The report is sobering. It struck me that this was the first effort at loading the larger vehicles. What appears to be the root cause, however, is that one of the smaller vehicles broke loose as the initiator of this tragic loss of control on take off. (Or I misunderstood the report)
This leaves me scratching my head.
A size/class of vehicle that they had previously moved seems to have been the trigger to the larger problem of cargo shift.
The other bit that had me scratching my head: the report states that the flight deck crew didn't check the loadout in Bagram after a report of a failed restraining strap.
I need to read the report again to digest it. The swiss cheese holes did indeed line up. :{
@ JetJockey:
The report pinpoints a critical shortcoming in task analysis / mission analysis / and professional risk assessment regarding the new cargo: the Cougar vehicles. As you say, in some respects the crew were set up. As to an FAA cert: I am not sure a cert would have made a difference. The company had a formal process, and a formal position description, for loadmaster. (You may feel it wasn't rigorous enough ...) One could argue that this formal position and training means they exceeded regulatory requirement, as the company had identified a need to train/educate (at some level) their cargo crews.
Whether it is insufficient in the general scheme of their operation I won't try to guess.
Whether it prepared a crew to take on a new, novel, tougher task looks to be answered in the negative.

@ Pozidrive...
 

I'm sorry if I offended you with my comment but I'm sticking to my guns.

This is aviation where safety should be paramount and obviously this company was not on top of it.

Also once again the requirements and oversight for this type of operation was poor at best.

I can't believe there is no formal and up to date training mandated by the FAA (N registered aircraft) to be a loadmaster.

The aircraft was using illegal or non standard/non approved tie down systems... It was an accident waiting to happen and it did!

Feel very sorry for all the crews that lost their lives in this accident.

Not offended Jet Jockey, and agree with all your comments.


Just reminded of an old saying: "There are no new accidents, but there are new people having old accidents."

But to even ATTEMPT such a load in Bastian without having a W&B manual even for reference is damnear criminal! For the supervisors to allow it without getting proper guidance SHOULD BE criminal!

There is a great deal of Loadmaster experience out there
 

The sad fact is, that there is a wealth of experience out there. There are a lot of ex-military Loadmasters who for the sake of another decent salary could have saved the day and maybe have prevented this from happening.

Just maybe, some of the major players out there may start to employ experience and take responsibility. Maybe even the various Aviation Authorities may sit up and take note and then begin to regulate Cargo Airlines to carry out mandatory training for Loadmasters.

Etihad have Loadmasters and train them, as do some other airlines, they can obviously see the worth.

The company I work for has a 3 week Loadmaster training class. We have a special loads office that handles all oversized cargo requests. Nothing gets tied to the A/C floor without a tie down diagram that is approved by the special loads office. All oversized loads have two loadmasters that go along with the load. I don't see this job ever becoming an FAA licensed position.

I don't know much about cargo and so I went through the report as much to help me understand the thread as well as understand what happened.

Depressing.

Anyway, if it's useful to anyone else, here's the key info that I pulled out from the documents.
Key information from the NTSB Open Docket of Bagram Cargo Crash Documents

Good summary.

@ sidman...
 

I understand some companies are way better than others with their SOPs and operations but if a Loadmaster is part of a flight crew and that said person is totally responsible in the matter in which the aircraft loaded and the cargo secured then I'm sorry but believe these guys should also be licensed.

What if this crash happened leaving a major US airport like Atlanta, Kennedy or Chicago and the aircraft crashed in the middle of a town?

I bet you a beer that when the NTSB report became public knowledge and the people discovered anyone could be a Loadmaster (no license required with proper training) the :mad: would hit the fan.

Same for European EASA.

..and follow Flight and Rest rules as the rest of the crew.

Loadmaster of that flight was already 20+ hrs on duty (per NTSB docket) with another 3-4 hrs to go to Dubai and supervise offloading there ! Considered safe ?

Although, dare I say, since he's not FD crew, he probably catches up on sleep during the flights?

@HT

Probably so. Same applies in case of relief / double crew. Still they get their rest after the flight in accordance with rules.
I'm sure you will agree 'rest' and 'adequate facilities' are different at FL350 and ground, hotac etc.

I've just seen the pic of the loading of a military vehicle.

Fear of Landing ? NTSB Open Docket of Bagram Cargo Crash Documents

When we deliver agricultural tractors on trucks in the UK, the tyres are pumped up hard, real hard, to stop the tractor bouncing loosely around on the bed of the truck.

