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Safety Recommendation Details

Safety Recommendation A-10-084
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 modifications to life vest stowage compartments or stowage compartment locations to improve the ability of passengers to retrieve life vests for all occupants.
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: 4/8/2015
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Water Survival

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/8/2015
Response: We note that, on June 6, 2014, you issued a revision to Technical Standard Order (TSO) C l27b, “Rotorcraft, Transport Airplane, and Small Airplane Seating Systems.” The revision added new life vest retrieval requirements based on your review of the results of the US Airways flight 1549 accident investigation. In our March 21, 2014, letter to you about Safety Recommendation A-10-84, we stated that a draft of this TSO had proposed a maximum average life vest retrieval time of 10 seconds, which we regarded as unacceptable in view of our analysis provided in the US Airways flight 1549 accident report. In that analysis, we used information about average life vest retrieval times from a 2003 FAA study of life vest retrieval conducted at Civil Aerospace Medical Institute (CAMI) as well as the reported experience of passengers on US Airways flight 1549 who had attempted to retrieve a life vest while evacuating the sinking aircraft. We found that passengers in that accident were unwilling to spend the 7.5 or 8.4 seconds (the average reported retrieval time for seating systems in the CAMI study, depending on seating configuration) it would take to retrieve a life vest, in a cabin that was filling with water. Your letter discussed the reasons why you believe the revised TSO reflects the lessons learned from the US Airways flight 1549 accident investigation. It also discussed your belief that it is unreasonable to expect a significant percentage of passengers to retrieve their life vest in less than 7 seconds. Further, you stated that the retrieval time requirement in the revised TSO, combined with several new design requirements also addressing life vest retrieval that were also added to TSO C127b, result in a design commensurate with the level of safety in your regulations. We do not agree that the revised TSO satisfies the recommendation; rather, we continue to believe that our finding from the accident investigation shows that, in a real situation, passengers in a sinking airplane will not spend 7 to 8 seconds, let alone the up to 10 seconds allowed for in the TSO, to retrieve a life vest, and will instead evacuate the airplane without a vest. Because you regard your actions as complete and plan no further action, Safety Recommendation A-10-84 is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 2/5/2015
Response: -From Michael P. Huerta, Administrator: On June 6, 2014, the Federal Aviation Administration (FAA) issued a revision to the minimum performance standards for aircraft seats provided in Technical Standard Order C127b (TSO). The revision includes increased details on seating systems and stringent life vest retrieval requirements. Based on the Board's previous comments, the FAA has prepared this final response to address your concerns and close our action for this recommendation. The Board's first concern that changes to TSO regarding seat standards will not address life vest installations at locations other than in the seats is technically correct. However, almost all life vest installations are located in the seats because they must be within reach of the seated occupant. In rare cases, the FAA has certified life vest installation in the ceiling, just above the occupant, in a compartment clearly identified as having a life vest inside. However, these cases fall beyond the scope of the recommendation because when the life vest compartment is opened, the life vest is readily exposed and visible to the occupant, as opposed to being located under the seat. Because the TSO will address nearly all life vest installations, the FAA believes we have addressed the Board's concern. The Board's second concern pertains to the proposed 1 0-second life vest retrieval time. The FAA asks that you consider the following rationale and evidence in making your determination of acceptable life vest retrieval time standards. To the FAA's knowledge, no studies were conducted on the actual US Airways flight 1549 life vest installations, nor were actual life vest retrieval time data acquired from the accident. However, pertinent information from the NTSB accident report on US Airways flight 1549 stated that: • Flight attendants did not command passengers to put on life vests before the water impact; • Two passengers retrieved and put on their life vests before impact; • A third passenger was unable to do so and, therefore, abandoned his attempt; • Many passengers forgot about or were unaware that a life vest was under their seat; • Other passengers could not remember where it was stowed; • 5 passengers (3 percent) reported retrieving a life vest from under their seats after impact; • An additional 5 passengers (3 percent) reported retrieving a life vest from under a different seat after impact; • 21 passengers (14 percent) reported being given a life vest that carne from the airplane by someone during or after they had evacuated; and • 77 passengers (53 percent) retrieved seat cushions during the evacuations. In addition, the FAA found five passenger interview statements regarding life vest retrieval.1 Our review of these statements revealed that only 3 percent of passengers attempted to retrieve the life vests from their own seats. As a result, we concluded