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NTSB Preliminary Report – UPS Boeing MD-11F Crash [pdf](ntsb.gov)
108 points by gregsadetsky 5 hours ago | 130 comments
  • philip12094 hours 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.

    • PunchyHamster3 hours ago |parent

      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

      • mrb3 hours ago |parent

        Yup. That's exactly what experts said of American Airlines flight 191 which was basically the same engine mount, same failure. Engine flipping over the wing.

        • dreamcompileran hour ago |parent

          American 191's engine mount failed because of improper maintenance. It remains to be seen whether this failure had the same cause or if it was something else, such as metal fatigue.

          • jacobgkauan hour ago |parent

            A failure due to metal fatigue would still be a failure to properly maintain the aircraft, right? I know by "improper maintenance," you're referring to actual improper things being done during maintenance, and not simply a lack of maintenance. But I'm reading things like "the next check would've occurred at X miles," and, well... it seems like the schedule for that might need to be adjusted, since this happened.

            • dreamcompiler34 minutes ago |parent

              Yes, when I said "improper" I meant the American 191 maintenance crew took shortcuts. The manual basically said "When removing the engine, first remove the engine from the pylon, then remove the pylon from the wing. When reattaching, do those things in reverse order." But the crew (more likely their management) wanted to save time so they just removed the pylon while the engine was still attached to it. They used a forklift to reattach the engine/pylon assembly and its lack of precision damaged the wing.[0]

              Fatigue cracking would be a maintenance issue too but that's more like passive negligence while the 191 situation was actively disregarding the manual to cut corners. The crew chief of the 191 maintenance incident died by suicide before he could testify.

              [0] https://en.wikipedia.org/wiki/American_Airlines_Flight_191#E...

            • tremon10 minutes ago |parent

              If the (FAA-approved) maintenance schedule says "the next check should occur at X miles" and X miles hasn't happened yet, then it's not going to be classified as improper maintenance -- it's going to be classified as an incomplete/faulty manual.

              Now, of course, if that maintenance schedule was not FAA-approved or if the check was not performed at X miles, that's going to be classified as improper maintenance.

      • inferiorhumanan hour ago |parent

        Flipping backwards is what caused the engine to fly to the right and land to the right of the takeoff runway. The stills in the NTSB preliminary report clearly show the engine flying over the aircraft, to the right, and then heading straight down.

    • cj4 hours ago |parent

      There might be some truth in that. But the report doesn't confirm that theory.

      • rconti4 hours ago |parent

        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.

        • scottlamb3 hours ago |parent

          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.

        • cj4 hours ago |parent

          That the engine was flung into the fuselage due to gyroscopic forces.

          • inejge3 hours ago |parent

            Well, some force flung it inboard and above the fuselage (gods, that CCTV stills sequence.) Knowing that the engine rotates CCW, there are not many candidates.

      • philip12094 hours ago |parent

        I'm presenting it "useful not true" - not an RCA.

    • londons_explore4 hours ago |parent

      I assume such forces are calculated and added in when deciding hot thick to make those mounting brackets.

      • loeg3 hours ago |parent

        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.

      • HumblyTossed2 hours ago |parent

        Yep. Now do 3 decades of metal fatigue.

        • supportengineeran hour ago |parent

          Did I understand the report correctly that the part was scheduled to be replaced in the future after a certain number of hours, it just hadn't hit the threshold yet ?

          • tremon21 minutes ago |parent

            If you're referring to this quote (excerpted from the AVHerald article linked elsewhere in the thread), I don't think so:

            > At the time of the accident, N259UP had accumulated a total time of about 92,992 hours and 21,043 cycles [..] A special detailed inspection (SDI) of the left pylon aft mount lugs would have been due at 29,200 cycles and of the left wing clevis support would have been due at 28,000 cycles

            This isn't talking about replacement, only inspection; and it wasn't going to happen in the near future: 7k cycles at four flights/day means inspection is due in 5 years.

      • baggy_trough4 hours ago |parent

        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.

