Room for improvement in the internal communications of air crews as well as communications between airport operators and other actors in the field

The causes of the occurrence are in many ways related to deficiencies in internal communications both between colleagues as well as the airport and the other actors in the field.

“In Finnair’s manuals and instructions, the personnel are instructed on who is supposed to give the driver of the staircase vehicle the OK sign to indicate that the passengers have exited the aircraft and that the staircase vehicle can be driven away. However, in the accident that occurred on 13 January 2020, the crew members were not clear on who was supposed to give the sign – and neither did they share the situational awareness on whether the sign had been given or not. As a result, the crew member that was eventually injured thought that she was responsible for giving the sign. She went on top of the vehicle to give the sign. However, as the staircase vehicle started to move, the crew member overbalanced and fell,” states the Investigator-in-charge Janne Kotiranta.

In the investigation, it was also discovered that there was room for standardisation in the practices of calling for help. However, in the accident under investigation, help arrived quickly nevertheless.

Aviation operators have a statutory duty to draw up an occurrence report on occurrences, incidents and accidents, which is also sent to the Finnish Transport and Communications Agency. The safety management organisations of aviation operators draw up risk assessments on occurrences and take measures to improve safety, if necessary. The Occurrence Reporting Regulation also obliges every organisation and actor involved in the accident to draw up an occurrence report; however, the Regulation does not require the organisations to share the incident reports with each other. Even though 50 occurrences related to the issue have taken place in Finland within the last five years, the safety risks mentioned in the occurrence reports have not resulted in notable monitoring or other measures by the Finnish Transport and Communications Agency. Neither has Finnair initiated any significant measures with regard to the occurrences concerning them related to the issue.

“Simply reporting the occurrences does not do any good, if the issues mentioned in the reports are archived at the bottom of the drawer. The aim should be to process the reports in a coordinated manner so that lessons could be learned from the problems and incidents,” adds Professor Veli-Pekka Nurmi, Executive Director of the Safety Investigation Authority.

As a result of this accident, the Safety Investigation Authority has issued six safety recommendations related to the practices of calling for help in case of an accident, improving the situational awareness of the cabin crew by clarifying and streamlining internal communications, as well as communication between different actors concerning occurrences.

Link to summary and investigation report

Further information:

Investigator-in-charge Janne Kotiranta, tel. +358 2951 50703

Veli-Pekka Nurmi, Executive Director, Professor, tel. +358 2951 50701, Twitter: @VPNurmi

Photo: Swissport Finland Oy

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