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NTSB Preliminary Report – UPS Boeing MD-11F Crash [pdf]

https://www.ntsb.gov/Documents/Prelimiary%20Report%20DCA26MA024.pdf
75•gregsadetsky•2h ago

Comments

frenchman_in_ny•1h ago
Adding summary analysis from AVHerald [0]

[0] https://avherald.com/h?article=52f5748f&opt=0

tremon•18m ago
> On the aft lug, on both the inboard and outboard fracture surfaces, a fatigue crack was observed where the aft lug bore met the aft lug forward face. For the forward lug's inboard fracture surface, fatigue cracks were observed along the lug bore. For the forward lug's outboard fracture surface, the fracture consisted entirely of overstress with no indications of fatigue cracking

If I'm parsing this correctly, they're saying that fatigue cracks should have been visible in the aft pylon mount, and that the forward mount was similarly fatigued but showed no damage on the outside?

Aman_Kalwar•1h ago
Appreciate the transparency in these reports. The technical breakdowns always highlight how complex aviation safety is.
philip1209•1h ago
Originally explained on the blancolirio channel on YouTube -

The timing and manner of the break make a lot more intuitive sense when you consider that the engine is essentially a massive gyroscope. As the plane starts to rotate, the spinning engine resists changes to the direction of its spin axis, putting load on the cowling. When the cowling and mount fail, that angular momentum helps fling the engine toward the fuselage.

cj•1h ago
There might be some truth in that. But the report doesn't confirm that theory.
philip1209•1h ago
I'm presenting it "useful not true" - not an RCA.
rconti•1h ago
What theory? That the mount failed? Or the rotation of the engine in the photos going up and over the fuselage?

It seems like both are true, but doesn't necessarily prove WHY the mount failed.

cj•50m ago
That the engine was flung into the fuselage due to gyroscopic forces.
scottlamb•35m ago
Not an aviation expert at all, so take this with a grain of salt, but I think "the spinning engine resists changes to the direction of its spin axis" offers two important insights:

* why it failed at rotation (the first/only sudden change of direction under full throttle) rather than as soon as it was mounted onto the plane, while taxiing, as soon as they throttled up, mid-flight, or on landing. This is important because at rotation is the worst possible time for this failure: no ability to abort take-off, no ability to land safety under no or severely limited power, little time to react at all, full fuel. Knowing these failures are likely to manifest then stresses the importance of avoiding them.

* why it failed in such a way that it damaged the rest of the plane.

Not so much what was wrong with the mounting in the first place, if that's what you're asking. Presumably it was designed to withstand the forces of this moment and clearly has done so many times before.

londons_explore•1h ago
I assume such forces are calculated and added in when deciding hot thick to make those mounting brackets.
baggy_trough•1h ago
Yes, but the point is that this moment of the takeoff is when a failure that's been waiting to happen is most likely both because of the thrust and the gyroscopic resistance.
loeg•39m ago
Yes, obviously; MD-11s aren't flinging engines off the wing every single takeoff. A 34 year old airframe may or may not actually match design strength, though.
PunchyHamster•36m ago
I think far simpler explanation is "the back part failed first and engine is making thrust so it just flipped over on now-hinge mounting
mrb•2m ago
[delayed]
albert_e•1h ago
The surveillance video mentioned in page 2 -- from which the series of still images are shown -- is that available publicly?
rft•49m ago
I haven't seen that one, this video [1] includes a different angle taken from a vehicle on the airport.

[1] https://youtu.be/POKJUJk_2xs?t=342

sosodev•1h ago
A commenter in HN thread covering the initial crash mentioned that the left engine detaching might have been the cause https://news.ycombinator.com/item?id=45821537

The referenced AA Flight 191 is shockingly similar. It makes me wonder if aviation really is back sliding into a dangerous place.

lotsofpulp•1h ago
Are you referring to AA 191 in 1979? That seems like low enough frequency event to not be worried about it.

