# NTSB BFO94LA002: Fairchild SA 227-AC, N550TD, Newark, NJ, November 5, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: November 5, 1993, 12:06 local (17:06 UTC) - Place: Newark, NJ - Location: 40.6925° N, 74.1687° W: Placed by OpenAirDocs at NEWARK LIBERTY INTL (EWR), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=40.6925&lon=-74.1687&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 15 uninjured; on the ground: 1 fatal - Status: Completed, report October 20, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 8862 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO94LA002 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8862/pdf - Page: https://openairdocs.org/ntsb/BFO94LA002 ## Probable cause 1) THE FAILURE OF THE RAMP AGENT TO FOLLOW PROPER PROCEDURES DURING THE SERVICING OF THE AIRPLANE, AND 2) HER LACK OF ATTENTION TO THE HAZARDS SURROUNDING HER. FACTORS RELATED TO THE ACCIDENT ARE 1) THE PRESSURE PLACED ON THE RAMP AGENT TO RUSH THE SERVICING OF THE DELAYED FLIGHT, AND 2) THE INADEQUATE MANUALS PROVIDED BY THE OPERATOR CONCERNING RAMP SAFETY. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Propeller/rotor contact to person, standing - engine(s) operating - airport facilities,ramp facilities - congested - procedures/directives - not followed, ground personnel (cause) - inattentive, ground personnel (cause) - facility,inadequate workplace, distraction, company/operator management - pressure, ground personnel (contributing factor) - facility,inadequate manuals/directives, company/operator management (contributing factor) ## Analysis THE RAMP AGENT WAS SERVICING A FLIGHT THAT WAS 40 MINUTES BEHIND ITS SCHEDULED DEPARTURE TIME. AFTER BOTH ENGINES HAD BEEN STARTED, THE CAPTAIN GAVE THE HAND SIGNAL TO DISCONNECT THE AIRPLANE FROM THE GROUND POWER UNIT (GPU). UPON RECEIVING THE SIGNAL, THE RAMP AGENT WALKED FROM THE FRONT OF THE AIRPLANE, AROUND THE RIGHT WING, AND TO THE REAR OF THE AIRPLANE. A SECOND RAMP AGENT THEN ARRIVED TO ASSIST. THE FIRST RAMP AGENT DISCONNECTED THE GPU, HANDED THE PLUG TO THE SECOND RAMP AGENT, DUCKED UNDER THE RIGHT WING, WALKED FORWARD INTO THE PROPELLER ARC, AND WAS STRUCK SEVERAL TIMES BY THE MOVING PROPELLER. THE RAMP AGENT RECIEVED TRAINING ON RAMP SAFETY AND WAS DESIGNATED AN INSTRUCTOR OF RAMP SAFETY. THREE AIRPLANES WERE AT THE GATE AREA AT THE TIME OF THE ACCIDENT. THE RAMP AREA DOES NOT HAVE ANY MARKINGS FOR AIRPLANE PARKING OR GROUND OPERATIONS. THE MANUALS USED BY THE AGENT'S EMPLOYER DID NOT REFERENCE WALKING UNDER WINGS OR CLEARANCE FROM PROPELLER ARCS DURING RAMP OPERATIONS. ## Factual narrative HISTORY OF FLIGHT On November 5, 1993, at 1206 hours eastern standard time, a ground crew person was fatally injured after being struck by a propeller from N550TD, a Fairchild SA 227-AC airplane, being operated as Northwest Airlink Flight 3724, while the airplane was standing at the Newark International Airport, Newark, New Jersey. The airplane was not damaged and none of the 13 passengers and two crewmembers were injured. Visual meteorological conditions prevailed and a instrument flight rules flight plan was filed. The flight was preparing to depart to Boston, Massachusetts, and was being conducted under 14 CFR 135. According to the Police Division of the Port Authority of New York and New Jersey, three airplanes were at the gate area at the time of the accident ". . . due to weather delays of up to one hour." There were two ramp agents attempting to service the three airplanes. Flight 3724 was preparing to depart the ramp for a flight to Boston. The flight was about 40 minutes behind its scheduled departure time. According to the captain and the first officer, the victim, acting as a customer service/ramp agent, had given the "all clear" hand signal to start the right engine, and then gave the "all clear" signal to start the left engine. She gave these signals while standing in front of the airplane in view of the crew. The victim was servicing the airplane by herself during this time. After both engines were started, the captain gave the hand signal to disconnect the ground power unit (GPU) located on the right rear portion of the airplane. The captain stated that after he gave the signal, he looked at the cockpit instruments for the ". . . indication that the GPU was disconnected." The first officer was looking at his checklist at that time. Another customer service/ramp agent had just completed servicing another airplane on the ramp and walked to the rear of Flight 3724 to help the victim. According to the ramp agent, the victim appeared to receive the signal to disconnect the GPU and walked from the front of the airplane toward the rear around the outside of the right wing. She approached the right, rear portion of the airplane where the GPU was plugged in. According to the ramp agent: She disconnected the [GPU] plug from the aircraft, turned around and walked to the rear of the plane with the cord. I was standing next to the [GPU] cart that held the cord. She handed me the cord and I began to stow the cord in the cart. As I was putting the cord in, I looked up and at first did not see [the victim]. I looked and saw [the victim] heading back to the front of the plane. She wasn't walking around the wing, she was walking straight back under the plane towards the engine. I called at her. I called her name several times but she did not hear me. She had bent down and was walking right into the prop. I saw the prop hit her. A passenger seated in the airplane next to the right propeller stated that the victim ". . . walked into the outside edge of the prop . . . from rear of plane." The first officer stated that he ". . . heard a thud and the plane shook . . . " causing him to look outside the airplane. He saw the victim