Pilot Debrief

BOEING 737 76Q near San Diego, CA — 2016-04-14

Final reportDCA16CA133
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Date
2016-04-14
Location
San Diego, CA, USA
Airport
KSAN
Aircraft
BOEING 737 76Q
Registration
N565WN
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Ground

Probable cause

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

NTSB 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.

Analysis

Primary failure mode
Human factors
First missed decision gate
Agent should not have placed hand on the beltloader while it was running.

NTSB coding

Evidence available

  • 1 docket document
View NTSB final reportView NTSB docket

Docket documents1

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