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Operations Group Chairman's Factual Report

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Operations Group Chairman's Factual Report NATIONAL TRANSPORTATION SAFETY BOARD Office of Aviation Safety Washington, D.C. 20594 October 30, 2014 Group Chairman’s Factual Report OPERATIONAL FACTORS DCA13MA081 1 OPS FACTUAL REPORT DCA13MA081 Table Of Contents A. ACCIDENT ............................................................................................................................ 4 B. OPERATIONAL FACTORS GROUP ................................................................................... 4 C. SUMMARY ............................................................................................................................ 5 D. DETAILS OF THE INVESTIGATION ................................................................................. 5 E. FACTUAL INFORMATION ................................................................................................. 6 1.0 History of Flight .............................................................................................................. 6 2.0 Flight Crew Information ................................................................................................. 9 2.1 The Captain ............................................................................................................... 10 2.1.1 The Captain’s Pilot Certification Record ............................................................ 11 2.1.2 The Captain’s Certificates and Ratings Held at Time of the Accident ............... 11 2.1.3 The Captain’s Training and Proficiency Checks Completed .............................. 11 2.1.4 The Captain’s Flight Times ................................................................................. 12 2.1.5 The Captain’s Schedule History .......................................................................... 12 2.2 The First Officer ....................................................................................................... 13 2.2.1 The First Officer Certification Record ................................................................ 13 2.2.2 The First Officer Certificates and Ratings Held at Time of the Accident........... 14 2.2.3 The First Officer Training and Proficiency Checks Completed ......................... 15 2.2.4 The First Officer’s Flight Times ......................................................................... 15 2.2.5 The First Officer Schedule History ..................................................................... 15 2.3 The Loadmaster ........................................................................................................ 16 2.3.1 The Loadmaster’s Certification Record .............................................................. 16 2.3.2 The Loadmaster’s Training and Proficiency Checks Completed........................ 17 2.3.3 Loadmaster Training ........................................................................................... 17 2.3.3.1 Loadmaster Initial Training ............................................................................ 18 2.3.3.2 Loadmaster Recurrent Training ..................................................................... 18 2.3.4 The Loadmaster’s Schedule History ................................................................... 19 3.0 Medical and Pathological Information.......................................................................... 19 4.0 Aircraft Information ...................................................................................................... 20 4.1 Aircraft Dimensions .................................................................................................. 21 5.0 Cargo Operations Manual ............................................................................................. 22 5.1 Load Responsibility .................................................................................................. 22 5.1.1 Load Planner ....................................................................................................... 22 5.1.2 Load Supervisor/Loadmaster .............................................................................. 23 2 OPS FACTUAL REPORT DCA13MA081 5.1.3 Loader Operator .................................................................................................. 24 5.1.4 Forklift Operator or Pallet Transport Operator ................................................... 24 5.1.5 Pilot in Command................................................................................................ 25 6.0 Camp Bastion Loading ................................................................................................. 25 6.1 Pre-load planning ...................................................................................................... 25 6.2 Pallet build-up and Shoring ...................................................................................... 27 6.3 Camp Bastion Pallet Build-up Demonstration Photos .............................................. 32 6.3.1 12-Ton MATV Build-up Demonstration Photos ................................................ 32 6.3.2 18-ton Cougar Build-up Demonstration Photos .................................................. 34 6.4 Securing to the Main Deck ....................................................................................... 36 6.5 Cargo Operations Manual Guidance for Motor Vehicles. ........................................ 39 6.6 Camp Bastion Loading Photos.................................................................................. 40 6.6.1 Military Photos .................................................................................................... 40 6.6.2 National Air Cargo Photos .................................................................................. 43 7.0 Weight and Balance ...................................................................................................... 49 7.1 Weight and Balance Trim Sheet ............................................................................... 51 8.0 Meteorological Information .......................................................................................... 52 9.0 Air Traffic Control ........................................................................................................ 53 9.1 Bagram Tower Photos............................................................................................... 54 10.0 Communications ........................................................................................................... 55 11.0 Airport Information ....................................................................................................... 55 11.1 Airport Communications .......................................................................................... 56 11.2 Charts ........................................................................................................................ 57 12.0 Organizational and Management Information .............................................................. 57 13.0 Relevant Procedures...................................................................................................... 61 13.1 Flight Crew Operations Manual (FCOM)................................................................. 61 13.2 B747-400 Flight Crew Procedures............................................................................ 62 13.2.1 Flight Crew Pre-flight of Cargo ....................................................................... 62 13.2.2 Normal Procedures .......................................................................................... 64 13.2.3 Takeoff Briefing .............................................................................................. 65 13.2.4 Normal Takeoff Profile ................................................................................... 65 13.2.5 Tactical Departures .......................................................................................... 66 13.2.6 Brake Temp Checklist ..................................................................................... 67 13.2.7 National Airlines Upset Recovery Guidance ................................................... 67 3 OPS FACTUAL REPORT DCA13MA081 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 ........................................................................
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