What happened
On August 6, 2013, at approximately 07:07 UTC, an incident occurred at Karlovy Vary Airport (LKKV) involving an Airbus A320, registration VQ-BRE, operated by Ural Airlines j.s.c. The aircraft was parked at stand 2 following the completion of passenger boarding for flight U6 740 to Ekaterinburg.
A station manager, acting on behalf of East-West AERO s.r.o., was on board the aircraft near the forward door. After the final passenger had boarded, the manager noticed the aircraft door was not fully closed and, due to noise from the Auxiliary Power Unit (APU) and incoming warm air, decided to close the door. The manager moved the safety barrier on the mobile stairs and pulled the door shut.
Simultaneously, a ramp service worker, having received a non-verbal signal (a thumbs-up) from a ramp coordinator, proceeded to move the mobile stairs away from the aircraft. Unaware that the stairs had already been displaced, the station manager stepped backward out of the aircraft door and fell from a height of 3.5 meters onto the concrete apron. The individual sustained serious injuries, including pelvic fractures, spinal injuries, and multiple rib fractures, and was subsequently airlifted to a hospital in Plzeň.
The investigation
The ÚZPLN investigation examined the actions of the ground handling personnel, the aircraft crew, and the operational procedures of the involved companies. The investigation reviewed security camera footage, radio communications between the crew and the tower, and interviewed the ramp coordinator, the cabin crew, and the ground service workers.
Investigators found that the ramp coordinator had approached the aircraft door to ask the flight attendant if the stairs could be moved. The flight attendant, who was busy with passenger announcements, did not communicate the pilot's instruction to the ramp coordinator. Furthermore, the investigation revealed that the station manager had not received formal training regarding the specific handling of aircraft doors or the operational procedures of the airport handling provider.
Findings
- The primary cause of the incident was the failure to follow established procedures for removing mobile stairs from the aircraft, combined with the station manager's unauthorized manipulation of the aircraft door and a failure to verify that the stairs were still in place before exiting.
- The ramp coordinator did not follow the correct sequence of actions for withdrawing the stairs and lacked sufficient English language proficiency to communicate clearly with the crew.
- The station manager was not professionally trained for her specific duties and was performing tasks based on informal knowledge passed from colleagues.
- The cabin crew failed to react to the unauthorized door manipulation and did not relay the captain's instructions regarding the removal of the stairs to the ground staff.
- There were significant systemic deficiencies, including inadequate internal audits, incomplete operational documentation, and a culture of non-compliance with established ground handling manuals (GOM) among the various service providers.