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OPS FACTUAL REPORT DCA13MA081
NATIONAL TRANSPORTATION SAFETY BOARD
Office of Aviation Safety
Washington, D.C. 20594
October 30, 2014
Group Chairman’s Factual Report
OPERATIONAL FACTORS
DCA13MA081
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National Airlines Crash Report: B747-400 Accident at Bagram Air Base, Schemes and Mind Maps of Aviation
Details about the National Airlines flight 102 crash that occurred on April 29, 2013, at Bagram Air Base, Afghanistan. The report includes information about the weight and balance data, OpSpecs, manuals, interviews, and cargo operations related to the accident. It also discusses the role of National Air Cargo in the loading process and the lack of communication and training between National Airlines and National Air Cargo loaders.
What you will learn
- What was the role of National Air Cargo in the loading process of the National Airlines B747-400?
- What procedures were followed for managing air cargo operations according to Advisory Circular 120-85?
- What caused the National Airlines B747-400 crash at Bagram Air Base, Afghanistan?
- What were the qualifications and experiences of the crew members involved in the National Airlines B747-400 crash?
- What were the communication and training issues between National Airlines and National Air Cargo loaders?
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NATIONAL TRANSPORTATION SAFETY BOARD
Office of Aviation Safety Washington, D.C. 20594
October 30, 2014
Group Chairman’s Factual Report
OPERATIONAL FACTORS
DCA13MA
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13.2.7.1 Nose High Recovery .................................................................................... 69 13.2.8 Boeing Upset Recovery Procedures ................................................................ 70 13.2.9 Upset Recovery Training Aid .......................................................................... 70 13.3 Loadmaster Procedures ............................................................................................. 72 13.3.1 Loadmaster Duties ........................................................................................... 73 13.3.1.1 Preflight Duties ............................................................................................ 73 13.4 Main Deck Access .................................................................................................... 75 14.0 FAA Oversight .............................................................................................................. 76 14.1 General ...................................................................................................................... 76 14.2 Loadmaster Oversight ............................................................................................... 78 14.3 Enroute and Ramp Inspections ................................................................................. 79 14.4 Department of Defense Restrictions ......................................................................... 81 14.5 Cargo Operations Oversight ..................................................................................... 82 14.6 Risk Management ..................................................................................................... 84 14.7 Advisory Circular 120-85: Air Cargo Operations .................................................... 85 14.8 FAA Guidance Post-Accident................................................................................... 85
F. LIST OF ATTACHMENTS ................................................................................................. 85
A. ACCIDENT
Operator: National Airlines Location: Bagram, Afghanistan Date: April 29, 2013 Time: 1527 Local Time (1057Z)^1 Airplane: Boeing B747-428BCF^2 Registration Number: N949CA, Serial #
B. OPERATIONAL FACTORS GROUP
Captain David Lawrence - Chairman Captain Jon Wiesinger^3 Senior Air Safety Investigator B747-400 Captain National Transportation Safety Board (NTSB) National Airlines (NAL) 490 L’Enfant Plaza East S.W. 5955 TG Lee Blvd, # Washington, DC 20594 Orlando, FL 32822
(^1) Bagram, Afghanistan local time was UTC (Universal Coordinated Time) + 4:30. Times listed in this Factual
Report are UTC unless otherwise noted. (^2) Boeing Converter Freighter. The B747-400BCF is a former passenger configured airplane that has been converted
to a cargo configuration. (^3) National Airlines Captain Jose Rodriguez served on the Ops Group until September 19, 2013.
