groundSAFETY

A small child’s fall reminds adults of the need for close supervision and reveals inadequate updates to operators.

AirstairBy Wayne Rosenkrans Vigilance

3-year-old girl’s fall from the she held onto the lower handrail,” the and disembarkation in place forward integral airstair of a report said. “When [the girl] reached of portable ground-based steps or an Ryanair -800 — an the top of the stairs, she turned towards airbridge, and safe operation depended approximate height of 8.5 to her mother, leaned backwards and fell on a combination of barriers, proce- A9.0 ft (2.6 to 2.7 m) — has prompted through the gap between the extend- dures and warnings on placards. “These the U.K. Air Accidents Investigation able handrail and the top of the airstair, airstairs include an integral two-rung Branch (AAIB) to issue several safety onto the hardstanding [ramp pave- handrail on either side,” the report said. recommendations, including one for ment] below.” Other passengers also “These [handrails] rise into position airstair modification. She was released were on the airstair at the time. during deployment of the stairs, but due from a hospital after a 24-hour assess- The incident occurred at 1225 to the geometric restrictions imposed by ment and treatment of minor injuries. local time on July 17, 2009, at London the retraction mechanism design, they The child had climbed the airstair Stansted , the AAIB report do not extend to the fuselage side. to the upper platform followed by her said. The airplane was manufactured “In order to bridge the gap between mother, who was carrying a younger in 2005 and certificated to applicable the top of the handrails and the fuse- sibling and a carry-on bag. “Due to her European standards. lage, a manually extendable handrail is mother’s lack of a free hand, the child This integral airstair (Figure 1, p. 38) fitted to each of the integral rails. After

climbed the airstair unassisted, but primarily was used to facilitate routine deployment of the airstair, these are © Radu Dobrescu/.net

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attention to pas- Forward Integral Airstair on Boeing 737s sengers boarding [or deplaning] with small children or [pas- sengers] with special needs.” The AAIB re- port cited a paragraph Forward entry door from this template Aft handrail for operators, which extended position says, in part, “Small Support strut children on airstairs Forward handrail should be attended by retracted position an adult or respon- sible person.”4 Exterior control for Forward lower handrail airstair extension/retraction Investigation of the 2009 incident, however, found no Aft lower handrail process in place for operators to receive amendments to these type-specific cabin safety recommenda- Airstair tions. “The flight (door in cocked position) attendant manual re- FAA = U.S. Federal Aviation Administration ceived by the operator Notes: The upper handrail extensions, when secured to the inside of the door opening, are designed to provide a with its first Boeing continuous support from the ground to the airplane cabin. However, an FAA special airworthiness information bulletin (SAIB NM-07-47) in September 2006 advised 737-series owners and operators of four occurrences in which, during the 737-800 was issued on process of disembarking or entering the airplane, unattended small children fell through or over the handrails or lost their 28 September 1998,” balance and fell from the airstair. the report said. Source: U.K. Air Accidents Investigation Branch; FAA Investigators Figure 1 noted that, at the time of the incident, imple- extended and secured to points in the a service bulletin developed by Boeing mentation of the most current airstair entry door frame. Each extendable rail Commercial Airplanes,2 and another safety improvements recommended by is supported by a strut extending from developed by Monogram Systems, the Boeing and the airstair manufacturer the side rail of the airstair.” manufacturer of the airstair.3 was incomplete. “The airstair … had “These bulletins required warning the warning placards on the risers and Previous Child Falls placards to be added to the risers of anti-slip material installed in accor- Four similar incidents involving small the airstair steps and the door dance with [the] Monogram Systems children had prompted the U.S. Federal apertures, together with the addition of [service bulletin], but the door aper- Aviation Administration (FAA) in anti-skid material to the top platform ture placards, detailed in [the] Boeing September 2007 to issue advisory infor- and the side rails,” the report said. “The [service bulletin], had not yet been mation to all current owners and opera- [Boeing bulletin] also highlighted the applied,” the report said. tors of 737s. This comprised a special fact that Boeing had revised the flight Small children require close su- airworthiness information bulletin,1 attendant manual for the 737 series of pervision because of limitations of the calling for the incorporation of the aircraft, to include a warning regarding geometry of the rails. “When deployed, latest safety advice and advances from the need for operators to pay particular the left and right extendable handrails

