Why did the pilots LOSE control?! National Air Cargo flight 102

this video has been made together with skillshare an absolutely fantastic online learning platform use the link below in the description for your special deal it's the 29th of april 2013 and on runway 03 at bagram air base in afghanistan a boeing 747-400 freighter from national air cargo is getting ready for takeoff the aircraft starts rolling down the runway they rotate normally and only a few seconds after that something catastrophic happens the aircraft pitches up violently and what happens after that has been caught on a dashcam video and i bet that anyone who's seen that video remembers it on the video you can clearly see how the aircraft is climbing at an almost impossible angle at one certain point it looks like the aircraft is suspended in mid-air before it turns over its right-hand wing falls down and crashes into the ground what led up to this as always with an accident like this there is not one single thing rather than a chain of events that led up to it so now with the help of the final report let's examine what the links in that chain consisted of stay tuned national air cargo flight 102 was the second flight of the day for the involved crew they had started the day in cambustion in afghanistan where they had loaded up their cargo and then they had done a short about one and a half to two hour flight over towards bagram air base where they were due to refuel check their cargo and then do their final leg over to al maktoum international airport in dubai the aircraft supply was a converted 747 400 freighter that was originally built back in 1993 and sold to air france france operated it as a combo aircraft for a few years before they converted it into a freighter and then sold it off to national air cargo now in order for you guys to understand this accident you also need to understand a few technical details about the 747 400. so when it was converted from a passenger aircraft over to a cargo aircraft a company called telair did that conversion what they did was they converted the main deck of the 747 into a freighter deck and it was built to house something called unit load devices ulds and you will probably know them as containers the way that that is done is basically there are rails with ball bearings in the floor of the aircraft and there are also locking devices at medium intervals so that you could take one of these containers you can kind of push it in into nice neat rows and then for each load device you can flick up a little lock switch and when they're locked in place they are unable to move so the load is protected from movement both forward aft and for side loads okay and it is extremely important when you are flying with freight that the load is not allowed to move in any way for weight and balance but also to protect the aircraft now there are occasions where you need to be able to load bigger things into these freighters okay so where the containers are just not big enough to house what you want to move and in order to be able to do that you then need to be able to secure that type of cargo as well and because of that there are also multiple locking points in the cargo deck so that if you have a larger type of cargo you'll be able to put straps around that cargo and lock it into place but when you do so it is very important that you calculate how much g load each of these straps can actually take both like i said front aft and to the sides but also up and down this is probably the most important job that the load master has when faced with these types of non-standard cargo now you also need to understand a little bit about the hydraulic system of the 747 so the 747 has four independent hydraulic systems each is driven by its individual engine from the engines and from the hydraulic pumps connected to the engines you have a hydraulic lines running out to each of the systems that are required to have hydraulics that include things like landing gear for example it includes flight spoilers but also the primary flight controls when it comes to the primary flight controls which are the ailerons the rudders the elevators you have multiple backups so if one system fails you still have control over that rudder you also have a jack screw which is activated by a hydraulic motor that runs the stabilizer okay so when the pilots are trimming for example the jack screw will move the stabilizer up and down depending on what kind of trim they need to set which i've actually done a separate video about if you want to check that out the hydraulic fluid lines they run under the main cargo deck floor on the 747 and then they run through something called the aft pressure bulkhead out to their respective pcus their power control units which are the little motors that are actually activating the rudders or elevators depending what's needed they will also activate the motor that's driving the horizontal stabilizer now the aft pressure bulkhead is basically like an end plate of the pressure vessel right that's the back part of where you have the pressurized air inside of the aircraft and then behind the air pressure bulkhead there's no pressurization anymore just forward of the air pressure bulkhead there is a little rack that's holding the flight data recorder and the cockpit voice recorder and why i am telling you all of this is going to become really important soon on the accident flight there were seven people on board the captain of the flight was captain brad heisler he was 34 years old he has about 6 000 hours in total but only about 400 hours flying the 747 400. together with him was first officer