Keep Calm and Fly the Plane: Lessons from US Airways 1549
The title of the NTSB (National Transportation Safety Board) report is pretty straightforward: “Loss of Thrust in Both Engines After Encountering a Flock of Birds and Subsequent Ditching on the Hudson River US Airways Flight 1549 Airbus A320‐214, N106US Weehawken, New Jersey January 15, 2009.”
The “Miracle on the Hudson” has been parlayed into a hit movie, and has fairly become the stuff of legend. But the stuff of legend is, by definition, not necessarily the stuff of fact.
In this article, we will try to separate the Hollywood myth from the cold, hard facts, in order to take away some important safety lessons for pilots.
Note: In no way will we be “armchair quarterbacking” this accident. We will not comment on the decisions made and actions executed by the crew, both in the cockpit and the cabin, except in the context of learning.
The sole scope of this article is to draw lessons from issues raised by the NTSB report. While the exhaustive report covers everything from “flight crew performance” to “wildlife hazard mitigation” and “passenger education,” again, we will solely focus on what we, as pilots, can learn.
If you’re an airline pilot—or even a private pilot—you’ve probably been asked this question: “What would you have done? Could you have landed at an airport?”
The NTSB report states, “About 1 minute after the bird strike, it was evident to the flight crew that landing at an airport may not be an option.”
From nearly the first hour of flight training, pilots are trained in “forced landings” (gliding in with the engine or engines out). For the fledgling small plane pilot, this entails the flight instructor pulling the throttle to idle, and then letting his student run through the procedure of selecting a suitable emergency landing spot, attempting an engine restart, and communicating May Day over the radio—all the while flying the engineless plane. Every pilot learns it, every pilot practices it.
But the choice of a suitable landing field is rarely clear-cut. As a young bush pilot in Alaska, the prospect I constantly faced and contemplated while flying a single engine Cessna was the “Hobson’s Choice” of rugged mountains, tree-packed forests, freezing arctic waters, or rocky shorelines. This dire choice comes into play in my novel, “The Last Bush Pilots.”
In the case of the Hudson crash, the Captain elected “freezing waters,” rather than risk the hope of making it to a “shoreline” by overflying the “tree-packed forest” of a densely populated city.
For pilots, in general, would this be considered the “right” choice?
During the investigation, the NTSB conducted multiple simulator tests at the Airbus Training Center in Toulouse, France. Investigators put flight crews through several scenarios, “to determine whether the accident airplane could have glided to and landed at LGA (La Guardia) or TEB (Teterboro) after the bird strike.”
Four scenarios were presented. In the first, all pilots were able to make the field. It was the third scenario, however, that most closely simulated the accident, and proved to be the most telling.
The NTSB notes that a direct return to LGA would have required crossing Manhattan, a highly populated area, and putting people on the ground at risk. The report states that, “In eight of the 15 runs (53 percent), the pilot successfully landed after making an immediate turn to an airport after the loss of engine thrust.”
Even on a normal flight, landing on LGA’s relatively short runways, virtually sandwiched between high rises, can be a challenge. In the test, slightly over half of the flights were successful at landing at the airport. The flip-side implication is, nearly half resulted in a crash—in one of the most densely populated areas in the world.
As the mixed success of the NTSB simulator runs proved, the statement, “Could you have landed at the airport?” is almost a moot point. Would you bet your life—and those of your passengers—on 50/50 odds? Even Russian roulette offers you a better chance.
Of course, the crew did not have the benefit of knowledge of these odds. Even so, in the report, the captain stated that, “once a turn to LGA was made, it would have been an irrevocable choice, eliminating all other options —the only— option that was ‘long enough, smooth enough, and wide enough’ was the Hudson River.”
Lesson: No matter your experience level in the cockpit, nor equipment you fly, constantly be on the lookout for emergency landing fields. Contemplate the best choice(s) for any given situation. Practice simulated forced landings regularly.
Go for the sure thing, even if it is less than ideal, rather than risking all and hoping for the best. Droves of fatal accidents have been blamed on the pilot attempting to turn back to the runway—and falling heartbreakingly short—rather than landing straight ahead in, say, a farm field.
And, finally, learn to “think and fly outside the box”; the best landing field may not even be a “field.”
The NTSB report goes on to say, “the captain stated … that he thought that he had obtained green dot speed (best glide speed—Ed.) immediately after the bird strike.” It further states, “However, FDR data indicated that the airplane was below green dot speed,” finally concluding, “the captain’s difficulty maintaining his intended airspeed during the final approach resulted in high AOAs (angle of attacks—Ed.), which contributed to the difficulties in flaring the airplane, the high descent rate at touchdown, and the fuselage damage.”
While the captain of the Hudson crash may be regarded a “superpilot” by the layman, even the most perfect of flights are rife with errors, simply because the human pilot is just that—human. That is why we have two pilots up front, and also why automation has made aviation exponentially safer.
Put any pilot, no matter how well-trained and experienced, in a high stress emergency, and you will be guaranteed errors. The trick is to minimize those errors by eliminating the distractions and focusing on the primary task—flying the plane.
The NTSB acknowledges this challenge, stating: “During emergency situations, such as the accident event, pilots experience high levels of stress resulting from high workload, time pressure, and noise. Stress can lead to a phenomenon known as ‘tunnel vision,’or the narrowing of attention in which simple things can be overlooked.
The NTSB concludes the captain’s difficulty maintaining his intended airspeed during the final approach resulted, in part, from high workload, stress, and task saturation.”
