Trainers tell us there is much to be learned from aircraft accidents and incidents. Getting airlines and others to talk the training benefits is challenging. Robert W. Moorman reports.
Nine years later and they’re still talking about it - US Airways’ short-lived Flight 1549, an Airbus A320-214, which ditched in the Hudson River shortly after takeoff from New York City’s LaGuardia Airport. The Jan. 15, 2009 flight, which came to be known as the “Miracle on the Hudson,” struck a flock of Canada geese during climb-out and crash landed without engine power in the frigid waters near Manhattan. All 155 passengers and crew survived.
Luck and impressive dead-stick flying by Capt. Chesley “Sully” Sullenberger and First Officer Jeff Skiles, who flew the aircraft initially, and quick thinking by veteran flight attendants Sheila Dail, Doreen Welsh and Donna Dent helped transform what could have been a disaster into a survivable water landing. The crew received national fame for their heroics, although they didn’t describe the event in those terms - it was a team effort.
No one likes to dwell on accidents, particularly image and litigious-conscious airlines, yet accidents provide a template for better training of flight and cabin crew. Emergency procedures and training has improved at several airlines that have experienced an accident or incident.
Dail, who spoke at WATS 2018, recalled that short, but memorable US Airways flight and how some cabin crew procedures were changed after the ditching. The life vest demonstration is now given before every flight, not just for over water flights. The flight attendants also recommended that the pilot give the cabin crew one word, “water” before ditching.
While achieving zero accidents is unrealistic, the number has dropped appreciably when industry, regulators, unions, safety advocates, flight crews and others strive to improve training.
“Training has evolved as we have learned the lessons of previous accidents and incidents,” said Capt. John Cox, founder of Washington D.C.-based Safety Operating Systems and retired airline pilot. “We are better at windshear avoidance and recovery, upset prevention and recovery, low visibility operations, evaluations and in-flight fire procedures.”
Improvements in Upset Prevention and Recovery Training (UPRT) through expanded envelope simulators or in-airplane training will help reduce the number of loss of control accidents, said Cox. [UPRT is now mandated by EASA and will soon be required by the FAA.] Additionally, mandating and standardizing training on how to respond to a lithium-ion battery fire in the flight deck or cabin is needed. FAA guidance is “outdated and inadequate,” resulting in crews being ill prepared to deal with this rising risk, said Cox.
Accidents or incidents also help fast track onboard safety enhancing devices. Following the Dec. 20, 1995 American Airlines Flight 965 fatal accident near Cali, Colombia, there was a major push on developing and certifying Enhanced Ground Proximity Warning Systems (EGPWS), now known as Terrain Awareness Warning System (TAWS).
Following the August 23, 1995 Delta Air Lines Flight 191 accident near Dallas Ft. Worth International Airport and the Pan Am July 8, Flight 759 accident shortly after takeoff from New Orleans came a focus on windshear avoidance and recovery. Windshear recovery today is part of every check ride.
The FAA’s requirement of Automatic Dependent Surveillance ADS-B Out by January 2020 for all aircraft flying in Classes A, B, C and certain E Class airspace at or above 10,000 feet, plus the installation of fire detecting and suppression systems in cargo holds, have come about, in part, because of past accidents or incidents.
The National Transportation Safety Board issued 35 recommendations to the FAA and EASA following the investigation of Flight 1549. Of the 26-recommendations to the FAA, the agency adopted eight. Thirteen recommendations were not adopted and five remain still active, according to an FAA spokesman.
Some recommendations from the Flight 1549 report called for additional training. Included was a suggestion that Part 121, Part 135 and Part 91 operators include a dual-engine failure at low altitude for initial and recurrent ground and simulator training. The Board recommended pilot training on approach and touchdown techniques to use when ditching with and without power as well as awareness instruction on visual illusions that can occur when landing on water.
The Board also issued recommendations for cabin crew. These included a requirement that operators brief passengers on all flotation equipment on the airplane, including a full demonstration of life vest retrieval and donning procedures before all flights. A requirement to modify life vest stowage compartment locations for easier retrieval was also recommended.
A requirement to have Airbus operators amend the ditching portion of the engine dual failure checklist to include a step to move the ground proximity warning system and terrain alerts to off during final decent. The Board also recommended that regulatory authorities work with the aviation industry to determine if procedures need to be developed for pilots regarding forced landings on water.
Independent training houses have done their part in developing post-accident training programs when there seemed to be pattern. FlightSafety International’s (FSI) four-part Advanced Training Program for pilots came about as a direct result of numerous fatal and non-fatal accidents involving commercial and business aircraft. The four courses were developed in partnership with Gulfstream Aerospace, a wholly owned subsidiary of General Dynamics, which makes upscale business jets.
