US Airways Flight 1549 Incident: A Reflective Report On Safety Measures And Decision-making Process

Human Error in Aviation Incidents

This report focuses on the incident that took place on January 15, 2009. This major accident involved the ditch by US Airways flight no.1549 (A320-214). When accident took place it was flying over Hudson River nearly about 8.5 miles away from LaGuardia Airport which is situated in New York City. The tragedy was the outcome of damage of thrust in both engines along with stumbling attack from a flock of birds. In these circumstances, around 150 passengers along with a differently abled child and five crew members were successful to evacuate through over wing and forward exist (Vine, 2015). Meanwhile, four passengers got seriously injured along with one flight associate and the plane got extensively damaged.

The issue of safety measures discussed below includes alternative and nonstandard specification structure, abandoning training, dual engine let-down, in flight locomotive diagnostics, integration certification taxing of engine bird, biota hazardous extenuation along with the consequences of airplane response to pilot involvements. It was revealed that simulated barometric features were consistent at that point when accident took place (Paries, 2017). The probable causes were firstly, the endorsement of ditching credential from federal aviation administration (FAA) devoid of knowing whether the pilots would be able to attain the ditching constraints without locomotive trust. Secondly, there was sustained lack of training granted to flight crew members on the tact of ditching. At last, the difficulty aroused on the captain’s side in order to maintain the envisioned airspeed at final slant. This occurred due to task accumulation which was the outcome of adverse situation (The New York Times, 2018).

Furthermore, the decision making ability of the crewmembers that were present on the flight was the major reason for survivability of accident. Some other causes in this regard were the availability of forward rafts and slides in the airplane even though it was not mandatory to be kept. There was logical and fast operation done by crew members in task of evacuating people from the airplane.  Also, the degree of awareness with which the responders had vigorously reacted on the accident site to save maximum number of people was commendable. These were some of the potential reasons which safeguarded the lives of the people who were boarded on the plane.

The decision making process refers to how an individual use the degree of proficiency and previous engrossments in realistic terms to make decisions. In this context, studies have revealed that the decision to use flaps 2 rather than flaps 3 was operational in nature. The pilot was concerned about saving enough of energy so that successful running and landing of airplane would be possible. Moreover, the decision to use engine dual catastrophe was taken because it was the utmost applicable checklist option contained in US Airways of QRH to address and meet the contingencies of the accident event. It provided the guidance in the circumstances when engine was not restarting and thereby, a forced mooring or dumping was necessary. Also because of low altitude and time gap available at that point of time, crew members were not able to open and start part 2 and 3 of the list (Cranwell, 2018).

Reflective Report on US Airways Flight 1549 Incident

Extending ahead, the decision to start the APU was taken by the captain even though it was not mentioned in checklist. In the event of its non-occurrence, the airplane would not have been possibly remained in the mode of normal law. As a result, it enhanced the conceivable outcome of ditching while ensuring along that the primary source of power was obtainable to the plane (European Commission, 2012). The choice in regards of descent and ditching airspeed was taken as captain thought that they had gained the green dot speed immediately after the bird strike, the reality was reverse. Significantly, there was difficulty in maintaining of the intended airspeed throughout the final approach.

As a result, there was high commensuration of AOAs which was supportive enough in flaring of the plane. Along with the rate of touchdown eventually became high because of damage in fuselage section.  The decision to ditch the airplane on Hudson River was taken since it was only alternative available according to airplane’s altitude, airspeed and position. The captain took the decision of not to land at LGA, instead end up on the layers of Hudson and reported the same to ATC. The captain did so because he believed that returning back to LGA would not be a realistic choice and it could result in more serious issues. Also, it was found that in case the return decision to LGA was favoured than it would place the densely populated area on ground at high degree of risk as it mandatory to cross the boundaries of Manhattan (Vance, 2014). Therefore, I would conclude that the captain’s decision has provided the highest chances of probability on the grounds of survivability.   

The international aviation industry is a mixture of highly complex and intense sociotechnical system of the material structures and regulations of the organisation. The proportion of deviations and variance quickly propagate within the system in order to leave the impact on passengers and airlines purely far away from the basis of destination. Up to the large extend, the formula for smooth running of aviation industry is formally inscribed into the technologies and procedures. Now days, the sociotechnical systems are flattering more complex in nature and progressively automated. In the context of flight no. 1549 it is widely viewed that human error plays a significant role in mainstream of the system failures, which propagates the increase in recognition of the oversimplified view. The captain’s culture and capabilities had upstroke as compared to the procedures regarding the focus on automation of flight deck (US AIRWAYS FLIGHT 1549 ACCIDENT, 2018).

