NTSB releases cause of 747 crash piloted by former MN man

This video, from 2013, might be the most shocking video of an aviation disaster ever recorded.

A Boeing 747 crashed while taking off from Bagram Air Base in Afghanistan.

A former Pine Island, Minn., man, Jeremy Lipka, 37, of Brooklyn, Mich., was the pilot.

Today, the National Transportation Safety Board released the cause.

The plane had been improperly loaded, it said in a summary released this afternoon.

The airplane’s cargo included five mine-resistant ambush-protected (MRAP) vehicles secured onto pallets and shoring. Two vehicles were 12-ton MRAP all-terrain vehicles (M-ATVs) and three were 18-ton Cougars. The cargo represented the first time that National Airlines had attempted to transport five MRAP vehicles. These vehicles were considered a special cargo load because they could not be placed in unit load devices (ULDs) and restrained in the airplane using the locking capabilities of the airplane’s main deck cargo handling system.

Instead, the vehicles were secured to centerline-loaded floating pallets and restrained to the airplane’s main deck using tie-down straps. During takeoff, the airplane immediately climbed steeply then descended in a manner consistent with an aerodynamic stall.

The National Transportation Safety Board’s (NTSB) investigation found strong evidence that at least one of the MRAP vehicles (the rear M-ATV) moved aft into the tail section of the airplane, damaging hydraulic systems and horizontal stabilizer components such that it was impossible for the flight crew to regain pitch control of the airplane.

The likely reason for the aft movement of the cargo was that it was not properly restrained. National Airlines’ procedures in its cargo operations manual not only omitted required, safety-critical restraint information from the airplane manufacturer (Boeing) and the manufacturer of the main deck cargo handling system (Telair, which held a supplemental type certificate [STC] for the system) but also contained incorrect and unsafe methods for restraining cargo that cannot be contained in ULDs. The procedures did not correctly specify which components in the cargo system (such as available seat tracks) were available for use as tie-down attach points, did not define individual tie-down allowable loads, and did not describe the effect of measured strap angle on the capability of the attach fittings.

Because the load had shifted to the rear of the plane and damaged the controls, there was no way for the pilot to do the one thing that could’ve kept the plane flying: pointing the nose down to pick up airspeed.

The person in charge of loading the aircraft had been on duty for 21 hours, the NTSB said. And he was not trained in how to load the equipment.

The agency also said only one — not five — of the vehicles could have been safely transported in a 747.

Killed along with Lipka were Jamie Brokaw, 33, of Monrole, Mich.; Gary Stockdale, 51, of Romulus, Mich.; pilots Brad Hasler, 34, of Trenton, Mich.; first officer Rinku Summan, 32, of Canton, Mich.; loadmaster Michael Sheets, 36, of Ypsilanti, Mich.; and maintenance crewman Timothy Garrett, 51, of Louisville, Ky.

  • MrE85

    That’s horrifying.

  • John

    So, based on what they found, how many checks were bypassed and safety systems/protocols violated to get all that stuff onto the plane, up into the air, and then crash?

    I lost count. It seems like many, many things were ignored. Sickening.

    • jane

      The flight crews that I am familiar with have/had checklists. Every flight is to be followed with a check list.

      • John

        This looks like it goes way beyond the flight crew and checklists.

        5 times as much cargo assigned to the plane as the NTSB says the plane is capable of carrying (that may be a misinterpretation, but the article says that the plane was only capable of safely carrying one of the vehicles on board). Who decided that was safe?

        Critical safety information omitted from the National Airline’s procedure books. (so, it wouldn’t be on the check list, because it wasn’t in the book the pilot/crew had access to).

        There were many safety systems ignored/bypassed in this event, some of which were likely beyond the control of the flight crew.

        My understanding is that ultimately the pilot is responsible for determining fitness to fly, but he/she has to have some level of trust for a lot of different groups before assuming that risk. The short list: loading crew, airplane manufacturer, mechanics, flight controllers, etc. it’s true, the pilot never should have attempted the flight, but I think ti’s also true that the flight never should have been authorized in the first place.

        • jane

          Exactly. The military crews that I flew (we were in the back end for those of you who need more info) with many, many, years ago would never attempt a stunt like this, IF the details of the report are true.
          We were labeled a lax bunch, but we had a good time and still got the job done and lived to tell about it.

  • KTFoley

    Tragic. Major accidents are often traced to a cascade of small errors, but this one seems to have come from the everyday failures that show up in so many bureaucracies:

    Build a process so it can’t be followed.
    Document it so the vital information is wrong or missing.
    Omit the training.
    Remove the oversight.

    Seven people die.

  • Paul

    The story I always knew was it was carrying tanks that shifted on departure. Such a crazy incident.

    • jane

      Well, whoever, whatever was on that plane and what REALLY happened will remain a mystery because the entire plane went up in smoke. Poof, gone. Whether it was poor judgment or another assassination will remain on the minds and karmic debt of those behind the scenes. I would not want to be them.