jamie lee brokaw he is a relative low timer 33 years old 1100 hours of total time and only about 209 hours on the 747. together with the flight crew in the flight deck was also the load master which his name is michael sheet is 36 years old and the other people on board was a backup flight crew a first officer and a captain together with two mechanics that was also going on the flight we need to talk a little bit about the type of cargo that they were carrying on this flight so as i was saying before this 747 was built to carry these ulds these containers but they had a contract from the united states air force mobility command to carry a much larger type of freight on this particular flight so they had been asked to carry five huge vehicles right called m-wraps that's mine resistance ambush protected vehicles there were two types of these vehicles that were supposed to be carried um they were supposed to carry two smaller versions called matves weighing in at 12 tons and then three huge cougar vehicles weighing in at 18 tons each now these vehicles was way too big to be able to put into well certainly any type of uld so they had to be brought on on specially built pallets and in fact those pallets normally used were too weak so you had to use double pallets with some plywood in between in order to spread out the weight of these vehicles so these are really big these vehicles were then secured onto these pallets using chains and then they were loaded into what's called centerline loading inside of the 747 so that means that they're lined up with bang on the centerline in order to not shift the weights left or right of the center line and the way that they were loaded was that the the smaller matwie was at the very back and then there was three cougars and then at the front once again a smaller mattv the loadmaster that was loading these vehicles onto the 747 um doesn't seem to have used the load manual for this even though this was the first time that he was loading a type of vehicle like this and also this is the first time that the flight crew was going to fly with this type of cargo and it seems like he was basically just using his experience up at that point and he calculated the weight of each vehicle and he thought all right for the smaller ones we're going to need 24 strap to keep it in place and then for the bigger ones we would probably take two more so 26 straps now just to get you some perspective to this when the chief load master of national air cargo was asked to do a recalculation of how many strap was actually needed he initially came to the conclusion that he also would put 24 straps but then he did a recalculation and said no actually for the smaller vehicles the matrice he would need 32 straps and for the bigger cougars he would use as many as 46 straps and when boeing went in and did their calculation they said that actually because this is a special type of cargo you would need as many as 60 straps to keep it in place i want to point out at this point that these type of vehicles they're not just any type of cargo all right they are what's called special cargo load and also they're longer than normally allowed special cargo load which means that there are specific restrictions to how many of these that you can carry and how you have to restrain these just because if they for whatever reason would come loose they could seriously damage the aircraft and also they could come in and actually damage the upper floor which is where the crew was housed so they're very very specific rules when it comes to carrying this now none of these rules seems to have been covered in the loading manual of national air cargo airlines and incredibly it seems like the loadmaster on this occasion didn't even know that these rules existed but when after the accident the faa started looking into this it became clear that not only was the manual not correctly written there was not even any specific training required to become a load master because the loadmaster wasn't like a pilot for example or an air traffic controller regulated by any specific training or certification instead it was up to the individual airlines to train these people to make sure that they knew what they were doing and the faa had severely failed in their oversight to make sure that these type of risks and these types of lapses of both knowledge and communication was allowed to occur now you might ask yourself so doesn't the pilots have some kind of responsibility when it comes to making sure that the cargo is properly loaded and secured and yes legally speaking the palatine command is always responsible for the safety of their aircraft but in reality this type of responsibility is delegated to the load monster and if the loadmaster comes up before the flight and said that they're happy with the way that the aircraft is loaded and secured then the pilots are going to take their words for it and that would be it the first flight of the day that was done by the crew was going from cambastion over towards bagram air base and it seems like that had gone okay there was no indications of any problems during that flight but after the landing and as the aircrew was getting ready for the subsequent leg over to watch dubai it looks like the loadmaster had gone back and checked on the cargo and he reported up to the first officer the first officer then comes into the cockpit and the conversation that follows was actually captured on the cockpit voice recorder and i have to say that it's one of the most chilling conversations that i've heard in combination with an accident because at time 1428 utc the uh the first