Submission to the

National Transportation Safety Board
for the

Investigation of National Airlines Flight 102
Boeing 747-428BCF, N949CA
Bagram, Afghanistan, April 29, 2013

March 19, 2015

Steven Santangelo
Director of Maintenance
National Airlines, Inc.

 Table of Contents

1.

Factual Information
1.1
History of Flight
1.2
Crew Information
1.3
Aircraft Information
1.4
NAL/NAC Corporate Organization, Management and
Safety Programs
1.5
NAL cargo operation policies and procedures
1.6
Crew scheduling and rest requirements

Page
2
2
7
14
15
17
23

2.

Investigation and Analysis
2.1
General Investigation Summary
2.1.1 Security Issues
2.1.2 Accident Debris Field
2.1.3 Post Crash Witness Marks and Metallurgical Analysis
2.1.4 Weather Conditions
2.1.5 FDR and CVR Post Crash Evidence
2.2
Cargo Loading Operations Conformed to Industry Practice
2.3
The Flight Crew was Well-Trained
2.4
Flight Crew Scheduling Complied with Regulations
2.5
Flight Crew Actions Did Not Cause the Accident
2.6
National Airlines' General Safety Culture is Robust

24
24
24
25
26
27
27
28
28
28
29
29

3.

Probable Cause

31

1

 Executive Summary
1.

Factual Information
1.1

History of Flight
(a)

Flight and Accident Sequence

On April 29, 2013, National Airlines Flight 102, a Boeing 747-400 converted freighter, crashed
shortly after takeoff from Bagram Air Base (OAIX). (Operations Factual Report, pages 5 and
20). The aircraft was totally destroyed by the impact and post-crash fire. (Operations Factual
Report, page 5). The seven crewmembers onboard were fatally injured. (Operations Factual
Report, page 5). The original route of the flight was from OAIX to Dubai, United Arab
Emirates, Al Maktoum International Airport (OMDW). (Operations Factual Report, page 5).
The flight was being operated as part of the International Security Assistance Force (ISAF),
outlined in United Nations Security Council Resolution 1386 (adopted 2001). (Operations
Factual Report, page 6). National Airlines operated a multi-modal contract with US
TRANSCOM (Contract Number HTC711-12-D-R010) to transport military equipment.
(Operations Factual Report, page 6). Flight 102 was denoted ISAF 95AQ (I95AQ) for Air
Traffic Control (ATC) purposes. (Operations Factual Report, page 7). The flight included a
crew of seven, four pilots, two mechanics and one loadmaster. (Operations Factual Report, page
7). The aircraft crashed at 1527 local time (1057 UTC). (Operations Factual Report, pages 4-5).
The original schedule for the crew was to operate Flight NCR510 from Chateauroux, France
(LFLX) to Camp Bastion, Afghanistan (OAZI) and then continue NCR510 departing Camp
Bastion to Dubai (OMDW). (Operations Factual Report, page 7). The flight was unable to
obtain an overflight permit for the flight departing Camp Bastion. (Operations Factual Report,
page 7). This resulted in a refuel stop at Bagram and then continuation to OMDW. (Operations
Factual Report, page 7).
The aircraft was loaded at Camp Bastion, including five Mine Resistant Ambush Protected
(MRAP) armored military vehicles. (Operations Factual Report, page 7). The flight data
recorder (FDR) recorded takeoff gross weight was 676,000 pounds. (Boeing FDR Data Study,
page 3). FDR data show the airplane was configured for a flaps 10 takeoff with a recorded
stabilizer setting of approximately -0.85 degrees, consistent with the aircraft’s preflight weight
and balance. (Boeing FDR Data Study, page 3). A review of the weight and balance following
the accident indicates the aircraft gross weight may have been 685,000 lbs. accounting for 20
foot pallets, wood shoring, straps, tie downs, and accurate weights for the MRAPs. (Boeing
FDR Data Study, page 3).
NCR102 taxied out normally for departure on runway 03 at Bagram at 1044:53Z. (Operations
Factual Report, page 8). Recorded information shows that the captain was the pilot flying (PF)
and the first officer was the pilot monitoring (PM). (Operations Factual Report, pages 65-66).
Meteorological Aviation Reports (METARs) reported that at 1055Z, the winds were at 7 knots
from 20 degrees true (north-northeast). (Operations Factual Report, page 8). There were
scattered clouds at 4,000 feet with a broken ceiling at 8,000 feet. (Operations Factual Report,
page 8). Special Weather Observations were taken at 1058Z and 1059Z, indicating an air mass
2

 change resulted in a 7 degree decrease in temperature and wind gusts at 11 knots from 350
degrees true north. (Operations Factual Report, page 53).
At 1045:32Z during its taxi, NCR102 received the following ATC departure clearance to Dubai:
Direct to SIBLO via diverse vectors. 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.
(Operations Factual Report, page 8).
NCR102 acknowledged the takeoff clearance at 1055:47Z. (Operations Factual Report, page 8).
There were no further communications between NCR102 and Bagram ATC. (Operations
Factual Report, page 8). According to interviews with ATC tower personnel, all
communications with the accident crew were normal, and the takeoff roll appeared normal.
(Operations Factual Report, page 8).
Per the recorded FDR information, maximum takeoff thrust was used (engine N1 = 108 percent).
(Boeing FDR Data Study, page 3). Slight left rudder, on average, was commanded during the
takeoff roll to maintain runway centerline. (Boeing FDR Data Study, page 3). Fluctuations in
computed airspeed were observed during the takeoff roll consistent with gusty wind conditions.
(Boeing FDR Data Study, page 3).
Calculations based off of the FDR information indicated the airplane rotated around the Charlie
intersection of the runway, which, according to ATC interviews, was a typical rotation point for
the B747. (Operations Factual Report, page 8). Rotation was initiated with a nose-up column
input at a speed of approximately 153 knots, and the airplane rotated to a normal takeoff pitch
attitude. (Boeing FDR Data Study, page 3). Approximately 9 seconds after the Captain called
for the First Officer to rotate the airplane, the cockpit voice recorder (CVR) stopped recording,
and approximately 3 seconds later the FDR stopped recording. (Operations Factual Report, page
8). Valid data ended with the airplane at 33 feet radio altitude and 171 knots computed airspeed.
(Boeing FDR Data Study, page 3). The airplane was pitched at approximately 13 degrees and
banked right at approximately 4 degrees. (Boeing FDR Data Study, page 3). Elevator
deflections were around 5-6 degrees trailing edge up when the data ended. (Boeing FDR Data
Study, page 3). The last valid recorded wind data indicate the winds were approximately 12
knots from 40 degrees true, a marked change in speed and direction from the pre-departure
METARs. (Boeing FDR Data Study, page 3). The left rudder used during the takeoff roll
(runway magnetic heading=27 degrees) was consistent with the recorded wind data (right
crosswind). (Boeing FDR Data Study, page 3). According to witnesses and video evidence,
after becoming airborne, the airplane continued to pitch up until it appeared to stall, turned to the
right, and then descended to impact with the ground just beyond the departure end and to the
right of runway 03. (Operational Factors Attachment 1, pages 3, 7, and 15).
(b)

Cargo and Loading

On April 26, 2013, the load planning department for National Air Cargo in Dubai, UAE
contacted the National Airlines Chief Loadmaster advising that National Air Cargo was planning
to load 5 Mine Resistant Ambush Protected (MRAP) armored military vehicles on the National
3

 Airlines flight from Camp Bastion to Dubai on April 29, 2013. (Operations Factual Report, page
25). The text of the email sent to the National Airlines Chief Loadmaster from the National Air
Cargo load planning department in Dubai stated:

(Operations Factual Report, pages 25-26).
The National Airlines Chief Loadmaster responded the same day via email:

(Operations Factual Report, page 26).
Three of the vehicles were 4-wheel drive MRAP “Cougars” weighing 18 tons each, and two
were MRAP All-terrain Vehicles (MRAP ATV, or MATV’s) weighing 12 tons each.
(Operations Factual Report, page 26).
On April 26, 2013, the National Air Cargo Dubai load planner sent a pre-planned load sheet to
Camp Bastion indicating an initial load of 95,313 kilograms (235,752 pounds) that included the
five MRAPs. (Operations Factual Report, page 26). National Air Cargo evaluated the load and
decided double pallets should be used for the heavier vehicles. (Interview of Allen Robert
White, Operational Factors, Attachment 1, page 19). (Operations Factual Report, page 26). The
cargo loaders were provided with pictures of the load to assist with pallet buildup and tie downs.
(Interview of Ralph Brown, Operational Factors, Attachment 1, page 13 and Interview of Allen
Robert White, Operational Factors, Attachment 1, page 19). The loaders were familiar with
palletized heavy vehicles, as National Air Cargo had previously provided instructions to them on
how to palletize a 12-13 ton Stryker combat vehicle. (Interview of Luis Gregorio, Operational
Factors, Attachment 1, page 17).
National Air Cargo employees began loading the accident airplane on the morning of April 29,
2013. (Operations Factual Report, page 27). The first 12-ton MRAP was loaded using the
National Air Cargo 14-ton lift, and placed in the forward section of the aircraft structure.
(Operations Factual Report, page 27). The ground crew then stopped loading at 0630 local time
and waited for the military to arrive with their 60-ton Atlas “K-loader” so the 18-ton Cougars
could be lifted. (Interview of Ralph James Brown, Jr., Operational Factors, Attachment 1, page
8). The loading of the remaining MRAPs occurred at about 0830 local time. (Operations
Factual Report, page 27).
Because the MRAPs were too large to drive onto the main deck of the B747-400, each of the
MRAPs were placed on aluminum pallets. (Operations Factual Report, page 27). Twenty-foot
PGF commercial pallets were used for the 12 ton vehicles, whereas the loadmaster decided to
build a double-pallet for the 18 ton vehicles. (Interview of Ralph James Brown, Jr., Operational
Factors, Attachment 1, page 9)
4

