Investigation Summary
Envoy Air flight 3408 arrived at Montgomery Regional Airport with an inoperative APU, requiring the flight crew to keep the No. 1 (left) engine running to maintain electrical power until a ground power unit (GPU) could be connected. The ground crew, employed by Piedmont Airlines, held two safety briefings prior to the arrival, specifically noting that the engines would remain running and that no one should approach the aircraft until the engines were spooled down and the red beacon lights were extinguished. Surveillance footage showed the ramp agent walking toward the tail to place a safety cone, stumbling near the jet-blast area, and then walking along the leading edge of the left wing toward the fuselage. The lead ramp agent observed her near the operating engine and attempted to warn her to move away. However, she stopped in front of the No. 1 engine and was subsequently pulled into the inlet. Post-accident toxicology detected delta-9-THC and metabolites in the agent's system. Additionally, medical records revealed she suffered from relapsing-remitting multiple sclerosis and diabetes, conditions that can cause cognitive impairment, fatigue, and diminished concentration.
Final Conclusions
The NTSB concluded that the ramp agent's cognitive impairment resulted in her failure to follow trained procedures and pre-landing briefings. This impairment led to her presence in the hazardous ingestion zone of the operating No. 1 engine. The investigation noted that while the agent had received proper training and the operator's procedures were adequate, her underlying neurological condition (multiple sclerosis) and the presence of psychoactive substances (THC) likely compromised her executive functioning and vigilance. The NTSB Final Report was published on December 19, 2024.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Age 47. Last FAA Medical: October 12, 2022. Last Flight Review: October 6, 2022.
First Officer
Age 27. Last FAA Medical: April 18, 2022. Last Flight Review: September 10, 2022.
Systems & Failure Modes
Red Beacon Lights
Safety lights mounted on the top and bottom of the fuselage used to alert ground personnel that engines are running or about to start.
Engine Indicating and Crew Alerting System (EICAS)
The system displayed a 'FAIL' symbol and a cargo door open message to the flight crew during the event.
Auxiliary Power Unit (APU)
A small internal engine used to provide power and air conditioning while the main engines are off; its inoperative status necessitated keeping a main engine running at the gate.
Interesting Facts
- 01The aircraft's red beacon lights were illuminated throughout the accident sequence, signaling that engines were running.
- 02The Embraer 175 inlet hazard area is defined as a 8.3-foot radius around the engine inlet.
- 03The American Eagle Ground Operations Manual specifies a 15-foot ingestion safety zone for all aircraft types.
- 04The accident ramp agent had completed recurrent safety training three months prior to the accident.
- 05Postmortem toxicology detected delta-9-THC at 7.4 ng/mL in the ramp agent's blood.
- 06A service bulletin for spiral-painted engine spinners, which provide a visual cue of engine rotation, had not been implemented on this aircraft.
- 07The ramp agent had been issued a corrective action form for unsatisfactory performance related to task management in December 2021.
Safety Actions & Advisories
Safety-Sensitive Position Reclassification
Source ↗The NTSB investigation highlighted that the Department of Transportation does not currently classify ramp personnel as 'safety-sensitive.' The report discussed the potential benefits of reclassifying these roles to mandate federal drug and alcohol training and random testing, which might have detected the agent's cannabis use and allowed for intervention prior to the accident.
Visual Engine Rotation Cues
Source ↗The investigation noted that a service bulletin was available to equip engine spinners with spiral painting to provide a visual cue of engine rotation. While not implemented on the accident aircraft, such cues are intended to improve ground crew awareness of operating engines.
Known Controversies & Unanswered Questions
Safety-Sensitive Designation for Ramp Personnel
Reference ↗The NTSB investigation highlighted a regulatory gap where the Department of Transportation does not classify ramp personnel as 'safety-sensitive.' This means they are not subject to mandatory federal drug and alcohol testing or training. The NTSB suggested that such a classification might have allowed for the detection of the agent's cannabis use prior to the accident.
Location
ACCIDENT SITE · Coordinates taken from the ntsb final report.