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|
Attributes | |
ACN | 295059 |
Time | |
Date | 199501 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dtw |
State Reference | MI |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-C/F |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer |
Experience | flight time total : 3500 |
ASRS Report | 295059 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | pilot : flight engineer |
Events | |
Anomaly | non adherence : published procedure other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | other |
Narrative:
Aircraft was to be moved from yip to dtw for loading and eventually leave on a trip. I was the flight engineer on board along with the company chief engineer who was going to give me a line check on the aircraft (B747-200). He wanted to make sure I knew about the fuel system differences between the 100 and 200 series aircraft. Fueling and preflight of the aircraft was carried out. Part of my preflight was to inspect the load, if any, and locks on the cargo door. When I went down on the cargo deck to start this inspection, there were 2 stacks of pallets in position 3L and 3R. Both were in a normal position. I then walked on back to the cargo door to inspect it. It checked out good. Then I walked back to the front of the aircraft checking the floor, sides, etc, for conditions. I also looked at the left side of the pallets in 3L and 3R and did not notice anything unusual or out of place. I then completed the rest of the preflight. When we arrived at dtw and parked, was the first indication that something had gone wrong. Our maintenance met us at dtw and told us that one set of pallets had broken loose and traveled back to the tail and puncturing 2 holes in the aft pressure bulkhead and damaging a structural member by door L-5. When pallets are carried it is an industry standard that a pallet is put down first, then usually a separator made out of wood is put down on the first pallet. After that other pallets are stacked and they are secured to the first pallet with cargo straps. Then the whole thing is loaded into position and held in place by the floor locks. I believe that pallets loaded like this should also be secured with straps to the floor. The fact that the aircraft arrived from a trip with same pallets on board and experienced no problems and did not move until jan/sat/95 might suggest sabotage or forgetfulness on somebody else to make sure the pallets were positively locked if they had moved them. In other words put them back the way you found them.
Original NASA ASRS Text
Title: CARGO SHIFT. LOADING PROC CARGO.
Narrative: ACFT WAS TO BE MOVED FROM YIP TO DTW FOR LOADING AND EVENTUALLY LEAVE ON A TRIP. I WAS THE FE ON BOARD ALONG WITH THE COMPANY CHIEF ENGINEER WHO WAS GOING TO GIVE ME A LINE CHK ON THE ACFT (B747-200). HE WANTED TO MAKE SURE I KNEW ABOUT THE FUEL SYS DIFFERENCES BTWN THE 100 AND 200 SERIES ACFT. FUELING AND PREFLT OF THE ACFT WAS CARRIED OUT. PART OF MY PREFLT WAS TO INSPECT THE LOAD, IF ANY, AND LOCKS ON THE CARGO DOOR. WHEN I WENT DOWN ON THE CARGO DECK TO START THIS INSPECTION, THERE WERE 2 STACKS OF PALLETS IN POS 3L AND 3R. BOTH WERE IN A NORMAL POS. I THEN WALKED ON BACK TO THE CARGO DOOR TO INSPECT IT. IT CHKED OUT GOOD. THEN I WALKED BACK TO THE FRONT OF THE ACFT CHKING THE FLOOR, SIDES, ETC, FOR CONDITIONS. I ALSO LOOKED AT THE L SIDE OF THE PALLETS IN 3L AND 3R AND DID NOT NOTICE ANYTHING UNUSUAL OR OUT OF PLACE. I THEN COMPLETED THE REST OF THE PREFLT. WHEN WE ARRIVED AT DTW AND PARKED, WAS THE FIRST INDICATION THAT SOMETHING HAD GONE WRONG. OUR MAINT MET US AT DTW AND TOLD US THAT ONE SET OF PALLETS HAD BROKEN LOOSE AND TRAVELED BACK TO THE TAIL AND PUNCTURING 2 HOLES IN THE AFT PRESSURE BULKHEAD AND DAMAGING A STRUCTURAL MEMBER BY DOOR L-5. WHEN PALLETS ARE CARRIED IT IS AN INDUSTRY STANDARD THAT A PALLET IS PUT DOWN FIRST, THEN USUALLY A SEPARATOR MADE OUT OF WOOD IS PUT DOWN ON THE FIRST PALLET. AFTER THAT OTHER PALLETS ARE STACKED AND THEY ARE SECURED TO THE FIRST PALLET WITH CARGO STRAPS. THEN THE WHOLE THING IS LOADED INTO POS AND HELD IN PLACE BY THE FLOOR LOCKS. I BELIEVE THAT PALLETS LOADED LIKE THIS SHOULD ALSO BE SECURED WITH STRAPS TO THE FLOOR. THE FACT THAT THE ACFT ARRIVED FROM A TRIP WITH SAME PALLETS ON BOARD AND EXPERIENCED NO PROBS AND DID NOT MOVE UNTIL JAN/SAT/95 MIGHT SUGGEST SABOTAGE OR FORGETFULNESS ON SOMEBODY ELSE TO MAKE SURE THE PALLETS WERE POSITIVELY LOCKED IF THEY HAD MOVED THEM. IN OTHER WORDS PUT THEM BACK THE WAY YOU FOUND THEM.
Data retrieved from NASA's ASRS site as of July 2007 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.