Avient Aviation MD11 at Shanghai on Nov 28th 2009, overran runway on takeoff
Last Update: February 29, 2020 / 12:49:56 GMT/Zulu time
Incident Facts
Date of incident
Nov 28, 2009
Classification
Crash
Flight number
Z3-324
Departure
Shanghai Pudong, China
Destination
Bishkek, Kyrgyzstan
Aircraft Registration
Z-BAV
Aircraft Type
McDonnell Douglas MD-11
ICAO Type Designator
MD11
Airport ICAO Code
ZSPD
Pudong's runways 35L (third runway built) and 35R (first runway built) had to be closed, runway 35L could be reopened 6 hours after the crash. Runway 34 (second runway built) continued to operate all time. About 50 fire engines were at the scene to extinguish the fires.
There are reports, that the airplane had already rotated for takeoff but failed to become airborne resulting in at least one tailstrike.
A Shanghai based pilot witnessing the crash said, that the main gear left the ground just before the end of the runway, the airplane however did not climb more than 10 feet, impacted approach lights and antennas and fell back onto the ground.
Photos (see second image below) support the observation of the Shanghai based pilot showing some tops of the approach lights being damaged and subsequent gear tracks on soft ground until the airplane began to break up.
The three fatalities as well as the critically injured are US citizens, another Belgium, Indonesian and a Zimbabwean were on board of the airplane.
The hospital says, that the injured US citizen is currently stable suffering from multiple rib fractures, blast lung injury and pneumothorax. Doctors are hopeful to scale down the injury condition from critical to serious in about 72 hours unless complications occur. The other three survivors received injuries mainly to chest and limbs.
China's Civil Aviation Accident Investigation Board joined by the NTSB have recovered the black boxes of the aircraft.
Avient Aviation is registered in Harare (Zimbabwe). Z-BAV (msn: 48408) was formerly registered as N408SH, PR-LGD (Varig Logistica) and HL7372 (Korean Air). Avient Aviation had received the airplane just 8 days earlier. The airplane should have flown to Harare (Zimbabwe) via Bishkek.
Over the recent more than 10 years The Aviation Herald attempted several times to get hold of the final report via Chinese Authorities, ICAO and other resources but failed to obtain the final report. On Feb 28th 2020 The Aviation Herald however received a brief abstract in Chinese, which includes the conclusions of the accident investigation. The abstract of the investigation results reads (translated to English by AVH):
The crew did not properly operate the thrust levers so that the engines did not reach take off thrust. The aircraft had not reached Vr at the end of the runway and could not get airborne.
According to the design criteria of the MD11 the crew needs to push at least two thrust levers to beyond 60 degrees, which will trigger autothrust to leave "CLAMP" mode and adjust the thrust to reach the target setting for takeoff, the servo motors would push the thrust levers forward in that case. During the accident departure the pilot in the left seat did not advance the thrust levers to more than 60 degrees, hence the server motors did not work although autothrust was engaged bur remained in CLAMP mode and thus did not adjust the thrust to reach takeoff settings.
The crew members perceived something was wrong. Audibly the engine sound was weak, visibibly the speed of the aircraft was low, tactically the pressure on the back of the seat was weaker than normal. Somebody within the crew, possibly on the observer seats, suggested the aircraft may be a bit heavy. The T/O THRUST page never appeared (it appears if autothrust is engaged and changes from CLAMP to Thrust Limit setting. Under normal circumstances with autothrust being engaged a click sound will occur as soon as the thrust levers reach the takeoff thrust position. A hand held on the thrust levers will feel the lever moving forward, however, the crew entirely lost situational awareness. None of the anomalies described in this paragraph prompted the crews members' attention.
When the aircraft approached the end of the runway several options were available: reject takeoff and close the throttles, continue takeoff and push the throttle to the forward mechanical stop, continue takeoff and immediately rotate. The observer called "rotate", the captain rotated the aircraft. This shows the crew recognized the abnormal situation but did not identify the error (thrust levers not in takeoff position) in a hurry but reacted instinctively only. As the aircraft had not yet reached Vr, the aircraft could not get airborne when rotated. As verified in simulator verification the decision to rotate was the wrong decision. The simulator verification showed, that had the crew pushed the thrust levers into maximum thrust when they recognized the abnormal situation, they would have safely taken the aircraft airborne 670 meters before the end of the runway. The verification also proved, that had the crew rejected takeoff at that point, the aircraft would have stopped before the end of the runway.