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Captain Normand Bissonnette Lt. Colonel Mark Barker - Observer B747-400 FSB/FOEB Chair AMC Liaison to FAA Standards Federal Aviation Administration (FAA) 800 Independence Ave., SW Room 826 1601 Lind Avenue Washington, DC 20591 Seattle, WA 98057
Captain David S. Goodwill Boeing Flight Technical and Safety P.O. Box 3707 MC 20- Seattle, WA 98124-
C. SUMMARY
On April 29, 2013, at about 1527 local time (1057Z), a Boeing 747-400, N949CA, operated as National Airlines flight 102, crashed shortly after takeoff from the Bagram Air Base (OAIX), Bagram, Afghanistan. All 7 crewmembers onboard were fatally injured and the airplane was destroyed from impact forces and post-crash fire. The 14 Code of Federal Regulations (CFR), Part 121 Supplemental cargo flight was destined for Dubai World Central - Al Maktoum International Airport (OMDW), Dubai, United Arab Emirates (UAE).^4
D. DETAILS OF THE INVESTIGATION
On May 2, 2013, the NTSB Operations Group (Group) Chairman arrived in Bagram, Afghanistan. Other group members from the operator (National Airlines), the FAA, and the Department of Defense (DoD) assisted the Operations Group with the on-scene activities. Upon arrival, the group met the IIC and received an in-brief from the military’s Incident Safety Board at Bagram regarding the accident site. The group then conducted an initial review of the wreckage and accident site. The group received weight and balance information, Operations Specifications (OpSpecs), National Airlines manuals, Boeing manuals, and additional documentation related to the accident flight.
On May 3, 2013, the Group assisted in the documentation of the wreckage site. Interviews with witnesses, ATC personnel, and National Air Cargo personnel were scheduled, and the group reviewed manuals and dispatch information related to the accident flight.
On May 4, 2013, the Group interviewed ATC controllers (Midwest Air Traffic Services), and toured/documented the ATC control tower at Bagram. In addition, the Group interviewed National Air Cargo loaders from Camp Bastion who loaded the accident airplane.
On May 5, 2013, the Group participated in a progress meeting and received a brief on CVR/FDR recorder data. The Group interviewed Flight Ops vehicle drivers who conducted the FOD
(^4) The investigation was originally led by the Afghanistan Ministry of Transportation and Civil Aviation (MoTCA),
which appointed an IIC. The NTSB had assigned a U.S. Accredited Representative under the provisions of ICAO Annex 13, and was assisting the IIC (NTSB Accident DCA13RA081). In October 2014, the MoTCA delegated the investigation to the NTSB (NTSB Accident DCA13MA081).
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air traffic control (ATC) identification purposes, and the civilian call sign was National Airlines flight 102 (NCR102). The flight had a crew of 7 (4 flight crew members, two mechanics, and one loadmaster).^7
The original schedule was for the crew to operate flight NCR510 from Chateauroux, France (LFLX) to Camp Bastion, Afghanistan (OAZI), and then continue NCR510, departing Camp Bastion at 0235Z for a scheduled 2 hour and 35 minute flight to the Dubai World Center at Al Aktoum, UAE airport (OMDW). According to the National Airlines flight dispatcher for the flight, National Airlines could not obtain a Pakistan over-flight permit for the flight departing Camp Bastion to Dubai, and the dispatcher flight planned NCR102 to operate from Camp Bastion to Bagram, refuel, and continue NCR102 from Bagram to Dubai. This resulted in a total duty day of 25 hours and 4 minutes,^8 with a planned total flight time of 14 hours and 11 minutes for the duty day.^9 The accident crew began their duty day by operating NCR510 on April 28, 2013, departing Chateauroux, France at 1526Z and arriving into Camp Bastion, Afghanistan (OAZI) at 0029Z on April 29, 2013. According to National Air Cargo ground personnel, the inbound flight NCR510 to Camp Bastion was held for more than an hour in flight due to indirect fire (IDF) at the airport from the Taliban. The flight release for the Bagram to Dubai flight was emailed to the captain while the crew was in Camp Bastion.^10
