N264NN

HISTORY OF FLIGHTOn 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.

On the day of the accident, ground crewmembers (also referred to as ramp agents) who were employed by Piedmont Airlines were assisting airplanes after their arrival at MGM. One ground crewmember reported that the ground crew held a safety briefing about 10 minutes before flight 3408 arrived at the gate.

The ground crew also held a subsequent safety “huddle” before the airplane arrived at the gate. The purpose of the safety huddle was to restate information provided during the safety briefing; specifically, the engines would remain running until ground power was connected, and the ground crewmembers should not approach the airplane at that point. The safety huddle also emphasized that safety cones should not be set down until the engines were off and had spooled down and the flight crew extinguished the airplane’s red beacon lights.

The flight crewmembers reported that, after an uneventful flight with an inoperative auxiliary power unit (a minimum equipment list item), they taxied the airplane to the ramp with both engines running for the company-required 2-minute engine cool-down period. As the airplane approached the gate, the flight crew saw three ramp agents and noted that the gate area was clear. After stopping the airplane and setting the parking brake, the captain gave the brake set hand signal to the ramp agent who was marshalling the airplane, which was followed by the hand signal to connect the airplane to ground power.

As the captain was shutting down the No. 2 (right) engine, the “DOOR CRG FWD OPEN” engine indicating and crew alerting system message appeared, indicating that ramp personnel had opened the forward cargo door (where the baggage was located). The first officer (FO) opened his cockpit window to inform the ramp agents that the engines were still operating. The captain made a brief announcement to the passengers, asking them to remain seated until the seatbelt sign was turned off.

The captain then told the FO that the seatbelt sign should stay illuminated until the airplane was connected to ground power and the No. 1 (left) engine (which was operating at the time due to the inoperative auxiliary power unit) was shut down. Immediately thereafter, the captain saw a “FAIL” symbol on the engine display, felt the airplane “shake violently,” and noticed that the No. 1 engine had shut down. The captain stated that he was unsure of what had occurred and that he extinguished the emergency lights, shut off both batteries, and left the flight deck to investigate. The captain subsequently realized that a ramp agent had been ingested into the engine.

Surveillance video showed that, after the airplane was marshalled to the gate and the nosewheel was chocked, the accident ramp agent began walking toward the airplane tail to place a safety cone. (The video did not capture the accident ramp agent placing a safety cone at the left wingtip, which was also one of her responsibilities.) As she approached the jet-blast area directly behind the No. 1 engine, she stumbled and continued walking before leaving the camera’s field of view.

The accident ramp agent reappeared on camera and began walking away from the airplane and toward the left wingtip. After temporarily disappearing from the camera’s field of view again, the ramp agent reappeared on camera as she was walking alongside the leading edge of the left wing toward the fuselage. One second later, she appeared to stop in front of the No. 1 engine and turn to the left (away from the engine and facing the camera). Subsequently, her left leg moved back toward the operating No. 1 engine. As her left foot touched the ground, her right leg lifted off the ground and moved upward, and her torso entered the engine inlet. Immediately afterward, her left leg lifted off the ground and entered the engine inlet.

The airplane’s upper red beacon light appeared illuminated throughout the accident sequence. The lower red beacon light could not be seen on the surveillance video.

According to a postaccident interview with the lead ramp agent, on the day of the accident, the accident ramp agent was expected to place a safety cone at the left wingtip, walk to the tail of the airplane and place another safety cone there, and then continue around the tail to the right side of the fuselage to assist with baggage unloading. The lead ramp agent stated that, after he set the chocks on the nosewheel of the airplane, he observed the accident ramp agent about to set the safety cone at the airplane tail while the No.1 engine was still operating. He yelled at and motioned for her to move away from the airplane. She began to move away from the airplane, and he turned away so that he could operate the ground power cord. Shortly thereafter, he heard a “bang” and noticed that the left engine had shut down. The lead ramp agent stated that none of the accident ramp agent’s duties would have required her to be on the left side of the airplane in front of or near the No. 1 engine. AIRCRAFT INFORMATIONThe airplane was a mostly metallic, low-wing, conventional tail monoplane. The airplane’s two high-bypass-ratio turbofan engines were mounted below the wings. The accident airplane model was also referred to as an Embraer ERJ175.

