Date: December 31, 2022
Location: Montgomery Regional Airport, Montgomery, Alabama, USA
Aircraft: Embraer ERJ-175, registration N264NN
Operator: Envoy Air (operating as American Eagle)
Flight Number: AA-3408
Route: Montgomery, AL (USA) to Dallas Fort Worth, TX (USA)
Occupants: Unknown
Fatalities: 1 ground worker
Summary of Events
On December 31, 2022, a tragic incident occurred at Montgomery Regional Airport when a ground worker was fatally injured after being ingested into the left engine of an Embraer ERJ-175 operating as American Eagle Flight AA-3408. The aircraft was parked at the gate with its engines running as the auxiliary power unit (APU) was inoperative. The accident occurred during routine ground handling while the aircraft awaited ground power connection.
This incident prompted an investigation by the National Transportation Safety Board (NTSB) and raised concerns about safety protocols, ground crew training, and cognitive impairment risks among ramp personnel.
Aircraft Details
• Type: Embraer ERJ-175
• Registration: N264NN
• Engines: 2x General Electric CF34-8E
• Configuration: Passenger aircraft
Sequence of Events
1. Arrival at Gate:
• The aircraft taxied to the gate with both engines running due to an inoperative APU.
2. Safety Briefings:
• Ramp agents participated in pre-arrival safety huddles, emphasizing the need to stay clear of the engines until they had spooled down and the red beacon lights were turned off.
3. Incident:
• Despite the briefings, a ramp agent approached the left engine to place a safety cone and was ingested into the running engine. Surveillance footage confirmed the sequence of events.
4. Immediate Aftermath:
• The captain noticed a violent shake and an automatic shutdown of the left engine. Emergency lights were extinguished, and the aircraft’s systems were powered down.
Initial Findings
The NTSB identified the following initial factors:
1. Operating Environment:
• The aircraft’s engines were running due to an inoperative APU, increasing the risks during ground operations.
2. Ramp Agent Actions:
• The ramp agent’s decision to approach the engine was inconsistent with training and safety protocols.
3. Training and Procedures:
• The ramp agent had received training on jetblast and engine ingestion risks. Company policies clearly outlined safe distances and procedures for approaching running engines.
Probable Causes
The NTSB concluded that the fatal incident was caused by:
1. Cognitive Impairment:
• The ramp agent’s judgment was likely impaired due to underlying medical conditions (multiple sclerosis and diabetes) and cannabis use, which may have affected decision-making and situational awareness.
2. Deviation from Protocols:
• The ramp agent failed to adhere to safety procedures despite clear briefings and visible cues, such as the illuminated red beacon lights and the operating engine noise.
3. Inadequate Classification of Safety Roles:
• Ramp personnel were not classified as safety-sensitive positions, exempting them from federally mandated drug and alcohol testing, which could have detected cannabis use.
Safety Risks Identified
1. Cognitive Impairment:
• Medical and toxicological factors increased the risk of unsafe behaviors among ground personnel.
2. Inadequate Safety Oversight:
• The lack of mandatory drug and alcohol testing for ramp personnel exposed a critical gap in safety management.
3. APU Dependency:
• Operating with an inoperative APU heightened the risk during ground operations.
Recommendations
1. Expand Safety-Sensitive Classifications:
• Classify ramp personnel as safety-sensitive positions, subjecting them to federally mandated drug and alcohol testing.
2. Enhance Safety Briefings:
• Reinforce the importance of maintaining safe distances from operating engines through continuous training and safety drills.
3. Review APU Dependence:
• Encourage operators to prioritize resolving APU issues to minimize risks associated with running engines during ground operations.
4. Cognitive Risk Assessments:
• Implement regular health assessments for ground personnel to ensure they are fit to perform safety-critical tasks.
Safety Lessons
This tragic incident underscores the critical importance of adhering to safety protocols, ensuring proper classification of safety-sensitive roles, and addressing cognitive risk factors among ground personnel. Robust training, oversight, and procedural enforcement are essential to prevent similar occurrences in the future.
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Our investigation reports are based on all the evidence and facts we have at the time of writing and posting. We apologise if any details are missed or are not fully accurate.
