NTSB · Safety Recommendation
Safety Recommendation A-15-017
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Provide initial and recurrent training for all principal inspectors who have oversight responsibilities for air carrier cargo handling operations that specifically addresses operator cargo procedures, documents, restraint, and support for technical decisions related to special cargo loads.
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
August 31, 2017 · NTSB Correspondence · FAA
We note that you have developed the following training for principal inspectors who have oversight responsibilities for air carrier cargo handling operations:
• “Air Cargo Operations Web-Based Training,” which includes basic concepts, relevant requirements, and guidance on transporting hazardous materials and special cargo.
• “Air Cargo Operations Practical Applications Workshop,” which includes the fundamental knowledge and skills needed to evaluate an operator’s air cargo operations as part of certification and continued oversight and includes a “just-in-time” model with cargo training highlights that inspectors can reference before performing surveillance.
We also note that principal inspectors who oversee air carrier cargo handling operations are required to complete this training on a recurring basis. These actions satisfy the intent of Safety Recommendation A-15-17, which is classified CLOSED--ACCEPTABLE ACTION.
May 31, 2017 · Recipient Response · FAA
-From Michael P. Huerta, Administrator: The Air Cargo Operations Web-Based Training (course 27000257 in the FAA Employee Learning Management System) provides Aviation Safety Inspectors with the basic concepts, relevant requirements, and guidance, including information about transporting hazardous materials and special cargo. This course serves as a prerequisite for the Air Cargo Operations Practical Applications Workshop.
The Air Cargo Operations Practical Applications Workshop (course FAA21000056 in the FAA Employee Learning Management System) provides inspectors with the fundamental knowledge and skills needed to evaluate an operator's air cargo operations as pa11 of certification and continued oversight.
As of April 5. 2017, the new training is available for Fiscal Year 2017 String Instruction at the FAA Academy. All inspectors are required to attend the revised course. Principal inspectors who oversee air carrier cargo handling operations arc required to complete the training on a recurring basis at an interval determined by their first-level supervisor.