Aviation safety investigations & reports

Boeing Co 767-338ER, VH-OGC

Investigation number:
Status: Completed
Investigation completed


Approximately 20 minutes after departure, the crew was advised that a pallet weighing 3,696 kg, which had been included in the load/trim calculations, was not on the aircraft. This resulted in the aircraft's centre of gravity being slightly rear of the calculated position, but still within required limits.

The airline's normal practice was to operate a Boeing 747 on the Nagoya service. However, on this occasion the service was operated by a Boeing 767. The pallet which had not been loaded was purpose-built by the shipper to optimise the available space on Boeing 747 aircraft. Its design included an extension at each end which precluded loading through the cargo compartment door of Boeing 767 aircraft. Communications within the operator's freight system provided early notification of the aircraft change. However, this information was not provided to the shipper. The operator's freight section at Cairns, when receiving the pallet, did not recognise its unsuitability.

In preparation for loading the aircraft at Cairns, the leading hand loader was provided a Load Instruction Report (LIR). The LIR showed the load distribution of the aircraft on arrival, and the load distribution for departure as required by the load controller. A third section of the LIR was to be completed by the leading hand following loading to confirm the actual load distribution on departure. The LIR would then be passed to the load controller. Aircraft had, on occasions, departed before the load controller received the LIR.

On finding that the pallet could not be loaded, the leading hand advised the load controller who was on the flight deck at the time. The controller checked the pallet and indicated to the leading hand that by rearranging other containers, it could be loaded. However, the high noise environment of the loading area made conversation difficult, and the controller did not remain to ensure that the pallet could be loaded. He left the aircraft satisfied that the problem was resolved without the need to amend the loading documentation. The leading hand assumed that the load controller recognised that the pallet could not be loaded, and directed that it be returned to the freight shed.

The aircraft departed before the controller received the amended LIR which indicated that the pallet had not been loaded.


The operator's procedures did not ensure that the implications of the aircraft type change were properly communicated to those involved in the preparation and acceptance of the pallet. Consequently, the pallet was accepted for shipment without recognition that it was oversize for the aircraft.

When advised by the leading hand that the pallet could not be loaded, the load controller apparently focussed only on the available area within the cargo compartment. He had not recognised that the overhang prevented the pallet from being manoeuvred through the cargo door. The high level of ambient noise and assumptions made by both the controller and the leading hand may explain why neither understood the point the other was attempting to make.

The processing of the LIR was inadequate in that the defence intended by the leading hand's written confirmation of the aircraft loading was circumvented. The load controller, having assumed that the loading was in accordance with the original documentation, dispatched the aircraft without ensuring confirmation of the final loading status.

Safety Action

Safety action by operator

The operator has introduced a new load control management system that is now controlling loading in all ports except one. The last port should be incorporated into the system by April 1999.

The new system is computer-based and eliminates any requirement for load controllers to leave their workstations. Regardless of their location, gang leading hands have immediate radio communication with load controllers to discuss any problems or variations. Freight shed staff, customer service staff and traffic staff have immediate communication with load controllers by telephone.

A manual for operation of the system has been produced and issued to staff.

Safety action by BASI

BASI is monitoring the operation of the new system.

General details
Date: 24 January 1998   Investigation status: Completed  
Time: 1200 hours EST    
Location   (show map): Cairns, Aero.    
State: Queensland   Occurrence type: Loading related  
Release date: 01 March 1999   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 767  
Aircraft registration VH-OGC  
Serial number 24317  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Cairns, QLD  
Destination Nagoya, JAPAN  
Last update 13 May 2014