History of Flight
On February 24, 2015, about 0616 central standard time, a FedEx MD-11F, registration N584FE, landed at Lambert–St Louis International Airport (STL) following automatic activation of the main deck fire suppression system. The flight was operating as a cargo flight from Memphis International Airport (MEM) to Minneapolis-St Paul International Airport (MSP) under 14 CFR Part 121. The captain was the pilot flying. During cruise at FL360 about 80 miles north of STL, lights illuminated on the flight deck glareshield indicating the Fire Suppression System (FSS) had activated on the main cargo deck. Simultaneously, two jumpseat riders in the courier compartment heard a loud metallic bang noise and observed the FSS discharge indication lights illuminated near the forward left (1L) door. At 0556:57, a crewmember in the courier area called the flight deck via intercom advising they heard a sound "like a can got punctured." At 0557:33, the flight crew declared an emergency with ATC and coordinated a diversion to STL. During the diversion, the crew reviewed abnormal procedures and planned on evacuating after clearing the runway. On approach, the flight advised ATC that the fire was not confirmed but the indications were present and not going away. At 0609:39, the flight crew notified a crewmember they would "get off the aircraft" on the taxiway. At 0616:00, the airplane landed on runway 12L, exited at taxiway K, and stopped at the intersection of taxiway K and F. At 0616:29, the crew accomplished the evacuation checklist and exited the flight deck. The first officer performed the emergency door/slide opening procedure at the 1L door. According to crewmembers, the slide did not appear to deploy completely, appearing "caught up in the straps that are part of the slide." Airport Rescue and Firefighting (ARFF) personnel pulled on the slide and it then appeared to complete deployment. The first officer jumped into the slide; the slide did not slow his descent, and he impacted the tarmac, sustaining a fracture to his L1 vertebrae. ARFF held the base of the slide while the remaining crewmembers lowered themselves using the slide.
Injuries
One crew member received serious injury; three crewmembers were not injured.
Personnel Information
The flight crew consisted of two pilots and two additional pilot observers. The captain, age 55, was hired by Federal Express in January 1997 and completed initial MD-11 training in June 2011. He reported approximately 12,476 hours total time, including 6,470 hours as pilot-in-command and 2,974 hours in the MD-11. He held a valid FAA ATP certificate with type ratings for B-737, B-757/767, and MD-11, and a current first-class medical certificate issued September 2, 2014. The first officer, 51 years old, was hired in June 2006. He reported approximately 9,695 hours total flight time and 2,642 hours in the MD-11. He held an FAA ATP certificate with type ratings for B-757/767, MD-11, and B-727 SIC privileges, and a current first-class medical certificate issued October 7, 2014.
Aircraft Information
N584FE, serial number 48436, was a McDonnell Douglas MD-11F equipped with three General Electric CF6-80 turbofan engines. Manufactured in 1992, the airplane had approximately 75,064 hours and 16,731 cycles. The airplane was equipped with emergency escape slides at the two forward doors (1L and 1R). The 1L door was equipped with Evacuation System 60289-117, serial number 0406, manufactured by Air Cruisers in April 1994. The slide/raft assembly was overhauled and recertified to zero time in June 2013.
Evacuation Slide Examination
Post-incident examination of the 1L slide/raft was unable to determine the causes for the slide/raft not inflating to full extension. Visual inspection at the manufacturer indicated the carrying case dated December 13, 1995 was in overall good condition with no notable damage; the maintenance card was not found. Storage side straps were intact; the left side strap showed drag marks, torn webbing, and friction burn marks. Both reservoir attachment straps were torn apart with soiled and abraded fibers. The inflation cable was undamaged; frangible links had separated with proper color coordination. The inflation hose (manufactured October 1992) had dirty abrasion marks; a placard indicated last test in 2005. The reservoir and valve assembly had a torn sling webbing and abrasion. The left aspirator had scratches inside the mixing tube; the right aspirator showed some denting and scuffing. The slide was partially inflated for inspection with no apparent leaks or notable damage. The reservoir and valve assembly passed a leak check. A floor run functional test inflated the slide successfully, with upper tube pressure 2.54 psi and lower tube 2.43 psi (CMM minimum 2.3 psi). A calibration check of the valve regulator peak pressure measured 497 psi (CMM requirement 550 ± 50 psi). The inflation hose passed a hydro test at 900 psi with no leaks or deformation.
Survival Aspects
Video footage from an airport ramp camera showed the airplane stop, the 1L door open, and the slide/raft not fully inflate during deployment. The slide/raft was held up at the first set of frangible links at the airplane attachment end. ARFF personnel approached the partially inflated slide/raft; one firefighter jumped to grab it, and it continued to unfold onto the ramp. The firefighter pulled it into an attitude consistent with normal deployment but did not hold it while the first crewmember evacuated. That crewmember jumped into the slide/raft, which collapsed under his weight, resulting in forceful contact with the tarmac. The remaining three crewmembers slid down with firefighters supporting the slide. The 1R exit was not opened.
Tests and Research
Manufacturer records indicated three previous instances of slide/raft not fully deploying, none on an airplane in service. In 2005, an inadvertent deployment during maintenance did not fully deploy due to container assembly straps not properly stowed. In 2011, two incidents during functional tests: one where an unsecured assembly strap partially obstructed an aspirator; another where a release strap was incorrectly attached causing delayed deployment and partial aspirator blockage.