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Attributes | |
ACN | 666159 |
Time | |
Date | 200507 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon |
Operator | common carrier : air carrier |
Make Model Name | BAe 146 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude climbout : initial climbout : takeoff ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel |
Qualification | other |
ASRS Report | 666159 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other personnel other |
Events | |
Anomaly | non adherence : company policies non adherence : far non adherence : published procedure non adherence other |
Independent Detector | other other : 1 |
Resolutory Action | other |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Aircraft Chart Or Publication |
Primary Problem | Company |
Narrative:
This problem occurred because there continues to be a lack of coordination among flight crews; baggage handlers; and operations control. At approximately xa:45 -- about three hours into my shift -- I received an ACARS message from air carrier XXXX; ZZZ1-ZZZ2. It was a one word message that read: 'done.' because I had no idea what it was that the crew had accomplished; I started to send a message back to get some clarification. At about that moment; one of the assistant dispatchers who man our load control unit came to my position and wanted to know where YYYY was -- he was trying to contact the crew to resolve a load manifest issue. I quickly found the flight in the software application we use to fuel plan and route our trips. Using another function; I 'instructed' the computer to locate the flight on my display. To the assistant dispatcher's shock and dismay; YYYY was already off ZZZ1. A quick check of the load control program indicated that while the passenger weights had been finalized; the cargo numbers still weren't. As it so happened; the chief dispatcher was in operations control observing operations. When he became aware that aircraft YYYY had left the gate without any final numbers; he rushed to my position; challenging the assistant dispatcher. He alternately demanded to know how it was even possible that an aircraft could get out of the gate without an accurate load manifest and then asserting that it wasn't possible; that our procedures don't permit an aircraft to push back without final numbers. I showed the chief dispatcher my display and he pointed to the load control screen. I stated quite simply that whatever was supposed to happen; the aircraft clearly was aloft without numbers. The assistant dispatcher and one or two of his colleagues in load control quickly reviewed the aircraft's loading; apparently with updated data from the ramp -- in short order they determined that the aircraft was tail-heavy; and that by moving passenger from coach to 1ST class; the aircraft's cg would be brought into the envelope. I asked the assistant dispatcher whether he had calculated which zone in coach would be affected (there are two) -- since the aircraft was tail-heavy; it only made sense to take passenger from the rearmost part of the cabin and move them forward. He didn't seem to think it made much difference; and; in the interest of time; I did not debate the issue with him. I ACARS'ed his instructions to YYYY; and within three mins or so received a message back that passenger had been moved. The flight continued on to its destination without further incident. Clearly; no one intended for this aircraft to get off the ground without correct data on loads. However; it happened. I believe the factors that contribute to this type of event include: time pressures that often lead baggage handlers and gate agents to continue loading aircraft up to the very last minute. Technology that often enables updates on loads between pushback and takeoff. Complacency due to the type's demonstrated ability to fly under a very wide range of 'as loaded' conditions. Unaddressed or only partially addressed training issues for the assistant dispatchers who work in load control (the unit is comprised of individuals whose aviation backgrounds range from zero up to pilot or dispatch licenses). Unaddressed or only partially-addressed training for baggage handlers. Unaddressed or only partially-addressed training issues for gate agents. Moreover; there just hasn't been enough time to 'shake out' the load control unit -- many flight crews and ramp people are not aware that dispatchers no longer manage load data and that the loading function is 'managed' by a separate; dedicated group within operations control. I suspect the load control unit's performance will improve over time; however; without better coordination between operations control and the ramp; the possibility of a critically misloaded aircraft attempting a takeoff remains.
Original NASA ASRS Text
Title: A DISPATCHER RPTS THAT AN ACFT BECAME AIRBORNE WITHOUT A FINAL WT AND BALANCE. THE ACFT WAS OUT OF LIMITS. PAX WERE MOVED INFLT TO CORRECT THE IMBALANCE.
