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On 15 December 2016, a Boeing 737-476SF (Special Freighter) aircraft, registered ZK-TLK (TLK), conducted a night freight flight from Sydney, New South Wales, to Melbourne, Victoria. On approach to Melbourne Airport, the captain noted the aircraft nose attitude appeared to be too high and airspeed appeared to be too low for that phase of flight. After landing at Melbourne Airport, the captain was notified that a loading error had occurred at Sydney Airport.

On the evening of the incident, two 737 freighter aircraft, operated by the same freight company, with the same paint scheme, were conducting freight flights into and out of Sydney Airport. The aircraft were parked next to each other on arrival at Sydney. The planned loads for the aircraft were distributed into containerised and non-containerised freight. The containerised freight was loaded into the upper compartments of the aircraft, but the non-containerised freight, which was loaded into the lower compartments, was inadvertently swapped between the two aircraft.

As a result of this occurrence, the loading supervisor introduced an independent cross-check of the loading of the lower compartment freight against the load instruction report.

This incident highlights the risk associated with a single source of error propagating through a safety critical process.

Aviation Short Investigations Bulletin - Issue 59

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General details
Date: 17 December 2016 Investigation status: Completed 
Time: 11:00 ESuT  
Location   (show map):Sydney Airport Investigation type: Occurrence Investigation 
State: New South Wales Occurrence type: Loading related 
Release date: 27 April 2017 Occurrence class: Operational 
Report status: Final Occurrence category: Incident 
 Highest injury level: None 
Aircraft details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 737-476SF 
Aircraft registration: ZK-TLK 
Serial number: 24434 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Sydney, NSW
Destination:Melbourne, Vic.
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Last update 14 November 2018