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|
Attributes | |
ACN | 418416 |
Time | |
Date | 199810 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : ltn airport : ltn |
State Reference | FO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : hkg |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | other other : other pilot : flight engineer pilot : atp pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 300 flight time total : 5200 flight time type : 2600 |
ASRS Report | 418416 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : cfi pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 193 flight time total : 193 flight time type : 193 |
ASRS Report | 418420 |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Air Traffic Incident | other |
Narrative:
While bringing the aircraft to a stop during our taxi for takeoff, we noticed the sound of a container moving in the upper cargo deck. We immediately returned to the cargo apron and investigated. We determined that the butt locks in position #1, #3, #4, #5 and #10, #11, #12 were verified up. A hidden and unknown empty position was present in position #7. There was 1 container in front of and 2 behind position #7. The load sheet and weight and balance indicated otherwise. The aircraft was not loaded according to the computer generated air carrier load sheet issued to us (see attached load sheet and weight and balance). Additionally, position #7 did not have its locks up allowing position #6 to move back and forth between position #6 and #7. We have concluded that a combination of failures caused this incident. Our prearranged transportation from the hotel to the airport (FBO) was late. After repositioning the aircraft for loading, everyone involved in the loading process was operating quickly to avoid further delays. The flight engineer (as designated by me) was proactive in monitoring the loading process. At one point he climbed the k-loader and entered the main cargo area during loading. However, as stated in aom bulletin, his other required pilot duties kept him from this for only a short time. A FBO manager (ground handler mzmz) and air carrier manager (kyzk) were both present and actively monitored the entire loading process. They even indicated to us that the 'hands on' loaders are required airport authority/authorized temporary employees and are not of the highest quality. All of this, coupled with the fact that the aircraft was not loaded according to the air carrier load plan and that the load plan was (and typically is) given to the remaining 2 crew members in the cockpit after the loading process was/is nearly complete, did contribute greatly to this incident. Brussels dispatch was notified immediately and the aircraft was completely reloaded before departing again for brussels.
Original NASA ASRS Text
Title: A B727-200 FREIGHTER WAS ON TAXI OUT FOR TKOF WHEN BRAKING HARD HEARD THE CARGO CONTAINERS MOVING DUE TO CARGO LOADED IMPROPERLY.
Narrative: WHILE BRINGING THE ACFT TO A STOP DURING OUR TAXI FOR TKOF, WE NOTICED THE SOUND OF A CONTAINER MOVING IN THE UPPER CARGO DECK. WE IMMEDIATELY RETURNED TO THE CARGO APRON AND INVESTIGATED. WE DETERMINED THAT THE BUTT LOCKS IN POS #1, #3, #4, #5 AND #10, #11, #12 WERE VERIFIED UP. A HIDDEN AND UNKNOWN EMPTY POS WAS PRESENT IN POS #7. THERE WAS 1 CONTAINER IN FRONT OF AND 2 BEHIND POS #7. THE LOAD SHEET AND WT AND BAL INDICATED OTHERWISE. THE ACFT WAS NOT LOADED ACCORDING TO THE COMPUTER GENERATED ACR LOAD SHEET ISSUED TO US (SEE ATTACHED LOAD SHEET AND WT AND BAL). ADDITIONALLY, POS #7 DID NOT HAVE ITS LOCKS UP ALLOWING POS #6 TO MOVE BACK AND FORTH BTWN POS #6 AND #7. WE HAVE CONCLUDED THAT A COMBINATION OF FAILURES CAUSED THIS INCIDENT. OUR PREARRANGED TRANSPORTATION FROM THE HOTEL TO THE ARPT (FBO) WAS LATE. AFTER REPOSITIONING THE ACFT FOR LOADING, EVERYONE INVOLVED IN THE LOADING PROCESS WAS OPERATING QUICKLY TO AVOID FURTHER DELAYS. THE FE (AS DESIGNATED BY ME) WAS PROACTIVE IN MONITORING THE LOADING PROCESS. AT ONE POINT HE CLBED THE K-LOADER AND ENTERED THE MAIN CARGO AREA DURING LOADING. HOWEVER, AS STATED IN AOM BULLETIN, HIS OTHER REQUIRED PLT DUTIES KEPT HIM FROM THIS FOR ONLY A SHORT TIME. A FBO MGR (GND HANDLER MZMZ) AND ACR MGR (KYZK) WERE BOTH PRESENT AND ACTIVELY MONITORED THE ENTIRE LOADING PROCESS. THEY EVEN INDICATED TO US THAT THE 'HANDS ON' LOADERS ARE REQUIRED ARPT AUTH TEMPORARY EMPLOYEES AND ARE NOT OF THE HIGHEST QUALITY. ALL OF THIS, COUPLED WITH THE FACT THAT THE ACFT WAS NOT LOADED ACCORDING TO THE ACR LOAD PLAN AND THAT THE LOAD PLAN WAS (AND TYPICALLY IS) GIVEN TO THE REMAINING 2 CREW MEMBERS IN THE COCKPIT AFTER THE LOADING PROCESS WAS/IS NEARLY COMPLETE, DID CONTRIBUTE GREATLY TO THIS INCIDENT. BRUSSELS DISPATCH WAS NOTIFIED IMMEDIATELY AND THE ACFT WAS COMPLETELY RELOADED BEFORE DEPARTING AGAIN FOR BRUSSELS.
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.