In Nebraska, I coached my son’s soccer team. There was this one kid on my team who moved like the living dead from those Zombie movies. The ball would fall in his zone and he’d move his arms as if running, while his legs operated at continent-drifting speed. I’m watching this comedy routine, thinking, ‘Does he honestly think me, the parents, and the other team are that stupid?’
That’s called: Phoning It In. It’s when one does not put their best foot forward; the lack of effort reflecting a failure of intent. I know he was a kid, didn’t want to be there; probably played to please Mom or Dad. But he still let the team down with his total lack of effort.
The world of aviation safety depends on the full exertion put forth by safety specialists; their diligence assures industry that we will learn from our mistakes; the industry will be that much safer. Indifferent responses to tragedy diminish us all; it cheapens what all aviators work hard to maintain: Safety.
The 2013 National Airlines flight 102 crash in Bagram, Afghanistan, was a catastrophic end to a normal flight. Everyone has seen the 747’s last moments: it appears to hang on its engines before nosing over, then pancaking in. This accident represents a chance at salvation, a teaching moment. Each tragedy, an opportunity to prevent repetition, but only … only … if the correct lessons are learned.
To begin with, this accident happened while flying a military charter, the type of contracted flights that have been going on for decades. This is important: The Department of Defense (DoD) audits the airlines it contracts to annually; they verify the operator’s cargo loading procedures are up to DoD’s standards for the equipment and personnel being moved. They must do this. Why? Because air operators don’t normally transport multiple 18-ton Cougar vehicles and 12-ton Mine-Resistant Ambush-Protected all-terrain vehicles. Some military equipment exceeds the normal dimensions of an 88-inch by 125-inch cookie sheet pallet. This is not an excuse; it speaks directly to the DoD’s responsibility in this matter. And the air carrier’s, in this case: National’s.
According to the National Transportation Safety Board (NTSB) archives, the investigators dispatched to Bagram had a limited combined knowledge of the types of air carrier issues they would be facing. The investigator-in-charge (IIC) was a general aviation accident investigator; he had inadequate air cargo industry and DoD knowledge, forcing him to rely heavily on the other on-site investigators.
The NTSB’s decision to dispatch investigators unfamiliar with air cargo and military charter procedures is disturbing; the Board missed an opportunity to fix major problems by not having a working knowledge of how. The investigators’ unfamiliarity with air cargo meant that little was accomplished in reconciling the probable cause or writing constructive recommendations about air carrier operations.
The probable cause started correctly, finding National’s cargo loading procedures insufficient. However, instead of pursuing contributing factors, the NTSB deflected blame to the Federal Aviation Administration (FAA), claiming the FAA provided inadequate oversight of National’s military ‘special cargo’ procedures. Why didn’t the FAA do surveillance? The State Department doesn’t allow the FAA to conduct surveillance inside war zones.
The recommendations began with A-15-13: Rewrite or revise Advisory Circular (AC) 120-85: Air Cargo Operations. Pushing this recommendation first demonstrates the NTSB’s confusion with what an AC does. Although Advisory Circulars are considered guidance, they are advisory – not regulatory. ACs are normally employed during the air carrier’s certification phase, prior to approving/accepting their programs, procedures or limitations. Furthermore, operators are not required to follow an AC if their plan is better.
Five other recommendations proved ineffective, as well. A-15-14 proposed creating job specifications for an uncertificated position: Cargo Load Master (CLM). A CLM, or any job title resembling this, is a position defined by, e.g. the air carrier’s operations manual, which, if they run charters, has already been approved. A-15-16 and A-15-18 suggested beefing up guidance, amounting to using stronger language.
A-15-15 was a productive recommendation: Revising FAA Order 1800.56O to review all air operators’ weight and balance manual procedures. However, A-15-15 ignored the DoD’s involvement in the auditing process, thus overlooking a major contributor to this accident.
A-15-17 demonstrated the Board’s inexperience. The NTSB recommended providing initial and recurrent training for “Principal inspectors who have oversight responsibilities for air carrier cargo handling operations …” A principal – whether operations, avionics, or maintenance – has already received training before they take the position; cargo handling procedures are part of any certificate course, whether a passenger or cargo air carrier.
Recurrent training is a broad term. All aircraft, e.g. general aviation, Part 135, or Part 121, carries cargo in some form, so oversight of these operators is the best form of recurrent training. Certifying operators is involved; the FAA cannot revoke certification without just cause.
What about the FAA; how would they comply with such a recommendation? All air carrier and repair station FAA principals receive certification training; it takes them through the whole certification process; instruction supplemented with regulations and guidance. The FAA Academy does teach an Air Cargo course; it is a familiarization (FAM) course – not certification.
Cargo air carrier certification is no different than passenger air carrier certification, whether Part 121 or 135; the only difference is how one uses the seat tracks.
Another point: Air cargo is an operations-intensive industry. Airworthiness’s part is limited to manufacturing, modification, and maintenance of the aircraft and cargo components. Operations deals with everything and everyone else; from training to loading to scheduling, Operations controls every aspect of the air carrier’s cargo movements. Without understanding this, the NTSB is putting all principals in the same boat.
This accident investigation was phoned in from the start. The DoD will hopefully learn from these mistakes to prevent another accident. The NTSB had an opportunity to make good solid changes; it instead settled for an incomplete report, wasting a chance to make right a curable problem. This investigation let the entire aviation industry down.
Stephen Carbone is an avid writer of aviation fiction; his first novel Jet Blast has appealed to mechanics, pilots, air traffic controllers, etc. by giving accurate depictions of the accident investigation process. A former airline mechanic, he has been involved in many aspects of commercial aviation and went on to investigate major aviation accidents for the NTSB. A member of ISASI, Stephen holds a Masters degree in Systems Safety from ERAU. His weekly blog can be found at: https://danieltenace.com.
