History of Flight
On December 31, 2022, about 1539 central standard time, Envoy Air flight 3408, an Embraer 170 airplane (N264NN), sustained minor damage when it was involved in an accident while parked at the gate with one engine operating at Montgomery Regional Airport (MGM), Montgomery, Alabama. The 63 passengers and crew aboard the airplane were not injured. One ramp agent on the ground was fatally injured. The flight was operating under Title 14 Code of Federal Regulations Part 121 as a regularly scheduled domestic passenger flight from Dallas Fort Worth International Airport (DFW), Dallas, Texas, to MGM.
Ground crewmembers employed by Piedmont Airlines held a safety briefing about 10 minutes before the flight arrived, and a subsequent safety huddle before arrival. The huddle emphasized that engines would remain running until ground power was connected, and that safety cones should not be set down until engines were off and red beacon lights extinguished.
After an uneventful flight with an inoperative auxiliary power unit, the flight crew taxied with both engines running for a 2-minute cool-down. At the gate, the captain gave the brake set and ground power connection hand signals. As the captain shut down the No. 2 (right) engine, the forward cargo door was opened. The first officer informed ramp agents that engines were still operating. The captain kept the seatbelt sign on. Subsequently, the No. 1 (left) engine shut down after a “FAIL” symbol and a violent shake. The captain realized a ramp agent had been ingested.
Surveillance video showed the accident ramp agent walking toward the tail to place a cone, stumbling near the jet-blast area behind the No. 1 engine, then moving alongside the left wing toward the fuselage. She stopped in front of the operating engine, turned left, and her leg moved back toward the engine. Her torso and legs entered the inlet. The upper red beacon light was illuminated throughout.
The lead ramp agent stated that after he set chocks, he observed the accident ramp agent about to set a cone at the tail while the engine was running. He yelled and motioned for her to move away. She began moving away, and then he heard a bang and the engine shut down.
Aircraft Information
The airplane was a mostly metallic, low-wing, conventional tail monoplane with two high-bypass-ratio turbofan engines mounted below the wings. It was equipped with upper and lower red beacon lights with LED bulbs generating 400 candela. The Embraer 175 Airport Planning Manual depicted an inlet hazard area with a 2.5-meter (8.3-ft) radius around each engine inlet and an exhaust hazard area extending about 26 meters (85 ft) behind the engines, generating wind velocities of at least 65 miles per hour.
Additional Information
The accident ramp agent, age 34, had worked for Piedmont Airlines at MGM since November 2021. She completed new-hire ramp training in December 2021, which covered jetblast, ingestion zones, and safe engine approach procedures. She completed recurrent training in September 2022. Her training records showed satisfactory completion.
Employee corrective action forms indicated unsatisfactory performance related to task management in December 2021 and appearance concerns in August 2022. The lead ramp agent conducted safety huddles and assigned responsibilities.
A service bulletin existed to equip engines with spiral-painted spinners as a visual cue of engine operation, but Envoy Air had not implemented it. The Department of Transportation does not consider ramp personnel positions safety-sensitive, so they are not required to undergo drug and alcohol training or testing. Piedmont Airlines had a drug and alcohol policy prohibiting being at work impaired.
Medical and Pathological Information
The ramp agent had relapsing-remitting multiple sclerosis, diabetes mellitus, and obesity. In August 2021, her cognition was assessed as normal. Telehealth visit in February 2022 noted occasional leg weakness (“legs go to spaghetti”) and arm uncoordination, vision loss, and high blood sugars. The neurologist documented stable multiple sclerosis with no new relapse.
An autopsy determined the cause of death was multiple blunt force injuries. The FAA Forensic Sciences Laboratory detected delta-9-tetrahydrocannabinol (delta-9-THC) in cavity blood at 7.4 ng/mL and in urine. 11-hydroxy-THC was detected in urine only. Carboxy-delta-8-THC and 9-THC were detected. No ethanol was found.
Organizational and Management Information
Envoy Air Inc., a subsidiary of American Airlines Group, operated the flight as American Eagle. Piedmont Airlines, also an American Airlines subsidiary, provided ground support. The American Eagle Ground Operations Manual contained safety rules, including never approaching an aircraft with engines running until spooled down and beacons off, and keeping 15 feet from ingestion zones. The jetblast zone was 100 feet at idle. The manual specified engine spool-down times of 30-60 seconds and waiting until individual fan blades were visible. The lead ramp agent noted that ramp personnel were responsible for staying 15 feet from a running engine, but judging distance was difficult.