NTSB Preliminary Report Ramp Agent Fatality 31 Dec 2022 Montgomery Al.
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I’m a ramp rat out here in L.A. and the biggest issue I come across here is complacency. The repetition of turning a plane becomes mindless after a certain point. There is nothing that we do that requires us to think beyond what muscle memory tells us. A new ramper might be vigilant in keeping up with safety, but the sad bottom line is safety far too often gets thrown out the window when you have a guy that’s been turning planes for 10-20 years.
A big problem is also training and staffing. I can not tell you how many new people get into the industry and just get thrown out there. “Watch what I do and don’t break anything” is something that almost feels like a training motto at this point. Very rarely is someone actually taught and explained what the hell they’re doing out there, let alone what’s expected of them. I just recently had a new hire tell me that he’s been here for 4 months and his instructor never walked the ramp to explain the markings out there. This kid couldn’t tell me the difference between the safety diamond and the taxi line. Of course he isn’t going to know about the ingestion markings at the gate if he can’t even be taught the most obvious type of line markings a gate is gonna have.
Ramps are almost always severely understaffed, and the pressure to not cause a delay can get high if you have 2 guys turning anything bigger than something like a crj. Quick turns are an even bigger problem because you can’t exactly make MST(minimum service time)on a larger aircraft like a 737 if you only have two guys to turn it from brakes set to brakes off. Sometimes pilots will help us not catch a delay by popping the brakes while we’re still loading to generate that out time and then set them again.
The job is some of the most fun I’ve ever had in my life. I think it’s a job that can be truly accepting of anyone and can be a job for all walks of life.
With that said this job wants to kill us. There is nothing safe about what we do, no matter how much safety is prioritized. A huffer cart can kill you. An engine can kill you. A tug can kill you. Jet wash can severely hurt you if it doesn’t kill you. The bin can severely hurt you. The belt loader, the bag drop, an uncontrolled taxiway, other guys pushing out the gate next to you, holding traffic for a gate to open up. Everything we do is high risk, but the monotony of doing the exact same thing every day the exact same way piled up with the lack of training( and to be honest the lack of common sense that airlines tend to not check for when they bring in a new hire) leads to horrible tragedy’s such as this. The second you turn off your brain you can die. The moment you aren’t paying attention to the person next to you they can die.
Rampers have one of the most dangerous entry jobs if you ask me. We’re a dime a dozen. We aren’t a mechanic or flight crew, which are far less expendable. You can take anyone and teach them how to ramp and they’ll either shine or figure out how to do it, but we don’t have any requirements to do what we do when we apply for the position. We don’t have to have any type of training a pilot or a mechanic has to have in order to do what they do. We just have to have a clean record and be willing to work any schedule and that’s basically the only requirement.
All of these things lead exactly to what this video is about. I love my job and I love this lifestyle and I’ll keep doing it until my body gives out, but the culture on the ramp and the lack of care from the airlines over who does this job for them is frightening to me and it’s only going to inevitably lead to more accidents like this.
awesome comment. Thanks for this one.
Thank you.
They say the employees most likely to be injured are the newest ones and the oldest ones. New ones haven't learned and the oldest get complacent. From my perspective in management of cotton gins for 30 years, it's 100% true. It was the main reason employees were terminated. Violation of safety rules. Didn't feel bad about it. I was doing all of them a favor.
Do you think compartmentalize these things should be more training?
Thanks
Twice last year, I pulled into the gate with engines running and wasn’t able to shut down right away and rampers immediately swarmed the airplane, popped the cargo door etc in clear violation of all safety protocols. In both cases after we shut down I ran outside to put my foot in somebody’s ass. In both cases,the rampers were utterly dismissive of my concerns, and treated me as if I was a fool for being concerned. They could barely conceal their contempt as they explained that there was absolutely no danger, and they knew this because they do it all the time. I elevated my concerns to their management and as far as I know, nothing was done. Hopefully this incident changes a few minds…..
Sounds like you got some slack clowns on the ground there. Hope their maint. is not like that.
@@tomsherwood4650 Exactly.
What airport ?
Where there's smoke there's fire.
Bet that whole place
is a mess 👍
A 225 pound guy, isn’t a 110 pound girl - Women are at greater danger in every job that once was male only and must take more precaution. That’s not a sexist comment, it’s just damn common sense. - Same goes for a light weight guy too. The world has changed so safety rules are more important now to cover all the diversity
Basically agree. Safety rules were always important, though, not just b/c of increased diversity.
I'm a legacy airline Captain and have seen this more than once at my own airline. I recently challenged a ground crew as to why they did it. The response "We're told to do that to get the crew's pay clock to stop". I couldn't believe my ears. With "any" door open and parking brake set it stops the pay clock, shows the in time and ends the "block time" on the aircraft. My airline would deny it, but that's straight from the person that did it. I'll bet you it's no different at Piedmont, no matter what the report says. Follow the money and know that the FAA on-time statistics is a factor as well.
FAA would monitor American Airlines on time performance (AA). AA in turn would monitor Piedmont's (PT). The big three operating airlines are monitored for on time performance only for the aircraft they operate, not for the regional aircraft that operate under their livery.
So, as a worker with less of a salary than the pilot, you are to risk your life to "clock out" the pilots and shave a couple of bucks worth of time off. Lovely.
This is absolutely shocking. I’m stunned, flabbergasted. Fuck this industry.
Basic investigation rule = Follow The Money for a reason. Buddy told me, "Money isn't everything, but what's in 2nd is long way back!!" He was confined to White House for WW2, confined war for U.S. to: '42, '43, & '44 plus few months '41-'45 totaling 3.5 yrs. He was #1 on Fire Evac List! FDR was #3 behind Elenore! If FDR could trust him, we can too!! In meeting w/Generals & Secretaries, MacArthur asked Howard to please fetch him a cup of coffee. FDR glanced up & exclaimed, "Where'd Howard go?" His real Secretary answered, "MacArthur ordered a cup of coffee". FDR not suffering fools waited for "coffee man", then ordered MacArthur to fetch Howard a cup of coffee. When coffee arrived, Howard gave presentation!
It will not stop until some brave people make it stop.
I'm a 35 year airline mechanic. I constantly see my beacons being ignored, from baggage tugs driving behind to vehicles driving in front of me when I'm waiting for ground crew to guide me in. It's very frustrating. Any time the beacon is on, no one should approach the aircraft. Even if the engines aren't running, we may have the beacon on to let people know we're pressurizing the airplane for air leak tests. What disturbs me about this incident is that the crew briefed about the placarded APU before the fatal incident. I'm somewhat skeptical about whether that briefing actually occurred.
Even a complacent employee should have understood they were about to do something nonroutine. The inlet of a wing mounted engine must be respected. A 737 taxiing will suck water out of cracks in the pavement. Another thing to note is that the lower lip of the inlet cowl on these planes is right at knee level. You will have zero chance of saving yourself if you get drawn into the jet suction. Years ago, we had red markings on the ramp to remind people of the hazard zone. We got rid of them, because they got so slippery when deicing fluid was on them that they became more of a hazard than a safety enhancement.
At any rate, this was a very preventable tragedy. Sincere condolences to her family and friends, and to the people who witnessed this.
I will say as a traveler that multiple airports in California have those red markings in place.
However, California is obviously a state not well known for icing or cold temperatures.
I work for Southwest Airlines as a Ramp Agent. I can tell you my 17 years working at WN I have seen some close calls. People get complacent and accidents happen. Thanks Juan!
Is there any mandatory reporting or is it a culture of silence on close calls?
I spent 36 years with Allegheny, US Air, US Airways, American. Most of that time was spent working on the ramp. I saw co-workers be seriously injured but never one killed. The unfortunate agent who was killed, her trauma was over in a split second. The trauma that her co-workers, the passengers, and the crew experienced will be with them for a lifetime. Working on the ramp is not a joke and it can be deadly.
In addition, my guess is there was a lot of ass covering going on. There may have been a safety briefing before the flight arrived but my experience says maybe not. The running joke was always, "Safety is important... provided it doesn't interfere with the operation.
👍
@@mwilk19 There's no need to imply ass covering without evidence. However, as a coworker was killed, there isn't much to say other than exactly what was seen. Whether or not she or many of the crew were in the habit of walking too close to an engine, or pre-empting safety regs to process the flight, will not be shared outside the work team for some time to come. She died. Why she walked in front of that engine isn't for us to say, but speculation outside the team is certainly grotesque at this early date.
I love US scare ! The best when the blizzards on the East coast shut down airports. I'll never forget the generosity of a flight attendant at PIT that took me to an empty gate and hooked me up with the last flight out.
The person was blown over at the rear of the engine so she had to know the engine was running. Short of intentional this event is baffling. We will never know.
This incident has been the talk at the station I work at. We updated our inbound process just a little over a year ago to have all personal stay outside the safety envelope until the engine and beacon is off and the marshaller cleared you to approach. The reason we clarified this was because people were rushing during peak seasons and management was scared of something like this happening. A few common phrase we started to say were, "It's already delayed", "Take your time, the plane can wait", "One flight at a time", and "No injuries no deaths". There were so many near misses management was beating the message down our throats. One of the managers, an ex cop, told us the worst reports to do were injuries because you'd have to sit and watch your colleagues writhing in pain on repeat for hours on end.
My condolences go out to all those that were there in person or are related to the deceased. One of the worst ways to go and completely preventable too. The station should have a top to bottom investigation on station norms and training.
Very well said.
