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Safety Recommendation Details

Safety Recommendation A-15-015
Details
Synopsis: 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.
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.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Aviation
Location: Bagram, UN, Afghanistan
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA13MA081
Accident Reports: Steep Climb and Uncontrolled Descent During Takeoff, National Air Cargo, Inc., dba National Airlines, Boeing 747 400 BCF, N949CA
Report #: AAR-15-01
Accident Date: 4/29/2013
Issue Date: 7/29/2015
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/18/2018
Response: You wrote that you are still reviewing the weight and balance programs of all cargo operations to verify that they comply with their type certificate or supplemental type certificate weight and balance manual operating limitations. We note, however, that you have determined there is no need to include Part 121 cargo policy and procedures in FAA Order 1800.56P because you have enhanced your safety assurance system (SAS) data collection tools by adding three new elements: “Carriage of Cargo (Airworthiness),” “Cargo Equipment and Appliances (Airworthiness),” and “Carriage of Cargo (Operations).” We do not believe that SAS addresses the concerns discussed in this recommendation. The intent of this recommendation is for you to revise your inspector guidance in 1800.56P to institutionalize current guidance for special cargo inspections now and into the future. We believe this is important because inspectors still use the published guidance to determine surveillance planning, and the duties and responsibilities associated with special cargo oversight are not clearly delineated between operations and maintenance inspectors. Therefore, we encourage you to update Order 1800.56P with the Part 121 cargo operator policy and procedures. Pending the completion of your reviews and the recommended revisions to Order 1800.56P, Safety Recommendation A-15-15 is classified OPEN--UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/27/2018
Response: -From Daniel K. Elwell, Acting Administrator: The FAA determined there is no need to implement Title 14 Code of Federal Regulations ( 14 CFR) Part 12 1 cargo policy and procedures into FAA Order 1800.560 because of enhancements already made to the Safety Assurance System (SAS). As noted in previous letters, we enhanced the SAS Data Collection Tools by adding three elements: • Element 6.3.4 Carriage of Cargo (Airworthiness); • Element 6.3.3 Cargo Equipment and Appliances (Airworthiness); and • Element 6.3.1 Carriage of Cargo (Operations). These new enhancements address previously-identified gaps in airworthiness cargo surveillance. Additionally, since the April 2013 accident that served as the impetus for this recommendation, the FAA has published numerous Safety Alerts for Operators (SAFO), Information for Operators (lnFO). and other guidance documents to mitigate entry of non-FAA approved data. The following is a list of these documents: SAFOs/ lnfOs: • SAFO 13005. Part 121 Air Carriers Transporting Heavy Vehicle Special Cargo Loads; • SAFO 13008, Part 121 Air Carriers Perfom1ing Special Cargo Loads Operations; • SAfO 17003, Non-compliance with a Manufacturer·s FAA-approved Aircraft Weight and Balance Manual (WBM); • SAFO 17004, Cargo Retention Methods Using Pallets Straps; • InFO 13012, FAA-approved Boeing 747 Sample WBM; and • In FO 150 I 0, Approved WBM Supplements for Certain Boeing Aircraft. Notices: • N8900.3 I 7, Accepting/Revising Manuals for All Parts 91 K, 12 1, 125, and 135 Certificate Holders/Operators Transporting Cargo on Transport Category Aircraft; and • N8900.262, Review of Weight and Balance Control Programs Including Special Cargo Operations. Advisory Circular (AC): • AC 120-85A, Air Cargo Operations, which provides guidance for developing a cargo operations program as part of the weight and balance control program. In our May 3 1, 2017, response, we stated that our reviews of part 121 certificate holder weight and balance programs and air cargo operations' compliance with 14 CFR 91. 9(a) per the Type Certificate or Supplemental Type Certificate WMB operating li mitations would determine our need to update FAA Order 1800.56P. However, as we began completing reviews, it became apparent that adding to the Order was not necessary because the operators are being inspected under SAS. Our reviews are ongoing.