The airplane was equipped with upper and lower red beacon lights mounted on the top of the fuselage and the underside of the airplane, respectively. The beacon lights incorporated light-emitting diode bulbs that generated 400 candela. The beacon switch located in the cockpit overhead panel controlled both beacon lights.

The Embraer 175 Airport Planning Manual depicted the inlet and exhaust hazard areas, as shown in figure 1. The inlet hazard area comprised a 2.5-meter (8.3-ft) radius around each engine inlet. The exhaust hazard area extended about 26 meters (85 ft) behind the engines and generated wind velocities of at least 65 miles per hour.

ENGINE EXHAUST HAZARD AREA VELOCITY = 65 mph OR GREATER

= 29.0 m/s (95.3 ft/s)

2

26 m

(86 ft)

1

R=2.5 m (8.3 ft)

2.6 m

(8.6 ft)

2

INLET HAZARD AREA - CONDITION: 20 kn HEADWIND/CROSSWIND/TAILWIND BASED ON 12.2 m/s (40 ft/s) CRITICAL VELOCITY WITH 0.9 m (3 ft) CONTINGENCY FACTOR.

1

EXHAUST HAZARD AREA - CONDITION: 20 kn HEADWIND WITH GROUND EFFECTS

Hazard Areas - Ground Idle

Figure 1. Inlet and exhaust hazard area (Source: Embraer 175 Airport Planning Manual). AIRPORT INFORMATIONThe airplane was a mostly metallic, low-wing, conventional tail monoplane. The airplane’s two high-bypass-ratio turbofan engines were mounted below the wings. The accident airplane model was also referred to as an Embraer ERJ175.

The airplane was equipped with upper and lower red beacon lights mounted on the top of the fuselage and the underside of the airplane, respectively. The beacon lights incorporated light-emitting diode bulbs that generated 400 candela. The beacon switch located in the cockpit overhead panel controlled both beacon lights.

The Embraer 175 Airport Planning Manual depicted the inlet and exhaust hazard areas, as shown in figure 1. The inlet hazard area comprised a 2.5-meter (8.3-ft) radius around each engine inlet. The exhaust hazard area extended about 26 meters (85 ft) behind the engines and generated wind velocities of at least 65 miles per hour.

ENGINE EXHAUST HAZARD AREA VELOCITY = 65 mph OR GREATER

= 29.0 m/s (95.3 ft/s)

2

26 m

(86 ft)

1

R=2.5 m (8.3 ft)

2.6 m

(8.6 ft)

2

INLET HAZARD AREA - CONDITION: 20 kn HEADWIND/CROSSWIND/TAILWIND BASED ON 12.2 m/s (40 ft/s) CRITICAL VELOCITY WITH 0.9 m (3 ft) CONTINGENCY FACTOR.

1

EXHAUST HAZARD AREA - CONDITION: 20 kn HEADWIND WITH GROUND EFFECTS

Hazard Areas - Ground Idle

Figure 1. Inlet and exhaust hazard area (Source: Embraer 175 Airport Planning Manual). ADDITIONAL INFORMATIONThe accident ramp agent, age 34, had worked for Piedmont Airlines at MGM since November 2021; her position required her to continuously work around jetpowered airplanes. She completed new-hire ramp training in December 2021, which included a discussion about jetblast, ingestion zones, and procedures for safely approaching an engine. The ramp agent’s training records indicated that she had satisfactorily completed recurrent training in September 2022.

In December 2021, a Piedmont Airlines manager completed an employee corrective action form about the ramp agent, which indicated that she had been demonstrating unsatisfactory performance on the airport ramp related to task management. Another employee corrective action form about the accident ramp agent, dated August 2022 (about 4 months before the accident), stated in part that she had been “asked on numerous occasions” to ensure that her appearance was consistent with company standards.

During a postaccident interview, the lead ramp agent stated that his duties included conducting the safety huddle, assigning responsibilities to other ramp agents, informing ramp agents of any special circumstances related to an arriving airplane (such as the inoperative auxiliary power unit on the accident airplane), and ensuring that the ramp is set up properly.

A service bulletin was available to equip airplane engines with spinners that have spiral painting to provide a visual cue showing engine operation. Envoy Air had not implemented the service bulletin.

The Department of Transportation does not consider ramp personnel pos...