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Final Report

Summary

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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