lying on the ground. He then informed the captain; both engines were immediately shut down. The wheel chocks were in place during the accident, and the airplane did not move. The victim was wearing ear protection at the time of the accident. According to a report of the accident by the Port Authority, "In an attempt to expedite the departure of [the flight, the victim] deviated from the normal procedure of walking around the wing." The accident occurred during the hours of daylight at 40 degrees, 41.58 minutes North, and 74 degrees, 10.11 minutes West. PERSONNEL INFORMATION According to the victim's employer, Precision Airlines, Inc., the victim, age 22, had been employed by the company since June 1, 1992. A review of her training records indicated that she received five days of "new hire" training during her first month of employment. According to the Director of Stations at Precision Airlines, the training included ramp safety. The training records also indicated that the victim had been designated as an instructor to train others on ramp safety. The victims's time card for the day of the accident indicated that she had began her duty day about 0500 hours. AIRCRAFT INFORMATION The airplane, a Fairchild model SA-227 Metroliner, is a low-wing, twin-engine commuter transport. It is powered by two Garrett TPE 331 four-blade turboprop engines. According to information obtained by the Port Authority of New York and New Jersey, the engines were operating at 1113 revolutions per minute at the time of the accident. AERODROME INFORMATION According to the Port Authority of New York and New Jersey, the accident occurred at Terminal "B", Satellite B4, Gate 40 area. The area is controlled and used by Northwest Airlink to service their aircraft and load/unload passengers. No jetways are used, and all operations occur outside on the ramp. According to FAA Aviation Safety Inspectors, the ramp area used by Northwest Airlink does not have any markings to designate parking locations for airplanes, nor are there any markings for passenger boarding walkways and ground crew personnel boundaries. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the victim by Dr. Shaikh, M.D., at the State of New Jersey Medical Examiner's Office, Newark, New Jersey, on November 6, 1993. The cause of death listed on the report of autopsy was "multiple injuries - accident." A toxicological examination was conducted on specimens taken from he victim by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma. On their report dated January 18, 1994, negative results were reported for alcohol and all screened drugs. ADDITIONAL INFORMATION Precision Airlines, Inc., the victim's employer, provides ramp service to Northwest Airlink by contractual agreement. Northwest Airlink is operated by Northeast Express Regional Airlines, Inc. Northeast Express Regional Airlines, Inc. and Precision Airlines, Inc. are both subsidiary companies of the Northeast Air Group. The Northeast Air Group controls several airline, dispatch, and maintenance companies. According to the Director of Stations for Precision Airlines, Inc., the following is a synopsis of the procedures used to service airplanes during ramp operations: In a one-person operation, the ramp service agent goes to the front of the aircraft (visible to the pilot). The left engine is started, then the right. The pilot indicates, via hand signals, to disconnect the ground power unit which is plugged into the area of the right wing between the right engine and the fuselage. The agent walks around the wing, disconnects the unit, and moves the unit away from the aircraft. Walking around the wing, the agent returns to the front of aircraft and signals the pilot before removing the wheel chocks from the nose gear. The agent then returns to the visible position and signals the pilot to taxi. In a two-person operation, one agent is stationed at the front of the airplane in view of the pilot, while the second agent is at the GPU near the rear of the right wing. The left engine is started, then the right. The pilot signals the front agent to disconnect the GPU. After the rear agent disconnects the unit, he/she moves the vehicles away from the aircraft. The front agent then signals that the chocks will be removed. After removing them, the agent returns to his/her original position and signals the pilot to taxi. In both procedures, no one is to pass under the wing of the aircraft into the area of the propeller. At the tim ## Aircraft - Registration: N550TD (not matched to a registry record) - Reported make and model: FAIRCHILD SA 227-AC - Category: Airplane - Serial number: AC-487B - Airframe hours: 8767 - Engines: Garrett TPE 331-11 1000 lbs thrust turbo prop - Damage: No damage - Flight: Part 135 - Operator: Northeast Express Airlines Inc, doing business as Northwest Airlink - Registered owner: Chrysler Asset Mgmt. Corp. - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, November 1, 1993, 19 hours before - Destination: BOS, BOSTON, MA - Flight plan: IFR - Airport: EWR, Newark International Apt. ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 4,700 total, 1,700 in this make and model, 4,300 as pilot in command, 180 in the last 90 days, 60 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 20° at 12 knots - Visibility: 3 statute miles - Lowest ceiling: 1,300 ft overcast - Temperature: 59 °F, dew point 57 °F - Altimeter: 29.00 inHg - Observed at: EWR ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19931105048929A](https://openairdocs.org/incident/19931105048929A), Nov 5, 1993: Swrngn SA227AC, Newark, NJ, 1 fatal. Ground crew person lowered her head and passed under port wing. Walked into NR2 propeller. Fatally injured. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.