Thursday Waypoints - Five Safety Lessons from "The Miracle on the Hudson"

Ten years ago this past Tuesday, Captain Chesley “Sully” Sullenberger, First Officer Jeffrey Skiles, and Flight Attendants Sheila Dail, Donna Dent, and Doreen Welsh were crew members aboard an Airbus A320 whose flight would unexpectedly end not far from its destination. Not long after departing New York’s LaGuardia Airport, USAir Flight 1549 would find itself on the surface of the Hudson River with all passengers and crew shaken, cold, and some injured, but alive after the successful ditching of an airliner just east of Midtown Manhattan. The “Miracle on the Hudson” was a feat of piloting and aircrew teamwork during an immensely challenging situation that resulted in an almost optimum outcome despite the endless possibilities for a different result.

As most now know, the flight struck birds at about 3,000 feet above the ground. The result of the bird strike was a complete loss of power to both of the aircraft’s engines at an altitude where it became a critical emergency that required immediate and decisive action. Over the next three and a half minutes, the crew attempted to find a feasible slice of asphalt upon which to put the aircraft. After considering returning to LaGuardia or perhaps an emergency landing at Teterboro (New Jersey)’s commuter airfield to east/southeast of the stricken aircraft, the crew reached the sobering conclusion that a landing on the Hudson River was the best alternative.

Despite the decade that has passed since the miracle landing and safe rescue of Flight 1549’s 155 passengers and crew, there are still some distinct safety lessons that organizations of all stripes can understand to help their safety education, training, and emergency response programs.

Technology designed to keep you safe may not work exactly the way you planned. According to the National Transportation Safety Board’s (NTSB) report (page 98) on the accident, just feet above touchdown on the Hudson, the airplane’s flight control computer entered a protection mode that prevented Captain Sullenberger from placing the nose of the aircraft up at the angle he wanted for touchdown on the water. This protection mode protocol was meant to prevent aircrew from maneuvering the aircraft in an unsafe manner and was not able to comprehend the events happening to the aircraft at that moment. This is not to say that the flight control computer’s protection mode was/is not useful, but technology – even that designed to foster safety – may be placed in unfamiliar situations for which it was not designed to operate.  

It is very difficult – sometimes almost impossible – to mitigate against every risk. About 14,000 bird strikes occur every year in the United States. Quite simply, birds and aircraft share the sky and although it would be helpful if the birds and airplanes simply stayed away from each other, birds are – and will be – a perpetual hazard to aircraft. While there are tools available that either attempt to keep birds away from airplanes or educate aviators on bird hazards in certain areas of the country, birds are a constant risk for all those who take to the sky. Like combustible dust in manufacturing or driving in general, risk mitigation planning may have some inherent limitations due to depth and breadth of the risk(s) but…       

…that does not mean you should not have a broad and diverse risk mitigation plan. The fundamentals of risk mitigation are such that a plan aims to reduce the chance of the risk’s occurrence and not the severity of the risk. The severity will always exist; an effective plan uses all available resources to reduce the exposure of humans and equipment to the risk. Tools, education, and training will always evolve to better address reducing exposure. Risk mitigation planning must similarly evolve to continue fostering risk mitigation mindsets that can address complex, unexpected problems.

Virtually minimal communicating during time-critical emergencies can be lifesaving. During the approximately three and a half minutes of Flight 1549’s time in the air, Captain Sullenberger would say just 65 words to air traffic control. Captain Sullenberger and First Officer Skiles would say just 245 words between each other during the event. Much of this communication brevity was thanks to standardized phrases and industry-specific jargon used to convey a wealth of information using as few words as possible and be understood by many. As part of any safety incident plan or emergency training, what does your plan have in place to convey information with as little verbiage as possible when the situation demands it? Are there standard phrases or key words to articulate the gravity of the situation, especially when time is critical?   

The “Human Element” is more impactful that you probably estimate. Though this received an extra layer of drama in Clint Eastwood’s movie about the flight, the impact of human reaction and decision making is a must for consideration in safety planning, safety training and education, and emergency action planning. The NTSB’s report (pages 49 – 50) revealed a mixed bag of results in aircraft simulator runs, with different aircrews, that replicated Flight 1549’s flight profile, but from different decision points in the flight. While it is impractical to account for every individual’s experience and decision making methodology when crafting safety and emergency response plans, the simple awareness that the “human element” is present in everyday situations is an essential building block in safety and emergency response plans and training.