Boeing 747-281B – JA8182

Incident Overview

Date: Tuesday 11 August 1987

Aircraft Type: Boeing 747-281B

Owner/operator: All Nippon Airways – ANA

Registration Number: JA8182

Location: Washington, DC – ÿ United States of America

Phase of Flight: Standing

Casualties: Fatalities: 1 / Occupants: 335

Component Affected: Aircraft door and handrail system.Aircraft door and handrail system.

Investigating Agency: NTSBNTSB

Category: Accident

A Flight attendant fell from the aircraft during the opening of the L5 door. Assistance was provided by a company ground person who was outside the aircraft on the boarding step. The boarding step was not against the aircraft but was approximately 1 foot away. Upon opening the door, the flight attendant fell approximately 20 feet below the ground. The company procedure required hand signaling communication between personnel inside and outside during door opening. Radio communications were used between the ground personnel and a company representative. The ground person was unable to activate the door and request the company representative to open it. The company representative requested assistance from the nearby flight attendant. The boarding steps were initially fully against the aircraft but were pulled away when the door did not clear the handrails of the boarding step. The aircraft has a curve at the L5 door location. The boarding steps are square shaped.A Flight attendant fell from the aircraft during the opening of the L5 door. Assistance was provided by a company ground person who was outside the aircraft on the boarding step. The boarding step was not against the aircraft but was approximately 1 foot away. Upon opening the door, the flight attendant fell approximately 20 feet below the ground. The company procedure required hand signaling communication between personnel inside and outside during door opening. Radio communications were used between the ground personnel and a company representative. The ground person was unable to activate the door and request the company representative to open it. The company representative requested assistance from the nearby flight attendant. The boarding steps were initially fully against the aircraft but were pulled away when the door did not clear the handrails of the boarding step. The aircraft has a curve at the L5 door location. The boarding steps are square shaped.

Description

A FLIGHT ATTENDANT FELL FROM THE ACFT DURING OPENING OF THE L5 DOOR. THE F/A WAS HELPING A COMPANY GROUND PERSON, WHO WAS OUTSIDE ON THE BOARDING STEP. THE BOARDING STEP WAS NOT AGAINST THE ACFT BUT ABOUT 1 FT AWAY FROM IT. WHEN THE DOOR WAS OPENED, THE F/A FELL THRU THE OPEN DOORWAY AND TO THE GROUND ABOUT 20 FT BELOW. THE COMPANY PROCEDURE REQUIRES HAND SIGNAL COMMUNICATION BETWEEN PERSONNEL INSIDE AND OUTSIDE DURING DOOR OPENING. THE INVESTIGATION REVEALED THAT RADIO COMMUNICATIONS WERE BEING USED BETWEEN THE GROUND PERSONNEL AND A COMPANY REP. THE GROUND PERSON COULD NOT ACTIVATE THE DOOR AND REQUESTED THE COMPANY REP TO OPEN IT. THE DOOR STILL WOULD NOT OPEN. THE COMPANY REP REQUESTED HELP FROM THE NEARBY FLIGHT ATTENDANT. THE BOARDING STEPS WERE INITIALLY FULLY AGAINST THE AIRCRAFT BUT WERE PULLED AWAY WHEN THE DOOR WOULD NOT CLEAR THE HANDRAILS OF THE BOARDING STEP. THE AIRFRAME HAS A CURVATURE AT THE L5 DOOR LOCATION. THE BOARDING STEP IS SQUARE SHAPED. Probable Cause:

Primary Cause

Radio communication failures and lack of coordination between personnel during the critical door opening sequence.Radio communication failures and lack of coordination between personnel during the critical door opening sequence.

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