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Safety Recommendation Details

Safety Recommendation A-10-095
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 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: 8/4/2015
Addressee(s) and Addressee Status: European Aviation Safety Agency (Closed - Unacceptable Action)
Keyword(s): Water Survival

Safety Recommendation History
From: NTSB
To: European Aviation Safety Agency
Date: 8/9/2017
Response: As a result of our investigation of the US Airways flight 1549 accident, we also issued Safety Recommendation A-10-84 to the Federal Aviation Administration (FAA), which asked the FAA to take the same action as that specified in Safety Recommendation A-10-95. In our November 20, 2014, letter to you about Safety Recommendation A-10-95, we described our concerns with the FAA’s revision to Technical Standards Order (TSO)-C127. At that time, we indicated that, because of these concerns, your plan to revise European Technical Standards Order (E)TSO-C127 similar to the FAA’s revision of TSO-C127 would not constitute an acceptable response. On June 17, 2015, you told us that you were continuing to revise (E)TSO-C127 to allow for up to a 10 second life vest retrieval time. On August 4, 2015, we replied that, in a real situation, passengers in a sinking airplane will not spend even 7 to 8 seconds to retrieve a life vest, but will instead evacuate the airplane without a vest. However, because you did not intend to revise (E)TSO-C127 to specify a retrieval time of less than 7 seconds, Safety Recommendation A-10-95 was classified “Closed—Unacceptable Action” We note that, on August 5, 2016, you issued (E)TSO-C127b. This revision allows for up to a 10-second life vest retrieval time. Because we continue to regard this retrieval time as unacceptable, Safety Recommendation A-10-95 remains classified CLOSED—UNACCEPTABLE ACTION.

From: European Aviation Safety Agency
To: NTSB
Date: 4/28/2017
Response: -From Rachel Daeschler, Deputy Strategy and Safety Management Director and Head of Safety Intelligence and Performance Department: The Agency has collaborated with FAA to revise the minimum performance standards for aircraft seating systems, (European) Technical Standard Order (E) TSO-C127a by adding new life vest retrieval requirements taking into account this safety recommendation. Consequently, the FAA has published TSO-C127b dated 06.06.2014. The Agency has also revised ETSO-C127 (from issue 'a' to issue 'b') under rulemaking task RMT.0206. The associated ED Decision 2016/013/R amending CS-ETSO (amendment 11) entered into force on 5 August 2016.

From: NTSB
To: European Aviation Safety Agency
Date: 8/4/2015
Response: As a result of our investigation of the US Airways flight 1549 accident, we also issued Safety Recommendation A-10-84 to the Federal Aviation Administration (FAA), which asked the FAA to take the same action as that specified in Safety Recommendation A-10-95. On June 6, 2014, the FAA revised Technical Standards Order (TSO) C127b, “Rotorcraft, Transport Airplane, and Small Airplane Seating Systems,” adding new life vest retrieval requirements. Prior to the TSO’s publication, we informed the FAA that the proposed document did not adequately address Safety Recommendation A 10 84 because— 1. TSO C127 addresses issues with seating systems. Although many life vests for aircraft are stowed in the seat, life vests are also stored in other locations, which the TSO does not address. 2. The standard proposed in the draft TSO, which incorporates by reference SAE International Aerospace Recommended Practice (ARP) 5526C, “Aircraft Seat Design Guidance and Clarifications,” was a life vest retrieval time of less than 10 seconds. On February 5, 2015, the FAA (1) described the reasons why the agency believed the revised TSO reflected the lessons learned from the US Airways flight 1549 accident investigation and (2) its belief that expecting a significant percentage of passengers to retrieve their life vests in less than 7 seconds was unreasonable. The FAA said that the retrieval time requirement in the revised TSO, combined with several new design requirements also addressing life vest retrieval that had been added to TSO C127b, resulted in a design commensurate with the level of safety specified in FAA regulations. On April 8, 2015, we replied that we did not agree that the revised TSO satisfied the recommendation; rather, we continued to believe that our investigation of the US Airways flight 1549 accident clarified that, in a real situation, passengers in a sinking airplane will not spend even 7 to 8 seconds, let alone the up to 10 seconds that the TSO allows, to retrieve a life vest. Since the FAA considered its actions complete, Safety Recommendation A 10-84 was classified “Closed—Unacceptable Action.” In our November 20, 2014, letter to you about Safety Recommendation A-10-95, we described our concerns with the FAA’s revision to TSO C127b. At that time we indicated that, because of these concerns, your plan to revise European Technical Standards Order (E)TSO C127 similar to the FAA’s revision of TSO C127b would not constitute an acceptable response. Pending your requiring life vest stowage compartments or stowage compartment locations (in seats and other locations) that would permit all life vests to be retrieved in under 7 seconds, Safety Recommendation A-10-95 was classified “Open?Unacceptable Response.” EASA’s response to our first concern regarding life vests stowed in locations other than seats is acceptable. However, you are continuing to revise (E)TSO C127b to allow for up to a 10 second life vest retrieval time. Because we still believe that, in a real situation, passengers in a sinking airplane will not spend even 7 to 8 seconds to retrieve a life vest, but will instead evacuate the airplane without a vest, Safety Recommendation A-10-95 is classified CLOSED—UNACCEPTABLE ACTION.

