ValuJet 592

Minutes after takeoff, the pilots of the DC-9 reported smoke in the cabin and requested a return to Miami International Airport. The plane then dropped off radar and into the Everglades, killing all 110 people aboard. It was among the worst air disasters in Florida’s history. 

What investigators knew was that the plane had been destroyed in midair by a massive on-board fire. When investigators finished their job, they believed they had the cause. Canisters which generated oxygen for the plane’s emergency systems, apparently improperly stored and loaded aboard the plane, ignited and caused tires in the hold to blaze.

The improper handling of the canisters, which used a chemical reaction to produce oxygen and in the process, generated heat, was blamed on SabreTech, a ValuJet subcontractor. Something caused a canister to spark about 6 minutes into the flight, torching the tires upon which the box had been placed.  The cabin was filled with smoke, control cables were burned, and the doomed plane plunged to its death (CBS Miami, 2014).

The National Transportation Safety Board (NTSB) determined that the probable cause of the accident resulted from a fire in the Class D cargo compartment initiated by the actuation of one or more oxygen canisters improperly carried as cargo, the failure of SabreTech to properly prepare, package, and identify chemical oxygen generators presenting them to ValuJet for transportation, and the failure of the Federal Aviation Administration (FAA) to require smoke detection in Cass D cargo space.  Additional factors were found that ValuJet and its subcontractors failed to ensure knowledge that ValuJet had a no carry policy for hazardous cargo (NTSB, 1996).



Here is the National Geographic documentary on the crash.
https://www.youtube.com/watch?v=-WoA2GgHntA

CBS Miami. (2014). Doomed ValuJet Flight 592 killed all, 16 years ago today. Retrieved from: http://miami.cbslocal.com/2012/05/11/doomed-valujet-flight-592-killed-all-16-years-ago-today/

NTSB. (1996) In-Flight Fire and Impact with Terrain Valujet Airlines Flight 592. Retrieved from: https://www.ntsb.gov/doclib/reports/1997/AAR9706.pdf

     I will be discussing again the crash of National Air Cargo 747 at Bagram AB Afghanistan once again.  I am doing so due to the fact I have been approached to be an expert consultant on the incident due to my prior military qualifications and my civilian 747 qualifications.  I was advised not to be involved by my existing employers due to possible contract issues with our customer.  I have looked into this specific crash extensively and have read numerous articles and posts about it.  This video was in the days immediately after the crash and even then the experts brought up the significance of possible cargo shifting in flight.  Amongst the Loadmasters and pilots I work and associate with, we felt it was either a flight control issue or a cargo shift due to how immediate the change in flight characteristics we all are used to seeing.


https://www.youtube.com/watch?v=aVL8RifMQ-s

Emery Crash at Mather AFB

An Emery Worldwide cargo plane crashed into an auto salvage yard after taking off from a Sacramento-area airport, killing all three crew members aboard.  The crash of the DC-8 transport service plane created a spectacular series of explosions as more than 100 cars burst into flames.  The plane took off from the former Mather Air Force Base at 7:52 p.m. 17 Feb, 2000 bound for Dayton, Ohio.

Shortly after takeoff, the pilot called the airfield's departure control and reported a problem.  "Right before the crash, the pilot said the plane had a center of gravity problem".   There was some kind of imbalance and he was having problems controlling the aircraft. On a plane like this, you load the cargo so the weight is distributed.   Capt. Dan Haverty of the American River Fire Department said the pilot informed departure control that he had a problem with "unsettled cargo."  The plane was carrying automatic transmission fluid, clothing and small amounts of "detonating explosives," Haverty said (Corwin & Warren, 2014). 

The post-crash investigation actually found that a maintenance issue was the cause of the crash.  The National Transportation Safety Board determined that the probable cause of the accident was a loss of pitch control resulting from the disconnection of the right elevator control tab. The disconnection was caused by the failure to properly secure and inspect the attachment bolt (fss.aero, 2014).

Corwin, M & Warren, J. (2014). Cargo plane crashes outside Sacramento, killing 3. Retrieved from: http://articles.latimes.com/2000/feb/17/news/mn-65402

fss.aero. (2014). Loss of Pitch Control on Takeoff, Emery Worldwide Airlines, Flight 17, McDonnell Douglas DC-8-71F, N8079U, Rancho Cordova, California, February 16, 2000. Retrieved from: http://www.fss.aero/accident-reports/look.php?report_key=25

Air Detective (AD) Tip 14

    

