Aviation safety investigations & reports

Loading related event involving Airbus A320, VH-VGI, Melbourne Airport, Victoria, on 21 December 2016

Investigation number:
AO-2016-177
Status: Completed
Investigation completed

Final Report

Download Final Report
[Download  PDF: 111KB]
Alternate: [Download  DOCX: 241KB]
 

On 21 December 2016, an Airbus A320, registered VH-VGI, and operated by Jetstar Airways, was being loaded at Melbourne Airport, Victoria, prior to operating flight JQ792 to Sunshine Coast, Queensland.

At 0500 Australian Eastern Daylight-savings Time, a clerk at a freight organisation commenced their shift at the organisation’s Melbourne Airport office. The organisation recently introduced a new processing system, however a decision was made to use the old system due to the amount of freight for processing and system issues.

The team was short one person. The replacement clerk was starting work at 0700. Until then, the clerk was responsible for processing freight on all narrow-body flights from Melbourne. The clerk spent about 20 minutes on the radio, and processed freight for 9 or 10 flights over half an hour. During this time, the clerk identified two pieces of freight (flowers and meat) to be sent to the Sunshine Coast, weighing a total of 93 kg. The clerk put the freight in a unit loading device (ULD) and wrote the ULD number on the same page with the details of a ULD destined for Adelaide. The clerk entered the ULD as going to the Sunshine Coast in the office. However, they inadvertently put the Sunshine Coast freight card on the ULD (containing medical goods, weighing 245 kg) destined for Adelaide. This ULD was subsequently loaded on the Sunshine Coast flight.

The clerk realised the error when the ULD destined for Adelaide could not be located. The clerk who commenced at 0700 noticed the ULD on the Sunshine Coast flight paperwork. When the ULD was found, it was loaded on the next flight Sunshine Coast flight.

This investigation highlights the effect of high workload on data input errors, as well as the importance of system feedback of incorrectly entered data.

Aviation Short Investigations Bulletin - Issue 59

Download Final Report
[Download  PDF: 111KB]
 
 
Alternate: [Download  DOCX: 241KB]
 

Read report

Photo

To download, click the link, then right-click and select Save As.

Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations and should be credited accordingly.

General details
Date: 21 December 2016   Investigation status: Completed  
Time: 9:00 ESuT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Melbourne Airport    
State: Victoria   Occurrence type: Loading related  
Release date: 27 April 2017   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A320-232  
Aircraft registration VH-VGI  
Serial number 4466  
Operator Jetstar Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Melbourne, Vic.  
Destination Sunshine Coast, Qld  
Last update 14 November 2018