ASN Aircraft accident Boeing 747-428 (BCF) N949CA Bagram Air Base (BPM)

Home » Database » 2013

Status:	Accident investigation report completed and information captured
Date:	Monday 29 April 2013
Time:	15:27
Type:	Boeing 747-428 (BCF)
Operator:	National Airlines (National Air Cargo)
Registration:	N949CA
MSN:	25630/960
First flight:	1993-01-29 (20 years 3 months)
Engines:	4 General Electric CF6-80C2B1F
Crew:	Fatalities: 7 / Occupants: 7
Passengers:	Fatalities: 0 / Occupants: 0
Total:	Fatalities: 7 / Occupants: 7
Aircraft damage:	Destroyed
Aircraft fate:	Written off (damaged beyond repair)
Location:	Bagram Air Base (BPM) ( Afghanistan)
Crash site elevation:	1492 m (4895 feet) amsl
Phase:	Takeoff (TOF)
Nature:	Cargo
Departure airport:	Bagram Air Base (OAI/OAIX), Afghanistan
Destination airport:	Dubai World Central-Al Maktoum International Airport (DWC/OMDW), United Arab Emirates
Flightnumber:	NCR102

Narrative:
A Boeing 747-400BCF cargo plane, operated by National Air Cargo, crashed on takeoff from Bagram Air Base (BPM), Afghanistan. All seven crew members were killed in the accident.
The accident flight was operated as part of the International Security Assistance Force (ISAF) to transport military equipment.
The original schedule was for the crew to operate flight NCR510 from Chateauroux, France to Camp Bastion, Afghanistan, and then continue to the Dubai World Center at Al Aktoum, UAE. Because no Pakistan over-flight permit was obtained, the flight was re-routed as NCR102 to operate from Camp Bastion to Bagram, refuel, and continue NCR102 from Bagram to Dubai.
According to the load manifest, while in Camp Bastion, the airplane was loaded by National Air Cargo ground personnel with 94,119 kg of cargo, including 5 Mine Resistant Ambush Protected (MRAP) armored military vehicles that were loaded on the main deck of the airplane. Two of these vehicles weighed about 12 tons each, and the other three weighed about 18 tons each.
It was the first time National Airlines had transported 18-ton military vehicles when they were loaded on the accident airplane in Camp Bastion.
The airplane departed Camp Bastion at 07:45Z and arrived into Bagram at 09:23Z (13:53 local time). On arrival into Bagram, the crew experienced a brake overheat condition after landing on runway 03. The crew parked the airplane on the Foxtrot ramp and ran a checklist to address the brake temperature indications in the cockpit, and discussed the required cooling time of 1 to 1.5 hours.

The crew did not take on any additional cargo in Bagram, and only took on fuel for the flight to Dubai.
At about 14:27 hours local time while the airplane was still on the ramp in Bagram, the captain was made aware of a broken strap found by one of the other crewmembers, and the cockpit crew had a discussion about a possible shift of the cargo load during landing in Bagram.
There was additional discussion on re-securing the load prior to departure.
Flight NCR102 taxied out normally for departure on runway 03 at Bagram at 15:14. After receiving clearance, takeoff was commenced at 15:26. The takeoff roll appeared normal. The airplane rotated normally around the Charlie intersection of the runway. Approximately 9 seconds after the crew called to rotate the airplane, the cockpit voice recorder (CVR) stopped recording, and approximately 3 seconds later the flight data recorder (FDR) stopped recording. According to witnesses and video evidence, after becoming airborne, the airplane continued to pitch up until it appeared to stall, turn to the right, then descended to impact with the ground just beyond the departure end of runway 03 and to the right.

An investigation of the wreckage revealed at least the aft-most MRAP broke loose of its restraints during takeoff, shifted aft and damaged the FDR/CVR before penetrating the aft pressure bulkhead. The MRAPs aft movement was determined to have compromised at least Hydraulic Systems #1 and #2 and may have contacted the stabilizer jackscrew assembly.

Probable Cause:

PROBABLE CAUSE: "National Airlines inadequate procedures for restraining special cargo loads, which resulted in the loadmasters 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 Administrations inadequate oversight of National Airlines handling of special cargo loads."

