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Loading related

Aircraft loading issue - VH-­ZPF, Adelaide Aerodrome, South Australia, on 16 May 2010

Summary

On 16 May 2010, an Embraer ERJ 190 aircraft, registered VH-ZPF, was being operated on a positioning flight from Adelaide, South Australia (SA) to Brisbane, Queensland (Qld). After arriving in Brisbane, the pilot in command (PIC) reported that the load and trim sheet for the aircraft was inaccurate due to certain items being counted twice in the aircraft's load and trim calculations.

It was found that an error occurred when the Adelaide airport movements coordinator (AMCO), during a period of high workload, inadvertently selected the incorrect aircraft configuration in the company's computerised load and trim system.

The aircraft was not operated outside its weight and balance limitations; however, there were implications for how the pitch trim was set prior to takeoff.

The operator has raised an amendment to its flight operations manual to clarify the correct configuration to use when compiling a load and trim sheet for a positioning flight. The operator has also implemented changes to its load control system software to prevent the inadvertent selection of the incorrect configuration while preparing a load and trim sheet.

Occurrence summary

Investigation number AO-2010-034
Occurrence date 16/05/2010
Location Adelaide Aerodrome
State South Australia
Report release date 14/10/2010
Report status Final
Investigation level Short
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Embraer-Empresa Brasileira De Aeronautica
Model ERJ 190
Registration VH-ZPF
Serial number 19000193
Sector Jet
Operation type Air Transport High Capacity
Departure point Adelaide SA
Destination Brisbane Qld
Damage Nil

Aircraft loading event - Airbus A330-202, VH-EBB, Sydney Airport, New South Wales, on 4 July 2009

Summary

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 misloading.

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.

Occurrence summary

Investigation number AO-2009-034
Occurrence date 05/07/2009
Location Sydney Airport
State New South Wales
Report release date 19/05/2011
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Airbus
Model A330
Registration VH-EBB
Serial number 522
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney, NSW
Destination Melbourne, Vic.
Damage Nil

Weight and balance event - Airbus A330-303, VH-QPJ, Sydney Aerodrome, New South Wales, on 6 March 2009

Summary

On 6 March 2009, an Airbus A330‑303 aircraft, registered VH-QPJ, was being loaded for dispatch on a scheduled international passenger service between Sydney, New South Wales and Hong Kong. Operational changes prior to the aircraft's dispatch required an adjustment of the planned load, with the load controller electing to offload a pallet of freight originally scheduled for that flight, and substituting it with a lighter pallet in the load management system.

Following the pallet substitution in that system, the load controller did not amend the loading instructions that had been previously issued to the ramp staff loading the aircraft. That resulted in the ramp staff being unaware of the changed loading requirement and the loading proceeded as initially planned.

The discrepancy between the actual aircraft load and operator's load management system was not detected during the completion of the load controller's 'Final Distribution Check' prior to issuing the final load sheet to the flight crew. That resulted in the aircraft exceeding the structural maximum taxi weight by 384 kg and the maximum structural take-off weight by about 884 kg. It also resulted in the flight crew entering inaccurate centre of gravity and zero fuel weight data into a number of the aircraft's systems.

Due to a delay in the notification of the loading error to the operator's relevant departments, the aircraft operated another 10 sectors before maintenance inspections for an overweight taxi were completed.

As a result of this occurrence, the operator implemented several changes to the process for managing load control activities. Those changes included: implementing a procedure to ensure the immediate notification of loading-related incidents and changes to the operating procedures in load control, including the introduction of a read and sign process for important ramp and load control communications; the appointment of a load control standards officer; and the conduct of a training needs analysis for load control officers.

Occurrence summary

Investigation number AO-2009-011
Occurrence date 06/03/2009
Location Sydney Aerodrome
State New South Wales
Report release date 22/03/2011
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Airbus
Model A330
Registration VH-QPJ
Serial number 712
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney, NSW
Destination Hong Kong, China
Damage Nil

Weight and balance event, Airbus A330-301, Changi Singapore, VH-QPC

Safety Action

SAFETY ACTIONS

Operator

The operator has implemented the following safety actions in order to enhance the existing organisational and individual risk controls affecting A330 aircraft loading:

  • planning is underway for a single load control system commencing March 2007 for the company’s domestic and international operations
  • inter-departmental communication lists have been amended to ensure the timely promulgation and availability of relevant aircraft documentation for use by flight crews
  • the Route Manual Supplement has been amended to clearly mandate the requirement for flight crews to check an aircraft’s critical load data against other company documentation before accepting a provisional load sheet
  • the Flight Crew Operating Manual has been amended to place shared responsibility for the final check of an aircraft’s load sheet data with the pilot in command, and copilot
  • the load control officer training syllabus has been revised to include aspects of this occurrence, and additional load control checklists have been introduced for use by load controllers
  • the audit process when updating the company’s load control system has been amended to include an independent cross-check of any changes to an aircraft’s basic record, or of any ‘copied’ details
  • a log has been created to record all out of hours changes to the company’s load control system.