that there is insufficient information in the NTSB accident report to establish the average life vest retrieval time. Since no data was provided in the accident report to establish an average retrieval time, the FAA believes the noted average retrieval times refer to the 2003 FAA/DOT study and report? According to the study and report, average life vest retrieval times for configurations similar to those on US Airways flight 1549 were 8.5 seconds for the economy class configuration and 7.4 seconds for the first class configuration. More importantly, the noted 8.5 and 7.4 second life vest retrieval times are average times, rather than maximum times. The range of actual life vest retrieval times was between 4 and 20 seconds, with 75 percent of vests retrieved within approximately 10 seconds. The study included a subjective assessment of the ease of retrieval, which showed strong correlation between the ease of retrieval and the retrieval time, with 10 seconds or lower corresponding to "Easy, with minor difficulty." The new life vest retrieval time standard in TSO-C 127b is "retrieval in less than 10 seconds by a minimum of 5 test subjects with a success rate of no less than 7 5 percent" which is consistent with the findings of the study and report. From the results of our studies, the FAA determined that retrieval times for a given seat system and life vest configuration vary widely. This is an expected outcome when untrained occupants are involved in an emergency. We chose the new TSO standard based on our studies and find it is an appropriate level of safety consistent with our regulations. For example, the standard for a trained flight crew member to don a "quick-donning" oxygen mask is 5 seconds. We find that such a short time is only appropriate for a trained flight crew member. Even with the best design of life vest stowage, to expect a significant percentage of passengers to retrieve their life vest in less than 7 seconds is unrealistic. Ensuring the ease of life vest retrieval is a broader objective than setting a specific retrieval time requirement, as documented in the FAA/DOT study and report. Therefore, we added several design requirements to our seat TSO to ensure consistent and simple life vest retrieval. The combined requirements, including life vest location, pull strap design, and unobstructed retrieval path, taken in total, result in a design solution commensurate with the level of safety in our regulations, and meet the intent of the Board's recommendation. Based on the actions noted above, I believe the FAA has effectively addressed this recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 3/21/2014
Response: In your January 27, 2012, letter, you described your plan to draft a revision to Technical Standards Order (TSO) C127, “Rotorcraft, Transport Airplane, and Small Airplane Seating Systems” to add new life vest retrieval requirements based on information from your review of the results of the US Airways flight 1549 accident investigation. We note that, in August 2012, you published the draft revision to TSO C127 for public comment. We regret that we missed the opportunity to comment on this document and are concerned that the revision does not adequately address Safety Recommendation A-10-84. Our first concern is that TSO C127 addresses issues with seating systems. Although many life vests for aircraft are stowed in the seat, life preservers are also stored in other locations, which the TSO will not address. Our second concern is with the retrieval time standard proposed in the draft TSO, which incorporates by reference SAE International Aerospace Recommended Practice (ARP) 5526C, “Aircraft Seat Design Guidance and Clarifications.” The draft TSO indicates that subsection 3.3.2 of the ARP is revised, including the following: f. The life preserver is within easy reach of, and can be readily removed by a seated and belted occupant for all seat orientations, and installations that are intended for use during taxi, takeoff and landing; i.e. the life preserver can be quickly (less than 10 seconds) and reliably (on the first attempt) retrieved …. [Emphasis added.] In our investigation of the US Airways flight 1549 accident, we found that the average retrieval time for life preservers was 8.5 seconds for the economy class configuration, and 7.4 seconds for the first class configuration. Our investigation also found that many passengers will not wait that long before abandoning the retrieval attempt and evacuating without a life vest, particularly in the likely event that water enters the cabin after a water impact; this was our reason for issuing Safety Recommendation A-10-84. We believe that retrieval time must be significantly less than the 7-8 seconds found in the accident; however, the draft TSO proposes retrieval times that are even longer. Accordingly, please reconsider the proposed retrieval time standard. Pending issuance of a requirement for life vest stowage compartments or stowage compartment locations (in seats and other locations) that permits all life vests to be retrieved in less than 7 seconds, Safety Recommendation A-10-84 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 12/13/2013
Response: The Federal Aviation Administration (FAA) is finalizing the revision to the minimum performance standards for aircraft seats provided in Technical Standard Order C127, Rotorcraft, Transport Airplane, and Normal and Utility Airplane Seating Systems. We are incorporating public comments, and expect to publish the revised standard by April 30, 2014. As previously mentioned, the revision includes improved life vest retrieval requirements. I will keep the Board informed of the FAA's progress and provide an update by June 30, 2014.

