BOEING 747-400 BCFNational Air Cargo
Bagram, AF · 2013-04-29·N949CA
What happened
NTSB summary, verbatimThe Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-15/01. 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 was destined for Dubai World Central - Al Maktoum International Airport, Dubai, United Arab Emirates.
Photographs
139the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationNational Airlines' inadequate procedures for restraining special cargo loads, which resulted in the loadmaster's improper restraint of the cargo, which moved aft and damaged hydraulic systems Nos. 1 and 2 and horizontal stabilizer drive mechanism components, rendering the airplane uncontrollable. Contributing to the accident was the Federal Aviation Administration's inadequate oversight of National Airlines' handling of special cargo loads.
Occurrence sequence
3 stepsNTSB coding · CICTT taxonomy- 1 · Prior to flightAircraft loading event
- 2 · Initial climbLoss of control in flightdefining event
- 3 · Uncontrolled descentFlight control sys malf/fail
Findings
7 causal · 0 contributing- CAUSEOrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — Operator
- CAUSEPersonnel issues › Action/decision › Action › Incorrect action selection — Other
- CAUSEOrganizational issues › Support/oversight/monitoring › Oversight › Oversight of operation — FAA/Regulator
- CAUSEPersonnel issues › Action/decision › Action › Lack of action — Other
- CAUSEAircraft › Aircraft systems › Hydraulic power system — Damaged/degraded
- CAUSEAircraft › Aircraft systems › Flight control system › Stabilizer control system — Damaged/degraded
- CAUSEAircraft › Aircraft oper/perf/capability › Performance/control parameters — Attain/maintain not possible
Safety recommendations
6 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Revise the guidance material in Advisory Circular (AC) 120-85, “Air Cargo Operations,” chapter 201(a)(4), to specify that an operator should seek Federal Aviation Administration (FAA)-approved data for any planned method for restraining a special cargo load for which approved procedures do not already exist, and remove the language in the AC that states that procedures other than those based on FAA-approved data can be used.
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.
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.
TO THE FEDERAL AVIATION ADMINISTRATION: Include specific guidance in the Federal Aviation Administration inspector handbook that defines responsibilities for principal inspectors for the oversight of an operator’s loading, restraint, and documentation of special cargo loads.
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.
TO THE FEDERAL AVIATION ADMINISTRATION: Implement temporary risk-reduction methods any time that required surveillance items for 14 Code of Federal Regulations Part 121 and 135 operators are deferred, and establish appropriate limitations on surveillance deferrals.
Sequence of events
9 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)- 07:50 GMT (previous flight)previous flightp.4FDR began recording for the previous flight from Camp Bastion; aircraft took off at 08:04 from runway 19 with maximum pitch after rotation of 17 degrees; cruise at around 29,000 ft reached at 08:30 with descent about 20 minutes later; vertical acceleration perturbations of +0.62 g to +1.36 g in the descent; landed at Bagram runway 03 at 09:09 with minimum longitudinal acceleration -0.27 g; last fuel 46,200 lb, gross weight 617,280 lb; FDR stopped at 09:19:28
- 10:41:23 GMTpre-flightp.4FDR began recording for the accident flight; total fuel 106,000 lb, gross weight 677,120 lb
- 10:44 GMTtaxip.4Flaps lowered to 10 degrees, leading edge flaps extended, flight control check performed
- 10:55:47 GMTtakeoffp.4Last radio call before takeoff after taxiing and lining up on runway 03
- 10:55:54 GMTtakeoffp.4N1 for all four engines began to increase, reaching full power at 10:56:11
- 10:56:33 GMTtakeoffp.4At 137 knots the pitch parameter began to increase (rotation)
- 10:56:40 GMTtakeoffp.4Slight right roll of +2 degrees recorded
- 10:56:42 GMTlift-offp.4One sample of the air/ground sensor transitioning from ground to air at 163 knots; the sensor toggled between air and ground over the next 1.5 seconds
- 10:56:45 GMTinitial climbp.4Last recorded data point: airspeed 171 knots, pitch 13 degrees, roll +4 degrees right, radio altitude 33 ft, gross weight 675,200 lb; the CVR ceased at approximately the same moment; other sources indicate the flight continued past this time
NTSB analysis
from the final reportThe Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-15/01. 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 was destined for Dubai World Central - Al Maktoum International Airport, Dubai, United Arab Emirates.