The first course deals with takeoff briefings and pilot’s “Go, No Go” decision to abort a takeoff. After careful examination of several accidents and incidents, FSI determined that the major reason pilots chose to abort the takeoff “was based on reflex action as opposed to thoughtful data and briefing,” said Dann Runik, executive director of FSI’s Advanced Training Programs. “If we were going to have any hope of stopping the wrecking of perfectly good airplanes, we had to develop new training.”
The second course on energy management during flight also based on FSI’s review of numerous accidents as well as Flight Operational Quality Assurance (FOQA) data.
Five percent of the thousands of approaches into a commercial airport annually are considered unstable, according to the data.
“Ninety-nine percent of those unstable approaches showed that the pilot continued to an unstable landing or, in some cases, a runway overrun or destruction of the airplane,” said Runik.
That 5% needle had not budged in 20 years. Consequently, FSI developed a program to educate the pilot on the so-called neutral energy state, the optimal speed and configuration for approaching an airport. In the course, pilots learn to determine the energy-neutral state of their aircraft. They are able to calculate in advance if their approach could become unstable and how to apply corrective action, such as adding or reducing speed. While each aircraft operates differently, applying inputs in advance could reduce the number of unstable approaches.
The third training module is a mouthful: Cockpit Resource Management/Human Factors /Line Oriented Flight Training (LOFT) is based primarily on fatal accidents. One or a combination of poor communications, aeronautical decision-making and threat and error management skills could cause a fatal accident. The benchmark for this training course is a long-range international flight logged into the flight simulator.
“If the pilots had better communications skills, some of these accidents could have been prevented,” said Runik. “This [course] is a deep dive into the psychological aspect of how flight crews communicate with each other.”
Many believe that CRM grew out of the January 13, 1982 Air Florida Flight 90 crash into the 14th Street Bridge over the Potomac River near Washington D.C. Yet the human factors concept dates back to the lack of communication between captains and first officers aboard early commercial jet flights, said Runik.
The fourth course deals with the much-talked-about Upset Prevention and Recovery Training (UPRT), which professional pilots must receive to obtain Air Transport Pilot (ATP) certification. Loss of control in flight remains the number one cause of accidents, according to the NTSB.
FSI is now able to offer pilots UPRT in a full flight simulator (FFS) once Gulfstream gave the trainer the experimental flight test data of the G550. The data, which includes stall speeds, were inserted into the software package of FSI’s G550 FFS. The data has since been incorporated into other simulator packages.
One of the hallmarks of the four advanced courses is to teach pilots to expect the unexpected. One scenario built into the simulator is similar to what the pilots of US Airways Flight 1549 experienced with the bird strike and subsequent ditching in the Hudson River, said Runik.
Post-accident NTSB recommendations on Flight 1549, which could apply to other accidents or incidents “focus on critical thinking, task-shedding, decision-making and workload-management competencies, which can be achieved through the simulation of multiple emergency and abnormal procedures and scenarios during initial and recurrent ground and simulator training,” stated CAE.
Incorporating the effects of envelope protection (specifically angle of attack) during normal, abnormal, and emergency operations into ground-school training is also noteworthy.
Ola Hansson, managing director of Lufthansa Aviation Training (LAT) said accidents and incidents have prompted the airline to improve several elements of flight crew training.
The airline trains for operations on narrow runways of less than 45 meters, 148 feet approximately. LAT requires ditching instruction for pilots once every three years of recurrent training. Specific training requirements vary among the airlines within the Lufthansa Group, which includes Austrian Airlines, Swiss International Airlines, Brussels Airlines, Eurowings and Germanwings.
Procedures too changed for Lufthansa and partner airlines as a result of incidents and accidents. The two-person flight deck rule mandate came about as a result of the March 24, 2015 fatal crash of Germanwings Flight 9525. Accident investigators found that Co-pilot Andreas Lubitz, who had a history of depression, deliberately crashed the Airbus A-320-211 into the Alps, killing all 150 passengers and crew.
LAT is in the process of harmonizing the pilot and cabin crew training programs of all airlines under the Lufthansa umbrella. The transition is difficult. Some of the once independent carriers “are having a tough time letting go of history,” said Hansson, adding that harmonization of training for various aircraft types would take time. LAT is introducing a new program to better obtain data of incidents/accidents, from which flightcrew training could be enhanced. The program is meeting resistance in Germany because of the strict laws to protect personal data, said Hansson.
