Docket No. SA-532 Exhibit No. 6-A NATIONAL TRANSPORTATION SAFETY BOARD Washington, D.C. Survival Factors Group Chairman’s Factual Report (186 Pages) NATIONAL TRANSPORTATION SAFETY BOARD Office of Aviation Safety Washington, DC 20594 SURVIVAL FACTORS GROUP CHAIRMAN’S FACTUAL REPORT May 22, 2009 I. ACCIDENT Operator : US Airways, Inc. Airplane : Airbus A320-214 [N106US] MSN 1044 Location : Weehawken, NJ Date : January 15, 2009 Time : 1527 eastern standard time1 NTSB # : DCA09MA026 II. SURVIVAL FACTORS GROUP2 Group Chairman : Jason T. Fedok National Transportation Safety Board Washington, DC Member : David Lefrancq Airbus Toulouse, France Member : Barrington Johnson Association of Flight Attendants Charlotte, NC Member : Dr. Didier Delaitre Bureau d’Enquetes et d’Analyses Paris, France Member : Mark James Federal Aviation Administration Kansas City, MO Member : Brenda Pitts Federal Aviation Administration Garden City, NJ 1 All times are reported in eastern standard time unless otherwise noted. 2 Not all group members were present for all activities. 1 Member : John Shelden Federal Aviation Administration Renton, WA Member : Bob Hemphill US Airways, Inc. Phoenix, AZ III. SUMMARY On January 15, 2009, about 1527 eastern standard time (EST), US Airways flight 1549, an Airbus A320-214, registration N106US, suffered bird ingestion into both engines, lost engine thrust, and landed in the Hudson River following take off from New York City's LaGuardia Airport (LGA). The scheduled, domestic passenger flight, operated under the provisions of Title 14 CFR Part 121, was en route to Charlotte Douglas International Airport (CLT) in Charlotte, North Carolina. The 150 passengers and 5 crewmembers evacuated the airplane successfully. One flight attendant and four passengers were seriously injured. IV. DETAILS OF THE INVESTIGATION 1.0 Airplane Configuration The airplane was configured with 12 first class passenger seats, 138 economy class passenger seats, two cockpit flight crew seats, two cockpit observer seats, and five retractable, flight attendant jumpseats. (Two aft-facing seats were wall-mounted at door 1L, a forward-facing, bulkhead-mounted “direct view” jumpseat was in the aft aisle, and an aft-facing jumpseat was wall-mounted on each side of the aft galley.) See Figure 1. The accident airplane was equipped as an Extended Overwater (EOW) airplane. The following table compares the ditching equipment carried by EOW vs. non-EOW US Airways A320s: EOW A320 (20 in fleet) Non-EOW A320 (55 in fleet) • Crew life vests at every jumpseat • Crew life vests at every jumpseat location location • Passenger life vests at every seat for • No passengers life vests primary passenger flotation • Seat cushions for auxiliary • Seat cushions for primary passenger passenger flotation flotation • 10 infant life vests • 10 infant life vests • 2 ELTs • 2 ELTs • 4 slide/rafts • 4 slides (detachable) • 4 survival kits • No survival kits • 4 life lines • 4 life lines Table 1. US Airways A320 fleet information 2 Figure 1. Cabin configuration of N106US 2.0 Cabin Crew Information 2.1 Cabin Crew Training Summary Name and Position Initial Initial Last FAA Ground EOW Recurrent Certificate Training Training Training Number Donna Dent – F/A ‘A’ 6/22/82 8/20/90 1/31/08 2997383 Doreen Welsh – F/A ‘B’ 9/15/70 9/18/89 7/17/08 3002558 Sheila Dail – F/A ‘C’ 2/27/80 10/17/89 1/31/08 2997210 Table 2. Cabin crew training summary 3 2.2 Cabin Crew Statements Cabin crew statements were requested but not obtained from the flight attendants by US Airways until mid-April 2009. They are included as Attachment 1. 2.3 Cabin Crew Interviews Flight Attendant ‘A’ Age: 51 Hgt: 5’7 ¾” Wgt: 145 lbs. Aft-facing forward jumpseat (outboard seat) Jason Fedok (NTSB), Brenda Pitts (FAA), Barrington Johnson (AFA), Bob Hemphill (US Airways), and David Lefrancq (Airbus) interviewed flight attendant (F/A) A on January 16, 2009. Attorney Dane Jacques was present as the interviewee’s personal representative. The flight was the last leg of a four day trip. The flight was scheduled to depart for Charlotte and they were headed home. The flight attendants were based in CLT. An elderly woman in a wheelchair preboarded.3 There was a lap child on the flight.4 Boarding was routine. There were six “chairmen” (frequent flyers) in first class who she knew were seasoned travelers. There were two non-revenue “jumpseat” riders. One female American Airlines pilot was seated in 3D. The other pilot was a “strong man” who was seated in 6E. He was “incredible” and helped a lot during the evacuation. The airplane pushed back from the gate on time. There was a little delay before the airplane began to move. Taxi was normal. There was a manual safety demonstration. They