The crew did not follow standard operating procedures for managing thrust on takeoff. The crew operations manual stipulates that the left seat pilot advances the thrust levers to EPR 1.1 or 70% N1 (depending on engine type), informs the right seat pilot to connect autothrust. The pilot flying subsequently pushes the thrust levers forward and verifies they are moving forward on servos, the pilot monitoring verifies autothrust is working as expected and reaches takeoff thrust settings. In this case the left seat pilot not only did not continue to push the thrust levers forward, but also called out "thrust set" without reason as he did not verify the takeoff thrust setting had been achieved.
It is not possible to subdivide the various violations of procedures and regulations. The crew had worked 16 hours during the previous sector. In addition, one crew member needed to travel for 11 hours from Europe to reach the point of departure of the previous sector (Nairobi Kenya), two crew members need to travel for 19 hours from America to the point of departure of the previous sector. These factors caused fatigue to all crew membes. The co-pilot was 61 years of age, pathological examination showed he was suffering from hypertension and cardiovascular atherosclerosis. His physical strength and basic health may have affected the tolerance towards fatigue. All crew members underwent changes across multiple time zones in three days. Although being in the period of awakeness in their biological rhythm cycle, the cycle was already in a trough period causing increased fatigue.
The captain had flown the Airbus A340 for 300 hours in the last 6 months, which has an entirely different autothrust handling, e.g. the thrust levers do not move with power changes in automatic thrust, which may have caused the captain to ignore the MD-11 thrust levers. The co-pilot in the right hand seat had been MD-11 captain for about 7 years but had not flown the MD-11 for a year. Both were operating their first flight for the occurrence company. The two pilots on the observer seats had both 0 flight hours in the last 6 months.
The co-pilot (right hand seat) was pilot flying for the accident sector. The captain thus was responsible for the thrust management and thrust lever movement according to company manual. A surviving observer told the investigation in post accident interviews that the captain was filling out forms and failed to monitor the aircraft and first officer's actions during this critical phase of flight.
There are significant design weaknesses in the MD-11 throttle, the self checks for errors as well as degree of automation is not high.
Metars:
ZSPD 280130Z 01008MPS CAVOK 12/07 Q1028 NOSIG
ZSPD 280100Z 01009MPS 9999 SCT020 12/06 Q1028 NOSIG
ZSPD 280030Z 01007MPS 9999 SCT020 12/07 Q1028 NOSIG
ZSPD 280000Z 36007MPS 9999 SCT020 12/07 Q1027 NOSIG
ZSPD 272330Z 01008MPS 9999 FEW020 12/07 Q1027 NOSIG
ZSPD 272300Z 01008MPS CAVOK 12/07 Q1027 NOSIG
ZSPD 272230Z 02009MPS 9999 OVC040 12/07 Q1027 NOSIG
ZSPD 272200Z 01008MPS 9999 OVC040 12/07 Q1026 NOSIG
Incident Facts
Date of incident
Nov 28, 2009
Classification
Crash
Flight number
Z3-324
Departure
Shanghai Pudong, China
Destination
Bishkek, Kyrgyzstan
Aircraft Registration
Z-BAV
Aircraft Type
McDonnell Douglas MD-11
ICAO Type Designator
MD11
Airport ICAO Code
ZSPD
This article is published under license from Avherald.com. © of text by Avherald.com.
Article source
You can read 2 more free articles without a subscription.
Subscribe now and continue reading without any limits!
Read unlimited articles and receive our daily update briefing. Gain better insights into what is happening in commercial aviation safety.
Send tip
Support AeroInside by sending a small tip amount.
Newest articles
Red Air MD82 at Miami on Jun 21st 2022, runway excursion causes gear collapse on landing
A Red Air Dominicana McDonnell Douglas MD-82, registration HI1064 performing flight L5-203 from Santo Domingo (Dominican Republic) to Miami,FL (USA)…
Southwest B737 near Dallas on Apr 25th 2024, engine shut down in flight
A Southwest Airlines Boeing 737-700, registration N793SA performing flight WN-4195 from Denver,CO to San Antonio,TX (USA), was enroute at FL410 about…
Subscribe today
Are you researching aviation incidents? Get access to AeroInside Insights, unlimited read access and receive the daily newsletter.
Pick your plan and subscribePartner
A new way to document and demonstrate airworthiness compliance and aircraft value. Find out more.
ELITE Simulation Solutions is a leading global provider of Flight Simulation Training Devices, IFR training software as well as flight controls and related services. Find out more.
Your regulation partner, specialists in aviation safety and compliance; providing training, auditing, and consultancy services. Find out more.
AeroInside Blog
Popular aircraft
Airbus A320Boeing 737-800
Boeing 737-800 MAX
Popular airlines
American AirlinesUnited
Delta
Air Canada
Lufthansa
British Airways