According to the load manifest, while in Camp Bastion, the airplane was loaded by National Air Cargo (NAC) ground personnel with 94,119kgs of cargo,^11 including 5 Mine Resistant Ambush Protected (MRAP) armored military vehicles that were loaded on the main deck of the airplane.^12 National Air Cargo was contracted by National Airlines to perform the pallet build up and loading of the cargo.^13 Two of these vehicles weighed about 12 tons each, and the other three weighed about 18 tons each.^14 According to National Airlines, the accident captain and first officer (FO) did not have prior experience carrying mine resistant armored vehicles,^15 and it was the first time National Airlines had transported 18-ton military vehicles when they were loaded on the accident airplane in Camp Bastion.^16
NCR102 departed Camp Bastion at 0745Z and arrived into Bagram at 0923Z. On arrival into Bagram, the crew experienced a brake overheat condition after landing on runway 03. The crew
2V5.” (^7) See Attachment 6 – General Declaration. (^8) According to the National Airlines General Operations Manual (GOM), Section 6.2, page 3-6, the flight
crewmembers’ duty time began 90 minutes before scheduled departure time on an overwater or international leg, and ended 30 minutes after block arrival of the flight. (^9) For additional information on augmented crews and duty time restrictions, see Section 2.0 Flight Crew Information
of this Factual Report. (^10) See Attachment 4 – Dispatch Release. (^11) See Attachment 21 – Weight and Balance. (^12) See Attachment 21 - Weight and Balance. (^13) For an explanation of the relationship between National Airlines and National Air Cargo, see Section 12.
Organizational and Management Information of this Factual Report. (^14) For detailed information on the MRAP cargo load in Camp Bastion, see Section 6.0 “Camp Bastion Loading” of
this Factual Report. 15 See Attachment 9 – Flight Crew Experience with MRAPs. (^16) See Attachment 1 – Interview Summaries.
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parked the airplane on the Foxtrot ramp^17 and according to recorded information, the crew ran a checklist to address the brake temperature indications in the cockpit, and discussed the required cooling time of 1 to 1.5 hours.^18 The crew did not take on any additional cargo in Bagram, and only took on fuel for the flight to Dubai. The airplane refueled to 48,000 kilograms of fuel. 19 A National Air Cargo ground crew met the airplane during refueling, and only spoke with the loadmaster at the entrance of the main deck door. The flight release for the Bagram to Dubai leg had been emailed to the captain while the airplane was in Camp Bastion, so there was no paperwork exchanged, and the ground crew did not enter the airplane or cockpit and only spoke with the loadmaster.^20
According to recorded data, at about 0957 while the airplane was still on the ramp in Bagram, the captain was made aware of a broken strap found by one of the other crewmembers, and the cockpit crew had a discussion about a possible shift of the cargo load during landing in Bagram. There was additional discussion on re-securing the load prior to departure.
According to interviews with ATC personnel at Bagram, NCR102 taxied out normally for departure on runway 03 at Bagram at 1044:53Z. At 1045:32, NCR102 received and acknowledged the following ATC departure clearance to Dubai during its taxi to runway 03:^21
Direct to SIBLO via diverse vectors.^22 On departure fly runway heading until 3 DME, then turn left heading two one zero. Climb and maintain two eight zero, squawk zero four seven three. Departure frequency on two four point eight.
