What happened
During a cargo loading operation, a freight company employee misidentified a container by misreading its digits, confusing number 1483 with 4183. This error led to the delivery of the wrong container to the correct loading bay. The leading hand on site assumed that the numbers on the container card and the Deadload Weight Statement (DWS) were the result of a transcription error. To avoid delays during a tight turnaround for the final flight to Brisbane that night, the leading hand used a pen to manually change the numbers on the documentation to match the physical container.
Upon inspection, the captain noticed the discrepancy between the original and the hand-written figures. However, after receiving assurances from the leading hand that the correct container had been loaded, the captain accepted the amended DWS. This resulted in the loading of an incorrect container, which caused the actual take-off weight to be approximately 660 kg higher than the calculated weight.
The investigation
The investigation focused on the sequence of events leading to the weight discrepancy and the decision-making process regarding the documentation. Investigators examined the cargo terminal operator's handling of the container and the subsequent verification process by the flight crew. The inquiry looked into why the discrepancy was not flagged for formal correction through the issuance of a new DWS and container card.
Findings
- A cargo terminal operator crew member misread similar container numbers, leading to the delivery of the wrong unit to the ramp.
- The leading hand failed to request a new DWS and container card, opting instead to manually alter the existing documents to match the container number.
- Pressure from a limited turnaround time and the importance of meeting the night's final flight schedule contributed to the decision to bypass standard procedures.
- The captain accepted the hand-written amendments based on the leading hand's verbal assurance.
- Although the aircraft was heavier than planned, the error did not impact performance or handling because the container was positioned near the aircraft's centre of gravity.