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National

NTSB: Hudson River crash 'a perfect storm of circumstances'

Barbara Barrett - McClatchy Newspapers

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May 04, 2010 05:39 PM

WASHINGTON — The National Transportation Safety Board said Tuesday that the circumstances of the so-called "Miracle on the Hudson" — daytime flight, clear weather, available waterway and experienced flight crew — amounted to a good, though not a perfect, touchdown of US Airways Flight 1549 into a frigid ribbon of water on Jan. 15, 2009.

The Airbus A320 also happened to be equipped with life vests and inflatable slide rafts for over-water flights, though they weren't required on this route. The plane took off from New York's LaGuardia airport and was bound for Charlotte, N.C.

Birds struck the plane less than two minutes after takeoff, and Capt. Chesley Sullenberger steered the aircraft into the Hudson River.

Had the rafts and life vests not been aboard, the board said, some passengers probably would have drowned. Instead, all 150 passengers and five crew members survived.

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"It turned out to be very fateful," said Deborah Hersman, the chairwoman of the National Transportation Safety Board. "Had they not had this equipment, the results would have been very different."

The board, as expected, found the probable cause of the accident to be the ingestion of migratory Canada geese into the two engines of the plane, clogging the systems and resulting in a near-complete loss of thrust.

However, the board also found areas in which the flight crew or the aircraft could have performed better, given better equipment and training.

"As heroic as the Hudson ditching was, we must not forget it was the outcome of a perfect storm of circumstances," Hersman said.

Investigators made nearly three dozen recommendations on repelling bird strikes, training pilots for low-altitude ditching of aircraft when both engines have failed and safety features that could save lives.

Almost all the recommendations were to the Federal Aviation Administration and its European counterpart, the European Aviation Safety Agency. None of the recommendations is binding.

Tuesday's report highlighted several shortcomings that safety board members said should be corrected. Many centered on the fact that although pilots had trained to ditch airplanes from altitudes of 20,000 feet or higher, they hadn't had formal training — or a quick checklist — to bring down a plane with two failed engines from 2,800 feet.

The board concluded that as the plane glided toward earth, the pilots wasted valuable time trying to reignite dead engines that they didn't know couldn't possibly have been restarted.

Then, stressed by the cockpit alarms, the plane's rapid descent and the quickly approaching threat of a crash, the pilots became overwhelmed by a lengthy cockpit checklist as a computerized voice chanted, "Terrain ... pull up ... terrain ... pull up. ..."

An onboard protection system kept the plane from stalling completely, but it also prohibited the pilots from pitching the aircraft's nose up to reduce the rate of descent as it landed, something they hadn't learned in training.

Because the pilots were busy in the cockpit, they also didn't warn passengers or flight attendants that they'd be landing in water. Only two passengers figured out what was going on and donned their life vests before the plane touched down.

Had the plane not contained life rafts, investigators said, flight attendants would have ordered the passengers to jump into the 41-degree water. Passengers would have carried floating seat cushions rather than life vests. Some could have died of cold shock within three or four minutes, investigators said.

Investigators also pointed out the quick response of ferries that were operating in the Hudson River as another positive circumstance. The first ferry pulled up next to the plane's stranded passengers within four minutes of the aircraft's splashdown.

Only flights that are considered "extended over water" must include life vests and detachable life rafts. The FAA proposed regulations in 1988 that would require the equipment on all flights, but that proposal was withdrawn in 2003 because of cost concerns, investigators said. Tuesday, the NTSB made the recommendation again.

Investigators also recommended finding new ways to get passengers to pay attention to safety briefings and to require that such briefings include demonstrations of how to put on the life vests.

FAA spokesman Les Dorr said Tuesday that the agency would respond to the safety board's recommendations within 90 days.

He said the FAA, like the safety board, wanted to look at issues surrounding flight crew training, the aircraft and wildlife management to reduce the chance of bird strikes.

NTSB RECOMMENDATIONS:

The board made 33 recommendations Tuesday in response to the Jan. 15, 2009, accident of US Airways Flight 1549. Among them:

  • Work with the military, manufacturers and NASA to complete development of technology capable of informing pilots about the continuing operational status of an engine.
  • Once the technology is developed, require that it be implemented.
  • Modify federal codes for small and medium birds so that tests are done on engines at lower fan speeds, to make them more aligned with the typical speeds of planes that are climbing just after takeoff.
  • Require manufacturers to develop pilot checklists for dual engine failure at low altitudes.
  • Once the checklist is completed, require it be implemented.
  • Require simulator training on how to handle dual-engine failure at low altitudes.
  • Require training for pilots on visual illusions that can occur with water landings.
  • Require Airbus operators to amend the ditching checklist to switch off terrain alert systems during final descent.
  • Develop technologies with the FAA and the U.S. Department of Agriculture that can be installed on aircraft to reduce the likelihood of bird strikes.
  • Conduct research on the most beneficial passenger brace positions with newer seat models.
  • Require sufficient life rafts on all new transport-category airplanes.
  • Require operators to provide information about life lines, which are stowed above the wings and used in water landings.
  • Require modifications to life vest storage to make the vests easier to retrieve.
  • Require safety briefings on all floatation equipment, including a full demonstration of correct life vest retrieval and donning procedures, on all routes.
  • Require all aircraft to be equipped with life vests and floatation seat cushions.
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    Hudson River crash: Three tales of fear and salvation

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