Aviation safety investigations & reports

Loading related event involving Boeing 737, VH-VUF, Adelaide Airport, SA, on 13 December 2016

Investigation number:
Status: Completed
Investigation completed

Final Report

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On 13 December 2016, a Virgin Australia Boeing 737-800 aircraft, registered VH-VUF, was being prepared to operate flight VA 1393 from Adelaide, South Australia to Brisbane, Queensland.

The graphical load instruction report (GLIR) showed Brisbane bags and cargo (seafood and four dogs) to be loaded in the forward compartment (section 21), and connecting flight and priority Brisbane bags to be loaded in the aft compartment (section 31).

During loading, a loading staff member advised the leading hand the bags would not fit in the compartment with the cargo. The leading hand moved 55 bags into section 31 and saved the changes in the load control system (LCS). Two buttons on the tablet’s screen greyed out and the load control status changed.  The leading hand refreshed the device, the status returned to normal, and presumed the changes were accepted. The loading staff started loading these bags in section 31.

The load controller noticed a request in the LCS for 55 bags (equal to 870 kg) to be moved from section 21 to section 31 and a high priority message stating the take-off index exceeded the aft limit by 4.8 index units, meaning the aircraft was outside the centre of gravity limits. In response, the LCS was locked for 7 minutes while the load controller re-calculated the required changes to the load.

The load controller sent a message to the leading hand in the system denying the request to move bags and to move passengers or 40 bags in section 21. The load controller received no response, assumed changes were accepted, amended the LCS, and unlocked the system. The leading hand did not receive these messages and subsequently finalised the flight.

After the aircraft departed, the leading hand re-checked the paperwork and saw the bags had been moved back to section 21 by load control. The airport movement co-ordinator contacted the load controller and determined the aircraft was out of balance and the flight crew should be advised 40 bags (equal to 626 kg) were in section 31, not section 21 and three passengers would have to move forward to return the aircraft to balance. The flight crew were then contacted with the request to move passengers forward.

This investigation highlights the importance following procedures and communication have during the loading process.


Aviation Short Investigations Bulletin Issue 61

Download Final Report
[Download  PDF: 133KB]
Alternate: [Download  DOCX: 187KB]

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General details
Date: 13 December 2016   Investigation status: Completed  
Time: 9:50 CSuT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Adelaide Airport    
State: South Australia   Occurrence type: Animal strike  
Release date: 27 July 2017   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 737-8FE  
Aircraft registration VH-VUF  
Serial number 34168  
Operator Virgin Australia Airlines  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Adelaide, SA  
Destination Brisbane, Qld  
Last update 14 November 2018