Aircraft Accidents and Lessons Unlearned II: National Air Cargo 102
I’ve been involved in commercial aviation for 35 years. Most of that time was spent dealing with air cargo and much of it has involved, both directly and indirectly, major accident investigation. I have learned that there are two unreliable sources of information concerning accidents: a video recording and an expert eyewitness. I’ll use the National Airlines 102 accident at the Bagram Airbase, Afghanistan, as an example.
A video recording is unreliable because when the video is reviewed, it’s assumed the obvious answer is undeniable; the airplane obviously did something and people – even professional investigators – are quick to conclude that the accident happened in accordance with what was obviously seen: an aircraft stalls in flight, pointing nose up, because, e.g. a sudden, unexpected aft shift of weight. And to support the theory, the freight on National 102 (an 18-ton armored vehicle) fits the profile of a proper cause, e.g. a multi-ton vehicle lets loose to bring about an out-of-balance configuration; the vehicle broke through the aft pressure bulkhead, destroying everything beyond and catastrophically upsetting the aircraft’s balance. All other possibilities, e.g. flight control problems, are ignored for what is considered the ‘obvious’. It may not be incorrect – in this case, it is what caused the accident – but a presumption of evidence is often as hard to disprove as an accused criminal’s presumption of guilt.
The problem with expert eyewitnesses is that they ‘ad lib’ their visual account; it’s like the fishing story where the Flounder keeps getting bigger and fights harder each time one tells the story until it becomes a Marlin. Events or anomalies suddenly ‘precede or follow’ the accident, e.g. a flash or noise; technically, in the back of the eyewitness’s mind, B747s just don’t fall out of the sky without an explosion or the BOOM-BOOM of an engine compressor stall. The eyewitness reacts to the unexpected event by ‘remembering’ things that did not happen or overlooking things that did; he/she supports what he/she ‘sees’ by relying on their expert’s pride. The more time between event and interview, the more the story evolves in their memory. “Of course, there was a flash of light. I’m an expert; I know what I saw.” As an investigator, I would trust the memory of 7-year old Johnny Junior, professional second grader, as opposed to 30-year old John Senior, professional airline pilot; Johnny Junior doesn’t know enough to pad his story with technical stuff.
On April 29, 2013, National Airlines flight 102, aircraft N949CA, a Boeing B747-400, crashed on take-off out of Bagram Airfield in Afghanistan (NTSB number DCA13MA081; Accident Report AAR-15/01). The aircraft rotated off Runway 3; it climbed several hundred feet before it seemed to hang on its engines in a stall; it then nosed over and impacted terrain to the immediate southeast of Runway 3-21. A video was taken by an airport worker that captured the event, showing the B747 aircraft in an aerodynamic stall; the attitude of the aircraft was so severe that it appears that the aircraft was in an out-of-control, imbalance situation. This initial presumption corrupted the investigation; the probable cause was determined before the fire was even put out, based on what was seen. The National Transportation Safety Board (NTSB) wrote the report based on the fact that the rear-most armored vehicle broke loose – case closed.
However, it was not the cause of the accident.
The second thing: an air traffic controller observed the take-off, noting that the ‘airplane’s rotation appeared normal’, not aware that, at that moment, the situation would rapidly decay before his/her eyes. Even as the B747’s unusual take-off played out, the controller’s brain probably couldn’t comprehend the emergency as it was happening: that on an uneventful day a B747 was in distress; that some ‘hot-dogging’ pilot’s flying skills must explain the unusual angle of climb. This can’t be happening, can it?! He/She doubted what their eyes were seeing until reality kicked in, but then it was too late; the aircraft was in flames on the ground and their technical expertise and logic started filling in the blanks of what they must have observed; they manufactured some explanations for the incident in their minds. Suddenly there were flashes or noises that were never there … or were, e.g. the debris exiting the aircraft’s tail. Perhaps the controller, in his/her mind, couldn’t understand the impending disaster at the time it was happening, because there was just … too much … to process, and too little time to do it in.
While the shifting freight may have caused the accident, it wasn’t the cause. To find the cause(s), one has to look beyond the accident and the location (Bagram). This is something the NTSB did not do. By not looking beyond the accident, what was missed may happen again.
