Guest post by Stephen Adshead
On 15 January 2009, US Airways Flight 1549 was hit by a large flock of birds, shortly after takeoff, disabling both engines. The pilot - Chesley Sullenberger (aka Sully) – weighed up returning to LaGuardia or attempting to land at Teterboro Airport in New Jersey, but quickly determined that neither was feasible. In near silence (there was zero thrust coming out of the engines) he smoothly ditched the Airbus A320 into the Hudson River. Having made sure that everyone had evacuated, and retrieved the maintenance logbook, Sully walked off the plane. All his passengers and crew survived.
Sully had spent a career preparing for the vital decisions he made that day and from the first moment that mattered (deciding where to land) to the last (being the last one to walk off the plane) he exuded calm authority – This is the Captain. Brace for impact. When Sully and First Officer Jeff Skiles flew together again on 1 October 2009, four of Flight 1549’s passengers, and a significant number of the US media, requested to be aboard. When Sully gave the pre-flight announcement, the applause drowned out his voice. A few even stood up.
Around the same time that Sully reunited with Skiles, the Federal Aviation Administration (FAA) announced that it is seeking a $5.4m civil penalty against US Airways (and a $3.8 million fine against United Airlines). The FAA alleges US Airways operated eight aircraft on a total of 1,647 flights last autumn and winter whilst the planes were in a potentially unsafe condition. According to CNN, two Airbus A320s were allegedly flown without complying with an ordered inspection for possible cracking of a landing gear part.
Any failure to carry out inspections could have been – though fortunately wasn’t - a moment that mattered. A less obvious moment, however, was a cost-cutting measure relating to stationery.
When Skiles picked up the emergency procedures manual he discovered that the tabs marking out, for example, the guidance on safely ditching into water, had been removed. In the time between bird-strike and brace-for-impact, and in a flight that lasted, in total, 6 minutes, Skiles could have been found thumbing through the index. Fortunately for the 150 or so passengers and crew, Sully already knew how to ditch a powerless plane into water. His training, experience and perhaps most importantly judgement allowed him, in the moments that mattered, to overcome all of the obstacles before him (and to transcend the limits of the stationery cupboard).
Sully is a visiting scholar at the University of California’s Centre for Catastrophic Risk Management and co-authored with NASA a paper dealing with error-inducing contexts in aviation. There are many risk management lessons here, including broadening where to look for “error-inducing contexts” and the potential impact of poor judgement exercised by even the lowliest within an organisation. As for the tabs, Sully had complained previously about the decision to remove them and raises the topic once more in his new book ‘Highest Duty’. I would wager that he will now be heard and the tabs will be put back in.
Stephen Adshead is a litigator-turned-risk manager-turned-blogger.