NTSB · Safety Recommendation
Safety Recommendation A-10-068
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Develop and validate comprehensive guidelines for emergency and abnormal checklist design and development. The guidelines should consider the order of critical items in the checklist (for example, starting the auxiliary power unit), the use of opt outs or gates to minimize the risk of flight crewmembers becoming stuck in an inappropriate checklist or portion of a checklist, the length of the checklist, the level of detail in the checklist, the time needed to complete the checklist, and the mental workload of the flight crew.
Safety Issue and Context
On January 15, 2009, about 1527 eastern standard time,1 US Airways flight 1549, an Airbus Industrie A320-214, N106US, experienced an almost total loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport (CLT), Charlotte, North Carolina, and had departed LGA about 2 minutes before the in-flight event occurred. The 150 passengers, including a lap-held child, and 5 crewmembers evacuated the airplane via the forward and overwing exits.
One flight attendant and four passengers received serious injuries, and the airplane was substantially damaged. The scheduled, domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Response History
July 18, 2012 · NTSB Correspondence · FAA
We disagree with the FAA that current guidance on checklist design available to operators and manufacturers in Information for Operators (InFO) memorandum 10002, “Industry Best Practices Reference List,” sufficiently addresses this recommendation, which we indicated in the letter that transmitted this recommendation to the FAA. Many of the references contained in the InFO are 15 or more years old, and the document does not discuss more recent and relevant work performed at the National Aeronautics and Space Administration’s Ames Research Center.
We also disagree that FAA Order 8900.1, “Flight Standards Information Management System,” contains sufficient guidance for FAA inspectors to use when approving an operator’s checklists and procedures. The FAA believes that Volume 3, Chapter 32, Section 1, Paragraph 3-3128, of this order, which defines “immediate action,” addresses this recommendation. Regarding other items, the FAA maintains that it cannot create a different checklist for every scenario presented to a pilot, and a pilot may be required to use critical thinking to decide when to abandon one checklist in favor of another that better meets the situation.
We reiterate the conclusion stated in our investigation report on the US Airways flight 1549 accident, and in the letter that transmitted this recommendation to the FAA, that (1) although the Engine Dual Failure checklist used by the crew did not fully apply to the accident event, it was the most applicable checklist the quick reference handbook contained for addressing the event and (2) the flight crew‘s decision to use this checklist was in accordance with US Airways procedures. This recommendation was issued because no other checklist existed that better met the situation.
The FAA stated that, after conducting a review of the guidance available to manufacturers, operators, and inspectors, it believes that the guidance and guidelines currently existing for emergency and abnormal checklist design are sufficient, and that neither the development of a new advisory circular (AC) nor the revision of an existing AC is necessary. The NTSB continues to believe, however, that our findings from the US Airways flight 1549 accident investigation contradict both the FAA’s findings and its position that it has effectively addressed this recommendation. Consequently, Safety Recommendation A-10-68 is classified CLOSED—UNACCEPTABLE ACTION.