Pre-Flight

Survival on the Hudson: Inattention to Safety Briefings, Life Vests and Life Lines Increased Risks After US Airways Flight 1549 Touched Down

by Wayne Rosenkrans

This article was originally published in the July 2010 issue of AeroSafety World magazine and is reprinted with the permission of the Flight Safety Foundation.

The public’s intuition that “fortuitous” circumstances contributed to all occupants surviving the January 2009 ditching of an Airbus A320 in the Hudson River has been seconded by the final accident report of the U.S. National Transportation Safety Board (NTSB) on US Airways Flight 1549.Footnote 1 Now-famous images of people without life vests or life lines standing on the wings, however, contain a less obvious message about shared responsibility for safety aboard aircraft. Rather than dwell on the unusually favourable circumstances, the NTSB took the opportunity to redirect the attention of government, the airline industry and the travelling public to the critical survival factors they do control.

For example, noting that “only about 10 passengers [of 150] retrieved life vests themselves after impact and evacuated with them” and that only 77 retrieved flotation-type seat cushions, the survival factors sections of the report essentially said that crew members and passengers disregard at their peril the life-saving knowledge and equipment provided. “The NTSB notes that, after exiting the airplane through the overwing exits, at least nine passengers unintentionally fell into the water from the wings,” the report said.

Several explanations were offered by investigators. “Although the accident flight attendants did not command passengers to don their life vests before the water impact, two passengers realized that they would be landing in water and retrieved and donned their life vests before impact, and a third passenger attempted to retrieve his life vest but was unable to do so and, therefore, abandoned his attempt,” the report said. “Many passengers reported that their immediate concern after the water impact was to evacuate as quickly as possible, that they forgot about or were unaware that a life vest was under their seat, or that they did not want to delay their egress to get one. Other passengers stated that they wanted to retrieve their life vest but could not remember where it was stowed.” In all, 101 life vests were left stowed under passenger seats.

The accident analysis does not devalue the positive outcomes of the captain’s judgment, the cabin crew’s performance or the passengers’ orderly behaviour, and the report notes, “The NTSB concludes that the captain’s decision to ditch on the Hudson RiverFootnote 2 rather than attempting to land at an airport provided the highest probability that the accident would be survivable. . . . Contributing to the survivability of the accident was the decision making of the flight crew members and their crew resource management during the accident sequence; the fortuitous use of an airplane that was equipped for an extended-overwater [EOW]Footnote 3 flight, including the availability of the forward slide/rafts, even though it was not required to be so equipped; the performance of the cabin crew members while expediting the evacuation of the airplane; and the proximity of the emergency responders to the accident site and their immediate and appropriate response to the accident,” the report said.

The lessons learned reflected the importance of leaving as little to chance as possible in preparations to survive an aircraft accident. “The investigation revealed that the success of this ditching mostly resulted from a series of fortuitous circumstances, including that the ditching occurred in good visibility conditions on calm water and was executed by a very experienced flight crew. . . . The investigation revealed several areas where safety improvements are needed,” the report said.

The accident airplane was one of 20 EOW-equipped A320s among the airline’s fleet of 75 A320s. Each of four slide/rafts was rated to carry 44 people and had an overload capacity of 55. Also aboard, but not counted toward EOW equipment, were two off-wing ramp/slides, one at each pair of overwing exits.

“The accident airplane had the statements, ‘Life Vest Under Your Seat’ and ‘Bottom Cushion Usable for Flotation,’ printed on the [overhead] passenger service units (next to the reading light switches) above each row of seats,” the report said. The four life lines were designed to be retrieved after ditching from an overhead bin, attached to top corners of door frames on both sides of the airplane fuselage and anchored to a designated point on top of each wing.

The importance of these items becomes clear by considering that only two detachable slide/rafts were available for Flight 1549 occupants—at door 1L and door 1R—with a combined capacity to carry 110 of the 155 occupants if the airplane had sunk before they were rescued. The NTSB determined that about 64 occupants were rescued from these slide/rafts, while about 87 were rescued from the wings and off-wing ramp/slides.