Outside of taking on "entry level jobs" that pay well because "Nobody in his right mind wants to do this", I'm no expert... BUT I would suggest (based on experience) that this station NEEDS someone dressed to come in "off the street" for the job with a hidden camera and microphone... Go the whole route for about 3 months recording, and then review all that footage...
Trust me, at any station, it would be illuminating to say the least...
From a "basic level mechanic" in a variety of transportation businesses and several sectors of the industry, to reptile wrangling in Florida before there were even official "Animal Control" or "Fish and Wildlife Management" positions to contend with the exotics trade... I can't tell you how many times I've gotten the "Job briefing" with "Safety is our top priority. Nobody dies today!" only to have every single safety rule, regulation, or even decent piece of advice tossed right out the window as soon as the clock starts ticking... It's like clocking in shuts down any common sense you THOUGHT you'd be working with.
I still wrangle reptiles (it oddly grows on you) and I no longer give that "Nobody dies today" speech... I let everyone know, "YOU are responsible for your own safety. Do NOT let me or anyone else talk you into something you can't do or aren't comfortable trying."
But the reality is that EVERY business out there has a hassle about pay and time on the clock. EVERYBODY is being pushed to do it quicker and cheaper. Management doesn't help... ever.
"Nothing is impossible for the jack-asses in air conditioned offices who do NOT have to do it."
I don't know who said it first, but he was a g** d*** genius. It's absolutely true, from the balding old men in Washington who make impossible laws and regulations, to the "High Brass" who keep scraping the budget so they can pour more money into the pockets of uneducated and inexperienced stockholders thousands of miles away in every direction who don't even care whether the job is "do-able" or not. ;o)
@TheBushka58 yep......sad but true. Kudos to all ground crews.
@TheBushka58Who ever was on that ramp is responsible for each other's safety!
@@gnarthdarkanen7464 Sounds like a good idea! But a new hire wouldn't know what to look for in terms of safety! More like a town hall meeting with experienced ramps(10 or more years)! But if that happened and the public got to view this! Most would never fly again!
I’m glad you did this video. I thought it was one of the most unfortunate accidents in aviation, in quite awhile. So easily preventable.
ERJ 170 captain here. Read this preliminary report shortly before operating a flight and while completing that flight our APU failed shortly before parking. With this incident fresh on my mind, I opened the window to alert the ramp crew immediately that we required ground power and the number 1 engine was running. Thankfully the ramp crew followed safety protocol and stayed out of the safety zone until we had power and shut down the engine. Also to answer the question on when the clock stops on the ERJ 170 our "in" or arrival time is recorded with the parking brake set and the main boarding door disarmed and opened
I flew the e170 at Compass for six years. Most of that as a captain. I think, unfortunately, this is probably a severe case of expectation bias. At a main hub, I would say ground crews would be rushed. They have 17 other flights to get to in the next 45 minutes. At an outstation though? I doubt it. Here's the thing. Most regional carriers work based on turn time. Flying for Delta, for example, the standard turn at an outstation is 30 minutes for a regional jet (or the scheduled departure time if the plane is on time or early). This timer is started when the plane blocks in. And on the ERJ, this occurs when the parking brake is set, AND the forward boarding door is opened. Based on this, the ground crew should have had no particular reason to be rushed because the clock hadn't started. On the E170, it is a limitation that refueling does not occur unless the passenger boarding door is opened. At Compass, for this reason, we would leave the beacon on until the door was opened rather than the engines shut down. This is to prevent an overzealous fueler from starting before it is safe to do so.
This looks like a case of management giving instructions, and the lower people not listening. It sounds like at least TWO of the ground crew simply ignored everything they were told. When possible, it is ALWAYS communicated that the APU is inoperative for this very reason. That said, when I was a captain, I HATED the idea of sitting at the gate with an engine running for this exact scenario. I did not want to the pilot who sucked in a ramper. The other thing too, is at most airports, the ground power is connected to the jet bridge. And the jet bridge cannot normally move with the ground power energized. What this means is there might be a delay until the jet bridge is parked. The above limitation also creates a danger because the beacon often remains on after the engines are shut down (when the APU is working). So the ground crew gets used to starting the process based on thinking the engines are shut down rather than the beacon. Because the beacon is waiting on the door. I should say, I don't know if Envoy has these same procedures. So when I had very short taxis like this, I would ALWAYS taxi slow enough so that when I set the parking brake, the two minutes was up and that number two engine was going to be shut down. But I still wouldn't have stopped this from happening.
Sadly, what happened here is always possible with an inoperative APU. What's crazy is that at least TWO people were potentially involved on either side of the airplane. The forward cargo door is immediately in front of the engine. Enough so that you have to skirt between the belt loader and the engine to do your preflight inspection, much like the 737. How they didn't suck two people in during this incident is a miracle. But the fact that it seems like the victim got nearly knocked over prior to walking around the wing and then getting sucked into the engine that did that... I hate to be mean, but this person had no business working in a hazardous environment like an airport ramp. If you can go through two safety briefings, have the engine literally blast you, and then walk into said engine, I guess it was just bound to happen. And now this flight crew has an accident on their record as a result when they really did everything right.
Exactly. Something was obviously very wrong here at this Airport. The Pilots couldn´t look quick enough, so much basic safety violations happened here in a few seconds.
Thank you very much for sharing your experience.
As a ramper of about 11 years, pretty much nailed every point 🤷♂️ some hubs tho don’t use the certain type of jetbridge ground power you are talking about. Here in ANC, most of the jet bridges just have the cord cooled up on the jetbridge and you can plug it in even if the jet bridge isn’t up to the plane. The power can even be on and the bridge can still move. However I have worked at some airports where it’s winched up to the top. If it’s not fully winched up, it won’t allow the jetbridge to move. With all that being said, thankfully I haven’t seen any super close calls when the engine is running. What makes me most nervous is when APU’s are inop and require an air start.
🤙
@@NicolaW72 What do you think the pilots did wrong? The red beacon was on indicating "Not safe to approach."
@@chetmyers7041 as I see it, the discipline or self-discipline of the Rampers was not automatic. There are clear safety rules in all walks of life which you ignore at your peril! Step off a kerb and get hit by a bus. Do not smoke when at the gas station. Don't put your fingers in a power socket. The world is full of rules. Follow them. In this instance, there needs to be a senior Ramper who must always be consulted before entering the exclusion zone. No ifs, no buts.
I've been working the ramp for 18 years for a Canadian airline. We have 5 weeks of training for new ramp employees before they're set to be scheduled on a crew. Since covid, we hired a lot of new staff, but being unionized helps due to less pressure from management.
This video has still been a learning experience for myself, and I will apply some of this knowledge into my daily safety at work. Thank you!
How often do they do refresher training?
@x stuff like dangerous goods, cabin security check, deicing is yearly. There's audits and safety bulletins on a semi regular basis. If you've been off for 6 months or more, you need a ramp refresh.
That's why we got rid of most unions in America. They cut into profits with all their "training" and "safety" concerns.
@Fake Drummer that makes absolutely no sense. All the non Unionized airline workers here make almost half of what we do. Limited benefits, vacations etc. While we're $30+ hourly.
Since Reagan's PATCO incident, how have unions fared in the airline industry?
I've worked on the Ramp in Australia for nearly 2 decades. I'm a leading hand, supervisor and trainer covering all aspects of ground handling for narrow body aircraft including the E170 aircraft and some wide body aircraft. There's a heavy focus on safety before schedule with what we do here. Having said that following covid there is a massive push from airlines to save money and one of the biggest areas has been in handling costs when contracting 3rd party ground handlers which is the case for me. We are turning aircraft with less staff while being expected to provide the same level of service as we did before covid. While we constantly hear about safety first there is definitely time pressure being placed on independent handlers from airlines while expecting everything to be perfect from a safety aspect.
Add to that the fact bonuses are typically given for quicker times and people will take shortcuts to get said bonuses
@@applec2400 And penalties---"corrective action" for slower times.
@@applec2400 management might get bonuses, the grunts on the ground are unlikely to see a cent.
Decades ago I worked on "the line" ("ramp" in US terminology) in Australia. Safety was a very big part of our job. I remember when the airlines transitioned away from B-727 and DC-9 to A-300, B-767 and B-737 - the whole "engine slung under the wing" thing brought about additional safety mitigations, e.g. be VERY careful and aware when plugging into the aircraft while engines are still running, and make sure you can grab and hold onto the nose gear if anything went wrong (e.g. electrical power glitch when switching over to APU source could cause the engine to spool up automatically).
Is this why Joyce sacked all the baggage handlers? He wants some of this sweet safety-breach money? There's good money to be made risking poorly paid workers lives.
Awesome video Juan! I worked for Envoy on the ramp as a Crew Chief at CLE for a few years and hopefully I'll be helpful. While there was certainly time pressure to start the offload scan within a certain amount of time once the parking brake was set, safety always came first. We were told time and time again to NEVER enter the safety envelope of an aircraft when the beacon light was on. I would say this was a weekly safety topic, not only on the safety calls I was on, but to all of us that worked the ramp. It was covered at nauseum in all of our recurrent CBT for the ramp. I remember working a very late E190 PHL turn and the pilots actually forgot to turn the beacon light off and I'm proud to say my team never entered the safety envelope. They waited and waited and waited until the pilots got that light off before anyone approached the aircraft. I would say for some reason the E170 series of aircraft were the aircraft that got the most "close calls" in the system. When I was at EGOM as a new hire, our instructor told us about another story EXTREMLY similar to this, again, on an E175. Luckily another ramp agent saw the agent walking towards the plane and was able to grab her and pull her away before she got close. Many people put pressure on themselves, or their team, when you have to quick turn a plane... especially a regional. Regionals had less time available for us to get our job done versus a mainline quick turn. I don't know if this flight was a quick turn or not but if it was, it would make a little more sense to me. You certainly had to hustle to get a regional quick turn done in time because if it got out late, as the Crew Chief, I had to answer as to why the flight pushed even a minute late. I guess to sum it up the best I can, while there was plenty of pressure on us to turn the flight on time and get our job done, safety was always put first at CLE. I would be incredibly happy to chat with you and give you even more insight as to the training and what goes on from our perspective on the ramp!
