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Chairman Deborah A.P. Hersman |
Good Morning. My name is Debbie Hersman and it is my privilege to serve as the Chairman of the National Transportation Safety Board. I would like to take a moment to introduce my colleagues: Vice Chairman Chris Hart, and Board Member Robert Sumwalt.
Welcome to the boardroom of the National Transportation Safety Board. Under the 1976 Government in the Sunshine Act, multi-member federal agencies conduct much of their business in open session. Therefore, Board meetings are often called "Sunshine" meetings. While the public is invited to observe the meeting, only the Board Members and NTSB staff will participate in today's discussions.
On January 15, 2009, our nation watched in awe as television networks brought us live coverage of US Airways Flight 1549's dramatic ditching near the heart of Midtown Manhattan - one of the world's most densely populated regions.
When it became clear that all 150 passengers and five crewmembers would be evacuated safely, America let out a collective sigh of relief. When the public heard more about the quick thinking and professionalism of Captain Sullenberger and his crew, the incident soon became known as the "Miracle on the Hudson."
And it truly was a miracle. The National Transportation Safety Board's investigation revealed that the conditions that led to the ultimate success of the ditching were no less improbable than the conditions that caused the crash in the first place.
Among these conditions:
- the incident occurred during the day in good visibility on calm water;
- the flight crew was very experienced and demonstrated excellent crew resource management;
- the plane was extended overwater equipped, even though this was not required for that particular flight; and
- the plane was ditched in an area immediately accessible to rescue vessels.
Once the birds and the airplane collided and the accident became inevitable, so many things went right. This is a great example of the professionalism of the crewmembers, air traffic controllers, and emergency responders who all played a role in preserving the safety of everyone aboard. Their heroism, along with a plane that was equipped with better safety features than required, along with favorable geographic and climatic conditions, paved the way for this miracle to take place.
Because the NTSB's job is to investigate accidents, we rarely have the chance to celebrate when things go right. We join the aviation community, the responders in New York and New Jersey and all Americans in honoring the uncommon heroism of the people who "just did their jobs," but who did them efficiently, and through their actions, brought a measure of pride to their professions.
There are many who will say -- the crew performed admirably, the plane was well-equipped, and all of the passengers survived. Why not leave it at that? What could be learned from an accident that will always be known as a "Miracle"?
I understand that sentiment, but it's simply not what we do at the NTSB. We are charged with making transportation safer and as heroic as the Hudson ditching was, we must not forget that it was the outcome of a perfect storm of circumstances. If any one of the favorable conditions I mentioned had been different - for example, if visibility had been poor; if the flight had simply met, rather than exceeded, safety equipment standards; if the incident took place over open water, where rescue vessels were not on hand; if even a single element had changed, the ditching could have ended not as a miracle but as a tragedy. The heroism of the flight crew was a necessary but not sufficient condition of the incident's successful outcome.
I know that some will wonder why the NTSB always looks at the glass as half empty? The answer is that our job is to do what we can to save lives and prevent injuries by challenging others to make improvements to procedures, equipment, and communications.
When our investigators looked at the facts we saw some stark realities:
- In our public hearing, experts testified that the population of large birds is on the rise. This aircraft encountered a flock of Canada Geese, which happens to be the large bird (over 4 lbs) most commonly involved in aircraft strikes. Between 1990 and 2008, there were 1,491 Canada Goose strikes in civil aviation in the US - so this type of event isn't unusual, this was just the most spectacular example of a bird strike resulting in an almost complete loss of thrust in both engines.
- We found that pilots are not trained, nor are aircraft certified, for low altitude ditchings without any available thrust.
- Although a 1985 NTSB study determined that at least 179 certificated airports in the US are located within 5 miles of a significant body of water and a 1996 FAA report found that 75% of large airports worldwide had at least one overwater approach, we found that life vests and life rafts are not required unless an aircraft is operating 50 miles from the nearest shoreline. The fact is there are no requirements for most domestic airplanes flying in and out of DC, Chicago, NY, Miami, Seattle, or LA to have life vests or life rafts - something that you cannot survive without for any significant length of time in cold water - and the water on January 15th was a frigid 41 degrees.
Our report today focuses on the lessons learned so that future crewmembers and every passenger will be able to benefit from what our team has uncovered over the last 16 months. Moments after the accident aircraft was ditched into the Hudson River - as the passengers and crew members were being evacuated to safety - the Safety Board began its work investigating the causes and circumstances of this accident.
On behalf of my fellow Board members and the men and women of the Safety Board, I extend my heartfelt appreciation to the countless individuals and organizations, on both sides of the Hudson River, who came together to support the rescue efforts that January afternoon or who otherwise provided invaluable assistance to our investigation. This includes the responders who were first on-scene, as well as the many local, state, and national organizations, and countless good Samaritans. To each of you, your assistance and expertise was significant. Thank you. I'd like to thank, as well, Dr. Dove and the entire staff of the Smithsonian Institute's Feather Identification Laboratory for its wildlife analysis.
As we begin today's Board meeting, I want to acknowledge the survivors of Flight 1549 - some who are with us in the Boardroom and others who may be watching the proceedings via webcast. While everyone is thankful that this accident did not result in lives lost, we recognize that some passengers were injured and that many passengers, and their families, are still recovering in the aftermath. Although the accident had a positive outcome, its impact was nonetheless significant. Rest assured that as we deliberate today, we will be thinking of everyone affected - to consider not only the many things that went well, but also the areas where we can do better. A few weeks ago, the NTSB staff submitted the accident report on Flight 1549 for the Board's consideration:
The Board Members have had the intervening weeks to study these documents. While we might have met with staff individually to discuss the draft, today is the first opportunity for all of the Board Members to meet together to discuss the issues contained in the draft report.
During this meeting, the Board Members will hear staff presentations addressing the primary issues identified in the investigation. The Board members will also solicit staff comments and explanations on many points. Once we have discussed the draft report, we will then consider the conclusions, probable cause determination, and specific safety recommendations proposed by staff.
Sometimes all or part of a draft conclusion, probable cause or recommendation is revised or rejected by the Members. This is because these are the Board's actual deliberations over the documents. That is the purpose of the Sunshine Act -- to provide the public with a window into the decision making process.
My fellow Board Members and I are dedicated to a thorough and objective investigation of every accident before the Board. The rules governing our participation require impartiality to ensure such objective inquiries. I want to note that Member Sumwalt flew as a pilot for US Airways for a number of years. Also, Vice Chairman Hart, while employed at the FAA, occasionally participated in safety meetings, forums, and training events alongside Captain Sullenberger.
We conferred with our Designated Agency Ethics Official and our General Counsel, and they have concluded that no conflict of interest and no reason for disqualification exists for either Board Member. As he made clear at the Public Hearing, Member Sumwalt no longer has business relationships with US Airways nor any financial interest in the company. Vice Chairman Hart has had only occasional contact with Captain Sullenberger, which do not create any concerns about his impartiality. Accordingly, all sitting Board Members are qualified to participate in these proceedings.
Approximately 30 minutes after this meeting, copies of the abstracts containing conclusions, probable cause, and recommendations approved by the Board can be obtained from the Board's Public Affairs Office, and will be placed on the Board's website.
