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Safety Recommendation Details

Safety Recommendation A-15-017
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: 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.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
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: 8/31/2017
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/31/2017
Response: 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.

From: FAA
To: NTSB
Date: 5/31/2017
Response: -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. I believe that the FAA has effectively addressed safety recommendation A-15-17 and consider our actions complete. I will provide an update to the other recommendations by April 30, 2018.

From: NTSB
To: FAA
Date: 10/12/2016
Response: We note that you are currently revising your Air Cargo Course, which is given as initial and recurrent training, to include the issue of special cargo. Pending our review of the revised course and confirmation from you that all principal inspectors who oversee air carrier cargo-handling operations will be required to complete the training on a recurring basis, Safety Recommendation A-15-017 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/8/2016
Response: -From Michael P. Huerta, Administrator: We are currently revising our initial and recurrent training for air cargo to include special cargo. We anticipate that the prototype course will be completed by December 2016. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an update by Jul y 31, 2017.

From: NTSB
To: FAA
Date: 1/27/2016
Response: We are pleased to learn that you are revising your Air Cargo Course, given as initial and recurrent training, to include the issue of special cargo. Pending our review of the revised course, and confirmation from you that all principle inspectors who have oversight responsibilities for air carrier cargo handling operations will be required to complete the training on a recurring basis, Safety Recommendation A-15-17 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/27/2015
Response: -From Michael P. Huerta, Administrator: The FAA's Air Cargo Course for initial and recurrent training is now under revision to include special cargo. We will provide an update by March 2016.