What happened
During a flight operated by VGI to the Sunshine Coast, a significant discrepancy was identified between the recorded weight on the load sheet and the actual weight of the cargo. A Unit Load Device (ULD) weighing 245 kg was loaded onto the aircraft, despite the official load sheet documenting the weight of that specific ULD as only 93 kg.
This error was traced back to a documentation swap during the cargo processing stage. A clerk inadvertently attached the freight card intended for the Sunshine Coast flight to an Adelaide-bound ULD, and conversely, attached the Adelaide flight's card to the Sunshine Coast ULD. Because both containers shared the same ULD number, the incorrect container was dispatched to the Sunshine Coast.
The investigation
Investigators examined the cargo processing workflow and identified that the error was facilitated by the limitations of the legacy data entry system. Under the old processing system, it was possible to enter the same ULD number into the database twice without triggering an error message. Because the system lacked an automated error feedback mechanism, the clerk was unaware that a duplicate entry had been made.
Furthermore, the investigation found that the person responsible for entering the data was also tasked with performing the final data cross-check. This lack of independent verification made errors harder to detect, especially during periods of increased operational pressure.
Findings
- The primary cause of the weight discrepancy was the misplacement of freight cards on the incorrect ULDs.
- The legacy system allowed for duplicate ULD numbers to be entered without providing any warning or error feedback to the operator.
- The clerk was managing a high workload due to the absence of another staff member and seasonal demand, as they were responsible for all narrow-body flight freight organization alone.
- The lack of a secondary person to perform the data cross-check increased the risk of undetected manual entry errors.