Ural A320 at Karlovy Vary on Aug 6th 2013, ground staff fell from aircraft

Czech's UZPLN released their final report in Czech concluding the probable causes of the accident was:

- failure to follow ground control procedures for removal of stairs from the aircraft

- unauthorized handling of front door by dispatch agent and inattention after pushing the door open to verify whether the stairs had been moved

Contributing factors were:

- failure to comply with internal rules laid out to all companies involved. At the time of the accident individual/personal/alternative procedures, deficiencies in internal control documentation and familial environment within the companies involved substituted the rules

- lack of activities of internal audit as well as absence of supervision of the operator by the state

The UZPLN reported that a dispatch agent had climbed the stairs after the last passenger had boarded the aircraft. The agent entered the cockpit and handed the loadsheet to the captain, then waited for the signed copy of the loadsheet to be returned by the captain.

In the meantime luggage had been completed loading, the cargo door had been closed. The flight attendants were performing their passenger briefings, however, there was a lot of noise in the cabin hindering the announcements, so that the purser decided to partially close the front door to complete the passenger brief. The purser shut the door but did not lock the door and continued the passenger briefing.

The operator of the stairs observed that all doors of the aircraft had been closed and the front door was about to be closed, he climbed up to the stairs to ask the flight attendant whether he could remove the stairs but did not receive a reply, the flight attendant appeared to be nodding however. Usual procedures would be the flight attendant at the door would use defined gestures to signal the stairs could be removed.

Seeing that the door was ajar with the rest of the fuselage the operator of the stairs moved the stairs to outside the danger zone.

The captain handed the signed copy of the loadsheet to the agent, who then left the cockpit, forcefully pushed the ajar but not closed front door open and walked on without checking. She fell about 3.5 meters down onto the apron. Ground workers observed her fall and called an ambulance. The agent (41) received serious injuries, was stabilized at the apron and subsequently airlifted to a hospital.

The agent provided testimony that she had not been professionally trained to handle the front door, but had adopted procedures by watching her collegues. She saw the door had not been locked closed, she was aware that no signal to remove the stairs had been given and no flight attendant was around the front door at the time when she left the cockpit.

The UZPLN stated that the agent was not qualified to conduct such activities (opening the door).

The UZPLN stated that the ground supervisor (41) had not received language training to perform such work activities, he had been working in this position for about 3.5 years at the time of the accident.

The UZPLN stated the stair operator (27) had been working two years as ground handler. As the crew did not communicate he moved the stairs.

The purser had her attention divided between a number of tasks including passenger briefing, passenger messages and communication with the dispatch agent. She observed the agent left the cockpit and her hand on the door handle but did not react. She had not registered that the stairs had been towed away, no command to do so had been given.

The UZPLN analysed that the Ural Airlines manual for ground handling of the aircraft specifically stated that the stair operator can drive the stairs away only upon permission by the aircraft commander, the stairs and operator should be monitored continuously until the stairs have left the danger zone around the aircraft. In addition, only the aircraft commander can instruct to close the door. Ural Airlines had entered a contract with the ground handling company in 2010, the ground handling company however had failed to effectively communicate with Ural Airlines with respect to required procedures, ground personnel therefore had not received appropriate training.

Non-verbal signalling is being used in aviation, however involves a risk of misunderstanding. Hence only specific hand gestures can be taken as valid communication.

The UZPLN analysed that the dispatch agent tampered with the front door without consultation with the crew, as such did not respect established procedures of the aircraft operator. There are indications however that Ural Airlines repeatedly tolerated that behaviour. After opening the door she walked out with the head turned towards the aisle and never checked whether the stairs were actually in place.

The half closed door from inside (left) and outside (right) (Photos: UZPLN):