Professionalism/Chesley Sullenberger and US Airways Flight 1549

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On January 15th, 2009, US Airways Flight 1549 struck a flock of geese and lost thrust in both engines, forcing a landing in the Hudson River mere minutes after takeoff. Despite the ditching, there were no fatalities thanks to the communication and decision making of the pilots, as well as the environment created by the FAA and US Airways.

Evacuation of US 1549 on the Hudson River


Background[edit]

Sullenberger & Skiles[edit]

Captain Chesley Sullenberger III began his aviation career flying gliders at the US Air Force Academy in 1969. Following graduation Sullenberger served as a fighter pilot from 1975 to 1980 where he rose in rank to become a flight leader and training officer. Sullenberger then transitioned to commercial aviation, being hired by Pacific Southwest Airlines, which would later be acquired by US Airways. At the time of the incident, Sullenberger had recorded nearly 20,000 hours in the cockpit with almost 5,000 hours in command of the Airbus A320, the make of Flight 1549. [1]

First Officer Jeff Skiles was also a seasoned pilot with nearly 16,000 hours logged in the cockpit. Skiles worked his way up the civilian aviation ladder from flight instructor, to cargo, to regional transport until he was hired by US Airways in 1986. [2] At the time of the incident, Skiles held FAA ratings for the Airbus A320, Boeing 737, and Folkker 100 though he had only recently completed his training for the A320, accumulating just 37 hours. His check airman noted he was a very skilled pilot. [1]

Bird Strikes in Aviation[edit]

Wildlife Hazard Management at LaGuardia[edit]

LaGuardia (LGA) maintains a wildlife hazard management plan as part of its FAA certification to operate as a commercial airport. The plan in effect at the time of the US Airways incident was developed in 2002 by the USDA, Animal and Plant Health Inspection Service (APHIS), and Wildlife Services. This plan focused on excluding, dispersing, or removing natural hazards from the airfield. To accomplish this, LGA drained all observed standing water, deterred bird perching, prohibited feeding wildlife, covered trash containers, and sponsored studies to identify grasses that deter waterfowl. LGA personnel also helped manage the Canadian goose population on Rikers Islands, which is situated just off the end of the runways. The US Airways bird strike occurred well outside the altitude and distance parameters of the LGA wildlife hazard management plan.

Engine Certification Requirements[edit]

The engines on US Airways 1549 were certified for the current bird ingestion standards of 1996 which required the engine to not catch fire, burst, or be unable to shut down if striking a single large bird (4 lbs). If ingesting smaller birds (up to 2.5 lbs), the engines were to the function for at least twenty minutes and not lose more than 25% of thrust. By 2007 certification standards required engines to produce some thrust for at least twenty minutes after striking a flock of large birds (up to 5.5 lbs). However, engines previously certified did not have to meet the new standards. The engines on US Airways 1549 were not tested in such conditions, and the size of the average Canadian goose (8.25 lbs) exceeds the current certifications.

Landing in the Hudson[edit]

Two minutes and seventeen seconds into the flight, US Airways 1549 struck a flock of Canadian geese at an altitude of 2,818 feet and 4.5 miles from LGA, disabling both engines. The aircraft continued to climb for the next 20 seconds peaking at 3,060 feet. Sullenberger immediately took command of the aircraft from Skiles and began turning back towards LGA. Due to the low altitude Sullenberger was unsure if he could reach the runway and did not want to risk crashing into a populated area. He began paralleling the Hudson and requested a possible landing at Teterboro, which he quickly determined he couldn't make. Sullenberger informed Air Traffic Control that they would be ditching in the Hudson and turned he complete attention to the task. Three and a half minutes after the strike Sullenberger ditched the aircraft into the Hudson with level wings and pitched up near ferry terminals. NTSB Board Member Kitty Higgins stated it "has to go down the most successful ditching in aviation history."[3]

Communication[edit]

All subsequent quotes from Sullenberger, Skiles, or the controller are from the NTSB's report of the contents of the Cockpit Voice Recorder[4].

Intracockpit[edit]

Below are quotes from the conversation between Sullenberger and Skiles.