One of my colleagues, who conducted a more thorough review of the accident report’s ‘minor’ details than I did, pointed out to me that the flight originated in Fort Bastion in Afghanistan. This ‘minor’ detail, mentioned in the Report’s narrative of the flight’s history, is not minor at all, but a major fact: the time the B747 spent in Bagram, no freight was loaded or unloaded; it was only refueled. This means that the B747’s weight and balance manifest was calculated in another airport and was unchanged in Bagram; that the B747 flew from Fort Bastion to Bagram without incident. The NTSB failed to exploit this important fact. It should have because it places a good portion of the accident’s responsibility on a ramp that took two hours to fly from.
Let me refer back to the January 8, 2003, Air Midwest accident in Charlotte airport, where the Beech 1900D crashed due to weight and balance errors and incorrectly rigged flight controls: the elevators were incorrectly rigged five days before. That specific Beech 1900D flew eight successful flights before the disastrous combination of too much heavy baggage and the inability for the elevators to compensate, came together, resulting in a preventable accident that killed twenty-one people.
In Fort Bastion, a British-run military field, there was no United States’ (US) Department of Defense (DoD) oversight to verify their military load crews were following proper procedures in the securing of the vehicles to their individual pallets; I’m not talking about inside the B747, but on their shipping pallets built up hours before loading. In the process of moving the pallets with the vehicles secured by chains on fork lifts, excessive work-hardening of the pallet material where the chains were attached took place. The pallets that were being abused were probably not new; they most likely had been used and abused for an undetermined amount of time. Strapping 36,000 pounds of armored vehicle to a pallet with weakened attach points didn’t guarantee the pallet could be relied on for its integrity in holding the vehicle securely. The NTSB missed this fact; they did not go back to Fort Bastion to look at the ramp operating procedures.
In addition, the 18-ton vehicle’s tires were deflated; they were not fully inflated and rigid; the wheels were not blocked. This may have been proper shipping procedures for the military, but by deflating the tires, this allowed shifting and bouncing of the vehicle’s frame on the pallet in flight, alternately placing and removing stress on different parts of the restraining strap netting; the movements would relieve one part of the restraining net while simultaneously putting excessive stress on the opposing side, weakening the integrity of the restraint. The NTSB missed this fact because they did not look into the Fort Bastion ramp’s operating procedures.
The NTSB reported that the Federal Aviation Administration (FAA) was irresponsible in its lack of oversight of National Airlines and their procedures for shipping military equipment. This is a deflection of responsibility on the NTSB’s part. The US State Department doesn’t allow government employees to go to certain international locations, especially places considered in-conflict, or war zones; Afghanistan is such a war zone. Additionally, Fort Bastion is a British military base; the FAA and DoD have no jurisdiction on a foreign country’s base.
However, the DoD conducts annual audits on each of the operators it contracts to. The DoD then works with the FAA to clear any safety discrepancies – including loading procedures – before the contracts are continued and, in some cases, signed. The DoD were the authority with eyes on site; they should have been in front of National’s loading procedures, especially those procedures that address unusual loads, e.g. 18-ton vehicles. These loads require special handling or may require restriction in how many are allowed to be shipped on a civilian aircraft at one time. The DoD audits, in cooperation with Great Britain, should provide oversight of Fort Bastion’s ground handling procedures, to assure the pallets were not improperly handled, possibly weakening the attach points. The NTSB overlooked these facts.
Finally, the team the NTSB used to investigate the accident had little to no personal air carrier operations experience. In order to understand what is to be investigated, e.g. an air carrier’s operations, the investigator(s) must be educated and/or experienced in the cultures of how air operators, e.g. air cargo operators, work. As a result, the NTSB missed many important operational anomalies that should have made it into the Findings, the Probable Causes and the Recommendations of the National 102 Accident Report. I have documented here at least three or four that I found; there may be more. It is my experience that if findings in an investigation are missed, people die.
These report errors guarantee that safety groups and air carriers will most likely work off the NTSB’s faulty information. As a result, the training called for, the surveillance expected and the goals set will be wrong. Worse, the accident may be repeated, and at great cost.
This is why sometimes we have to step back, close our eyes to the obvious, e.g. videos or eyewitness testimony, and use our heads. When we settle on what caused the accident and not pursue the cause of the accident, we all lose.