did not demonstrate the life vests because it was not an overwater flight. The announcement for takeoff was made. She pressed the cabin ready light. A second announcement was made for takeoff and she checked the cabin ready light a second time. The airplane took off and on climbout she heard a loud “thud.” It immediately got “very quiet.” All engine noise stopped except that she thought she might have heard the fans still rotating. (She demonstrated the sound it made by clinking on a glass with her fingernails.) Flight attendant ‘C’ asked her, “what was that?” Flight attendant ‘A’ overheard a passenger in first class say something about a bird and told F/A ‘C’ that they may have had a bird strike. It was so quiet that the flight attendants could hear each other, even though they were whispering. There was a “burning electrical smell” in the cabin. Flight attendant ‘C’ told her that she saw “smoke” or “haze” in the back of the cabin. Flight attendant ‘A’ was behind a solid partition (without window) and could not see far into the cabin. She saw passengers on the right side of first class looking out the windows. Flight attendant ‘C’ tried to calm a male passenger in seat 1D who appeared panicked by telling him to “breathe, just breathe.” 3 She did not provide the woman with a special briefing. 4 She believed the young boy was in row 19. She did not see him during the evacuation. 4 Flight attendant ‘A’ did not feel the airplane turn but had the sensation that the airplane was descending rapidly. It was “too quiet.” She was hoping they were returning to the airport. Flight attendant ‘C’ said she saw F/A ‘B’ motioning in the aft cabin and attempted to contact her via the interphone but the call did not go through so flight attendant ‘C’ hung the handset back up. Flight attendant ‘A’ commented that she believed the design of the buttons and “zones” on the phone were unnecessarily complicated. It seemed like “forever” but the captain eventually made a public address (P/A) announcement “brace for impact.” Flight attendant ‘C’ asked her, “what did he say?” Flight attendant ‘A’ confirmed he said “brace for impact.” They both were already in their brace positions and began shouting the commands, “brace, brace, heads down, stay down!” They repeated those commands continuously through impact. Flight attendant ‘A’ described a “really hard landing” followed by a “gradual deceleration.” The captain made a P/A announcement, “evacuate!” There were no other instructions from the flight deck. She had no difficulty releasing her restraints and started to shout the evacuation commands, “leave belongings, come this way!” Flight attendant ‘A’ went to assess door 1L and realized the airplane was still moving. She shouted to F/A ‘C,’ “wait, we are still moving!” She looked out the window and only then realized they were in the water. She told F/A ‘C’ that “we have water on this side.” Flight attendant ‘A’ held the assist handle and opened door 1L. Water did not come in the door. She was expecting to see the slide/raft inflate automatically, but it did not. She pulled the manual inflation handle and the slide/raft inflated normally. Regardless of whether the slide/raft inflated or not, she stated that pulling the manual inflation handle was part of their procedures and they were taught to do that in training. She remembered having to “put a lot into it to get the door to lock against the fuselage.” She started to shout commands “come this way, don life vest!” She got a good flow going and used her protected position on the cockpit side of the doorway. The passengers exited in a single line. Most of them sat and “scooted” into the slide/raft. A lot of passengers had seat cushions but a lot had nothing at all. One woman came to the door with a vest out of its pouch. She asked her “what do I do with this?” F/A ‘A’ put the vest over her head and sent her out the door. When the flow stopped she moved inboard and grabbed the jumpseat shoulder harnesses and yelled commands down the aisle. She did this because she felt the passengers “needed to see us.” The evacuation was orderly, quick, and quiet. No passengers pushed. There were no problems with carry-on baggage. There were no signs of any damage in the airplane. When passengers boarded the raft there was no build up of passengers by door 1L. She could not estimate the proportion of people wearing life vests or carrying seat cushions. At some point during the evacuation she grabbed two life vests from beneath the jumpseat and passed one to F/A ‘C.’5 Flight attendant ‘A’ noticed an injured man in the 5 She stated that the crew life vest was easy to open. She inflated the life vest in the slide/raft once she was outside the airplane.