.2.5 FedEx Emergency Evacuation Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
1.17.2.5.1 Regulatory Requirements and Federal Aviation
Administration Oversight of Emergency Training . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
1.17.2.5.2 Previous Safety Board Emergency Exit Training
Device Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
1.17.3 FedEx Enhanced Oversight Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
1.17.4 Federal Aviation Administration and Department of
Defense Oversight of FedEx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
1.18.1 MD-11/-10 Flight Characteristics and Differences . . . . . . . . . . . . . . . . . . . . . . . . . 40
1.18.2 Previous Safety Board Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.1
General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2
The Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2.3
Failure of the Right Main Landing Gear Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.4
Flight Crew Performance—Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
2.5
Survival Factors Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
2.5.1
Emergency Exit Door/Slide Operation and Training . . . . . . . . . . . . . . . . . . . . . . . 51
2.5.2
Cockpit Window Emergency Evacuation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2.6
Memphis ATCT Actions and Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2.7
FDR Aileron Update Rate Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.1
Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.2
Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
4. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.1
New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.2
Previously Issued Recommendation Reiterated in This Report . . . . . . . . . . . . . . . . . . 61
5. Appendixes
A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

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v
Aircraft Accident Report
Figures
1. MEM airport diagram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2. Photograph of the damage to the right side of the airplane.. . . . . . . . . . . . . . . . . . . . . . . . . 17
3. FedEx’s MD-11/-10 emergency evacuation door trainer, with
the girt flap assembly in place, as it would appear when the
door/slide is opened. The arrow indicates the manual inflation handle . . . . . . . . . . . . . . . . 18
4. FedEx’s MD-11/-10 emergency evacuation door trainer, with the
girt flap assembly lifted. The arrow indicates the slide/raft disengage handle . . . . . . . . . . . 19
5. The airplane’s vertical speeds (as identified by the Safety
Board’s performance study) during the accident landing and the two
previous landings, with altitude displayed above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
6. Pitch attitudes recorded by the FDR during the accident landing
and two previous landings. The vertical black line (FDR elapsed time
0 seconds) represents the airplane’s touchdown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

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vi
Aircraft Accident Report
Abbreviations

AC
advisory circular
ADC
air data computer
AFFF
aqueous film forming foam
AFS
autoflight system
agl
above ground level
AIRMET
airmen’s meteorological information
ALPA
Air Line Pilots Association
ARFF
aircraft rescue and firefighting
ASOS
automated surface observation system
ATC
air traffic control
ATCT
air traffic control tower
ATIS
automatic terminal information service
ATP
airline transport pilot
C
Celsius
CAWS
central aural warning system
c.g.
center of gravity
CFR
Code of Federal Regulations
CVR
cockpit voice recorder
EOP
enhanced oversight program
FAA
Federal Aviation Administration
FCC
flight control computer
FCIF
flight crew information file
FDR
flight data recorder
FL
flight level
FMS
flight management system

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Abbreviations
vii
Aircraft Accident Report
FOM
flight operations manual
fpm
feet per minute
Fps
feet per second
FSB
Flight Standardization Board
ft-lb
foot-pound
Hg
mercury
IND
Indianapolis International Airport
IRS
inertial reference system
ITU
initial, transition, or upgrade training
ILS
instrument landing system
MAC
mean aerodynamic chord
MEM
Memphis International Airport
MFD
Memphis Fire Department
MIT
Massachusetts Institute of Technology
ms
millisecond
MSCAA
Memphis/Shelby County Airport Authority
msl
mean sea level
OAK
Metropolitan Oakland International Airport
POI
principal operations inspector
P/N
part number
PRIA
Pilot Records Improvement Act
PST
Pacific standard time
RMFD
Rural/Metro Fire Department
sm
statute miles
S/N
serial number
WAGS
windshear alert and guidance system
WME
wind measuring equipment

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viii
Aircraft Accident Report
Executive Summary
On December 18, 2003, about 1226 central standard time, Federal Express
Corporation (FedEx) flight 647, a Boeing MD-10-10F (MD-10), N364FE, crashed while
landing at Memphis International Airport (MEM), Memphis, Tennessee. The right main
landing gear collapsed after touchdown on runway 36R, and the airplane veered off the
right side of the runway. After the gear collapsed, a fire developed on the right side of the
airplane. Of the two flight crewmembers and five nonrevenue FedEx pilots on board the
airplane, the first officer and one nonrevenue pilot received minor injuries during the
evacuation. The postcrash fire destroyed the airplane’s right wing and portions of the right
side of the fuselage. Flight 647 departed from Metropolitan Oakland International Airport
(OAK), Oakland, California, about 0832 (0632 Pacific standard time) and was operating
under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument
flight rules flight plan.
The National Transportation Safety Board determines that the probable causes of
the accident were 1) the first officer’s failure to properly apply crosswind landing
techniques to align the airplane with the runway centerline and to properly arrest the
airplane’s descent rate (flare) before the airplane touched down; and 2) the captain’s
failure to adequately monitor the first officer’s performance and command or initiate
corrective action during the final approach and landing.
The safety issues in this report focus on flight crew performance, emergency
evacuations, MEM air traffic control and aircraft rescue and firefighting issues, and flight
data recorder reliability.

