What happened
On the day of the incident, several modifications were made to the planned loading procedures for two aircraft. During the process, an aircraft swap was scheduled to take as part of operations in Sydney. While the loading supervisor updated their ramp report to reflect changes to lower compartment freight, they failed to manually update the new parking bay assignments in their documentation.
As the supervisor managed loading activities under the pressure of an approaching airport curfew, they directed the lower compartment freight intended for TLK to be loaded onto JTQ, and vice versa. Because the staff loading the upper compartments were following different instruction reports that contained the correct bay numbers, the lower and upper compartments were loaded inconsistently.
During the subsequent flight, the pilot of TLK noted that the flight management computer was calculating approach speeds based on a zero-fuel weight that was lower than the actual weight of the aircraft. To compensate for the insufficient airspeed, the aircraft's nose attitude increased to maintain the required flight path.
The investigation
The investigation focused on the communication of loading changes and the accuracy of the ramp reports. It was determined that the loading supervisor's attention was divided between managing freight and meeting the airport curfew. While the supervisor had updated the freight details, the omission of the updated parking bay numbers in the manual update led to the misdirection of cargo.
Findings
- The loading supervisor failed to include updated parking bay numbers in a manual update to the ramp report.
- The supervisor directed the lower compartment freight for TLK to JTQ, and the lower compartment freight for JTQ to TLK.
- JTQ was operated with a centre of gravity marginally forward of the limit.
- The pilot of TLK entered a zero-fuel weight into the flight management computer that was less than the actual weight, leading to an incorrect target airspeed calculation on final approach.