Ah, my friend, you left out a key piece of information: When you had to explain why the flight pushed "a minute late." And you said, "safety issue," was that the end of the conversation or did they say, "Don't let that happen again."
Because there is a serious conflict in your summary -- they busted your ass when you were a minute late but did they bust it when someone violated the safety envelope without injuries?
I doubt it and *that* matters, people get habituated to do what keeps them out of trouble. It sounds like the ramp agents have all the pressure but none of the power -- if the pilots leave the beacon running and it causes your team to run late, you're still the one who has to explain what went wrong.
You have integrity, did ever crew chief you met have the same integrity? Did every crew chief feel a personal responsibility to make sure their crew never violated the envelope or did they say, "That's on you crew."
Did that E190/PHL turn take an outbound delay and did it go on Flt Ops?
It WAS running behind schedule.
As a crew chief, how do you train new hires on inop APUs! And then who signs them off?
I've been on the ramp for 16 years. Every single day I've been out there I've seen this kind of complacency. Most ramp agents just go through the motions, just doing their job. They don't take the danger seriously and the fact that so many get lucky every day reinforces the mentality. This unfortunate woman went about this flight the same way she had with hundreds of others in the past. The briefing went in one ear, out the other. The jet blast didn't faze her.. She was just doing her job, completely on auto-pilot if you will. Some of us take safety very seriously and in the end no one can insure you get home safe at the end of the day except yourself.
a perfect summary of what happened IMO
Yes. Lots here are blaming management pressure, which I have no doubt is a factor, but at the end of the day you're responsible for your own life and safety and I truly believe that this accident occurred due to the worker's complacency. I hate to blame the victim, but she got careless due to complacency, IMO.
Sounds like modern day coal miners.
Sixteen tons and what do I get?
Do you really think they had briefings? Wouldn't the second briefing be seen in the video? No FOD walk,equipment set up( air start unit aka; huffer)!
Don't disagree but opening that cargo door was an invitation to approach. Would it have prevented this accident? Maybe/maybe not? When I've been involved in other dangerous operations and I said, "Oh, I can do this piece over here while we wait..." I've gotten chewed out for this exact reason. We wait until it's safe before we start doing things to make sure everyone is on the same page. (And in my job, we called out what we were doing but obviously that wouldn't work here).
Safety is a pattern, it's unlikely this was the first time this mistake was made and blown off.
Juan, good breakdown of events. As a former ALPA Safety Chairman and Ramp Safety Rep at my former airlines allow me to weigh in please. For years I struggled with my former carrier with ramp safety. I did manage to get them to install LED Safety whips on our tugs so that the pilots could see the tugs when attached to the aircraft but it was an uphill battle. The company fired their ramp employees back in the early 2000 to save money and contracted to the lowest bidder. Training multi cultural new hires from second and third world countries proved difficult. I witnessed a Samoan woman beating the stuffing out of a Somalian man when she was disrespected. The FO asked me if he should call the cops to stop it but I told him “No, looks like she’s got it under control.”
I digress, in my briefings to the ramp management and personnel in meetings I addressed rushing. I advised them to be aware that when you find yourself rushing it is a sigh that something is going to go bad. I likened it to “when snorkeling suddenly all the little fish disappear….something bad is about to happen.” I would get complaints from crews about the ramp and I just had to arrive at the point to where I explained that the company doesn’t spend the time and effort training them and that’s management’s fault. When it comes to management I told them “Don’t expect Olympic results from special Olympic athletes.” They don’t change anything until the metal gets bent or someone gets hurt.
With that said Rampers are some of the hardest workers in the industry and do not get the training, pay or leadership they deserve.
Thanks Gundog! Great insight!
Hats off and kudos to the Samoan woman. Job well done.
your analogy somewhat shows the chasm between you and ramp staff,
unless you are somewhere like The Keys, or Hawaii, most people who work the ramp never had or will have the means to consider snorkeling as a vacation.... so they probably had no clue what you talked about....
@@stanislavkostarnov2157 He was briefing management, not the ramp agents.
Regardless, if someone can't draw parallels between a story about fish sensing impending danger and humans blatantly ignoring impending danger, the complexity of a job in aviation *may* not be for them.
...snorkeling experience notwithstanding.
@@jackmosher7561 I thought he was talking about a lecture for new trainee's, but OK.
& believe me, the "fish sensing impending danger" bit is not in any way obvious from what he said unless you know the context!!! trust me on this one!
In addition to the beacon, there should be a laser projecting a red pattern on the ground when an engine is running and plane is stopped. Pretty cheap to implement.
Now that’s a life saving idea right there
I was thinking something on the ramp, but something on the plane is so much easier to implement. Great minds think alike.
Edit: Do like laser tag, if they enter that zone, they get a squawk and flash!
When I was in the Marines, I was a hot pad refueler (day and night) for rotary and jet aircraft and Helicopters. We had very specific places to park certain aircraft and lines that you DID NOT CROSS if you wanted to live long enough to enjoy liberty. Night time was especially dangerous, because you could not see the rotors spinning and it was easy to walk into one if you were not paying attention to where you were. Cutting corners work just fine until they don't and someone gets killed. Thank you for the update.
Ironic that (for the most part) our military is more concerned over safety than the private sector.
"Cutting corners work just fine until they don't and someone gets killed." Now THAT is a very important point. There are a lot of monumentally stupid and dangerous things you can do and get away with 90% of the time or even 99% of the time, which is why people who say "we've been doing it that way for a long time and nothing's ever happened" make me want to scream and pull my hair out and punch people. That's how the space shuttle Challenger disaster happened. They knew they had a problem with the boosters, but they kept getting away with it because the design had a safety margin, until one launch when conditions where a bit worse and they exceeded the margin and then BOOM, seven dead astronauts.
@@phillipzx3754 Military members were concerned about safety because we didn't want to die. Military leadership........not so much....
@@TheMarkemmy I did 20 years in the Army (71-91). Mostly with the 18th Airborne Corps. ;-)
Texting and driving. Safe 99.999% of the time. So, everyone does it and it has become a begrudgingly accepted behavior (little to no enforcement) @@TonboIV
*I’m a ramp manager for a major airline. My first question is: Was the deceased wearing Bluetooth / music headphones? I see it nearly everyday and people are so slow to understand the importance of keeping your head on a swivel and your ears open on the ramp.*
I'm a retired construction foreman and we had to ban cell phones and earbuds as soon as they were invented for the reasons you stated. Some people don't get it.
@@wrp3621 I understand what you are writing. When the fuelers did not show up the question was does anyone have a phone. If the fuelers delay the departure it is on the ramp agent, not the fueler. Think about the implications of that.
@@richardhaas39 that’s what radios are for and that method of communication has worked on the ramp for decades. Also, a fueling delay belongs to the fueler (most often a vendor these days); a bag loading delay belongs to the ramp; a passenger boarding delay most likely is charged to passenger service or crew swap.
@@justsnappy Ramp and fueler are not on the same frequency. Who exactly would you be radioing? Everybody with a radio that is your frequency is already on the ramp.
@@richardhaas39 you’d radio operations or the ramp supervisor / manager to escalate. It’s done everyday.
I know the feeling of the "Ingestion Zone". It happened to me when I was in the Air Force. Late Sunday night from a full shift, an F111 came in and it's during the colder months as I was wearing a coat with a hood. As I was chocking the wheels, I got one done and was crab walking to the other wheel. I didn't exactly go straight but went diagonally under an engine running. Felt my hood of my coat lift along felt my hair being pulled I dropped and layed flat on the ground. Got my bearing back where I was and skimper away from the intake. Then finished chocking the other wheel. Felt lucky to be alive and learned first hand of that Ingestion zone. You do have to be extra careful around aircrafts!! RIP to that ramp worker.
Nellis AFB was my first duty station out of tech school in July 1976. I was assigned to the 474th TFW until the last of the F-111A aircraft lit the ABs, trundled down the runway, and turned north toward Mountain Home AFB. I never worked the flightline, but I knew a number of people who did, and I got out to see the actual aircraft when they weren't trying to turn them. So you have my SINCEREST sympathies!
But here's a question I've never been able to get an answer to: do the engineers at General G-ddynamics have some kind of fetish for seeing how much FOD they can suck up with their aircraft? The Deuce, the Six and the B-58 never seemed to have a problem, but it always looked to me like Aardvarks and Lawn Darts were designed to facilitate low level flight by placing the intakes so close to the ground that the aircraft would suck themselves to the surface. Unfortunately, that meant that crew chiefs, Ammo troops and others who had to work around the aircraft with engines running were in constant danger of becoming "one with their aircraft".
I am convinced that EVERY ENGINEER who works on a new aircraft design MUST accompany a trained maintenance person around the aircraft and get a HANDS-ON feel for how badly designed their aircraft can be from a maintenance/ground handling perspective.
