CABINsafety
By Wayne Rosenkrans Survival on the Hudson Inattention to safety briefings, life vests and life lines increased risks after US Airways Flight 1549 touched down.
he public’s intuition that “fortuitous” cir- images of people without life vests or life lines cumstances contributed to all occupants standing on the wings, however, contain a less surviving the January 2009 ditching of an obvious message about shared responsibility for Airbus A320 in the Hudson River has been safety aboard aircraft. Rather than dwell on the Tseconded by the final accident report of the U.S. unusually favorable circumstances, the NTSB National Transportation Safety Board (NTSB) took the opportunity to redirect the attention on US Airways Flight 1549.1 Now-famous of government, the airline industry and the
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traveling public to the critical survival factors the Hudson River2 rather than attempting to land they do control. at an airport provided the highest probability that For example, noting that “only about 10 pas- the accident would be survivable. … Contribut- sengers [of 150] retrieved life vests themselves ing to the survivability of the accident was the after impact and evacuated with them” and that decision making of the flight crewmembers and only 77 retrieved flotation-type seat cushions, the their crew resource management during the ac- survival factors sections of the report essentially cident sequence; the fortuitous use of an airplane said that crewmembers and passengers disre- that was equipped for an extended-overwater gard at their peril the life-saving knowledge and [EOW]3 flight, including the availability of equipment provided. “The NTSB notes that, after the forward slide/rafts, even though it was not exiting the airplane through the overwing exits, required to be so equipped; the performance of at least nine passengers unintentionally fell into the cabin crewmembers while expediting the the water from the wings,” the report said. evacuation of the airplane; and the proximity of Several explanations were offered by investi- the emergency responders to the accident site gators. “Although the accident flight attendants and their immediate and appropriate response to did not command passengers to don their life the accident,” the report said. vests before the water impact, two passengers The lessons learned reflected the importance realized that they would be landing in water of leaving as little to chance as possible in prepa- and retrieved and donned their life vests before rations to survive an aircraft accident. “The impact, and a third passenger attempted to investigation revealed that the success of this retrieve his life vest but was unable to do so and, ditching mostly resulted from a series of fortu- therefore, abandoned his attempt,” the report said. itous circumstances, including that the ditching “Many passengers reported that their immediate occurred in good visibility conditions on calm concern after the water impact was to evacuate water and was executed by a very experienced as quickly as possible, that they forgot about or flight crew. … “The investigation revealed sever- were unaware that a life vest was under their seat, al areas where safety improvements are needed,” or that they did not want to delay their egress to the report said. get one. Other passengers stated that they wanted The accident airplane was one of 20 EOW- to retrieve their life vest but could not remember equipped A320s — among the airline’s fleet of where it was stowed.” In all, 101 life vests were left 75 A320s. Each of four slide/rafts was rated to stowed under passenger seats. carry 44 people and had an overload capacity of © AP Photo/Alexandre Valerio The accident analysis does not devalue the 55. Also aboard, but not counted toward EOW positive outcomes of the captain’s judgment, the equipment, were two off-wing ramp/slides, one Close proximity cabin crew’s performance or the passengers’ or- at each pair of overwing exits. of personnel and derly behavior, and the report notes, “The NTSB “The accident airplane had the statements, Survival on the Hudson vessels capable concludes that the captain’s decision to ditch on ‘Life Vest Under Your Seat’ and ‘Bottom Cushion of rescuing Flight Usable for Flotation,’ printed on the [overhead] 1549 occupants passenger service units (next to the reading light overcame the switches) above each row of seats,” the report serious threat of cold said. The four life lines were designed to be water immersion. retrieved after ditching from an overhead bin, attached to top corners of door frames on both sides of the airplane fuselage and anchored to a designated point on top of each wing. The importance of these items becomes clear by considering that only two detachable slide/
U.S. National Transportation Safety Board Board Safety Transportation National U.S. courtesy(Photo of passenger 4C) rafts were available for Flight 1549 occupants
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— at door 1L and door touchdown at about 1527 local time. The captain 1R — with a combined opened the flight deck door and commanded an capacity to carry 110 evacuation by speaking directly to the forward of the 155 occupants flight attendants and passengers. He observed if the airplane had then that the evacuation already had begun. sunk before they were “The water in the back of the airplane rose rescued. The NTSB quickly, which, in addition to improvised determined that about commands from flight attendant B to ‘go over 64 occupants were res- the seats,’ resulted in numerous passengers cued from these slide/ climbing forward over the seatbacks to reach a rafts, while about 87 usable exit,” the report said. “However, some aft were rescued from the passengers remained in the aisle queue to the wings and off-wing overwing exits. Many of these passengers noted ramp/slides. that, when they arrived at the [overwing] exits, the wings were crowded and people were exiting Survival Scenario slowly. They also reported that the aisle forward Loss of thrust in both of the overwing exits was completely clear and engines prompted that the flight attendants were calling for pas- the captain of Flight sengers to come forward to the slide/rafts.” 