The National Transportation Safety Board (NTSB) has released its final investigation report finding that a ramp agent’s cognitive impairment resulted in their death from being ingested into an aircraft engine on Dec. 31, 2022.
The report, published on Thursday, cites illicit drug use, neurological issues, and low vigilance in leading to the worker being killed at the Montgomery Regional Airport in Alabama.
“The National Transportation Safety Board determines the probable cause(s) of this accident to be: The ramp agent’s cognitive impairment, which resulted in her (1) inconsistent behavior with trained procedures and pre-landing briefings, (2) presence on the left side of the airplane while the left engine was still operating, and (3) subsequent ingestion into the engine,” the report stated.
American Eagle flight 3408 was parked at its gate when a ramp agent walked directly in front of the left engine and was ingested. A subsequent NBC report covering the incident cited the NTSB as saying the worker was too close to the engine.
The NTSB shared new toxicology results in Thursday’s final report saying the agent had relapsing-remitting multiple sclerosis – which the agency notes “can adversely affect cognition including executive functioning, information processing and working memory.”
Although no cognitive impairment was documented at the ramp agent’s most recent neurology visits, the report stated she had a substantial risk of such impairment because of her condition.
“This investigation was unable to determine whether she was experiencing a multiple sclerosis flare at the time of the accident,” the report stated.
The ramp agent also had diabetes that was treated with medications, including insulin, though their postmortem urine glucose result was normal and did not indicate a major metabolic disturbance from extreme high blood sugar at the time of the incident, the report added.
“The investigation was unable to determine, from the available evidence, whether the ramp agent was experiencing milder high blood sugar effects (such as fatigue) or low blood sugar effects (such as diminished concentration),” the agency stated.
The ramp agent’s toxicology testing detected delta-9-THC and its metabolites, indicating that she had used a cannabis product. The report stated that cannabis has the potential to cause cognitive impairment and can worsen these effects in individuals with multiple sclerosis. It also stated that a person’s blood concentration of delta-9-THC does not directly predict that person’s impairment.
Toxicology testing also detected carboxy-delta-8-THC, a non-psychoactive metabolite of delta-8-THC – which was not detected.
“This result indicated that the ramp agent had likely used a product containing chemically synthesized delta-8-THC given that very little delta-8-THC occurs naturally in the cannabis plant,” the report stated. “However, because no delta-8-THC or psychoactive metabolite of delta-9-THC was detected in the ramp agent’s blood, she was not likely impaired by delta-8-THC effects at the time of the accident.”