Weather for departure was good visibility, winds 020 degrees at 7 knots, scattered clouds at 4,000 feet with a broken ceiling at 8,000 feet.^23 NCR102 received and acknowledged their takeoff clearance at 1055:48Z. There were no other communications from NCR102 to ATC. According to interviews with ATC tower personnel, all communications with the accident crew were normal, and the takeoff roll appeared normal. The airplane rotated normally around the Charlie intersection of the runway, which according to ATC interviews, was a typical rotation point for the B747. According to preliminary recorded information, approximately 9 seconds after the crew called to rotate the airplane, the cockpit voice recorder (CVR) stopped recording,
(^17) See Attachment 28 – Bagram Airfield Diagram. (^18) See Attachment 24 – B747 Brake Temp Checklist. According to recorded information, all brake temperatures
returned to normal about an hour after the airplane was parked. 19 Post-accident fuel analysis was completed in Bagram, Afghanistan. See Attachment 21 - Weight and Balance. (^20) Flight plans at National Airlines were automated and filed via NavTech. The computer flight planning system
combines the Flight Release and Computer Flight Plan into a single document. Required weather reports and NOTAMs are included with the Flight Release. Source: National Airlines General Operations Manual, Section 4.3.2. (^21) See Attachment 5 – ATC. (^22) Diverse Vector Area/s (DVAs) may be established at the request of the ATM and coordinated jointly with the
appropriate Service Area OSG and Mission Support Services, Terminal Procedures and Charting Group for candidate airports within the facility's area of jurisdiction. DVAs should be considered when an obstacle(s) penetrates the airport's diverse departure obstacle clearance surface (OCS). The OCS is a 40:1 surface and is intended to protect the minimum climb gradient. For additional information, see FAAO JO 7210.3, Para 3−9−5, Establishing Diverse Vector Area/s (DVA). 23 This was the recorded weather at 1055Z, about 2 minutes prior to the accident. For additional information, see Section 8.0 Meteorological Information of this factual report.
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Due to the extensive damage of the airplane, it could not be determined if either augmented flight crewmember occupied any of the cockpit jumpseats at the time of the accident. According to the National Airlines FCOM “Normal Procedures”, page NP.11.3, for augmented crews, the Captain shall assign Relief Officer (R/O) duties. As a minimum, these duties shall include:
_- Occupying an observer’s seat prior to the BEFORE START checklist until after the completion of the AFTER TAKEOFF checklist.
- Occupying an observer’s seat prior to the Approach Briefing and DESCENT/APPROACH checklist through completion of the SHUTDOWN checklist. PF and PM duties may change during a flight. For example, the captain could be the PF during taxi but be the PM during takeoff through landing._
The accident captain and first officer were flying multi-day pairings that began on April 18, 2013 for the captain and on April 17, 2013 for the first officer. Both accident pilots began flying together in Ramstein Air Base (ETAR) on April 20, 2013 to McGuire Air Force Base (KWRI), and were paired together for the remaining days until the accident.
2.1 The Captain
The accident captain was 34 years old and resided in Southgate, Michigan. His date of hire with National Airlines was June 3, 2004. He upgraded on the B747-400 on June 22, 2012, having previously served as a captain on the DC-8. Prior to his employment with National Airlines, the accident captain was a flight instructor at Jackson Community College in Jackson, Michigan from May 2002 to April 2004. He graduated from Eastern Michigan University in Ypsilanti, Michigan in December 2001 with a Bachelor of Science degree in Aviation Management.
The National Airlines check airman who last provided the accident captain his B747- proficiency check said the accident captain was “a well prepared student” and dedicated.^27 The check airman also said the captain was “excellent” in his training, and “was a pleasure to be an instructor for” and “pretty sharp.” One National Airlines first officer stated he remembered the accident captain as being very knowledgeable and having great CRM (crew resource management) procedures.
The captain was current and qualified under National Airlines and FAA requirements. A review of FAA PTRS^28 records found no prior accident, incident or enforcement actions. A search of
facility is to provide a suitable area for flightcrew members to rest during long-haul operations while operating in an augmented crew configuration.” 26 Source: National Airlines GOM, Section 6.5.3 “Three or More Pilots and an Additional Airman (as required).” (^27) See Attachment 1 – Interview Summaries. (^28) The Program Tracking and Reporting Subsystem (PTRS) is a comprehensive information management and
analysis system used in many Flight Standards Service (AFS) job functions. It provides the means for the collection, storage, retrieval, and analysis of data resulting from the many different job functions performed by Aviation Safety Inspectors (ASIs) in the field, the regions, and headquarters. This system provides managers and inspectors with current data on airmen, air agencies, air operators, and many other facets of the air transportation system. Source: FAA.
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records at the National Driver Registry (NDR) found no history of driver’s license revocation or suspension.