      • shtzvhdx2 hours ago |parent

        Aluminum has limited loading cycles

        • dreamcompileran hour ago |parent

          I'd be very surprised to read that the aft lug that cracked (and the bearing it contained) were made of aluminum. They were almost certainly steel or Inconel.

  • frenchman_in_ny4 hours ago

    Adding summary analysis from AVHerald [0]

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

    • the-grump3 hours ago |parent

      "Your IP address 104.28.103.15 has been used for unauthorized accesses and is therefore blocked! Your IP address belongs to Cloudflare and is being used by many users, some of which are hackers and hide behind the cloud/proxy to avoid being tracked down. Hence the automatic defense closed access from that IP address.

      "Make sure to not use a proxy/cloud service for visiting AVH (e.g. Apple Users turn off your private relay) but your native IP address, then access should be possible without a problem again."

      No thank you, AV Herald.

      • kube-system2 hours ago |parent

        That's a pretty nice message. Most sites that filter VPNs and proxies just kill the connection, give a generic error, or subject you to endless captchas.

        • ErroneousBosh2 hours ago |parent

          I block all traffic from Cloudflare outright on my servers.

          Every so often they sneak in new blocks of IP addresses though so you're playing whack-a-mole with a particularly scummy opponent.

    • tremon3 hours ago |parent

      > 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?

      • toast05 minutes ago |parent

        > 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?

        If you can get to the report, Figure 7 shows the left pylon, with the forward and aft lug enlarged in the inset. Both lugs cracked on two sides. They're saying both cracks on the aft lug as well as the inboard crack on the forward lug were observed to be fatigue cracks, but the forward lug outboard fracture was observed to be entirely a stress crack.

        Outboard and inboard are just away from and towards the center of the plane. On the left pylon, that's left and right, respectively. So, it looks like the left side crack in the forward lug developed from overstress, but the other three cracks were from fatigue. My expectation is that fatigue should be apparent upon the right kind of inspection, if timely, even if the metal has yet to fracture.

      • pfdietz3 hours ago |parent

        It sounds like the aft lug failed first, and then the not quite as compromised forward lug failed in overload.

  • kurtoid3 hours ago

    Link doesn't seem to be available now:

    > Page not found

    > The page you're looking for doesn't exist.

    • zorgmonkey2 hours ago |parent

      I found a link to the PDF that seems to work https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/G...

      Also in case that link stops working I got it from this page https://www.ntsb.gov/investigations/Pages/DCA26MA024.aspx

      EDIT: nevermind immediately after posting this comment it is now giving a 403 error

      • greenavocado2 hours ago |parent

        Your first link is working fine

        • zorgmonkey2 hours ago |parent

          Yeah working again for me too, they're probably having some sort of server problems

    • AceyMan2 hours ago |parent

      If anyone saved a copy locally, it'd be great if you could share it somewhere. (I, for once, did not, and the tab is gone now :-/ ).

  • Aman_Kalwar4 hours ago

    Appreciate the transparency in these reports. The technical breakdowns always highlight how complex aviation safety is.

  • waiwai933an hour ago

    Looks like it's been moved to https://www.ntsb.gov/investigations/Documents/DCA26MA024%20P...

  • rft4 hours 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.

    • bunderbunder4 hours ago |parent

      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.

      • ralph842 hours ago |parent

        At this point there aren’t any trijet designs like that being built, and it’s unlikely we’ll ever see a new trijet design. It served a role in the transition from four engines to two, but now with ETOPS-370 there’s no commercially viable route that can’t be served with an appropriate twinjet.

      • buildsjets3 hours ago |parent

        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...

        • bunderbunder3 hours ago |parent

          The industry also responded to those crashes. For example, the El Al 1862 incident prompted a redesign of the engine strut that was subsequently mandated as a retrofit for all 747s.

          And here's a more detailed description of that ground run incident. It also found that the failure was related to a design flaw, and mandated that aircraft be grounded for inspection and rework. https://skybrary.aero/accidents-and-incidents/b762-los-angel...

