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|
Attributes | |
ACN | 1587150 |
Time | |
Date | 201810 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Aircraft 1 | |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | Taxi |
Flight Plan | IFR |
Person 1 | |
Function | Dispatcher |
Qualification | Dispatch Dispatcher |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy Deviation - Procedural Hazardous Material Violation |
Narrative:
As the flight was about half-way to its destination; a load agent called to advise that he got a phone call from the crew chief who suspected that the captain did not receive a hard-copy of the notification to captain (notoc) before departure. I sent an ACARS message to the crew asking to confirm it. After it was confirmed I called the load supervisor; requesting he ask [cargo operations control] (coc) to send the captain a notoc via ACARS. He responded that he was not sure we could do that. I explained that the coc manual states that a notoc may be sent via ACARS if the flight is already airborne. In the end; I called coc myself and explained the situation and requested that they sent an ACARS notoc. Instead [ops agent] sent me some information that I relayed to the crew. This was her message; which was obviously not in compliance with established procedures: 'cargo ops control report cc failed to provide. Captain with dg notification for aircraft X. We have 1 [piece] 20KG. Overpack lithium ion batteries contained in equipment loaded in dp(fwd). Please notify captain. Thank you.' to make matters worse; the captain informed me that his ACARS printer was inoperative and on placard. I instructed him to write the information down on paper. After landing; the captain called me to explain that the dg were on his close-out; but that he completely missed it and would file a [report] as well. For some reason; the captain was not given a notoc prior to departure. Not sure who was in charge of providing the crew with a notoc; maybe the crew chief? But somehow; it is the crew chief who suspected that the captain left without his notoc. By that time though the flight was already in cruise. I do not know why it went undetected for that long...fatigue? Distraction? SOP's not followed? Complacency? Inexperience? Lack of training? Regardless of the reason the ground crew missed it; the flight left with 20 kilos of dangerous goods (lithium batteries). If the captain had not missed the dg on his closeout; the flight could have ground interrupted to get a hard copy. The load supervisor I talked to was unaware of any procedure to send a notoc via ACARS. Coc agent did not seem to know about the proper mask to be used to send a notoc via ACARS. At the same time; another dispatcher approached me with another flight that apparently had left the gate without a notoc and he was wondering about the proper course of action. As he was not airborne yet; I told him the flight had to return to the gate for a hard-copy or have someone go the airplane to hand him a hard-copy. A notoc can only be sent via ACARS if the flight has already departed per the coc. That's two flights in a row departing ZZZ without a notoc within a couple of hours or less. [Suggest] better training for crew chiefs; coc agents; load supervisors as it relates to the dissemination of notocs. Maybe send a directive system-wide to remind all parties involved that dangerous goods are just what they are: potentially dangerous; and therefore should be paid careful attention to.
Original NASA ASRS Text
Title: Dispatcher reported aircraft departed without required HAZMAT form Notification to Captain.
Narrative: As the flight was about half-way to its destination; a Load Agent called to advise that he got a phone call from the crew chief who suspected that the Captain did not receive a hard-copy of the Notification to Captain (NOTOC) before departure. I sent an ACARS message to the crew asking to confirm it. After it was confirmed I called the Load Supervisor; requesting he ask [Cargo Operations Control] (COC) to send the Captain a NOTOC via ACARS. He responded that he was not sure we could do that. I explained that the COC Manual states that a NOTOC may be sent via ACARS if the flight is already airborne. In the end; I called COC myself and explained the situation and requested that they sent an ACARS NOTOC. Instead [Ops Agent] sent me some information that I relayed to the crew. This was her message; which was obviously not in compliance with established procedures: 'Cargo ops control report cc failed to provide. Captain with DG notification for Aircraft X. We have 1 [piece] 20KG. Overpack lithium ion batteries contained in equipment loaded in DP(FWD). Please notify Captain. Thank you.' To make matters worse; the Captain informed me that his ACARS printer was inoperative and on placard. I instructed him to write the information down on paper. After landing; the Captain called me to explain that the DG were on his close-out; but that he completely missed it and would file a [report] as well. For some reason; the Captain was not given a NOTOC prior to departure. Not sure who was in charge of providing the crew with a NOTOC; maybe the Crew Chief? But somehow; it is the Crew Chief who suspected that the Captain left without his NOTOC. By that time though the flight was already in cruise. I do not know why it went undetected for that long...fatigue? Distraction? SOP's not followed? Complacency? Inexperience? Lack of training? Regardless of the reason the ground crew missed it; the flight left with 20 kilos of dangerous goods (Lithium batteries). If the Captain had not missed the DG on his closeout; the flight could have ground interrupted to get a hard copy. The Load Supervisor I talked to was unaware of any procedure to send a NOTOC via ACARS. COC agent did not seem to know about the proper mask to be used to send a NOTOC via ACARS. At the same time; another dispatcher approached me with another flight that apparently had left the gate without a NOTOC and he was wondering about the proper course of action. As he was not airborne yet; I told him the flight had to return to the gate for a hard-copy or have someone go the airplane to hand him a hard-copy. A NOTOC can only be sent via ACARS if the flight has already departed per the COC. That's two flights in a row departing ZZZ without a NOTOC within a couple of hours or less. [Suggest] better training for crew chiefs; COC agents; Load Supervisors as it relates to the dissemination of NOTOCs. Maybe send a directive system-wide to remind all parties involved that dangerous goods are just what they are: potentially dangerous; and therefore should be paid careful attention to.
Data retrieved from NASA's ASRS site and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.