The murder suicides in the last few decades seem more concerning.

crote•7m ago
Rather the opposite: if the cause is similar to AA 191, why weren't the actions taken after AA 191 to prevent a repeat effective? If we can get a repeat of that incident, what's preventing the industry from repeating the mistakes from all those other incidents from the past decades? Why aren't they learning from their past mistakes - often paid for in blood?
jeffbee•59m ago
I don't know if it's "sliding back" as much as it is that this plane is also fundamentally from the 1970s.
sosodev•50m ago
The MD-11 was developed after that crash. Shouldn't its design and maintenance procedures have been informed by the incident?
buildsjets•26m ago
The MD-11 is nothing but a re-engined and a re-named DC-10. They share the same type certificate.

https://www.easa.europa.eu/en/document-library/type-certific...

loeg•19m ago
Maintenance was informed by the earlier incident. It's why we haven't seen even more DC-10/MD-11 failures sooner. Designs too have kinda been informed by this -- it's not like Boeing or Airbus make trijets anymore.
gosub100•26m ago
40 years between severe accidents is fine in terms of expected failures. It's also not a good comparison because in the 70s maintenance crew were using a forklift to remive engines, improperly stressing the engine pylon. This was done as a shortcut
londons_explore•1h ago
I was under the impression that a plane could deal with an engine failure at any point in flight - including during takeoff.

Dropping an engine entirely is a similar situation to a failure - with the benefit that you now have a substantially lighter if imbalanced aircraft.

Should this plane have been able to fly by design even with an engine fallen off?

lotsofpulp•1h ago
It didn’t fall off, it flew up and then landed back on the plane.

https://www.reddit.com/r/aviation/comments/1p276xx/ntsb_issu...

buildsjets•1h ago
And also ripped open a giant hole in the fuel tank which allowed all of the fuel to be released and ignited.
baggy_trough•1h ago
Yes, but when the engine came off, it also disrupted the third engine in the tail. Can't take off in this model with 2 out of 3 engines gone.
jeffbee•58m ago
Even if they had the thrust (doubtful) there wouldn't be enough lift with a gaping hole in the leading edge of one wing.
sq_•44m ago
Yeah, if they had had more altitude, I would guess that this would have looked even more like the AA 191 crash from 1979, with the left wing stalling and causing a roll and pitch down.

That in turn reminds me of the DHL flight out of Baghdad in 2003 that was hit by a missile [0]. Absolutely amazing that they managed to keep it together and land with damage like that.

[0] https://en.wikipedia.org/wiki/2003_Baghdad_DHL_attempted_sho...

crote•16m ago
An important factor in AA 191 is that the engine leaving did significant damage to the hydraulic lines in that wing - including those for the leading-edge slats. At the time the plane was not equipped with any mechanism to keep the slats extended, so after hydraulic pressure was lost airflow over the wings caused them to retract, which significantly lowered that wing's stall speed.

After AA 191 the DC-10 was equipped with a locking system: loss of pressure now results in the slats getting stuck in their current position. The MD-11 will undoubtedly also have this system, so a direct repeat of AA 191 is unlikely.

sokoloff•35m ago
The video of the aircraft crossing the road wings level (well after #1 separated) and maintaining relatively controlled flight until too much energy bled off suggests to me the aircraft was likely to be controllable to a landing if sufficient thrust was available.
loeg•21m ago
I thought the leading edge of the wing was intact in this case? I may be misremembering.
bunderbunder•56m ago
Yeah, pilots I know saw puffs of flame coming out of the engine, and said that that's a tell-tale sign of a compressor stall. Which could have been caused by debris from the separating left engine striking the turbine.
loeg•21m ago
Debris, or even just smoke from the wing fire.
jpk2f2•1h ago
Not only did it happen at the worst possible moment, it took out a second engine on it's way out and over the plane. Two engines should've been enough to get off the ground and potentially land the plane, but one engine on a trijet isn't enough.
yuvadam•40m ago
El Al 1862 was another flight [1] that had an engine fall off, taking another engine out with it. The pilots managed to fly around for a few minutes and attempt a landing, but there was too much structural damage.

It doesn't seem aircraft are designed to survive these types of catastrophic failures.