          I'm not a regulator or aerospace engineer or anything like that so I can't really say which actions are or are not appropriate. But I do want to observe that these are all unique failures with unique risk profiles that can't all be painted with a single broad brush. All I was trying to do in the previous post was speculate on why a MD-11 failure could result in a grounding of the DC-10 and KC-10A as well. The first thing that came to mind is that I think those are the only remaining trijets of that general shape that are still around. Though I suppose another possibility is that they all share an identical pylon design or something like that.

      • loeg3 hours ago |parent

        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?

        • MBCookan hour ago |parent

          It wasn’t failed. It was designed for a very specific reason and served that purpose well.

          Once the reason went away, better designs took over.

          They were designed to allow smaller jets to fly over the ocean further than a two engine jet was allowed (at the time). Airlines didn’t want to waste all the fuel and expense of a huge 4 engine jet, but 2 wouldn’t do. Thus: the trijet.

          The rules eventually changed and two engine jets were determined to be safe enough for the routes the trijets were flying.

          Using two engines that were rated safe enough used less fuel, so that’s what airlines preferred.

          It was never designed to be used anywhere else as a general design. Two engines did that better.

          • loeg7 minutes ago |parent

            You've framed this as disagreeing with me, but I don't think you are. I agree the design made sense in the 1960s, when we didn't know any better and requirements were different.

          • inferiorhuman42 minutes ago |parent

            In the case of the quad jets, Boeing tried the 747-SP and had minimal marketing success.

            In the case of the trijets the MD-11 lived on as a freighter because it had a much higher capacity than anything else smaller than a 747.

              It was never designed to be used anywhere else as a
              general design. Two engines did that better.
            
            Not quite. Dassault still makes a three engined bizjet and in theory the Chinese fly a three engined stealth jet.
        • potato37328422 hours ago |parent

          > in which case, why have the tail engine at all?

          "you know what this motorized piece of anything needs, less power"

          -nobody, ever

          • loeg8 minutes ago |parent

            You know you can just make the wing engines 50% more powerful, right?

      • rft3 hours ago |parent

        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

        • wat100002 hours ago |parent

          Airlines operate to a much stricter standard than one in a million. If one in a million flights ended in a fatal crash, the US alone would see about 3 airline passenger deaths per day on average. The actual average over the past 10 years is under 0.02 deaths per day.

          It's true that you can never get to zero. There's always a chance of some catastrophic failure. The lesson of modern airline safety is that you can get extremely close to zero by carefully analyzing and learning from the failures, which is exactly why these thorough investigations are done. The lesson from UA232 was to make sure one failure can't take out all of the hydraulic systems.

          In this specific instance, "the engine fell off and took out another engine, leaving the aircraft with insufficient power to climb" is definitely not in the realm of "probabilities will get you eventually." It's very much in the realm of a mechanical failure that should not happen, combined with a bad design flaw that turns that failure from a mere emergency into pretty much guaranteed death.

          Cargo is held to a lower standard than passenger service, but I suspect this will still spell the end of the DC-10 and MD-11, at least in the US. Engines will fail, and for an aircraft of this size, that needs to be survivable in all phases of flight just for the safety of people on the ground.

          • 16bytes2 hours ago |parent

            > Airlines operate to a much stricter standard than one in a million. If one in a million flights ended in a fatal crash, the US alone would see about 3 airline passenger deaths per day on average.

            I think you conflated flights (several 10Ks per day) with passengers (several million per day).

            One in a million flights is one accident every few decades.

            > at least in the US. Engines will fail

            As per the report, this appears to be a structural failure, not an engine failure.

            • wat10000an hour ago |parent

              If randomly distributed, one in a million flights crashing and killing all passengers means that one in a million passengers dies.

              The US sees about 25,000 airline flights per day, or around 9 million per year. So with one in a million flights crashing, we'd expect roughly 9 crashes per year.

    • PunchyHamster2 hours ago |parent

      It wasn't just one engine off, aside from possibly damaging tail engine you also have damage to the wings and control surfaces that might've just not got enough lift because of that.