Survival Scenario

Loss of thrust in both engines prompted the captain of Flight 1549 to commit to the ditching as the safest course of action despite it necessitating an evacuation in harsh winter temperatures. The flight crew later said that its top priority then was to touch down with a “survivable sink rate.” Analysis of the digital flight data recorder showed that “the airplane touched down on the Hudson River at an airspeed of 125 kt calibrated airspeed with a pitch angle of 9.5°, [a descent rate of 12.5 ft per second (fps)] and a right roll angle of 0.4°,” the report said.

The evacuation began within seconds of the airplane’s rapid deceleration on the river’s surface, after touchdown at about 15:27 local time. The captain opened the flight deck door and commanded an evacuation by speaking directly to the forward flight attendants and passengers. He observed then that the evacuation had already begun.

“The water in the back of the airplane rose quickly, which, in addition to improvised commands from flight attendant B to ‘go over the seats,’ resulted in numerous passengers climbing forward over the seatbacks to reach a usable exit,” the report said. “However, some aft passengers remained in the aisle queue to the overwing exits. Many of these passengers noted that, when they arrived at the [overwing] exits, the wings were crowded and people were exiting slowly. They also reported that the aisle forward of the overwing exits was completely clear and that the flight attendants were calling for passengers to come forward to the slide/rafts.”

The NTSB estimated the evacuation sequence and timing: The left overwing exits were opened by passengers at 15:30:58, contrary to the airline’s ditching procedures, and the first passenger subsequently exited; flight attendant A opened door 1L to its locked-open position against the fuselage at 15:31:06, and no water entered, but this crew member had to operate the manual inflation handle to deploy the slide/raft because the automatic system appeared to have failed; flight attendant C opened door 1R at 15:31:11, automatically causing full deployment of the slide/raft at 15:31:16; one passenger jumped into the water from door 1L at 15:31:23 before its slide/raft began to inflate; the slide/raft at door 1L began to inflate at 15:31:26; the first vessel arrived on scene at 15:34:40; and the last vessel departed the scene after rescuing the last passengers from the left off-wing ramp/slide at 15:54:43.

Eight of the passengers exited the aircraft, re-entered the aircraft to obtain one or more life vests, then exited from a different door. Flight attendant B did not become aware of a serious injury to her left shin until aboard the door 1R slide/raft.

“A review of passenger exit usage indicated that, in general, passengers from the forward and mid parts of the cabin evacuated through the exit closest to their seats,” the report said. “However, aft-seated passengers indicated that water immediately entered the aft area of the airplane after impact and that the water rose to the level of their seat pans within seconds; therefore, they were not able to exit from their closest exits because these exits were no longer usable.” Several safety equipment irregularities occurred, affecting crew actions and passenger behaviour. “Flight attendant C . . . stated that door 1R started to close during the evacuation, intruding about 12 in. [30 cm] into the doorway and impinging on the slide/raft,” the report said. “She stated that she was concerned that the slide/raft would get punctured, so she assigned an ‘able-bodied’ man to hold the door to keep it off of the slide/raft.”

One female passenger with a lap-held child received assistance from a fellow passenger shortly before the touchdown. “When the captain [announced] ‘Brace for impact,’ the male passenger in [seat] 19F offered to brace her [nine-month-old] son for impact,” the report said. “The lap-held child’s mother [in seat 19E] stated that she thought the passenger in 19F ‘knew what he was doing,’ and she gave her son to him.” None of these passengers was injured.

All three flight attendants described the evacuation process as relatively orderly and timely. The captain and first officer said that while assisting the cabin crew with the evacuation, they observed passengers without life vests outside the airplane. “[The captain and first officer] obtained some life vests from under the passenger seats in the cabin and passed them out to passengers outside of the airplane,” the report said. The flight crew also conducted the final cabin inspection to ensure no passengers had been left, then exited onto the slide/raft at door 1L.

Emergency Response

Air traffic control tower personnel at LaGuardia Airport activated the area’s emergency alert notification system via its crash telephone at 15:28:53. This immediately notified numerous agencies to respond with predetermined personnel and equipment according to the LaGuardia Airport emergency plan. The airport dispatched one rescue boat. Personnel from New York Waterway (NY WW) also responded to the accident although they were not part of the emergency plan.