of success to the captain that one of those straps was busted and then he mentioned something about a knot and he also said that there was loads of these straps both the ones that keeps it from moving forward and moving aft and they were all loose now the augmenting captain was also in the corporate at the time and he makes some joking remarks about you know the fact that they were loose but the captain doesn't seem to be amused at all about this in fact he's saying well i hope he's actually beefing them up a bit and he's not just tying them down and they first off is responsible while he's clinching them down now 15 minutes later the loadmaster appears inside of the cockpit and we can hear the conversation and basically the captain asks the loadmaster how far did they move and the loadmaster responds well only a few inches and the captain says oh that's scary are those huge things moving i don't like that i don't like that at all he continues to say well i've never heard of such a thing you would think that those two big heavy things you know you would think that they wouldn't wouldn't even move at all and the load master responds but they always move everything moves if it's not tied down properly the fact that this cargo has moved in this way is an indication of a very very serious problem okay and it seems from this conversation that the captain is definitely aware of that and he does not like it whatsoever so does the loadmaster but they don't really seem to see the scope of the problem here 45 minutes after that initial conversation uh was had in the cockpit the aircraft is ready for departure they get their taxi out clearance they start to taxi out there is a lot of conversations in the cockpit at the time but nothing really relating to the cargo anymore and they get clearance to taxi into position for holding point run with 03 and await a departing aircraft at time 1525 the aircraft is lined up on the runway and they begin their takeoff role and up until this point we have all of the cbr data and the flight recorder data available to us so we know that the engines spooled up normally the aircraft accelerated normally very much like it had done on the previous flight flying out of campustion and then the aircraft rotates the last recording that was made on the cockpit voice recorder is the first officer asking for gear up about two seconds after that all recordings are lost both the flight data recorder and the cockpit voice recorder stops recording but before they do so those last two three seconds as the aircraft is getting airborne it indicates an abnormal pitch up so everything that we know from this point onwards is based on eyewitness account and that famous dash cam video that we've all seen so we know that after rotation the aircraft started pitching up uncontrollably eyewitness account says that they saw some puffs of white smoke coming out the back of the aircraft and the dash cam video would show the last couple of seconds of the flight showed how the aircraft basically climbed up until it lost all its forward airspeed it then pitched up slightly to the left and then over to the right and crashed into the ground at an almost wings level position this was a non-survivable event and all seven crew members perished in the accident the air crash investigation team now had a really tricky task to try to figure out why this happened in the first case they went out and they started scouring for clues and they started looking at the runway and round about taxiway charlie which has been approximately the point where the aircraft would have rotated they started finding some debris they found some pieces of aircraft skin they also found hydraulic tubing from hydraulic system 2 and they also found an antenna from one of the armored vehicles the matv the one that was situated in the very back of the aircraft and then as they followed the runway along they found more pieces of debris until they reached the actual crash site the crash site was located about 590 feet of the northeast departure end of runway 03 and it was pretty well held together now the forward and center part of the aircraft had been completely consumed by fire so it was very little that they could find but they could find all of the armored vehicles and the last matri was found in the general area of the horizontal stabilizer and the vertical fin and when they started looking at that map v because that last part of the aircraft had not been touched by fire they started finding some really interesting clues for example inside of the matavi they found material from the aircraft back wall which would indicate that the vehicle would have been in contact with that prior to the crash when the vehicle got crushed on the aft pressure bulkhead which was fractured into several pieces there was also a tire mark imprint which matched up with the spare tire on the mattv they also found the jack screw that is used to control the horizontal stabilizer and that had been severed and pushed into the stabilizer and at the point where the breakage had happened also very closely matched where the matui would have impacted it if it came rolling backwards based on all of these finds they could not start to kind of piece together a picture of what happened on this accident flight and because they had found pieces of aircraft skin hydraulic tubing and the mattress antenna around taxiway charlie that would indicate that at least one of the armored vehicles had started to move backwards just as the aircraft rotated the first thing that vehicle would have impacted would be the rack that held the flight data recorder and the