The tyres on the m.v. seem to be very underinflated, and it's likely that on a bumpy take off this may cause snatch loading of the chains and straps by allowing the vehicle to move in all axes.

Sidman: 3 weeks training
 

Sidman, it is commendable that your company does 3 weeks training, but is that sufficient?

ATPL student pilots get 25 hours minimum just in Mass and Balance and they are not the cargo experts. They receive no Dangerous Goods or restraint training in that time, this is usually done by their respective airline.

I am ex-RAF and our basic Loadmaster Training is much more extensive (I admit military LM training has to be more in depth). But dangerous good training, and restraint training cannot be cut short, it has to be in depth and there needs to be a credible amount of practical training.

Sadly this all comes to light in the wake of such a tragic accident.

In my opinion there does need to be some form of regulation and licensing for loadmasters.

Sidman, it is commendable that your company does 3 weeks training, but is that sufficient?

We do 5 days of Haz-Mat and the remaining 2 weeks is all LM training. Most of the people we hire have come from other cargo airlines or the Military. When you start working after training you have to ride with another LM until they are comfortable that you can work on your own.

The only L/M's that move outsized cargo are the ones with the most experience.
Like I said before we require 2 L/M to move outsized cargo.

As far as the FAA License goes. You will then get into crew rest for L/M and need to hire more people. With the license you will have people asking for more money as they now have something to lose.

The FAA is aware that L/M's are spending 30+ hours on the plane with little or no rest. Catching a nap on the plane does not help when you get down line and the plan starts to fall apart. Thats when people start to take short cuts to get the job done.

I hope change is coming soon.. And I am glad that I don't have to spend 30 hours on a plane anymore..

As mentioned elsewhere, the tires are deflated after the dunnage is placed under the vehicle, so more of the weight is carried by the dunnage and spread across the pallet.

When we carry a LM we normally also carry a mechanic, FAA certificated A&P. For the same reason, no ground staff at the destination. There are no duty time limits for an A&P, they're on the plane for days.

Cargo Crash at Bagram
 

As MarkerInbound says the flight mechanic carried on these ACMI/Charter Ops is FAA licensed but like the L/M still has no official duty limitations (and it's not always easy to get rest between stops especially if carrying couriers etc)

Having read the report again, it is uncertain what the trigger event was (in a kinetic sense). It may have been the last vehicle (12 ton), or that vehicle may have moved aft (into the bulkhead) due to something forward of it shifting aft and the cascade beginning. The report was unable to conclude how it happened with certainty.
This leaves open the unknown on whether or not having this new load (three of them) to restrain ended up in a trigger event. After digesting again the extended discussion in the report on the details of loads, restraints, and this being new, the idea of cheese holes lining up leads me to guess that one of the larger loads triggered the restraint failure. They can't say with certainty, so they don't, which is as it should be.

Agricultural tractors have (usually) no suspension system. Road going vehicles (almost) always have a suspension system. Military vehicles (usually) have highly compliant, long travel suspension systems to handle rough roads and terrain at (relatively) high speed. When these vehicles are loaded using either chains or straps, the chains/straps are preloaded to compress the suspension system. Properly preloaded, they cannot "bounce around". This applies to vehicles loaded into a military cargo aircraft.

In commercial cargo aircraft the floor panels cannot handle the high downward point loads created by vehicle tires and so the vehicles are first loaded onto pallets. The pallets then spread/direct the downward loads to the rollers and rails which distribute them to the seat tracks which in turn distribute the loads to the floor beams. Usually when heavy vehicless are loaded onto the pallets, dunnage is placed under the vehicle chassis and the tires are deflated. This is because the pallets also cannot handle the high downward point loads created by the tires. The dunnage effectively spreads the load over a much greater surface area of the pallet. Straps and netting then restrain the load on the pallet. All the upward, sideward, and fwd/aft loads are transferred to the pallet edges, which then transfers those loads to the pallet rails and locks. The pallet rails and locks are pre-engineered for these loads, so it's extremely wise to use them.

But in the case of a "floating load" (which this reportedly was) straps and netting transfer all the upward, sideward, and fwd/aft loads to various "D" rings installed in the rails and seat tracks. Thus most of the load engineering is tossed out and the loadmaster must do the load engineering "on the fly". Since each "D" ring is only rated to 5Klb, the loadmaster must be high knowledgable and extremely vigilant in how he ties down the load. Clearly, the loadmaster in this situation was in over his head and/or tragically negligent.