“The airplane was ditched on the Hudson River near the NY WW Port Imperial Ferry Terminal in Weehawken, New Jersey,” the report said. “Many NY WW ferries were operating over established routes in the local waterway, and the ferry captains either witnessed the accident or were notified about it by the director of ferry operations. Seven NY WW vessels responded to the accident and recovered occupants.”

The first responders considered the winter weather conditions a serious risk to survival. “The post-crash environment, which included a 41°F [5°C] water temperature and a 2°F [minus 17°C] wind chill factor and a lack of sufficient slide/rafts (resulting from water entering the aft fuselage), posed an immediate threat to the occupants’ lives,” the report said. “Although the airplane continued to float for some time, many of the passengers who evacuated onto the wings were exposed to water up to their waists within two minutes.”

The Port Imperial Ferry Terminal was designated as the central triage site; nevertheless, captains of vessels dropped off the Flight 1549 occupants at the closest locations in New York and New Jersey because the aircraft was drifting and some passengers were wet and at risk of cold-induced injury.

Among the 45 passengers and five crew members transported to hospitals, flight attendant B and two passengers had sustained serious injuries. One of those passengers was admitted to a hospital for treatment of hypothermia. The other was treated for a fractured xiphoid process, an “ossified extension” of the lower part of the sternum. “Two passengers not initially transported to a hospital later furnished medical records to the NTSB showing that one had suffered a fractured left shoulder and the other a fractured right shoulder,” the report said. “Flight attendant B sustained a V-shaped, 12-cm-long 5-cm-deep [5-in. by 2-in.] laceration to her lower left leg that required surgery to close.” The cause of flight attendant B’s laceration was a vertical beam that punctured the cabin floor in front of her jump seat about 11 in. (28 cm) forward of the seat pan.

Life Vest Awareness

Passenger interviews indicated that about 70 percent of the passengers did not watch any of the preflight safety briefing. “The most frequently cited reason for [inattention] was that the passengers flew frequently and were familiar with the equipment on the airplane, making them complacent,” the report said.

Flight 1549 passengers could learn about the availability of life vests only from the safety information cards in seatback pockets or the overhead statements, although some assumed that all commercial passenger jets carry life vests. “US Airways’ FAA-accepted In-Flight Emergency Manual followed [FAA] advisory circular guidance and specified that, if the airplane is equipped with both flotation seat cushions and life vests, flight attendants should brief passengers on both types of equipment, including the location and use of life vests,” the report said. “The cockpit voice recorder recorded flight attendant B orally brief the location and use of the flotation seat cushions; however, it did not record her brief the location of or the donning procedures for life vests. . . . A life vest demonstration was not required because the flight was not an EOW operation.”

Braced But Injured

The safety information cards also provided instructions on the operation of the emergency exits and depicted passenger brace positions that were similar to FAA guidance on brace positions. Three of four seriously injured passengers were hurt during the airplane’s impact with the water.

“The two female passengers who sustained very similar shoulder fractures both described assuming similar brace positions, putting their arms on the seat in front of them and leaning over,” the report said. “They also stated that they felt that their injuries were caused during the impact when their arms were driven back into their shoulders as they were thrown forward into the seats in front of them. The brace positions they described were similar to the one depicted on the US Airways safety information card.”

The passenger seats on the accident airplane were 16-g compatible seats. The NTSB noted that new seats have a non-breakover seatback design, which minimizes head movement and body acceleration before striking the seatback from behind, resulting in less serious head injuries.

“Guidance in [FAA Advisory Circular 121-24C] did not take into consideration the effects of striking seats that do not have the breakover feature because research on this issue has not been conducted,” the report said. “The NTSB concludes that . . . in this accident, the FAA-­recommended brace position might have contributed to the shoulder fractures of two passengers.”

Unused Life Vests

Overall, 19 passengers attempted to obtain a life vest from under a seat, and 10 of them reported difficulties retrieving it. “Of those 10 passengers, only three were persistent enough to eventually obtain the life vest; the other seven either retrieved a flotation seat cushion or abandoned the idea of retrieving flotation equipment altogether,” the report said.

