The National Transportation Safety Board ( NTSB
) has published its final report into an incident when a Piedmont Airlines employee, handling an American Eagle ( Envoy Air
) flight after it had landed in Montgomery, Alabama, was sucked into an engine of an Embraer E175 in December 2022.
Sudden engine failure
According to the NTSB, after an uneventful flight, the American Eagle
E175, registered as N264NN, landed at Montgomery Regional Airport (MGM) on December 31, 2022. The Envoy Air pilots, who operated the 
American Airlines
regional subsidiary’s itinerary, left the number one engine running while they waited for ground power due to an inoperative auxiliary power unit (APU).
Shortly after they arrived at the gate, the captain saw a ‘FAIL’ symbol on his engine display. The aircraft vibrated violently, and the pilot noticed that the left-hand engine had shut down. Immediately, both pilots determined that the engine had ingested a ramp agent.
Photo: Wenjie Zheng | Shutterstock
At the time of the event, Piedmont Airlines’ ramp agents were responsible for supporting aircraft after arriving at the Alabaman airport. Before the E175’s
arrival, the ramp agents discussed everyone’s roles and the safety precautions each must take.
This included maintaining a position away from the aircraft until the engines had spooled down and the red beacon light was turned off. According to the investigators, at least one of the red beacon lights was working at the time of the engine ingestion.
“This investigation evaluated the accident ramp agent’s training and American Eagle’s procedures, her medical conditions and toxicology results, and her judgment.”
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Details of the accident will become clearer following an FAA and NTSB investigation.
Staying further away than the Embraer’s recommended distance
The NTSB highlighted that, as detailed in the American Eagles Ground Operations Manual, ramp personnel were required to stay 15 feet (4.5 meters) from an engine. This is almost two times the Embraer’s
boundary for the engine hazard area of 8.3 feet (2.5 m).
In an interview with the NTSB, the leading ramp agent of the day told the investigators that they made sure that the ramp agent, who was ingested into the left-hand engine, participated in the safety huddle and understood their duties.
“Notably, he tried to warn her, while she was at the back of the airplane, to move away from the operating engine. Thus, the accident ramp agent’s training and the operator’s procedures were not factors in this accident.”
Photo: Ceri Breeze | Shutterstock
The NTSB stated that the ramp agent completed their new-hire ramp training in December 2021 and recurrent training in September 2022. The training included information about jet blasts, potential ingestion zones, and procedures to approach an engine safely.
American Eagle’s manual also specified jet blast and ingestion zones, engine spool down, procedures for approaching an airplane, and waiting until the airplane’s red beacon lights were turned off.
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The agency called out three “deficiencies” that contributed to the tragic incident.
Cognitive impairment
A post-accident analysis revealed that the ramp agent had relapsing and/or remitting multiple sclerosis, which can adversely affect cognition. While doctors did not document any cognitive impairment during the agent’s last visit, they had a “substantial risk of such impairment because of her condition.” The NTSB could not determine whether this impacted their decision to walk in front of an engine.
They also had diabetes that was treated by medication, including insulin. As a result, the condition increases the risk for abnormally high or abnormally low blood glucose, which could result in fatigue or diminished concentration.
“The ramp agent’s postmortem urine glucose result was normal; thus, she was not likely experiencing a major metabolic disturbance from extreme high blood sugar at the time of the accident.”
The NTSB stated that toxicology tests revealed that delta-9-THC and its metabolites and carboxy-delta-8-THC were also detected, meaning the agent “had used a cannabis product.”
Investigators, however, noted that the blood concentration of the former does not directly predict a person’s impairment.
Cannabis has the potential to cause cognitive and psychomotor impairment and can worsen cognitive impairment in individuals with multiple sclerosis. However, a person’s blood concentration of delta-9-THC does not directly predict that person’s impairment. Details of the ramp agent’s cannabis use, including dose, route, timing, and specific effects, could not be determined from the available toxicological evidence.
The investigators concluded that at the time of the incident, the ramp agent’s behavior demonstrated their deficient judgment, which was likely due to cognitive impairment following their medical and toxicological cognitive risk factors.
Photo: lorenzatx | Shutterstock
“The ramp agent’s cognitive impairment, which resulted in her (1) inconsistent behavior with trained procedures and pre-landing briefings, (2) presence on the left side of the airplane while the left engine was still operating, and (3) subsequent ingestion into the engine.”
According to the NTSB, the Department of Transportation (DOT) does not consider ramp personnel to be safety-sensitive. Thus, Piedmont Airlines
was not mandated to provide mandatory drug and alcohol training and testing, including random examinations.
If these positions had been safety-sensitive, the ramp agent would have been subjected to federal drug testing, which might have allowed Piedmont Airlines to detect whether the person involved in the incident had used cannabis before they were ingested by the engine.
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