@John Demeritt a lot of the design is how much munitions can be loaded as to where the engine intake is placed. Munitions that are dropped out the belly engines are on the wings and weapons on the wings makes a tight center fuselage. Believe why on the A-10 putting the engines on top gave the best wing usage. But wasn't very fast where the F-111 was because much larger engines. ;)
@@fiat.freakx19, a lot of thought was put into the design of the Warthog. There's a lot of talk about the placement of the Avenger cannon, but not so much about the engine placement. One thing about the A-10 is that putting the engines atop the fuselage minimizes the possibility of FOD ingestion. But the other point is that the high placement, along with the use of high bypass turbofans, reduces the IR signature significantly. The YA-9 used the same TF-34 engines, but they were buried in the wing roots and exhausted directly aft, unshielded by the vertical and horizontal stabilizers. And being slung so low to the ground -- great for munitions loading under the wings -- they were great at sweeping FOD off the runways . . . along with tool boxes, ground crew, and anything else loose around the intakes.
As for speed . . .no, the Hawg isn't fast. But I've heard it said that the advantage is that when an A-10 is making an attack run, anyone foolish enough to draw attention to themselves by firing at the Hog Driver will find that the Hog Driver has time to grab a grease pencil and write the soon to be deceased's name, address, phone number, name of next of kin, and coordinates on the ground on the inside of the canopy before finishing the run they're on and turning their attention to the person who fired on them.
Oh, and one more thing: TF-30s suck. Especially if you stick an afterburner on them. They're one of two reasons the F-111s and the F-14s ended up in the Bone Yard, while F-15s and F-16s are still flying.
Glad you are still with us.
@John Demeritt I worked on the F-15 at Luke AFB. I was on the transfer team that got rid of A and B models to make room for the E model. I worked 405th EMS and was a 431x1 airframe mechanic. Was released in 1989/end of my enlistment by Regan during military cut back on bases and jobs. Combined airframe/engine/hydraulic into one person and kicked other two out :(
Luke don't have the 15's anymore got the 16's and 35's now. Enjoyed it when I was in 1985-1989!!
I was a crew chief in the Air Force and worked on the flight line. Launch and recovery duties put me in close proximity of F-4 and F-16 engines. No matter how routine my work became, I was always cognizant of the danger.
It would be really interesting to look into the ground crews training at this airport. The amount of safety violations that occurred after the plane landed from the cargo door being open and people walking close to the plane while both engines were running is very telling.
I agree. It seems from the moment the agent moved toward the cargo door, it signalled that it was safe to start their ramp duties 😨
Indeed. Not only the victim violated basic safety rules.
Yeah, couldn't possibly be personal responsibility... must be someone else's fault...
I'll bet the safety training is fine.
I'll bet it was the Go! Go! Go! Attitude that contributed to this incident in a Big way.
The training is standardized across the airline. Initial is done via computer modules and then they fly you to a centralized training facility somewhere like CLT or DFW (for AA). After that, anyone who is on the ramp is fully aware of safety zones, briefings etc.
Juan: I will say this one more time, and then refrain from commenting on your videos unless I have something meaningful to contribute; EXCELLENT! Your graphics and analysis of each event is outstanding. I was fortunate to have a 35 year career with the FAA, as an Air Traffic Controller, including many staff support and managerial positions; e.g. Manager of the Quality Assurace Branch, FAA, Eastern Region. In spite of my extensive experience, you continue to educate me on aviation issues of which I was not previously aware. Thank you.
Years ago I worked for a major meal distributor at the Bay Area airports and saw things on the ramp that would be considered very dangerous. This was due to the fact if we had caused the airline to delay their 'Push back', we were heavily penalized monetarily for every minute of the delay, so shortcuts were observed, but nothing like this story here.
I've done a lot of flying for Attitude Aviation as a midwest-based ferry pilot. They're no longer in the flight school business, as they're focused on the photography thing now. Fun group of people to work with. They usually take me to Beebs after I get there.
Yep, many changes there. Beebs is not what it used to be
A few years ago, I took a Southwest flight from Dallas to Chicago that had a stop in St Louis at about 9PM. We landed in St Louis in a thunderstorm so violent that they decided to lay over for an hour before continuing the flight to Chicago. After landing, and while taxiing to the ramp and within about 100 feet of the parking spot, I heard a loud thump from the right rear lower fuselage area of the 737 we were on. This was while we were still going about 3 mph and about 15 seconds before we stopped moving.
I did aircraft maintenance in the military. Yes, the loud sound I heard could have been the thump of an overcenter strut engaging or a cargo door release popping, but the fact that we still rolled for 15 seconds after the report, and the fact that there as about a 40 mph wind blowing, let me to mention to the pilot on the way out what I had heard and that I was worried that we'd suffered a ground accident. My report cause us to be delayed by another 10 minutes for an inspection. I have heard cargo doors released while aircraft were still moving, but those circumstances made it seem so unlikely. I've always been ashamed that I probably reported a routine sound, but to this day I can't imagine what it was.
Better safe than sorry. You did the right thing.
BRAVO👍👍👍👍
Your video on this should be made into a mandatory safety video for all ramp workers. Well done on the explanation Juan.
I refueled airliners for 11 years at SJC; USAir, Southwest, American, TWA and many others; I'm also a private pilot. I know what the ramp environment is like; all ramps are clearly marked with a STAY CLEAR zone around areas where engine ingestion is a possibility. I avoided those areas like the plague at all times; that's just what you do... right? I find similar issues as a ground crew member at various Young Eagles events; some pilots forget the mantra TREAT ALL PROPS AS HOT. I make a point of it every time I'm around every aircraft, whether alone or with others. STAY CLEAR OF PROPELLER ARCS AND JET INTAKES. PERIOD!
I fly out of MGM twice per month. Before the accident the painted safety outlines were non-existence, completely faded. Now all the painted outlines are very bright with new paint. flying back there tomorrow.
Both airports I worked on the ramp did not have ingestion zones painted. While the all props are hot is a good thing to live by, there are times servicing aircraft where you need to know the ingestion zone is safe because you’re going to be in it. At times I feel like the all props are spinning, and every gun is loaded mentality breeds complacency, because people aren’t necessarily thinking about what is actually happening.
The Google Earth photos of the MGM ramp show there are no safety zones painted on the ramp
Excellent use of the semicolon. ;-)
@@johnlichtenstein6158 Staying out of the ingestion zones at all times - period - does not breed complacency. If you stay out of the zone, you will never be sucked into the engine. And when you do have to enter the zone (for any reason), you'll be d***ed sure to confirm it's safe. And this does not mean condition yourself to always walk on a painted line.
Juan - You do such a great job of reporting and explaining! Again, you delivered this report in your perfectly professional manner. Such a sad and horrific accident...obviously preventable! Thank you for consistently clear, concise and informative reporting!
such a sad and avoidable tragedy...condolences to her family, loved ones and especially her three small children...RIP Courtney Edwards
Oh man, I hope we get a more in-depth report on hours worked, training, past violations, the whole work-up we get for pilots. Those kids deserve the truth to be out there to help prevent any future accidents like this. Deeply saddening.
@@x--. I'd even look into it being suicide.
@@Shabaka87 Not impossible but extremely unlikely just given the suicide statistics. While men don't mind the gore, women overwhelming do and prefer overdose or similar. She wanted to go home to her kids.
A few years ago I worked as a fueler at Sky Harbor in Phoenix. One incident I remember was watching a ramper carrying a safety cone walk up to an engine that was spooling down. Her hair was pulled towards the intake, and I could even see her leaning back to fight the pull. The only thing that saved her was the engine slowed enough to lose suction. If she had walked up a few seconds earlier, things would have been messy.
And what's the SOP for close-calls? Do they get reported and result in corrective action or is it, "Glad they didn't get blended today. Keep up the good work!"
@@x--. "no one got hurt, not important" pretty much how it works.
@@sirmonkey1985 That's a lot of the world and it means more folk get dead instead of educated on how to do better.
I also some people don't have the attention necessary to maintain the situational awareness. Hell! I know that a few times in my life, as a driver, I got lucky that my inattentiveness didn't end in disaster. Scoring a perfect 100% is just dang hard.
Hey Juan, former Envoy Pilot here.
The IN time will be sent when at parking brake set plus any doors open.
I worked on the ramp and can say that for sure the ramp is a VERY dangerous place. A small lapse in judgement can result in serious injuries or death.
Question... Do all ramp agents wear safety headgear, and was it possible the ramp agent confused the engine sound with what she thought was the APU?
@@TheGospelQuartetParadise supposedly they were briefed about the APU not working.
They were briefed that the APU was not operating and she was blown off balance at the rear of the engine. She had to know the engine was still running.
@@larrybe2900 Indeed, exactly.
@@TheGospelQuartetParadise Former ramper at SFO. Everyone wearing hearing protection but both APU and engines are very loud. The APU is generally much higher pitched, almost squealing sound and you can sense its direction from the tail. Distinct and different from lower pitched engines, and you can easily tell the difference. And easy to hear the second fuel is cut off and the engines start spooling down. The main issue are Rampers that don’t pay attention, listen and look at engine spinners and beacon lights. Complacency takes over. Get the 1st bag off in 3 minutes. Management all over you if that doesn’t happen.
THANK YOU FOR INCLUDING A LINK TO THE REPORT! I've seen another video on this, and they didn't include a link, and I had to scramble to find it. It's a small touch, but definitely one that's appreciated.
