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Safety Recommendation Details

Safety Recommendation A-10-068
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: Develop and validate comprehensive guidelines for emergency and abnormal checklist design and development. The guidelines should consider the order of critical items in the checklist (for example, starting the auxiliary power unit), the use of opt outs or gates to minimize the risk of flight crewmembers becoming stuck in an inappropriate checklist or portion of a checklist, the length of the checklist, the level of detail in the checklist, the time needed to complete the checklist, and the mental workload of the flight crew.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 7/18/2012
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Checklist

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/18/2012
Response: We disagree with the FAA that current guidance on checklist design available to operators and manufacturers in Information for Operators (InFO) memorandum 10002, “Industry Best Practices Reference List,” sufficiently addresses this recommendation, which we indicated in the letter that transmitted this recommendation to the FAA. Many of the references contained in the InFO are 15 or more years old, and the document does not discuss more recent and relevant work performed at the National Aeronautics and Space Administration’s Ames Research Center. We also disagree that FAA Order 8900.1, “Flight Standards Information Management System,” contains sufficient guidance for FAA inspectors to use when approving an operator’s checklists and procedures. The FAA believes that Volume 3, Chapter 32, Section 1, Paragraph 3-3128, of this order, which defines “immediate action,” addresses this recommendation. Regarding other items, the FAA maintains that it cannot create a different checklist for every scenario presented to a pilot, and a pilot may be required to use critical thinking to decide when to abandon one checklist in favor of another that better meets the situation. We reiterate the conclusion stated in our investigation report on the US Airways flight 1549 accident, and in the letter that transmitted this recommendation to the FAA, that (1) although the Engine Dual Failure checklist used by the crew did not fully apply to the accident event, it was the most applicable checklist the quick reference handbook contained for addressing the event and (2) the flight crew‘s decision to use this checklist was in accordance with US Airways procedures. This recommendation was issued because no other checklist existed that better met the situation. The FAA stated that, after conducting a review of the guidance available to manufacturers, operators, and inspectors, it believes that the guidance and guidelines currently existing for emergency and abnormal checklist design are sufficient, and that neither the development of a new advisory circular (AC) nor the revision of an existing AC is necessary. The NTSB continues to believe, however, that our findings from the US Airways flight 1549 accident investigation contradict both the FAA’s findings and its position that it has effectively addressed this recommendation. Consequently, Safety Recommendation A-10-68 is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 5/18/2012
Response: -From Michael P. Huerta, Acting Administrator: While the Federal Aviation Administration (FAA) agrees that emergency and abnormal checklist design and development are important, we maintain that aircraft manufacturers and operators are responsible for their design and development. As noted by the Board, to assist manufacturers and operators in this task, the FAA published (in March 2010) Information for Operators (InFO) 10002, "Industry Best Practices Reference List," which specifically addresses checklist design. Additionally, as also noted by the Board, we provide guidance under FAA Order 8900.1, Flight Standards Information Management System (FSIMS), to assist principal operations inspectors during the approval of an operator's checklists and procedures. Volume 3, chapter 32, section 6 of the FSMIS is very clear on the contents and characteristics of checklists to be used by employees in the performance of their duties. Specially addressing the concerns of the Board as it pertains to emergency and abnormal checklists, Order 8900.1, volume 3, chapter 32, section 1, paragraph 3-3128, defines "immediate action" as, "[a]n action that must be taken in response to a non-routine event so quickly that reference to a checklist is not practical. ..." These types of immediate action items generally take the form of required memory items for crewmember qualification. Memory items are used when there is a need for correct, immediate action by the crew. In these situations a written checklist is too lengthy and cumbersome for a rapidly evolving situation. The crew executes the memory item(s) to resolve the immediate problem, then consults the written checklist to verify proper completion and follow-on action. As the Board noted, there cannot be a checklist for every scenario presented to a pilot. A pilot may be required to use critical thinking to decide when to abandon a checklist in favor of another checklist that better meets the situation. After a review of the guidance available to manufactures, operators, and inspectors, the FAA believes the proper guidance and guidelines currently exist for emergency and abnormal checklist design. We believe neither the development of a new advisory circular (AC) nor the revision of an existing AC is necessary. I believe the FAA has effectively addressed this safety recommendation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 3/17/2011
Response: The FAA's commitment to review and revise the guidance contained in Order 8900.1, "Flight Standards Information Management System," volume 3, chapter 32, section 6, is responsive to part of this recommendation. The NTSB understands that the guidance contained in Order 8900.1 is used by FAA principal operations inspectors (POIs) when they determine whether to accept an operator's checklists and procedures. However, a response that will fully satisfy this recommendation will involve the development of detailed guidance on necessary characteristics of emergency and abnormal checklists, in addition to revising the order. The FAA typically issues such guidance for use by operators and manufacturers in advisory circulars (AC). A full response to this recommendation will involve the development of a new AC or the revision of an existing AC to include detailed information about such checklists and procedures. The NTSB is concerned that the FAA may have misinterpreted what is intended by "validate" in this recommendation. The recommended action is not to validate every emergency and abnormal checklist submitted to the FAA for approval, but to validate guidance in light of current or new research. Accordingly, pending such revisions to Order 8900.1 and the provision of appropriate detailed guidance in an AC or other appropriate document, Safety Recommendation A-I 0-68 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/23/2010
Response: CC# 201000368: - From J. Randolph Babbitt, Administrator: The contents and design of emergency and abnormal checklists are a combined effort between the aircraft manufacturers and operators. The FAA does not validate, but rather accepts or approves operators' checklists and procedures. The FAA inspectors accomplish this based on the guidance provided in FAA Order 8900.1, Flight Standards Information Management System, volume 3, chapter 32, section 6 (enclosure 1). The general guidance contained in that order recommends that the checklists use standardized terminology, follow a logical sequence, and incorporate an appropriate level of detail based on the user. With a more detailed review of the guidance available to operators and inspectors, we will consider revising and/or issuing new guidance on checklist design, specifically for emergency and abnormal procedures.