     The United Parcel Service 747 crash at Minhad AB Dubai, was a crash that was induced due to the fact a fire in the cargo area

created an environment that the crew could not effectively control and operate the aircraft in.  Smoke in the cockpit and an inability to 

maintain altitude forced a UPS Boeing 747-400 crew to attempt a return to Dubai before the aircraft crashed near the airport, killing

both pilots (Kaminski-Morrow, 2014).  This flight was a total loss but through the process of AD 14 was used to find the probable

cause through its process.  The investigators were able to deduct they had smoke in the cockpit from their communications with Air

Traffic Control.  They were able to determine from the Cockpit Voice Recorder (CVR) that the Co-pilot went to the cargo area to

investigate and potential put any fire out.  There were no declared shipments of hazardous materials onboard the airplane.  However, at

least three of the shipments contained lithium ion battery packs that met the Class 9 hazardous material criteria, according to the report

(Ranter, 2014).  this was determined through their investigation that the lithium batteries were the likely cause.  This was an entirely

difficult investigation for determination in that their was an all consuming fire when the aircraft impacted the ground.  Lithium batteries

have been suspect in many aircraft incidents in the past and are now a concern for hazardous shipments.

Kaminski-Morrow, D. (2014). Crashed UPS 747 had smoke in cockpit. Retrieved from: http://www.flightglobal.com/news/articles/crashed-ups-747-had-smoke-in-cockpit-347002/

Rantor, H. (2014). Report on UPS B747F in-flight fire accident: captain likely incapacitated. Retrieved from: http://news.aviation-safety.net/2011/04/05/report-on-ups-b747f-in-flight-fire-accident-captain-likely-incapacitated/

National Air Cargo 747 Bagram AB Crash

National Air Cargo 747 Crash.  Bagram, Afghanistan

The speculation and investigation into the crash have led investigators to conclude that the tie-down used to secure the MRAP's failed and led to shifting cargo which in turn made the conditions un fit for flight. 

Daily Mail. (2014). Did cargo shift cause Bagram 747 crash? Retrieved from: http://www.dailymail.co.uk/news/article-2335148/Bragram-747-cargo-plane-crash-MRAP-vehicles-plane-carrying-broke-free-straps-causing-crash.html

Simulators & AD 13

Simulators & AD 13

     Flight Simulators have been a training tool used extensively for flight crews since world War II.  The first pilot training aids were actually in use before WWI.  Edwin A. Link provided a giant step forward when in 1931 he received a patent on his "pilot maker" training device (U.S.A.F fact sheet, 2014).  Virtually all WWII pilots took instruction in one form or another in a Link trainer.  With regards to my subject of this blog; Loadmasters are now receiving training on ground and flight simulation.  Simulation not only is less wear and tear on the aircraft, it is an extremely cost effective way to eliminate the need for scarce training dollars. 

     Both the C-17A and now the C-130J aircraft have linkable cockpit and cargo area simulators.  The loadmaster, who sits in a simulated fuselage, can simulate air drops, combat offloads and night-vision-goggle scenarios. Recently, a lot of the training procedures completed on an aircraft have been moved to the simulator due to its realistic nature (Morgan, 2014).  C-17 pilots and loadmasters use a simulator complex to train on special requirements multiple times a month, both of these save the Air Force up to 90 percent of the actual cost of flying. The newest trainers are preparing loadmasters in the virtual reality realm; he C-130 Loadmaster Virtual Reality Trainer enables operators to train in a 3-dimensional environment using computers, special goggles, and fiberoptics. Loadmasters increase their confidence and effectiveness through virtual reality exer-cises and become better prepared for flight training with no additional manpower required (Air Force HSI, 2005).

                          

     AD 13 (Paper Trail Checklist), is quite relevant when discussing accidents that are related to cargo contents or specific loading procedures.  Aircraft and maintenance records can be crucial to an investigation when determining if all aircraft related equipment was both present and functional.  The operational and personal records of the flight and ground crews allow an investigation to determine the fitness of those involved to include their current status of training levels.  Not discussed are the actual transportation or manifest records.  They are vitally important to determine if the cargo offered for movement was properly identified and configured for aerial shipment.  The cross check of all hazardous movements can be a life or death step in determining if it was a cause or attributable factor in an accident. 

U.S.A.F fact sheet. (2014). Link Trainer. Retrieved from: http://www.nationalmuseum.af.mil/factsheets/factsheet_print.asp?fsID=3371

Morgan, J. (2014). Aircrews learn emergencies in safe environment. Retrieved from: http://www.amc.af.mil/news/story.asp?id=123277169

Air Force HSI. (2005). C-130 Loadmaster Virtual Reality Trainer. Retrieved from: http://www.wpafb.af.mil/shared/media/document/AFD-090121-028.pdf



    

       The main reason I chose this topic is that I have been involved with cargo aircraft my entire adult life 22+ years as a C-5 A/B/C, C-17A & 747-200/300/400/8F/LCF Aircraft Loadmaster and current C-17A Loadmaster Simulator Instructor.  In addition I am also the son of a retired US Air Force C-124, C-133A/B & C-5A Aircraft Loadmaster.  Soon my second born Son will be following in the tradition when this spring he will be enlisting in the Alaska National Guard as a C-17A Loadmaster.  I have a vested interest in identifying past cargo induced accidents so that I may highlight and pass this on to my current and future students.

