Jump to Content
Download Final Report
[ Download PDF: 15KB]
 
 
 
On the morning of 16 October 1997, Boeing 767 ZK-NBC was prepared at Sydney (Kingsford-Smith) Airport for a flight to New Zealand. When one of the engines was found to be unserviceable, the passengers and their baggage were offloaded and placed on another flight. In anticipation of the aircraft becoming serviceable, two cargo containers were left in the cargo hold, one secured and one unsecured, and the hold doors were left open. When a change occurs to an aircraft's arrival or departure time, a delay checklist is used by operations staff to ensure that all departments are aware of the new time. Due to deficiencies in the delay checklist, a number of departments of the ground handling company were not advised of the new departure time. So that repairs and engine runs could be performed, the aircraft was towed from the international terminal to the maintenance area. It is likely that the towing crew closed the hold doors at this time. The decision to move the aircraft was made without advising Ramp Control, who are responsible for the loading. By late afternoon, new parts for the engine had been located, another flight crew was positioning from Auckland and a new departure time of 2300 hours was planned. A load instruction form was prepared by Load Control, covering the two cargo containers already on board and one additional container which was to be loaded. Ramp Control was not advised of the new departure time, assumed that the aircraft would depart the following morning and did not allocate a loading team. The aircraft was towed to the international terminal at about 2100 for refuelling, but the cargo hold doors were not opened. The loadsheet officer reported receiving information that led him to believe that the additional cargo container would be loaded at this time. The flight crew arrived at the load control office to sign the loadsheet. The loadsheet officer assumed that the containers had been loaded in accordance with the load instruction report and signed the loadsheet. After refuelling, the aircraft with the flightcrew onboard, returned to the engine run area for the fitment of parts and engine runs. It was declared serviceable at 2230. The flight crew started engines and taxied for takeoff from the maintenance area. At 2249, 11 minutes before the curfew at Sydney Airport commenced, the aircraft took off for its flight to Christchurch with no passengers onboard. After landing, when the cargo hold was opened, it was found that the unsecured container had moved around in flight but had not caused any damage to the aircraft. Significant factors in this occurrence were: 1. Poor communications between a number of departments at Sydney Airport. 2. The failure of the loadsheet officer to ensure that the aircraft had been loaded in accordance with the load instruction form before signing the loadsheet. 3. The priorities of the loadsheet officer which placed the departure of the aircraft before the curfew, ahead of adherence to the published loading procedures. The ground handling agent advised that the following safety action has been carried out to prevent recurrence. 1. A review of the procedures for communications between departments at Sydney airport has been carried out. 2. The delay checklist, used by operations staff to advise departments of changes to aircraft times, has been reviewed. 3. New procedures that require the person responsible for loading to sign the load instruction form on completion of loading, have been introduced. 4. Written instructions have been issued to all ramp and load control staff confirming the operator's loading and documentation procedures. 5. Additional monitors have been installed in the load control and ramp control offices to keep staff advised of delays to aircraft arrival and departure times.
Download Final Report
[ Download PDF: 15KB]
 
 
 
 
General details
Date: 16 October 1997 Investigation status: Completed 
Time: 22:30 EST Investigation type: Occurrence Investigation 
 Occurrence class: Operational 
Release date: 18 May 1998 Occurrence category: Incident 
Report status: Final  
 
Aircraft details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 767-200 
Aircraft registration: ZK-NBC 
Sector: Other 
Damage to aircraft: Nil 
Departure point:Sydney NSW
Destination:Christchurch NZ
 
 
 
Share this page Provide feedback on this investigation
Last update 28 October 2014