What happened
On 16 December 2024, a Boeing 737-8K5, registration G-TAWB, was prepared for a scheduled commercial flight from East Midlands Airport to Lanzarote. During the turnaround process, the aircraft was running behind schedule. As the Senior Cabin Crew Member (SCCM) began the procedure to close the front passenger door, the passenger steps were pushed away from the aircraft.
The movement of the steps created a gap between the fuselage and the equipment. The SCCM, who was in the process of releasing the door's gust lock, was unable to maintain her footing and fell into the gap, landing on the ramp. The fall resulted in serious injuries to the crew member, including multiple broken bones. While a dispatcher remained on the top of the steps and avoided falling, the SCCM was unable to prevent her descent.
The investigation
The AAIB investigation examined the ground handling procedures, the equipment used, and the coordination between the ramp and dispatch teams. The investigation focused on the use of Skyway Towable Passenger Stairs, which lacked the interlocking safety barriers found on more modern equipment. These barriers are designed to prevent the steps from being moved until the aircraft door is fully secured.
Investigators also reviewed CCTV footage and interviewed various personnel, including ramp agents, dispatchers, and flight crew. The inquiry looked into the training of the dispatchers involved and the established practices for door closure and equipment removal at the airport. The investigation also assessed the communication between the different ground handling teams and the effectiveness of the airport's emergency response.
Findings
- The primary cause of the accident was the removal of the passenger steps while the aircraft door was still open and the crew member was positioned in the doorway.
- A long-standing procedural workaround existed where dispatchers, who were not qualified to operate the steps, would complete the door closure process. This practice had been embedded in the local culture for many years.
- There was a lack of clear communication and defined responsibility regarding who should confirm that the door was closed and the steps were clear of personnel.
- The presence of multiple dispatchers at the stand created confusion; the ramp staff assumed the door closure was complete because they saw a dispatcher leaving the steps.
- The specific type of steps used did not feature interlocks to prevent movement until the aircraft door was secured.
- The ramp staff's view of the top of the steps was obstructed by the equipment itself, making it difficult to verify if the area was clear.
Safety action
Following the accident, the ground handling company implemented several changes, including:
- Issuing safety alerts to ensure only qualified ramp staff interact with the steps.
- Updating procedures to ensure the allocated dispatcher is identified to the ramp team during the pre-flight briefing.
- Implementing a system where trainee dispatchers wear distinct high-visibility clothing to avoid confusion.
- Updating audit criteria to monitor compliance with step operation qualifications.
- The aircraft operator issued a safety notice and updated its manual to require that crew members keep both feet inside the aircraft during door closure.