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Safety Recommendation Details

Safety Recommendation A-15-013
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: 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.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
Mode: Aviation
Location: Bagram, UN, Afghanistan
Is Reiterated: No
Is Hazmat: 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: 1/27/2016
Addressee(s) and Addressee Status: FAA (Closed - Reconsidered)

Safety Recommendation History
From: NTSB
Date: 1/27/2016
Response: We note that AC 120-85A, “Air Cargo Operations,” published on June 25, 2015, recommends that operators seek FAA-approved data for any planned method for restraining a special cargo load for which approved procedures do not already exist and contains no language stating that procedures other than those based on FAA-approved data can be used. Because the revised AC was published before Safety Recommendation A-15-13 was issued, the recommendation is classified CLOSED—RECONSIDERED.

From: FAA
Date: 10/27/2015
Response: -From Michael P. Huerta, Administrator: The FAA has completed a major revision of AC 120-85 after evaluating special cargo operations such as: load planning, restraint calculations, restraint methods, freight staging, freight forwarding, and interlining of cargo. AC 120-85A was published on June 25, 2015, and enhances the safety of flight operations by clearly identifying the responsibilities of parties and enhancing the guidance concerning the operator's Weight and Balance control program, including procedures for cargo restraint and aircraft loading; unit load devices and restraint devices; and the transport of special cargo. AC 120-85A contains procedures for FAA approvals for carriage of cargo outside the original limits set by the manufacturer. It also provides clarity regarding cargo handling training requirements. The FAA believes that AC 120-85A, which is available at the URL listed below, meets the requirement of this recommendation and requests that it be classified as "Closed-Acceptable Action."