Accident investigation:

Investigating agency:	NTSB
Status:	Investigation completed
Duration:	2 years and 3 months
Accident number:	NTSB/AAR-15-01
Download report:	Final report

Classification:

Cargo shift
Loss of control

Sources:

» Wall Street Journal
» NTSB
» National Airlines
» SKYbrary

METAR Weather report:

09:55 UTC / 14:25 local time:
KQSA 290955Z COR 10017G30KT 9999 SCT085 BKN140 BKN200 17/06 A2992 RMK PK WND 09032/0856 LTG DSNT NW CB DSNT E SLP213 WND DATA ESTMD ALSTG/SLP ESTMD COR 13

10:55 UTC / 15:25 local time:
KQSA 291055Z 02007KT 9999 FEW040 BKN080CB BKN150 18/06 A2994 RMK PK WND 06026/1005 WSHFT 1027 LTG DSNT NW CB DSNT NW SLP124 WND DATA ESTMD ALSTG/SLP ESTMD

10:58 UTC / 15:28 local time:
KQSA 291058Z 35011G17KT 9999 FEW050 BKN080CB BKN150 14/05 A2993 RMK LTG DSNT NW SLP124 WND DATA ESTMD ALSTG/SLP ESTMD

10:59 UTC / 15:29 local time:
KQSA 291059Z 35011G17KT 9999 FEW050 BKN065 BKN090 14/05 A2993 RMK WND DATA ESTMD ALSTG/SLP ESTMD

11:55 UTC / 16:25 local time:
KQSA 291155Z 33008G17KT 9999 -TSRA SCT050CB BKN090 BKN170 13/04 A2996 RMK CB OHD MOV N SLP139 60000 70000 51014

Follow-up / safety actions

NTSB issued 6 Safety Recommendations

Issued: 14-JUL-2015	To: FAA	A-15-13
Revise the guidance material in Advisory Circular (AC) 120-85, "Air Cargo Operations," chapter 201(a)(4), to specify that an operator should seek Federal Aviation Administration (FAA)-approved data for any planned method for restraining a special cargo load for which approved procedures do not already exist, and remove the language in the AC that states that procedures other than those based on FAA-approved data can be used. (Closed - Reconsidered)
Issued: 14-JUL-2015	To: FAA	A-15-14
Create a certification for personnel responsible for the loading, restraint, and documentation of special cargo loads on transport-category airplanes, and ensure that the certification includes procedures; training; and duty hour limitations and rest requirements consistent with other safety-sensitive, certificated positions. (Open - Acceptable Response)
Issued: 14-JUL-2015	To: FAA	A-15-15
Add a special emphasis item to Federal Aviation Administration (FAA) Order 1800.56O, "National Flight Standards Work Program Guidelines," for inspectors of 14 Code of Federal Regulations Part 121 cargo operators to review their manuals to ensure that the procedures, documents, and support in the areas of cargo loading, cargo restraint, and methods for securing cargo on transport-category airplanes are based on relevant FAA-approved data, with particular emphasis on restraint procedures for special cargo that is unable to be loaded via unit loading devices or bulk compartments. (Open - Await Response)
Issued: 14-JUL-2015	To: FAA	A-15-16
Include specific guidance in the Federal Aviation Administration inspector handbook that defines responsibilities for principal inspectors for the oversight of an operators loading, restraint, and documentation of special cargo loads. (Open - Unacceptable Response)
Issued: 14-JUL-2015	To: FAA	A-15-17
Provide initial and recurrent training for all principal inspectors who have oversight responsibilities for air carrier cargo handling operations that specifically addresses operator cargo procedures, documents, restraint, and support for technical decisions related to special cargo loads (Open - Acceptable Response)
Issued: 14-JUL-2015	To: FAA	A-15-18
Implement temporary risk-reduction methods any time that required surveillance items for 14 Code of Federal Regulations Part 121 and 135 operators can be deferred, and establish appropriate limitations on surveillance deferrals. (Open - Unacceptable Response)

Show all...

Photos

accident date: 29-04-2013
type: Boeing 747-428BCF
registration: N949CA

N949CA

accident date: 29-04-2013
type: Boeing 747-428BCF
registration: N949CA

Video, social media

Aircraft history

date	registration	operator	remarks
29 JAN 1993	F-GISE	Boeing	first flight
10 FEB 1993	F-GISE	Air France	delivered
08 SEP 2010	TF-NAD	National Airlines	operated by Air Atlanta Icelandic
13 JUL 2011	N949CA	National Airlines	new registration

Map

This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Bagram Air Base to Dubai World Central-Al Maktoum International Airport as the crow flies is 1745 km (1091 miles).
Accident location: Approximate; accuracy within a few kilometers.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

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Boeing 747

1574 built
56^th loss
27^th fatal accident
19^th worst accident (at the time)
20^th worst accident (currently)

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Afghanistan

30^th worst accident (at the time)
31^st worst accident (currently)

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