1549 to commit to The NTSB estimated the evacuation sequence the ditching as the and timing: The left overwing exits were opened safest course of action by passengers at 1530:58, contrary to the airline’s despite its necessitat- ditching procedures, and the first passenger ing an evacuation in subsequently exited; flight attendant A opened harsh winter tempera- door 1L to its locked-open position against the tures. The flight crew fuselage at 1531:06, and no water entered, but later said that its top this crewmember had to operate the manual priority then was to inflation handle to deploy the slide/raft because touch down with a the automatic system appeared to have failed; “survivable sink rate.” flight attendant C opened door 1R at 1531:11, au- Analysis of the digital tomatically causing full deployment of the slide/ flight data recorder raft at 1531:16; one passenger jumped into the showed that “the water from door 1L at 1531:23 before its slide/raft airplane touched down began to inflate; the slide/raft at door 1L began to on the Hudson River inflate at 1531:26; the first vessel arrived on scene at an airspeed of 125 at 1534:40; and the last vessel departed the scene kt calibrated airspeed after rescuing the last passengers from the left with a pitch angle of off-wing ramp/slide at 1554:43. 9.5 degrees, [a descent Eight of the passengers exited the aircraft, re- Top, one passenger jumped into the 41º F (5º C) rate of 12.5 fps] and a entered the aircraft to obtain one or more life vests, Hudson River from door 1L before the slide/ right roll angle of 0.4 then exited from a different door. Flight attendant raft was deployed manually; bottom, overwing- degree,” the report said. B did not become aware of a serious injury to her exit life line–attachment points were unused, The evacuation left shin until aboard the door 1R slide/raft. and nine passengers fell into the water. began within seconds “A review of passenger exit usage indicated after the airplane’s that, in general, passengers from the forward and rapid deceleration on mid parts of the cabin evacuated through the exit the river’s surface after closest to their seats,” the report said. “However, Board Safety Transportation National U.S. Photos:
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aft-seated passengers indicated that water im- rescue boat. Personnel from New York Waterway mediately entered the aft area of the airplane after (NY WW) also responded to the accident al- impact and that the water rose to the level of their though they were not part of the emergency plan. seat pans within seconds; therefore, they were not “The airplane was ditched on the Hudson able to exit from their closest exits because these River near the NY WW Port Imperial Ferry exits were no longer usable.” Terminal in Weehawken, New Jersey,” the report Several safety equipment irregularities oc- said. “Many NY WW ferries were operating over curred, affecting crew actions and passenger established routes in the local waterway, and behavior. “Flight attendant C … stated that the ferry captains either witnessed the accident door 1R started to close during the evacuation, or were notified about it by the director of ferry intruding about 12 in [30 cm] into the doorway operations. Seven NY WW vessels responded to and impinging on the slide/raft,” the report said. the accident and recovered occupants.” “She stated that she was concerned that the slide/ The first responders considered the winter raft would get punctured, so she assigned an weather conditions a serious risk to survival. Top, the detachable ‘able-bodied’ man to hold the door to keep it off “The post-crash environment, which included a door 2L slide/raft of the slide/raft.” 41° F [5° C] water temperature and a 2° F [mi- was one of two One female passenger with a lap-held child nus 17° C] wind chill factor, and a lack of suf- unavailable due received assistance from a fellow passenger ficient slide/rafts (resulting from water entering to aft water entry; shortly before the touchdown. “When the the aft fuselage) posed an immediate threat to bottom, a manual captain [announced] ‘Brace for impact,’ the the occupants’ lives,” the report said. “Although inflation handle and male passenger in [seat] 19F offered to brace her the airplane continued to float for some time, a ditching release [nine-month-old] son for impact,” the report many of the passengers who evacuated onto the handle were found in said. “The lap-held child’s mother [in seat 19E] wings were exposed to water up to their waists the forward galley. stated that she thought the passenger in 19F within two minutes.” ‘knew what he was doing,’ and she gave her son The Port Impe- to him.” None of these passengers was injured. rial Ferry Terminal All three flight attendants described the was designated as the evacuation process as relatively orderly and time- central triage site; ly. The captain and first officer said that while nevertheless, captains assisting the cabin crew with the evacuation, they of vessels dropped observed passengers without life vests outside the off the Flight 1549 airplane. “[The captain and first officer] obtained occupants at the clos- some life vests from under the passenger seats est locations in New in the cabin and passed them out to passengers York and New Jersey outside of the airplane,” the report said. The flight because the aircraft crew also conducted the final cabin inspection to was drifting and some ensure no passengers had been left, then exited passengers were wet onto the slide/raft at door 1L. and at risk of cold- induced injury. Emergency Response Among the 45 Air traffic control tower personnel at LaGuardia passengers and five Airport activated the area’s emergency alert noti- crewmembers trans- fication system via its crash telephone at 1528:53. ported to hospitals, This immediately notified numerous agencies flight attendant B to respond with predetermined personnel and and two passengers equipment according to the LaGuardia Airport had sustained serious emergency plan. The airport dispatched one injuries. One of those www.flightsafety.org | AeroSafetyWorld | July 2010 | 27 CABINsafety
