DCA13MA081

NTSB accident investigation · Boeing 747-400 BCF · Bagram, Afghanistan · April 29, 2013

Accident · FatalClass 1 · MajorFinal report
Date
April 29, 2013, 15:27 local (10:57 UTC)
Place
Bagram, Afghanistan
Injuries
7 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N949CABoeing 747-400 BCF
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report August 26, 2015
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
Federal Aviation Administration, Boeing, National Airlines, Telair
Safety recommendations
Yes
Case key
86758

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

National Airlines' inadequate procedures for restraining special cargo loads, which resulted in the loadmaster's improper restraint of the cargo, which moved aft and damaged hydraulic systems Nos. 1 and 2 and horizontal stabilizer drive mechanism components, rendering the airplane uncontrollable. Contributing to the accident was the Federal Aviation Administration's inadequate oversight of National Airlines' handling of special cargo loads.

Findings · 7

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Policy/procedure: adequacy of policy/procOrganizational issues › Management · OperatorBoeing 747-428: 1 caseAll aircraft: 106 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · OtherBoeing 747-428: 1 caseAll aircraft: 397 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBoeing 747-428: 1 caseAll aircraft: 61 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · OtherBoeing 747-428: 1 caseAll aircraft: 792 casesProbable cause
Hydraulic power systemAircraft › Aircraft systems · Damaged/degradedBoeing 747-428: 1 caseAll aircraft: 22 casesProbable cause
Flight control system: stabilizer control systemAircraft › Aircraft systems · Damaged/degradedBoeing 747-428: 1 caseAll aircraft: 13 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleBoeing 747-428: 1 caseAll aircraft: 1,269 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-15/01. 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 was destined for Dubai World Central - Al Maktoum International Airport, Dubai, United Arab Emirates.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-15/01. 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 was destined for Dubai World Central - Al Maktoum International Airport, Dubai, United Arab Emirates.

Aircraft

Registration
N949CA
Reported as
Boeing 747-400 BCF
Category
Airplane
Serial number
25630
Airframe hours
76,938
Engines
General Electric Snecma CF6-80C2B1F, turbo jetGeneral Electric Snecma CF6-80C2B1F, turbo jetGeneral Electric Snecma CF6-80C2B1F, turbo jetGeneral Electric Snecma CF6-80C2B1F, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Part 121
Operator
National Air Cargo, doing business as National Airlines
Registered owner
Wells Fargo Bank Northwest Na Trustee
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · April 29, 2013
Departed
OAIX · Bagram
Destination
OMDW · Dubai
Airport
OAIX · Bagram Air Base, runway 03, 11,819 × 151 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
34
Injuries
Fatal
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 22, 2012
Seat
Left
Toxicology
Performed
Flight hours
6,000 total · 439 in this make and model · 4,700 as pilot in command · 162 in the last 90 days · 74 in the last 30 days · 14 in the last 24 hours
Role
Co-pilot
Age
33
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 1, Without waivers/limitations
Last flight review
October 10, 2012
Seat
Right
Toxicology
Performed
Flight hours
1,100 total · 209 in this make and model · 451 as pilot in command · 140 in the last 90 days · 71 in the last 30 days · 14 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 7 knots
Lowest ceiling
8,000 ft broken
Temperature
64 °F, dew point 43 °F
Altimeter
29.94 inHg
Observed at
OAIX

Docket · 81

The files NTSB released with the investigation on February 3, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 190 MB in all.