From: European Aviation Safety Agency
To: NTSB
Date: 6/17/2015
Response: -From Rachel Daeschler, Deputy Strategy and Safety Management Director, Head of Safety Intelligence and Performance Department, European Aviation Safety Agency: Thank you for your letter dated 20 November 2014 which provides the assessment by NTSB of the EASA reply to NTSB Safety Recommendation A-10-95 (EASA ref. UNST-2010-095). Here below you will find our feedback on the two concerns de,scribed in your letter: 1. The 10 seconds retrieval time standard of the published TSO C127b l future ETSO C127b (refer to our NPA 2015-02 dated 27 /02/2015): As correctly stated in your letter when referring to FAA CAMI study DOT/FAA/AM-03/09, the values of 8.5 and 7.4 seconds are average retrieval times. Actual retrieval times ranged from 4 to 20 seconds, with 75% of the life vests retrieved within 10 seconds. Furthermore all retrievals in 10 seconds or less were rated as "Easy, with minor difficulty". Therefore the TSO/ETSO retrieval time standard ('retrieval in less than 10 seconds by a minimum of 5 na•ive test subjects with a success rate of no less than 75 percent') is consistent with the findings of the study. Requiring a high percentage of the occupants (who are untrained) to retrieve a life vest in less than 7 seconds, instead of 10 seconds, will add a marginal benefit compared to the burden of designing an appropriate solution and appears to be unrealistic according to the evidences brought by the study, especially for people who are less efficient (elderly, children, ...). In addition to the retrieval time standard, it must also be considered that the revised TSO/ETSO standard incorporates several new improvements on top of the minimum life vest retrieval time, which altogether contribute to the life vest "easy retrieval" objective: storage location, design of the pull strap, unobstructed retrieval path. Furthermore, the revised TSO/ETSO introduces the requirement to evaluate live vests "easy retrieval" by means of naive subject testing. 2. Storage of life vests other than in the seating system: There are indeed some certified configurations, where the life vest is not stored in a container that is part of the seat assembly but rather on seat-associated furniture or on an interior components in the area surrounding the seated occupant. It is correct that (E)TSO C127b will not address those locations. Moreover, an ETSO approval is not necessary to approve the installation of seats on a large aeroplanes (ref. 21.A.303(a)). EASA finds that each life vest stowage provision, regardless of its location, should be subject to the same performance standards. Therefore, EASA intends to introduce the same criteria that will be in ETSO C127b, in Interpretative Material Certification Review Items and, in a subsequent phase, in CS-25 (most probably as a new AMC 25.1411(f)). EASA considers that the above proposed measures will establish an adequate level of safety, thus meeting the NTSB safety recommendation.

