Incident
On 17 July 2009, a Boeing 737-800 (registration EI-DLJ) operated by Ryanair was boarding passengers at London Stansted Airport using the forward integral airstairs. A three-year-old child, accompanied by her mother who was carrying a younger sibling and a carry-on bag, climbed the airstairs unassisted while holding the lower handrail. Upon reaching the top platform, the child turned, leaned backward, and fell through the gap between the extendable handrail and the top of the airstairs onto the hardstanding below. The child received initial medical attention at the scene, was airlifted to a hospital, and was released 24 hours later. The child sustained minor injuries; no other injuries were reported.
Aircraft and Airstair Description
EI-DLJ was a Boeing 737-800 manufactured in 2005, powered by two CFM 56-7B26 turbofan engines. The aircraft was fitted with retractable forward airstairs, which include integral two-rung handrails on each side. These handrails rise during deployment but do not extend to the fuselage side due to geometric design. To bridge the gap between the top of the handrails and the fuselage, manually extendable handrails are fitted. After airstair deployment, these are extended and secured to points in the entry door frame, supported by a strut from the side rail. A gap exists between the extendable handrail and the airstairs platform, large enough for a small child to pass through.
Investigation
The AAIB investigated the incident. At the time, the airstairs had warning placards on the risers and anti-slip material installed as per Monogram Systems Service Bulletin 870700-52-2130, but the door aperture placards specified in Boeing Service Bulletin 737-52-1157 had not been applied. The investigation observed boarding and disembarkation procedures at various operators. In 95% of disembarkation cases, passengers with several small children and hand baggage received no assistance from crew. However, when single passengers with small children pre-boarded, assistance was provided in 78% of cases. In this incident, the passenger had opted for priority boarding but received no assistance from cabin or ground crew.
The operator's SEP manual required three cabin crew to remain at doors during boarding, with a fourth providing cabin assistance. The manual stated that passengers accompanying young children should be instructed to hold hands when descending stairs. However, crew at the forward doors had limited ability to identify passengers needing assistance while on the airstairs.
Safety Actions and Recommendations
Following the incident, the operator reviewed measures and developed a modification to install a roller-tensioned, high-visibility tape between the door aperture and the extendable handrail strut. This modification awaited airworthiness approval and was to be applied to the fleet as a priority.
The AAIB issued three Safety Recommendations:
- 2010-017: Boeing should establish a process to inform operators of all Boeing commercial aircraft of changes to the relevant Flight Attendants Manual.
- 2010-018: Ryanair should review its boarding and disembarking procedures to ensure assistance is available to passengers accompanied by children and those with special needs.
- 2010-019: Boeing should review the design of the forward airstairs to add a removable barrier minimizing the possibility of a child falling through the gap.
Previous Events
Four similar incidents involving small children falling from Boeing 737 airstairs had been reported previously. In September 2007, the FAA issued Special Airworthiness Information Bulletin NM-07-47, recommending that operators incorporate Boeing Service Bulletin 737-52-1157 and Monogram Systems Service Bulletin 870700-52-2130. These bulletins required warning placards and anti-skid material, and Boeing revised the Flight Attendant Manual to include a warning about assisting passengers with small children or special needs. The manual revision was dated 29 October 2008, but the operator had not received this update, as Boeing does not provide a revision service for manuals delivered with aircraft.