LOT B738 at London on May 20th 2019, too many cooks spoil the broth

Last Update: December 13, 2019 / 18:12:33 GMT/Zulu time

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Photo of LOT Polish Airlines SP-LWA, Boeing 737-800 — LOT Polish Airlines SP-LWA, Boeing 737-800 (Photo credit: Support your local Air Museum! (HawkeyeUK) / Flickr / License: CC by-sa)

Incident Facts

Date of incident
May 20, 2019

Classification
Report

Airline
LOT Polish Airlines

Flight number
LO-286

Departure
London Heathrow, United Kingdom

Destination
Warsaw, Poland

Aircraft Registration
SP-LWA

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A LOT Polish Airlines Boeing 737-800, registration SP-LWA performing flight LO-286 from London Heathrow,EN (UK) to Warsaw (Poland) with 128 passengers and 6 crew, was climbing out of London when the crew was informed the aircraft was 953 kg heavier than stated on the load sheet. The crew adjusted the aircraft weight in the flight management computer and proceeded to Warsaw for a safe landing.

The UK AAIB released their final bulletin concluding the probable causes of the serious incident were:

The load sheet presented to the commander gave an aircraft weight 953 kg lighter than actual, due to the omission of a consignment of mail loaded in compartment 2.

The mail was initially recorded in the system twice but subsequently both entries were removed.

The AAIB summarized: "The load sheet error occurred because a consignment of mail was initially recorded twice in the operator’s computer load management system. A correction was applied by both the dispatcher and by an electronic message from the cargo company, which resulted in both entries being removed. "

The AAIB analysed:

A consignment of mail was initially recorded twice in the load management system. It was not determined why this had occurred. The handling agent reported that this was not uncommon but that this was normally resolved by the dispatcher. On this incident flight, the dispatcher noticed the duplication and deleted one entry and produced a correct LIR.

Shortly afterwards the cargo company sent an electronic message to update the system.

This resulted in the 953 kg of mail being removed from the system entirely.

When the dispatcher produced the load sheet the system generated a message to tell him that there had been an external change. However, the dispatcher was not familiar with the message and did not appreciate the implications. The dispatcher did not notice that the consignment of mail was missing from the load sheet.

After the flight had departed the dispatcher realised the mail had been omitted and sent a corrected load sheet to the aircraft.