2.1.1 The Captain’s Pilot Certification Record
FAA records of the accident captain indicated the following:
Private Pilot – Airplane Single Engine Land certificate issued May 4, 1999. Commercial Pilot – Airplane Single Engine Land (Not valid for carriage of passengers for hire in airplanes on cross-country flights of more than 50NM, or at night) certificate issued May 14, 2001. Commercial Pilot – Airplane Single Land, Instrument Airplane certificate issued August 14,
Flight Instructor – Airplane - Single Engine (expires January 31, 2004) certificate issued January 30, 2002. Flight Instructor – Airplane - Single Engine, Instrument Airplane (expires December 31, 2005) certificate issued December 19, 2003. Renewed December 8, 2005; December 18, 2007; December 29, 2009; November 30, 2011. Commercial Pilot – Airplane Single and Multiengine, Land Instrument Airplane certificate issued January 9, 2004. Airline Transport Pilot – Airplane Multi-Engine Land, DC-8 (DC-8 Circ. Apch. VMC Only, ATP Circ. Apch. VMC Only), Commercial Privileges Airplane Single Engine Land certificate issued July 21, 2006. Airline Transport Pilot – Airplane Multi-Engine Land, B-747-4 DC-8 (DC-8 B747 Circ. Apch. VMC Only, ATP Circ. Apch. VMC Only, English Proficient), Commercial Privileges Airplane Single Engine Land certificate issued June 22, 2012.
2.1.2 The Captain’s Certificates and Ratings Held at Time of the Accident
AIRLINE TRANSPORT PILOT (issued June 22, 2012) AIRPLANE MULTIENGINE LAND, B747-4 DC-8 (DC-8 B747 CIRC. APCH. VMC ONLY, ATP CIRC. APCH. VMC ONLY, ENGLISH PROFICIENT), COMMERCIAL PRIVILEGES AIRPLANE SINGLE ENGINE LAND
FLIGHT INSTRUCTOR (issued November 30, 2011) AIRPLANE SINGLE ENGINE INSTRUMENT AIRPLANE
MEDICAL CERTIFICATE FIRST CLASS (issued May 24, 2012) LIMITATIONS: MUST WEAR CORRECTIVE LENSES.
2.1.3 The Captain’s Training and Proficiency Checks Completed^29
Date of Hire June 3, 2004 Date First Upgrade to Captain Position (DC-8) July 7, 2006
(^29) Source: National Airline. See Attachment 3 – Crew Training Records.
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destination of Hill Air Base, Utah (KHIF). The total duty for the 3 segments was 18 hours 45 minutes with a total block time of 12 hours 43 minutes. He remained at Hill Air Base, Utah for 73 hours 21 minutes before his next flight assignment.
On April 27, 2013, he operated as part of an augmented crew (two captains and one first officer) positioning the accident airplane from Hill Air Base, Utah to Chateauroux, France. The total duty was 12 hours 8 minutes with a total block time of 9 hours 32 minutes. At Chateauroux, France, the accident captain was off duty for 12 hours 18 minutes before his next assignment.
On April 28, 2013, he was scheduled to operate as part of a “heavy“ crew of two captains and two FOs flying three segments with a total duty of 25 hours and 4 minutes and a total block time of 14 hours 11 minutes. The revised segments would have been from Chateauroux, France to Camp Bastion Airfield, Afghanistan continuing to Bagram, Afghanistan then the final leg to Al Maktoum, UAE. At the time of the accident, the captain and flight crew had completed the first two segments for a total block time of 10 hours 41 minutes. He had checked in at 1400Z on April 28, 2013 and had been on duty for approximately 21 hours at the time of the accident.
2.2 The First Officer
The accident first officer was 33 years old and resided in Three Rivers, Michigan. His date of hire with National Airlines was February 23, 2009. He transitioned to B747-400 first officer on July 20, 2012, having previously served as a DC-8 first officer. Prior to his employment with National Airlines, the accident first officer was an instruments and flight controls craftsman technician on the B-1B bomber for the United States Air Force at Dyess Air Force Base in Abilene, Texas from January 2002 to March 2008. He graduated from the Community College of the Air Force in December 2007 with an Associates of Science Degree in Aviation Maintenance Technology.
