On 4 July 2009, an Airbus A330-202, registered VH-EBB, was being operated on a scheduled passenger/freight flight from Sydney, New South Wales to Denpasar, Indonesia via Melbourne, Victoria. During loading of the aircraft at Sydney International Airport, a unit load device (ULD) was loaded onto the aircraft without the proper authorisation. Prior to the aircraft taxying for departure, loading personnel realised that the ULD had been mistakenly loaded. However, there was confusion in the communication of that information to the flight crew and they operated the flight to Melbourne without knowledge of the mis-loading.
The investigation found that the pilot in command rejected the loading of the ULD before it was loaded in the forward cargo hold, but the status of that ULD was not clearly communicated to the ground handling team and it was returned to the outgoing freight holding area of the departure bay. Contrary to the aircraft operator's procedures, the ULD was subsequently loaded into the aircraft's aft cargo hold, in the absence of a leading hand and without reference on the loading instruction report or the authorisation of the pilot in command. Contributing to the occurrence was a lack of procedure or guidance for the segregation of freight that had been rejected during loading.
The investigation identified a number of factors that did not contribute to the incident, but increased operational risk. Those factors related to the performance of the leading hand role, load-checking and procedures for communicating with flight crew after pushback.
The aircraft operator initiated proactive safety action to improve the training and supervision of loading staff, including guidelines for all staff involved with the training and support of new ports or ground handling agents. The operator also implemented procedures to enable ground handling agents to make emergency contact with the aircraft crew after pushback and incorporated those procedures in the relevant manuals.
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.
|Date:||05 July 2009||Investigation status:||Completed|
|Time:||1515 EST||Investigation level:||Systemic - click for an explanation of investigation levels|
|State:||New South Wales||Occurrence type:||Loading related|
|Release date:||19 May 2011||Occurrence category:||Incident|
|Report status:||Final||Highest injury level:||None|
|Aircraft manufacturer||Airbus Industrie|
|Type of operation||Air Transport High Capacity|
|Damage to aircraft||Nil|
|Departure point||Sydney, NSW|