Operations Group Chairman's Factual ReportItem 1 · .PDF · 21 photos · 4.6 MBOperations Report - Errata 1Item 2 · .PDF · 180 KBOperations Report - Errata 2Item 3 · .PDF · 141 KBOperations - Attachment 1 - Interview SummariesItem 4 · .PDF · 824 KBOperations - Attachment 2 - Crew InformationItem 5 · .PDF · 424 KBOperations - Attachment 3 - Crew Training RecordsItem 6 · .PDF · 49.1 MBOperations - Attachment 4 - Dispatch ReleaseItem 7 · .PDF · 1.8 MBOperations - Attachment 5 - ATCItem 8 · .PDF · 5.4 MBOperations - Attachment 6 - General DeclarationItem 9 · .PDF · 228 KBOperations - Attachment 7 - Operations SpecificationsItem 10 · .PDF · 3.3 MBOperations - Attachment 8 - FAA ResponsesItem 11 · .PDF · 2.0 MBOperations - Attachment 9 - Flight Crew Experience with MRAPsItem 12 · .PDF · 287 KBOperations - Attachment 10 - Flight Crew ProceduresItem 13 · .PDF · 1.5 MBOperations - Attachment 11 - Loadmaster ProceduresItem 14 · .PDF · 1.3 MBOperations - Attachment 12 - Loadmaster TrainingItem 15 · .PDF · 353 KBOperations - Attachment 13 - Main Cargo Deck AccessItem 16 · .PDF · 922 KBOperations - Attachment 14 - NAL B747-400 FlightsItem 17 · .PDF · 3.2 MBOperations - Attachment 15 - NAL Normal ChecklistItem 18 · .PDF · 1.5 MBOperations - Attachment 16 - National Air Cargo Stryker PrepItem 19 · .PDF · 2 photos · 565 KBOperations - Attachment 17 - Portable OxygenItem 20 · .PDF · 3 photos · 772 KBOperations - Attachment 18 - Stabilizer Trim ChecklistItem 21 · .PDF · 137 KBOperations - Attachment 19 - Tactical DeparturesItem 22 · .PDF · 147 KBOperations - Attachment 20 - WeatherItem 23 · .PDF · 1.3 MBOperations - Attachment 21 - Weight and BalanceItem 24 · .PDF · 18.8 MBOperations - Attachment 22 - Witness StatementsItem 25 · .PDF · 10.8 MBOperations - Attachment 23 - Ypsilanti SimulatorItem 26 · .PDF · 1.1 MBOperations - Attachment 24 - B747 Brake Temp ChecklistItem 27 · .PDF · 460 KBOperations - Attachment 25 - SAFO 13008Item 28 · .PDF · 204 KBOperations - Attachment 26 - B747 Normal Takeoff CalloutsItem 29 · .PDF · 129 KBOperations - Attachment 27 - B747 Normal Takeoff ProceduresItem 30 · .PDF · 210 KBOperations - Attachment 28 - Bagram Airfield DiagramItem 31 · .PDF · 1 photo · 190 KBOperations - Attachment 29 - Bastion Loading Demo PhotosItem 32 · .PDF · 52 photos · 6.7 MBOperations - Attachment 30 - Bastion LoadingItem 33 · .PDF · 12 photos · 9.5 MBOperations - Attachment 31 - ChartsItem 34 · .PDF · 376 KBOperations - Attachment 32 - 8900.1 CHG 116 Cargo InspectionsItem 35 · .PDF · 414 KBOperations - Attachment 33 - 8900.1 Enroute InspectionsItem 36 · .PDF · 96 KBOperations - Attachment 34 - 8900.1 Risk ManagementItem 37 · .PDF · 105 KBOperations - Attachment 35 - AC 120 85Item 38 · .PDF · 689 KBOperations - Attachment 36 - NAC ULD Inspections ProcessItem 39 · .PDF · 1.1 MBOperations - Attachment 37 - FAA PTRS DataItem 40 · .PDF · 248 KBOperations - Attachment 38 - Party FormsItem 41 · .PDF · 1.4 MBOperations - Attachment 39 - National Airlines Organizational ChartsItem 42 · .PDF · 248 KBAddendum 1 - FAA ResponsesItem 43 · .PDF · 641 KBSystems Group Chairman's Factual ReportItem 44 · .PDF · 11 photos · 1.7 MBSystems Factual - Attachment 1 w/photosItem 45 · .PDF · 4.8 MBMaintenance Records Group Chairman's Factual ReportItem 46 · .PDF · 2.4 MBFlight Data Recorder (FDR) Group Chairman's Factual ReportItem 47 · .PDF · 383 KBAttachment 1 - FDR Tabular Event FlightItem 48 · .CSV · 1.2 MBAttachment 2 - FDR Tabular Prev FlightItem 49 · .CSV · 1.5 MBMaterials Laboratory Factual Report - StrapsItem 50 · .PDF · 1.2 MBMaterials Laboratory Paint Memo - Paint TestItem 51 · .PDF · 30 KBVideo StudyItem 52 · .PDF · 16 photos · 1.4 MBFDR Data StudyItem 53 · .PDF · 1.3 MBCockpit Voice Recorder Group Chairman's Factual ReportItem 54 · .PDF · 949 KBStructures Group Chairmans Factual ReportItem 55 · .PDF · 9.2 MBStructures Report - Errata 1Item 56 · .PDF · 224 KBStructures Report - Attachment 1Item 57 · .PDF · 814 KBStructures Report - Attachment 2Item 58 · .PDF · 636 KBStructures Report - Attachment 3Item 59 · .PDF · 327 KBStructures Report Attachment 4Item 60 · .PDF · 6.9 MB
All 81 files on NTSB’s docket