What happened
Between October 1997 and January 1998, a series of five separate incidents occurred involving the movement of cargo during flight. In these instances, Boeing 767 and 747 aircraft were operated with unit load devices or pallets that were not properly restrained. In four of these five cases, the cargo was able to shift freely within the empty spaces of the aircraft cargo holds.
The first incident was initially investigated by the Australian Bureau of Air Safety Investigation in Sydney. While that investigation was still active, four additional similar occurrences took and were identified, prompting the Commission to expand its scope to examine the broader loading processes used by the operator.
The investigation
To understand the systemic risks, the Commission conducted a detailed investigation into the second incident of the series. To ensure a comprehensive view, investigators also incorporated findings from the other four incidents being handled by different investigative bodies.
Beyond analyzing the specific flight data, the investigation included interviews with personnel who were not directly involved in the accidents. This allowed investigators to evaluate the company's standard operating procedures and assess how individual tasks related to the aircraft loading process were understood and executed across the organization.