Aviation safety investigations & reports

Boeing Co 737-476, VH-TJZ

Investigation number:
200002989
Status: Completed
Investigation completed

Summary

After a five-minute delay in securing the aft cargo door, the Boeing 737 was cleared for pushback. The ground engineer then passed a message to the crew to 'call control', but gave no indication of urgency. The crew decided to concentrate on the departure and to call control when airborne.

After takeoff, the crew contacted Load Control and were advised that the load controller had been attempting to make contact to inform them that the loadsheet may have been inaccurate. The crew were not warned via the ACARS data communication system before takeoff. The crew had not been monitoring the Load Control frequency as they had already received the final loadsheet. Aircraft performance and handling were not affected.

Investigation revealed that the leading hand of the loading gang had given a 'Ramp Clearance' to the load controller while the loading of the cargo hold was still in progress. The 'Ramp Clearance' indicated to the load controller that either all compartments had been loaded as required, or that the entire load had been accounted for and was either alongside the aircraft or in transit to the aircraft. However, due to unserviceable webbing in the doorway of compartment 4 of the aft cargo hold, the loading gang relocated 10 bags to compartment 3 of the aft hold after the leading hand had given the 'Ramp Clearance' and the load controller had sent the final load sheet to the aircraft.

The leading hand advised the load controller of the change, and the load controller amended the load calculations. The load controller then attempted to contact the crew on the Load Control frequency, without success, as the crew were not monitoring the frequency. The load controller then contacted Movement Control in Cairns to have the ground engineer attending the departure, ask the crew to 'call control'. The engineer passed the message, but the crew did not contact Load Control until after takeoff. Thus, the aircraft departed with the loadsheet unamended.

Standard Operating Procedures for Load Control specified that ACARS messages should not be sent to the aircraft after the final loadsheet was issued. This was based on the need to avoid distracting the crew performing vital actions during departure, plus the likelihood that the crew could miss the message. The load controller was required to inform the crew verbally of any late changes to the loadsheet. In addition, when the company implemented its new load control system, management decided that due to cockpit workload, crews would be required to monitor only two frequencies (Air Traffic Control and Movement Control) during the period within 15 minutes of pushback.

Prior to the occurrence, the company had initiated a review of procedures relating to the issue of ramp clearances. Alternative procedures were being trialled. However, the new procedures were not a factor in the occurrence.

At the conclusion of the trials, new procedures were implemented in Melbourne in December 2000, and training was scheduled for February and March 2001 prior to implementation of the new procedures at other ports.

General details
Date: 16 July 2000   Investigation status: Completed  
Time: 1550 hours EST    
Location   (show map): Cairns, Aero.    
State: Queensland   Occurrence type: Loading related  
Release date: 22 May 2001   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 737  
Aircraft registration VH-TJZ  
Serial number 28152  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Cairns, QLD  
Departure time 1555 hours EST  
Destination Brisbane, QLD  
Last update 13 May 2014