INVESTIGATION REPORT: IRIncident
Date of Incident

12-OCT-2019

Type of Incident

AIRLINE DELAY

Reported By

STERLING GLOBAL Aviation Logistics (SGAL)

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Shipment Details
Job Number

2733217C

Type of
Shipment

LIVING DONOR KIDNEY

Customer

OURLEGACY

Shipper

OURLAGACY, Maitland, FL (MCO)

Customer Reference

AGJH395-KIDNEY-L

Consignee

Carolina Donor, Winston Salem, NC

Investigation
All Times EDT
Lori Gore of UNOS placed an order with SGAL to transport a Living Donor Kidney on the OURLEGACY
account, at 16:07 on 12-OCT-2019.
The original routing for the organ was:
American Airlines (AA) Flight 1939, departing MCO at 19:19 and arriving Charlotte (CLT) at 21:08.
The organ would then be driven 84 miles to the consignee, with a delivery deadline of 23:59 on the 12th.
AA refused the booking for that flight, as they stated the organ would have to be tendered by 17:00 in order to
make the requested flight. The only option on AA would be departing on the morning of the 13th.
SGAL then confirmed that the organ could be recovered “after hours” at Delta (DL) Greensboro (GSO), which
was 24 miles from the consignee.
Lori Gore was advised, and the organ was then booked with DL utilizing “DASH Critical” service on:
DL Flight 1118, departing MCO at 19:35 and arriving Atlanta (ATL) at 21:10
Connecting with:
DL Flight 2960, departing ATL at 22:10 and arriving at GSO at 23:25.
The delivery deadline was revised to 01:30 on the 13th.
The shipment was picked up at 17:10, and tendered to DL MCO at 18:13.
The booking was not updated post-tender on www.deltacargo.com, so SGAL requested that the driver return to
DL MCO to verify the status of the shipment. The driver later called and placed the DL MCO agent on the line,
who confirmed that the shipment was received and booked on both flights through to GSO. They added that no
GPS unit would be placed on the shipment, as they did not have one in stock.
SGAL confirmed the organ on board the 1st leg of the routing, which departed MCO at 19:44 and arrived ATL at
20:54, however after being unable to confirm the shipment on board the 2nd leg which departed ATL at 22:08,
contacted DL in efforts to verify the status and location of the organ.
The DL Rep advised that the shipment was showing as “unconfirmed” on the 2nd leg, and was now manifested
on a flight arriving at 11:45 on the 13th. SGAL advised that they would likely be terminating the shipment in
order to drive it to the consignee, but would verify and call back.
Asia of UNOS was advised at 22:50, and later called back at 23:08 to authorize the shipment being terminated
with DL and driven to the consignee. The consignee location was also Wake Forest University Baptist Medical.
The organ was recovered from DL ATL at 01:01, and delivered to Leonila Bulauitan at Wake Forest at 06:14 on
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CORP-QA46.1 (15 Aug
2018)

 the 13th.

Root Cause
Sterling Global Aviation Logistics’ Quality Assurance Team has reviewed the airline handling error and
determined that Delta Airlines (DL) MCO Dash operations did not provide the requested service level required
for our customer’s urgent, life-saving shipment. DL’s management has initiated a CAPA request to identify the
specific issues that caused this error. While this is being completed, DL has added GPS inventory to their MCO
operations unit to eliminate the recurrence on a forward going basis.

Compiled By
Signature

Printed Name

Position

Date

Joe McGaffin

Joe McGaffin

Director Quality
Assurance

16-Oct-2019

Approved By
Signature

Printed Name

Position

Date

Dan Conrad

Dan Conrad

VP of Quality Assurance

22-Oct-2019

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CORP-QA46.1 (15 Aug
2018)