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Safety Recommendation Details

Safety Recommendation A-10-066
Details
Synopsis: On January 15, 2009, about 1527 eastern standard time,1 US Airways flight 1549, an Airbus Industrie A320-214, N106US, experienced an almost total 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, New York. The flight was en route to Charlotte Douglas International Airport (CLT), Charlotte, North Carolina, and had departed LGA about 2 minutes before the in-flight event occurred. The 150 passengers, including a lap-held child, and 5 crewmembers evacuated the airplane via the forward and overwing exits. One flight attendant and four passengers received serious injuries, and the airplane was substantially damaged. The scheduled, domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require manufacturers of turbine-powered aircraft to develop a checklist and procedure for a dual-engine failure occurring at a low altitude.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: Weehawken, NJ, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA09MA026
Accident Reports: Loss of Thrust in Both Engines, US Airways Flight 1549 Airbus Industrie A320-214, N106US
Report #: AAR-10-03
Accident Date: 1/15/2009
Issue Date: 5/21/2010
Date Closed: 7/23/2014
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Checklist, Engine Out

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/23/2014
Response: In your October 29, 2012, letter about this recommendation, you stated that your review of transport-category airplane flight manual (AFM) procedures had confirmed our finding that most procedures and training to restart the engines following an all-engines-out scenario are focused on failures occurring in cruise flight. You also agreed that developing the recommended revised checklist and procedures would help flight crews better manage a total power loss at low altitude and would therefore constitute an improvement over the current level of safety. You stated that, although these events might not occur frequently enough to justify mandatory action, you would address future aircraft type certifications by developing guidance encouraging airplane manufacturers to include low altitude conditions when they develop AFM procedures for an all engines-out scenario. On January 11, 2013, we replied that such action would satisfy the recommendation in an acceptable alternate manner if you were able to persuade all aircraft manufacturers to develop the recommended checklists and procedures for all transport category airplanes. We note that, based on your review of all-engines-out power loss events, you have now decided that low altitude events do not occur frequently enough to warrant mandatory action. You continue to agree, however, that the development of specific procedures for all-engines-out scenarios should include consideration of altitude, and we note that you have revised project specific inflight engine restart guidance for new or major design change transport category airplane programs to include this element. Your staff provided a copy of an issue paper titled “Inflight Engine Restart” that you use in reviewing and approving new type certifications. Paragraph 1, “Airplane Flight Manual,” Subparagraph b, “Procedures Necessary For,” line iv, addresses low altitude restart procedures. This line states that a procedure is needed to address dual engine failure that occurs at low altitude and during which the flight crew has limited time to address the failure before they must prepare for a forced landing. The development and implementation of the issue paper constitutes an acceptable alternative means of addressing Safety Recommendation A-10-66, which is classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

From: FAA
To: NTSB
Date: 5/9/2014
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) has completed its review of all-engines-out power loss events for transport-category airplanes. These events have resulted from a variety of causes; the FAA has implemented appropriate airworthiness actions to address these causes. As a result, the rate of these occurrences has remained small, with even fewer instances occurring at low altitudes. We have concluded that low altitude events do not warrant mandatory corrective action due to the low probability of this event occurring. Therefore, the FAA does not plan to mandate changes to existing manuals to address this issue. The FAA will continue to take appropriate airworthiness actions to mitigate these occurrences. Although not meeting our risk threshold for mandatory corrective action, the FAA agrees that consideration of altitude should be included in the development of specific procedures for all-engines-out scenarios as a best practice. This expectation is now included in project-specific inflight engine restart guidance for new or major design change transpor1 category airplane programs. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 1/11/2013
Response: The NTSB notes that the FAA reviewed a variety of transport-category airplane flight manual (AFM) procedures, and confirmed the finding from our investigation of the US Airways flight 1549 accident that most procedures and training to restart the engines following an all engines out scenario are focused on failures occurring in cruise flight. The FAA agrees that developing the recommended revised checklist and procedures would help flight crews better manage a total power loss at low altitude and would therefore be an improvement over the current level of safety. The FAA plans to address future aircraft type certifications by developing guidance for airplane manufacturers to include low altitude conditions when they develop AFM procedures for an all engines out scenario. We believe that this will be an effective action for new aircraft designs that the FAA will approve in the future. For in-service aircraft, the FAA is investigating the occurrences of these failures to determine whether the risk warrants mandatory corrective action for all existing transport airplanes. If it does not, the FAA will consider alternative actions to meet the intent of this recommendation for such airplanes. We believe that if the FAA is able, without a mandate, to convince all aircraft manufacturers to develop the recommended checklists and procedures for all transport category airplanes, the recommendation will be satisfied in an acceptable alternate method. Accordingly, pending completion of the FAA’s planned action, Safety Recommendation A-10-66 is classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 10/29/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) has completed its review of a variety of transport-category Airplane Flight Manual (AFM) procedures. We acknowledge the Board's finding that the majority of procedures and training to restart one or both engines following an all-engines-out scenario are focused on failures occurring in cruise flight conditions, which represent the most likely operations for transport airplanes. When a successful engine relight cannot be accomplished at low altitude, it is crucial for the flight crew to maintain control, locate a suitable landing site, and configure the aircraft for forced landing. Adopting the Board's recommendation may allow flight crews to better manage the outcome following this emergency and could therefore be an improvement over the current level of safety. We are investigating the occurrences of these failures to determine if the risk warrants mandatory corrective action for all existing transport airplanes. If it does not, we will consider alternative act ions to achieve the intended safety improvements of this recommendation. To address future airplane certifications, we plan to develop guidance for transport-category airplane manufacturers to include low altitude conditions when they develop AFM procedures for an all -engines-out scenario. We expect to complete our review and determine the appropriate course of action by December 2012.

From: NTSB
To: FAA
Date: 12/16/2011
Response: We note that the FAA is continuing its review of emergency procedures specified in the flight manuals of transport category airplanes to determine how these manuals specifically address, for various aircraft, dual-engine failures that occur at low altitude. Pending completion of this review and the recommended action, Safety Recommendation A-10-66 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/4/2011
Response: - From J. Randolph Babbitt, Administrator: The FAA is reviewing transport category airplane night manual emergency procedures to determine how dual-engine failures that occur at low altitude are specifically addressed for a variety of aircraft. We anticipate that we will complete this review by December 31,2011. The results of this review will allow us to determine if there is a need for additional procedures to guide flight crews in handling dual-engine failures occurring at a low altitude. We will provide an update of this review and subsequent analysis of the potential safety benefits that may be gained by requiring additional specific procedures for a dual-engine failure occurring at low altitude. I will keep the board informed of the FAA's progress on this recommendation and provide an updated response by August 2012.

From: NTSB
To: FAA
Date: 3/17/2011
Response: The NTSB looks forward to reviewing the results of the FAA's review of existing requirements for a checklist and procedure for a dual-engine failure, as well as its requirement for the development and implementation of a specific checklist for a dual-engine failure occurring at a low altitude. Pending our review of this information, once the FAA's reviews and subsequent actions have been completed, Safety Recommendations A-10-66 and -67 are classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/23/2010
Response: CC# 201000368: - From J. Randolph Babbitt, Administrator: Currently § 25.1585(a)(3) requires emergency procedures for foreseeable but unusual situations in which immediate and precise action by the crew may be expected to substantially reduce the risk of catastrophe. We will review the existing requirements for a checklist and procedure for a dual-engine failure, and investigate the feasibility of requiring a specific checklist for a dual-engine failure occurring at a low altitude.