The National Airlines B747-400 check airman who provided initial B747-400 simulator training for the accident first officer said the accident first officer’s simulator performance was good for a pilot new to the airplane, coming off the DC-8, and he was “very well prepared.”^35 A B747- captain for National Airlines who flew with the accident first officer said the accident first officer’s pilot monitoring skills were great, and he was very professional. Another captain said the accident first officer had “good flying skills for his low pilot time in general.”^36
The first officer was current and qualified under National Airlines and FAA requirements. A review of FAA PTRS records found no prior accident, incident or enforcement actions. A search of records at the National Driver Registry (NDR) found no history of driver’s license revocation or suspension.
2.2.1 The First Officer Certification Record
FAA records of the accident first officer indicated the following:
(^35) See Attachment 1 – Interview Summaries. (^36) See Attachment 1 – Interview Summaries.
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Private Pilot – Airplane Single Engine Land certificate issued May 26, 2008. Private Pilot – Airplane Single and Multiengine Land certificate issued June 25, 2008. Private Pilot – Airplane Single and Multiengine Land Instrument Airplane certificate issued August 3, 2008. Commercial Pilot – Airplane Multiengine Land, Private Pilot privileges Airplane Single Engine Land Instrument Airplane certificate issued September 19, 2008. Ground Instructor Advanced Instrument certificate issued September 24, 2008. Flight Instructor – Airplane Multiengine (expires October 31, 2010) certificate issued October 1,
Flight Instructor – Instrument Airplane Multiengine (expires October 31, 2010) certificate issued October 4, 2008. Commercial Pilot – Airplane Single and Multiengine Land, Instrument Airplane certificate issued October 8, 2008. Flight Instructor – Instrument Airplane Single and Multiengine (expires October 31, 2010) certificate issued October 10, 2008. Renewed October 22, 2010; September 12, 2012. Mechanic Airframe, Powerplant certificate issued February 14, 2009. Flight Engineer Turbo-jet Powered certificate issued April 17, 2009. Commercial Pilot – Airplane Single and Multiengine Land DC-8 (DC-8 SIC Privileges Only), English Proficient certificate issued March 24, 2011. Commercial Pilot – Airplane Single and Multiengine Land, Instrument DC-8 (DC-8 SIC Privileges Only, DC-8 Circ Apch – VMC Only), English Proficient certificate issued July 7, 2011. Commercial Pilot – Airplane Single and Multiengine Land, Instrument Airplane, B747-400 DC- 8 (B747-400, DC-8 SIC Privileges Only; B747-400, DC-8 Circ Apch – VMC Only), English Proficient certificate issued August 8, 2012.
2.2.2 The First Officer Certificates and Ratings Held at Time of the Accident
COMMERCIAL PILOT (issued August 8, 2012) AIRPLANE SINGLE AND MULTI-ENGINE LAND AIRPLANE, B-747-400, DC-8 SIC PRIVILEGES ONLY; B747-400, DC-8 CIRC APCH – VMC ONLY; ENGLISH PROFICIENT
FLIGHT INSTRUCTOR (issued September 12, 2012) INSTRUMENT AIRPLANE SINGLE AND MULTI-ENGINE
MECHANIC AIRFRAME, POWERPLANT (issued February 14, 2009)
FLIGHT ENGINEER TURBO-JET POWERED (issued April 17, 2009)
MEDICAL CERTIFICATE FIRST CLASS (issued March 23, 2013) LIMITATIONS: NONE.
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On April 22, 2013, he was part of a “heavy” crew that positioned the airplane from Rockford, Illinois to Kunsan Air Base, Korea. The total duty was 16 hours 01 minute with a total block of 14 hours 08 minutes. At Kunsan Air Base he was off duty for a total of 20 hours 58 minutes.
