Boeing Co 767-338ER, VH-OGC

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.

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.

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.