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Safety Recommendation Details

Safety Recommendation A-10-073
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 Airbus operators to amend the ditching portion of the Engine Dual Failure checklist and any other applicable checklists to include a step to select the ground proximity warning system and terrain alerts to OFF during the final descent.
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: 7/21/2016
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Checklist, Collision Avoidance, Engine Out

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/21/2016
Response: On August 30, 2013, you informed us that the current airplane flight manual (AFM) checklist method for progression from the Dual Engine Failure checklist to the Ditching checklist was acceptable and that turning off the GPWS and the TAWS was appropriately placed within the Ditching checklist. On January 16, 2014, our staffs met to discuss this recommendation and details regarding which of three possible checklists had been revised, as well as to consider the instances in these checklists over which the AFM and the quick reference handbook (QRH) did not agree. We note that on January 5, 2016, you issued Notice N 8900.339, “Actions Required to Identify and Correct Discrepancies Between Airplane Flight Manuals and Flight Deck Quick Reference Handbooks.” The notice alerts principal operations inspectors (POIs) that discrepancies may exist between some AFMs and their associated QRHs, and directs the POIs to review the QRHs for compliance with the FAA-approved abnormal/emergency procedures checklists found in the AFMs. The notice also defines POI actions in the event that discrepancies are found. Although the notice expires on January 5, 2017, we note that, on March 15, 2016, FAA Order 8900.1, “Flight Standards Information Management System,” volume 3, chapter 3, sections 5 and 12, was revised to include the guidance contained in the notice. These revisions will result in the discovery and resolution of the discrepancy we found in the US Airways flight 1549 checklists regarding turning off GPWS/TAWS. These revisions constitute an acceptable alternate response to Safety Recommendation A-10-73, which is classified CLOSED—ACCEPTABLE ALTERNATE RESPONSE.

From: NTSB
To: FAA
Date: 12/27/2013
Response: The FAA indicated that the current airplane flight manual checklist method for progression from the Dual Engine Failure checklist to the Ditching checklist is acceptable and that turning off the GPWS and the TAWS is appropriately placed within the Ditching checklist. Although the FAA considers its action in response to this recommendation to be complete, a meeting between our staffs has been scheduled for January 16, 2014, to discuss details regarding which of three possible checklists have been revised. Pending the results of that meeting, Safety Recommendation A-10-73 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/30/2013
Response: -From Michael P. Huerta, Administrator: The Dual Engine Failure checklist procedures (portion enclosed, dated December 14, 201 0) found in the airplane flight manual (AFM) of the Airbus 320 (A320) progresses to two separate checklists dependent upon whether a forced landing or a ditching event is anticipated. As such, the Forced Landing and Ditching checklists are extensions of the Dual Engine Failure checklist. If the event anticipated after a duel engine failure is ditching, the Ditching checklist (enclosure dated January 15, 2013) is used. Item number 3 of the 23 checklist items found on the Ditching checklist is "Turn-off TA WS - GPWS." The Federal Aviation Administration (FAA) finds the current AFM checklist method for progression from the Dual Engine Failure checklist to the Ditching checklist is acceptable. We also find that turning off the ground proximity warning system (GPWS) and terrain alerts (terrain alert and warning system or TAWS) is appropriately placed within the Ditching checklist so that it is accomplished prior to final descent. As stated in our October 29, 2012, letter to the Board we cannot mandate that specific items are part of checklists. FAA principal operations inspectors (POI) and operators understand that aircraft checklists published in AFMs are not approved by the FAA. When a part 121 operator proposes to use an AFM checklist, the POI must review and approve that checklist for that operator. A cursory review of part 121 certificate holders operating A320 aircraft, the aircraft involved in the incident that triggered this recommendation, indicates cockpit crew quick reference handbooks are updated to reflect turning-off of GPWS and TAWS early in their Ditching checklist. We find that further coordination with the European Aviation Safety Agency (EASA) and Airbus is not required because the checklist (dated January 1 5, 201 3) has been modified in a manner that is responsive to this recommendation. The checklist that was approved by RASA is applicable to Airbus models A319, A320, and A321. 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: This recommendation was issued because our investigation of the US Airways 1549 accident revealed that, although the A320 Flight Manual emergency procedures for ditching and forced landing already include a step to select GPWS and terrain alert OFF, the ditching portion of the Engine Dual Failure Checklist did not include turning off the GPWS and terrain alerts. The FAA continues to work with the European Aviation Safety Agency and Airbus to determine what changes are needed to the ditching portion of the Engine Dual Failure Checklist in responding to the recommendation. Although we understand that the FAA cannot mandate the inclusion of specific items on checklists, when a Part 121 operator proposes to use an AFM checklist, the FAA’s principal operations inspector (POI) for the carrier must review and approve that checklist for that operator. We believe that after Airbus has made the recommended revisions, through the FAA’s POIs the agency will be able to ensure that appropriate revisions are made in operators’ checklists. Pending the FAA’s taking the recommended action, Safety Recommendation A-10-73 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/29/2012
Response: -Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) continues to work with the European Aviation Safety Agency and Airbus to evaluate the recommended changes to the ditching portion of the Engine Dual Failure Checklist. After this review is complete, we will determine whether any changes are necessary. The FAA reminds the Board that we cannot mandate that specific items are part of checklists. The FAA principal operations inspectors (POIs) and operators understand that aircraft checklists published in airplane flight manuals (AFM) are not approved by the FAA. When a part 121 operator proposes to use an AFM checklist, the POI must review and approve that checklist for that operator. We will keep the Board informed of our progress on this safety recommendation and provide an update by August 2013.

From: NTSB
To: FAA
Date: 3/17/2011
Response: This recommendation was issued because the NTSB's investigation of the US Air 1549 accident revealed that, although the A320 series Flight Manual emergency procedures for ditching and forced landing already include a step to select GPWS and terrain alert OFF, the ditching portion of the Engine Dual Failure Checklist does not include turning off the GPWS and terrain alerts. The FAA's plan to work with the European Aviation Safety Agency (EASA) and Airbus to determine what changes are needed to the ditching portion of the Engine Dual Failure Checklist is the first step in responding to the recommendation. Accordingly, pending the FAA's taking the recommended action, Safety Recommendation A-10-73 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/23/2010
Response: CC# 201000368: - From J. Randolph Babbitt, Administrator: We are working with the European Aviation Safety Agency (EASA) and Airbus to evaluate the recommended changes to the ditching portion of the Engine Dual Failure Checklist, and will then determine whether the changes are necessary. Airbus A3l8, A3l9, A320, and A321 Flight Manual emergency procedures for ditching and forced landing already include a step to select ground proximity warning system and terrain alert OFF.