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Safety Recommendation Details

Safety Recommendation A-10-083
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 brief passengers on all flotation equipment installed on an airplane, including a full demonstration of correct life vest retrieval and donning procedures, before all flights, regardless of route.
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: 8/31/2017
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Water Survival

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/31/2017
Response: In your March 23, 2012, letter about this recommendation, you said that you planned to address it by updating Information for Operators Bulletin 07013 to remind airline operations training managers about the guidance and policy contained in FAA Order 8900.1, Volume 3, Chapter 33, “Cabin Safety and Flight Attendant Management,” paragraph 3-3575(c), which indicates there may be a need to inform each passenger about the individual flotation equipment located at that passenger’s seat, and that this may require different passenger briefing cards at different seats. When we replied on June 14, 2012, we reiterated the findings from our US Air flight 1549 investigation that led to this recommendation. We found that, of the 150 passengers aboard US Airways flight 1549, 77 passengers retrieved flotation seat cushions and evacuated with them, but only 10 passengers evacuated with life vests. Passenger interviews revealed that most of the 150 passengers were frequent travelers who were very familiar with the preflight briefing and that, over the years, the information about the seat cushions had “sunk in” to their consciousness. Several passengers stated that, even in their stressed state, they were able to specifically recall how they were supposed to hold the cushion to their chests with their arms crossed. Passenger interviews indicated that about 70 percent of the passengers did not watch any of the preflight safety briefing, indicating that passenger attention to the preflight briefings was generally low. However, it appears that, over time, frequent travelers have become accustomed to hearing the phrase, “your seat cushion may be used as a flotation device,” and have remembered it. In addition, only 12 passengers indicated that they had read the passenger briefing card. We believe that one reason half of the passengers were aware of the flotation seat cushions on board the airplane is that preflight briefings address flotation seat cushion use on virtually all flights. We do not believe that the information in the passenger safety briefing card is repeated and that it would “sink in” through repeated exposure, but we believe that information about life preserver availability and use would if passengers were repeatedly exposed to demonstrations of donning a life preserver. We have not received any further information regarding your actions to satisfy this recommendation in the 5 years since your previous letter. In our June 14, 2012, letter, we classified Safety Recommendation A-10-83 “Open—Unacceptable Response” because it focuses on passenger safety briefing cards and does not discuss demonstrations of life vest donning. We generally expect action to satisfy a recommendation to be completed within 5 years. Because it is now over 7 years old and there does not appear to have been any progress in the 5 years since your previous letter, Safety Recommendation A-10-83 is classified CLOSED—UNACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 6/14/2012
Response: The FAA plans to address this recommendation by updating Information for Operators bulletin 07013 to remind operations training managers for airlines about the guidance and policy contained in FAA Order 8900.1, Volume 3, Chapter 33, “Cabin Safety and Flight Attendant Management,” paragraph 3-3575(c). This guidance currently indicates there may be a need to give information to each passenger about the piece of individual flotation equipment that is located at that passenger’s seat, which may require different passenger briefing cards at different seats, as well as individual briefings at some seats. The FAA plans to incorporate material from a September 2008 technical report on research conducted at the FAA’s Civil Aerospace Medical Institute, “Effective Presentation Media for Passenger Safety I: Comprehension of Briefing Card Pictorials and Pictograms.” In the letter that transmitted this recommendation to the FAA, we indicated that, although life vests were not required for the accident flight, because the vests were present on the airplane, the flight attendants were required to brief the passengers on their location and use. However, a life vest demonstration was not required because the flight did not involve extended over-water operation. Of the 150 passengers aboard US Airways flight 1549, about 77 passengers retrieved flotation seat cushions and evacuated with them, but only about 10 passengers retrieved life vests after impact and evacuated with them. Passenger interviews revealed that most of these passengers were frequent travelers who were very familiar with the preflight briefing and that, over the years, the information about the seat cushions had “sunk in” to their consciousness. Several passengers stated that, even in their stressed state, they were able to specifically recall how they were supposed to hold the cushion to their chests with their arms crossed. Passenger interviews indicated that about 70 percent of the passengers did not watch any of the preflight safety briefing, indicating that passenger attention to the preflight briefings was generally low. However, it appears that, over time, frequent travelers have become accustomed to hearing the phrase, “your seat cushion may be used as a flotation device,” and have remembered it. In addition, only 12 passengers indicated that they had read the passenger briefing card. We believe that one reason half of the passengers were aware of the flotation seat cushions on board the airplane is that preflight briefings address the use of the flotation seat cushions on virtually all flights. We do not believe that the information in the passenger safety briefing card is repeated and therefore that it would “sink in” over repeated exposure, but we believe that information about the availability and use of life preservers would, if passengers were repeatedly exposed to demonstrations of donning a life preserver. The FAA’s planned response to this recommendation is not acceptable because it concentrates on passenger safety briefing cards, and does not discuss the recommended action of requiring demonstrations of life vest donning. Accordingly, pending the FAA’s taking the recommended action, Safety Recommendation A-10-83 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 3/23/2012
Response: -From Michael P. Huerta, Acting Administrator: To address the safety issue identified in this recommendation, the Federal Aviation Administration (FAA) is currently drafting an update to Information for Operators (InfO) 07013 to remind operations training managers for parts 121, 135, and 91 subpart K operators about the guidance and policy contained in FAA Order 8900.1, Flight Standards Information Management System (FS1MS), volume 3, chapter 33 (Cabin Safety and Flight Attendant Management), paragraph 3-3575(c). This guidance acknowledges that: When a passenger is informed about more than one type of flotation or life preserver it can be confusing. One method for informing passengers is to give each passenger information about the piece of individual flotation equipment that is located at that individual passenger's seat. In some cases, this may mean different cards at different seats and individual briefings at certain seats. The FAA is coordinating the draft InfO with the FAA Aerospace Medical staff to incorporate material from a September 2008 technical report titled, Effective Presentation Media for Passenger Safety I: Comprehension of Briefing Card Pictorials and Pictograms. This report is available at: http://www.faa.gov/library/reports/medical/oamtechreports/2000s/media/200820.pdf. The FAA anticipates the InFO update to be completed by late spring 2012. I will keep the Board informed of the FAA's progress on this safety recommendation, and provide an update by December 2012.

From: NTSB
To: FAA
Date: 3/17/2011
Response: The FAA's planned review of existing regulatory requirements and guidance concerning passenger briefings, including the specific information provided to passengers on flotation equipment, is the first step in responding to this recommendation. Pending completion of that review and of appropriate regulatory revisions, Safety Recommendation A-10-83 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/23/2010
Response: CC# 201000368: - From J. Randolph Babbitt, Administrator: We agree with the Board that passengers who receive predeparture briefings are better equipped to handle emergency situations. We will review existing regulatory requirements and guidance surrounding passenger briefings, including the specific information provided to passengers on flotation equipment. Upon completion of that review, we will consider all available policy and regulatory options to meet the intent of this recommendation.