[1] - https://en.wikipedia.org/wiki/El_Al_Flight_1862

Bender•39m ago
From the wing down I assumed it may have depended if the engine coming out unintentionally means redundant hydraulic lines and mounts are also getting disconnected causing a complete loss of control not that it would have helped much at that point beyond minimizing ground damages.
loeg•22m ago
They seem to have lost the tail engine too. Yes, it is a significant problem that engine failures aren't independent, so trijets are kind of a bad design.
chimpontherun•59m ago
surprised to see typos in aviation terms and acronyms: ADS-8 (page 3) and 747-BF (page 5)
ynniv•55m ago
pretty weird...

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maxbond•44m ago
These all seem like OCR errors...? Why would there be OCR in this workflow? Did they print this out and then generate a PDF from a scan instead of the original source? To maintain an air gap maybe?
ynniv•29m ago
it would seem so. so the question is why they would maintain an air gap for a safety report
Denvercoder9•44m ago
Swapping B and 8 in both cases, which is typically something that happens with OCR. Weird.
rft•58m ago
Grounding all MD-11s and DC-10s is a major move. I guess it makes sense as a big factor was the fatigue cracks on the pylon (lugs), despite the pylon not being behind on inspections. I am wondering what the inspections of pylons in other planes will yield, likely that will determine whether the grounding will continue.

But beyond figuring out why the engine mount failed, I am very interested in what caused the actual crash. "Just" losing thrust in a single engine is usually not enough to cause a crash, the remaining engine(s) have enough margin to get the plane airborne. Of course this was a major structural failure and might have caused additional damage.

EDIT: It seems there was damage to the engine in the tail, even though this was not specified in the preliminary report, likely because it has not been sufficiently confirmed yet.

SteveNuts•53m ago
Even if they end the grounding of the MD-11/DC-10 I'd be shocked if any airlines still using them will continue to use them.

Seems like the risk/reward just isn't really there for the few of them still in service, and if anything happened it would be a PR nightmare on top of a tragedy.

Definitely an end of an era!

mandevil•40m ago
I think that the Mad Dogs only exist as freighters (~or their derivative KC-10 tankers~-Edited to correct that they retired last year) these days. I think the last pax service for any of them was over a decade ago.

And air freight just gets a lot less public attention, I think they are going to keep flying them if they don't get grounded.

joleyj•31m ago
The airforce retired the KC-10 in 2021.
buildsjets•29m ago
The KC-10 went out of service last year. None are operating.
loeg•24m ago
Yeah, but DC-10 based tankers for wildfire fighting were still flying until the recent grounding: https://en.wikipedia.org/wiki/DC-10_Air_Tanker

(Blancolirio points out that the DC-10 tanker is what they modernized to relatively recently -- before that they were flying even more dangerous WW2 airframes for firefighting.)

mandevil•14m ago
Damnit, I knew that! Just forgot it in the moment.
rft•36m ago
Given that the report only mentioned a single other seemingly related accident in 1979 I am not sure that objectively this is a reason to discontinue flying these planes. The fact that these planes have been in service since the early 70s is a testament to their safety and reliability in itself. Of course public perception, especially with the videos of huge fireballs from hitting one of the worst possible locations, might put enough pressure on airlines to retire the planes anyway.

I agree on the end of an era. Hearing something else besides just Airbus- or Boeing-something always gives me a bit of joy. Even though MDs and DCs are of course Boeings in a sense now as well.

loeg•26m ago
Airlines haven't been using them, or at least not 1st world airlines. Just freight and wilderness fire fighters.
bunderbunder•49m ago
And if the failure of a wing engine can cause the rear engine to fail, that would raise concerns about all "two in front one in back" trijets. Similar to how putting the Space Shuttle orbiter's heat shield directly in the line of fire for debris that comes off he rocket during launch turned out to be a bit of a problem.
loeg•36m ago
Yeah, the trijet design seems failed in general. Unless you can design it to tolerate any wing+tail dual engine failure -- in which case, why have the tail engine at all?
buildsjets•32m ago
And the failure of an inboard wing mounted engine can cause the failure of an outboard wing mounted engine on the same side, as in the case of El Al 1862. https://www.faa.gov/lessons_learned/transport_airplane/accid...

