Pilot Debrief

BOEING 737 330 near Lanai, HI — 2014-10-17

Final reportDCA15LA011
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Date
2014-10-17
Location
Lanai, HI, USA
Airport
LNY
Aircraft
BOEING 737 330
Registration
N301KH
Category
Airplane
Highest injury
None
Fatalities
0

Probable cause

the improper loading and securing of the cargo pallets, which shifted on departure, resulting in substantial damage to the aft pressure bulkhead.

NTSB narrative

Aloha Air Cargo flew to an out-station with none of their personnel located there. The decision was made to limit the number of Additional Crew Members (ACMs) due to concerns about the return flight's weight and balance. With the choice of taking the load planner or the mechanic, Aloha Air Cargo made the decision to take the mechanic, which was against the company loading procedures since the mechanic was not trained on cargo securing nor were there any approved personnel at the destination to assist with loading and securing the empty pallets. Since the load planner would not be making the flight, he discussed with the mechanic on how to load the empty pallets for the return flight, which was to load and lock each empty pallet in their original loaded location. However, while in LNY, Aloha Air Cargo dispatch recommended that all the pallets be placed in position 9 due to concerns about weight and balance. It is unknown if the mechanic tried to contact the load planner to discuss the new configuration. The cargo floor locks will only secure the bottom pallet when engaged properly and not the stacked pallets. The decision was made to secure the stacked pallets with a cargo strap which was insufficient to keep the pallets from moving. Even though it was stated that during the loading process that the locks were "up" and locked, when the Marshaller entered the airplane he observed the locks between station 8 and 9 were down/unlocked. In addition, there was damage found to the right hand forward and aft locking mechanisms, implying these locks were used but failed due to overload.

NTSB coding

View NTSB final report

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