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Safety Recommendation Details

Safety Recommendation A-10-079
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, on all new and in-service transport-category airplanes, that cabin safety equipment be stowed in locations that ensure that life rafts and/or slide/rafts remain accessible and that sufficient capacity is available for all occupants after a ditching.
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: 7/5/2011
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Water Survival

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/5/2011
Response: In response to this recommendation, the FAA reviewed the location of cabin safety equipment on the accident airplane, particularly the location of the life rafts and slide/rafts. The FAA stated that the location of this equipment is based on available exits as determined by the floatation analysis conducted as part of the airplane’s type certification. For the accident airplane, the aft exits were designated as ditching exits. The FAA’s review of the accident determined that the airplane had impacted the water at a vertical descent rate outside the envelope of a “foreseeable ditching event,” which caused more aft fuselage damage than had been considered in the ditching analysis. This extensive damage allowed water to flood the aft end of the fuselage. As a result, the FAA is not considering changes to the requirements for the location of the life rafts or slide/rafts, as this equipment should be accessible, with sufficient capacity, under what the FAA characterizes as “foreseeable ditching scenarios.” The FAA’s analysis assumes that the pilot can ditch the aircraft within the envelope of a foreseeable ditching event. Although airplane systems are evaluated to determine whether they respond as expected, the operational procedures themselves and the ability of pilots to achieve the parameters are not. Because operational procedures and the ability of pilots to achieve the Airbus ditching parameters have not been tested, the assumption of a mostly intact fuselage when evaluating the “probable structural damage and leakage” resulting from a ditching, as required by 14 Code of Federal Regulations Section 25.801(d), rests on an assertion that this condition can be reliably attained rather than on a demonstration or analysis to that effect. Using postaccident flight simulations, the NTSB’s investigation of the US Airways 1549 accident indicated that attaining the Airbus ditching parameters without engine power is possible but highly unlikely without training. Further, attaining the parameters may not prevent a significant fuselage breach for a number of plausible conditions, such as a heavy airplane, swells, winds, or other conditions. Therefore, in our report on this accident, we concluded that the review and validation of the Airbus operational procedures conducted during the ditching certification process for the A320 airplane did not evaluate whether pilots could attain all of the Airbus ditching parameters, nor was Airbus required to conduct such an evaluation. We further concluded that, during an actual ditching, it is possible but unlikely that pilots would be able to attain all of the Airbus ditching parameters because it is exceptionally difficult for pilots to meet such precise criteria when no engine power is available, and this difficulty contributed to the fuselage damage. Because of the operational difficulty of ditching within the Airbus ditching parameters and the additional difficulties that water swells and/or high winds may cause, it is very likely that, in general, after ditching an A320 airplane without engine power, the “probable structural damage and leakage” will include significant aft fuselage breaching and subsequent water entry into the aft area of the airplane. Therefore, it should be assumed that, after a ditching, water entry will prevent the aft exits and slide/rafts from being available for use during an evacuation. During the ditching certification process, the FAA examines the manufacturer’s assumptions regarding the airplane’s expected integrity and buoyancy calculations. This recommendation was issued because we questioned the FAA’s acceptance of the assumption that a ditching in which the fuselage is not significantly breached is a reasonable expectation across a range of realistic environmental conditions, pilot skills, and experience. Despite our findings in the report on the US Airways flight 1549 accident, and the supporting information in the letter that transmitted this recommendation to the FAA, the FAA’s analysis again used the conditions in Airbus’s ditching analysis without regard to how likely it would be that a pilot could attain these parameters. After this questionable assumption, the FAA concluded that, because the aircraft hit the water at a higher vertical velocity than in the ditching analysis, it was not necessary to consider that the fuselage breach made the water survival equipment at the aft end of the airplane unavailable. The FAA stated in its letter that it considers its action in response to this recommendation to be complete and plans no further action. Consequently, Safety Recommendation A-10-79 is classified CLOSED – UNACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 3/17/2011
Response: CC# 201000368:The FAA is reviewing current regulations related to this recommendation and will determine what regulatory changes will be made. Pending the FAA's taking the action recommended, Safety Recommendation A-10-79 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 3/15/2011
Response: CC# 201100130: - From J. Randolph Babbitt, Administrator: Life rafts and/or slide/rafts are located on each airplane based on available exits as determined in part by the floatation analysis. For the subject airplane, the aft exits were designated as ditching exits as they provide the best means for escape under most scenarios. We reviewed the accident with respect to the ditching regulations. We have determined that the airplane impacted the water at a vertical descent rate outside the envelope of a foreseeable ditching event. As a result, the airplane sustained more aft fuselage damage than had been considered in the ditching analysis. This extensive damage allowed water to flood the aft end of the fuselage which was not considered in the floatation analysis. The FAA is not considering changes to the requirements for the location of the life rafts and/or slide/rafts as this equipment should be accessible, with sufficient capacity, under foreseeable ditching scenarios. I believe we have satisfactorily responded to this safety recommendation, and I consider our actions complete.

From: FAA
To: NTSB
Date: 9/23/2010
Response: CC# 201000368: - From J. Randolph Babbitt, Administrator: Current regulations require that the equipment be located near the ditching exits. Regulations also require overload capacity for rafts such that the largest raft may be lost and the remaining rafts have capacity for all occupants. As noted in the Board's recommendation, the accident in question caused significant damage in the rear fuselage rendering the aft ditching exits and slide/rafts unusable. We will assess this scenario and make a determination regarding mandatory action on the existing fleet and the possibility of changes to regulations for new airplanes.