Analysis

ANALYSIS

The risk for the operator of employing two weight and balance profiles was that it increased the possibility of errors during operations.

The lack of an audit requirement affecting the newly created weight and balance profile, and the lack of a capability for an on-ground warning to the crew of an incorrectly loaded aircraft, meant that the operator's load control system relied on the recognition by the crew of any error in the aircraft's load profile. The investigation could not quantify the impact on workload caused by the requirement for the crew to calculate the aircraft's take-off performance7, but it may have precluded their critical analysis of the aircraft's weight and balance profile. In any case, in this instance, the company's reliance on crew intervention to prevent the application of the incorrect load profile proved unreliable.

The omission of an independent check of the aircraft's basic weight and index parameters by the company's Singapore load controllers negated another potential defence in the operator's load control system. In addition, the implied discretionary requirement in the Route Manual Supplement for flight crews to check flight critical data could have contributed to the apparent breakdown in the crew's loading preparations for the flight. Had either of the Singapore load controllers, or the flight crew more comprehensively followed company procedures, the error in the aircraft's weight and balance profile may have been detected prior to commencing the take-off.

7. Using the aircraft's Performance Supplement Manual.

Factual Information

FACTUAL INFORMATION1

History of the flight

At 1503 Coordinated Universal Time (UTC) on 9 December 2004, the pilot in command of an Airbus Industrie A330-301 aircraft (A330), registered VH-QPC, commenced the take-off from Singapore on a scheduled regular public transport service to Darwin, NT. The pilot in command reported that the aircraft felt nose heavy during rotation2, but that after the aircraft was trimmed, a more normal feel was restored. Following the flight it was found that the aircraft's take-off centre of gravity3 (CG) was forward of the manufacturer's forward limit.

The decision by the operator to operate the domestically configured aircraft on an international service was not communicated to the company department that had responsibility for updating the aircraft's flight document library. As a result, the take-off performance charts for the departure from Singapore were unavailable for use by the flight crew. The flight crew reverted to calculating the aircraft's take-off performance using the aircraft's Performance Supplement Manual.

The operator maintained two distinct weight and balance profiles for application in its A330 operations. The profiles were:

  • an international profile, employing a basic index4 (BI) of about 292, and used in conjunction with an international weight and balance template
  • a domestic profile, with a BI of about 192, and used in conjunction with a domestic weight and balance template.

The aircraft's international weight and balance profile was created a number of months before the occurrence flight. During that process a corrupted international profile was created. The system and the operator did not recognise that there was an error in the data in the new profile. There was no requirement for the audit of that profile as it was created from existing certified data. Subsequently, the aircraft's corrupted international profile remained undetected during the intervening months of domestic operations leading up to the occurrence flight.

A number of company defences were promulgated to ensure that the operator's aircraft were correctly loaded:

  • the Flight Administration Manual placed responsibility with all flight crew members to ensure that company aircraft were operated within their CG limits
  • the Route Manual Supplement required that, before accepting a provisional load sheet, the crew 'should' confirm their aircraft's critical load data against other aircraft documentation
  • the Flight Crew Operating Manual specified that the pilot in command was responsible for the final check of an aircraft's load sheet data.

The copilot reported extracting the aircraft's basic weight5 (BW) and BI parameters from a fleet weight and balance folder that was located in the operator's Singapore flight dispatch office. The parameters were then provided to the local load control staff in order for them to produce the loadsheet6 for the flight.

The flight crew reported that, in this instance, neither the copilot nor the second officer could recall having checked the aircraft's critical load data, and that the pilot in command did not check the aircraft's load sheet.

There was no evidence that the load control staff completed the required independent check of the BW and BI parameters for the aircraft and, as a result, an international BI was unwittingly applied to what remained, effectively, the aircraft's domestic weight and balance template.

Aircraft information

No evidence was found of a defect in the aircraft or its systems that may have influenced the circumstances of the occurrence.