Most passengers who attempted to don or donned life vests were already seated in a slide/raft or ramp/slide or were standing on a wing. “Of the estimated 33 passengers who reported eventually having a life vest, only four confirmed that they were able to complete the donning process by securing the waist strap themselves,” the report said. “Most of the passengers who had life vests either struggled with the strap or chose not to secure it at all for a variety of reasons.”

Airline industry safety standards for overwater flight have not anticipated scenarios in which passengers exit onto the wings after a ditching, the report said. “Each overwing exit pair [in this case] was equipped with an automatically inflating, off-wing Type IV exit ramp/slide,” the report said. “The off-wing ramp/slides did not have quick-release handles [for detachment].”

Despite a regulation requiring life lines at overwing exits—which are intended to be opened by passengers, not flight attendants—circumstances in which they could be used effectively after ditching have been unclear, the report said. The passenger safety information card lacked information about the location of the life lines and how to use them. “Further, no information is provided to passengers about life lines during the preflight safety demonstration or individual exit row briefings,” the report said, and placards above the overwing exit signs only depicted deployed life lines from a pair of overwing exits. The NTSB concluded that life lines could have been used to assist Flight 1549 passengers on both wings, “possibly preventing them from falling into the water.”

The off-wing ramp/slides on the accident airplane, as is typical in the industry, had no quick-release girts to enable occupants to free the ramp/slides from the sinking airplane for flotation out of the water or for use as handholds. “Some passengers immediately recognized their usefulness and boarded the ramp/slides to get out of the water,” the report said. “Eventually, about eight passengers succeeded in boarding the left off-wing slide and about 21 passengers, including the lap-held child, succeeded in boarding the right off-wing ramp/slide.”

Summary statements in the report encouraged the government and airline industry to reconsider past NTSB recommendations validated by the facts of this event. “The circumstances of this accident demonstrate that even a non-EOW flight can be ditched, resulting in significant fuselage breaching,” the report said. “Therefore, all passengers, regardless of whether or not their flight is an EOW operation, need to be provided with adequate safety equipment to ensure their greatest opportunity for survival if a ditching or other water-related event occurs.”

Footnotes

Footnote 1

NTSB. “Aircraft Accident Report: Loss of Thrust in Both Engines After Encountering a Flock of Birds and Subsequent Ditching on the Hudson River, US Airways Flight 1549, Airbus A320-214, N106US, Weehawken, New Jersey, January 15, 2009.” Accident Report NTSB/AAR-10/03, PB2010-910403, Notation 8082A, May 4, 2010. The report contains safety recommendations, including references to NTSB safety recommendations dating from the 1980s that remain relevant to survival factors. It is available at  http://www.ntsb.gov/doclib/reports/2010/AAR1003.pdf.

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Footnote 2

About two min after takeoff, at an altitude of 2 800 ft, the aircraft experienced an almost complete loss of thrust in both engines after encountering a flock of birds and subsequently was ditched about 8.5 mi. (14 km) from LaGuardia Airport, New York City, New York, USA. The accident occurred on January 15, 2009.

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Footnote 3

EOW operations, with respect to aircraft other than helicopters, are operations over water at a horizontal distance of more than 50 NM (93 km) from the nearest shoreline.

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Aviation Weather—What You Need to Know

by Louis Sauvé, Civil Aviation Safety Inspector, Flight Information Services & Weather, ANS Operations Oversight, National Operations Branch, Civil Aviation, Transport Canada

Weather information is crucial in preparing for a flight. Current conditions and forecasts based on aviation weather reports are key elements in all phases (preparation, en route and arrival) of a flight.

Transport Canada Civil Aviation regulates the provision of aviation weather under Canadian Aviation Regulation (CAR) 804 and a number of exemptions to this regulation.

There are two main categories of aviation weather service providers:

  1. Providers of METAR/SPECI weather information that operate in accordance to CAR 804.
  2. Providers of weather information under an exemption that does not lead to the production of a METAR.