 The National Air Cargo Operations Specialist used 14 chains to secure the 12-ton MATVs to the
pallet. (Operations Factual Report, page 28). For the 18-ton Cougars, the Specialist built a
“double-pallet” comprised of one pallet on top of another pallet, with plywood between the two
aluminum pallets to reduce friction. (Operations Factual Report, page 28). The two pallets were
attached to each other with straps, three lengthwise and two widthwise, for five straps total.
(Operations Factual Report, page 28).
According to interviews, National Air Cargo personnel chained the Cougars down with eight
chains attached to the top pallet and six chains attached to the bottom pallet for a total of 14
chains. (Operations Factual Report, page 29). Two chains were attached to the bottom, and two
backwards and forwards, and the same on the other side of the vehicle. (Operations Factual
Report, page 29). The axle chains were the only ones attached to the top pallet. (Operations
Factual Report, page 29). Due to the weight of each of the vehicles, shoring (load spreading)
was used underneath each vehicle via wood blocks. (Operations Factual Report, page 30).
The pallets and vehicles were then loaded on the main deck of the B747-400. (Operations
Factual Report, page 27). The pallets were restrained with straps attached to the main deck.
(Operations Factual Report, page 27). Because the palletized cargo was loaded into the center of
the main deck and secured to the main deck itself using seat tracks, the pallets were called
center-loaded “floating pallets,” a practice often utilized by National Airlines and the cargo
industry generally. (Operations Factual Report, page 27).
The front vehicle was a 12-ton MATV, followed by the three 18-ton Cougars. (Operations
Factual Report, page 31). The aft-most vehicle was a 12-ton MATV, and was located near the
main cargo loading door in the aft of the airplane. (Operations Factual Report, page 31). The
pallets were secured to the aircraft with the use of straps. According to the National Air Cargo
loaders, 24 straps were used to secure the 12 ton vehicles, and 26 straps were employed for the
18 ton vehicles. (Operations Factual Report, page 36). After landing in Bagram, it is possible
additional straps were added in the loadmaster's discretion. (COM Rev. 8, Ch. 6, Section 4.4).
The weight and balance loading process was documented in a completed Load Manifest that
ensured the aircraft was loaded in such a way that all weight restrictions were complied with and
that the center of gravity was within its envelope for the entire flight. (Operations Factual
Report, page 50).
Flight 102 departed Camp Bastion at 0745Z and arrived into Bagram at 0923Z. (Operations
Factual Report, page 7). On arrival into Bagram, the crew experienced a brake overheat
condition after landing on runway 03. (Operations Factual Report, page 7). The crew parked the
airplane on the Foxtrot ramp. (Operations Factual Report, pages 7-8). The crew then ran a
checklist to address the brake temperature indications in the cockpit, and discussed the required
cooling time of 1 to 1.5 hours. (Operations Factual Report, page 8). The airplane refueled to
48,000 kilograms of fuel, but did not take on any additional cargo. (Operations Factual Report,
page 8). A National Air Cargo ground crew met the airplane during refueling and conferred with
the loadmaster at the entrance of the main deck door. (Operations Factual Report, page 8).

5

 The National Airlines Weight and Balance Manual, Section 8.8 “Load Manifest” page 1-11
stated the following in part:
The Captain, Loadmaster or other qualified personnel who have been properly
trained, may be delegated the authority for performing the weight and balance
computation for each flight. The Captain is responsible for ensuring that the aircraft
does not exceed any performance limited weight or center of gravity limits. The
Captain has final responsibility.
The weight and balance sheet for the accident flight is set forth below.

(Operational Factors – Attachment 21 – Weight and Balance, page 8).
6

 1.2

Crew Information

The accident crew consisted of two captains, two first officers, two mechanics and one
loadmaster. (Operations Factual Report, page 9). The two additional pilots (captain and first
officer) were considered augmented flight crew members so the flight could be operated under
the provisions of 14 CFR 121.523. (Operations Factual Report, page 9). This regulation
provides:
b) Each certificate holder conducting supplemental operations should schedule its
flight hours to provide adequate rest periods on the ground for each airman who is
away from his principal operations base. It shall also provide adequate sleeping
quarters on the airplane whenever an airman is scheduled to be aloft as a flight
crewmember for more than 12 hours during any 24 consecutive hours.
c) No certificate holder conducting supplemental operations may schedule any flight
crewmember to be on continuous duty for more than 30 hours. Such a crewmember
is considered to be on continuous duty from the time he reports for duty until the
time he is released from duty for a rest period of at least 10 hours on the ground. If a
flight crewmember is on continuous duty for more than 24 hours (whether scheduled
or not) duty [sic] any scheduled duty period, he must be given at least 16 hours for
rest on the ground after completing the last flight scheduled for that scheduled duty
period before being assigned any further flight duty.
(Operations Factual Report, page 9).
A flight crew member assigned to a crew of 3 or more may not be scheduled to be on continuous
duty for more than 30 hours. (Operations Factual Report, page 9). Further, according to the
National Airlines General Operations Manual, when any flight crew member was scheduled to
be aloft as a flight crewmember for more than 12 hours in any consecutive 24 hours, adequate
crew rest facilities shall be aboard the aircraft. (Operations Factual Report, page 9).
The National Airlines General Operating Manual (dated September 13, 2012), Section 6.3.6
“Heavy (Double) Crew (747 Aircraft)” stated, in part:
The 747 aircraft can also be flown with a Heavy (sometimes referred to as a Double)
Crew due to its rest facility. This crew consists of 4 pilots. As highlighted above
under augmented crew (747 aircraft), this type of crew can have a duty day of 30
hours.
(Operations Factual Report, page 9).
(a)

Captain

The accident captain was 34 years old. (Operations Factual Report, page 10). His date of hire
with National Airlines was June 3, 2004. (Operations Factual Report, page 10). He upgraded on
the B747-400 on June 22, 2012, having previously served as a captain on the DC-8. The captain
was current and qualified under National Airlines and FAA requirements. (Operations Factual
7

 Report, page 10). He had no prior history of accidents, incidents or enforcement actions.
(Operations Factual Report, page 10).
The captain's certificate history was as follows:
Private Pilot, Airplane Single Engine Land

Certificate issued 5/4/1999

Commercial Pilot, Airplane Single Engine Land

Certificate issued 5/14/2001

Commercial Pilot, Airplane Single Land,
Instrument Airplane

Certificate issued 8/14/2001

Flight Instructor, Airplane, Single Engine

Certificate issued 1/30/2002

Flight Instructor, Airplane, Single Engine,
Instrument Airplane

Certificate issued 12/19/2003
Renewed 12/8/2005,
12/18/2007, 12/29/2007,
12/30/2011

Commercial Pilot, Airplane Single and Multiengine
and Instrument Airplane

Certificate issued 1/9/2004

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 7/21/2006

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 6/22/2012

(Operations Factual Report, page 11).
The captain’s flight times were as follows:
Total pilot flying time

6,000

Total Pilot-In-Command (PIC) time
Total B747-400 time
Total B747-400 PIC time
Total flying time last 24 hours
Total flying time last 30 days
Total flying time last 90 days
Total flying time last 12 months

