I have spent much time reading NTSB accident reports over my career. They are usually very educational, even for those of us outside the aviation industry. This incident involving this mother of three being sucked into a jet engine has captured a lot of headlines due to its graphic nature, but there will be so much to learn from this incident in the coming months/years. So far what we can learn from this tragedy… Administrative Controls have severe limitations! Here is the preliminary information from the NTSB. See if you can see the weaknesses, slips, lapses, mistakes, and violations that caused this accident.
I will say this; the NTSB made clear that two (2) ground crew members placed themselves in harm’s way and had to be corrected by another ground crew member; one of these members was the deceased. This after both of these workers had attended a “safety briefing” 10 minutes before the plane arrived and a “safety huddle” before the aircraft reached the gate. Both meetings specifically stated that engines would remain on at the gate until ground power was connected to the plane.
NOTE: any emphasis is by me
On December 31, 2022, at about 1539 eastern standard time (EST), an Embraer 170 airplane, N264NN, was involved in an accident while parked at the gate with one engine running at Montgomery Regional Airport (MGM), Montgomery, Alabama. The 63 passengers and crew onboard were uninjured. One ramp personnel was fatally injured. The flight was operating under the provisions of Title 14 Code of Federal Regulation Part 121 as a regularly scheduled domestic passenger flight from Dallas Fort Worth (DFW), Texas to MGM.
The flight crew reported that after an uneventful flight, they elected to leave both engines running for the required two-minute engine cool-down period. As the airplane approached the gate, three ramp agents were present but clear of the safety area. After stopping the aircraft and setting the parking brake, the captain gave the hand signal to connect the airplane to ground power. As he was shutting down the number 2 (right) engine the “DOOR CRG FWD OPEN” engine indicating and crew alerting system (EICAS) message appeared (indicating that the forward cargo door had opened). The first officer (FO) opened his cockpit window to inform the ramp agent that the engines were still operating. The captain then made a brief announcement asking the passengers to remain seated until the seat belt sign had been turned off. He then relayed his intentions to the FO that the seat belt sign would stay illuminated until they had connected to ground power and could shut down the number 1 (left) engine. Immediately thereafter, he saw a warning light illuminate, and the airplane shook violently, followed by the immediate automatic shutdown of the number 1 engine. Unsure of what had occurred, he extinguished the emergency lights and shut off both batteries before leaving the flight deck to investigate.
Video surveillance captured the accident sequence and showed the airplane being marshaled to the gate. After the nose wheel was chocked, the ramp agent marshaling the airplane walked toward the forward cargo door located on the right side and near the front of the airplane.
Simultaneously, another ramp agent appeared, walking towards the back of the airplane with an orange safety cone, where she disappeared from view. A third ramp agent located near the right wing tip could be seen gesturing with his hand toward the back of the airplane. Meanwhile, a fourth ramp agent knelt near the airplane’s nose wheel. The ramp agent from the back of the airplane reappeared and began walking away from the airplane and towards the left wing tip, where she disappeared from the camera’s field of view. The marshaller could be seen backing away from the airplane’s open forward cargo door, and the ramp agent from the back of the airplane reappeared, walking along the leading edge of the left-wing and directly in front of the number one engine. She was subsequently pulled off her feet and into the operating engine. Throughout the course of the accident, the airplane’s upper rotating beacon light appeared to be illuminated (a warning indicator).
The ground crew reported that a safety briefing was held about 10 minutes before the airplane arrived at the gate. A second safety “huddle” was held shortly before the airplane arrived at the gate, to reiterate that the engines would remain running until ground power was connected. It was also discussed that the airplane should not be approached, and the diamond of safety cones should not be set until the engines were off, spooled down, and the airplane’s rotating beacon light had been extinguished by the flight crew.
One ramp agent located near the right wing tip stated that he observed another ramp agent approach the back of the airplane to set the rear safety cone. He observed her almost fall over from the engine’s exhaust while he attempted to alert her to stay back and wait for the engines to be shut down. He also stated that he observed the airplane’s upper and lower rotating beacon lights illuminated.
Another ramp agent stated that after choking the nose wheel of the airplane, he observed another ramp agent approach the forward cargo door, and he knelt to wave him off. He then observed another ramp agent about to set the safety cone at the rear of the airplane, he yelled and waved her off as the number 1 engine was still running. He observed her as she began to move away from the airplane before he turned to lower the cord for the ground power. Shortly thereafter, he heard a “bang” and the engine shut down.
| Did you notice that… there were two different employees who placed themselves in the hazard zone of the engine and had to be corrected. Yet it is suspected that BOTH of these team members particpated in the Safety Briefing 10 minutes before the plane landed and the “safety huddle” just before the plane arrived at the gate. |
The American Eagle Ground Operations Manual, Revision 3 dated July 13, 2022, states in part:
To Keep Employees Alive and Aircraft Intact, You Will:
NEVER approach an aircraft to position ground equipment next to an aircraft or open cargo bin doors until the engines are shut down and the rotating beacon(s) turned off, except when conducting an approved single engine turn.
Jetblast/Ingestion Zones
This information is preliminary and subject to change. Jet engines spin with powerful speed and are extremely dangerous until spooled down. The area in front of the engine is called the ingestion zone. The ingestion zone for all aircraft types is 15 feet. You must never enter the ingestion zone until the engine has spooled down.
Spool Down
The engine must be spooled down before entering the ingestion zone. This can take between 30-60 seconds, depending on aircraft type. This applies to both wing and fuselage/tail mounted engines. You must wait until you can clearly see the individual fan blades before entering the ingestion zone.