cockpit voice recorder which is why all of the recording stopped only a few seconds after rotation the vehicle would then have continued back crashing into the aft pressure bulkhead which is where the hydraulic tubing went in to the flight controls rupturing at least hydraulic system one and two and possibly more now as it did this and it dropped to the hydraulic systems that would possibly have been the explanation of the eyewitness account of white puffs of smoke as the aircraft was climbing away that would most likely have been hydraulic fluid that was being vaporized into the air as this vehicle then continued into the jack screw and actually severed the jack screw the jack screw actually was bent backwards and forced into the horizontal stabilizer and the horizontal stabilizer by the force of this would have been bent downwards and when it did so that would have forced the nose of the aircraft into a uncontrollable pitch up momentum and because the jack screw was now severed there would be no chance for the flight crew to try to control the stabilizer movement and the loss of hydraulic pressure could have actually made you know control of the elevator impossible as well when they looked at the data from the last couple of seconds of the flight data recorder it very closely resembled the kind of pitch up that you would get if the horizontal stabilizer was pushed pitched down into the position that they actually found it in the crash site this paints an absolutely horrific picture of what happened during the 30s last seconds of this flight because this means that as the crew rotated the insufficient strapping of at least one of these vehicles would have just torn through these straps that held it down came rushing backwards causing all of this damage that we just discussed basically disabling the pitch control of the aircraft so the aircraft would have continued to pitch and no matter what the flight crew would have done up in the front no matter how much they would have pushed the yolk forward nothing would happen instead the aircraft would just continue with this nose up attitude until it ran out of forward momentum went into an aerodynamic stall and then crashed into the ground there would have been absolutely nothing that the flight crew could do once the uh the damage to the horizontal stabilizer was done this video has been made possible with the support and help of skillshare an absolutely fantastic online learning platform now i know that you're watching this because you're a curious person a lifelong learner someone who constantly wants to improve on what you're doing and if that is who you are then you should definitely check out skillshare they have thousands of high quality video courses and pretty much anything that you can imagine anything from how to improve your photography for maybe your instagram feed or how to improve your youtube channel which is something that i have been looking at personally but also things like how to become a private pilot just using your home simulator to prepare for it now the 1000 first of you who uses this link in the description below or up here you will get a free trial of skillshare which means that you can win and you can check if there's anything in there that you know spikes your interest and your curiosity and if there is then it is really affordable all right it's less than ten dollars per month to sign up so i highly recommend it when the national transportation safety board came with their final report they came to the following conclusion 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 load master's improper restraint of the cargo which moved aft and damaged hydraulic systems number one and two and the 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 the ntsb also came with several recommendations some of them were revised guidance material for air cargo operations relating to restraining special cargo loads create a certification for personnel responsible for loading and restraining special cargo loads including training and duty time limitations which believe it or not had not existed up until this point also improve oversight of cargo airlines compliance and develop training for inspectors of port 121 cargo operators now if you would like to see another video of a boeing 747 that went down just after departure but for a completely different reason then check out this video that i did just a few weeks back now i also hope that you understand that i'm doing these videos in order to show you how the aviation business are learning from its mistakes and how we are continuously working to make sure that whatever leads up to a tragic event like this is not being repeated if you're enjoying this series and the kind of content that i do i hope that i have earned a subscription from you so please subscribe to the channel so you know when i put my next video out with maybe the next air crash or something completely different and up until then have an absolutely fantastic day and i'll see you next time bye [Music] you

Channel: Mentour Pilot

Views: 622,670

Keywords: National Air Cargo flight 102, Afghanistan air crash, bagram 747 crash, bagram 747 crash cockpit voice recorder, Aircrash, air crash investigation, aircrash confidential 2021 new series, air crash documentary, air crash movies, fear of flying help, Nervous passenger, mentour pilot crash, Cargo shift, mrap vehicle, boeing 747 take off, boeing 747 crash, boeing 747 documentary, boeing 747-400, Boeing 737MAX, mentour pilot 737 max, microsoft flight simulator 2020 crash

Id: hvZEr3IkLJI

Length: 24min 40sec (1480 seconds)

Published: Fri Mar 12 2021