Description

On 4 July 2009, an Airbus A332 being operated by Jetstar Airways on a scheduled passenger flight from Sydney to Melbourne carried a 750 kg ULD which had been expressly rejected by the aircraft commander during the loading operation without flight crew awareness. There was no reported effect on aircraft handling during the flight.

Investigation

An Investigation was carried out by the ATSB to establish the circumstances of the misloading since it was recognised that a similar chain of events was capable of having far more serious consequences.

The investigation established that the aircraft commander had decided to reject the subject ULD prior to it being loaded in the forward hold noting that it was not on the LIR (load instruction report) and had no associated paperwork or information about its contents. The decision was not made because of any likely conflict with the aircraft MTOM or loaded C of G. The decision of the aircraft commander was advised directly to the ramp supervisor who reported communicating it to the loading team. However, the instruction was not understood by all the personnel involved with the result that it was returned to the outgoing freight holding area of the departure gate and subsequently loaded into the aft hold of the aircraft. This action was found to have occurred without reference by the loading team to the LIR for the flight or on the basis of subsequent authority from the aircraft commander.

The error was only appreciated when the assigned aircraft operator representative asked the assigned ramp supervisor for sight of the ‘final’ version of the LIR after the aircraft had pushed back. At that juncture, a series of actions aimed at communicating the finding to the flight crew failed due to serial misunderstanding and confusion amongst ground staff in various locations on the airport. ATC were not involved and the aircraft subsequently took off.

The investigation found that there had been an absence of any procedure or guidance covering the segregation of freight rejected during loading. A detailed examination of the applicable hold loading process identified a number of other factors which, although they had not directly contributed to the incident being investigated, had created an inappropriate level of operational risk in respect of all hold loading. These factors included communications with flight crew after pushback.

It was noted that the ground handling contractor had only recently been appointed and was new to ground handling of the A330. It was also noted that prior to the commencement of the new contract, Jetstar had conducted a risk assessment of the new contractor’s “ability to develop, train and / or acquire the necessary systems, people and equipment in readiness for the contract”. That risk assessment had identified a number of risks including seven that related to lack of experience with containerised aircraft.

As a result of the Investigation, Jetstar Airways implemented a comprehensive review of all the procedures involved and as a result introduced a series of both reactive and more widely proactive changes. No mention was made of any action to address the failure of the original risk assessment process in the wider context of ensuring the effectiveness of future risk assessments.

The Final Report of the Investigation was released on 19 May 2011. No Safety Recommendations were made.

Further Reading

• Ground Operations
• Aircraft Load and Trim
• Unit Load Devices (ULD)
• Ground Accident Prevention Program