       

     Aircraft accidents are a constant newsworthy event, some of the less likely causes are those that can be attributed to the cargo being carried.  When it has been determined cargo had been a contributing factor, most if not all of the situations were correctable or preventable.  The most recent that comes to memory is the National Air Cargo crash at Bagram AB Afghanistan. 
National Air Cargo B744 crashed after it was determined loose cargo consisting of three armored vehicles and two mine sweepers totaling at 80 tons of weight, caused the accident. The cargo slammed so hard at the back of the aircraft, that parts of the aircraft separated and wiring in the back was severed. As result of the shift and loss of aircraft parts the center of gravity moved so far back, that the attitude of the aircraft could no longer be controlled, the nose of the aircraft rose beyond the flying envelope of the aircraft and the aircraft stalled destroying the aircraft and killing all crew in the resulting impact. Parts of the aircraft, that separated as result of the initial load shift, were recovered from the runway. The straps used to tie down the cargo were recovered from the accident site, although charred they provided evidence of having fractured before final impact, it was unclear however, whether the fracture(s) had happened before or after takeoff (Hradecky, 2014).
      Another being the crash of United Parcel Service Flight 6 crash in Dubai.  The final determination was that “the investigation concludes with reasonable certainty that the location of the fire was in an element of the cargo that contained, among other items, lithium batteries.” (Kapur, 2014)






Hradecky, S. (2014). Crash: National Air Cargo B744 at Bagram on 29 Apr 2013. Retrieved from:      http://avherald.com/h?article=46183bb4

Kapur, V. (2014). UPS Dubai crash: GCAA final report links accident to lithium batteries. Retrieved from: http://www.emirates247.com/news/emirates/ups-dubai-crash-gcaa-final-report-links-accident-to-lithium-batteries-2013-07-25-1.515438

C-124 - http://www.nationalmuseum.af.mil/factsheets/factsheet.asp?id=289
C-133 - http://www.boeing.com/boeing/history/mdc/c-133.page
C-5 - http://www.lockheedmartin.com/us/products/c5.html
C-17 - http://www.boeing.com/boeing/defense-space/military/c17/index.page

Aircraft Loadmaster -
      A Loadmaster is an aircrew member that performs the calculations and plans cargo and passenger placement to keep the aircraft within permissible center of gravity limits throughout the flight.  The loadmaster may physically load the aircraft, but primarily supervises loading crews and procedures. Once positioned aboard the aircraft, the loadmaster ensures that their charge is properly secured, as an unexpected shift of the load can produce serious handling problems for the aircraft. Chains, straps, and integrated cargo locks are among the most common tools used to secure the cargo. Because cargo may shift during abrupt maneuvers, the loadmaster must determine the appropriate type, quantity and placement of cargo restraint. 
      Many loadmasters may also be required to be qualified for "aerial delivery" of paratroops or cargo by parachute. Compared to the relatively routine transportation of cargo, airdrop can be a highly technical and dangerous undertaking. Under some situations, the most effective way to resupply ground troops is by aerial delivery of equipment, ammunition, food, and medical supplies. 
      Until the 1980s, loadmasters were found primarily within the military, but as civilian airlines became more involved in air freight operations with large airplanes, particularly, the Boeing 747, many companies began using loadmasters on flights where complex cargo loads were carried.



AD Tips that can be used are pretty common to all investigations to include cargo induced accidents.  Overall the process starts with the stipulation that we are not trying to determine the cause but are attempting to collect evidence, observe what is at hand and find facts.  Photography and video can be crucial in the collection of evidence.  Small, middle, and big picture framing allows others to sample the evidence without focusing necessarily on one thing.  The 5-M concept is applicable in that Man is always involved.  Machine?  Was it configured and operating properly?  Medium can be attributed to material handling equipment and devices.  Mission is considered when evaluating time of day, conditions, and expertise.  Management is involved with the composition of all involved and the assigning of proper resources.  Ultimately Human Factors (HF)are the leading contributor in most all accidents.  The SHELL concept of HF can be used to evaluate all of the interchangeable relationship between the loading, unloading, and preparation of cargo for flight.  Ultimately much can be learned from the human interview process, first hand knowledge immediately after an accident is an invaluable tool in determining the causes of an accident..