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Safety Recommendation Details

Safety Recommendation A-15-016
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: 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.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable 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 - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/18/2018
Response: We note that you continue to revise the following sections of FAA Order 8900.1, “Flight Standards Information Management System”: • Volume 3, Chapter 47, section 1, “Evaluating a Certificate Holder’s/Applicant’s Weight & Balance Control Program.” • Volume 6, Chapter 2, section 4, “Ramp Inspections for Part 91K, 125, 141, 142 Operators and Part 121 and 135 Air Carriers.” • Volume 6, Chapter 2, section 5, “Ramp Inspections on Cargo Loading (including Part 125).” Pending revisions to the order that provide clear guidance on how each inspector should oversee an operator’s loading, restraint, and documentation of special cargo loads, Safety Recommendation A-15-16 remains classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/27/2018
Response: -From Daniel K. Elwell, Acting Administrator: As we have reported in previous responses, we are revising the following sections of FAA Order 8900.1 , Flight Standards Information Management System, to specifically address this recommendation: • Volume 3 Chapter 47, Section 1, Safety Assurance System: Evaluating a Certificate Holder's Applicant's Weight and Balance Control Program; • Volume 6, Chapter 2, Section 4, Safety Assurance System: Ramp Inspections for Part 91 K. 125. 141 , 142 Operators and Part 121and135 Air Carriers; and • Volume 6. Chapter 2, Section 5, Safety Assurance System; Ramp Inspections on Cargo Loading (including Part 125). We previously reported that we expected to have the revisions completed by February 2018. The coordination process has taken longer than anticipated. The revised documents are in the final coordination stage, and we anticipate publishing the revisions prior to December 2018. I will keep the Board informed of the FAA's progress on these recommendations and provide an update by February 28, 2019.

From: NTSB
To: FAA
Date: 8/31/2017
Response: We note that you are revising the following sections of FAA Order 8900.1, “Flight Standards Information Management System”: • Volume 3, Chapter 47, section 1, “Evaluating a Certificate Holder’s/Applicant’s Weight & Balance Control Program.” • Volume 6, Chapter 2, section 4, “Ramp Inspections for Part 91K, 125, 141, 142 Operators and Part 121 and 135 Air Carriers.” • Volume 6, Chapter 2, section 5, “Conduct Ramp Inspection on Cargo Loading (Including Part 125).” Pending completion of revisions to the order that provide clear guidance on how each inspector should oversee an operator’s loading, restraint, and documentation of special cargo loads, Safety Recommendation A-15-16 remains classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/31/2017
Response: -From Michael P. Huerta, Administrator: The FAA continues to revise the following portions of FAA Order 8900.1. Flight Standards information Management System: • Volume 3 Chapter 47. Section 1, Safety Assurance System: Evaluating a Certificate Holder's/Applicant’s Weight and Balance Control Program; • Volume 6, Chapter 2, Section 4, Safety Assurance System: Ramp Inspections for Part 91K. 125, 141, 142 Operators and Part 121 and 135 Air Ca1Tiers; and • Volume 6, Chapter 2, Section 5, Safety Assurance System: Conduct Ramp Inspection on Cargo Loading (Including Part 125). As we have progressed with updating the previous chapters, we discovered that th is section also needed to be revised as it addresses some of the same issues. The guidance contained in the sections above is for the inspectors with oversight of an operator’s loading, restraint, and documentation of special cargo loads and clearly defines the specific areas of airworthiness and operations responsibilities in relation to elements of weight and balance, airplane limitations, and cargo operations. We expect to have the revisions completed by February 2018. 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 issued this recommendation based on our finding in the investigation of the April 29, 2013, National Airlines accident, that the lack of clear guidance regarding FAA inspector responsibility for oversight of cargo-handling personnel resulted in minimal oversight at National Airlines and enabled critical safety deficiencies to persist. We were concerned that the safety-critical duties of cargo-handling personnel were overseen by both the principal operations inspector and the principal maintenance inspector, and there was no clear guidance on how each inspector should oversee an operator’s loading, restraint, and documentation of special cargo loads. We note that, to address this concern, you are currently revising the following sections of FAA Order 8900.1, “Flight Standards Information Management System”: • Volume 3, Chapter 47, Section 1, “Evaluating a Certificate Holder’s/Applicant’s Weight & Balance Control Program”; and • Volume 6, Chapter 2, Section 4, “Ramp Inspections.” Pending completion of revisions to FAA Order 8900.1 that satisfy Safety Recommendation A-15-016, it is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/8/2016
Response: -From Michael P. Huerta, Administrator: The FAA is currently revising the following sections of FAA Order 8900.1, Flight Standards Information Management System: Volume 3, Chapter 47, Section I, Evaluating a Certificate Holder's! Applicant's Weight & Balance Control Program; and Volume 6. Chapter 2, Section 4, Ramp Inspections. These revisions will clearly define the responsibilities for the principal inspectors with oversight of an operator· s loading. restraint, and documentation of special cargo loads. We estimate that the revisions will be completed in 2017.

From: NTSB
To: FAA
Date: 1/27/2016
Response: We have reviewed the guidance contained in revised Order 8900.1, published on June 25, 2015, but have found no responsibilities that it defines for principle inspectors regarding the oversight of an operator’s special cargo loads. As this accident investigation demonstrated, such ambiguity led to a lack of oversight. Pending our review of further revisions to Order 8900.1 that address this concern, Safety Recommendation A-15-16 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/27/2015
Response: -From Michael P. Huerta, Administrator: On June 25, 2015, the FAA published revisions to FAA Order 8900.1, Flight Standards Information Management System. The revisions include changes to: • Volume 3, Chapter 47, Section 1, which provides guidance for evaluating a certificate holder's/applicant's Weight and Balance control program procedures; and • Volume 6, Chapter 2, Section 5, which provides guidance for conducting surveillance and inspection on Title 14, Code of Federal Regulations parts 91K, 121, 125, and 135 passenger, cargo, combination, and regional passenger aircraft that transport cargo, passenger baggage, company material, and hazardous materials in the upper deck, lower deck, forward and/or aft cargo compartments, or pods. We believe the revised Order 8900.1, available at the URL below, meets the requirement of this recommendation and request that it be classified as "Closed-Acceptable Action." http://fsims.faa.gov/PICDetail.aspx?docld=8900.1.CH0407.