    • SteveNuts4 hours ago |parent

      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!

      • mrpippy2 hours ago |parent

        UPS and FedEx each have around 25 MD-11s, Western Global has 2 I think, the Orbis Flying Eye Hospital is an MD-10, some cargo airline in Botswana has one, and 10 Tanker has some DC-10 firefighting tankers.

        That’s the entire worldwide fleet.

      • rft3 hours ago |parent

        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.

        • TinkersW3 hours ago |parent

          One other accident that was similiar, but these planes have had a ton of crashes for other reason.

          • rft2 hours ago |parent

            I managed to find some statistics on hull losses per million departures [1, p. 13]. Seems like indeed MD-11s have a highish rate of incidents by that metric compared to other types, even if they are not catastrophically less safe than other planes. That metric stacks the statistics a bit against cargo planes, which most (all?) MD-11s are now. These planes tend to fly longer haul instead of short hop, so you get more flight time/miles but less departures. There are also likely some other confounding factors like mostly night operations (visibility and crew fatigue) and the tendency to write off older planes instead of returning them to service after an incident. Plus these aircraft have been in operation long enough that improvements in procedures and training would impact them less than more modern types, as in they already had more accidents before these improvements.

            [1] https://www.boeing.com/content/dam/boeing/boeingdotcom/compa...

            • inferiorhuman2 hours ago |parent

              The DC-10 had a number of other problems, but the MD-11 has always had a reputation of being an unforgiving aircraft especially when compared to the DC-10. It's less about training and more that the MD-11 was simply too many design compromises piled on to an old design.

              The MD-11 had a pretty short service life as a passenger aircraft because it simply wasn't very fuel efficient compared to the competition, safety wasn't really the motivating factor. However fuel consumption was behind some of the poor design choices McDonnell/Boeing made. In broad strokes: McDonnell/Boeing shrunk the control surfaces to improve fuel consumption "necessitating" poorly designed software to mask the dodgy handling and higher landing speeds. This exacerbated a DC-10 design "quirk" where hard landings got out of hand very quickly and main landing gear failure would tend to flip the plane.

              Yeah you can train around this but when something else goes tits up you've got a lot less leeway to actually recover safely.

      • mandevil3 hours ago |parent

        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.

        • joleyj3 hours ago |parent

          The airforce retired the KC-10 in 2021.

        • buildsjets3 hours ago |parent

          The KC-10 went out of service last year. None are operating.

          • loeg3 hours ago |parent

            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.)

          • mandevil3 hours ago |parent

            Damnit, I knew that! Just forgot it in the moment.

        • inferiorhuman2 hours ago |parent

          Most of the DC-10s in service in the US are used for fire fighting.

          • mandevilan hour ago |parent

            Yes, but there are many MD-11's still flying as freighters. There are four fire-fighting DC10's out of ~8 still flying, but there are 25 Mad Dogs (MD-11) at UPS, 38 with FedEx, and Western Global has 4, so there are plenty of MD-11F's around.

          • dreamcompileran hour ago |parent

            Here are 4 of them. All grounded now.

            https://www.10tanker.com/gallery

          • dingaling2 hours ago |parent

            And with Omega Air, for contracted air refuelling

            https://www.omegaairrefueling.com/

      • virtue3an hour ago |parent

        Most of them are used as cargo planes. Which have dramatically lower usage rates than passenger planes (and they are retired passenger planes)

        Sucks for the pilots flying them for sure tho.

      • loeg3 hours ago |parent

        Airlines haven't been using them, or at least not 1st world airlines. Just freight and wilderness fire fighters.

    • cyberax3 hours ago |parent

      > 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.

    • lazide3 hours ago |parent

      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.

      • crote3 hours ago |parent

        > 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.

        • lazide3 hours ago |parent

          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.

          • inferiorhumanan hour ago |parent

            Fully functioning engines departing from aircraft isn't common but it's not unheard of either. Off the top of my head it's happened a few times on the 747 and 737.