The load sheet indicated to the flight crew and load control staff that the aircraft had been correctly loaded in order for the aircraft's CG to remain within limits for all phases of the flight. The investigation determined that the aircraft's CG was located forward of the manufacturer's forward limit for the take-off.

The manufacturer stated that the CG for the take-off did not exceed the aircraft's structural and landing gear limitations, and that the aircraft was 'sufficiently manoeuvrable' at all times. However, an out of limits forward CG increases the risk of there being insufficient elevator authority for a pilot to rotate an aircraft during take-off, or to flare an aircraft for landing. The result would be that take-off and landing distances would be greater than planned by the pilot.

There was no capability for the aircraft's systems to warn the flight crew of an out of limits CG while on the ground. Airborne warning of an out of limits aft CG was possible.

  1. Only those investigation areas identified by the headings and subheadings were considered to be relevant to the circumstances of the occurrence.
  2. Positive, nose-up pitch of the aeroplane about the lateral axis immediately prior to becoming airborne.
  3. The point at which an aircraft would balance if suspended. It must be located within specific limits for safe flight.
  4. In simplified terms, the position of the aircraft's centre of gravity before fuel and payload are added.
  5. Mass of the aircraft, including of the aircraft's fixed equipment and residual fluids.
  6. A performance planning document that annotated the aircraft's weight, centre of gravity for take-off and landing, and the loading requirements for the flight.

Summary

At 1503 Coordinated Universal Time (UTC) on 9 December 2004, the pilot in command of an Airbus Industrie A330-301 aircraft, registered VH-QPC, commenced the takeoff from Changi Airport, Singapore on a scheduled regular public transport service to Darwin, NT. The pilot in command reported that the aircraft felt nose heavy during rotation, but that after the aircraft was trimmed, a more normal feel was restored. Following the flight it was found that the aircraft’s take-off centre of gravity (CG) was forward of the manufacturer’s forward limit.

The investigation found that:

  • there had been a corruption of the aircraft’s weight and balance data within the international load control system
  • the error did not manifest itself until the aircraft was used on an international service and the aircraft’s weight and balance was calculated using the corrupted data in the international load control system
  • the Singapore load controllers did not carry out a check of the basic aircraft’s data as they were required to do by the operator
  • the flight crew did not carry out a check of the basic aircraft data as they were required to do by the operator.

The operator made a number of changes to procedures that will enhance the existing organisational and individual risk controls affecting A330 aircraft loading. The operator will also introduce a single load control system from March 2007, which will minimize the likelihood of a recurrence of the data corruption event leading to this incident.

Occurrence summary

Investigation number 200405064
Occurrence date 09/12/2004
Location Singapore, Changi, Aero.
State International
Report release date 30/06/2006
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Airbus
Model A330
Registration VH-QPC
Serial number 564
Sector Jet
Operation type Air Transport High Capacity
Departure point Singapore
Destination Darwin. NT
Damage Nil

Boeing 737-476, VH-TJZ

Summary

After a five-minute delay in securing the aft cargo door, the Boeing 737 was cleared for pushback. The ground engineer then passed a message to the crew to 'call control' but gave no indication of urgency. The crew decided to concentrate on the departure and to call control when airborne.

After take-off, the crew contacted Load Control and were advised that the load controller had been attempting to make contact to inform them that the load sheet may have been inaccurate. The crew were not warned via the ACARS data communication system before take-off. The crew had not been monitoring the Load Control frequency as they had already received the final load sheet. Aircraft performance and handling were not affected.

Investigation revealed that the leading hand of the loading gang had given a 'Ramp Clearance' to the load controller while the loading of the cargo hold was still in progress. The 'Ramp Clearance' indicated to the load controller that either all compartments had been loaded as required, or that the entire load had been accounted for and was either alongside the aircraft or in transit to the aircraft. However, due to unserviceable webbing in the doorway of compartment 4 of the aft cargo hold, the loading gang relocated 10 bags to compartment 3 of the aft hold after the leading hand had given the 'Ramp Clearance' and the load controller had sent the final load sheet to the aircraft.

The leading hand advised the load controller of the change, and the load controller amended the load calculations. The load controller then attempted to contact the crew on the Load Control frequency, without success, as the crew were not monitoring the frequency. The load controller then contacted Movement Control in Cairns to have the ground engineer attending the departure, ask the crew to 'call control'. The engineer passed the message, but the crew did not contact Load Control until after take-off. Thus, the aircraft departed with the load sheet unamended.

