Executive summary
Between 17 October 1997 and 12 January 1998 various Boeing 767 and 747 aircraft were flown with unrestrained unit load devices or pallets. In four cases the cargo was able to move freely along the adjacent empty spaces in the cargo hold of the aircraft.
An investigation of the first incident was initiated in Sydney, at the Commission’s request, by the Australian Bureau of Air Safety Investigation. While that investigation was in progress four further incidents occurred.
As a result the Commission decided to investigate the general area of the company’s aircraft loading process by a detailed investigation of the second incident, and to utilise the findings of the investigations into the other four incidents by other parties, as a guide for the emphasis on the various causal factors involved. Other personnel who were not involved in any of the incidents were interviewed to obtain their understanding of the individual tasks which related to the aircraft loading, and thus give a greater breadth to the appraisal of the company’s procedures.
The safety issues identified related to:
· the consultation associated with the modification of company aircraft,
· the process for amending company manuals,
· the supervision of aircraft pre-departure procedures,
· the aircraft loader’s awareness of loading hazards,
· the co-ordination on the ramp,
· the training and qualification of personnel,
· the pressures on ramp personnel,
· the checking of individual competence,
· the incident notification procedures, and
· unauthorised interference with the aircraft equipment.
These matters have been addressed in the safety recommendations and actions proposed by the operator which are referred to in this report.
This report includes inquiry 97-018.