Before Takeoff

Sullenberger Your brakes, your aircraft.
Skiles My aircraft.

This clear communication shows who has control of the aircraft. Both pilots knew their roles.

Takeoff

Sullenberger And what a view of the Hudson today.
Skiles Yeah.
Skiles Flaps up please, after takeoff checklist.
Sullenberger Flaps up.
Sullenberger After takeoff checklist complete.
Sullenberger Birds.
Skiles Whoa.

Both pilots verified all plane conditions with each other. Things were going according to plan until birds entered the engines. Sullenberger's remark on the Hudson foreshadowed the result of this problem.

Exchanging Flight Controls

Sullenberger My aircraft.
Skiles Your aircraft.
Sullenberger Get the QRH [quick reference handbook]...loss of thrust on both engines.

The phrase "my aircraft" was used before during takeoff. It asserts control of the situation and demonstrates who's in charge. This time, Sullenberger took over and Skiles was in charge of monitoring the conditions and checking the QRH.

Response to Incident

Skiles If fuel remaining, engine mode selector, ignition.
Sullenberger Ignition.
Skiles Thrust levers confirm idle.
Sullenberger Idle.
Skiles Airspeed optimum relight. Three hundred Knots. We don’t have that.
Sullenberger We don’t.

Both pilots verified conditions of plane. This helped Sullenberger make a decision.

Air to Ground[edit]

Below are samples from conversations between the pilots and LaGaurdia Departure Control.


Plane Crash

Sullenberger Mayday mayday mayday. Uh this is uh Cactus fifteen fourty nine hit birds, we've lost thrust in bothengines, we're turning back to LaGuardia.
Departure Controller Cactus fifteen fourty nine, if we can get it for you do you want to try to land runway one three?
Sullenberger We're unable. We may end up in the Hudson.
Departure Controller Cactus fifteen fourty nine turn right two eight zero, you can land runway one at Teterboro.
Sullenberger We can't do it.
Sullenberger We're gonna be in the Hudson.

The accident ruined the engines and forced Sullenberger to land quickly. The LaGaurdia Departure Control freed up runways at LaGuardia and Teteroboro, but Sullenberger quickly decided that it was safer to land in the Hudson. His decision was based on his previous conversations with Skiles, who analyzed the state of the aircraft after impact. Constant communication between the two pilots was why Sullenberger successfully landed the plane with no casualties.

Radio Silence

Departure Controller Cactus fifteen forty nine radar contact is lost you also got Newark airport off your two o'clock in about seven miles.
Sullenberger doesn't respond
Departure Controller Cactus fifteen twenty nine uh, you still on?
No response
Departure Controller Cactus fifteen twenty nine if you can uh....you got uh runway uh two nine available at Newark. It'll be two o'clock and seven miles.
No response

After informing the controller about the situation, Sullenberger breaks contact. Communicating effectively is more important than constantly communicating. During the intervals of silence, Sullenberger and Skiles are actively talking and attempting to solve the problem, thus effectively prioritizing their time.

Decision-making[edit]

Crew Resource Management[edit]

Crew Resource Management (CRM) is an aviation technique designed to improve communication, teamwork, and decision-making in the cockpit. The First Officer is encouraged to speak up whenever he notices a problem without undermining the captain’s authority. Prior to its implementation, human error caused over 70 percent of air crashes [5]. CRM emphasizes the call-and-response communication demonstrated by Sullenberger and Skiles, to facilitate quick decision making. While completing the loss of thrust checklist, Skiles states "airspeed optimum relight. Three hundred knots. We don't have that,” which Sullenberger simply confirms "we don’t," thus noting the issue and preparing for an unpowered ditching. While trying to restart the engines, Skiles remarks "Is that all the power you got? (wanna) [try] number one? Or we got power on number one,” to which Sullenberger responds "Go ahead, try number one." Sullenberger directly asks for Skiles' input 22 seconds before landing "got any ideas?", though Skiles was unable to come up with anything: "actually not."

While Sullenberger and Skiles were familiar with each other, the CRM techniques enabled them to work not as two individuals, but as a team to determine the best course of action to minimize casualties.