From: NTSB
To: FAA
Date: 8/31/2017
Response: You told us that, rather than using a custom data collection tool to address this recommendation as you originally planned, you have enhanced your safety assurance system (SAS) data collection tools by adding Element 6.3.4, “Carriage of Cargo (AW).” In addition, we note that you are in the process of reviewing the weight and balance programs of all cargo operations to verify that they comply with their type certificate or supplemental type certificate weight and balance manual operating limitations. We also note that, upon completing these reviews, you will determine the need to include the implementation of Part 121 cargo operator policy and procedures into Order 1800.56P. Pending the completion of your reviews, and the addition of a special emphasis item to Order 1800.56P that addresses the concerns discussed in this recommendation, Safety Recommendation A-15-15 remains classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/31/2017
Response: -From Michael P. Huerta, Administrator: The FAA reported that we planned to conduct a special emphasis inspection Custom Data Collection Tool (CDCT) on restraint procedures for special cargo through the revision of several Data Collection Tools. The FAA decided not to conduct the CDCT and instead enhanced Safety Assurance System (SAS) Data Collection Tools with the addition of Element 6.3.4, Carriage of Cargo (AW), which launched September 30. 2016. This new element responds to several SAS - Assistance Feedback and Enhancements identifying a gap in airworthiness cargo surveillance. The FAA is also conducting reviews of all part 12 1 certificate holder weight and balance programs. The FAA is verifying that all cargo operations comply with section 91.9(a) per the Type Certificate or Supplemental Type Certificate Weight and Balance Manual operating limitations. (Refer to section 25. 1583). Once all of the cargo carriers· Weight and Balance Control program reviews are complete, the FAA will determine the need to facilitate the implementation of part 12 1 cargo operator policy and procedures into FAA Order I 800.56P, National Flights Standards Work Program Guidelines. I will provide the Board with an update on this recommendation by April 30, 2018.

From: NTSB
To: FAA
Date: 10/12/2016
Response: We note that you plan to conduct a special-emphasis inspection of restraint procedures for special cargo, which will require you to revise data collection tools (DCTs) 6.3.1, “Carriage of Cargo,” and 6.3.3, “Cargo Handling Equipment, Systems, and Appliances.” Pending publication of a notice regarding these DCTs once they are available and the completion of special-emphasis inspections of all Part 121 supplemental operators who transport special cargo, Safety Recommendation A-15-015 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/8/2016
Response: -From Michael P. Huerta, Administrator: The FAA intends to conduct a special emphasis inspection (Custom Data Collection Tool. or Custom DCT) on restraint procedures for special cargo through the revised DCTs (6.3.1) Carriage of Cargo and (6.3.3) Cargo Handling Equipment. Systems, and Appliances. The FAA plans to publish the notice for these DCTs. and to have this special emphasis inspection completed by all part 121 supplemental operators who transpot1 special cargo, by the end of calendar year 2016.

From: NTSB
To: FAA
Date: 1/27/2016
Response: We note that you are determining whether a special emphasis item needs to be added to Order 1800.56O. Pending our review of your decision, and completion of the recommended action, Safety Recommendation A-15-15 remains classified OPEN—AWAIT RESPONSE.

From: FAA
To: NTSB
Date: 10/27/2015
Response: -From Michael P. Huerta, Administrator: The FAA will work to determine the need to facilitate the implementation of part 121 cargo operator policy and procedures into Order 1800.560, National Flight Standards Work Program Guidelines. We have established the Cargo Focus Team to provide technical support for inspectors and to provide a standardized approach to air cargo issues. In response to the guidance changes established by this group, the following Safety Assurance System Data Collection Tools related to cargo operations were updated and released on October 19, 2015: • (6. 1.1) Training of Station Personnel; • (6.2.4) Line Station Operations/Ground Personnel Duties; • (6.3.1) Carriage of Cargo; • (6.3.3) Cargo Handling Equipment, Systems, and Appliances; • ( 4.2.1) Maintenance/Inspection Requirements; • (4.4.5) Weight & Balance Program; and • (3.3.3) Flight/Load Manifest/Weight & Balance Control.