Once again thanks for the explanation Juan, and me as an A&P I dont get tired of explaining how careful you have to be while walking around these aircraft, the weather, the noise and specially the rush of pushing the plane out on time.
These days aicraft are quiet, specially the 737 max, thanks 👍🙌
From my experience, the answer to the time pressures is two fold. Yes we are under pressure to get the airplane put within the minimum turn time but never to the point to where the airline wants us to take these types of risks. On the other hand, since I work for a contractor, the pressure can be greater than what the airline demands due to delays hurting our contract and having to meet performance criteria. This pressure in turn leads to us sometimes taking shortcuts to do whatever it takes to get the job done. I've literally had a high ranking person from corporate tell us to do whatever it takes just a few weeks before this accident occurred. Another factor that plays a part in this is lack of training and complacency. We're constantly short staffed so we feel compelled to take short cuts to make it work. When new people are hired and we're on a a time crunch we don't have time to properly train new hires so bad habits become common place since we don't always have the time to correct them. Not sure if this is universal at all stations but this is my experience at the station I work at.
Short staffing is prevalent in many avenues. Still, I have to wonder if ramp crew members were on certain substances.
I sort of wonder because having jet blast knock you on your ass should be terrifying. I work ACS and ramp in the UK and I’m not ashamed to admit that the engines scare me a bit. I’ve been two or three bud lengths behind an A320 during taxi and felt the jet blast push against my body. It doesn’t hurt, nor is it dangerous or unpleasant but it at least makes me respect the distance needed to keep me safe from it.
Sounds like if your delaying flights constantly, something is wrong with the ramp! Could be understaffed,poor training,bad management,bad ramp management!
I worked as a ramp agent at SJC (San Jose Intl) for Delta 2020 thru 2021 per diem. I only worked a couple days a month. Not Approaching the aircraft until the red beacon underneath is no longer illuminated is very basic knowledge and NEVER violated. Even us per diem employees were given extensive training regarding this topic.
Very sad but I’m curious her training. My assumption is the ramp crew got lazy and began breaking basic safety rules. So sad
I worked for a Canadian region airline that operates a fleet of Dash-8 aircraft. The Dash-8s typically taxi with one engine but do not turn off its engines before the GPU is connected. So everyone on the ramp waits for whoever brings the aircraft in to connect the GPU and for the engine to feather and stop, before approaching the aircraft to chalk the main gear and to position the cones. Also, we are instructed to never walk through the blades of the engine even when they are not spinning.
Only way to be sure. Never go in the ingestion zone.
At least you know the dash 8 usually does it this way .... so you are guarded already.
It’s sad “never walk through the blades” has to be explained to someone
@@applec2400 Do you think everyone that are reading or making comments about this actually work at airports?
As a safety professional and a former OSHA state program compliance officer, I can say that in my experience, safety for ground crew in aviation is commonly ignored as it takes a backseat to FAA regulations, which are only concerned with the aircraft. I have seen people fall 11 feet out the back of a 777 because fall protection simply does not exist at an airport, and nobody has bothered enforcing the existing regulations. Especially with smaller carriers, the concept of safety exists almost exclusively in the context of the FAR, and not as it applies to all the ground crew working in and around aircraft.
Also, the reason the NTSB did not travel to the scene is because this would be OSHA jurisdiction as Alabama does not have an approved State Plan. They should be the primary investigating agency and the agency with enforcement authority over ground operations.
In my previous career I worked both as a flight attendant and a ramp agent controller. In both jobs, safety has always been on top of our minds and approaching an aircraft with beacon lights on was simply a big DO NOT DO THAT! Pressure? Yes, there's always pressure and I hear that it's getting worse (at least in Belgium). But when I was working on the ramp I always placed emphasize to never approach an aircraft with running engines and to adhere all safety measures. I always placed people on report when I saw violations. In aviation there's just no place for cutting safety corners.
I don't work in aviation, but in the industries I have worked in, all of them with some element of danger, I have observed that "safety briefings" appear to be something to be endured, not something to learn from. When ( NOT if ) something tragic occurs there is a rash of compliance, finger pointing, and of course mourning, but after a period the same "it won't happen to me" attitudes return. It does my head in, especially as I know that I can be guilty of it myself.
Horrific incident. So pointless.
Condolences to all concerned.
Juan, I dispatch the E175. Two points: It is possible for a cargo door to be opened prior to the triggering of the IN time, which is not driven by the brake, but by the opening of door 1L. The OUT time is set by dropping of the brake.
Additionally, when we have an aircraft with an APU MEL proper procedure is to call the station and tell them that we are sending an aircraft with an APU inop. We do this before the flight leaves so that if for some reason they can’t do an air start, we don’t end up with an airplane stuck. It also reminds the station that they need to take care because of the different way an aircraft must be handled with an inop APU.
Now that I have heard your take on the report, it settled some questions. It confirmed my suspicion of an APU “involved” situation (I was thinking crossbleed start), but if the right engine was shut down before gate arrival (usual practice for quick turns), it further confirms that it had to be engine 1 involvement.
It doesn’t explain why the ramp agent was in that position, because this should not have happened.
Thank you for raising awareness on the role of rampers in aviation. I spent five years on the ramp at GSP (not with American). When I resigned four months ago I was the senior ramp agent at one of the highest performing stations in the company. I've worked hundreds of 170/75 arrivals. That whole accident narrative sounds bizarre e.g. a very inexperienced crew, extremely inefficient procedures, poor coordination of effort. First thing I'd want to know is how many weeks had the victim been on the job? What was the average experience level of the ramp agents involved? (Yes. There is always pressure: too few agents, too inexperienced, ridiculous minimum turn time imposed, etc. The attrition rate for station agents is egregious. An on-time departure was always just another successful sh---show.) Was there a lead agent at the gate for the arrival? Bottom line is this question: What extraordinary circumstance brought the victim in front of the #1 engine? All the immediate and urgent work was in front of the #2 engine. Was it common practice at that station to set the safety diamond cones from starboard to port---I've NEVER seen it done that way? Was it common practice to set the port cone off the left wing and then take a shortcut under the fuselage to unload bags? If so, this fatality is on management! The only time I was ever in front of the #1 engine on arrival was after I had marshaled and was doing my arrival inspection looking for any damage on the aircraft so we could avoid the blame---usually after the bags were on their way to the terminal.
A word to you 170/75 drivers: don't do this! Given the typical safety posture of regional ground OPS, why would you EVER set your brakes and let the engines run at the gate. If it's a short taxi then slow it down. Burn the two minutes before you get to the gate. Roll into the gate with your #2 spooling down. Set your ground crew up for success. (Oh. Right. It's not 'your' crew is it?) That said, an INOP APU is an MEL on the flightdeck, but it's an IROP on the ramp at a regional airport. As a rule IROPs at a regional station are a dangerous escalation of routine chaos---arrivals and departures. (Had the victim EVER worked a 170/75 arrival with an INOP APU? Was the victim aware that arrival was an IROP? Who was in the chain of custody for that IROP notice to the ramp agents?) Isn't there a way to run on batteries for a couple minutes till the jetbridge can get positioned and the GPU engaged? The deferred maintenance on regional aircraft is appalling. How long had that APU been INOP?
The crews I worked with were always skeleton and frenzied--routinely three experienced ramp agents. (I've worked a turn or two with one other person. That's a transcendent level of sh---show.) Everyone but the marshaling agent would be at the starboard side of the gate waiting to work the bags. Immediately at fuel cut-off we'd walk into the safety diamond and place the safety cone within inches of the #2 engine cowling. (Pilots frequently forget or delay to turn off the beacon lights. If you wait till you can see individual fan blades you're not a 'team player'. The marshaler is always tasked with something more urgent than managing the engine shut-down hand signals.) There was never even a perceptible breeze at the engine inlet. As soon as the cone was in place that agent would open the cargo door while the belt loader was approaching. The belt loader driver was usually the agent wingwalking the starboard wing. While the belt loader was positioning, the dismounted agent would set the right main gear chocks then go get the bag cart and tractor into position to unload bags. The marshaling agent would chock the nose, set the nose cone and wait for the jetbridge to get positioned so the ground power could be connected. When that was done the marshaler would signal the flightdeck that the GPU was connected and then walk off to position the safety cones at the port wing tip and tail, check the aft bin for bags (usually empty), then go get the towbar connected to the nose gear for departure.
I've heard colleagues talk about a company station in the north east where a lone regional ramp agent routinely does all these tasks on mainline aircraft arrivals and departures. SOLO! This is commercial aviation at its finest i.e. most efficient. As a licensed airman (A&P) I could go on and on about the systemic imbalance of efficiency thoroughness tradeoffs. [Clarification: Hollnagel speaks of an ETTO safety paradigm that is systemic and subconscious, but then he says "the system may be able to correct itself and to find a balance of functioning that is both reasonably *effective* and reasonably thorough." I suggest that the play between individual efficiency and communal effectiveness is a Freudian artifact that warrants religious scrutiny. My faith is religious and it's not in 'the system'---yet.] All the fragmented operational relationships have either competing efficiency requirements or chronic above/ below-the-wing cross-training confusion. (If SWA runs their ramp at every airport like the ramp runs at GSP, then SWA is a glaring exception to the regional rule.) Here's a data point: when the pandemic slowdown ended, American at GSP (not Envoy) went into a hiring frenzy and started adding an extraordinary number of flights--particularly kick-offs. There was an unprecedented three simultaneous kick-offs ---to the minute. The pressure was so great that a senior ramp agent I knew switched to ticket counter after decades on the ramp.
