# NTSB ATL92LA022: British Aerospace 3101, N311PX, Memphis, TN, November 9, 1991

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: November 9, 1991, 08:48 local (14:48 UTC)
- Place: Memphis, TN
- Location: 35.0424° N, 89.9767° W: Placed by OpenAirDocs at FREDERICK W SMITH INTL/MEMPHIS (MEM), within about a mile (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=35.0424&lon=-89.9767&mi=10
- Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 1 serious, 10 uninjured
- Status: Completed, report February 8, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 8546
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL92LA022
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8546/pdf
- Page: https://openairdocs.org/ntsb/ATL92LA022

## Probable cause

THE FAILURE OF THE RAMP AGENT TO POSITION AN ADDITIONAL STEP BELOW THE LAST STEP OF THE AIRSTAIR DOOR AND THE GROUND; THE AGENT FAILED TO FOLLOW A VERBAL COMPANY PROCEDURE.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Miscellaneous/other, standing - engine(s) not operating
  - miscellaneous equipment - not used, ground personnel (cause)
  - procedures/directives - not followed, ground personnel (cause)

## Analysis

THE AIRPLANE WAS PARKED AT THE PASSENGER TERMINAL WITH BOTH ENGINES SHUT DOWN AS PASSENGERS DEPLANED.  REPORTEDLY, TWO RAMP AGENTS WERE POSITIONED AT THE BOTTOM OF THE AIRSTAIR DOOR AND WERE ASSISTING THE DEPLANING PASSENGERS.  HOWEVER, ACCORDING TO THE WIFE OF THE INJURED PASSENGER, HER HUSBAND, A DIABETIC, WAS NOT ASSISTED BY THE TWO AGENTS. AS THE PASSENGER STEPPED FROM THE LAST STEP TO THE GROUND (APPROXIMATELY 18 INCHES) HE FELL AND BROKE HIS HIP.  A NORTHWEST AIRLINK OFFICIAL STATED THAT A STEP WAS NOT POSITIONED BELOW THE FINAL AIRSTAIR STEP AS REQUIRED BY VERBAL COMPANY POLICY.  A WRITTEN POLICY REGARDING THIS MATTER IS BEING FORMULATED AND WILL BE INSERTED INTO THE STATION MANUAL. SUBSEQUENT TO THIS ACCIDENT, ALL RAMP AGENTS HAVE BEEN RETRAINED IN THE USE OF THE ADDITIONAL STEP REQUIREMENT FOR THE JETSTREAM AIRPLANES.

## Aircraft

- Registration: [N311PX](https://openairdocs.org/deregistered/N311PX-2001-07-26), registration cancelled 2001-07-26, S/N 679 (OpenAirDocs)
- Reported make and model: BRITISH AEROSPACE 3101
- Registry model: [British Aerospace BAE JETSTREAM 3101](https://openairdocs.org/model/british-aerospace-bae-jetstream-3101) (registry code 1500216) (OpenAirDocs)
- Category: Airplane
- Serial number: 679
- Engines: GARRETT TPE-331 940 horsepower turbo prop
- Damage: No damage
- Flight: Part 135
- Operator: Northwest Airlink
- Registered owner: Express Airlines, Inc.
- Airworthiness certificate: Standard, Transport
- Last inspection: Unknown, January 2, 2000
- Departed: MEI, MERIDIAN, MS
- Flight plan: IFR
- Airport: MEM, Memphis International, runway 36, 7,319 × 150 ft, concrete

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 32; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 4,800 total, 2,000 in this make and model, 240 in the last 90 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 50° at 5 knots
- Visibility: 15 statute miles
- Lowest ceiling: none
- Temperature: 30 °F, dew point 16 °F
- Altimeter: 30.00 inHg
- Observed at: MEM, 1 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 19911109056499A](https://openairdocs.org/incident/19911109056499A), Nov 9, 1991: Bag JETSTM3101, Memphis, TN. Passenger fell and broke his hip while descending the stairs. Hospitalized.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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