NTSB Factual Report

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

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.