So yeah. That accident narrative was bizarre, and my sincere condolences to this rampie's family and colleagues. Commercial aviation is a tightly-coupled and high-consequence system. Don't be a team player---slow down and smile. Do not blame the victim.
I have spent my 43 year Airline career mostly on the ramp but I have also been a flight instructor since the late eighties so I have a broad base of knowledge our industry. I currently run a ground operations training department for a primarily cargo airline. We traditionally hire additional help for peak operations and I have always made it a point to give my "the ramp is a dangerous place speech" to every class. I was shocked beyond belief when I saw this in the national news. It is pounded into everyones head as often as we can if the beacon is on you stand outside the lines and wait for it to go off. Normally maintenance are the ones to break that rule and I have to preach I don't care don't follow their example. Horrible way for us to add to our training why we say beacon on stand back.
If there are lines is it possible the plane was not properly situated and she paid attention to what should have been but in reality wasn't? Of course that should be stated if that was the case if lines were present.
Well sometimes in maintenance we are approaching the aircraft with the beacon on because we need to. Leak checks etc. We are obviously trained to be very cognizant of what we’re doing and staying out side of ingestion and blast zones, but our job requires us getting right up to an engine while running at times for FOM
@@larrybe2900 I'm sure the plane was parked correctly or the Marshall would not have given the sign to chock the front wheels.
I think she just was on auto pilot because normally the engines are shut down pretty quickly after it stops, like 30 secs. these were running for what sounds like a min or 2 since they needed to hook up ground power cable, and that takes a while as it's held up by a winch that has to lower the cable down, and then be dragged over, it's very heavy and plugged into the nose of the plane, and then confirm the correct light came on before they shut the engine down. sounds like this happened while still lowering the cable.
I know engines are expensive, but I wonder if it wouldn't be prudent to find one that's end of life and use it to demonstrate just how dangerous they can be with a decent sized thawed turkey carcass. Maybe once a year and film it for those who can't attend.
@@larrybe2900 I read the report. The plane was parked where it was supposed to be, the lines are visible in the video the NTSB reviewed, and the upper beacon light was on in the video. Also the ground crew did state the lower beacon was also on, but it wasn't visible from the angle of the camera that recorded the incident.
Unfortunately, we have no idea why the victim violated the safety envelope. It may be drugs. It may be an illness that had her off her game. It could be the pressures to turn around the aircraft. It could have even been mental illness. We don't know. My brother's girlfriend works for American, and we were talking about it last weekend. While she's not a ramp agent, she told me that EVERYONE is taught that if you can't see the individual blades on the engine, the engine is running and you are to stay away. I don't know why this ramp agent ignored the safety briefings and her safety training. And there is no way to find out.
The fact that so many ramp personnel seemed almost oblivious to the unusual condition of this aircraft makes me suspect of the effectiveness of the safety briefings. Clearly the danger was underestimated.
yeah, i'm feeling a bit dubious about the "double safety briefing" actually taking place ... when so many of them immediately violated it. something smells fishy.
Do you really even need a briefing not to walk in front of/around a running jet engine? Between the beacon light, sound, spinning blades, 100+ mi/h wind, etc. it seems like common sense. It should be hammered in starting day one
Provided the safety brief actually occurred like management says it did...
@@Hadzz95 Inop APUs is basically hands on training! Once someone actually have witness a live Airstart! And next time the ramp hears and inop APU! They will volunteer to get a bucket of sparks(kidding)! Plus technically there should be briefings before ever flight! For equipment set up,FOD walk, might have a motorized wheel chair, baby strollers,car seats etc!
You are doing a report from my neck of the woods and I spent the last 3 weeks in your backyard doing snow coverage. Keep it up!
Non expert here: am I crazy to think these ramp agents probably had a norm of being loose with the regs and just got unlucky on this occasion when the CPU wasn’t running (so they might confuse the noise, but also they needed the special procedure to attach ground power)? It seems unlikely that the one time there was an anomalous situation was also the only time they didn’t adhere to procedure.
Question for commenters. When you are an airline passenger, do you attentively watch the safety briefings on every single flight you take?
I was a plant superintendent over seeing truck dump body manufacturing back in the mid 2000s. When accidents occurred drug testing was done with a high percentage being positive. Today it’s scary to be on any highway, 100 applications were sent for employment with 15 being able to pass the piss test 🤷🏻♂️this was 15 years ago.
@@sncy5303 anyone who could develop a quick test for whether someone was under the influence of some of the drugs said piss tests look for would likely make a fortune while simultaneously doing the world a big favor. Imagine if it was as easy to figure out approximately how high some was as a properly used breathalyzer makes figuring out approximately how drunk someone is?
I was on the KDFW ramp in the 90's for a regional airline. ~90% of our staff were safe, aware & were proficient around our aircraft and others. AMR rampers working charters and international flights under contracts were about the exact opposite. Many of them didn't have a clue. I remember one asking "how aircraft moved on the ground"'. Asked "if the wheels had motors or something?" It was just another job for them to put food on the table
I didn't work where you worked, but I have had these sorts of people ask why the designers hide the drive shafts running from the engines to the wheels.
Another asked how do they get the engines to go from forward to reverse so quickly when applying reverse thrust. My colleagues said (jokingly) that the aircraft had a full synchro gearbox ...
@@vk2ig Rev-matching on the freighters & older birds without synchromesh! Incredible...I guess we all can't know everything(: 73
They aren’t paid enough to care about knowing those things.
Thanks for your input. I'm not surprised by what you are saying.
It's a reasonable question. From a child. In the lounge area. I wouldn't want to hear that from someone with an airport employee badge.
(There has been talk of putting an electric motor in the nose wheel, but the added weight generally isn't worth it. How much gas does it take taxiing around, vs. the mass of flying that motor tens of thousands of miles? Plus, the engines do need some time to cool down.)
Been waiting for this for a while. But I'm glad, as always, you waited for enough facts to come out before trying to address it. I figured the day would come when enough info was available. Thank you, Juan, as always, for the careful and accurate analysis you put out. Being the first to post is not often being the best. You take the time to look at all the data available, and I appreciate that.
For electricians one of the quickest ways to get fired is forgetting to lockout-tagout, no excuses. I am betting that the ramp agents had been behaving recklessly for sometime but no one lost their job over it. This accident was the manifestation of a chronic lack of supervision and discipline.
If you are short staffed and fire someone you are more short staffed.
Having worked in the oil and gas industry for 30 years, where safety is beaten into the heads of employees every day, and briefed before every work activity, it remains a mystery as to why people still violate safety rules. Most times, it's a moment of inattention, sometimes it's a minor cheat in order to make the work easier or faster, occasionally it's just plain negligence, and sometimes it's a failure to understand or remember one's training. In spite of best efforts, the holes in the Swiss Cheese occasionally still line up, necessitating that those involved reflect on the question of whether they did all they should have to prevent the incident. Sometimes, the answer is 'no', subsequently causing them to live with guilt for the rest of their lives. That's not easy. The price of safe operations is good training, a deep safety culture, good safety systems, and a personal dedication to eternal vigilance. A little paranoia, also, goes a long way.
Given how multiple ramp agents violated procedures at the same time, it sounds to me like habitual violation of safety rules in order to meet time-based incentives
You're right, and I hope the guy who was on the nose wheel, who tried his best, can get over this horrible incident.
I was on the USS Coral Sea coming home from Westpac in 1982 and we were on our way to Alameda. A CPO with 2 weeks left before he retired lost his situational awareness and was blown into a A-6 pile on and killed instantly. It shocked the crew and sadden us all he only had 2 weeks left and he died because he was probably thinking about something else on the flight deck. I used to watch F-4's spool up for take off and the power coming from those engines was no joke.
santafedave - Yeah, I may have put too much power in those F-4s. Submitted design '54, but DOD really didn't get 'em started until Ike gave it dbl green in '56. Had to fly test model when 13 & Demo Pilot puked himself near death over Lk Superior. Only prior exp was 1 yr flyin' Dentist's '40's Aeronca so lucky to land. They were good in Vietnam, & when NASA suspected oil canning on booster to be used on manned missions, F-4 came thru w/surveillance model. They hurtled towards booster, then launched, w/F-4 zooming beside it for oil-caning photos. Good for lots of things I guess. On production models, all my guns removed, & they got missiles instead. When F-4's lost, DOD put pods on 'em, and they instantly won! If DOD had left guns designed in, I doubt we woulda lost any! Interesting aside is, when Ike asked Dad why original drawings were in black crayon, he told him, "Every time he was bad, Mom took another crayon out of the box until all gone. He found a piece of black crayon on sidewalk, so that's what ya got. Sorry drawings were on scrap paper, but my DOD brother said not to touch it, & he submitted it just like that." Ike ashamed sobbing said, "I had no idea folks were this broke....Dept. of Education must be usin' funds for their own salaries, and the hell with our classrooms...I'm gonna fix that", & FIX THAT HE DID!!
Juan, thank you very much for making this video and I can only hope new people coming into this industry realize just how dangerous this occupation can be, especially working around these engines. Complacency with safety can be costly, unfortunately as seen here - God rest her soul.
One of the problems I've noticed - and it's been brought to the attention of the safety committee many times - ramp personnel will approach the front of the aircraft at a quartering angle after positioning safety cones under the wingtips. You can not see if the spinner/blades are turning if you approach the engine from the sides, and more than likely can't hear it either. I've seen some close calls with employees walking right past the nose cowl with the engines still running. This time the engine grabbed one.