Standard Operating Procedures for Load Control specified that ACARS messages should not be sent to the aircraft after the final load sheet was issued. This was based on the need to avoid distracting the crew performing vital actions during departure, plus the likelihood that the crew could miss the message. The load controller was required to inform the crew verbally of any late changes to the load sheet. In addition, when the company implemented its new load control system, management decided that due to cockpit workload, crews would be required to monitor only two frequencies (Air Traffic Control and Movement Control) during the period within 15 minutes of pushback.

Prior to the occurrence, the company had initiated a review of procedures relating to the issue of ramp clearances. Alternative procedures were being trialled. However, the new procedures were not a factor in the occurrence.

At the conclusion of the trials, new procedures were implemented in Melbourne in December 2000, and training was scheduled for February and March 2001 prior to implementation of the new procedures at other ports.

Occurrence summary

Investigation number 200002989
Occurrence date 16/07/2000
Location Cairns, Aero.
State Queensland
Report release date 22/05/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-TJZ
Serial number 28152
Sector Jet
Operation type Air Transport High Capacity
Departure point Cairns, QLD
Destination Brisbane, QLD
Damage Nil

Boeing Co 747-338, VH-EBT

Summary

The Boeing 747 departed Cairns with a load sheet showing its take-off weight as 316,500 kg and its landing weight at Narita as 241,500 kg. During descent, company staff at Narita advised the crew to amend the aircraft's landing weight to 243,200 kg, the difference being due to 1,850 kg of cargo stowed in position 11 that had been recorded incorrectly.

Company staff identified a unit load device (ULD) weighing 950 kg, which had been packed in Sydney and transported to Cairns. At Cairns, the weight of the ULD was wrongly recorded as 1,850 kg. The reason for the error was not established, but it was possible that loading staff at Cairns may have pulled an old weight tag from the ULD tag pouch and noted the weight written on it.

The incorrect weight of 1,850 kg was then transcribed as 185 kg onto a `deadweight statement' (baggage and cargo weight) which was sent to Load Control three hours before scheduled departure. Coincidentally, 185 kg was the weight of an empty ULD. The load controller used 185 kg as the ULD weight in preparing the Load Instruction Report (LIR) for the Cairns loading staff, but they did not detect the discrepancy between the ULD tag weight (1,850 kg) and the LIR weight (185 kg). As the load controller had used 185 kg in the load calculations, both the Provisional Load sheet and the Final Load sheet understated the aircraft gross weight.

While the aircraft was in transit, company staff at Narita queried the ULD weight with the load controller, who then contacted the Cairns freight staff. Three hours before the aircraft was due to land, the freight staff sent a revised deadweight statement to the load controller, showing the ULD weight as 1,850 kg. The load controller then recalculated the load weight and passed this to the company staff at Narita, who in turn advised the crew to increase the aircraft landing weight by 1,700 kg. As the actual weight of the ULD was 950 kg, the revised landing weight overstated the true landing weight by 750 kg.

Since the occurrence, the company Freight Branch has issued a reminder to freight terminal staff to remove old weight tags from ULDs and has asked the Cairns freight staff to take action to prevent incorrect completion of deadweight statement forms. In addition, the Ramp Training and Safety Co-ordinator at Cairns has issued a notice to loading staff to check all weights on ULD tags against the weights stated on the LIR.

Occurrence summary

Investigation number 200002693
Occurrence date 11/06/2000
Location Cairns, Aero.
State Queensland
Report release date 01/08/2000
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration VH-EBT
Serial number 23222
Sector Jet
Operation type Air Transport High Capacity
Departure point Cairns, QLD
Destination Narita, JAPAN
Damage Nil

Airbus A320-211, VH-HYK

Safety Action

The operator is trialling a variation to procedure, requiring loading crews to load priority baggage in the number 5 cargo hold to avoid the problem of the aircraft becoming light on the nose landing gear during unloading.

Summary

During the take-off roll, the Airbus A320 handling pilot needed to apply full nose-down elevator for a longer time than was normal. Despite the elevator position, the nosewheel momentarily lifted off the runway several times before the aircraft became airborne.

The crew did not consider the situation to be a threat to safety and completed the flight as scheduled. However, as the aircraft was being unloaded, the nose of the aircraft rose rapidly until the nose landing gear oleo was fully extended. The crew received the electronic centralised aircraft monitoring system (ECAM) message L/G LGCIU 1 AND 2 FAULT. The ground engineer instructed the catering truck driver to remove the catering truck from door R1 immediately. The cabin crew briefly stopped passenger disembarkation due to concerns that the step from the aircraft to the aerobridge was unsafe.