passengers was admit- “US Airways’ FAA-accepted In-Flight Emergency ted to a hospital for Manual followed [FAA] advisory circular guidance treatment of hypo- and specified that, if the airplane is equipped with thermia. The other both flotation seat cushions and life vests, flight Top, life vest storage pouches were was treated for a frac- attendants should brief passengers on both types beneath economy-class seats on Flight 1549; tured xiphoid process, of equipment, including the location and use of life bottom, the FAA had tested four underseat an “ossified extension” vests,” the report said. “The cockpit voice recorder stowage configurations. of the lower part of recorded flight attendant B orally brief the location the sternum. “Two and use of the flotation seat cushions; however, passengers not initially it did not record her brief the location of or the transported to a hos- donning procedures for life vests. … A life vest pital later furnished demonstration was not required because the flight medical records to the was not an EOW operation.” NTSB showing that one had suffered a Braced But Injured fractured left shoulder The safety information cards also provided U.S. National Transportation Safety Board Safety Transportation National U.S. and the other a frac- instructions on the operation of the emergency tured right shoulder,” exits and depicted passenger brace positions the report said. “Flight that were similar to FAA guidance on brace attendant B sustained positions. Three of four seriously injured pas- a V-shaped, 12-cm- sengers were hurt during the airplane’s impact long 5-cm-deep [5-in with the water. by 2-in] laceration to “The two female passengers who sustained her lower left leg that very similar shoulder fractures both described required surgery to assuming similar brace positions, putting their close.” The cause of arms on the seat in front of them and leaning flight attendant B’s lac- over,” the report said. “They also stated that they eration was a vertical felt that their injuries were caused during the im- beam that punctured pact when their arms were driven back into their the cabin floor in front shoulders as they were thrown forward into the of her jump seat about seats in front of them. The brace positions they 11 in (28 cm) forward described were similar to the one depicted on the of the seat pan. US Airways safety information card.” Administration Aviation Federal U.S. The passenger seats on the accident airplane Life Vest Awareness were 16-g compatible seats. The NTSB noted that Passenger interviews indicated that about 70 new seats have a nonbreakover seatback design, percent of the passengers did not watch any of which minimizes head movement and body ac- the preflight safety briefing. “The most fre- celeration before striking the seatback from behind, quently cited reason for [inattention] was that resulting in less serious head injuries. the passengers flew frequently and were familiar “Guidance in [FAA Advisory Circular 121- with the equipment on the airplane, making 24C] did not take into consideration the effects them complacent,” the report said. of striking seats that do not have the breakover Flight 1549 passengers could learn about feature because research on this issue has not the availability of life vests only from the safety been conducted,” the report said. “The NTSB information cards in seatback pockets or the concludes that … in this accident, the FAA- overhead statements, although some assumed recommended brace position might have contrib- that all commercial passenger jets carry life vests. uted to the shoulder fractures of two passengers.”
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Unused Life Vests quick-release girts to enable occupants to free Overall, 19 passengers attempted to obtain a life the ramp/slides from the sinking airplane for vest from under a seat, and 10 of them reported flotation out of the water or handholds. “Some difficulties retrieving it. “Of those 10 passengers, passengers immediately recognized their useful- only three were persistent enough to eventu- ness and boarded the ramp/slides to get out of ally obtain the life vest; the other seven either the water,” the report said. “Eventually, about ‘Most of the retrieved a flotation seat cushion or abandoned eight passengers succeeded in boarding the left the idea of retrieving flotation equipment alto- off-wing slide and about 21 passengers, includ- passengers who gether,” the report said. ing the lap-held child, succeeded in boarding had life vests either Most passengers who attempted to don or the right off-wing ramp/slide.” donned life vests already were seated in a slide/ Summary statements in the report encour- struggled with the raft, ramp/slide or standing on a wing. “Of the aged the government and airline industry to re- estimated 33 passengers who reported eventu- consider past NTSB recommendations validated strap or chose not to ally having a life vest, only four confirmed that by facts of this event. “The circumstances of they were able to complete the donning process this accident demonstrate that even a non-EOW secure it at all for a by securing the waist strap themselves,” the re- flight can be ditched, resulting in significant variety of reasons.’ port said. “Most of the passengers who had life fuselage breaching,” the report said. “Therefore, vests either struggled with the strap or chose not all passengers, regardless of whether or not their to secure it at all for a variety of reasons.” flight is an EOW operation, need to be provided Airline industry safety standards for overwa- with adequate safety equipment to ensure their ter flight have not anticipated scenarios in which greatest opportunity for survival if a ditching or passengers exit onto the wings after a ditching, other water-related event occurs.” the report said. “Each overwing exit pair [in To read an enhanced version of this story, go to this case] was equipped with an automatically