4,700
439
439
14
74
162
561

8

 (Operations Factual Report, page 12).
The National Airlines check airman who last provided the accident captain his B747-400
proficiency check said the accident captain was well prepared and dedicated. (Operations
Factual Report, page 10). The check airman also said the captain was “excellent” in his training,
and “was a pleasure to be an instructor for” and “pretty sharp.” (Operations Factual Report, page
10). One National Airlines first officer stated he remembered the accident captain as being very
knowledgeable and having great CRM (Crew Resource Management) procedures. (Operations
Factual Report, page 10).
The accident captain completed 12 OAIX (Bagram Airfield) operations within the preceding 12
calendar months. (Operations Factual Report, page 12).
Prior to departing on his sequence of flying, the accident captain was scheduled off days from
April 8, 2013, to April 17, 2013. (Operations Factual Report, page 12). On April 18, 2013, he
travelled from his home base in Detroit, Michigan, to Ramstein Air Base, Germany where he had
28 hours and 15 minutes off duty before his next flight assignment. (Operations Factual Report,
page 12). On April 20, 2013, he operated as part of a “heavy” crew (2 captains and 2 first
officers) from Ramstein Air Base, Germany to McGuire Air Force Base, and then deadheaded on
the aircraft to Rockford, Illinois, for a total duty day of 18 hours 58 minutes and a block time of
8 hours 29 minutes. (Operations Factual Report, page 12). In Rockford, Illinois, he was off duty
for 31 hours and 40 minutes. (Operations Factual Report, page 12).
On April 22, 2013 he was part of a “heavy” crew that positioned the aircraft from Rockford,
Illinois, to Kunsan Air Base, Korea. (Operations Factual Report, page 12). The total duty was
16 hours and one minute with a total block of 14 hours 08 minutes. (Operations Factual Report,
page 12). At Kunsan Air Base, he was off duty for a total of 20 hours 58 minutes. (Operations
Factual Report, page 12).
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 of Hill Air Base, Utah (KHIF). (Operations Factual Report, pages 12-13). The
total duty for the three segments was 18 hours 45 minutes with a total block time of 12 hours 43
minutes. (Operations Factual Report, page 13). He remained at Hill Air Base, Utah, for 73
hours 21 minutes before his next flight assignment. (Operations Factual Report, page 13).
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. (Operations
Factual Report, page 13). The total duty was 12 hours 8 minutes with a total block time of 9
hours 32 minutes. (Operations Factual Report, page 13). At Chateauroux, France, the accident
captain was off duty for 12 hours 18 minutes before his next assignment. (Operations Factual
Report, page 13).
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. (Operations Factual Report, page 13). 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. (Operations Factual Report, page
9

 13). 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. (Operations Factual Report, page 13). 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. (Operations Factual Report, page 13).
(b) First Officer
The accident first officer was 33 years old. (Operations Factual Report, page 13). His date of
hire with National Airlines was February 23, 2009. (Operations Factual Report, page 13). He
transitioned to B747-400 first officer on July 20, 2012, having previously served as a DC-8 first
officer. (Operations Factual Report, page 13).
The first officer was current and qualified under National Airlines and FAA requirements.
(Operations Factual Report, page 13). A review of FAA PTRS records found no prior accident,
incident or enforcement actions. (Operations Factual Report, page 13). A search of records at
the National Driver Registry (NDR) found no history of driver’s license revocation or
suspension. (Operations Factual Report, page 13).
The First Officers’ certificate history was as follows:
Private Pilot – Airplane Single Engine Land

Certificate issued 5/26/2008

Private Pilot – Airplane Single and Multiengine Land

Certificate issued 6/25/2008

Private Pilot – Airplane Single and Multiengine Land
Instrument Airplane

Certificate issued 8/3/2008

Commercial Pilot – Airplane Multiengine Land,
Private Pilot Privileges Airplane Single Engine Land
Instrument Airplane

Certificate issued 9/19/2008

Ground Instructor Advanced Instrument

Certificate issued 9/24/2008

Flight Instructor –Airplane Multiengine

Certificate issued 10/1/2008

Flight Instructor – Instrument Airplane Multiengine

Certificate issued 10/4/2008

Commercial Pilot – Airplane Single and Multiengine
Land, Instrument Airplane

Certificate issued 10/8/2008

Flight Instructor – Instrument Airplane Single and
Multiengine

Certificate issued 10/10/2008
Renewed 10/22/2010;
9/12/2012

Mechanic Airframe, Powerplant

Certificate issued 2/14/2009

Flight Engineer Turbo-jet Powered

Certificate issued 4/17/2009
10

 Commercial Pilot – Airplane Single and Multiengine
Land DC-8 (DC-8 SIC Privileges Only),
English Proficient

Certificate issued 3/24/2011

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 7/7/2011

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 8/8/2012

(Operations Factual Report, page 14).
The First Officer’s times were as follows:
Total pilot flying time

1100

Total Flight Engineer time
Total Pilot-In-Command (PIC) time
Total B747-400 time (SIC)
Total flying time last 24 hours
Total flying time last 30 days
Total flying time last 90 days
Total flying time last 12 months

720
451
209
14
71
140
219

(Operations Factual Report, page 15).
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.” (Operations
Factual Report, page 13). A B747-400 captain for National Airlines who flew with the accident
first officer said the FO’s pilot monitoring skills were great, and he was very professional.
(Operations Factual Report, page 13). Another captain said the accident first officer had “good
flying skills for his low pilot time in general.” (Operations Factual Report, page 13).
Prior to departing on his sequence of flying, the accident FO was at his Detroit, Michigan homebase on five days of leave that he had requested from April 3, 2013, to April 7, 2013, followed
by eight assigned days off. (Operations Factual Report, page 15). On April 16, 2013, he
travelled to Fresno, California, where he had 33 hours 11 minutes off duty before his next flight
assignment. (Operations Factual Report, page 15). On April 18, 2013, he operated as part of a
“heavy” crew (two captains and two FO’s) from Fresno, California, to McGuire Air Force Base,
and then continued to Ramstein Air Base, Germany for a total duty of 19 hours 28 minutes and
block time of 11 hours 57 minutes. (Operations Factual Report, page 15). He was off duty for
31 hours 02 minutes before his next flight assignment. (Operations Factual Report, page 15).
11

 On April 20, 2013, he operated as part of a “heavy” crew from Ramstein Air Base, Germany, to
McGuire Air Force Base, and then deadheaded on the airplane to Rockford, Illinois, for a total
duty day of 18 hours 58 minutes and a block time of 8 hours 29 minutes. (Operations Factual
Report, page 15). At Rockford, Illinois, he was off duty for 31 hours and 40 minutes.
(Operations Factual Report, page 15).
On April 22, 2013, he was part of a “heavy” crew that positioned the airplane from Rockford,
Illinois, to Kunsan Air Base, Korea. (Operations Factual Report, page 16). 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. (Operations Factual Report, page 16).
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. (Operations Factual Report, page 16). The total duty for
the 3 segments was 18 hours 45 minutes with a total block time of 12 hours 43 minutes.
(Operations Factual Report, page 16).
The accident first officer remained at Hill Air Base, Utah, for 73 hours 21 minutes before his
next flight assignment. (Operations Factual Report, page 16). 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. (Operations Factual Report, page 16).
On April 27, 2013, he operated as part of an augmented crew positioning the airplane from Hill
Air Base, Utah, to Chateauroux, France. (Operations Factual Report, page 16). The total duty
was 12 hours 08 minutes with a total block time of 9 hours 32 minutes. (Operations Factual
Report, page 16). In Chateauroux, France, he was off duty for 12 hours 18 minutes before his
next assignment. (Operations Factual Report, page 16).
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. (Operations Factual Report, page 16). 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. (Operations Factual Report, page 16). At the time of
the accident, they had completed the first two segments for a total block time of 10 hours 41
minutes. (Operations Factual Report, page 16). 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. (Operations Factual
Report, page 16).
(c)

The Loadmaster

The accident loadmaster was 36 years old. (Operations Factual Report, page 16). His date of
hire with National Airlines was November 22, 2010. (Operations Factual Report, page 16). The
“loadmaster” position is not defined in the Code of Federal Regulations (CFRs), and it is not a
certificated position. (Operations Factual Report, page 16). There are no duty time or rest
requirements for loadmasters, and there are no training requirements for loadmasters contained
in 14 CFR Part 121. (Operations Factual Report, page 16).
12

 According to company records, the accident loadmaster attended loadmaster initial training at
National Airlines from December 6, 2010, to December 14, 2010. (Operations Factual Report,
page 17). He attended a three day loadmaster recurrent training between December 1 and
December 3, 2011. (Operations Factual Report, page 17). 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. (Operations Factual Report, page 17). In addition, he attended a one day training
session on a computerized B747- 400 weight and balance system on May 8, 2012. (Operations
Factual Report, page 17).
According to National Airlines, the loadmaster initial training syllabus was a 68 hour course that
consisted of the following subjects:
Dangerous Goods training
Departmental Policies and Procedures
Flight and Cargo Documentation
Ground Operations
757 Emergency Equipment Training
757 Door Training
757 Ditching
Ground Security Coordinator Training
Passenger Operations security (2 hours)
Cargo operations security (2 hours)
Aircraft Familiarization and Weight and Balance
DC-8
B757
B747-400 (includes Telair DVD)
CRM Training
HR Orientation
Total Time

24 hours
4 hours
3 hours
8 hours
2 hours

4 hours

2 hours
4 hours
12 hours
2 hours
3 hours
68 hours

(Operations Factual Report, page 18).
According to National Airlines, the loadmaster recurrent training syllabus was a 24 hour course
that consisted of the following subjects:
Dangerous Goods training
Departmental Policies and Procedures
Flight and Cargo Documentation
Ground Operations
757 Emergency Equipment Training
757 Door Training
757 Ditching
Ground Security Coordinator Training
Passenger Operations security
Cargo Operations security
Aircraft Familiarization and Weight and Balance
DC-8
13