  • haeberli2 hours ago

    Link to page that links to the report, as of now: https://www.ntsb.gov/investigations/Pages/DCA26MA024.aspx

  • sosodev4 hours 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.

    • jeffbee4 hours ago |parent

      I don't know if it's "sliding back" as much as it is that this plane is also fundamentally from the 1970s.

      • sosodev4 hours ago |parent

        The MD-11 was developed after that crash. Shouldn't its design and maintenance procedures have been informed by the incident?

        • buildsjets3 hours ago |parent

          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...

        • 0xffff23 hours ago |parent

          Aside from the engine detaching, it doesn't appear that this incident is in any way similar to the previous incident.

          • sosodev2 hours ago |parent

            How do you figure? They're very similar planes. The left engine and its pylon detached in both cases during takeoff rotation. Both incident reports stated that proper maintenance would have prevented the detachment.

            The way the situation played out is different but the failure mode seems to be very similar if not the same.

            The NTSB report itself even references AA-191 as the only "similar event".

            • ocfan hour ago |parent

              The root cause does not appear (at this stage) to be the same: incorrect maintenance in AA191 as opposed to fatigue cracking here.

              Where does this report say proper maintenance would have prevented the incident?

            • mrguyorama40 minutes ago |parent

              AA-191 was caused by improper maintenance (dreamed up by people who were made to cut corners and was never compliant with manufacturer spec) damaging the pylons holding the engine.

              If someone did the same thing again, that would be rather unfortunate. Just more deaths for profit, even though we know it was dangerous.

              The parts that seem to have fatigued and failed were only like 80% of the way through their inspection period. They were to be inspected after 28k cycles. They were at 21k cycles.

              It sure looks the same from "Engine pulled itself off and flew away" angle, but if there is any similarity under the surface that's very bad. Flying was much much less safe in the 70s.

        • loeg3 hours ago |parent

          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.

    • barbazoo2 hours ago |parent

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

      I think it's cut throat capitalism at its best. Surely it was much too safe before, let's see how far back we can scale maintenance on the operations front but also how far back can you scale cost during development and production and then see where it takes us. If that changes the risk for population from 0.005 to 0.010, the shareholders won't care and it's great for profits.

      I think we can see both but especially the latter with Boeing.

      • dingaling2 hours ago |parent

        The entire MD-11 project was a budget-limited rush-job to try to capture some market share before the A340 and 777 came into service.

        It produced an aircraft that failed to meet its performance targets, was a brute to fly and was obsolete the moment its rivals flew.

        Douglas* by the early 1990s was a basket-case of warmed-over 1960s designs without the managerial courage to launch the clean-sheet project they needed to survive.

        * as a division of MDC

    • gosub1003 hours ago |parent

      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

    • lotsofpulp4 hours ago |parent

      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.

      • crote3 hours ago |parent

        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?

        • lotsofpulp3 hours ago |parent

          I understood the post I responded to to be referring to the cause as the engine detaching from the same type of plane, not the root cause for why the engine detached. Per the “investigation section” in the wikipedia article, I would be surprised if it was the same root cause:

          https://en.wikipedia.org/wiki/American_Airlines_Flight_191

          I assume the erroneous maintenance procedures that led to the loss of AA191 were rectified a long time ago.

          • mrguyorama36 minutes ago |parent

            >rectified a long time ago.

            There's no such thing as "This is fixed forever". If lax maintenance oversight has led to companies re-introducing known dangerous maintenance procedures or departing from known good ones, then we will be back in the 70s in terms of airplane safety and people will have to die again to relearn those lessons.

            Someone's always trying to claw you in the less safe direction. It's a constant battle to not regress.

            But IDK, hopefully this plane just got some sort of "unlucky" about fatigue somehow, and it doesn't have far reaching consequences.

  • londons_explore4 hours 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?

    • yuvadam3 hours ago |parent

      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

    • loeg3 hours ago |parent

      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.

    • jpk2f24 hours ago |parent

      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.

