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Safety Recommendation Details

Safety Recommendation A-10-090
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 EUROPEAN AVIATION SAFETY AGENCY: Require manufacturers of turbine-powered aircraft to develop a checklist and procedure for a dual-engine failure occurring at a low altitude.
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: 12/21/2011
Addressee(s) and Addressee Status: European Aviation Safety Agency (Closed - Unacceptable Action)
Keyword(s): Checklist, Engine Out

Safety Recommendation History
From: NTSB
To: European Aviation Safety Agency
Date: 12/21/2011
Response: In its letter, EASA references its Certification Specification 25.1585(a)(3), which requires that operating procedures be furnished for “emergency procedures for foreseeable but unusual situations in which immediate and precise action by the crew may be expected to substantially reduce the risk of catastrophe.” The letter also references EASA’s Acceptable Means of Compliance 25.1581, which states that the “Emergency Procedures” sections in airplane flight manuals should include procedures for handling such situations as multiple engine failures, crash landings, and ditching. The NTSB agrees with EASA that these requirements are adequate. However, we believe that regulations cited by EASA in its letter provide your agency with both the authority and the responsibility for taking the recommended action. In contrast, EASA believes that the development of a specific procedure for handling a case of multiple engine failure at low altitude is impractical, because of the variety of potential scenarios and the short time available for the crew to assess the situation, determine the appropriate procedure to follow, and execute such a procedure. EASA further believes that the existence of such a procedure could potentially have a negative impact, if the crew should need time and cognitive resources to determine which procedure best applies to the situation. The NTSB disagrees with EASA’s rationale for not taking the recommended action; rather, we believe the reasons cited by EASA for not taking the action in fact support the need for the recommendation. In the US Airways 1549 accident, approximately 17 seconds after the bird strike, the captain called for the quick reference handbook (QRH) engine dual failure checklist, and the first officer complied. Although this checklist did not fully apply to the situation, it was the only checklist available to the crew that contained guidance to follow when an engine restart is not possible and when a forced landing or ditching is anticipated. Therefore, we concluded that it was the most applicable checklist contained in the QRH to address the event, and that the flight crew’s decision to use this checklist was in accordance with US Airways’ procedures. However, the flight crew did not complete the checklist, which had three parts and was three pages long. The first officer spent about 30 to 40 seconds attempting to relight the engines, as indicated in part 1 of the checklist, but never reached the ditching portion of the checklist, which most directly applied to the accident situation. Although the flight crewmembers were able to complete most of part 1 of the checklist, they were not able to start parts 2 or 3 because of the airplane’s low altitude and the limited time available. We issued this recommendation because the circumstances of the US Airways flight 1549 accident indicated the need for a checklist to use during a dual engine failure or other abnormal event occurring at a low altitude, in order to increase the chances of a successful ditching by omitting many of the steps that took up the flight crew’s limited time. Among the items of the checklist that the crew did not have time to reach was setting the flaps for flaps 3. In the accident, the flight crew selected flaps 2, which likely caused the airplane to be flying at a higher airspeed when it landed on the river. Thus, we believe that the lack of an appropriate checklist contributed to the high airspeed at water contact, which in turn caused the fuselage damage. In summary, EASA has provided information demonstrating that, in our opinion, current EASA regulations provide the authority needed and basis for the recommended action. The NTSB disagrees that the development of a specific procedure for handling multiple engine failure at low altitude is impractical, and we believe that the circumstances of the US Airways flight 1549 accident clearly demonstrate that the recommended action is needed. EASA has decided to not take the recommended action, in large part because of the limited time available to the flight crew to respond appropriately to an emergency occurring at a low altitude. A procedure for handling a case of multiple engine failure at low altitude is needed, however, because of the limited time available to the flight crew in such an emergency. Because EASA indicated that it does not intend to take the recommended action, however, Safety Recommendation A-10-90 is classified CLOSED—UNACCEPTABLE ACTION.

From: European Aviation Safety Agency
To: NTSB
Date: 9/27/2011
Response: From John Vincent, Deputy Director for Strategic Safety, Executive Directorate: Current Certification Specification (CS) 25.1585 (a) (3) requires that operating procedures be furnished for "emergency procedures for foreseeable but unusual situations in which immediate and precise action by the crew may be expected to substantially reduce the risk of catastrophe". Acceptable Means of Compliance (AMC) 25.1581 on Aeroplane Flight Manual further states that Emergency Procedures should include the procedures for handling situations such as: Multiple engine failure, Crash landing or ditching, etc. EASA has reviewed the above mentioned applicable requirements and consider that they are adequate. The development of a specific procedure for handling a case of multiple engine failure at low altitude is considered to be impractical due to the variety of potential scenarios and the short time available for the crew to assess the situation, determine the appropriate procedure to follow, and execute such a procedure. The existence of such a procedure could potentially have also a negative impact, if the crew needs time and cognitive resources to determine first which procedure best applies to the situation.