NTSB · Safety Recommendation
Safety Recommendation A-15-015
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Add a special emphasis item to Federal Aviation Administration (FAA) Order 1800.56O, “National Flight Standards Work Program Guidelines,” for inspectors of 14 Code of Federal Regulations Part 121 cargo operators to review their manuals to ensure that the procedures, documents, and support in the areas of cargo loading, cargo restraint, and methods for securing cargo on transport-category airplanes are based on relevant FAA-approved data, with particular emphasis on restraint procedures for special cargo that is unable to be loaded via unit loading devices or bulk compartments.
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
May 7, 2020 · NTSB Correspondence · FAA
We note that, to address the gaps in cargo surveillance for airworthiness and operations inspectors, you have enhanced your safety assurance system (SAS) data collection tools (DCTs) by adding three new elements: “Carriage of Cargo (Airworthiness),” “Cargo Equipment and Appliances (Airworthiness),” and “Carriage of Cargo (Operations).”
We do not believe SAS addresses the concerns discussed in this recommendation, and we continue to believe a special emphasis item is needed in FAA Order 1800.56O to ensure that inspectors who use the Program Tracking and Reporting System—not DCTs under SAS—as their primary surveillance data collection tool have guidance on inspecting special cargo. However, because you do not intend to take any additional action, Safety Recommendation A-15-15 is classified CLOSED--UNACCEPTABLE ACTION.
February 18, 2020 · Recipient Response · FAA
-From Steve Dickson, Administrator: As mentioned in our letter dated June 27, 2018, the FAA determined there is no need to facilitate an implementation of part 121 cargo policy and procedures into FAA Order 1800.560, National Flights Standards Work Program Guidelines. All certification and continued operational safety for all part 121 certificate holders is wholly within the Safety Assurance System (SAS) using Element Design Data Collection Tools (DCTs), Element Performance DCTs, System Performance DCTs, Dynamic Observation Reports, and Custom DCTs. We enhanced the SAS data collection tools by adding Elements 6.3.4 Carriage of Cargo (Airworthiness).
6.3.3 Cargo Equipment and Appliances (Airworthiness), and 6.3.1 Carriage of Cargo (Operations). These new enhancements address previously identified gaps in cargo surveillance for airworthiness and operations inspectors. The incorporation of SAS has addressed this recommendation for cargo operators and their risk assessments.