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Final Report

Summary

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

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