On January 15, 2009… US Airways Flight 1549…experienced an almost complete loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City… The flight… had departed LGA about 2 minutes before the in-flight event occurred.

That’s from the 200-page report (NTSB/AAR-10/03) issued by the National Transportation Safety Board. Among the reasons I’ve been reading the report is to learn more about the interplay between training, learning, performance support, and the environment in which this emergency took place.

The NTSB report cites four major factors contributing to the survival of all 150 passengers and 5 crew members:

• The decisions and “crew resource management” of the flight crew
• The airplane itself, which was equipped with forward slide/rafts although these were not required on this flight
• The performance of the cabin crew in expediting the evacuation of the airplane
• The proximity and rapid arrival of emergency responders

A quick timeline:

• At 3:24 p.m. Eastern time, the tower cleared 1549 for takeoff.
• At 3:25:51, the captain reported the plain was at 700 feet, climbing to 5,000.
• At 3:27:10, “…the captain stated, ‘Birds.’ One second later, the CVR [cockpit voice recorder] recorded the sound of thumps and thuds followed by a shuddering sound.”

The report notes that the altitude was 2,818 feet and that engine speed started to decelerate.

• At 3:27:23, the captain took over control of the plane from the first officer, telling him, “Get the QRH [quick reference handbook] loss of thrust on both engines.”

Captain Chesley Sullenberger later reported that when he said this, First Officer Jeff Skiles already had the checklist out–showing how the two worked smoothly throughout the emergency.

• At 3:27:50, the first officer began calling out steps in the Engine Dual Failure checklist.
• At 3:29:11, the captain announced to the cabin, “Brace for impact.”
• At 3:30:41: the cockpit equipment broadcast “a 50-foot warning.” The flight data recorder reported 33 feet.

From impact to ditching, about three and a half minutes.

Who Does What, and What Gets Done?

In an interview with Air and Space Smithsonian, Sullenberger discussed his collaboration with First Officer Jeff Skiles. Typically, he said, the first officer flies the plane, and the captain monitors.  In this case, “even though Jeff was very experienced…[with] as much total flying experience” as Sullenberger, it was the first time Skiles had been on an Airbus A320 since training.  So Sullenberger decided “we were best served by me using my greater experience in the [A320] to fly the airplane.”

I also thought that since it had been almost a year since I had been through…recurrent training, and Jeff had just completed it…he was probably better suited to quickly knowing exactly which checklist would be most appropriate, and quickly finding it in this big multipage quick reference handbook that we carry in the cockpit.

Checklists and Focus

The NTSB report, in Appendix C, reprints the three-page Eng Dual Failure checklist.  Skiles and Sullenberger lacked time to get through more than the first page.  As it is, the checklist notes “optimal relight speed” [for the engines] is 300 nautical miles. Skiles at the time said, “We don’t have that.” The report states that the maximum airspeed after the bird strike was 214 knots.

The checklist also assumes far more altitude than 1549 had.  Step 3, on page 3 of the checklist, starts with what to do above an altitude of 3,000 feet.

Accidents and incidents have shown that pilots can become so fixated on an emergency or abnormal situation that routine items (for example, configuring for landing) are overlooked. For this reason, emergency and abnormal checklists often include reminders to pilots of items that may be forgotten. Additionally, pilots can lose their place in a checklist if they are required to alternate between various checklists or are distracted by other cockpit duties; however, as shown with the Engine Dual Failure checklist, combining checklists can result in lengthy procedures. [NTSB report, p. 92]

It seems clear to me that both captain and first officer believed that the engine-failure checklist was the best procedure to use.  While there is a procedure (a checklist) for ditching the A320, 1549’s crew never got to use it.  “Time would not allow it,” Sullenberger said in the A&S interview.  “The higher priority procedure to follow was for the loss of both engines.  The ditching would have been far secondary to that.”

Elsewhere the report notes that  “low-altitude, dual-engine failure checklists are not readily available in the industry” — in other words, this is not limited to US Airways or to Airbus.

Adding to stress for the flight crew was an array of alarms and warnings.  The ditching checklist, which they had no time to consult, included steps “to inhibit the ground proximity warning system and terrain alerts.”  In other words, since you know you’re ditching, you can shut these alarms off.

Training

According to the NTSB report, training at US Airways for dual-engine failure involves a full-flight simulator in which the failure occurs at 25,000 feet.  No training scenarios involve “traffic pattern altitudes,” which I take to mean “near airports.”  In addition, “dual-engine failure scenarios were not presented during recurrent training.” A similar approach is true for Airbus’s training.

The outcome

Sullenberger, Skiles, and the cabin crew (Sheila Dail, Donna Dent, and Doreen Walsh, each with at least 26 years’ experience with the airline) worked together to save the lives of 150 passengers.  Media reports tend to concentrate on the pilot’s actions, which were essential, since together with the first officer he was able to ditch the plane in a survivable manner.

The NTSB report notes that the accident “has been portrayed as a ‘successful’ ditching.”  It notes that the success “mostly resulted from a series of fortuitous circumstances” including these:

• An experienced flight crew
• Good visibility and calm water
• Extended-over-water equipment (e.g., rafts) on the plane though not required for this flight
• Nearness of vessels and responders available to rescue passengers and crew

Complex skills are…complex

I don’t have grand conclusions to put here.  I do think that the Sullenberger interview, and the details in the NTSB report, provide more balance than many mass-media “miracle on the Hudson” reports.  Clearly a success, in that everyone survived.  The causes of that success, and how to increase the likelihood of similar success in the future, are much more complex.

For example: Sullenberger at one time was a glider pilot.  A&S asked how that experience helped him.  “I get asked that question…a lot,” he said, “But that was so long ago, and those are so different from a modern jet airliner, I think the transfer [of experience] was not large.”

For all of 1549’s crew–in the cockpit and in the cabin–performance resulted from experience, and experience was shaped not only through time in the air, but through regular training intended to focus on critical events, to provide feedback, and to increase the likelihood of success in critical, unpredictable situations.

Consider by way of contrast a large group of untrained people: only 77 passengers (just over half) evacuated with their seat cushions.  This seemingly small element is a performance challenge: most passengers pay little attention to the safety briefing, and almost no one reads the safety card.  The NTBS report suggests that those who took cushions did so because  all preflight briefings point out that the cushion “may be used as a flotation device.”  In other words, some passengers were apparently habituated to that information and able to recall it when needed.

Life vests were not mentioned in the preflight safety briefing because 1549 was not an “extended overwater” flight.  19 passengers attempted to retrieve life vests from under their seats; only 3 “were persistent enough to eventually obtain the life vest.”  30 others tried to put a vest on once outside the plane, but only 4 said they were able to do so properly.

Small, regular deposits

You’d be hard pressed to find a better summation of building your own expertise than the way Sullenberger expressed himself to Katie Couric of NBC News:

One way of looking at this might be that for 42 years, I’ve been making small, regular deposits in this bank of experience, education, and training. And on January 15 the balance was sufficient so that I could make a very large withdrawal.