From: NTSB
To: FAA
Date: 4/30/2012
Response: The FAA indicated that it had reviewed our previous letters concerning this recommendation and had reconsidered its position that the existing regulations, policy, industry standards, and practice documents provided an acceptable level of safety. The FAA has now reviewed information from the US Airways flight 1549 accident investigation, and drafted a revision to Technical Standards Order (TSO) C127, which will add new life vest retrieval requirements. The FAA plans to publish the revised TSO for public comment by May 2012. The planned revision to the TSO may satisfy this recommendation, and we look forward to reviewing and commenting on the draft order when it is released. Accordingly, pending issuance of a revised TSO that fully addresses the issues specified in Safety Recommendation A-10-84, the recommendation is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/27/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) reviewed the Board's letters dated March 17, 2011, and July 5, 2011, and reconsidered our position. After further review of the US Airways Flight 1549 accident report, we understand that providing special emphasis of existing practices is not enough to meet the intent of the recommendation to improve life vest retrieval. We drafted a revision to the minimum performance standards for aircraft seats, Technical Standard Order (TSO) C127, which will add new life vest retrieval requirements. Based on the findings of the Board's investigation, we understand there are multiple factors that contributed to some of the passengers having difficulty retrieving life vests. Based on the accident report and our study on human factors of life vest retrieval, (DOTIFAA/AM 03/9), we concluded that retrieval time varies greatly for a given design. While some test subjects were able to reach and retrieve a life vest in a few seconds without difficulty, others required 20 or more seconds. Our study recognized this aspect of human factors as only one factor in the retrieval process. In addition to a new retrieval time, we will introduce a new requirement that the strap be connected to the life vest storage package, such that when the strap is pulled, the vest comes out with the strap. One motion of the occupant will result in retrieval of the life vest. This new requirement will help standardize life vest retrieval and address some of the confusion that a few passengers encountered during the US Airways flight 1549 accident. The details of the new requirements are drafted and we intend to publish the draft revision to TSO-CI27 for public comment by May 2012. I will keep the board informed of the FAA's progress on this safety recommendation and provide an updated response by April 2013.

From: NTSB
To: FAA
Date: 7/5/2011
Response: The FAA stated its belief that the existing regulations, policy, industry standards, and practice documents provide an acceptable level of safety and, therefore, it does not intend to require modifications to the life vest stowage compartment, as recommended. However, the FAA is revising FAA policy memorandum PS-AIR100-2003-ARP5526, adopting portions of a Society of Automotive Engineers Aerospace Recommended Practice (ARP) 5526B. Many of the relevant revisions of the ARP and FAA policy memorandum are based on a 2003 FAA study by the Civil Aerospace Medical Institute (CAMI), titled “Human Factors Associated with the Certification of Airplane Passenger Seats: Life Preserver Retrieval” (DOT/FAA/AM 03/9). The relevance of the CAMI study was discussed in the letter that transmitted this recommendation to the FAA. As we stated in that letter, and again in our March 17, 2011, letter about this recommendation, our investigation of the US Airways flight 1549 accident found that, although none of the configurations in the study was identical to the one in the accident airplane, the average retrieval time for the most similar configuration was 8.5 seconds for the economy class configuration and 7.4 seconds for the first class configuration. Both of these retrieval times were considered by the study to be within the “easy range.” The experiences from the accident flight validated the results of the FAA tests and confirmed that it takes many passengers at least 7 to 8 seconds to retrieve a life vest. We found that many passengers will not wait that long before abandoning the retrieval attempt and evacuating without a life vest, particularly in the likely event that water enters the cabin after a water impact, because doing so would delay evacuation. This recommendation was issued because we concluded that passenger behavior on the accident flight indicated as much. In our March 17, 2011, letter, we stated our agreement that the revisions to the ARP to reflect the CAMI study are an improvement and that FAA issuance of a revised policy memorandum providing guidance to its certification personnel, and to organizations seeking FAA certification that their designs comply with FAA design standards, might constitute an acceptable response. However, although our findings from the US Airways flight 1549 accident investigation confirmed the validity of the research design used in the CAMI study, our findings also documented that a 7- to 8-second retrieval time is unacceptably long. Therefore, an FAA response that will ensure that certified designs meet this unacceptable retrieval time does not constitute an acceptable response. The NTSB recognizes that the FAA’s current letter was sent before our March 17, 2011, letter and, therefore, the FAA did not have the opportunity to review our evaluation that their previous response was not acceptable. We ask that the FAA use the findings of our investigation of the US Airways flight 1549 accident to reconsider (1) its position that existing regulations, policy, industry standards, and practice documents related to the issues in this recommendation provide an acceptable level of safety and (2) its intention not to require modifications to life vest stowage compartments. Pending the identification of and requirement for life vest stowage compartment designs that improve retrieval times to less than the 7- to 8-second average documented in the US Airways 1549 event, Safety Recommendation A-10-84 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 3/17/2011