On April 23, 2013, he was part of a “heavy” crew that operated three segments originating at Kunsan Air Base to Iwakuni, Japan with a technical stop in Anchorage, Alaska, and then to the final destination Hill Air Base, Utah. The total duty for the 3 segments was 18 hours 45 minutes with a total block time of 12 hours 43 minutes.
The accident FO remained at Hill Air Base, Utah for 73 hours 21 minutes before his next flight assignment. During that period, he was assigned a 24 hour break on April 25, 2013, and an additional 10 hour rest period from 1430z on April 26, 2013 to 0030z on April 27, 2013.
On April 27, 2013, he operated as part of an augmented crew positioning the airplane from Hill Air Base, Utah to Chateauroux, France. The total duty was 12 hours 08 minutes with a total block time of 9 hours 32 minutes. At Chateauroux, France he was off duty for 12 hours 18 minutes before his next assignment.
On April 28, 2013, he was scheduled to operate a revised schedule as part of a “heavy" crew flying three segments with a total duty of 25 hours 04 minutes and a total block of 14 hours 11 minutes. The revised segments would have been from Chateauroux, France to Camp Bastion Airfield, Afghanistan continuing to Bagram, Afghanistan then the final leg to Al Maktoum, UAE. At the time of the accident they had completed the first two segments for a total block time of 10 hours 41 minutes. He had checked in at 1400z on April 28, 2013 and had been on duty for approximately 21 hours at the time of the accident.
2.3 The Loadmaster
The accident loadmaster was 46 years old and resided in Ypsilanti, Michigan. His date of hire with National Airlines was November 22, 2010. Prior to his employment with National Airlines, the accident loadmaster was a ground handling supervisor/trainer for CP Deliveries from 2004 until November 2010. According to his resume on file with National Airlines, from 2000 to 2004 he also was a “journeyman carpenter.”
2.3.1 The Loadmaster’s Certification Record
According to the FAA, the position of “loadmaster” was not defined in the Code of Federal Regulations (CFRs), and it was not a certificated position. There were no duty time or rest requirements for loadmasters, and there were no training requirements for loadmasters contained in 14 CFR 121. The FAA did not track the position of “loadmaster” or similar duty position.^41
(^41) See Attachment 8 – FAA Responses.
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2.3.2 The Loadmaster’s Training and Proficiency Checks Completed^42
According to company records, the accident loadmaster attended loadmaster initial training at National Airlines from December 6, 2010 to December 14, 2010. He attended a three day loadmaster recurrent training between December 1 and December 3, 2011. Between January 5 and January 9, 2012, the accident loadmaster attended B747-400 training that included a review of a Telair cargo loading DVD, B747-400 aircraft familiarization, and B747-400 weight and balance training. In addition, he attended a one day training session on a computerized B747- 400 weight and balance system on May 8, 2012.
The accident loadmaster received a line evaluation on the accident airplane on December 16, 2012 from Riga, Latvia to McGuire Air Force Base (KWRI) to Ramstein Air Force Base (ETAR). This evaluation included an evaluation of tiedown restraint criteria and calculations, shoring (load spreading) criteria and computations, and cargo conveyance/restraint systems operation. His overall performance was graded as satisfactory. According to the National Airlines Chief Loadmaster, an evaluation form was used for line evaluations, and the 1996 evaluation form the National Airlines Chief Loadmaster first created “had been altered over time,”^43 and National Airlines was in the process of implementing that form formally into their manuals (Cargo Operations Manual) since the accident.^44 According to the National Airlines Chief Loadmaster, the FAA had not yet signed off on the change.
