Steep Climb and Uncontrolled Descent During Takeoff, National
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Steep Climb and Uncontrolled Descent During Takeoff National Air Cargo, Inc., dba National Airlines Boeing 747 400 BCF, N949CA Bagram, Afghanistan April 29, 2013 Accident Report NTSB/AAR-15/01 National PB2015-104951 Transportation Safety Board NTSB/AAR-15/01 PB2015-104951 Notation 8710 Adopted July 14, 2015 Aircraft Accident Report Steep Climb and Uncontrolled Descent During Takeoff National Air Cargo, Inc., dba National Airlines Boeing 747 400 BCF, N949CA Bagram, Afghanistan April 29, 2013 National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 National Transportation Safety Board. 2015. Steep Climb and Uncontrolled Descent During Takeoff National Air Cargo, Inc., dba National Airlines, Boeing 747 400 BCF, N949CA, Bagram, Afghanistan, April 29, 2013. Publication Type NTSB/AAR-15/01. Washington, DC. Abstract: This report discusses the April 29, 2013, accident involving a Boeing 747-400 BCF, N949CA, operated by National Air Cargo, Inc., dba National Airlines, which 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. Safety issues relate to National Airlines’ deficient procedures for restraining special cargo loads; inadequate Federal Aviation Administration (FAA) guidance for operators for restraining special cargo loads; the lack of FAA certification for cargo handling personnel and, thus, a lack of standardized procedures, training, and duty hour limitations and rest requirements for personnel who perform the safety-critical functions of loading and securing cargo; inadequate training and guidance for FAA inspectors who have oversight responsibilities for air carrier cargo handling operations; and the ability to defer nonresourced FAA surveillance items without limitation. Safety recommendations are addressed to the FAA. The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. 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Alexandria, VA 22312 (800) 553-6847 or (703) 605-6000 http://www.ntis.gov/ NTSB Aircraft Accident Report Contents Figures ........................................................................................................................................... iii Abbreviations .................................................................................................................................v Executive Summary ................................................................................................................... viii 1. Factual Information ...................................................................................................................1 1.1 History of Flight .........................................................................................................................1 1.2 Personnel Information ................................................................................................................6 1.2.1 Captain .............................................................................................................................6 1.2.2 First Officer .....................................................................................................................7 1.2.3 Loadmaster ......................................................................................................................7 1.3 Airplane Information .................................................................................................................8 1.3.1 General Configuration and Cargo Handling Equipment .................................................8 1.3.2 Hydraulic Systems and Flight Controls .........................................................................10 1.4 Meteorological Information .....................................................................................................11 1.5 Airport Information ..................................................................................................................11 1.6 Flight Recorders .......................................................................................................................11 1.6.1 Flight Data Recorder......................................................................................................11 1.6.2 Cockpit Voice Recorder ................................................................................................12 1.7 Wreckage and Impact Information ..........................................................................................12 1.7.1 Debris Found on Runway ..............................................................................................12 1.7.2 Main Wreckage ..............................................................................................................12 1.7.2.1 General .............................................................................................................12 1.7.2.2 Aft Pressure Bulkhead Sections and Other Interior Components ....................13 1.7.2.3 Elevator Components .......................................................................................15 1.7.2.4 Horizontal Stabilizer and Trim Mechanism .....................................................15 1.7.2.5 Landing Gear Components ..............................................................................17 1.7.3 Rear M-ATV ..................................................................................................................17 1.8 Medical and Pathological Information.....................................................................................19 1.9 Tests and Research ...................................................................................................................19 1.9.1 Image Study: Landing Gear and Nose Gear Door Positions .........................................19 1.9.2 Airplane Performance Study ..........................................................................................21 1.9.2.1 Scenarios Involving Aft Movement of Single MRAP Vehicle .......................22 1.9.2.2 Scenarios Involving Aft Movement of Multiple MRAP Vehicles ..................23 1.9.3 Loading Studies for Tall Rigid Cargo Requirements ....................................................24 1.9.4 Explosives Examinations ...............................................................................................25 1.10 Organizational and Management Information .......................................................................26 1.10.1 General .........................................................................................................................26 1.10.2 Decisions, Actions, and Guidance Related to Accident Flight Cargo .........................28 1.10.2.1 Acceptance of Heavy Vehicle Special Cargo Load .......................................28 1.10.2.2 Pallet Build-Up, Shoring, and Loading of MRAP Vehicles ..........................29 1.10.2.3 Tie-Down of Accident Flight’s Cargo ...........................................................31 i NTSB Aircraft Accident Report 1.10.2.4 Flight Crew Responsibilities and Guidance Regarding Cargo ......................34 1.10.3 Training Programs .......................................................................................................34 1.10.3.1 Pilot and Dispatcher Training ........................................................................34