Response: The letter that transmitted this recommendation to the FAA referenced the findings of a 2003 FAA study, titled "Human Factors Associated with the Certification of Airplane Passenger Seats: Life Preserver Retrieval" (DOTIFAA/AM 03/9) by Mr. Vau Gowdy and Mr. Rick DeWeese. Our investigation of the US Air flight 1549 accident found that, although none of the configurations in the study was identical to the one in the accident airplane, the average retrieval time for the most similar configuration was 8.5 seconds for the economy class configuration, and 7.4 seconds for the first class configuration. Both of these retrieval times were considered by the study to be within the "easy range." The experiences from the accident flight validated the results of the FAA tests and confirmed that it takes many passengers at least 7 to 8 seconds to retrieve a life vest. In the letter transmitting this recommendation, we stated that many passengers will not wait that long before abandoning the retrieval attempt and evacuating without a life vest, particularly in the likely event that water enters the cabin after a water impact, because doing so would delay evacuation. This recommendation was issued because the NTSB had concluded that passenger behavior on the accident flight indicated as much. In its letter, the FAA stated that, on June 2, 2010, the results of the FAA's 2003 study had been incorporated into Society of Automotive Engineers (SAE) Aerospace Recommended Practice (ARP) 5526B. The FAA further stated that it planned to adopt the life vest-retrieval portions of the ARP as FAA policy and that no further revision to the certification regulations was required. The NTSB agrees that the revisions to the ARP to reflect the 2003 FAA study are an improvement and that FAA issuance of a policy memorandum providing guidance to its certification personnel, and to organizations seeking FAA certification that their designs comply with FAA design standards, may constitute an acceptable response. However, although our findings from the US Air flight 1549 accident investigation confirmed the validity of the research design used in the FAA's 2003 study, our findings also documented that a 7- to 8-second retrieval time is unacceptably long. Therefore, an FAA response that will ensure that certified designs meet this unacceptable retrieval time does not constitute an acceptable response. Accordingly, pending the identification of and requirement for life vest stowage compartment designs that improve retrieval times to less than the 7- to 8-second average documented in the US Air 1549 event, Safety Recommendation A-10-84 is classified OPEN – UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 3/15/2011
Response: CC# 201100130: - From J. Randolph Babbitt, Administrator: We have determined the existing regulations, policy, industry standards, and practice documents provide an acceptable level of safety. We do not intend to require modifications to the life vest stowage compartment. We have initiated a revision to FAA policy memorandum, PS-AIRIOO-2003-ARP5526, to adopt portions of SAE ARP5526B, Aircraft Seat Design Guidance and Clarification. The policy provides special emphasis to follow the twelve detailed criteria in the Aerospace Recommended Practice (ARP) closely. The following is an excerpt from the ARP text: When required, life vest stowage should be provided at each seating position in accordance with 14 CFR 25.1411 and 25.1541. If a seat cau be occupied for taxi, takeoff, and lauding, while facing in more than one direction, the life vest stowage provisions should be accessible for each of these positions. The life vest container should be located such that it does not hinder, in any way, the retrieval of the life vest by a seated and belted occupant. FAA report DOTIFAAIAM03/9, provides general guidance to assist in evaluating the life preserver installation features associated with the easy reach requirements in FAA regulations. I will keep the board informed of our progress on this safety recommendation and provide an update by April 2012.

From: FAA
To: NTSB
Date: 9/23/2010
Response: CC# 201000368: - From J. Randolph Babbitt, Administrator: Current FAA regulations require that life vests be conspicuously marked and located within easy reach of all seated occupants on transport category airplanes. We also require life vests to be directly accessible and stowed in an obvious location. We are committed to improving life vest retrieval and our work in this area is ongoing. We took the findings of a research study from 2003, published in FAA report DOT/FAAIAM-03/9, and proposed that industry accept and include them in SAE ARP5526B, which was approved on June 2,2010. We plan to adopt the life vest retrieval portions of the Aerospace Recommended Practice (ARP) as FAA policy. At this time, we do not plan to initiate rulemaking to change our regulations.