DCA16CA133

NTSB accident investigation · Boeing 737 76Q · San Diego, CA · April 14, 2016

Accident · Serious injuriesData collectionFinal report
Date
April 14, 2016, 16:24 local (23:24 UTC)
Place
San Diego, CA
Injuries
1 serious, 121 uninjured; on the ground: 1 serious
Damage
No damage
Phase of flight
Standing
Aircraft
N565WNBoeing 737 76Q
Defining event
Standing: Ground handling event
Weather
Visual (VMC) · Dusk
Status
Completed · report March 30, 2020
Report
Approved by Office Director
NTSB office
Major Investigations Division
Case key
93010

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

the ramp agents failure to keep his right hand at a safe distance from the underside of the moving belt.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: unnecessary actionPersonnel issues › Action/decision · Ground crewBoeing 737-76Q: 1 caseAll aircraft: 52 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

On Thursday, April 14, 2016, at approximately 1624 PDT a Southwest Airlines' ramp agent incurred a serious injury to his right arm and hand during the baggage unloading process at San Diego International Airport (KSAN), San Diego, California. Flight 3060 from Albuquerque International Sunport (KABQ), Albuquerque, New Mexico, arrived into Gate 2 at 1617 PDT, at which time ground personnel positioned a beltloader adjacent to the forward cargo bin entry door and began offloading baggage from the aircraft. Two Agents toward the forward portion of the aircraft were discussing their plan to unload a heavy powered wheelchair out of the forward cargo bin. One agent was situated in the cargo bin, while the other was on the ground to the left side of the beltloader. Based on a review of video footage, as they were talking, the agent on the ground was observed placing and removing his hand on the top of the running belt in a recurring motion. He then placed his hand at the bottom of the belt and appeared to attempt the same behavior (riding his hand on the belt). Moments later the ramp agent's arm became lodged in the beltloader, and he immediately fell to the ground. Other ramp personnel immediately became aware of the situation and attempted to aid the ramp agent. The beltloader was turned off with the ramp agent's arm still lodged inside the belt loader. A ramp supervisor obtained a pair of scissors and cut the belt on the beltloader off. However, the ramp agent was still not able to free himself. The supervisor quickly retrieved tools, removed the belt's access panel and roller bolts, and finally freed the ramp agent's arm from the belt. Paramedics arrived moments later. The ramp agent was examined in the ambulance and then taken to the hospital. The ramp agent sustained a burn on his forearm, a three-inch laceration on his hand, and a broken right wrist. It is unknown why the ramp agent decided to place his hand on the underside of the beltloader. Southwest Airlines has precautions and established procedures for ramp operations that is contained in their ground operations manual.

Factual narrative

On Thursday, April 14, 2016, at approximately 1624 PDT a Southwest Airlines' ramp agent incurred a serious injury to his right arm and hand during the baggage unloading process at San Diego International Airport (KSAN), San Diego, California. Flight 3060 from Albuquerque International Sunport (KABQ), Albuquerque, New Mexico, arrived into Gate 2 at 1617 PDT, at which time ground personnel positioned a beltloader adjacent to the forward cargo bin entry door and began offloading baggage from the aircraft. Two Agents toward the forward portion of the aircraft were discussing their plan to unload a heavy powered wheelchair out of the forward cargo bin. One agent was situated in the cargo bin, while the other was on the ground to the left side of the beltloader. Based on a review of video footage, as they were talking, the agent on the ground was observed placing and removing his hand on the top of the running belt in a recurring motion. He then placed his hand at the bottom of the belt and appeared to attempt the same behavior (riding his hand on the belt). Moments later the ramp agent's arm became lodged in the beltloader, and he immediately fell to the ground. Other ramp personnel immediately became aware of the situation and attempted to aid the ramp agent. The beltloader was turned off with the ramp agent's arm still lodged inside the belt loader. A ramp supervisor obtained a pair of scissors and cut the belt on the beltloader off. However, the ramp agent was still not able to free himself. The supervisor quickly retrieved tools, removed the belt's access panel and roller bolts, and finally freed the ramp agent's arm from the belt. Paramedics arrived moments later. The ramp agent was examined in the ambulance and then taken to the hospital. The ramp agent sustained a burn on his forearm, a three-inch laceration on his hand, and a broken right wrist. It is unknown why the ramp agent decided to place his hand on the underside of the beltloader. Southwest Airlines has precautions and established procedures for ramp operations that is contained in their ground operations manual.

Aircraft

Registration
N565WN
Reported as
Boeing 737 76Q (76Q)
Category
Airplane
Serial number
30282
Built
2002
Engines
CFM Intl CFM56-7B22, turbo fanCFM Intl CFM56-7B22, turbo fan
Damage
No damage
Flight
Part 121
Operator
Southwest Airlines Co
Registered owner
Wells Fargo Bank Northwest Na Trustee
Airworthiness certificate
Standard, Transport
Departed
KABQ · Albuquerque, NM
Destination
KSAN · San Diego, CA
Flight plan
VFR/IFR
Airport
KSAN · San Diego International Airpor

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Weather

Conditions
Visual (VMC) · Dusk
Wind
290° at 8 knots
Visibility
10 statute miles
Temperature
66 °F, dew point 52 °F
Observed at
KSAN

Docket · 1

The files NTSB released with the investigation on April 2, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 594 KB in all.