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Safety Recommendation Details

Safety Recommendation A-10-086
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: Conduct research on, and require 14 Code of Federal Regulations Part 121, Part 135, and Part 91 Subpart K operators to implement, creative and effective methods of overcoming passengers‘ inattention and providing them with safety information.
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):

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/31/2017
Response: In your April 9, 2013, letter you said that, during 2008, your Civil Aerospace Medical Institute (CAMI) conducted research that was described in “Effective Presentation Media for Passenger Safety I: Comprehension of Briefing Card Pictorials and Pictograms” (DOT/FAA/AM 08/20). This report was the first of a planned three-part study on the effectiveness of safety information provided to passengers, including results related primarily to passengers’ comprehension of pictogram information. At that time, you said that future research would examine improved evacuation equipment and new wayfinding technologies as well as aids to enhance rapid evacuation and advances in passenger education, media, and persuasive technology. In the past 4 years, we have not received any further information from you regarding your actions to satisfy this recommendation. We looked in the Proceedings of the Eighth Triennial International Fire and Cabin Safety Research Conference (held in 2016) and did not see any presentations by CAMI personnel on related research. We also examined your database, Aerospace Medicine Technical Reports, where CAMI research reports are typically published. We found two reports related to the research you described in 2013 concerning comprehension of symbolic exit signs and the application of wayfinding technology to transport-category passenger airplanes; however, we did not see any research results related to methods of overcoming passengers’ inattention and providing them with safety information. In our investigation of the US Air flight 1549 accident, passengers did not report that they did not understand the pictograms on the flight; rather, the overwhelming majority reported that they did not even read the passenger safety briefing card. As discussed above, we generally expect action to satisfy a recommendation to be completed within 5 years after it is issued. Because Safety Recommendation A-10-86 is now over 7 years old and there does not appear to have been any progress in addressing this recommendation, it is classified CLOSED—UNACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 7/8/2013
Response: We look forward to reviewing the findings of the FAA’s research on evacuation equipment and new wayfinding technologies, once this research is completed. Pending our review and the incorporation of the research into guidance used by principal operations inspectors to review and approve passenger safety briefings and briefing cards, Safety Recommendation A-10-86 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/9/2013
Response: -From Michael P. Huerta, Administrator: In the Federal Aviation Administration's (FAA) letter dated April 3, 2012, we discussed that the FAA's Civil Aerospace Medical Institute (CAMI) commissioned a report in 2008 titled, "Effective Presentation Media for Passenger Safety I: Comprehension of Briefing Card Pictorials and Pictograms (DOT/FAAIAM-08/20)." This 2008 report provides the first of three analyses of the effectiveness of safety information currently provided to passengers, including results related to comprehension of] 5 of 41 pictograms, with follow-on reports to address the effectiveness of the remaining briefing materials expected in late 2013 . Of the 15 pictograms initially reported, it was shown that those with which participants had the most exposure in everyday life (no smoking in lavatory, seat belt usage) or are verbally briefed before every flight (oxygen equipment usage) were comprehended at a higher rate (63.8 - 85.3 percent). Additionally, those pictograms comprehended at a lower rate included multiple elements and/or depicted multiple actions, especially flotation device usage pictograms and warning pictorials within larger pictograms (39.8 - 49.4 percent). Future research, in relation to this recommendation, will be conducted in four phases through December 31, 2015, in which improved evacuation equipment and aids to enhance rapid evacuation will be identified, assessed, and developed. In addition to new way-finding technologies in the "traditional" systems, such as lighting, symbolic media, and aural/tactile, research will examine advances in passenger education, media, and persuasive technology. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by March 31, 2014.