8 hours
1 hour
1 hour
2 hours
2 hours

4 hours

1 hour

 B757
B747-400 (includes Telair DVD)
CRM Training
Fundamentals of Instructing (check LMs)
Total Time

1 hour
2 hours
2 hours
1 hour
24/25 hours

(Operations Factual Report, pages 18-19).
On April 26, 2013, the accident loadmaster travelled from Detroit, Michigan (DTW) home base
to Hill Air Base, Utah. (Operations Factual Report, page 19). Prior to travel he had several days
off in Detroit. (Operations Factual Report, page 19).
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. (Operations Factual Report, page 19).
The total duty period was 12 hours 08 minutes with a total block time of 9 hours 32 minutes.
(Operations Factual Report, page 19). At Chateauroux, France, he was off duty for 12 hours 18
minutes before his next assignment. (Operations Factual Report, page 19). 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. (Operations Factual Report, page 19).
1.3

Aircraft information

The accident airplane (Serial number 25630, Registration N949CA) was a Boeing B747-428
BCF (Boeing Converted Freighter) manufactured February 10, 1993, and registered to Wells
Fargo Bank Northwest. (Operations Factual Report, page 20). The airplane was certified in the
Transport Category per 14 CFR Part 25 and Part 36. (Operations Factual Report, page 20).
According to the National Airlines B747-400 FCOM “Airplane General” 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

(Operations Factual Report, page 20).
According to maintenance records, the accident aircraft had one deferred maintenance item on
the accident flight for a hydraulic pump removed from the fly away kit (FAK). 1 (Operations

1

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 contents of the FAK is
{footnote continued}
14

 Factual Report, page 20).
N949CA was equipped with the Telair International main deck cargo handling system,
pursuant to supplemental type certificate (STC) ST00459LA. (Structures Factual Report, page
18). The cargo restraint equipment includes pallet locks, side guide restraints, centerline guide
restraints and retractable and fixed end stops. (Structures Factual Report, page 18). The
restraining system locks Unit Load Devices (ULDs) against forward, aft, vertical or lateral
movement. (Structures Factual Report, page 18). All restraining equipment is equipped with
integrated components that support the conveying capabilities of the cargo handling system.
(Structures Factual Report, page 18). All restraining equipment is installed in seat tracks, floor
fittings, or within other cargo components. (Structures Factual Report, page 18). The Telair
manual did not provide for any weight restriction with regard to use of seat tracks. (Interview
of Alfredo (Gumby) Gumbs, Operational Factors Attachment 1, page 31).
1.4

NAL/NAC Corporate Organization, Management and Safety Programs

National Airlines began as Murray Air in 1985 as a Part 135 certificate holder headquartered at
Willow Run Airport in Ypsilanti, Michigan. (Operations Factual Report, page 57). The company
acquired its 14 CFR 121 certificate in 2005 and operates under both Parts 121 and 135.
(Operations Factual Report, pages 57-58). In 2000, Daimler Chrysler contracted with Murray
Air to operate long-haul freight flights utilizing two DC-8’s operated under 14 CFR 125.
(Operations Factual Report, page 58). In November 2006, Murray Air, Inc. was purchased by
National Air Cargo and renamed National Air Cargo Group. (Operations Factual Report, page
58). The company did business as National Airlines and began to transition its fleet from an all
DC-8 cargo composition to a mix of B-747 cargo and B-757 passenger operations. (Operations
Factual Report, page 58). The company received FAA approval for passenger operations in June
2011, and hired a corps of experienced flight attendants to begin operations on the B-757.
(Operations Factual Report, page 58).
National Airlines' key management personnel have extensive experience in aviation and related
business enterprises. Collectively, National Airlines’ five FAA Part 119 personnel have over
140 years of experience.
At the time of the accident, National Airlines operated three B-747-400 cargo airplanes and one
B-757 passenger airplane. (Operations Factual Report, page 58). According to FAA records, the
airline had a total of 230 employees, of which 43 were captains, 35 were FOs, and 13 were check
airmen. (Operations Factual Report, page 58). Pilots were typically scheduled for 20 days on,
10 days off. (Operations Factual Report, page 58). Due to the growth of the B757 fleet,
National Airlines was hiring at the time of the accident. (Operations Factual Report, page 58).
There was no recent hiring or planned hiring, however, for the B747-400. (Operations Factual
Report, page 58). The pilots, loadmasters and flight followers/dispatchers were all non-union.
(Operations Factual Report, page 58).

{continued from previous page}
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.
15

 The National Airlines Part 119 Director of Operations was responsible for airline operations and
for the quality of the National Airlines Weight and Balance Program. (Operations Factual
Report, page 58). He had the authority to establish and modify the policies, procedures,
instructions, and information for the National Airlines Weight and Balance Program process.
(Operations Factual Report, page 58). The Director of Operations was also responsible for the
quality of the Flight Operations Training Manual. (Operations Factual Report, page 58). He also
had the authority to establish and modify that program. (Operations Factual Report, page 58).
National Airlines had a System Chief Pilot and two Fleet Managers (757 and 747-400).
(Operations Factual Report, page 58). Line Check Airmen reported to the System Chief Pilot
through each Fleet Manager. (Operations Factual Report, page 58).
The National Airlines Director of Training and Standards had been in that position since May of
2012, and had been delegated the authority by the Director of Operations to administer the flight
operations training program for Pilots, Flight Attendants, and Flight Followers. He also had the
final authority as to the content, revision, and distribution of the training program. (Operations
Factual Report, page 60). His duties at National Airlines included regulatory compliance and
effectiveness for pilot, flight follower, and flight attendant training. (Operations Factual Report,
page 60). He had three full-time staff and an additional six or seven pilots on the B757 and
B747-400, each who were simulator instructors and check airmen, and flight follower
instructors. (Operations Factual Report, page 60). National Airlines conducted B747-400
simulator training at Kalitta Air in Ypsilanti, Michigan and United Airlines in Denver, Colorado,
and B757 training in Miami. (Operations Factual Report, page 60).
The National Airlines Part 119 Director of Safety was responsible for SMS implementation,
ASAP oversight, FOQA flight data analysis, and a joint responsibility for the security program
with the Director of Security. (Operations Factual Report, pages 58-59). He was also a liaison
to the Department of Defense (DoD) and their safety program. (Operations Factual Report, page
59). The Safety department consisted of 3 employees; the Director, a safety assurance manager
and a flight safety analyst. (Operations Factual Report, page 59).
National Airlines had an ASAP program for the pilots and an online irregularity reporting
system. (Operations Factual Report, page 59). According to the FAA Principal Maintenance
Inspector (PMI), mechanics were a part of the ASAP program. (Operations Factual Report, page
59).
Pilots and loadmasters could file irregularity reports to report safety issues, and ASAPs could be
filed online with the web based access tool (WBAT). (Operations Factual Report, page 59).
National Airlines used WBAT for data collection and analysis. (Operations Factual Report, page
59). A pilot seeking to make a report had a number of options, including downloading the form
from the company intranet, sending the company an email, or making a phone hotline request.
(Operations Factual Report, page 59). National Airlines has never received any ASAP reports or
irregularity reports concerning load shifts. (Interview of Carlos Veliz, Operational Factors,
Attachment 1, page 42).
According to the National Airlines Weight and Balance Manual (dated October 10, 2012), hiring,
training, scheduling and management of loadmasters at National Airlines were the responsibility
of the Chief Loadmaster. (Operations Factual Report, page 59). He was also responsible for the
evaluation of loadmasters and “check loadmasters,” and manually scheduled loadmasters using
16

 an Excel spreadsheet. (Operations Factual Report, page 59). The loadmaster position is not
regulated or certificated by the FAA, and at the time of the accident there was no FAA guidance
available to loadmasters. (Operational Factors Attachment 8, page 3). There is also no oversight
by the FAA for loadmaster performance. (Operational Factors Attachment 8, page 3). In fact,
the FAA PMI and POI were unclear as to who had direct oversight over loading operations.
(Operational Factors Attachment 1, pages 50, 54, 57).
Despite the lack of such regulatory guidance, National Airlines voluntarily developed a training
program based on the chief loadmaster's extensive experience and existing industry best
practices. (Operational Factors Attachment 12). The chief loadmaster was also responsible for
training ground operations vendors like National Air Cargo the airline procedures at National
Airlines. (Interview of Alfredo (Gumby) Gumbs, Operational Factors Attachment 1, page 29).
National Airlines' loadmasters provide a report for every load, and these loads are reviewed and
discussed during a daily operations meeting that includes the Director of Safety. (Operational
Factors Attachment 1, pages 33 and 43). Further, audits of National Air Cargo are conducted at
least once a year by National Airlines using standard IATA checklists. (Interview of Alfredo
(Gumby) Gumbs, Operational Factors Attachment 1, page 33).
The company has daily operational meetings which include discussion of safety issues.
(Interview of Carlos Veliz, Operational Factors Attachment 1, page 43). There is also a safety
meeting held approximately once per month. (Interview of Carlos Veliz, Operational Factors
Attachment 1, page 43). The Safety Review Board meets quarterly. (Interview of Carlos Veliz,
Operational Factors Attachment 1, page 43).
1.5