Physics doesn't care if the cause is ignorance or negligence, the outcome is the same. However, a court of law will likely care. We'll have to wait and see how the lawsuits associated with this tragedy turn out.

Loadmasters and mechanics have no duty time limits, sometimes they are on the planes for as long as 5 days (I have worked for several cargo outfits).
I have flown the smaller MRAPS. The problem these have (and you can see it in the pictures that after they are driving onto the pallets, only a relatively small stack of wood is placed under the differentials, then the tires are deflated and they are being chained down. With the weight now centered in the middle, the chains will start to bow the pallet and they will not move unless the middle is right overtop a pdu.
The large Cougar actually has 2 stacks on top of a piece of wood that spreads the weight a bit more, and another stack under the middle. Not many chains to hold it down though. After the accident vehicles had a lot more chains tying them to the pallets.

By center loading you strap / chain / net the cargo to a pallet, after that you use straps to attach to the load and into seat tracks or other tiedown spots.
After the accident I have seen new guide lines where straps can only be used for 75% of their rated capacity, 2G up / down, 1.5 G forward / aft. Angles come into play now too. If a strap is put under a 60 degree angle, only half of the force can be used horizontally, 90 % vertically. under a 45 degree angle it is a 0.7 factor. A 5000 lb strap X.75=3750 lbs x.5 (a 60 degree angle)=1875 lbs / 852 kg horizontally, and 1534 kg vertically. Most straps are angled, since it provides both vertical and horizontal restraint (stright up does not provide for horizontal). You can use a strap from the floor up, through a ring and back down into the floor. Now supposedly this one strap counts as 2, something I don't agree on. If this one strap breaks, you lose 2.

The flight crew on this flight most likely checked the load in Bastion. Eventhough it was not written in the manual, it was a common procedure. All these guys had a cargo background. The assurance from the loadmaster that he replaced a strap and re-tightened everything should have been enough for most flight crews.

When this plane rotated something broke, most likely the floor or a seat track, a piece of cargo slid back ripping the wires from the data recorders and knocking out the 3 hydraulic lines that come together at the same point. On the video there is a stream of fluid coming from the tail, clearly visible.
I would really like to see some info on how much force the seat tracks are able to withstand, and the how much force the attachment of the seat tracks to the floor beams can withstand. It is not just the weight of the cargo, also how much tension there is on the straps. Unless you run into serious turbulence, the cargo causes little stress on the straps, even at rotation. However all the tightened straps pulling up on a seat track mounted to a few floor beams might be something no-one has ever thought about.

This is where I totally disagree. in 16 years of flying cargo, I have dealt with a wide range of loadmasters - from the very good ones to whom I went for advice, to the bad ones whom I could not trust to tighten a strap without checking afterward.

The fact that the crew had little or no experience with such loads should have raised their alert level, and they should have been asking a LOT of questions. A broken strap is NOT a common occurrence. A broken strap on an unusually large & heavy load is a red flag.

To merely replace a broken strap and re-tighten others would have NOT been a sufficient remedy on my airplane. I would have asked to see the load guidelines in the W&B Manual AND asked for additional straps rigged in the direction(s) along which the broken strap was rigged.

INTRUDER

I think that most of us would agree wholeheartedly with that strategy..
Which is where the question of fatigue becomes important.. there are very good reasons for why we have flight duty limitations and the relevant agencies don't give nearly as much attention to them as they deserve. The idea that this crew could be legally flying simply because they have 'rest' facilities on board is an absurdity. Quality of the rest period is hardly ever given any consideration. The company I fly for here in Afghanistan will quite happily quote the regulations covering rest days if we fly with no days off by stating that we remain legal by taking the 90 day rules and stating that we comply by having our rest days while off rotation.. so we can work 7 days a week for the duration of our time here. Legal ? Yes.. is it in the spirit of what the FAA were trying to achieve by ensuring rested crews ? The H*ll it is.
What frame of mind were the crew of the crashed 747 in during the stop-over ? It sounds as though the arrival was not exactly text-book which might give us a clue.

Each seat track notch is rated for 5000lbs of tension. It does not matter how many straps are attached to the seat tracks, so long as no single strap generates more than 5000lbs of tension. Exceeding 5000lb may cause the individal seat track notch to fail. Each notch has a 25% margin designed in when new. But the seat tracks take a beating, so there is no guarantee the 25% margin is still there after several flights.