2.3.3 Loadmaster Training
Loadmaster training requirements were not defined in the CFRs. Specifics on loadmaster training were not included in the National Airlines General Operations Manual, Flight Operations Training Manual or Weight and Balance Manual, nor was it required. The National Airlines Cargo Operations Manual listed general training modules of learning.^45 Training, evaluations, scheduling, policies and procedures for loadmasters at National Airlines were the responsibility of the Chief Loadmaster. The National Airlines Chief Loadmaster had held that position since he was hired by the airline in October 2010, and he was responsible for about 13 loadmasters and 3 “check loadmasters.” The National Airlines Chief Loadmaster told NTSB Staff he did not have any FAA certificates or licenses.^46 He stated he wrote the policies, procedures, training and evaluations for loadmasters at the airline.
Loadmasters and cargo loaders from National Air Cargo, responsible for pallet build up and loading of the airplanes, did not train together. Pilots and loadmasters also did not train together. While pilots received CRM training, the National Airlines Director of Safety stated he did not know if loadmasters were trained in CRM.
(^42) See Attachment 3 – Crew Training Records. (^43) See Attachment 1 – Interview Summaries. (^44) See Attachment 1 – Interview Summaries. (^45) For additional information, see Attachment 12 – Loadmaster Training. (^46) See Attachment 1 – Interview Summaries.
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DC-8 1 hour B757 1 hour B747-400 (includes Telair DVD) 2 hours CRM Training 2 hours Fundamentals of Instructing (check LMs) 1 hour* Total Time 24/25 hours
2.3.4 The Loadmaster’s Schedule History^50
On April 26, 2013, the accident loadmaster travelled from Detroit, Michigan (DTW) home base to Hill Air Base, Utah. Prior to travel he had been on days off in DTW.
On April 27, 2013 the loadmaster showed at the aircraft at 1610z, and operated a positioning flight from Hill Air Base, Utah to Chateauroux, France. The total duty was 12 hours 08 minutes with a total block time of 9 hours 32 minutes. At Chateauroux, France he was off duty for 12 hours 18 minutes before his next assignment. On the day of the accident, the loadmaster was scheduled to operate the same flight segments as the flight crew, operating from Chateauroux, France to Camp Bastion Airfield, continuing to Bagram, Afghanistan and then the final leg to Al Maktoum, UAE. At the time of the accident he had completed the first two segments for a total block time of 10 hours 41 minutes. He had checked in at 1400z on April 28, 2013 and was at approximately 21 hours of duty at the time of the accident.
3.0 Medical and Pathological Information
Autopsies were performed by the Armed Forces Medical Examiner, per 10 U.S. Code 1471. The accident captain, first officer, loadmaster, and remaining crew were all fatally injured, and the causes of death was listed as “multiple injuries,” with the manner of death listed as “accident.” Toxicology results for the accident captain, first officer and loadmaster were all negative.
(^50) Information provided to the NTSB by National Airlines. For additional information, see Attachment 2 - Crew
Information.
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4.0 Aircraft Information
Photo 1: Accident Airplane (N949CA)
The accident airplane (Serial number 25630, Registration N949CA) was a Boeing B747- BCF (Boeing Converted Freighter) manufactured February 10, 1993 and registered to Wells Fargo Bank Northwest. The airplane was certified in the Transport Category per 14 CFR Part 25 and Part 36. According to the National Airlines B747-400 FCOM “Airplane General”^51 the airplane was approved for the following kinds of flight and operation, both day and night, when the required equipment was installed and approved in accordance with the applicable Federal Aviation Regulations:
- Visual (VFR)
- Instrument (IFR)
- Icing Conditions
- Extended Overwater
According to maintenance records for the accident aircraft (N949CA, serial #25630), the one deferred maintenance item on the accident flight was for a hydraulic pump removed from the fly away kit (FAK).^52
(^51) Source: National Airlines B747-400 FCOM, page L.10. (^52) The National Airlines B747 Minimum Equipment List (MEL), page 24 stated the following: “Fly Away Kit
(FAK) – Sometimes called Spare Parts Kit (SPK), a Fly Away Kit is a National Airlines kit of tools, supplies and spare parts placed on the aircraft. The content of the FAK is aircraft specific and is determined by the Director of Maintenance. The FAK will have a specific location and contents in keeping with weight and balance control.”