What happened
On 3 February 2017, a Network Aviation Fokker F28 Mk 0100, registered VH-NHV (NHV), conducted a scheduled passenger flight from Perth to Kalgoorlie, Western Australia (WA). On board the aircraft were two flight crew, three cabin crew and 17 passengers.
The service to Kalgoorlie was originally scheduled in another company F28, registered VH-NHQ (NHQ). However, a fault occurred in NHQ after the aircraft was pushed back from the terminal for departure. The fault resulted in the aircraft returning to the terminal and the operator replacing NHQ with NHV for the service to Kalgoorlie.
The flight crew moved to NHV to start their pre-flight duties and took the certified load instruction sheet (LIS) for NHQ with them. After the flight crew boarded NHV, they received the customer management summary and passenger manifest with the registration NHQ. The crew identified the incorrect registration and rejected the paperwork. Subsequently a person, whom the captain believed was the loading supervisor for the ramp team loading the aircraft, entered the flight deck and inspected what the captain believed was the new LIS, again with the registration NHQ.[1] The captain asked this person if NHV was to be loaded as per NHQ and the response they[2] received satisfied them that that was the case. The captain then pen amended their LIS from NHQ to NHV.
The F28 has two cargo compartments forward of the wing, compartments A and B, and two compartments aft of the wing, compartments E and F. The flight to Kalgoorlie was planned to be loaded with 197 kg of freight and 272 kg of baggage (469 kg in total), distributed between compartments A and B.
The aircraft departed from Perth and landed at Kalgoorlie without incident. However, when the cargo compartments were opened after arrival at Kalgoorlie, there was no load on board the aircraft and the cargo nets were undone. The load was subsequently found to be on board NHQ in Perth, which had been towed into the operator’s hangar for maintenance.
Load instruction sheet
Both of the aircraft involved in this incident, NHQ and NHV, were classified as Group-A F28 aircraft, therefore the same LIS instructions applied to both aircraft for weight and balance purposes. When NHQ developed a fault, the maintenance watch staff in the operations control centre[3] identified NHV as the alternative aircraft for the Kalgoorlie service. The operator’s terminal staff produced an amended LIS for NHV and sent a copy of the LIS to their contracted ground handling service provider. The LIS was marked as edition 1, but should have been marked as edition 2. However, post-incident, the ground handling service provider reported to the operator that they did not receive a copy of the LIS for registration NHV.
The normal process for the LIS is, once it is certified by the loading supervisor that the aircraft is loaded in accordance with the LIS and all cargo compartments inspected, it is passed from the loading supervisor to the flight crew. The incident LIS was certified for NHQ, which the captain amended to NHV after consultation with a person whom they believed was from the loading team. Pen amendments were a permitted practice at the time of the incident. The captain believed it was the correct LIS, but with the incorrect registration.
The LIS was also used by the operator themselves to prepare the offload instruction report for the destination airport. To prepare the offload report, the operator’s ramp personnel would normally contact the contracted ground handling staff to retrieve the details from the final LIS.[4] However, in the absence of a loading team, they could also check the LIS that was on the flight deck.
Management of changes within ground services
The conduit for information within the ground handling service provider is their movement control (MOCO). For ramp loading activities, MOCO contacts the ground resource allocator/coordinator who allocates the ramp loading tasks. Tasks are related to flight numbers and the task for loading flight number 1608 (NHQ) was completed prior to the aircraft change to NHV. Any further loading tasks related to this flight number, were required to be manually generated.
The LIS amended to NHV, sent (faxed) from the operator to their ground handling service provider had edition 1 for flight number 1608, as did the previous LIS for NHQ. The ground handling service provider reported to the operator, after the incident, that they did not receive an LIS for the registration NHV and therefore no team was allocated the task to transfer the freight and baggage from NHQ to NHV.
Weight and balance
The operator reported that the F28 has a ‘very aft’ empty weight centre-of-gravity due to the location of the engines near the tail of the aircraft. However, the majority of the passengers (16 from 17) were seated in the forward rows and therefore the aircraft did not exceed weight and balance limits on the incident flight.
Previous incidents
On the 26 January 2017, the operator experienced an incident in which paperwork with errors were delivered to the flight crew (AO-2017-018). Incorrect cargo weight data was entered by the flight crew, but there was no reported effect on the handling of the aircraft.
Safety analysis
Following the unserviceability of NHQ, the operator re-allocated the Perth to Kalgoorlie service to NHV. The operator’s contracted ground handling service provider was responsible for loading the aircraft in accordance with the operator’s LIS.
The operator verbally notified their ground handling services provider of the unserviceability, but not of the replacement registration. The ground handling service provider allocated tasks with reference to the flight number and the task for flight number 1608 had been completed in their system. The replacement registration was identified on the amended LIS, but the LIS inadvertently indicated that it was edition 1.
It is probable that a team was not allocated to the task of transferring baggage and freight from NHQ to NHV because the LIS sent to the ground handling service provider, marked as edition 1, was for a task recorded as already completed.
The operator was responsible for producing the offload instruction for the destination. It is therefore possible that the person who entered the flight deck of NHV, while the flight crew were preparing for flight, was there only for the purpose of confirming the offload figures from the LIS because they could not make contact with the loading supervisor. The captain was a relatively new employee and had no prior experience of this practice. Consequently, they misunderstood the role of this person and the reason for their inspection of the LIS. The captain then pen amended the aircraft registration on the LIS from NHQ to NHV under the assumption that the LIS was actually for NHV. This was a permitted practice at the time, which resulted in the flight crew believing they had a certified LIS for the loading of NHV.
Findings
These findings should not be read as apportioning blame or liability to any particular organisation or individual.
- After NHQ became unserviceable, the operator sent the ground handling service provider a new load instruction sheet for NHV with the same flight number and edition as NHQ.
- NHV was not loaded because no team was allocated to the task of transferring the freight and baggage from NHQ to NHV.
- The policy of permitting flight crew to pen amend the load instruction sheet resulted in the aircraft departing with the flight crew believing they had a load instruction sheet certified for the loading of NHQ.
Safety action
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.
Operator
As a result of this occurrence, the aircraft operator has advised the ATSB that they are taking the following safety action:
Advisory bulletin
The operator issued an advisory bulletin to their staff, to communicate the aircraft loading system requirements, including the interface requirements between departments for aircraft dispatch. Note 3 of the bulletin states that ‘after a significant change, such as an aircraft change, a new LIS will be issued with an updated edition number, previous editions should be placed so as not to be referenced in error.’
Part of Aviation Short Investigations Bulletin - Issue 60
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- The captain reported that they were a relatively new employee to the company and had not observed this prior to this incident.
- Gender-free plural pronouns: may be used throughout the report to refer to an individual (i.e. they, them and their).
- The operations control centre includes staff from the operations and maintenance departments. Staff from the maintenance department are referred to as maintenance watch.
- This process ensures last minute changes to the aircraft loading are captured for the offload report.