NAV CANADA is the principal provider of METAR/SPECI in Canada. According to the March 2013 issue of the Canada Flight Supplement (CFS), there are 250 METAR sites across the country comprised of the following:

  • 66 weather stations (CWO) under contract with NAV CANADA
  • 62 community aerodrome radio stations (CARS)
  • 58 flight service stations (FSS)
  • 51 automatic stations (AWOS)
  • 13 sites operated by the Department of Defence

All of these stations—except for automatic stations—must comply with CAR 804 and provide weather information in accordance with the standards described in the following documents:

(a) Annex 3 to the Convention;
(b) the Manual of Standards and Procedures for Aviation Weather Forecasts (MANAIR);
(c) the Manual of Surface Weather Observations (MANOBS).

There are also a significant number of aerodromes offering weather information other than METAR/SPECI in Canada. This information is provided by UNICOMs, approach UNICOMs (AU) or private automated systems such as automated weather observation systems (AWOS) or limited weather information systems (LWIS).

According to that same issue of the CFS, there are approximately:

  • 200 UNICOM sites where there is a published instrument approach procedure
  • 80 AUs
  • 40 private AUTO sites

All of these services are provided in accordance with at least one of the following exemptions:

  • Exemption allowing for the provision of an altimeter setting measured by a dual aircraft altimeter system for use in instrument procedures.
  • Exemption allowing for the provision of wind direction and speed estimation for the purpose of supporting a straight-in landing from an instrument approach.
  • Exemption allowing for the provision of aviation weather services consisting of automated observation and reporting of any or all of the following: wind direction, speed and character; visibility; present weather; sky condition; temperature; dew point temperature or atmospheric pressure.

The exemption which permits the provision of weather information using automated systems was created based on recommendations submitted by a Canadian Aviation Regulation Advisory Council (CARAC) working group. This working group had been mandated to establish standards for the inclusion of automated systems into CAR 804. These recommendations were accepted and resulted in a Notice of Proposed Amendment (NPA) to CAR 804.

Meanwhile, in order to allow for the operation of such systems, an exemption to CAR 804 was created based on the working group’s recommendations.

Any person who wishes to provide a service described in one of these exemptions must inform the Minister by contacting one of Transport Canada’s regional offices.

The exemption is permissive. In most cases, if the service provider forwards basic information (such as address, type of service provided, etc.) in good order and accepts full responsibility for the service, the Minister will accept its operation.

The exemption applies exclusively to automated weather equipment used in support of an instrument procedure.

If you wish to provide a service under any of these exemptions, you may contact your Transport Canada regional office (www.tc.gc.ca/eng/regions-air.htm).

Sharing of Safety Information Key to Effective Industry-Wide Safety Management

by James Carr, Manager, Human Performance, NAV CANADA

NAV CANADA logoWe all know that sharing safety information within our organization is crucial to a robust safety culture and an effective safety management system.

Similarly, it stands to reason that improving safety performance industry-wide requires the sharing of safety information and data across all players within the industry.

NAV CANADA has always exchanged information with operators following occurrences to aid parties in better understanding what happened. More recently, the company has signed specific memoranda of agreement (MOA) with over 65 operators and other industry players, such as airport authorities, for the sharing of audio and surveillance data and other safety information related to specific occurrences.

Normally, operators submit requests for audio and/or surveillance data related to an incident, accident or other event they wish to examine more closely for potential safety lessons to NAV CANADA via an e-mail to operationalsafety@navcanada.ca. They should include a description of the event or a CADORS number, if applicable. If the operator does not yet have a MOA, one will be established to govern the use of the data provided.

When a request is received, Operational Safety will take steps to secure the relevant information, review it to ensure it accurately covers the event in question and make arrangements to transfer the information to the operator. The information usually includes audio files of radio communications and screen shots or short video files of radar playbacks.

Having this information allows operators to conduct more effective investigations following occurrences by providing clear information on what took place; or alternatively,  to examine events that may not have been reportable occurrences but still warrant a closer examination. In the past two years, NAV CANADA has shared information related to over 100 events under this information-sharing program. From discussions with participants in the program, it is clear that a number of safety improvements have occurred as a result.

While many larger operators and airports have taken the opportunity to access this type of information to aid their assessments, smaller operators and flying school operations can also benefit.

If you are interested in accessing NAV CANADA audio and/or surveillance data to aid in investigating your own occurrences, contact operational safety at operationalsafety@navcanada.ca for more details or to arrange a MOA.

