NTSB · Safety Recommendation
Safety Recommendation A-15-014
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Create a certification for personnel responsible for the loading, restraint, and documentation of special cargo loads on transport-category airplanes, and ensure that the certification includes procedures; training; and duty hour limitations and rest requirements consistent with other safety-sensitive, certificated positions.
Safety Issue and Context
On April 29, 2013, about 1527 local time, a Boeing 747-400 BCF, N949CA, operated by National Air Cargo, Inc., dba National Airlines, crashed shortly after takeoff from Bagram Air Base, Bagram, Afghanistan. All seven crewmembers—the captain, first officer, loadmaster, augmented captain and first officer, and two mechanics—died, and the airplane was destroyed from impact forces and postcrash fire. The 14 Code of Federal Regulations Part 121 supplemental cargo flight, which was operated under a multimodal contract with the US Transportation Command, was destined for Dubai World Central - Al Maktoum International Airport, Dubai, United Arab Emirates.
The airplane’s cargo included five mine-resistant ambush-protected (MRAP) vehicles secured onto pallets and shoring. Two vehicles were 12-ton MRAP all-terrain vehicles (M-ATVs) and three were 18-ton Cougars. The cargo represented the first time that National Airlines had attempted to transport five MRAP vehicles. These vehicles were considered a special cargo load because they could not be placed in unit load devices (ULDs) and restrained in the airplane using the locking capabilities of the airplane’s main deck cargo handling system. Instead, the vehicles were secured to centerline-loaded floating pallets and restrained to the airplane’s main deck using tie-down straps.
During takeoff, the airplane immediately climbed steeply then descended in a manner consistent with an aerodynamic stall. The National Transportation Safety Board’s (NTSB) investigation found strong evidence that at least one of the MRAP vehicles (the rear M-ATV) moved aft into the tail section of the airplane, damaging hydraulic systems and horizontal stabilizer components such that it was impossible for the flight crew to regain pitch control of the airplane. The likely reason for the aft movement of the cargo was that it was not properly restrained.
National Airlines’ procedures in its cargo operations manual not only omitted required, safety-critical restraint information from the airplane manufacturer (Boeing) and the manufacturer of the main deck cargo handling system (Telair, which held a supplemental type certificate [STC] for the system) but also contained incorrect and unsafe methods for restraining cargo that cannot be contained in ULDs.
The procedures did not correctly specify which components in the cargo system (such as available seat tracks) were available for use as tie-down attach points, did not define individual tie-down allowable loads, and did not describe the effect of measured strap angle on the capability of the attach fittings.
Response History
February 23, 2022 · NTSB Correspondence · FAA
We do not agree that asking air carriers to develop an FAA-approved special cargo program is responsive to this recommendation. Without creating a certification for loadmasters, we are unsure how you would ensure that air carriers’ programs include the procedures, training, and duty-hour limitations and rest requirements consistent with other safety-sensitive, certificated positions. We also do not believe the guidance referenced in your letter replaces the need for creating a certification for loadmasters.
Although Advisory Circular 120-85A, Appendix C, describes the duties of a load supervisor or loadmaster, we remain concerned that you have not defined the qualifications needed for this safety-critical position.
We continue to believe that personnel responsible for ensuring special cargo loads are properly loaded, restrained, and documented should be certified, and that their certification should include procedures, training, and duty-time and hour limitations consistent with other safety-sensitive, certificated positions. Such certification would help ensure that these personnel properly perform their safety-critical duties. However, because you have no intention of addressing this important safety issue, Safety Recommendation A-15-14 is classified CLOSED-- UNACCEPTABLE ACTION.
August 13, 2021 · Recipient Response · FAA
-From Steve Dickson, Administrator: In response to the Board’s letter dated September 29, 2020, the Federal Aviation Administration (FAA) reevaluated the Aviation Rulemaking Advisory Committee’s Loadmaster Certification Working Group’s final report and again determined that FAA certification of aircraft cargo handling personnel is not warranted at this time. As previously stated, under part 121, air carrier operators are responsible for the airworthiness of the aircraft during all phases of operations.
The aircraft load manifest must contain evidence that the aircraft is loaded according to approved schedules that ensure that the aircraft’s center of gravity is within approved limits before its planned flight.