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are intended to provide protection ground staff provided assistance, ac- the possibility of a child falling against people falling sideways off the cording to the AAIB. through the gap between the upper section of the airstair,” the report “When portable ground-based steps extendable handrail and its upper said. “While these handrails appear to or the aircraft’s integral airstair were platform.” provide adequate protection for adults, used, an adult boarding or disembark- The report explained the analytical a gap exists between the handrail and ing with ‘carry-on’ , which could basis of each safety recommendation. the airstair platform which is large not easily be placed over the shoulder, “The lack of an amendment service enough to allow a small child to pass and a small child, found themselves, in for the Boeing 737 through it and fall onto the [ramp pave- certain situations, in a position where manual … applies to all of the Boeing ment] below.” neither hand was available to provide commercial aircraft product line,” the According to procedures in Ryanair’s support during the ascent or descent. AAIB noted. “In this case … the opera- safety equipment and procedures man- This situation was further complicated tor would have been aware that some ual (SEP), three of four flight attendants when an adult was accompanied by changes had been made to the manual are assigned to maintain positions by more than one small child and ‘carry- upon receipt of [the FAA special air- the forward and rear doors, and near on’ baggage, as some of the children had worthiness information bulletin].” for the duration of to negotiate the steps with little assis- Investigators concluded that the boarding. “However, during boarding, tance from the adult.” absence of a barrier that specifically the ability of the cabin crewmember protects small children also should at the forward doors to identify those Mitigation Measures be addressed. “The gap between the passengers requiring assistance, while The AAIB said that Ryanair also extendable handrail and the upper they are ascending or descending the analyzed this incident and instituted platform of the Boeing 737 airstair airstair, is limited,” the report noted, measures to reduce the risk. “As a result, represents a hazard to small children citing a provision from the SEP, which the operator raised a modification which boarding or disembarking the aircraft,” says, “Passengers accompanying young introduces a roller‑tensioned, high- the report said. “Four previous events children should be instructed to hold visibility tape between the door aper- resulted in [amended guidance or their hands when descending the stairs ture and the extendable handrail strut,” safety bulletins that] do not provide and on the ramp.”5 The report did not the report said. “After approval by the physical protection against a child fall- mention the positioning of the flight relevant airworthiness authorities, this ing through the gap. The modification attendants in the 2009 incident. modification will be embodied on the proposed by the operator provides a operator’s fleet as a matter of priority.” significant visual cue to the lack of a Other The AAIB recommended that: rigid barrier in this area, but provides AAIB observers also looked beyond • “Boeing establish a process to only a limited physical protection the involved to assess super- inform the operators of all Boeing against falling.”  vision of small children on the 737 commercial aircraft of changes forward integral airstair. “In 95 per- This article is based on AAIB Bulletin 8/2010, EI- to the relevant flight attendant cent of cases, during disembarkation, DLJ, EW/C2009/07/08, published in August 2010. manual; passengers traveling with several small Notes children and hand baggage received no • “Ryanair review their current pas- senger boarding and disembark- 1. FAA. Special Airworthiness Information assistance from either cabin crew or Bulletin NM-07-47. September 2007. ground staff,” the report said. “How- ing procedures so that assistance 2. Boeing. Service Bulletin 737-52-1157. ever, ground [staff] and cabin crew is made available to passengers provided assistance in 78 percent of accompanied by children, and 3. Monogram Systems. Service Bulletin cases when single passengers accom- those with special needs; [and,] 870700-52-2130. panied by small children were allowed • “Boeing review the design of 4. Boeing Commercial Airplanes. Boeing to pre-board the aircraft.” The 2009 the Boeing 737 forward airstair Flight Attendant Manual, page 7.10.34. pre-boarding incident was an excep- with the intention of adding a October 29, 2008. tion: Neither the cabin crew nor the removable barrier to minimize 5. Ryanair. SEP Manual, Section 2.4.13.5. www.flightsafety.org | AeroSafetyWorld | September 2010 | 39