And BTW, preloading a strap places a preload on the individual notch of the seat track, but does NOT preload the seat track to floor beam interface. The floor beams only see the maneuver/gust loads. Think of sitting in a chair and grabbing the seat bottom and pulling up. That places no additional load on the chair legs. The chair legs see only the load of the occupant's weight.

FAA Fine Proposal
 

https://www.faa.gov/news/press_relea...m?newsId=19116

Saw this today and may be of interest to some of you.

......

It seems to be the case of another "Mickey Mouse" operator getting away with a poor operation until a disaster strikes.

"getting away with a poor operation until a disaster strikes"??

Seems doubtful. This was the first time these vehicles has ever been airlifted using a commercial air freighter. No one "got away" with a "poor operation" because disaster struck during the FIRST operation. Or at least the second take off of the first operation.

@KenV...
 

"The FAA alleges that during March and April 2013, National failed to comply with Federal Aviation Regulations while loading heavy military vehicles onto two Boeing 747 jetliners that the company operated. The jets were flown on seven flights while loaded with one or more Mine Resistant Ambush Protected Vehicles (MRAPs), each weighing between 23,001 pounds and 37,884 pounds."

My point is that perhaps up to two months prior to the crash the FAA all already warned them so yes IMO they kept playing "Russian Roulette".

Does the FAA advise DoD of these violations?
 

I wonder if DoD was advised of or had independent knowledge of the carrier's loading practices. If so, what did DoD or the US Army do about it?

I say this because back in my MAC C-141 days, our flight crew had to watch our straight-leg customers like a hawk when loading the airplane, even to the point or re-weighing pallets and such. Thank goodness we did, too.

In the haste that such loading and departures might be subject to (I don't know, wasn't there) its not hard to imagine some corners being cut or details overlooked.
No excuse, just saying.

I was the first time the Captain and F/O carried MRAPs and the first time National had carried the 18 ton version but not the first time they were carried by a civilian cargo company.

The FAA condone the suspect practice of extended flight duty periods to keep their 'customers' happy. If this crew had arrived at the a/c well rested after a decent break would they have shown more concern regarding the cargo shift ? The landing prior to the accident was an indication that the crew may have been performing below par. We can only speculate but the FAA's hands are not spotless here.

Bagram Update
 

Update on the Bagram Accident:

"
Today, we now know the probable causes that led to the accident. In an investigative report by the US National Transportation Safety Board (NTSB), we learn that on 29 April 2013, the five armoured military vehicles inside the Boeing’s cargo hold, weighing a total of 78 tons, were not properly restrained.
The NTSB’s investigation states: ‘‘These vehicles were considered a special cargo load because they could not be placed in unit load devices (ULDs) and restrained in the airplane using the locking capabilities of the airplane’s main deck cargo handling system. Instead, the vehicles were secured to centreline-loaded floating pallets and restrained to the airplane’s main deck using tie-down straps.’’ And found: ‘‘Strong evidence that at least one of the MRAP vehicles (the rear M-ATV) moved aft into the tail section of the airplane, damaging hydraulic systems and horizontal stabilizer components such that it was impossible for the flight crew to regain pitch control of the airplane.’’
In their report the NTSB points to several fatal errors on the part of National Airlines, amongst which: ‘‘National Airlines’ procedures in its cargo operations manual not only omitted required, safety-critical restraint information from the airplane manufacturer Boeing and the manufacturer of the main deck cargo handling system Telair, (…) but also contained incorrect and unsafe methods for restraining cargo that cannot be contained in ULD’s.’’ Also, that current Federal Aviation Administration (FAA) guidance for operators (and overseeing inspectors) for restraining special cargo loads is inadequate.
And finally, we learn that the person responsible for loading was trained by National Airlines and had just completed a straight 21-hour work period at the time of the crash. Following this investigation report, the NTSB has just issued six recommendations to the US Federal Aviation Administration (FAA), which includes the creation of an instruction manual for special cargo operators, together with training and certification for those responsible for loading, and a limitation of their working time."


Video - Inadequately secured cargo caused B747 Crash in Afghanistan - Aeronewstv


Note that the official NTSB Probable Cause has yet to be published.

Final report link
 

"3.2 Probable Cause
The National Transportation Safety Board determines that the probable cause of this accident was 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."


Final report link is here if not already in this thread.

http://www.ntsb.gov/investigations/A...ts/AAR1501.pdf