On 23 July 2015, an Airbus A330 aircraft, registered VH-QPJ and operated by Qantas Airways, was being loaded at Bangkok Airport, Thailand, prior to flying to Sydney, Australia. The loading supervisor was in Bangkok, and the load controller was in Warsaw, Poland.

The load controller in Warsaw issued a load instruction report (LIR) to the loading supervisor in Bangkok. The loading supervisor was required to load the aircraft in accordance with the LIR, then phone the load controller to read back the loading.

The loading supervisor read out the description and weight of the pallet loaded into position 23P. The load controller responded that the pallet in 23P was on standby, and directed the loading supervisor to offload that freight. The supervisor responded ‘yes’, and stated that the loading was in accordance with the LIR. The pallet in 23P remained loaded on the aircraft.

The load controller then prepared the final loadsheet for the flight, and transmitted it to the flight crew, which provided the aircraft weight and balance details. The flight crew then used this data to calculate reference speeds for take-off, fuel consumption rates, and initial climb altitude. At about midday local time, the aircraft departed Bangkok for Sydney. The flight crew did not detect any abnormal flight conditions, nor did they receive any warnings related to the aircraft’s weight or balance.

After the flight had closed, the load control system automatically generated a report. The loading supervisor identified that the pallet in 23P was not on this report and contacted the load controller. The load controller confirmed that the pallet should have been offloaded. The load controller then contacted the Operations Control in Sydney and advised them that a pallet had been loaded onto the aircraft, which was not included in the loadsheet, and that some operational limitations had been exceeded.

This incident highlights the importance, particularly when dealing with safety-critical data, of:

  • standard phraseology in verbal communications
  • ensuring a verbal instruction has been understood and complied with
  • validating verbal communication with written documentation.


Aviation Short Investigations Bulletin - Issue 45

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