Nominate a Person or Organization for the 2014 Aviation Safety Award!

SECURITAS logo Transport Canada is now accepting nominations for the 2014 Aviation Safety Award!

The Aviation Safety Award acknowledges sustained commitment to Canadian aviation safety for an extended period of time.

Nominations must demonstrate that the contribution to aviation safety meets at least one of the following categories:

  • A demonstrated commitment and an exceptional dedication to Canadian aviation safety over an extended period of time (three years or longer);
  • The successful completion of a program or research project that has had a significant impact on aviation safety in Canada;
  • An outstanding act, effort, contribution or service to aviation safety.

An award certificate signed by the Minister of Transport is normally presented to the recipient during the week of National Aviation Day (February 23).

The award recipient will be notified by January 15, 2014. For more information, please visit the Aviation Safety Award Web page.

How do I submit a nomination?

Nominators and nominees must sign the Nomination Form acknowledging that they agree to abide by the Award Rules as defined in the Nomination Guide.

In addition to the Nomination Form, supporting documentation is required to successfully nominate a candidate, including the category for which the candidate is to be considered and a narrative describing the contribution and its significance to aviation safety.

Nominations are to be forwarded via mail, fax or email* to:

Civil Aviation Communications Centre
TC Aviation Safety Award
Transport Canada
Civil Aviation Secretariat (AARCB)
Place de Ville, Tower C, 5th floor
330 Sparks St.
Ottawa ON  K1A 0N5
Fax: (613) 993-7038
E-mail: Services@tc.gc.ca
*If sending a nomination via e-mail please ensure to include a scanned copy of the nomination form.

The nomination period closes on December 7th, 2013. For complete information on submitting a nomination, please visit the Aviation Safety Award Nomination Web page.

Past award winners

In the last three years, the award recipients have reflected the diverse contributions made every day to the enhancement of aviation safety in Canada: From the CHC Safety & Quality Summit, for creating a world-leading forum to share best practices amongst delegates around the world, to St. Clair McColl, who was the first to have emergency push-out windows installed on his entire fleet of de Havilland Beaver floatplanes, to Vitorio Stana, who played a vital role in setting and maintaining high manufacturing safety standards for his company’s products.

Please visit the Past Recipients Web page to learn more about the recipients of the Aviation Safety Award.

Background

Transport Canada has had a long tradition of recognizing excellence in aviation safety. The first Aviation Safety Award was given in 1988 to Bob Carnie, vice-president of aviation safety at Reed Stenhouse Limited, for his outstanding contribution to the promotion of safety for both fixed- and rotary-wing aircraft operations.

Any individual, group, company, organization, agency or department may be nominated for this award. A nominee must be a Canadian-owned organization or a resident of Canada.

Is Your Aviation Document Booklet Expiring?

by the Transport Canada Civil Aviation Personnel Licensing Division

Transport Canada Civil Aviation (TCCA) introduced the Aviation Document Booklet (ADB) in 2008 to enhance the security of the licensing document and to provide a more lasting product for pilots, flight engineers and air traffic controllers. The ADB provides evidence that holders have qualified for certain aviation-related permits, licences, medical certificates and ratings.Footnote 1

Your ADB must be renewed within five years to ensure that the photograph is current. Some ADB holders may require earlier renewal for other reasons (for example, if a pilot holds a level 4 language proficiency). 


Your ADB must be renewed every five years. Please make a note of the expiry date as indicated in the example above, in the bottom right quadrant of the photo page.

How to renew your ADB

To renew an expiring ADB, applicants are required to submit a completed Application for an Aviation Document Booklet form (TP 26-0726) and a passport-style photograph to the TCCA regional office that holds their licensing file. TCCA requires four to six weeks to process a completed application. Applicants should submit their application form at least 90 days prior to their expiry date. There is no fee for the renewal of the ADB except for the cost of the photo and postage, which remain the responsibility of the applicant.

For more information, visit the ADB Web site at www.tc.gc.ca/ADB.

Footnotes

Footnote 1a

A Student Pilot Permit (SPP) is a standalone document. Students should not apply for an ADB if they only hold SPP.

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