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National Airlines Boeing 747 - 400 BCF 1 Bagram, Afghanistan April 29, 2013 Tim LeBaron, Investigator - in - Charge

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National Airlines Boeing 747-400 BCF

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Bagram, AfghanistanApril 29, 2013

Tim LeBaron,Investigator-in-Charge

Two Hats

• Domestic - Investigator in Charge (IIC)

• International - United Stated Accredited Representative

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Responding Group

• 4 from the NTSB• 1 from the FAA• 1 from Boeing• 4 from the operator• 1 military observer

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Accident Flight

• April 29, 2013,1527 local time• Boeing 747-400 BCF• Operated by National Air Cargo,

Inc., dba National Airlines• Bagram, Afghanistan• 7 crewmembers - fatal

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Bagram - Dubai

Camp Bastion

Bagram Air Force Base

Five MRAPs (Special Cargo Load)

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Two 12-ton M-ATVs Three 18-ton Cougars

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Accident Takeoff

• Cleared for takeoff about 1526• “Gear up” call, then CVR and FDR

stopped recording• Airplane impacted ground about 30

seconds after CVR/FDR ceased

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Crew Observations in Bagram

• Cargo had moved “a couple inches”• Straps keeping load from moving

backward were loose• One strap had broken• Straps were being “cinched down”

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Airplane Performance Study

• Evidence: Rear M-ATV moved aft• Performance simulation

• Available FDR data• Aerodynamic modeling

• Simulation matched rotation, initial climb data with one M-ATV shifted aft

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Question Needing Answers

• What caused the loss of control?• CG Shift?• Loss of Hydraulics

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Airplane Performance Study

• Scenario: Hydraulic Nos. 1 & 2 failed• Uncontrollable if 4 or 5 vehicles moved aft• No direct evidence more than one moved

aft • Uncontrollable if horizontal stabilizer

displaced at least 5 degrees from damage from M-ATV

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Question Needing Answers

• What caused the load to break loose?

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MRAPs (Special Cargo Load)

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12-ton M-ATV18-ton Cougar

Typical ULD Loading

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Loadmaster Role

• Loadmaster responsible for ensuring cargo secure

• Loadmasters responsible for special cargo, travel with airplane

• Pilots rely on loadmaster to ensure cargo secure

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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.

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ANY QUESTIONS?