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Safety Recommendation Details

Safety Recommendation A-10-070
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 14 Code of Federal Regulations Part 121, Part 135, and Part 91 Subpart K operators to provide training and guidance to pilots that inform them about the visual illusions that can occur when landing on water and that include approach and touchdown techniques to use during a ditching, with and without engine power.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
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: 6/3/2014
Addressee(s) and Addressee Status: FAA (Closed - Reconsidered)
Keyword(s): Flightcrew, Training and Education, Water Survival

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/3/2014
Response: We note that you reviewed aviation accidents involving transport category aircraft that resulted in water landings between January 2000 and February 2012 and found that, except for the US Airways flight 1549 accident, none included visual illusions in the narrative, either as a probable cause or as a recommendation. Because you could identify no other accidents similar to the US Airways flight 1549 accident, you do not believe the risk requires additional review of (1) currently available information regarding visual illusions for landing on water or (2) Part 121, 135, or 91 Subpart K operators’ training programs. Further, you believe that current regulations and guidance already address Safety Recommendation A 10 70. The regulations and guidance that you believe address the recommendation require recurrent pilot training to include discussion of previous aircraft accidents and incidents. You stated you believe that, since the US Airways accident occurred recently, the accident is a prime candidate for inclusion in the emergency training required by the regulations. Further, although your review and analysis did not result in any new action, you believe that, based on the data and existing regulations and guidance, you have effectively addressed this safety recommendation, and you stated that your actions to address it are complete. As your review and analysis showed, the circumstances of this accident are rare. Although we agree that the US Airways 1549 accident will be a prime candidate for discussion during recurrent training, we are concerned that, over time, the lessons from the US Airways flight 1549 accident will largely have been forgotten. Therefore, in the event of a similar accident involving ditching, the crew will have lost the opportunity to have learned from the earlier accident. We carefully considered the data that you reviewed, as well as the results showing this to be such a rare event. Although we believe that sufficient time must be available to fully train flight crews to properly respond to any situation they may confront, we also recognize that available training time might be better spent on more commonly encountered emergency and abnormal situations. Consequently, Safety Recommendation A 10 70 is classified CLOSED—RECONSIDERED.

From: FAA
To: NTSB
Date: 4/9/2014
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) conducted a search of the Board's Aviation Accident Database from January 2000 to February 2012, for accidents culminating in water landings. The search included operations under part 12 I, 135, and 91 subpar1 K (91 K) and focused on ditching (emergency landing of an aircraft on water) accidents involving transport category aircraft. Except for US Airways 1549, none of these accidents included visual illusions in the narrative, as a probable cause, or as a recommendation. The FAA could not identify any accidents similar to US Airways flight 1549, therefore we do not believe the identified risk requires additional review of 1) currently available information regarding visual illusions for landing on water or 2) part I 2 I, 135, and 91 subpart K operators' training programs as discussed in our September 23. 20 I 0, letter. We find that current regulations and guidance noted below address the intent of this recommendation. Title I 4, Code of Federal Regulations: • § 121.417(b)(4) requires emergency training to include a review and discussion of previous aircraft accidents and incidents as they pertain to actual emergency situations; • § 91 .1 083 (b)( 4) (for 9 I K operators) requires review and discussion of previous aircraft accidents and incidents involving actual emergency situations; • § 9 1.1 083(b )(3)(iii) for 91 K operators requires instruction in the handling of emergency situations including Ditching and Evacuation; and • § 135.33 I (b)(4) requires a review of the certificate holder's previous aircraft accidents and incidents involving actual emergency situations. FAA Order 8900, volume 3. chapter 19: • Section 10. paragraph 3- 1339 B states recurrent training should also include updated information on accidents and incidents: • Section 4, paragraph 3- I I 74 G recommends training in water landings and ditching at night; and • Section 4, paragraph 3-1 174 I of this section recommends review of NTSB accident reports of accidents and incidents. Since this accident triggered this recommendation. which happened recently, it is a prime candidate to be included in the emergency training required by the regulations and the Order. FAA Order 8900 can be found at: http://fsims.faa.gov/PICResults.aspx?mode=EBookContents. The FAA does acknowledge that the Board discussed in its previous letter the ••Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers" rulemaking. We note that this rulemaking effort was not intended to address this recommendation. Based on the data and existing regulations and guidance, I believe that the FAA has effectively addressed this safety recommendation. Therefore, I consider our actions complete.

From: NTSB
To: FAA
Date: 7/8/2013
Response: We previously reviewed the FAA’s supplemental notice of proposed rulemaking (SNPRM) titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers,” published at 76 Federal Register 29336-29526 on May 20, 2011. We are concerned that, although nearly 2 years have passed since we submitted our comments on the SNPRM, we have received no additional information regarding any efforts being made to address this recommendation. Pending our timely receipt of an update and completion of the recommended action, Safety Recommendation A 10 70 remains classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 7/15/2011
Response: Notation 8106A: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) supplemental notice of proposed rulemaking (SNPRM) titled "Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers," published at 76 Federal Register 29336-29526 on May 20, 2011. The notice proposes to amend the regulations for flight and cabin crewmember and aircraft dispatcher training programs in domestic, flag, and supplemental operations. The proposed regulations are intended to contribute significantly to reducing aviation accidents by requiring the use of flight simulation training devices (FSTD) for flight crewmembers and including additional training and evaluation requirements for all crewmembers and aircraft dispatchers in areas that are critical to safety. The proposal also reorganizes and revises the qualification, training, and evaluation requirements. The SNPRM is based on the FAA's review of comments submitted in response to the January 12, 2009, notice of proposed rulemaking (NPRM) on these issues and its determination that the NPRM did not adequately address or clarify some topics; it is also based on provisions of the Airline Safety and Federal Aviation Administration Extension Act of 2010. The NTSB did not find any proposed provisions in the SNPRM to require training for dual-engine power loss at low altitudes or of the visual illusions that can occur when landing on water. The NTSB believes this rulemaking is appropriate to address these issues and urges the FAA to include the recommended training requirements.

From: NTSB
To: FAA
Date: 3/17/2011
Response: The FAA's plan to (1) review currently available information regarding visual illusions for landing on water and (2) assess the training and guidance currently being provided to pilots on visual illusions for landing on water are appropriate first steps in responding to this recommendation. Accordingly, pending the results of the FAA's review and needed changes being made to ensure that pilots are provided the recommended training and guidance, Safety Recommendation A-10-70 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/23/2010
Response: CC# 201000368: - From J. Randolph Babbitt, Administrator: We concur with the Board that most air carrier training programs do not include a great deal of information regarding the visual illusions that can be associated with landing on water. The Board noted that the US Airways training is similar to industry guidance on ditching. Such training covers atmospheric conditions, sea states, and recommended direction of landing based on the direction of wind and water swells. To address this recommendation, we will review information currently available on visual illusions for landing on water. We will also review part 121, 135, and 91 subpart K operators' training programs to assess the training and guidance currently being provided to pilots on visual illusions for landing on water and determine if that includes approach and touchdown techniques to use during a ditching, with and without engine power. Based on those findings, we will evaluate all of our options in the training environment to ensure pilots are provided with the recommended training and guidance.