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Attributes | |
ACN | 445820 |
Time | |
Date | 199907 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : mbs.airport |
State Reference | MI |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : mbs.tower tower : cyul.tower |
Operator | common carrier : air carrier |
Make Model Name | DC-9 40 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain |
Qualification | pilot : multi engine pilot : atp pilot : instrument pilot : flight engineer pilot : commercial |
Experience | flight time last 90 days : 210 flight time total : 5778 flight time type : 1168 |
ASRS Report | 445820 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
Events | |
Anomaly | cabin event other non adherence : company policies |
Resolutory Action | other |
Consequence | other |
Supplementary | |
Problem Areas | Passenger Human Performance Flight Crew Human Performance Company Cabin Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Investigation by the captain revealed the following: the inadvertent deplaning of passenger was caused by a communications breakdown within the crew. Contributing factors: when captain directed lead flight attendant to open aft door, lead flight attendant relayed the request to the aft cabin flight attendant via aircraft interphone. Flight attendant in aft cabin opened aft door leading to ventral stairway. Passenger observed door opening, unseated themselves and freely filed out the door unrestr. This took place which the 'fasten seatbelts' sign was still illuminated. This deplanement was never directed or authority/authorized by either flight member. Furthermore, a PA announcement was never made by any crew member advising passenger that a deplanement was to commence out any exit. Note: upon further investigation, it has been determined that the flight attendant in the aft cabin did not know how to close the aft cabin door once it had locked itself in the open position. Based upon captain's post incident interview with the crew members, after captain had made an informational announcement regarding possible usage of aft stairs, and when the request was made to open the aft cabin door, assumptions were made by the flight attendants that captain had authority/authorized the deplaning of passenger through the aft ventral stairs. Those assumptions were incorrect. The flight crew did not observe the deplanement. Furthermore, flight crew members were never advised or notified by anyone that deplaning was underway. This includes the information exchange with the station agent who initially approached the aircraft and entered the cockpit via the aft ventral stairs. The first indication to the flight crew that passenger had escaped was when the first officer noticed the 2 young women walking towards the terminal. The second indication was by an ACARS message that the flight crew received while talking to the station agent in the cockpit. Had the flight crew been notified in a timely manner that deplaning was occurring, perhaps the security breach could have been avoided. Summary of reporter's attachment: aircraft diverted to en route alternate due to severe WX at destination. The arrival station parked aircraft away from terminal because of lack of personnel and gate space. Several calls were made to the company operations to get air conditioning and stairways, etc, without much result. Aircraft involved had a ventral stairway that was lowered to give station personnel access to the aircraft. During the time that that entry to the aircraft was open, there was enough lack of communication between the station and the crew members and the passenger that passenger left the aircraft and were unescorted on the secure ramp area outside the terminal. Passenger were retrieved and accounted for. Subsequently all passenger were taken off the aircraft and processed through security before aircraft departed.
Original NASA ASRS Text
Title: AIRLINE HAS UNESCORTED PAX LOOSE IN THE SECURE AREA OF ARPT RAMP.
Narrative: INVESTIGATION BY THE CAPT REVEALED THE FOLLOWING: THE INADVERTENT DEPLANING OF PAX WAS CAUSED BY A COMS BREAKDOWN WITHIN THE CREW. CONTRIBUTING FACTORS: WHEN CAPT DIRECTED LEAD FLT ATTENDANT TO OPEN AFT DOOR, LEAD FLT ATTENDANT RELAYED THE REQUEST TO THE AFT CABIN FLT ATTENDANT VIA ACFT INTERPHONE. FLT ATTENDANT IN AFT CABIN OPENED AFT DOOR LEADING TO VENTRAL STAIRWAY. PAX OBSERVED DOOR OPENING, UNSEATED THEMSELVES AND FREELY FILED OUT THE DOOR UNRESTR. THIS TOOK PLACE WHICH THE 'FASTEN SEATBELTS' SIGN WAS STILL ILLUMINATED. THIS DEPLANEMENT WAS NEVER DIRECTED OR AUTH BY EITHER FLT MEMBER. FURTHERMORE, A PA ANNOUNCEMENT WAS NEVER MADE BY ANY CREW MEMBER ADVISING PAX THAT A DEPLANEMENT WAS TO COMMENCE OUT ANY EXIT. NOTE: UPON FURTHER INVESTIGATION, IT HAS BEEN DETERMINED THAT THE FLT ATTENDANT IN THE AFT CABIN DID NOT KNOW HOW TO CLOSE THE AFT CABIN DOOR ONCE IT HAD LOCKED ITSELF IN THE OPEN POS. BASED UPON CAPT'S POST INCIDENT INTERVIEW WITH THE CREW MEMBERS, AFTER CAPT HAD MADE AN INFORMATIONAL ANNOUNCEMENT REGARDING POSSIBLE USAGE OF AFT STAIRS, AND WHEN THE REQUEST WAS MADE TO OPEN THE AFT CABIN DOOR, ASSUMPTIONS WERE MADE BY THE FLT ATTENDANTS THAT CAPT HAD AUTH THE DEPLANING OF PAX THROUGH THE AFT VENTRAL STAIRS. THOSE ASSUMPTIONS WERE INCORRECT. THE FLC DID NOT OBSERVE THE DEPLANEMENT. FURTHERMORE, FLC MEMBERS WERE NEVER ADVISED OR NOTIFIED BY ANYONE THAT DEPLANING WAS UNDERWAY. THIS INCLUDES THE INFO EXCHANGE WITH THE STATION AGENT WHO INITIALLY APCHED THE ACFT AND ENTERED THE COCKPIT VIA THE AFT VENTRAL STAIRS. THE FIRST INDICATION TO THE FLC THAT PAX HAD ESCAPED WAS WHEN THE FO NOTICED THE 2 YOUNG WOMEN WALKING TOWARDS THE TERMINAL. THE SECOND INDICATION WAS BY AN ACARS MESSAGE THAT THE FLC RECEIVED WHILE TALKING TO THE STATION AGENT IN THE COCKPIT. HAD THE FLC BEEN NOTIFIED IN A TIMELY MANNER THAT DEPLANING WAS OCCURRING, PERHAPS THE SECURITY BREACH COULD HAVE BEEN AVOIDED. SUMMARY OF RPTR'S ATTACHMENT: ACFT DIVERTED TO ENRTE ALTERNATE DUE TO SEVERE WX AT DEST. THE ARR STATION PARKED ACFT AWAY FROM TERMINAL BECAUSE OF LACK OF PERSONNEL AND GATE SPACE. SEVERAL CALLS WERE MADE TO THE COMPANY OPS TO GET AIR CONDITIONING AND STAIRWAYS, ETC, WITHOUT MUCH RESULT. ACFT INVOLVED HAD A VENTRAL STAIRWAY THAT WAS LOWERED TO GIVE STATION PERSONNEL ACCESS TO THE ACFT. DURING THE TIME THAT THAT ENTRY TO THE ACFT WAS OPEN, THERE WAS ENOUGH LACK OF COM BTWN THE STATION AND THE CREW MEMBERS AND THE PAX THAT PAX LEFT THE ACFT AND WERE UNESCORTED ON THE SECURE RAMP AREA OUTSIDE THE TERMINAL. PAX WERE RETRIEVED AND ACCOUNTED FOR. SUBSEQUENTLY ALL PAX WERE TAKEN OFF THE ACFT AND PROCESSED THROUGH SECURITY BEFORE ACFT DEPARTED.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.