The aircraft carried 136 passengers out of a maximum of 138. Only two seats in Business Class were empty. The aircraft also carried 700 kg of freight and 1131 kg of baggage in two forward and two aft compartments.

The nose landing gear oleo had been slightly over-inflated, but engineers did not consider that to be a problem requiring rectification. Prior to the latest inflation, the aircraft had operated with the leg slightly under-inflated. Engineers stated that the increase on oleo inflation would not have resulted in the leg fully extending on the ground.

The loading instruction report (LIR) indicated that the computed centre of gravity was well within the permissible range, 34.6% mean aerodynamic chord (MAC) compared to the aft limit of 40% MAC. The operator had a policy of not exceeding 38% MAC.

The loading gang at the destination reported that there was no discrepancy between the LIR and the distribution of the load in the cargo holds. However, loading crews had developed a procedure of loading priority baggage into the number 1 cargo hold to facilitate rapid unloading at the destination. Under some circumstances, that could lead to reduced weight on the nose landing gear until cargo stowed further aft had been unloaded.

Occurrence summary

Investigation number 199902679
Occurrence date 02/06/1999
Location Canberra, Aero.
State Australian Capital Territory
Report release date 07/12/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Airbus
Model A320
Registration VH-HYK
Serial number 157
Sector Jet
Operation type Air Transport High Capacity
Departure point Canberra, ACT
Destination Melbourne, VIC
Damage Nil

Boeing 747-438, VH-OJL

Safety Action

Local safety action

The operator completed a full audit of its load control operations at each port to identify and rectify any deficiencies.

Summary

The crew of the Boeing 747 received a provisional load sheet for the flight while they were carrying out their pre-flight checks. The information on the load sheet was close to the crew's expectations. However, when the final load sheet was subsequently delivered to the crew the computed centre of gravity (CoG) had moved forward significantly, from 25% mean aerodynamic chord (MAC) to 16% MAC.

The captain immediately queried the change. The load controller reported that the load computer program was corrupted, and that he had completed the computations using a manual backup method. He added that he was confident the information was correct.

While the aircraft was taxiing, air traffic control advised the crew to contact their company, who reported that the CoG figure stated on the final load sheet was incorrect, and provided a revised CoG figure that was closer to that shown on the provisional load sheet. However, when the crew entered that figure into the flight management computer (FMC) they received a "> STAB GREENBAND" warning from the engine indicating and crew alerting system (EICAS). The warning indicated that the stabiliser trim setting was incorrect for the CoG position, as sensed by the nose landing gear pressure switch, and that the aircraft was therefore "out of trim". The crew discussed the problem with the load controller, without resolution. The captain decided to return the aircraft to the terminal.

The crew requested company engineers to investigate the problem. In addition, they asked the load controller to investigate the distribution of passengers, baggage and freight. Engineers fitted a new nose landing gear pressure switch, and the load controller assured the crew that the computed figures were correct.

The crew again received a "> STAB GREENBAND" message from the EICAS when the aircraft commenced to taxi. After further discussions with company engineers, the aircraft returned to the terminal. The load controller subsequently informed the crew that further investigation had revealed that 50 passengers in "B Zone" had not been considered in the load calculations. The aircraft had therefore been "out of trim".

The operator reported that no fault was found in the load control computer system, and that the error had resulted from the load controller incorrectly interpreting computer generated information.

Occurrence summary

Investigation number 199902117
Occurrence date 28/04/1999
Location Sydney, Aero.
State New South Wales
Report release date 01/11/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration VH-OJL
Serial number 25151
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney, NSW
Destination Christchurch, NZ
Damage Nil

Boeing 767-338ER, VH-OGC

Safety Action

Safety action by operator

The operator has introduced a new load control management system that is now controlling loading in all ports except one. The last port should be incorporated into the system by April 1999.

The new system is computer-based and eliminates any requirement for load controllers to leave their workstations. Regardless of their location, gang leading hands have immediate radio communication with load controllers to discuss any problems or variations. Freight shed staff, customer service staff and traffic staff have immediate communication with load controllers by telephone.

A manual for operation of the system has been produced and issued to staff.

Safety action by BASI

BASI is monitoring the operation of the new system.

Analysis

The operator's procedures did not ensure that the implications of the aircraft type change were properly communicated to those involved in the preparation and acceptance of the pallet. Consequently, the pallet was accepted for shipment without recognition that it was oversize for the aircraft.

