No fatalities

2016-12-13: The Boeing Company 737-8FE (VH-VUF) — Virgin Australia Airlines — Adelaide Airport, South Australia

Adelaide Airport, South Australia

On December 13, 2016, a The Boeing Company 737-8FE (registration VH-VUF) operated by Virgin Australia Airlines was involved in an aviation accident near Adelaide Airport, South Australia. No fatalities were reported. Investigators recorded the probable cause as: These findings should not be read as apportioning blame or liability to any particular organisation or individual. This summary draws on records from the Australian Transport Safety Bureau (ATSB); 5 related events involving the same aircraft type or operator are linked below.

Sourcesthe Australian Transport Safety Bureau (ATSB)Primary reportUpdated 1779789542Data APIEditorial standards
Aircraft registered VH-VUF
Aircraft registered VH-VUF. Photo: Aeroprints.com / CC BY-SA 3.0, via Wikimedia Commons

A leading hand's failure to subscribe to the Load Control System resulted in undelivered messages about an out-of-trim aircraft after baggage was moved, and the error was not detected until after departure.

Incident Details

During a loading operation, the leading hand did not subscribe to the Load Control System (LCS), a step that is not compulsory but allows users to receive messages from load controllers, AMCOs, and other personnel. As a result, the leading hand did not receive messages from the load controller regarding the aircraft being out of trim after baggage was moved from section 21 to section 31.

System Operation

When the leading hand moved the baggage in the LCS, the system locked. This was indicated by greyed-out buttons and a change in the load control status to 'LL' at the top of the screen. These indications did not clearly signal that the load distribution change required acceptance by the load controller before proceeding. The leading hand was uncertain about the meaning of the load control status. After resetting the system, it returned to an open state, and the leading hand did not realize that changes had been made in the LCS.

Communication Issues

The load controller received an error message because the number of bags moved caused the aircraft to be out of balance. The load controller attempted to contact the leading hand via the LCS messaging system but was unaware that the leading hand was not subscribed, so the messages were not received.

Procedures

The operator had two procedures for load control to notify the leading hand of changes in the LCS. The first, 'deadload change ramp tolerance' in the standard operating procedures for the flight management mobile application, required load control to phone the leading hand or the AMCO if they denied a change request. The second, in the controlling document for 'out of balance operations,' required load control to communicate requirements to the leading hand, normally done via the LCS messaging system. In this incident, the load controller used the messaging system, which was ineffective because the leading hand was not subscribed.

Outcome

Once loading was completed, it was the leading hand's responsibility to confirm that the Load Distribution Report (LDR) reflected the actual aircraft loading. Although the leading hand did check, the error was not detected until after the aircraft had departed.