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 97-015.
Related Recommendations
Consider introducing more frequent inspections of the lateral load guides on the B767 in-hold loading equipment, or other appropriate measures, to ensure that any damage caused to these devices in the course of loading operations is detected and rectified promptly.
Ensure that load controllers check that the loading foreman's load sheet is completed correctly and signed.
Conduct a practical pre-contract audit of each international cargo handling contractor's ability to meet the requirements of the contract prior to entering into any future contract.
Review and improve the process which is intended to correlate amendments to the associated manuals when the Company makes a decision to modify equipment, to ensure any consequential amendments in the standard operating procedures are detailed in writing as soon as the modifications are embodied.
Amend all Company Manuals which refer to the operation of the actuators in the lateral load guides on the B767 in-hold loading equipment to ensure they describe the correct method of operation of the guides i.e. that they are operated manually instead of the automatic operation detailed at present.
Review the capabilities of each of the personnel involved in the loading process to ensure they meet the required standards, are cognisant of their duties, and have sufficient resources and training to distribute and secure the load correctly.
Consider re-commissioning the actuators in the lateral load guides on the B767 in-hold loading equipment.
Emphasise the need for loading foremen to be particularly vigilant while loading is taking place in an environment of disruptions or other factors which minimise the time available for loading or require the supervision of the loading of more than one aircraft at a time.