NAL cargo operation policies and procedures

National Airlines company policies and procedures regarding cargo operations were incorporated
in the National Airlines Cargo Operations Manual dated September 25, 2012 (the "Manual").
(Operations Factual Report, page 22). Section 1.2 of the Manual, entitled “Guiding Authorities,”
stated in part:
This Manual presents the Company Operations and System Control policies and procedures
for Carriage of Cargo Operations. These policies and procedures supplement the General
Operations Manual and General Maintenance Manual and were developed in accordance
with Advisory Circular AC 120-85, IATA Dangerous Goods Regulations, National Airlines
Hazardous Materials Manual, Flight Standards Information Management System 8900.1,
ATOS Data Collection Tool SAI 1.3.25 Cargo Handling Equipment, Systems and Appliances
(AW), ATOS Data Collection Tool SAI 3.1.8 Carriage of Cargo (OP) and all applicable
Federal Aviation Regulations (14 CFRs). The procedures and processes contained within
this chapter are used to ensure that no aircraft is allowed to take off unless all components
of the Cargo Operations program have been executed.
(Operations Factual Report, page 22).
The Manual was an FAA accepted manual and it complies with the recommendations of AC120-85.
(Operations Factual Report, page 22).

17

 The Manual states that its "procedures have been established to maintain control of weight and
balance of the Company's aircraft under the terms authorized by Operations Specifications E096
Weight and Balance Control Procedures." Id. at ¶ 1.2. The Manual specifically states that its
policies and procedures "were developed in accordance with Advisory Circular AC 120-85 . . .
and all applicable Federal Aviation Regulations (14 CFRs)."
Chapter 2 of the Manual includes weight requirements for palletized and bulk cargo. It states
that cargo loaded on National Airlines aircraft will be checked for accuracy of weight on a
certified scale. Manual at p. 2-18. Center of gravity requirements for pallet loads are set forth at
pp. 2-19 and 2-20. A Weight and Balance Loadplanner and a Weight and Balance Trim Sheet
specific to the B747 aircraft must be prepared and signed by the National Airlines employee who
has the duty of supervising the loading of the aircraft. Id. at p. 3-7.
Chapter 3 of the Manual contains detailed requirements for the loading and unloading of cargo.
The Manual notes that "[a]ll cargo operations personnel involved with the loading of an aircraft
are required to use the procedures, instructions, and information outlined in this manual," and
that "[c]hecklists and forms contained in this manual and the General Operations Manual must
be used to control the loading of an airplane." Id. at p. 3-1. Procedures for the loading of the
B747 aircraft are specified separately at pp. 3-7 to 3-16.
The National Airlines Weight and Balance Manual, Chapter 2 “Loading Information” page 2-3,
stated in part:
The Preparer/Agent completes the following on the form:
• Date
• Aircraft
• Flight Number
• Gross Weight
• *Pieces
• *Net Weight
• Destination
• *Customer
• ULD Number
*Denotes completion of this item may be done after loading as this pertains to down line
destinations and tracking. In completing the form the planner will ensure the aircraft will
operate within approved limits of the center of gravity. After completion of this form the
Agent will sign the form and brief the Flight and Ramp Operations Manager Down Line
Destinations or Loadmaster with any special loading requirements.
(Operations Factual Report, pages 22-23).
National Airlines used National Air Cargo in Dubai, UAE (Dubai World Central) for load
planning, cargo/pallet build up, and aircraft loading of the National Airlines B747-400.
(Operations Factual Report, page 23). There were four load planners in Dubai, and two were
“approved” by National Airlines, and the load planners were certified by ICAO standards.
(Operations Factual Report, page 23).

18

 The National Airlines Weight and Balance Manual, Chapter 2 “Loading Information” page 2-1
stated in part:
The National Airlines Load Supervisor (Loadmaster) or qualified representative is
responsible for the acceptance of all cargo planeside, and that all ULDs and pallets are
properly identified and tagged in accordance with the COM [Cargo Operations Manual]
requirements. The load supervisor is also responsible for verifying the aircraft is loaded and
cargo weights checked for accuracy in accordance with the loading manifest provided by the
National Airlines OCC. This verification is essential to ensure weight and balance
calculations previously performed by National Airlines OCC are valid.
(Operations Factual Report, page 23).
In addition, the National Airlines Cargo Operations Manual, Section 1.8.3 “Load Supervisor,” page
1-7, stated in part:
For the purpose of this manual, the title Load Supervisor can be interchanged with Plane
Side Representative, Experienced Cargo Handling Personnel, Loadmaster, Mechanic or
Flight Engineer. The Loading Supervisor is responsible for:
• Reviewing the location of any missing restraint (Beartrap, side lock etc.) and
advising maintenance for any corrections.
• Confirm load and proper ULD contour.
• Confirm Proper tie down.
• Reject any damaged pallets and nets or correct to meet Company requirements and
standards.
• Pallet, container and nets should be examined by the Loading Supervisor for
gouges, depressions, delaminated panels, cracked edge rails, bowing, and missing
corners and rivets to meet Company requirements and standards.
• Confirm Number
• Tail Stand and tail post are being properly used.
• Visually inspect the Aircraft for possible damage caused by ground support
equipment
• Signs appropriate Load Planning Sheet after loading completed verifying that the
aircraft was loaded according to the Load Planning Sheet and I/A/W Company
loading requirements, and that all locks, in the pallet positions, are properly
installed and in the pallet locked position. The original copy of form will be returned
to the Cargo Operations Agent for the Company principal base of operation or down
line destination, as applicable, file and a signed copy will be given to the crew. The
PIC of the flight must carry in the aircraft to its final destination the signed copy of
the load manifest. This will be placed with the trip paperwork which must also
include at a minimum, the flight release, airworthiness release, pilot route
certification and the completed flight plan that the PIC is responsible for obtaining.
If needed see additional information for the required trip paperwork in the GOM.
(Operations Factual Report, pages 23-24).

19

 National Airlines employed 13 loadmasters and three check loadmasters. (Operations Factual
Report, page 24).
The responsibilities for Load Operator were defined in the National Airlines Weight and Balance
Manual, Chapter 2 “Loading Information” page 2-4, which stated in part:
Responsible for the positioning and operation of cargo loader for transfer of freight to the
aircraft. In performing this operation the loader operator:
1. Verifies the position number on the appropriate Load Planning Sheet.
2. Checks proper sequencing of the load, position #1 loaded first then aft positions.
3. If trained and qualified, he may also perform the responsibilities of the Loading
Supervisor.
(Operations Factual Report, page 24).
The responsibilities for forklift operators or pallet transport operator were defined in the National
Airlines Weight and Balance Manual, Chapter 2 “Loading Information” page 2-4, and stated in part:
Responsible for movement of freight to aircraft for loading.
1. Positions ULD's on loader for main deck loading. When using a forklift equipped
with a scale, he may verify weights as indicated on Pallet Tags. In the event of a
variance of (+/-) 300 pounds, the Load Preparer and or Loading Supervisor will be
notified.
(Operations Factual Report, page 24).
In Chapter 6 of the Manual, shoring requirements are set forth as follows:
4.5 SHORING REQUIREMENTS
Shoring is used to spread highly concentrated loads over a greater base area than that
occupied by the cargo alone. Use of shoring permits carrying a load with a higher
concentration than would be normally allowed. It is also used to protect ULD2 surfaces from
damage caused by vehicle cleats, steel wheel rims, and packing case studs or protrusions.
Cargo exceeding the rated floor bearing capacity of a ULD or aircraft will require shoring
to distribute the load over a greater area. Shoring used for weight distribution may be
ordinary planking laid beneath the cargo, or it may be composed of plywood sheets.
Id., Chapter 6, pp. 6-11.
The Manual, Section 5.10 “Shoring” also stated in part:

2

A unit load device (ULD) is a pallet or container used to load luggage, freight, and mail on widebody aircraft and specific narrow-body aircraft.

20

 Shoring can become necessary for heavy (typically over 2000 lb./1000 kg) concentrated
loads in order to meet either the applicable aircraft area load or running load limitations, or
both.
Note: At least elementary shoring can also become necessary for practical reasons, even in
instances where neither the area load or the running load limitations are exceeded, on a
plate aluminum AS1491B (ISO 4171, IATA 50/1) type pallet in order to avoid local
deformation which might render it difficult to move on rollerized conveyors. For example, an
automobile directly loaded onto such a pallet usually does not exceed either limitation. Yet
its wheels will create local base sheet deformation, which should be avoided by placing
sufficiently stiff material, e.g. thick and long enough planks, below each wheel -unnecessary
precaution with a heavy duty pallet.
Accordingly, shoring can be performed either laterally in relation to the aircraft centerline
(area load limitation), or longitudinally (running load limitation), or both simultaneously .