So what is the solution? Have them walk forward and parallel to the aircraft for about 20 feet before approaching? How long would that last before 'Murphy' reared his ugly head again because of complacency?
Whatever the solution is, whatever new rule they come out with, it has to have a high level of accountability and responsibility. I'd rather see someone terminated and their feelings hurt than loose their life.
Great work Juan!! My 16 year old is in ground school and getting his hours to become an airline pilot! FIRE IN THE HOLE!! Models (gfs) showing back to a very wet pattern for CA starting in 4-5 days.
As we are going to many more of these smaller stations, we face this more and more. Bus cooldown is 3 min. We are so used to just pulling in to the gate as we approach, I have found myself getting to the gate with sometimes a min to go on cooldown. I am working on conditioning myself to not make the turn until I know I will not be leaving the engines running longer than necessary at the gate. Now this situation of an inop APU, which happens way to much these days, you don't have the luxury of shutting the engine down right away. This is where you have to hope that they ground crew is being safe and following protocols. Very sad, thanks for the great analysis of the report an tragic event.
So, if I am understanding this correctly, she nearly got knocked off her feet by engine exhaust and still walked in front of the engine?
that's how I understood it too. no one has said if she was a new hire. airlines are hiring a lot of new people these days
The way I read it it was two different people but maybe not.
Yes. While another Ramp Agent opened the Cargo Door in front of a running Engine, being lucky not to be ingested, too.
@@dsmreloader7552 not in this report and I don't work at that airport or airline, but the story I heard just today was they walked behind the engine got knocked down and then walked in front of the engine. doesn't exactly match what this report said, but close enough to make me think she walked behind the running engine to set the tail cone, which is very bad and then walked over, grabbed a cone by the wing tip and carried it straight into the engine.
very sad. I'm guessing she was a new hire or something else was on her mind.
After 2 safety meetings also
It’s mind-blowing to me that those ramp agents just blew right through the rule book like that. Cold, in a hurry - or both. No good excuse
Bosses pressuring them to meet time quotas.
As a retired jet engine mechanic, as Juan stated, you can never have a momentary lapse of paying attention. Spent a lot of time around running engines. We did use engine screens, but lot of other items could kill you since you would have hydraulic power applied.
Who do you suppose is going to tear apart the engine to get the body parts out? One of the airlines mechanics?
@@jamessicard6682 good question. More than likely since they are trained in engine maintenance. Would probably have medical, coroner personnel there at a minimum.
You would know firsthand, no doubt.
I was an aircraft mechanic on these airplanes and run taxi qualified. Standard procedures for us with an inoperative APU was to taxi to the gate with engines running. Upon marshal and entering the silhouette, we would shut down the left engine since that’s where the power cord will be connected on that side of the plane and added additional safety to the ramp crew entering that side of the plane to connect ground power.
I’m a captain on the 175 for a regional. Inop APU’s are not uncommon. I’ve stopped in front of the gate and made sure everyone is clear before I enter. I also shut down ENG 1 so the GPU can be connected and just turn on HYD SYS 1. Opening the Cargo door does not stop the clock. The MCD does.
Such a needless tragedy. My condolences to all who are closely affected by this event. I used to be more adventurous (but not while flying) until raising 4 kids & have always thought I would die in an accident & not from natural causes. If true, I hope it's not by such an easily avoidable cause.
My deepest respect to all ramp staff. Before this vídeo I used to give a lot for granted and was just annoyed by videos of suitcases being thrown around.
Never thought how dangerous and unforgiving that job can be.
Thank You, Juan
Wow! SO thorough, as usual! I had NO idea that being a “rampie” was so complex.
Just a choreographed process, from parking brake to parking brake!
Thank You!
Flew the 175 for a few years. It is my understanding that the opening of the cargo door does stop the clock as does the parking brake (like you said). With that said, the parking brake is usually set immediately after the plane comes to a stop....before chocks. So I don't think that would have been a factor in this case. I would also a ramper for a few years for Express Jet. There were time pressures, however we typically did not approach until the beacon was off.
Juan raised good questions at the end of the video. I have an additional question. It appears that two people let habit patterns applicable to normal operations take over: the person who opened the cargo door, and the victim. Two briefings were apparently held regarding the non-standard operation. What were the victim and person who opened the door doing during the briefings? Paying attention? Or perhaps looking at a cellphone and not paying attention? Not making accusations here, just an observation I’ve noticed in much of society over the years.
Did the victim see the cargo door open and wrongly assume all was okay? Need to question that cargo door person carefully.
@@paulsherman51 Never Assume anything on an airport Ramp.
As a ramp worker in Australia, the company I work for always wants an on time turn around but nothing surpasses safety. What happened in this situation goes against all of the training provided. Blows me away that they had 2 briefs of this aircraft yet still failed to comply with basic safety principles. Never approach an aircraft untill the engines have spooled down, beacon light is off and the leading hand has given the thumbs up to approach. These rules have been written with blood and that's why they exist.
HI Juan- Nice work on this and the rest of your videos.
I’m a 170 captain, and the cargo doors are irrelevant to the out and in times; it’s a logical AND of the main cabin door slide armed and parking brake off for the out time, and MCD slide disarmed (brake irrelevant, I think) for the in time.
Several times over the course of my tenure on the plane I’ve had to prematurely kill the remaining operating engine when I got a cargo door open annunciation (meaning the ramp personnel had prematurely opened the cargo door with an engine still running), almost exclusively when operating with the APU deferred, or on MEL (inoperative for you non-airline folks). I like others am convinced it’s either the operating pressure of management to minimize turn times, or the inherent nature of the rampers to disregard the danger because such mishaps are relatively uncommon.
It’s a terribly sad occurrence, and I hope the lesson resonates for decades to come both with those who work the ramp and those who manage them.
Why would you think there would be pressure from anybody for an Inop APU? When everybody knows that's the most dangerous task on the ramp! Just curious!
@@davidsmiths5471 Hi David--
I didn't mean there's pressure because of the inop APU, I meant that the pressure to turn aircraft around (service them quickly and get them back out on another flight) quickly exists regardless of the APU status.
So, ramp personnel sometimes rush the plane as soon as it parks to hurry up and get the bags off the plane (that's assuming either a solid work ethic, supervisory pressure, or both, maybe). Rather than wait for the engines to spool down, they often disregard the beacon (typically the signal used to indicate the engines are still operating) and the noise and make a beeline for the cargo door.
The forward cargo door (behind which we carry almost all the cargo, because of center of gravity reasons) on the Embraer 170/175 is dangerously close to the #2 engine inlet.
Juan, until you stated it in your video, I didn't know that the ground power connection on Embraer aircraft is on the left/port side of the fuselage. I have no idea as to why they would set up the aircraft like that, considering that the #1 engine would have to be left running, while ground power is being connected.
The Boeing 727, 737 that I flew have the ground power connection on the same side as the cargo doors -- the right/starboard side.
Whenever we would approach the gate in an aircraft with an inoperative APU, I would hold up a large placard up to the right side window, that stated that the APU was INOP. The rotating beacon was left "on" and, in theory anyway, no one was supposed to approach the airplane, except the person connecting the ground power. After connection, the #1 engine would be shutdown and a little later, after the engine was almost completely spooled down, the rotating beacon would be turned "off".
But many times, we would see a cargo door open light, even before we came to a complete stop at the gate during taxi-in, just to block us "in"!
Hi Juan, here in Europe I fly both B737 and Embraer 190. It is our habit on the Ejet to shut down the number one first when an external gpu has to be inserted mainly because the receptacle is on the left side. On the 737 it is the other way around. BUT: if you need to shut down the number one on the Ejet you have to manually activate an hydraulic pump.(this is to keep some necessary brake pressure)You do NOT have to do this when shutting down only the number two. I see lots of pilots shutting down the number two first just to not be bothered to switch on manually an hydraulic pump. (Pilot laziness?) Anyway, a very tragic and preventable accident. Btw: the clock does not stop when opening the cargo door.
Well… All the right answers were given interviewing the ground staff about the safety meetings at Cetera. I wonder if they were interviewed at a different time separately again if you might find a different story. Everybody knows what the right answers are especially when somethings gone wrong and nobody wants to get in trouble or lose their job, if they say the boss pressured them to get it done fast. And were there any language problems. Did the person who was killed speak the same language as the rest of the ground staff. The story about the safety briefings sounds a little too perfect to me, but maybe I’m just paranoid.
Yeah I know what you mean, the report makes it sound like they talked through and emphasized the unusual circumstances and safety precautions multiple times and the agents then just didn't listen and one got themselves killed. And maybe it did happen that way, it's certainly possible, but maybe there's some more nuance not mentioned in the report. Maybe this stuff was said in mandatory briefings where usually all the same stuff is repeated, so nobody really listened and noticed things were a bit different this time (basically, complacency through repetition)? Language issues, as you said? Time pressure that leads to routine disregarding of certain safety precautions, which normally works out ok, until it didn't, since things were a bit different this time?
You bet your ass some pencil whipping and story coordination went on. It's not paranoia to notice an all too perfect cover story, it's common sense.
Whats sad about our work environment is that the airline may be fined, the fatality's family will likely file a wrongful death lawsuit, they will get an undisclosed amount, the company will say in a public statement that, "Safety is our number one priority...", and they will publicly say that they're working on new training, then what happens? It may happen again cause somebody dropped the ball
Thanks for your service Juan!
