What happened
On February 1, 2005, an Airbus A319-113, registration F-GPMH, arrived at Orly Airport operating flight AF 7481 from Biarritz. During the flight, a passenger became ill, necessitating a medical emergency response upon arrival. To facilitate medical treatment in the forward galley, the crew and ground staff organized passenger disembarkation through the rear left door.
To assist this process, a ground agent positioned a self-propelled staircase at the rear door. After the passengers had safely exited the aircraft, a flight attendant suggested closing the door to protect the cabin from drafts and temperature changes. The captain agreed. However, while the aircraft door was still open, the ground agent began the maneuver to withdraw the staircase. As the vehicle moved backward, a flight attendant attempting to re-enter the aircraft fell between the staircase platform and the aircraft threshold. The crew and ground personnel rushed to assist, but the flight attendant succumbed to her injuries later that evening.
The investigation
The investigation focused on the coordination between the cabin crew and ground personnel, as well as the technical aspects of the equipment used. Investigators examined the positioning of the self-propelled staircase and its protective side guards. They noted that the staircase was positioned in a way that made closing the aircraft door impossible without first adjusting the staircase's side guards.
The inquiry also reviewed the operational procedures at Orly, finding that while formal local procedures existed, the actual practice of ground handling had evolved informally. This lack of alignment between written rules and actual practice created a risk of procedural shortcuts during unusual situations, such as the medical emergency encountered during this flight.
Findings
- The primary cause of the accident was the rapid withdrawal of the self-propelled staircase without adequate preparation, occurring while the aircraft door was still open.
- The driver of the staircase had an incorrect perception of the situation, believing the door was already closed.
- The positioning of the staircase and its side guards prevented the door from being closed without manual intervention on the stairs.
- The victim's sudden surprise at the moving staircase caused a reflexive attempt to reach the aircraft interior rather than grasping the staircase railing.
- An informal evolution in ground handling organization led to a breakdown in standard procedures during this non-routine event.
- A perceived sense of time pressure, driven by the need to manage the medical emergency and the unexpected use of the staircase, contributed to the error.