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Document Outline

• Cover
• Title Page
• Contents
• Figures
• Abbreviations
• Executive Summary
• 1. Factual Information
  • 1.1 History of Flight
  • 1.2 Injuries to Persons
  • 1.3 Damage to Aircraft
  • 1.4 Other Damage
  • 1.5 Personnel Information
    • 1.5.1 The Captain
      • 1.5.1.1 The Captains 72-Hour History
    • 1.5.2 The First Officer
      • 1.5.2.1 The First Officers 72-Hour History
      • 1.5.2.2 The First Officers Landing History
  • 1.6 Airplane Information
  • 1.7 Meteorological Information
    • 1.7.1 Weather for Memphis International Airport
    • 1.7.2 Massachusetts Institute of Technology/Lincoln Laboratory Study
  • 1.8 Aids to Navigation
  • 1.9 Communications
  • 1.10 Airport Information
    • 1.10.1 MEM Aircraft Rescue and Firefighting General Information
  • 1.11 Flight Recorders
    • 1.11.1 Cockpit Voice Recorder
    • 1.11.2 Flight Data Recorder
      • 1.11.2.1 FDR Recording of Aileron Positions
  • 1.12 Wreckage Information
    • 1.12.1 Tire and Other Markings on the Runway
    • 1.12.2 Landing Gear Assemblies
    • 1.12.3 Cargo and Shipping Containers
    • 1.12.4 Postaccident Examination of the Emergency Evacuation Slides
  • 1.13 Medical and Pathological Information
  • 1.14 Fire
  • 1.15 Survival Aspects
    • 1.15.1 Nonrevenue FedEx Pilots Activation of the L1 Door/Slide
    • 1.15.2 Emergency Evacuation Videotape
    • 1.15.3 Emergency Response
      • 1.15.3.1 RMFD Emergency Response
      • 1.15.3.2 Postaccident Federal Aviation Administration Actions
  • 1.16 Tests and Research
    • 1.16.1 Airplane Performance Studies
      • 1.16.1.1 Safety Boards Airplane Performance Study
      • 1.16.1.2 Wind Derivation
      • 1.16.1.3 Boeings Airplane Landing Energy Analysis
    • 1.16.2 Metallurgical Examination of the Right Main Landing Gear Assembly
    • 1.16.3 Flight Simulator Study
  • 1.17 Operational and Management Information
    • 1.17.1 FedEx General Information
    • 1.17.2 FedEx Crew Training, Guidance, and Procedures
      • 1.17.2.1 FedExs Missed Approach/Go-Around Policy
      • 1.17.2.2 FedEx Crosswind Landing Guidance and Procedures
        • 1.17.2.2.1 Crewmember Descriptions of the Accident Approach and Landing
      • 1.17.2.3 FedEx Windshear Guidance
      • 1.17.2.4 FedEx Emergency Evacuation Procedures and Guidance
      • 1.17.2.5 FedEx Emergency Evacuation Training
        • 1.17.2.5.1 Regulatory Requirements and Federal Aviation Administration Oversight of Emergency Tra...
        • 1.17.2.5.2 Previous Safety Board Emergency Exit Training Device Recommendation
    • 1.17.3 FedEx Enhanced Oversight Program
    • 1.17.4 Federal Aviation Administration and Department of Defense Oversight of FedEx
  • 1.18 Additional Information
    • 1.18.1 MD-11/-10 Flight Characteristics and Differences
    • 1.18.2 Previous Safety Board Actions
• 2. Analysis
  • 2.1 General
  • 2.2 The Accident Sequence
  • 2.3 Failure of the Right Main Landing Gear Assembly
  • 2.4 Flight Crew Performance„Oversight
  • 2.5 Survival Factors Issues
    • 2.5.1 Emergency Exit Door/Slide Operation and Training
    • 2.5.2 Cockpit Window Emergency Evacuation Issues
  • 2.6 Memphis ATCT Actions and Issues
  • 2.7 FDR Aileron Update Rate Issues
• 3. Conclusions
  • 3.1 Findings
  • 3.2 Probable Cause
• 4. Recommendations
  • 4.1 New Recommendations
  • 4.2 Previously Issued Recommendation Reiterated in This Report
• 5. Appendixes
  • Appendix A
    • Investigation
    • Public Hearing
  • Appendix B
    • Cockpit Voice Recorder Transcript

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