Great report Juan. I use to crew chief c-5s at Travis and Altus and have blocked in thousands of them. I have seen birds and rabbits get sucked into TF -39 ENGINES.
This just popped up and I watched it again. Very good explanation of this whole situation for all the lay people out there Juan. I can't tell you how many times I've had to manually open & close the start valve on engines because of an MEL situation. This usually involves kneeling right next to the intake during the whole start sequence. Once the engine is up to idle you can usually feel the suction from the intake and your shirt sleeves & vest are kind of flapping towards it. It's a good reminder of how much power these engines have and how much respect they must be given. FLY NAVY!!!
Researched and informative as always ...
.. now let’s discuss the difference between dangerous versus hazardous. (As my 7th grade chemistry teacher liked to distinguish those two words.)
Standing directly in front of a powered up turbine engine is dangerous because harm is imminent. Working at an airport ramp is hazardous because precautions can be taken to avoid dangerous situations.
If precautions can be taken to avoid imminent harm then the situation is always hazardous ... as a simple rule.
With two safety discussions prior, this should fall on management. They had the team pushed to the point that metrics are more important. Safety must be number one.
While metrics are important, safety has to be first priority. No one should assume that the engines are off and spooling down. If you can't see the individual fan blades from outside of the zone, you don't enter, no matter what. Perhaps there should be an interlock that prevents doing tasks that shouldn't happen until the red beacons are off.
Tragic. May God comfort the family of this agent. My sincerest condolences. Thanks again Juan for your insight.
Wow! So glad you covered this story Juan. Answered a lot of questions. I'm curious if we'll get the toxicology / intoxication report. UPS load crew activated the crew door slide today at my home base, mistakes are easy. Funny thing about today, the slide malfunctioned and didn't inflate.....
The In time on the E170 is based on parking brake set AND the L1 (forward boarding door) vent flap/slide being disarmed. Fairly certain that opening a cargo door would not trigger an in time.
I flew the E175 for three and a half years, luckily the APUs on our aircraft were pretty reliable, but I had probably between 5 and 10 flights with an MELed APU, one time they opened the fwd cargo door but luckily we had taxied in on the left engine. I think it was a genuine mistake on the ramper's part, not from pressure on the operation.
What would happen if they just killed both engines when that bin door was opened! Not blaming that crew at ALL!
I have seen this almost happen on the ramp at the airport I work at. Most of the time its because of new people and them not paying attention during their training or not paying attention to their surroundings. As a mechanic it boggles my mind to see someone with earbuds in place approach a running aircraft. The only time I am near a running jet engine is when my work duty requires that I do a run leak check or a manual start. If this is the case depending on which side of the engine I am one I will retreat either to the wing tip or the other side of the body of the aircraft before moving into view of the crew. Some operators require a set time after engine shutdown before approaching the aircraft.
My first thought was whether it was the first day on the job for the unfortunate victim
@blancolirio, I heard on another channel, that this jet was ferry-flighted to DFW for maintenance(and perhaps a new engine) on 9-Jan-2023. With the APU being INOP, in addition to the left engine probably being INOP, is it permissible by FAA regulations to ferry-flight on one engine with an INOP APU? I'm a Boeing guy, and not familiar with the MEL for the E170 series.
Probably fixed the APU in MGM
I fly 170s and 175s for Republic. Our time starts when we close the main cabin door and then release the parking brake. The time stops when we open the cabin door. I’m not sure if it’s different for other airlines but cargo doors have no impact on starting or stopping our flight time at Republic.
When I was in the Navy I worked on and around F8’s and A7’s. Both of these aircraft had intakes that were very low to the ground. That configuration required ground and maintenance crews to be alert especially during night operations. The engine would be running during launches, recoveries, and when the Jet was taxiing. Plane Captains and maintenance personnel had to be present and in close proximity to the plane when the engine was running during ground operations and on the flight deck of carrier operations.
Yes, opening a cargo door does provide the time stamp for arrival on the E175. Hope we all learn from this accident, there’s never a need to rush on the ramp.
Did I miss it, or do we still not know if the ramp crew worked for the airline or a contractor? It is hard to believe that the safety briefings were adequate when half of the crew did not follow them!
I worked ramp at PHX for a 6 months last year. While I did notice a disregard for certain policy's, everyone I encountered took the beacon light and running engines seriously.
I’m a E-170 Captain, opening the cargo door after brake release does not affect the OUT time once the brake has already been released, at least the way my company has it set up. I’m not sure if it is the same at Envoy.
Thanks again to Juan for an extremely thorough interpretation of the report about this tragic accident. I am not in the industry. I have no expertise on airport ramp protocol or safety measures.
I'm sure they are extensive. Just one comment........ it struck me that this incident occurred on the 31st of December, New Years Eve.
I hope that a preoccupation about evening activities that were to happen wasn't affecting the agents attention to their duties.
I apologize if that is off base and I do give my condolences to the family of this woman and to all her co-workers .
@blancolirio, aren't the injestion zones on larger engines on the 767-787-777 series more like 30-45 foot ingestion zone? Or is that just the stay-out zone?
Super video as always.
So they all knew the engines would be running. Had 2 safety briefings 10 minutes prior to "not aproach "the aircraft, so they all go swarmed the aircraft immediately with warning light flashing everywhere, she almost gets blown away at the rear because of the engines running and was waved off to get back, so then she walks to the front of the wing and walks right in front of the same running engine that almost blew her down 60 seconds earlier and gets sucked in and dies?
Yes, obviously.
@@NicolaW72 Well then, the investigation is over as far as i am concerned.
@@skydancerforever Probably, yes. Nobody will ever be able to know what was going on in her mind during the decisive seconds.
@@skydancerforever: The key point was: *they all* swarmed. Which means it was a culture issue, not a personal issue. If the whole team does the same mistakes, the problem is somewhere above those actually paying the price for violations.
Several years ago, we nearly had a similar incident happen at Heksinki Airport, a place where safety standards are quite high and respected. The ramp worker in question luckily was tall enough to hold onto the top of the engine and that it had just started to spool down. All it took for it to happen was a momentary lapse of concentration and too much of a hurry to begjn the unloading process. Working around jet engines can make us complacent to their dangers, however the safety rules are written in blood for a reason. We can all go home safely after work if we just don't try to cut corners and no time gets saved whilst those beacons are flashing!
I was an American eagle station agent for 13 years, I didn’t work on this specific ERJ model, but have worked on others. On-time departures are wanted and stressed by management and quick turns are common on late arrivals. Safety protocols are there for a reason and if not observed or shortcuts you could hurt yourself or someone else is stressed to all agents. We were advised All aircraft while the engine is running, safety zones must be observed and no equipment or agent should go near the aircraft until those engines are shut down. Also, we were told you should not go toward the back of the aircraft while the engines are running as you may be knocked down or hurt by the engine exhaust. If no jet bridge in MGM is used it appeared she may have been going to the door to disembark the passengers and would tap on the door to indicate acknowledgment to flight attendant.
This is an unfortunate tragedy and could have been avoided and my condolences go out to the agent’s family.
When I flew the ERJ we had cargo doors open before engines were off at outstations multiple times. It scares the crap out of you. Have also had ramp agents approach the engines while still running. As for your question about stopping the “clock”, the “In time” for the ERJ at my company at least was when the L1 door was opened. Since the mass hiring of new employees at airports, I have seen multiple safety issues, tug incidents, pushback incidents etc. I fear this at be a symptom of frantic hiring.
I am flight line maintenance and deal with this type of environment all the time and one must absolutely know what's going on around at all times. 34 years without incident.
In this case it sounds like lack of experience is more of a cause than anything else.
@@johnnyj540 Yup, inexperienced people, out of their element, doing a dangerous job to make ends meet. Mother of 3. All she’s thinking is
“l need this job.” Regs and safety briefings are good of course but newbies just fuck up sometimes. That’s reality.
A320 CA here. I’ve seen similar behaviors with a deferred APU. Scares the sh!t out of me too. This could’ve happened to me or any other crew. This 175 crew did everything perfect. It’s very sad that they’re going to have nightmares about this for years to come. Prayers to the rampers family.
So the question that needs to be asked is: Should the APU be taken off able to go on MEL and flown as INOP? I would say yes if you are going to remote stand park. At jetbridge with ground power I can see an APU allowed to be INOP.
Yes they are scary as hell!! I'd rather dump lavs all day then that!!
Looks to me like she saw her team mates already placing cones and opening the cargo door and assumed it was safe. They should show the video of this incident to all new hires going forward. It sounds like a morbid thing to do, but it would make a lasting impression and her death would ultimately save lives.
The US Army shows gross videos to boot trainees to pursuade them that this is NOT a video game but serious life business.
I think it's damn fine teaching.
Although I know that this was a case of APU INOP, there is something that flight crews can do to help ground crews start their work a little quicker if the APU is functional. The APU can be started at any point on taxi-in after the runway has been vacated, and many taxis are long enough to transition bleed air and electrical power loads to the APU before gate arrival. If this is all properly executed, the flight crew can shut down engines immediately after setting the parking brake, and upon 5-10% N2 (depending on type) can extinguish the red beacon lights, a little quicker than if they waited for gate arrival.
I was taxiing a 767 onto a gate at LAX and about five feet from my stop point, I got a master warning light due to a ramper opening the fwd cargo door. We were still moving.
I was a Ramp Agent for Air New Orleans, Piedmont Airlines, US Air and American Airlines. You have to pay attention to your surroundings, equipment you're using and where not to walk. It is very noisy, even with ear protection. So sorry the families loss.