And the failure of an engine mounted on the left wing can cause debris to cross through the fuselage structure and cause a failure of the engine mounted on the right wing, or to fly thousands of feet in any particular direction, as happened to American Airlines in both a ground run incident, and in their Flight 883 accident.

https://www.dauntless-soft.com/PRODUCTS/Freebies/AAEngine/

https://aerossurance.com/safety-management/uncontained-cf6-a...

rft•16m ago
At some point it comes down to probabilities. With so many flights going on, one in a million incidents become a certainty. For example UA232 [1] suffered failure in all 3 redundant hydraulic systems due to an uncontained engine failure. Any of the 3 systems would have been enough to retain control of the aircraft. Of course this lead to some investigations on why all 3 systems could be impacted at the same time and what can be done to limit failures.

Besides the technical aspects that flight is an impressive example of resilience and skill. Bringing that plane down to the ground in nearly one piece was essentially impossible and a one in a million chance in itself.

[1] https://en.wikipedia.org/wiki/United_Airlines_Flight_232

lazide•41m ago
Based on the original descriptions of the crash, I assumed the engine fell off.

From the photos, it’s clear it went up over the wing and impacted the fuselage with a (at least) minor explosion, which would have thrown foreign objects into the third engine in the tail for sure.

Losing 2/3 of the engines isn’t survivable on takeoff for this class of plane, at the weights they were at.

crote•30m ago
> I assumed the engine fell off

It's an engine - the thing pushing the entire plane forwards. Provided it is running (and at takeoff that's definitely the case), an engine being liberated from its plane suddenly has a lot less mass holding it back, so the logical thing to do is to shoot forwards. And because the wing is attached to the upper side of the engine, anything short of an immediate failure of all mounting points is probably also going to give it an upwards trajectory.

Add in air resistance, and you get the "swing across the wing and back" seen in the photos.

lazide•27m ago
Sure, but if the engine grenades it can take it’s mounts with it and not shoot off like a bottle rocket in front of and over the plane, dropping down and under the plane instead (or even just sit there). Same with a compressor stall, or whatever.

It’s clear from the photos this wasn’t the engine failing at all, and in fact the engine kept producing a ton of thrust (probably until it ran out of fuel as it pulled it’s fuel line apart while departing the wing), and instead the thing that is supposed to be so incredibly strong that it restrains all this chaos failed.

Which is a pattern in this family of aircraft, but definitely not a common or normal thing in general eh?

Most aircraft, the engine stays with the airframe even if it turns into a giant burning pile of shrapnel and dead hopes and dreams.

cyberax•25m ago
> EDIT: It seems there was damage to the engine in the tail, even though this was not specified in the preliminary report, likely because it has not been sufficiently confirmed yet.

Yes, the initial videos were showing the tail engine flaming out. And in the 1979 crash, the engine also severed hydraulic lines that hold the slats extended. So they folded in due to the aerodynamic pressure, essentially stalling the wing.

dzonga•36m ago
McDonnell-Douglass right there that's where the problems start.
GiorgioG•28m ago
It's just time to kill the MD-11 entirely. These 3-engine aircraft are too risky to continue flying.
LinuxAmbulance•25m ago
I'm surprised at how many years the plane went without having that part inspected. It looks like the failure was due to fatigue cracks, but the last time the part was inspected was in 2001?
LPisGood•18m ago
I’m seeing 2021 on page 10 - an I missing something?
loeg•17m ago
I believe the part was at least visually inspected in 2021:

> A review of the inspection tasks for the left pylon aft mount found both a general visual inspection (GVI) and a detailed visual inspection of the left pylon aft mount, required by UPS's maintenance program at a 72-month interval, was last accomplished on October 28, 2021.

serhack_•17m ago
Not an aviation expert, nor I want to be one, but the images look pretty intense.
pseudosavant•8m ago
It is incredible to me how quickly some lives can go from "another day as usual" to "gone" in a matter of seconds.