Decision Making Ability of Crewmembers

The FAA has composed around 100,000 wildlife strike reports voluntarily in nature and has written down database for the same. This database is made available to the operators at airport along with safety analysts so that specific species are identified and respective damage to be occurred is investigated in advance. Additionally, thereafter the engineers use the provided data to introduce and test new set of engine designs. Flight no. 1549 was flying over an altitude of about 3200 feet above the base ground level when it encountered the strike at engines and on layers of airframes (U.S. Department of Transportation, 2018). On safety levels in general terms, so that further occurrence could be prohibited wildlife hazard assessment plan needs to be outlined and managed. The attractants of wildlife likewise: water, food and habitat shall not be there at minimum of five miles from the airport. In event of any tragedy so occurred, than an analysis of the event must be made which prompts the assessment in deep. There shall be identification and proper record of the species observed and their local movements along with quantum of numbers. The set of priorities would be developed for the required modification in the habitat. The bird detection radar can be set to help the operators in managing of risk and act accordingly (Heimbs, 2011).

Apart from the fact of the bird strike extenuation efforts, there are several other series of minimum standards which needs to be duly complied with by FAA certifies.  In order to gain the approval, the aircraft must be flyable i.e. the design must be built according to all the remarks of safe fly. Moreover, it must be capable to survive in adverse situations of both internal and external factors which might interfere on the working of safe operations going on aircraft (Balachandran & Atkins, 2016). When Airbus A320 has received certification from FAA, the design and several operating measures took place accounting all the urgencies that was required. This further includes the framework of surprisingly injection of flock of birds, serene of disastrous landing on the land along with subsequent loss of power engine and airplane cost.

The power and control of A320 was on the pillars of two CFM56-5B4/P engines which were potential enough to meet the following requirements:

1. Flocking birds:  The engine was designed to bear the attack of flock of birds i.e. around seven 1.5 lb. birds in figures. The loss of power was not expected to be more than ¼ of the overall power and ahead it would continue to lane for five minutes after its take off as per the power settings (National Transportation Safety Board, 2015).
2. Single bird: The engine was highly capable to ingest the solitary large bird of 4lbs, while shutting down safely. In case of huge bird, the engine was designed to essentially shut down on priority with no fire or any kind of hazardous debris.

The airplane flotation ditching of A320 was certified to meet various requirements so that occupants gets every possible permit to escape. There must be sufficient number of exists above water while airplane is floating. The plane must float long enough in time unless and until there is emigration of passengers into the life rafts (U.S.News, 2009). All the essentials such as life vests, survival kits and rafts must be there in the airplane at any point of time.

International Aviation Industry and Sociotechnical Systems

The texture of the seats was crafted to withstand at least 9 times the force pushed by the gravity along with various above storage cubicles and interior features. Later, on the standards were increased to raise it up to 16 times the force of gravity enforced. However, these forthcoming standards were not applicable to the specifications of A320 (The New York Times, 2018). Nevertheless, the reaction by the engine was exactly on the line as was intended after the ingestion. Evidence suggests that in this incidence, minimal injuries were occurred only because of the fact that seats and interior performed very well in safeguarding the passengers from the event of crash. Moreover, the aircraft also floated for sufficient time so that passengers could be possibly evacuated.

There has been tailoring of specific training in operative areas which provide major emphasis on extents of high risk attached. Even though, the airline is not expected to spend major proportions of its operations over the layers of water. Still there need to be intact ditching training impart to cabin and flight crew members to face the consequences in worst circumstances (Romero, 2018). This furthermore, includes the detailed discretion of the realistic incident and measures to handle the circumstances successfully. The members of crew are trained on every emergency procedure which is developed by the manufacturer which even includes the section of ditching. The details about airplane model and type and attached configuration are shared with the crew members. The areas of decision making, crisis response, workload management as well as various situational awareness are given due importance while granting training to crew members (Wilkins, 2017). The pilot receives initial indoctrination training using the case studies available in data base, later on during recurrent training program specific instructions are briefed about A320. Some more areas to be covered under the adjoined head includes clean-up of the aircraft, management of crew resource, communiqué with air traffic control, ditching directions which are based upon calm or wind in addition with post ditching essentials. For e.g.: survival, first aid, nearby help sources, signalling etc. (Mulenburg, 2018).

At adverse circumstances, pilot undergoes highest level of stress and insecurity which arises from time pressure, workload and noise besides the fear of having life responsibilities of hundred in numbers. The decision making of the authorities is also affected by alerts received from the series of TCAS and GPWS along with numerous ATC communications. The justification received from captain was on the grounds that time was compressed and attention was narrowed because he was specifically focusing on upheld of the successful flight path (CHEST, 2018).

