Stobart AT72 at Dublin on Sep 30th 2015, passenger fell off stair
Last Update: May 25, 2016 / 16:09:49 GMT/Zulu time
Incident Facts
Date of incident
Sep 30, 2015
Classification
Accident
Airline
Stobart Air
Flight number
EI-3323
Departure
Manchester, United Kingdom
Destination
Dublin, Ireland
Aircraft Registration
EI-FAX
Aircraft Type
ATR ATR-72-200
ICAO Type Designator
AT72
On Oct 13th 2015 the French BEA reported in their weekly bulletin that the passenger received serious injuries, the occurrence was rated an accident by the Irish AAIU, which is investigating the occurrence.
On May 25th 2016 the Irish AAIU released their final report concluding the probable cause of the accident was:
The sudden retraction of the collapsible handrail which was being used by a passenger for support during disembarkation.
Contributory Factors
- The failure of the locking mechanism of the quick-release pin.
- The lack of a checking procedure to ensure functionality of quick-release pin.
The AAIU reported the passenger received a fracture to her right wrist, when the handrail collapsed and the passenger fell off the stairs.
The aircraft had completed an uneventful flight and was safely parked at the stand. Upon instruction from the flight deck the senior cabin crew member (SCCM) opened the aft left door, extended the stairs and put the handrail into the up position securing it with the quick release pin. After about 15 passengers had disembarked there were calls from passengers for assistance, the SCCM went down the stairs, noticed the handrail had collapsed and attended to the injured passenger with a grazed right arm. After she had talked to the injured passenger, she re-extended the handrail, reinserted the quick release pin that had come out of its hole, asked another flight attendant to stand aside and ensure the handrail remained in its correct position, and the remaining passengers disembarked without further incident.
The AAIU wrote about examination of the quick release pin: "The Investigation obtained the quick release pin that was in use at the time of the accident. The handle and plunger were found to operate only partially in the pull direction and the locking ball bearings were found retracted and could not be pushed out into the locking position using the plunger. Inspection revealed that whilst the pin would fit correctly into the locating holes of the cross-brace and stanchion, the pin could not be locked in position."
A following detailed examination revealed: "The pin was sent to the French Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA) for X-Ray examination. This revealed that the small washer of the internal spring mechanism had become displaced and had migrated down the shaft of the plunger, restricting its movement and leaving the plunger positioned such that the locking ball bearings were permanently retracted (unlocked)."
The AAIU analysed: "A witness report stated that the passenger was carrying a single item of hand baggage, and placed one hand on thestowable handrail as she exited the aircraft. Subsequently, during the initial stages of passenger disembarkation, slight movement of the handrail assembly allowed the pin to become dislodged, causing the collapsible handrail to return to the stowed position. The collapse of the handrail most likely occurred just as the subject passenger put her weight on it, causing her to lose balance and fall to the ground from the top of the aircraft steps, fracturing her wrist."
The AAIU concluded analysis: "X-Ray photography of the pin revealed damage or wear to an area of the spring mechanism which allowed the small spring retaining washer to migrate between the plunger and the sidewalls of the spring housing, thus impeding the movement of the plunger, eventually preventing the plunger from returning to the locking position. The exact nature/cause of this damage or wear was not determined by the Investigation."
The operator took safety actions to modify cabin crew procedures and maintenance procedures to ensure the quick release pin is locking properly. The aircraft manufacturer amended the manuals for cabin crew as well.
Aircraft Registration Data
Incident Facts
Date of incident
Sep 30, 2015
Classification
Accident
Airline
Stobart Air
Flight number
EI-3323
Departure
Manchester, United Kingdom
Destination
Dublin, Ireland
Aircraft Registration
EI-FAX
Aircraft Type
ATR ATR-72-200
ICAO Type Designator
AT72
This article is published under license from Avherald.com. © of text by Avherald.com.
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