    • Bender3 hours ago |parent

      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.

    • HumblyTossedan hour ago |parent

      It nuked the tail engine so actually TWO engines failed.

    • baggy_trough4 hours ago |parent

      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.

      • bunderbunder4 hours ago |parent

        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.

        • loeg3 hours ago |parent

          Debris, or even just smoke from the wing fire.

          • bunderbunder3 hours ago |parent

            It was specifically the distinct, rhythmic puffing. I'm not sure you could expect the same pattern from debris or a wing fire.

            • mlyle2 hours ago |parent

              I think they were saying that smoke/particulates could be sufficient to upset the rear engine-- things short of what we ordinarily call "debris".

            • loeg2 hours ago |parent

              I'm just saying that smoke alone can cause a compressor stall -- it doesn't necessarily require larger debris.

              • bunderbunder2 hours ago |parent

                Ah, gotcha. My bad.

      • jeffbee4 hours ago |parent

        Even if they had the thrust (doubtful) there wouldn't be enough lift with a gaping hole in the leading edge of one wing.

        • sokoloff3 hours ago |parent

          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.

          • PunchyHamster2 hours ago |parent

            ..for a moment. If there was sufficient hydraulics damage it might've stopped being controllable.

            And even if they worked the fire might've damaged the plane enough.

            For example https://www.faa.gov/lessons_learned/transport_airplane/accid...

            when they lost tail engine, all of the hydraulics went down

        • loeg3 hours ago |parent

          I thought the leading edge of the wing was intact in this case? I may be misremembering.

        • sq_3 hours ago |parent

          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...

          • crote3 hours ago |parent

            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.

    • lotsofpulp4 hours ago |parent

      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...

      • buildsjets4 hours ago |parent

        And also ripped open a giant hole in the fuel tank which allowed all of the fuel to be released and ignited.

    • LPisGood2 hours ago |parent

      This engine didn’t just fail, it failed catastrophically and took out another engine with it.

  • LinuxAmbulance3 hours 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?

    • loeg3 hours ago |parent

      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.

    • LPisGood3 hours ago |parent

      I’m seeing 2021 on page 10 - an I missing something?

  • chimpontherun4 hours ago

    surprised to see typos in aviation terms and acronyms: ADS-8 (page 3) and 747-BF (page 5)

    • Denvercoder93 hours ago |parent

      Swapping B and 8 in both cases, which is typically something that happens with OCR. Weird.

    • Grollicus2 hours ago |parent

      Reminds me of xerox scanner fun, maybe someone scanned it to pdf to publicise?

      Nontheless the pdfs have been replaced and the newer ones don't seem contain these errors anymore.

      • maxbond2 hours ago |parent

        With many eyes, all typos are embarrassing.

        The new document is an image.

    • ynniv4 hours ago |parent

      pretty weird...

        NATIONAL TRANSPORTATION SAFEN'BOAFID
        :J11...:i= of ArutiOn SMel@LA5 301
        A.,r Tral1C.IYU';UQlt-Ort!!
        NTS,B ri@ss @at.Joo JurtJer
        DCA26 22\C2<
      • maxbond3 hours ago |parent

        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?

        • ynniv3 hours ago |parent

          it would seem so. so the question is why they would maintain an air gap for a safety report

          • toast02 hours ago |parent

            It's a good policy. Document formats like to include lots of random junk, better to be safe.

  • serhack_3 hours ago

    Not an aviation expert, nor I want to be one, but the images look pretty intense.

    • pseudosavant3 hours ago |parent

      It is incredible to me how quickly some lives can go from "another day as usual" to "gone" in a matter of seconds.

  • albert_e4 hours ago

    The surveillance video mentioned in page 2 -- from which the series of still images are shown -- is that available publicly?

    • rft4 hours ago |parent

      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

  • GiorgioG3 hours ago

    It's just time to kill the MD-11 entirely. These 3-engine aircraft are too risky to continue flying.

  • dzonga3 hours ago

    McDonnell-Douglass right there that's where the problems start.