Pallet tiedown procedures are set forth at pp. 2-25 to 2-34. The Manual includes specific tiedown methods and strap requirements. The required number of straps are listed, but the actual
amount used may be in the discretion of the loadmaster. National's practice at the time of the
accident was to calculate the number of straps to be used as follows:
1.
2.
3.
4.

Multiply the weight of the item by the load factor applicable. (Fwd
1.5, Aft 1.5, Lateral (left and right) 2.0 and Vertical 2.5)
Divide the rated capacity of the strap by 75%. i.e., 5,000 Lbs. strap
capacity would be 3,750 Lbs.
Take the sum of the weight multiplied by the load factor and divide
by 3,750 Lbs. to get the number of straps needed.
Always round up to the next even number of straps if the number is
an odd number of straps. Always round up to the next even number
of straps if there is a number passed the decimal point.

At the time of the crash the FAA had not mandated compliance with the minimum requirements
of TSO-C172 with respect to strap quality. However, the National Manual had already
implemented these requirements and others found in ISO 16049-1, SAE AS 5385A, IATA
UTM60/2 before the April of 2016 deadline.
National Airlines uses actual weights and not average, assumed or estimated weights for
tendered cargo. Id. The Loadmaster, Flight Crew, Load Supervisor, or other National Airlines
authorized loading agent are responsible for ensuring that scales used to weigh cargo loaded on
company aircraft are within its calibrated interval except for scales located on military
installations. Id. at p. 4-11. In accordance with AC 120-85 National Airlines conducts periodic
audits of calibration of scales to ensure they are appropriately serviced and accurate to a known
standard. Id. Calibration records should show that scales are calibrated in accordance with a
standard established by the appropriate country, state, or local government regulations, or an
equivalent standard acceptable to the FAA. Id. National Airlines has procedures to ensure that
scales used for weighing cargo undergo a functional check between scale calibrations. Id.
21

 The Manual provides that damaged pallets, nets, and any other restraint equipment will be
removed from service and returned to its proper owner for appropriate action, such as repair by
qualified personnel. Id. at p. 2-12. Damage tolerances for both nets and pallets are set forth at
pp. 2-13 and 2-14.
Training is addressed in Chapter 7 of the Cargo Operations Manual. It applies to noncrewmenber Loading Supervisors, Ground Handling Personnel, and Operations Controllers.
Training is required for any individual who determines the serviceability of ULDs, handles
hazmat or frangible load requirements, determines cargo loading system maintenance, performs
repair of ULDs and cargo restraint systems, performs receiving inspections for contractor
repaired ULDs, is responsible for the operator's records requirements, supervises aircraft cargo
handling, and is responsible for ULD build-up and aircraft loading. Id. at 7-1.
The Cargo Operations Manual includes a Loadmaster Checklist, which covers, among other
areas, activities involving pre-departure, preparation for loading, loading, after loading and
before takeoff, after takeoff, and inflight. This is a paper product that is laminated and available
on the aircraft for the Loadmaster. The Manual notes that "[f]ollowing the checklist is a very
critical procedure in completing all areas of [the Loadmaster's] duties.
The National Airlines Weight and Balance Manual, Chapter 2, Section 1, page 2-1 “Aircraft Loading
Procedures” stated in part:
The National Airlines Load Supervisor (Loadmaster) or qualified representative is
responsible for the acceptance of all cargo planeside, and that all ULDs and pallets are
properly identified and tagged in accordance with the COM requirements. The load
supervisor is also responsible for verifying the aircraft is loaded and cargo weights checked
for accuracy in accordance with the loading manifest provided by the National Airlines
OCC. This verification is essential to ensure weight and balance calculations previously
performed by National Airlines OCC are valid.
Loadmasters were responsible for the weight and balance of the aircraft during the pre-planning
stages of the flight in accordance with manufacturer limitations. (Interview of Alfredo (Gumby)
Gumbs, Operational Factors Attachment 1, page 29). Loadmasters inspected cargo and pallets,
ensured strap and pallet limits were not exceeded, loaded in accordance with the aircraft, and
ensured the items were secured properly with the provided restraints or supplemental restraints.
(Interview of Alfredo (Gumby) Gumbs, Operational Factors Attachment 1, page 29).
Loadmasters notified the captain of any hazmat or dangerous goods locations. Id. at 10.4.4,
pages 10-26. Loadmasters also served as ground security coordinators. (Interview of Alfredo
(Gumby) Gumbs, Operational Factors Attachment 1, page 29).
Following the loading process, and prior to takeoff, loadmasters were required to deliver the
completed weight and balance to the captain and first officer. Id. at 10.4.4, pages 10-26. The
paperwork delivered to the crew included the zero fuel weight (ZFW), the MAC% (mean
aerodynamic chord), the takeoff power setting and the stabilizer trim setting. (Interview of Reid
Sutherland, Operational Factors Attachment 1, page 21). The pilots would then complete the
“PERF DATA” page in the flight management computer (FMC) using that information.
(Interview of Reid Sutherland, Operational Factors Attachment 1, page 21). The zero fuel weight
22

 was entered in the “PERF INIT” page, and takeoff speeds (V-speeds) would be generated by the
FMC. (Interview of Reid Sutherland, Operational Factors Attachment 1, page 21).
Loadmasters were specifically required to check the cargo before departure to ensure all the nets,
straps and chains were tightened. (Operations Factual Report, page 74). Loadmasters would
typically walk through the main deck with the loading supervisor prior to departure. (Operations
Factual Report, page 74). Any items that were found to need additional restraint were required
to be secured before departure. (Operations Factual Report, page 74). According to the Manual
special attention would be paid to items loaded on top of nets, pipes and small items.
(Operations Factual Report, page 74). All loose items were required to be secured before the
aircraft blocked out. Documents required to be onboard the airplane prior to the L1 door closing
included the following:
• Cargo Manifest
• AirWay bills
• Permits to Proceed (If applicable)
• Shipper’s Declarations for Dangerous Goods (Hazmat)
(Operations Factual Report, page 74).
The station copies of the flight paperwork were required to be left with the ground handler or station
representative. (Operations Factual Report, page 74). If Dangerous Goods were on the aircraft, a
scanned copy or photo of the NOTOC was required to be sent to National Airlines OCC.
(Operations Factual Report, page 74). The following documents should be left behind at the
departure station:
• A copy of the Flight Release
• A copy of the Weight and Balance
• A copy of the Load plan if not included on the Weight and Balance
(Operations Factual Report, page 74).
During flight, if the cargo onboard was transiting the next airport, the loadmaster would update the
next load plan to reduce time at the next airport. (Operations Factual Report, page 75).
National Airlines' use of loadmasters to assess and address risks associated with loads in lieu of
formalized risk analyses was consistent with industry standards, although there was no regulation
or FAA guidance in that area.
In general, loadmaster procedures were fully consistent with internal training and the FAAapproved Cargo Operations Manual, as well as with industry standards. In particular, the
securing of center-loaded pallets to seat tracks rather than side rails, using all available tie down
points, as occurred during the subject flights, was consistent with standard industry practice.
1.6

Crew scheduling and rest requirements.

National crews were scheduled thirty days in advance and bid two months at a time. (Interview
of Mike Vollmer, Operational Factors Attachment 1, page 47). Scheduling was done in blocks
23

 of 20 days of duty time and 10 days off. (Operations Factual Report, page 58). Crew scheduling
constantly reviewed the last 24 hours and the next 72 hours to help shorten duty days and
manage fatigue risk. (Operational Factors Attachment 1, pages 45, 47). Seven crew schedulers
were available 24 hours a day. (Interview of Mike Vollmer, Operational Factors Attachment 1,
page 47).
2.

Investigation and Analysis
2.1

General Investigation Summary
2.1.1 Security Issues

The accident occurred in an active war zone and theatre for Operation Enduring Freedom. Both
NATO and the United States had combat missions in the country. The inbound flight to Camp
Bastion had been delayed by indirect fire from the Taliban. (Operations Factual Report, page 7).
The purpose of the accident flight was to move Mine Resistant Ambush Protected vehicles of the
U.S. military from Bagram, Afghanistan, to Dubai.
After the flight, the Taliban took credit for the tragedy. The Taliban further threatened the
investigator-in-charge for Afghanistan's Ministry of Transportation and Civil Aviation (MoTCA)
to coerce him into accepting the Taliban's claim. Although the details surrounding his death are
unknown, the investigator-in-charge was subsequently killed.
The starting point for the investigation should have been to eliminate the possibility of terrorism.
This possibility is more than theoretical. According to National Air Cargo’s Vice President of
Ground Operations, not long after the April 29 accident flight an Improvised Explosive Device
(IED) was found by a National Air Cargo employee on an armored cargo truck shipped by the
military out of Afghanistan to a National Air Cargo facility in the UAE where such vehicles went
through a thorough decontamination wash. Although it was later determined that the IED was
not a live device, the fact the device went undetected through security sweeps out of Afghanistan
and into the UAE lends support to the view that terrorism should not have been discounted in the
accident investigation.
The investigation, however, failed to rule out the possibility of terrorism. The following basic
investigative actions were not taken following the accident to rule out the potential terrorist
claims:
1.