When advised by the leading hand that the pallet could not be loaded, the load controller apparently focussed only on the available area within the cargo compartment. He had not recognised that the overhang prevented the pallet from being manoeuvred through the cargo door. The high level of ambient noise and assumptions made by both the controller and the leading hand may explain why neither understood the point the other was attempting to make.

The processing of the LIR was inadequate in that the defence intended by the leading hand's written confirmation of the aircraft loading was circumvented. The load controller, having assumed that the loading was in accordance with the original documentation, dispatched the aircraft without ensuring confirmation of the final loading status.

Summary

Approximately 20 minutes after departure, the crew was advised that a pallet weighing 3,696 kg, which had been included in the load/trim calculations, was not on the aircraft. This resulted in the aircraft's centre of gravity being slightly rear of the calculated position, but still within required limits.

The airline's normal practice was to operate a Boeing 747 on the Nagoya service. However, on this occasion the service was operated by a Boeing 767. The pallet which had not been loaded was purpose-built by the shipper to optimise the available space on Boeing 747 aircraft. Its design included an extension at each end which precluded loading through the cargo compartment door of Boeing 767 aircraft. Communications within the operator's freight system provided early notification of the aircraft change. However, this information was not provided to the shipper. The operator's freight section at Cairns, when receiving the pallet, did not recognise its unsuitability.

In preparation for loading the aircraft at Cairns, the leading hand loader was provided a Load Instruction Report (LIR). The LIR showed the load distribution of the aircraft on arrival, and the load distribution for departure as required by the load controller. A third section of the LIR was to be completed by the leading hand following loading to confirm the actual load distribution on departure. The LIR would then be passed to the load controller. Aircraft had, on occasions, departed before the load controller received the LIR.

On finding that the pallet could not be loaded, the leading hand advised the load controller who was on the flight deck at the time. The controller checked the pallet and indicated to the leading hand that by rearranging other containers, it could be loaded. However, the high noise environment of the loading area made conversation difficult, and the controller did not remain to ensure that the pallet could be loaded. He left the aircraft satisfied that the problem was resolved without the need to amend the loading documentation. The leading hand assumed that the load controller recognised that the pallet could not be loaded, and directed that it be returned to the freight shed.

The aircraft departed before the controller received the amended LIR which indicated that the pallet had not been loaded.

Occurrence summary

Investigation number 199800262
Occurrence date 24/01/1998
Location Cairns, Aero.
State Queensland
Report release date 01/03/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 767
Registration VH-OGC
Serial number 24317
Sector Jet
Operation type Air Transport High Capacity
Departure point Cairns, QLD
Destination Nagoya, JAPAN
Damage Nil

Loss of control involving Beechcraft Baron 95-B55, VH-JDL, Tarago, New South Wales, on 19 June 1992

Summary

On 19 June 1992, at approximately 1853 hours, a Beechcraft Baron 95-B55, registration VH-JDL, disappeared from Air Traffic Control radar display, without prior indication of difficulty. The aircraft wreckage was located the following morning on a moderately timbered slope, 700 metres above mean sea level and 45 kilometres north-east of Canberra, Australian Capital Territory.

The pilot and all five passengers were killed and the aircraft was destroyed by impact forces. The investigation determined that the aircraft departed Bankstown Airport loaded in excess of the maximum allowable take-off weight, and that the pilot did not comply with either Instrument Flight Rules or Night Visual Flight Rules rating recency standards required for the conduct of the flight.

While cruising at 8,000 feet, the aircraft entered a rapid descent, during which it reversed direction in a left turn. The descent was briefly arrested at a low altitude, however, the aircraft again turned left and descended rapidly. The aircraft exhibited flight characteristics consistent with those of an aircraft loaded to an aft centre of gravity position. There are indications that the centre of gravity moved further aft during the flight, until reaching a point at which the pilot was unable to prevent significant diversions in both climb and descent from the reference altitude, culminating in the rapid descent.

Occurrence summary

Investigation number 199200014
Occurrence date 19/06/1992
Location Tarago
State New South Wales
Report release date 20/10/1993
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Loading related, Loss of control
Occurrence class Accident
Highest injury level Fatal

Aircraft details

Manufacturer Beech Aircraft Corp
Model 95
Registration VH-JDL
Serial number TC-1382
Sector Piston
Operation type Private
Departure point Bankstown, NSW
Destination Cooma, NSW
Damage Destroyed
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