Diagnosis[edit]

Following the bird strike, both pilots quickly diagnosed the situation to determine the best course of action. Just twenty-one seconds after impact, and eight after taking control, Sullenberger began to turn back towards Laguardia, while Skiles attempted to restart the engines. Roughly thirty seconds later, Sullenberger had assessed the situation and concluded that reaching LaGuardia was unlikely saying "we're unable. We may end up in the Hudson." In less than a minute, Sullenberger identified a water landing as the best option, despite available runways.

During this time Skiles began the loss of thrust checklist, which included engine restart procedures. Once it was clear the engines wouldn’t fully relight, Skiles prepped the plane for a water ditching. He deployed the flaps to slow the aircraft and called out speed and altitude updates to Sullenberger. The two quickly analyzed and attempt to correct the problems before identifying the best possible response. Airbus, after extensive simulation, stated that "although an emergency return to La Guardia Runway 13 was technically feasible from an aircraft flight performance point of view, the emergency landing on the Hudson seems the most appropriate decision.” [6]

Effectiveness of the system[edit]

Procedure[edit]

As crucial as the pilots were to the successful ditching, the procedures in place were equally important. US Airways’ CRM clearly defined pilots’ roles. Although Skiles was initially the pilot flying, he immediately ceded authority to Sullenberger after the incident. The call-and-response, "my aircraft," "your aircraft," was a verbal affirmation procedure known as Positive Exchange of Flight Controls[7]. This communication ensures that only one pilot is actively flying. From training, such communication is encouraged for all interactions to remove ambiguities. Although Sullenberger took command, there was no animosity or reluctance from Skiles, who acknowledged Sullenberger's authority and experience.

Immediately after taking control, Sullenberger instructed Skiles to "get the QRH." The QRH (Quick Reference Handbook) details checklists for various situations an aircraft type may encounter and is intended to assist pilots during emergencies[8]. Following the strike, Skiles focused on calling out and performing the full loss of thrust checklist from the QRH. Although only marginally successful, the procedure gave confidence to their decisions, and if the engines were less damaged may have helped avoid a ditching. Ditching is another such procedure, but Sullenberger was experienced enough to not need the QRH for instructions.

Autonomy[edit]

While the pilots had clearly defined roles and different levels of authority, there was no sense of authoritarianism. Sullenberger was clearly in charge, but he did not belittle Skiles or otherwise trivialize his thoughts. This allowed the two pilots to work autonomously, despite the difference in authority.

Likewise, the controller was clearly apprehensive about the situation when the crew stopped responding ("Cactus fifteen twenty nine uh, you still on?”), but he did not push the pilots or get upset at their lack of a response. Instead, despite losing radar he continued to offer suggestions and advice, "you also got Newark airport off your two o'clock in about seven miles." In a cockpit already saturated with various warnings and alarms, the controller’s ability to stay calm helped prevent the situation from becoming more difficult to manage.

Implications for Professionalism[edit]

The "Miracle on the Hudson" was made possible by the pilots’ quick thinking, active communication, and a system designed to promote teamwork. As Sullenberger and Skiles showed, open communication helped avert disaster. Although Sullenberger had the ultimate authority, he sought input from Skiles in a cooperative manner to successfully ditch the aircraft. This enabled Skiles to speak up if need be and act as a check for Sullenberger's decisions.

However, the professional environment must be conducive to such a culture. The pilots’ coordination was aided by the CRM procedures at US Airways. Further, air traffic control was supportive despite having little information about the state of the aircraft. These procedures were a product of appropriate regulations by the FAA.

These qualities are not limited to aviation and are useful in a broad range of fields. As a professional, the ability to quickly analyze a situation and decide on a course of action is imperative. When a problem occurs, a professional must react rapidly and with conviction to avoid disaster. Of course, "quickly" is a relative term for the situation. For a pilot, "quickly" can be measured in seconds. In the case of a software bug, which caused the Therac-25 incident, that might mean a few days. At a nuclear reactor such as Chernobyl or Three Mile Island, it could mean hours. While the time scale may differ, the professional’s ability to quickly and effectively respond based on their expertise can help avert disaster.

References[edit]