Determining whether the military conducted a security sweep of the MRAPs prior
to loading.

2.

Determining the security situation on the ground during the two hour loading
delay before the Atlas loader began loading the Cougars. (National Airlines uses
a Security Checklist, which is signed by the loadmaster and carried on board the
aircraft; this document was not recovered.)

3.

Testing items recovered from the runway following the accident in the vicinity of
Taxiway C, which was near the point of takeoff rotation, and items found along
24

 the flight path, for explosives. (Although bomb-sniffing dogs were used after the
accident, dogs cannot detect the residue of a bomb that has detonated.)
4.

5.

Determining the source of fluid/smoke observed by witnesses during the aircraft’s
brief flight.

Analyzing the CVR to detect the audio signature of an explosion.

The NTSB Operations Group arrived on site on May 2, 2013, and began documenting the
wreckage on May 3, 2013. (Operations Factual Report, page 5). Debris was found on the
runway and the surrounding environment, but no GPS coordinates were assigned to the debris.
Since no measurements were taken of where runway debris was found, the exact position and
sequence of parts coming from the aircraft could not be determined. As stated previously, an
analysis of these parts was not accomplished to determine the existence of explosive material.
2.1.2 Accident Debris Field
The approximate size of the debris field and the relative location of some of the items found
within it could be determined from an aerial survey.
The airplane impacted the ground about 590 feet northeast of the departure end of runway 03.
(Structures Factual Report, page 8). According to an aerial survey done by the U.S. military on
May 1, 2013, the debris field was 425 feet long. Using the identified aerial reference point 219
behind the APU housing and west of the main crash/fire to point 204, which is 70 feet east of
point 7 (cockpit wreckage), the width of the debris field is 421 feet using aerial reference points
355 to the north of the main wreckage/fire area, to point 533 to the south on the same drawing
(sheet 2 of 2) for a calculation of 178,925 square feet. The airplane forward of about body
station (STA) 2060 (Figure 1) located in section 46 was highly fragmented and consumed by
fire. (Structures Factual Report, page 8). Airplane debris was recovered about 4,500 feet
downwind from the departure end of runway 03 in the vicinity of taxiway Charlie. (Structures
Factual Report, page 8). Six pieces of structure were recovered in the area of taxiway Charlie,
three were identified as being located aft of the aft pressure bulkhead (APB) and one was
identified as being from the E8 rack containing the cockpit voice recorder (CVR) and flight data
recorder (FDR) located forward of the APB and aft of the L5 door on the left hand side (pilot) of
the airplane. (Structures Factual, Figure 51, page 38).
During the post-crash field investigation a crane was used to lift wreckage from the debris field.
It was observed that the crane rolled over other pieces of wreckage within the debris field thus
possibly damaging or burying physical evidence. Some wreckage was hauled in the back of
pickup trucks to a parking lot on Bagram Air Base. There was no chain of custody for the
wreckage. Moreover, although the military had posted guards, numerous individuals, such as
persons bringing flowers to the wreckage and first responders, had access to the wreckage.
None of the four other MRAP vehicles were documented within the debris field. While there
was significant impact and fire damage forward of the last recovered MRAP and aircraft tail
section, the lack of any attempt at documentation hampers the analysis on the potential for
explosives or movement of these vehicles during the brief flight.
25

 2.1.3 Post Crash Witness Marks and Metallurgical Analysis
During the investigation, the aft M-ATV was substantially damaged but not consumed by fire.
(Structures Factual Report, page 30). Pieces of the main deck interior panels were recovered
from inside the M-ATV and orange and green paint was found. (Structures Factual Report, page
30). Although these were visually similar to the orange paint on the CVR and the FDR cases,
and the green primer used on unpainted airplane structures appeared to match the green paint on
the rear portion of the aft M-ATV, the presence of paint markings on the vehicle prior to loading,
or paint transfer from an item not recovered in the wreckage, were not eliminated as possibilities.
A paint analysis to verify that paint was transferred from one surface to another was not
completed because there was insufficient paint to provide an adequate sample.
Further, the markings do not show when the impact occurred or the direction of travel of the
surfaces on which the paint was found. (See Section D.7 Structures Factual, page 30 and
Materials Laboratory Factual Report, 15-02, page 2).
70 total sections of strapping were recovered aft of the last MATV and were torn at varying
lengths. (Structures Factual Report, page 35). Twelve 5,000 LB straps of varying length were
found attached to 6 sections of the cargo system side guide rail. (Structures Factual Report, page
35). Three straps were attached to seat tracks. (Structures Factual Report, page 35). The straps
were submitted to the NTSB Material’s Laboratory for examination but no testing was done to
rule out explosives. (Materials Laboratory Factual Report 14-066). No explanation was
provided in support of a theory that the MATV somehow tore through all the straps.
Multiple sections of the main deck interior panels had evidence of contact with an MRAP tire but
the timing and direction of the contact could not be confirmed. (Structures Factual Report, page
41). The most aft MRAP was 96 inches wide. The aircraft at the APB is only 111 inches wide.
For the MATV to be in line with the APB liner, it would have to be positioned almost entirely on
the left side of the aircraft. (See Figure 73, Structures Factual, page 50). If positioned on the left
hand side, 31.5 inches of the vehicle would have been outside the aircraft.
In a centerline load, the tire witness marks would have been centered right of the APB liner
vertical center, not left. Based on the position of the witness marks and the centerline location,
the MRAP would have had to move to the left to leave the tire imprint. The last valid roll angle
was recorded when the FDR stopped recording and the aircraft was at 33 feet AGL. The roll
angle was +4 degrees right with a right lateral acceleration, and the aircraft heading is to the right
as is the ground track. (FDR Factual Report). Accordingly, the MRAP would have been pushed
to the left side of the APB liner (looking aft), not to the right by the dynamic forces acting on the
aircraft.
Thus, it appears the contact between the most aft MRAP and the APB was a consequence of the
accident crash sequence itself or an explosion inside the aircraft. The aluminum APB was not
inspected for loads that explosives might have put on the metal. The post-accident witness
marks do not support a theory that the aft most MRAP broke free moving aft as it was loaded on
the centerline and the aircraft dynamics of the flight would have pushed the last MRAP to the
opposite side of the aft fuselage during takeoff and climb. There is no evidence the seat track
restraints failed and no inspection was done to determine if the witness marks were made by
rubber. These witness marks can just as likely be explained as resulting from the impact
26

 sequence as the tail section of the aircraft moves forward, impacting the aft MRAP causing the
witness marks.
In addition, the imprint of the spare tire on the APB liner does not support an inference that some
part of the MRAP contacted the horizontal stabilizer jackscrew collar fitting. The witness marks
on the APB liner were not matched to anything on the MRAP other than the spare tire. The
source of the witness marks on the horizontal jackscrew collar fitting was not identified through
metallurgical analysis, the horizontal stabilizer was not subjected to metallurgical examination,
and the effect of vehicle weight on the portion of the stabilizer connecting to the fuselage was
not analyzed.
Although an MRAV antenna was found on the runway and the FDR/CVR bracket is in the
higher area of the interior, the rest of the parts found were from the lower part of the aft pressure
bulkhead (5-6 o’clock position).
All measurements of the MATV were taken with the tires at normal inflation pressure, however,
the tires were deflated prior to loading for shoring purposes. Also, the height of the pallets was
not considered. As a result, the measurements do not help determine the accident sequence or
the cause of the accident.
In addition, possible contact between one of the 238.5 inch aluminum pallets that the MRAPs
were secured to and the cargo floor restraints was not substantiated by a lab test, and does not
indicate whether movement occurred before or after ground impact.
2.1.4 Weather Conditions
As noted in the Boeing Simulation/FDR Study, page 3, weather observations noted an air mass
change which resulted in a 7 knot temperature decrease and a wind magnitude change to 360
degrees true north at 11 knots gusting to 17 knots. Witness Joshua Mullennix (page 36 of the
Witness Summary) indicated that Bagram Airfield had been under a weather watch with wind
gusts to 45 knots and lightning within 5 miles of the airfield. Also several witnesses noted
differing engine noises. (Operational Factors – Attachment 1, pages 7, 15, and 18). With the
unusual attitude experienced by the aircraft, along with the gusting wind conditions, the potential
for engine compressor stalls exists. This possibility, along with the effect of the wind magnitude
change and gusting conditions, was not reviewed during the investigation, nor was it accounted
for in the simulation analysis conducted by Boeing.
2.1.5 FDR and CVR Post Crash Evidence
The Operations, FDR and CVR Factual Reports allude to the recorders stopping at the same
time. This is contradicted by the recorded information. The last recorded, valid information
from the FDR was recorded at 10:56:45 (UTC). The end of the CVR Recording was noted in the
CVR Factual Report (page 29) at 10:56:47. Evidence indicates that the FDR continued to record
data for another 3.5 seconds after the CVR stopped recording, but the data synchronization was
lost. As a result, the actual parameter information could not be recovered (Boeing FDR Data
Study, page 4).