From: NTSB
To: FAA
Date: 6/14/2012
Response: The FAA provided information on its current research on passenger safety information that is being conducted at the FAA’s Civil Aerospace Medical Institute (CAMI). The first of three analyses being performed was documented in a 2008 report discussed by the FAA in its previous response to this recommendation. That report evaluated the pictograms provided on passenger safety briefing cards; future reports will address the effectiveness of the remaining briefing materials providing comparisons of safety briefing card presentation mode and style. The focus of the CAMI research is to identify best practices related to passenger safety briefing cards. After the research has been completed, the FAA plans to require appropriate revisions to passenger safety briefing materials. Although we believe that this research is both valuable and relevant to this recommendation, as described, CAMI’s work has a much narrower focus than what we recommended. Our original letter to the FAA indicated that this recommendation had been based on our conclusion that most of the passengers had not paid attention to the preflight safety briefing or read the safety information card before the accident flight, indicating that more creative and effective methods of conveying safety information to passengers are needed. Both the planned research and the planned followup activities in response to the recommendation appear to focus on safety briefing cards, without regard to the safety briefing. In addition, the research described appears to constitute reviewing existing briefing cards, with the aim of identifying best practices. The research is valuable and needed, but we are concerned that it will not consider creative and effective methods not included in current practices. Accordingly, we ask that the FAA consider expanding its research to include the safety briefing as well as the card, and that it consider creative and effective techniques that may not currently be in use. Pending the FAA’s completing the recommended action, Safety Recommendation A-10-86 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/3/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration's (FAA) Office of Aerospace Medicine Civil Aerospace Medical Institute (CAMI) Cabin Safety Research Team conducted a study on pictograms derived from airline passenger safety briefing cards, which resulted in a 2008 report, tided Effective Presentation Media for Passenger Safety I: Comprehension of Briefing Card Pictorials and Pictograms (DOT/FAAIAM-08/20). This 2008 report provides the first of three analyses or the effectiveness of safety information currently provided to passengers. The report includes results related to 15 of 41 pictograms, and follow-on reports will address the effectiveness of the remaining briefing materials. Combined, these examinations will provide comparisons of safety briefing card presentation mode and style, with a focus on identifying best practices for future enhancements. The 2008 report can be found at: http://www.faa. govnibraryIreports/medical/oamtechreportsl2000s/medial200820.pdf. We will use the findings from this research after completion, to make a decision on additional activities needed in this area, regarding changes to passenger safety briefing materials. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by March 2013.

From: NTSB
To: FAA
Date: 3/17/2011
Response: The FAA provided information on several recent reports that had resulted from research it is conducting at CAMI. The FAA also plans (I) to conduct additional research on passenger education programs, passenger safety information cards and video briefings, and alternative media and formats to enhance aircraft passenger safety and (2) to revise AC 12l-24C, "Passenger Safety Information Briefing and Briefing Cards," to include current research results on this subject. The actions described by the FAA are responsive to this recommendation. Accordingly, pending completion of the research described, and its incorporation into guidance used by POIs to review and approve passenger safety briefings and briefing cards, Safety Recommendation A-10-86 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/23/2010
Response: CC# 201000368: - From J. Randolph Babbitt, Administrator: Sections 121.571, 135.117, and 91.519 require part 121, 135, and 91 subpart K operators to provide safety briefings and briefing cards to inform passengers of routine and emergency safety procedures onboard aircraft. In FAA Order 8900.1, Flight Standards Information Management System, chapter 32, section 13 (enclosure 3), principal operations inspectors (POIs) are provided guidance for the approval and acceptance of flight attendant manuals and checklists, which includes passenger safety briefings and briefing cards. Existing language to POIs in that section states they are to encourage operators to be innovative and progressive in developing such policies, methods, procedures, and checklists. It also states POIs are to ensure the operator's material complies with the regulations, is consistent with safe operating practices, and is based on sound rationale or demonstrated effectiveness. One strategy to increase safety knowledge among passengers is to improve the comprehensibility and appeal of safety briefings and briefing cards. This very issue is one area the CAMI cabin safety research team continues to research. Examples of its research efforts and reports are: I. Availability of Passenger Safety Information for Improved Survival in Aircraft Accidents (DOT/FAA/AM-04/19). This 2004 report provides a review of safety information available to airline passengers and can be found at the following Web site: http://www.faa.gov/library/reports/medical/oamtechreports/2000s/media/041 9.pdf; 2. Effective Presentation Media for Passenger Safety I: Comprehension of Briefing Card Pictorials and Pictograms (DOT/FAA/AM-08/20). This 2008 report provides an examination of the safety information that is important for passengers to know and an investigation of the best methods for imparting that safety information. While this research continues, the first results have been published in this report, which can be found at the following Web site: http://www.faa.gov/library/reports/medical/oamtechreports/2000s/media/200820.pdf; and 3. Cabin Safety Research Technical Group (CSRTG). The FAA is a member of this international group whose goal is to enhance the effectiveness and timeliness of cabin safety research. Since 1995, the CSRTG has organized a Triennial International Aircraft Fire and Cabin Safety Research Conference. The sixth conference will be held in October 2010 and passenger safety awareness research will be presented. To review past conference proceedings, reference the following Web site: http://www.fire.tc.faa.gov/cabin.stm. The CAMI cabin safety research team has plans for future research on passenger education programs, passenger safety information cards and video briefings, and alternative media and formats to enhance aircraft passenger safety. We plan to revise Advisory Circular 121-24C, Passenger Safety Information Briefing and Briefing Cards, to reflect the most current research in this area. I will keep the Board informed of our progress on these safety recommendations and provide an update by July 2011.