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

“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.