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, various Boeing 767 and 7/47 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.
An initial investigation into the first occurrence was launched in Sydney by the Australian Bureau of Air Safety Investigation. However, as four additional incidents took place while that inquiry was still active, the Commission expanded 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 across the organization.