In a two-crew environment, the PF (Pilot Flying) must avoid the distraction of bells and alarms, and trust the PM (Pilot Monitoring) to run the checklists. That being said, CRM (Crew Resource Management) dictates that the PF must be kept “in the loop” and is often required to verify certain aspects of the checklist, so will naturally be distracted.
For example, in 2010, Qantas Flight 32 (QF32), Captain Richard de Crespigny had to maintain control of the world’s largest airliner, an A380, after the Number Two engine exploded inflight, damaging all but one system. Shorting wires resulted in over 100 warnings, many of them false. (Part One / Part Two / Part Three)
For two excruciating hours, Captain de Crespigny had to hand fly the crippled plane and assist his First Officer as he sloughed through dozens of checklists, all the while with endless alarm bells ringing.
It appears that the PF in the Hudson accident, while distracted at times, was nevertheless able to maintain adequate control, sufficient for a favorable outcome.
Lesson: The pilot flying must always do just that: Fly the Plane.
Aviate—Navigate—Communicate, in that order. On any given flight, and especially in an emergency, you will make mistakes. You will be distracted by the emergency itself. Stay in the loop, and help your partner stay in the loop by using good CRM and communication skills. Do your best to shut out the noise and avoid tunnel vision.
And again, Rule Number One is always, Fly the plane.
Speaking of CRM, the NTSB report talks at length about this as a factor, concluding that the flight crewmembers’ CRM “contributed to their ability to maintain control of the airplane … and fly an approach that increased the survivability of the impact.”
The report states, “Both pilots indicated that CRM was integral to the success of the accident flight …. each had specific roles, knew what each other was doing, and interacted when necessary …. The captain stated that the US Airways CRM and TEM (Threat and Error Management—Ed.) training, which was integrated into all aspects of US Airways training … gave pilots the skills and tools needed to build a team … and work together.”
The report concludes, “CVR data indicate that the communication and coordination between the captain and first officer were excellent and professional after the bird strike.”
In my opinion, CRM is one of the greatest contributions to aviation safety in the past 30 years. The traditional maritime attitude of, “The Captain is God” has given way to the more enlightened, “the Captain respects his crew, and actively integrates their unique skills and experience into finding the best solution.” Due to this simple change in philosophy, untold lives have been saved.
Lesson: Study CRM. Study TEM. Study and practice good communication skills and crew coordination. A good place to start would be by reading Captain JD Marcellin’s excellent book on CRM, “The Pilot Factor.”
One of the biggest challenges for the crew was running the cumbersome “Dual Engine Failure Checklist.” Airbus had designed this checklist under the assumption that the failures would occur at cruise altitude, and the crew would have ample time to run the multipage list.
According to the NTSB, “the captain stated that when he called for the QRH, about 17 seconds after the bird strike, the first officer already had the checklist out.”
Fortunately, the FO was fresh out of training and was familiar with the Dual Failure checklist. Even so, the crew had no hope of sloughing through the Dual Failure tome that day. Indeed, one of the NTSB recommendations was that Airbus create an expedited checklist for dual failure at low altitude.
Despite the challenges and time constraints, however, the crew was able to work through much of the list, including attempting an engine relight. Unfortunately, the crew ran out of time to execute Part 2 of the Dual Engine Failure Checklist: preparing for ditching.
Lesson: Study your airplane’s manual backwards and forwards. The more familiar you are with it, the more efficiently you can execute checklists, and minimize distractions to flying.
The ditching, while survivable, was less than ideal. The NTSB concluded that the pilots were inadequately trained in ditching procedures. Moreover, the report criticized Airbus for assuming at least one engine running during a ditching, and stated, “Post-accident flight simulations indicated that attaining the Airbus ditching parameters without engine power is possible but highly unlikely without training.”
Lesson: Regardless of your level of flying experience, whether you’re a professional pilot or weekend warrior, never stop learning, and never stop training. Read anything you can on handling emergencies, such as ditching. Who knows when one little tidbit may save your life.
Captain de Crespigny of QF32, for example, said that any time he checks out on a new aircraft, he goes above and beyond the standard training curriculum and reads the maintenance manuals on the engines and systems he is operating. This diligence no doubt helped him save the day on QF32.
The evacuation and rescue is considered one of the best aspects of the crash. Despite several mechanical and situational challenges, the cabin crew acted quickly, efficiently, and smartly, working with what they had and improvising along the way. This quick thinking helped evacuate a full flight from a sinking airplane. Moreover, the captain and FO assisted in the evacuation, and even handed out life jackets to those outside without one.
Lesson: Pilots should take note of this exemplary example by the flight attendants. Innovating procedures on the fly in order to solve an issue, such as evacuating an airplane, comes from experience, training, foresight, and, above all, keeping a calm and cool head during a life-threatening emergency.
There are plenty many more lessons we can learn from this—or any—accident. But the key takeaways we have discussed here are:
- No pilot is perfect, but when the geese hit the fan blades, keep calm and fly the plane.
- Always practice emergency procedures, and always be thinking of your worst-case scenario.
- Learn to think and fly “outside the box.” Go for the sure thing, even if it’s less than ideal, rather than hoping for the best.
- Study and practice good CRM, TEM, and communication skills.
- Study your manuals, checklists, and procedures. Read anything you can get your hands on regarding emergencies.
- Never stop learning, never stop training.
- I say again, Keep calm and fly the plane.