Emergency Planning & Response
Aviation groups also provide emergency related training. Many airline staff from over 80 countries have taken the three-day Emergency Planning and Response course offered by the International Air Transport Association (IATA). Attendees learn to: develop and execute an emergency plan; advocate for the role and responsibilities of the emergency planning specialist within an airline; follow ICAO, National Transportation Safety Board and State regulations; train airline staff for an emergency response; and identify and outline areas for improvement during an emergency.
The next course is scheduled to be taught in Istanbul, Turkey, from August 6-8, 2018. Three additional classes are planned in Montreal, Canada, Singapore, and Geneva, Switzerland. An adequate supply of students must sign up for the courses to be held. Contact IATA for additional details.
AIRCARE International offers various emergency training courses for business aircraft crews throughout the US and at Le Bourget Airport, near Paris, France. In addition to the fixed-based facilities in the US and Europe, the company can dispatch mobile teams to the customer’s headquarters or designated site. The company offers training on emergency procedures and water ditching. Hypoxia Awareness Trainers and an Inverted Underwater Egress Dunker at a local pool as well as cabin emergency trainers with smoke are available.
Despite the horror and heartbreak of aircraft accidents, they have made air travel safer for all by strengthening training and procedures. Training for emergencies is an evolving science. While the US Airways crew of Flight 1549 were well trained, and executed their emergency training admirably, they all concur that training and support of aircrews post-accident could be improved.
For the flightcrew of US Airways Flight 1549, the days following the ditching in the Hudson River on that bitterly cold January day were a blur of news interviews, TV appearances, the Super Bowl and an audience with the President of the United States. It was a feel good story for a nation tired of bad news.
It all seemed so grand, so heroic, a fitting, successful conclusion for the well-trained aircrew. Job well done. Time to move on.
Flight Attendant Sheila Dail, one of the five crewmembers aboard the “Miracle on the Hudson” flight, knew something was wrong upon returning home. She became anxious, panicky when late for an appointment. She lost her appetite and considerable weight. And she couldn’t sleep, even after following her nightly routine of reading. “I couldn’t focus on two sentences in a book,” Dail recalled. “I went to a psychologist, who specializes in trauma.”
Eventually, the symptoms fell away and Dail was able to return to her daily routine. Nine months after the ditching, she returned to work. But her post-accident trauma demonstrated to Dail that an in-house peer support group was needed for US Airways flight attendants, who had undergone a traumatic experience on the job.
She began researching how best to form such a group. She sought out and read material on support groups by the Baltimore, Md.-based International Critical Incident Stress Foundation (ICISF), which provided her with material on highly rated peer support teams, such as the one by Southwest Airlines. Dial’s Critical Incident Response Program is modeled after Southwest’s.
As her peer support group took shape, Dail became associated with Dick Richardson, partner of Experience to Lead, a company that provides leadership skills education. Dial is involved with Richardson’s Brace for Impact program, which instructs business leaders on what to do when things go wrong. The program is aptly named. Richardson was a passenger aboard US Airways Flight 1549. He hired Dail for his program because he wanted to get a crew member’s opinion on aspects of that memorable flight. Richardson too spoke at WATS 2018.
Unfortunately, Dail did not get support from the union, the Association of Flight Attendants – CWA, which represents 50,000 flight attendants at 20 airlines. AFA told Dail that the union provided that kind of counseling, Dial disagreed. The union was strong in protecting flight attendants on labor matters, but not strong in providing psychological support.
“AFA was opposed to my push for a neutral team of peers,” she said. “I had pushback from the EAP chairs (both US Airways leadership and National chairs). I felt it created a power struggle because it reflected on how the flight attendants were handled in the hours following the ditching.”
Eventually, Dail found support for an in-house peer support group from US Airways CEO Douglas Parker, whom she met at a dinner honoring the crew following the ditching. Parker told Dail to contact him if she ever needed help. She did and “played that card.” Parker directed US Airways vice president of flight services to contact her, and that started the ball rolling.
Dail went on to help form the in-house Critical Incident Response Program, which today is supported fully by American Airlines.
To learn about support groups, Dail attended a training session in Dallas with the US Customs and Border Protection, a unit of the Department of Homeland Security. That session covered some of the same symptoms Dail dealt with following the ditching. “It was like free therapy to sit in on this training,” she said.
Elsewhere worldwide, there are aircrew support groups. Lufthansa is linked unofficially to the Mayday Foundation (Stiftung Mayday), which supports flight crewmembers in distress with 340 trained volunteers. The group, which helps crewmembers who have experienced trauma on the job, includes professional pilots, flight attendants, emergency medical personnel and psychologists. – Robert W. Moorman
Published in CAT issue 3/2018