NTSB releases final report on Piedmont Airlines' fatal engine ingestion incident

Policy

Simple Flying | Simple Flying

By Sky Industry News

Dec 22, 2024

The National Transportation Safety Board (NTSB) has released its final report on a tragic incident involving a Piedmont Airlines employee. The ramp agent was ingested into an engine of an Embraer E175 aircraft in December 2022 at Montgomery Regional Airport, Alabama. The American Eagle flight, operated by Envoy Air, had landed after an uneventful journey when the accident occurred.

Upon landing, the pilots left one engine running due to an inoperative auxiliary power unit (APU). Shortly after reaching the gate, the captain observed a 'FAIL' symbol on the engine display as the aircraft vibrated violently. Both pilots realized that a ramp agent had been ingested into the left-hand engine.

Piedmont Airlines' ramp agents were responsible for assisting aircraft upon arrival. Before the E175's arrival, safety protocols required maintaining distance from engines until they spooled down and beacon lights were off. Investigators confirmed at least one red beacon light was operational during the incident.

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“This investigation evaluated the accident ramp agent’s training and American Eagle’s procedures, her medical conditions and toxicology results, and her judgment,” stated NTSB officials.

The NTSB highlighted that according to American Eagles Ground Operations Manual, personnel should remain 15 feet from an engine—a distance almost twice that of Embraer's specified hazard area. Despite participating in safety briefings, it appears procedural adherence was not a factor in this accident.

“Notably, he tried to warn her...to move away from the operating engine," added investigators regarding efforts made by colleagues to ensure safety compliance.

The report also revealed that while there were no documented cognitive impairments during recent medical evaluations of the ramp agent—who had multiple sclerosis and diabetes—there remained risks associated with these conditions affecting cognition. Additionally, toxicology tests detected delta-9-THC metabolites indicating cannabis use before the incident.

“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,” noted investigators.

Cannabis can potentially impair cognitive functions further in individuals with existing conditions like multiple sclerosis. However, specific details regarding usage could not be conclusively determined through available evidence.

“The ramp agent’s cognitive impairment...resulted in her inconsistent behavior with trained procedures,” concluded investigators about contributing factors leading up to this tragic event.

Currently classified as non-safety-sensitive positions by DOT regulations meant mandatory drug testing wasn't applicable for Piedmont Airlines’ ground crew members at that time. If such roles were deemed safety-sensitive federally mandated testing might have identified prior cannabis usage among employees involved before incidents occurred.