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Safety Recommendation Details

Safety Recommendation A-15-014
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: 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.
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: 8/31/2017
Response: We note that the loadmaster certification working group (LCWG) held its first meeting in August 2016. The LCWG was created by your aviation rulemaking advisory committee to consider creating a certification for personnel involved in loading special cargo. We also note that the LCWG anticipates completing its report sometime in 2018. Pending completion of the LCWG’s activities and action that will satisfy Safety Recommendation A-15-14, it remains classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/31/2017
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA), as we reported in our September 8. 2016, letter to the Board, convened a new subgroup of the Aviation Rulemaking Advisory Committee (ARAC), the Loadmaster Certification Working Group (LCWG). The LCWG first met in August 2016. The LCWG will provide advice and recommendations to the ARAC on whether "safety would be enhanced .. by creating a certification for .. persons engaged in the loading and supervision of the loading of special cargo." Once the LCWG completes its assigned tasks, the ARAC submits a recommendation report to the FAA. The final report from the LCWP is due to the ARAC by August 2018.

From: NTSB
To: FAA
Date: 10/12/2016
Response: We note that, rather than your original plan of holding a public forum to address this recommendation, you tasked your aviation rulemaking advisory committee (ARAC) with examining the issue of creating a certification for personnel involved in loading special cargo. The ARAC created the loadmaster certification working group (LCWG), which will develop potential revisions to satisfy this recommendation. Pending completion of the LCWG activities and action that will satisfy Safety Recommendation A-15-014, it remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/8/2016
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) decided to revise our original plan of holding a public forum and replace it with an Aviation Rulemaking Advisory Committee (ARAC) proposal. The FAA believes this action is closer to meeting the intent of the recommendation. The FAA's Rulemaking Management Counci l approved the ARAC proposal on March 23, 2016. A new ARAC subgroup, the Loadmaster Certification Working Group (LCWG). will provide advice and recommendations to the ARAC on whether '·safety would be enhanced'' by creating a certification for --persons engaged in the loading and supervision of the loading of special cargo." The notice for the LCWG published in the Federal Register on May 12, 20 16 (81 FR 29609).

From: NTSB
To: FAA
Date: 1/27/2016
Response: We note that the Cargo Focus Team (CFT), which was developed to provide technical support for inspectors, is organizing a public forum on certification for personnel responsible for the loading, restraint, and documentation of special cargo loads on transport category airplanes. We look forward to reviewing the CFT’s findings from the forum and its plan for creating the new certification. Pending our review of this information and completion of the recommended action, Safety Recommendation A-15-14 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/27/2015
Response: -From Michael P. Huerta, Administrator: The FAA has established a Cargo Focus Team (CFT) to provide technical support for inspectors. The CFT intends to provide direct support to field office personnel on subjects that require specialized expertise not often available to the field. The CFT, with industry involvement, plans to organize a public forum on the need to create a certification for personnel responsible for the loading, restraint, and documentation of special cargo loads on transport category airplanes, and how this goal can be achieved. The FAA expects the forum to occur in the second half of 2016.