From: NTSB
To: European Aviation Safety Agency
Date: 11/20/2014
Response: As a result of our investigation of the US Airways flight 1549 accident, we also issued Safety Recommendation A-10-84 to the Federal Aviation Administration (FAA). That recommendation asked the FAA to take the same action as that specified in Safety Recommendation A-10-95. In response to Safety Recommendation A-10-84, in August 2012, the FAA published for public comment a draft a revision to Technical Standards Order (TSO) C127, “Rotorcraft, Transport Airplane, and Small Airplane Seating Systems,” adding new life vest retrieval requirements in accordance with the findings of our investigation. On March 21, 2014, we wrote to the FAA, expressing our regret that we had missed the opportunity to comment on the draft revision to the TSO, and that the draft revision did not adequately address Safety Recommendation A-10-84 based on our following two concerns: 1. TSO C127 addresses issues with seating systems. Although many life vests for aircraft are stowed in the seat, life vests are also stored in other locations, which the TSO does not address. 2. 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,” specified a life vest retrieval time of less than 10 seconds. In our investigation report on the accident, we described a 2003 study conducted by the FAA’s Civil Aerospace Medical Institute (CAMI) that had found that the average retrieval time for life vests was 8.5 seconds for the economy class configuration, and 7.4 seconds for the first class configuration. We issued Safety Recommendations A-10-84 and A-10-95 because we had found in our accident investigation that passengers had struggled to retrieve their life vests and then had abandoned their attempts rather quickly, particularly because water was entering the cabin after the impact. In our March 21, 2014, letter to the FAA, we said that retrieval time must be significantly less than the 7-8 seconds found in the CAMI study; however, the draft TSO had proposed retrieval times that were even longer. We asked the FAA to 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 was classified “Open?Unacceptable Response.” We note that you collaborated with the FAA to revise the minimum performance standards for aircraft seating systems in TSO C127, and that the FAA published the revised TSO on June 6, 2014. We further note that you are preparing an equivalent revision of European Technical Standard Order (E)TSO-C127, which you plan to publish by the fourth quarter of 2014. We are aware that you believe the revised ETSO will include new life vest retrieval requirements that satisfy this safety recommendation. We are also aware that you have not previously been informed about our concerns that the revised ETSO does not specify an acceptable retrieval time nor address life vests stored in locations other than aircraft seats. However, because of these concerns, the revised ETSO does not constitute an acceptable response. 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-10-95 is classified OPEN—UNACCEPTABLE RESPONSE.

From: European Aviation Safety Agency
To: NTSB
Date: 9/22/2014
Response: -From Rachel Daeschler, Head of Safety Intelligence and Performance Department, Strategy and Safety Management Directorate: The Agency has collaborated with the Federal Aviation Administration (FAA) to revise the minimum performance standards for aircraft seating systems, (European) Technical Standard Order (E)TSO-C127a by adding new life vest retrieval requirements taking into account this safety recommendation. The FAA published TSO-C127b dated 06 June 2014. The Agency is preparing an equivalent revision of ETSO-C127 from issue 'a' to issue 'b' as part of rulemaking task RMT.0206 (Terms of Reference dated 26 June 2013). The NPA is planned for publication by Quarter 04 2014.

From: NTSB
To: European Aviation Safety Agency
Date: 9/9/2013
Response: We note that EASA intends to consider the new life vest retrieval requirements specified in the Federal Aviation Administration’s final Technical Standard Order C127b, once that order has been issued, before making similar amendments to European Technical Standard Order (ETSO) C127a. We look forward to reviewing the draft ETSO when it is released. Until then, Safety Recommendation A-10-95 remains classified OPEN—ACCEPTABLE RESPONSE.

From: European Aviation Safety Agency
To: NTSB
Date: 8/13/2013
Response: J. Vincent, Deputy Director for Strategic Safety, Executive Directorate: The Agency has collaborated with the Federal Aviation Administration (FAA) to revise the minimum performance standards for aircraft seating systems, (European) Technical Standard Order (E)TSO-C127a by adding new life vest retrieval requirements taking into account this safety recommendation. The FAA developed TSO-C127b. Corresponding amendment of ETSOC127 from issue 'a' to issue 'b' is included in the Terms of Reference of EASA rulemaking task RMT.0206 (ETS0.011) on regular update of Certification Specifications (CS) for ETSO, dated 26 June 2013, which has been published on the EASA Website.

From: NTSB
To: European Aviation Safety Agency
Date: 4/1/2013
Response: The planned revisions to the European Technical Standards Order may satisfy this recommendation, and we look forward to reviewing the draft order when it is released. Until then, Safety Recommendation A-10-95 is classified OPEN—ACCEPTABLE RESPONSE.

From: European Aviation Safety Agency
To: NTSB
Date: 12/19/2012
Response: -From John Vincent, Deputy Director for Strategic Safety, Executive Directorate: The Agency is collaborating with the Federal Aviation Administration (FAA) in view of revising the minimum performance standards for aircraft seating systems, (European) Technical Standard Order (E)TSO-C127a to add new life vest retrieval requirements taking into account this Safety Recommendation. The FAA draft TSO-C127b is open for comments until 05 December 2012 and the Agency will consider the final TSO for amending ETSO-C127a.