Wildlife Strike Reports and Prevention Measures

The learning’s I have gained after the deep and careful understanding of the tragedy occurred with A320 are:

1. Always practice the emergency processes and remain positive even in worst of the circumstances.
2. The person should learn to think and act out of the box. Initiate the proceedings for the surer thing, though if it is less ideal in nature instead of waiting and hoping for the best to take place.
3. Practice and study the techniques of TEM, CRM in addition with qualitative amount of communication skills (National transportation safety board, 2016).
4. One should never stop training and learning.
5. One should keep calm and wing the plane.
6. Studying of checklists, manuals, guidelines and procedure is utmost important. Any productive information regarding emergencies should be carefully scrutinized (Fraher, 2011).
7. The safety elements like life vests, survival kits and rafts should be boarded on plane before take-off.
8. Techniques like bird detection radar must be installed and be kept as working at all times so that alert could be provided in advance.
9. An effective and efficient incident management system (IMS) is vital to control and coordinate the activities of emergency responders.
10. The importance of communication along with cooperative efforts cannot be overstated.
11. The disasters accounts for the resources and talent of different individuals and agencies in proportionate degree at proportionate intervals.
12. The ditch was moreover addressed with the positive outcome such as “Miracle on the Hudson”.
13. The statistics and material in relative assessment to the safety management system must be updated with the advent of newly embedded technologies.
14. The national transportation safety board certification is mandatory in nature and airlines must abide by the rules and regulations which governs the certificate (U.S.NRC, 2011).
15. The rapidly and large scale incidence of escalation requires certain amount of extensive assurance to command respective staff positions.

Conclusion

It can be concluded that the precise reason on why US airways flight no. 1549 had a positive outcome have been briefly contested above. Moreover, it was the result of the pilot decision making process along with cabin crew member’s activeness. A checklist is useless in nature if not properly used. The training needs to be imparted to the pilot and crew members so that they could act in wise manner when met any consequences of critical nature. The involvement of independent regulators such as joint commission, accreditation council for graduate medical education and boards shall be increased in preventive measures of such crashes. Also, the intensivists should strictly adhere to the principles of CRM in event of emergencies.  There shall be the presence of calmness and positivity so that inclination towards worst could be minimised. At last, the captain’s pronouncement to ditch the plane on the bank of Hudson River rather than on an airport was the remarkable decision as it provided the highest panorama for survival.

References:

Balachandran, S., & Atkins, E. (2016) Markov decision process framework for flight safety assessment and management. Journal of Guidance, Control, and Dynamics, 54 (2), 1-14.

CHEST. (2018) What went right. Retrieved from https://pdfs.semanticscholar.org/40ea/640e7fc01b0bc799393429eee267afa3cc9d.pdf 

Cranwell, M.T. (2018) US Airways flight 1549: New Jersey Rescue Operations. Retrieved from https://www.fireengineering.com/articles/print/volume-162/issue-7/features/us-airways-flight-1549-new-jersey-rescue-operations.html  

European Commission. (2012) A positive safety culture. Retrieved from https://ec.europa.eu/transport/sites/transport/files/modes/air/events/doc/2012-04-19-seminar/af.pdf 

Fraher, A. (2011) Hero-making as a defence against the anxiety of responsibility and risk: a case study of US Airways Flight 1549. Organisational and Social Dynamics, 11(1), 59-78.

Heimbs, S. (2011) Computational methods for bird strike simulations: A review. Computers & Structures, 89(23-24), 2093-2112.

Mulenburg, J. (2018) Crew resource management improves decision making. Retrieved from https://www.nasa.gov/pdf/546130main_42i_crew_resource_management.pdf 

National Transportation Safety Board. (2015) Aircraft Accident Report. Retrieved from https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1003.pdf 

National transportation safety board. (2016) US Airways flight 1549 water landing Hudson river. Retrieved from https://graphics8.nytimes.com/packages/images/nytint/docs/documents-for-the-testimony-of-us-airways-flight-1549/original.pdf 

Paries, J. (2017) Lessons from the Hudson. In Resilience Engineering in Practice. CRC Press.

Romero, F. (2018) Learning from flight 1549: How to land on water. Retrieved from https://content.time.com/time/nation/article/0,8599,1872195,00.html 

The New York Times. (2018) Lessons from flight 1549. Retrieved from https://www.nytimes.com/2009/01/20/travel/20prac.html 

The New York Times. (2018) Plane crash shows flaws in standards of safety. Retrieved from https://www.nytimes.com/2009/06/12/nyregion/12usair.html 

U.S. Department of Transportation. (2018) US Airways Flight 1549. Retrieved from https://www.transportation.gov/content/us-airways-flight-1549 

U.S.News. (2009) How sullenberger really saved us airways flight 1549. Retrieved from https://money.usnews.com/money/blogs/flowchart/2009/02/03/how-sullenberger-really-saved-us-airways-flight-1549 

U.S.NRC. (2011) Safety Culture Communicator. Retrieved from https://www.nrc.gov/docs/ML1122/ML11228A218.pdf 

US AIRWAYS FLIGHT 1549 ACCIDENT. (2018) Hearing on US airways flight 1549 accident. Retrieved from https://www.gpo.gov/fdsys/pkg/CHRG-111hhrg47866/pdf/CHRG-111hhrg47866.pdf 

Vance, S. M. (2014) Analysis of factors that may be essential in the decision to fly on fully automated passenger airliners. Doctoral dissertation: Saint Louis University.

Vine, S. J., et al. (2015) Individual reactions to stress predict performance during a critical aviation incident. Anxiety, Stress, & Coping, 28(4), 467-477.

Wilkins, M. (2017) Managing Operator Mental Workload with Standards Based Decision Support. London: Routledge.