27

 In order for the theory that the aft most MRAP separated from its moorings, shifted aft, and
struck the CVR installation rack to be true, both recordings must stop simultaneously. Since it
appears the FDR recording continued for a substantial time after the CVR stopped, this theory
cannot be correct.
2.2

Cargo Loading Operations Conformed to Industry Practice

National Airlines met or exceeded applicable regulations and conformed to industry practices in
a number of ways. National Airlines relied on loadmasters to ensure proper loading and weight
and balance, used a Unit Loading Department to coordinate strap and chain inventory, and
inspected loads in compliance with IATA standards. It developed a comprehensive loadmaster
training program, used double pallets and shoring for heavy loads, and used seat tracks to secure
center-loaded vehicles.
As demonstrated in Section 2.1, above, there is no evidence that a cargo shift caused a loss of
control. Nor is there any evidence pallets were built incorrectly or the vehicles were shored
incorrectly.
At the time of the accident, National Airlines employed 16 loadmasters, including 3 check
loadmasters, all of whom were qualified on the 747.
2.3

Flight Crew Was Well-Trained

There is no evidence that pilot training was a factor in this accident. National Airlines maintains
an FAA approved training program and curricula for crewmembers. All crewmembers must be
trained prior to being assigned to any position or performing their required duties. The National
Airlines Flight Operations Training Manual (FOTM) describes the pilot training program and is
used as a guide to ensure that we meet all training requirements for training pilots, flight
instructors and check airmen. All National Airlines personnel must comply with applicable
regulations and company policies.
2.4

Flight Crew Scheduling Complied with Regulations

There is no evidence that flight crew training or scheduling were factors in this accident. The
accident captain received three full days off duty (73 hours, 21 minutes) leading up to his
assignment to the augmented crew (two captains and one first officer) that positioned the
accident airplane from Hill Air Base, Utah, to Chateauroux, France, on April 27, 2013.
(Operations Factual Report, page 13). The total duty time for that flight was 12 hours 8 minutes.
(Operations Factual Report, page 13). At Chateauroux, France, the accident captain was off duty
for 12 hours 18 minutes before his next assignment. (Operations Factual Report, page 13).
On April 28, 2013, the accident captain began a duty period of 25 hours and 4 minutes.
(Operations Factual Report, page 13). At the time of the accident, the captain had been on duty
for approximately 21 hours, with a total block time of 10 hours, 41 minutes. (Operations Factual
Report, page 13). The segments flown include Chateauroux, France, to Camp Bastion Airfield,
Afghanistan, and from Camp Bastion to Bagram. (Operations Factual Report, page 13). The
accident flight segment was from Bagram to Al Maktoum, UAE. (Operations Factual Report,
page 13).
28

 The accident first officer, after a 10 hour rest period at Hill Air Base, Utah, that concluded on
April 27, 2013, operated as part of an augmented crew positioning the airplane to Chateauroux,
France. (Operations Factual Report, page 16). The total duty period was 12 hours 08 minutes
with a total block time of 9 hours 32 minutes. (Operations Factual Report, page 16). At
Chateauroux, France, he was off duty for 12 hours, 18 minutes before his next assignment, which
consisted of flying with the accident Captain to Camp Bastion and then to Bagram, described
above. (Operations Factual Report, page 16).
Accordingly, neither crew member was scheduled to be on continuous duty for more than 30
hours, and neither had been on continuous duty for more than 24 hours at the time of the
accident. Further, the accident aircraft had an approved rest facility, and National Airlines used
augmented flight crews, so the first officer and captain could receive rest while aloft.
(Operations Factual Report, page 9). As such, National Airlines was in full compliance with 14
CFR 121.523. (Operations Factual Report, page 9). Further, as noted above, both crewmembers
had lengthy off duty periods before the accident trip from Chateauroux, France, commenced.
(Operations Factual Report, pages 12-16).
2.5

Flight Crew Actions Did Not Cause the Accident

The flight crew experienced a rapid pitch up almost immediately after liftoff from Bagram.
There is no evidence that any actions by the flight crew contributed to the pitch up of the aircraft
or the inability of the aircraft to recover from the stall condition. The loss of the CVR and FDR
information immediately after liftoff hampered the analysis of the post-accident departure
aircraft profile.
2.6

National Airlines' General Safety Culture is Robust

There is no evidence that National Airlines’ safety culture was a factor in this accident. Safety
issues were discussed daily during meetings that included the Part 119 Director of Safety, and a
Safety Review Board met on a quarterly basis. The airline used numerous channels for reporting
safety issues, including ASAP and irregularity reports that could be filed with pilots and
loadmasters. At the time of the accident, the airline had a FOQA program and was implementing
SMS.
National Airlines also voluntarily developed a loadmaster training program despite the absence
of regulatory requirements or guidance in the area. National Airlines' loadmasters provided a
report for every load, and the reports were reviewed and discussed during a daily operations
meeting that included the Director of Safety. Further, National Airlines audited National Air
Cargo at least once a year using standard IATA checklists.
Since the accident, National Airlines has adopted the following process improvements to further
increase its safety margin:
1.
The Cargo Operations Manual (COM) has gone through a major overhaul. COM has
incorporated restraint information from both the Boeing and Telair Weight & Balance and Load
Control Manual, including:
29

 •

Identifying approved tie-down points on Telair components and their limitations

•

Listing restraint values for straps connected to seat tracks and other floor components

•

Noting differences between the Boeing and Telair strap value charts

•

Implementing a manual worksheet to determine total restraint value per direction

•

Adding requirements pertaining to Tall Rigid Cargo and determining forward limits

•

Defining approved Unit Loading Devices (ULDs)

•

Treating un-netted pallets as un-approved ULDs

•

Treating T-2 (coupled military 463L pallets) as un-approved ULDs

•

Treating pallets with CG outside pallet limits as un-approved ULDs

•

Noting center load linear limits

2.
Several Loadmasters have attended formal training at the Boeing Performance
Engineering course. National Airlines is planning to send 4 LMs per year to all three courses to
further each LM's knowledge.
3.
National Airlines has advocated and assisted within NACA and Boeing’s working groups
to standardize the cargo industry with respect to aircraft manufacturer guidelines.
4.
National Airlines has created a Special Loads Team to evaluate possible loads offered for
airlift, including pre-planning tie-down, shoring and special handling equipment.
5.
National Airlines has produced training material for crews to identify possible problems
with cargo loaded on the aircraft.
6.
National Airlines has clearly defined when audits and training are required and use of LM
and Vendor training outlines and PowerPoint presentations.
7.
GMM Chapter 9 was created to address ULD and strap airworthiness, serviceability
procedures for the acceptance of ULDs plane side, including the cargo loading systems and
associated ULD airworthiness requirements for each make, model and series of aircraft operated
by National Airlines. A description along with instructions and information for cargo loading
ground operations is located in the National Airlines Cargo Operations Manual.
As a supplemental carrier, National Airlines does not own any ULDs, Pallets, Nets or
Straps. However all ULDs, Pallets, Nets, and Straps undergo an acceptance check by the Load
Supervisor or Load Master for serviceability prior to being loaded aboard the aircraft. The
acceptance check instructions and procedures are contained in the Cargo Operations Manual. In
the event that National Airlines was to purchase its own ULDs, Pallets, Nets or Straps the
processes, procedures and controls contained in this chapter have been put in place to ensure the
30

 airworthiness of these items. Also included is information to provide instructions for the
maintenance, preventive maintenance, alterations and preservation of National Airlines' cargo
handling equipment, systems, and appliances. These policies and procedures also provide a
program for the inspection and maintenance of Unit Load Devices (ULDs) by National Airlines
maintenance, or maintenance designees.
8.
Training was created to inform maintenance and load master personnel of the conditions
and limits for cargo handling equipment referenced in GMM Chapter 9.
9.
An FCD was created to clearly identify seat track usage in accordance with Boeing’s
Weight and Balance Manual. The seat tracks on the MCD are clearly identified with either a red
or green painted stripe adjacent to the track, indicating whether or not it is an acceptable location
to accept load bearing straps.
3.

Probable Cause

The probable cause of the accident was a departure stall at an altitude that was too low to
allow for recovery. The cause of the pitch up and departure stall could not be determined due to
the loss of the FDR and CVR information immediately after liftoff and the destruction of the
wreckage following impact and post-crash fire. Terrorist activity, such as explosive damage or
sabotage to the aircraft or its cargo, cannot be ruled out.

END

31