Narrative: THIS PROB OCCURRED BECAUSE THERE CONTINUES TO BE A LACK OF COORDINATION AMONG FLT CREWS; BAGGAGE HANDLERS; AND OPS CTL. AT APPROX XA:45 -- ABOUT THREE HRS INTO MY SHIFT -- I RECEIVED AN ACARS MESSAGE FROM ACR XXXX; ZZZ1-ZZZ2. IT WAS A ONE WORD MESSAGE THAT READ: 'DONE.' BECAUSE I HAD NO IDEA WHAT IT WAS THAT THE CREW HAD ACCOMPLISHED; I STARTED TO SEND A MESSAGE BACK TO GET SOME CLARIFICATION. AT ABOUT THAT MOMENT; ONE OF THE ASSISTANT DISPATCHERS WHO MAN OUR LOAD CTL UNIT CAME TO MY POSITION AND WANTED TO KNOW WHERE YYYY WAS -- HE WAS TRYING TO CONTACT THE CREW TO RESOLVE A LOAD MANIFEST ISSUE. I QUICKLY FOUND THE FLT IN THE SOFTWARE APPLICATION WE USE TO FUEL PLAN AND RTE OUR TRIPS. USING ANOTHER FUNCTION; I 'INSTRUCTED' THE COMPUTER TO LOCATE THE FLT ON MY DISPLAY. TO THE ASSISTANT DISPATCHER'S SHOCK AND DISMAY; YYYY WAS ALREADY OFF ZZZ1. A QUICK CHK OF THE LOAD CTL PROGRAM INDICATED THAT WHILE THE PAX WTS HAD BEEN FINALIZED; THE CARGO NUMBERS STILL WEREN'T. AS IT SO HAPPENED; THE CHIEF DISPATCHER WAS IN OPS CTL OBSERVING OPERATIONS. WHEN HE BECAME AWARE THAT ACFT YYYY HAD LEFT THE GATE WITHOUT ANY FINAL NUMBERS; HE RUSHED TO MY POSITION; CHALLENGING THE ASSISTANT DISPATCHER. HE ALTERNATELY DEMANDED TO KNOW HOW IT WAS EVEN POSSIBLE THAT AN ACFT COULD GET OUT OF THE GATE WITHOUT AN ACCURATE LOAD MANIFEST AND THEN ASSERTING THAT IT WASN'T POSSIBLE; THAT OUR PROCS DON'T PERMIT AN ACFT TO PUSH BACK WITHOUT FINAL NUMBERS. I SHOWED THE CHIEF DISPATCHER MY DISPLAY AND HE POINTED TO THE LOAD CTL SCREEN. I STATED QUITE SIMPLY THAT WHATEVER WAS SUPPOSED TO HAPPEN; THE ACFT CLEARLY WAS ALOFT WITHOUT NUMBERS. THE ASSISTANT DISPATCHER AND ONE OR TWO OF HIS COLLEAGUES IN LOAD CTL QUICKLY REVIEWED THE ACFT'S LOADING; APPARENTLY WITH UPDATED DATA FROM THE RAMP -- IN SHORT ORDER THEY DETERMINED THAT THE ACFT WAS TAIL-HVY; AND THAT BY MOVING PAX FROM COACH TO 1ST CLASS; THE ACFT'S CG WOULD BE BROUGHT INTO THE ENVELOPE. I ASKED THE ASSISTANT DISPATCHER WHETHER HE HAD CALCULATED WHICH ZONE IN COACH WOULD BE AFFECTED (THERE ARE TWO) -- SINCE THE ACFT WAS TAIL-HVY; IT ONLY MADE SENSE TO TAKE PAX FROM THE REARMOST PART OF THE CABIN AND MOVE THEM FORWARD. HE DIDN'T SEEM TO THINK IT MADE MUCH DIFFERENCE; AND; IN THE INTEREST OF TIME; I DID NOT DEBATE THE ISSUE WITH HIM. I ACARS'ED HIS INSTRUCTIONS TO YYYY; AND WITHIN THREE MINS OR SO RECEIVED A MESSAGE BACK THAT PAX HAD BEEN MOVED. THE FLT CONTINUED ON TO ITS DEST WITHOUT FURTHER INCIDENT. CLEARLY; NO ONE INTENDED FOR THIS ACFT TO GET OFF THE GND WITHOUT CORRECT DATA ON LOADS. HOWEVER; IT HAPPENED. I BELIEVE THE FACTORS THAT CONTRIBUTE TO THIS TYPE OF EVENT INCLUDE: TIME PRESSURES THAT OFTEN LEAD BAGGAGE HANDLERS AND GATE AGENTS TO CONTINUE LOADING ACFT UP TO THE VERY LAST MINUTE. TECHNOLOGY THAT OFTEN ENABLES UPDATES ON LOADS BETWEEN PUSHBACK AND TKOF. COMPLACENCY DUE TO THE TYPE'S DEMONSTRATED ABILITY TO FLY UNDER A VERY WIDE RANGE OF 'AS LOADED' CONDITIONS. UNADDRESSED OR ONLY PARTIALLY ADDRESSED TRAINING ISSUES FOR THE ASSISTANT DISPATCHERS WHO WORK IN LOAD CTL (THE UNIT IS COMPRISED OF INDIVIDUALS WHOSE AVIATION BACKGROUNDS RANGE FROM ZERO UP TO PLT OR DISPATCH LICENSES). UNADDRESSED OR ONLY PARTIALLY-ADDRESSED TRAINING FOR BAGGAGE HANDLERS. UNADDRESSED OR ONLY PARTIALLY-ADDRESSED TRAINING ISSUES FOR GATE AGENTS. MOREOVER; THERE JUST HASN'T BEEN ENOUGH TIME TO 'SHAKE OUT' THE LOAD CTL UNIT -- MANY FLT CREWS AND RAMP PEOPLE ARE NOT AWARE THAT DISPATCHERS NO LONGER MANAGE LOAD DATA AND THAT THE LOADING FUNCTION IS 'MANAGED' BY A SEPARATE; DEDICATED GROUP WITHIN OPS CTL. I SUSPECT THE LOAD CTL UNIT'S PERFORMANCE WILL IMPROVE OVER TIME; HOWEVER; WITHOUT BETTER COORDINATION BETWEEN OPS CTL AND THE RAMP; THE POSSIBILITY OF A CRITICALLY MISLOADED ACFT ATTEMPTING A TKOF REMAINS.
Data retrieved from NASA's ASRS site as of January 2009 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.