A woman is walking along the pier with her son when a wave rolls over the deck and washes the boy over the edge. He disappears under the water and she begins to pray. “Oh, Lord, save my son, don’t let him drown, I will do anything, I will be so grateful, he is my life…”
A few seconds later, another wave rolls over the pier and returns her son to her, coughing and soaked, but otherwise unharmed. She looks down at her son and back to the heavens. She raises her tear-streaked face to the sky as she cries out to the Almighty:
“Hey! Where’s his hat?”
I was reminded of this story as I read the latest news about The Miracle on the Hudson, in which Captain Chesley Sullenberger and his merry crew landed their Airbus 320 in the Hudson River and 155 people lived to tell the tale.
Several days ago, the National Transportation Safety Board issued its report on the accident, in which both jet engines died after ingesting undercooked poultry.
The NTSB investigation benefited from a rare luxury that is tragically lacking in most such inquiries: witnesses. Analysts could ask 155 people to recount the turmoil over three very tense minutes on the potentially doomed flight. Freed of the limitations of voice recorders and instrument readings, they could review, possibly for the first time, all the thousands of possible and actual events on a falling jet.
Shockingly, the NTSB discovered that not all contingency plans were activated and not every prescribed step was taken as the plane was falling from the sky. In some cases, the crew simply ran out of time to complete its checklist, which resulted from the fact that the bird strike happened at such low altitude. In his recent book, The Checklist Manifesto, Atul Gawande credits that checklist with keeping people focused and effective.
The agency’s analysts say the crew wasted too much time trying to restart the engines, indicating a need for better sensors to tell the pilots when it’s useless to even try. (It is impossible to imagine a pilot trusting such an indicator, after the impact of a bird strike or other incident, and NOT trying to restart the engines anyway.) Worse, they suggested that maybe these sensors could be designed by NASA. NASA?
Equally significant, the passengers were unprepared for the emergency because 70% of them ignored the safety briefing. You know, the prescribed, word-for-word briefing that begins with instructions on how to fasten a seat belt…a briefing so boring and rote that they don’t even bother to have living people deliver it on most flights.
The NTSB now wants the airlines to find catchier ways to deliver the safety briefing, so people listen. (My recommendation: show a video of USAir 1549 sinking in the Hudson River.)
The agency also recommends that water landing equipment be mandated on all flights, whether they are expected to travel over water or not. Of course, the equipment was on Flight 1549 and most people couldn’t figure out how to use it.
Most of the issues raised by the NTSB were tied to the idea that the process can be perfected. Nothing will be in the wrong place, passengers will arise, or sit, as a Crackerjack Evac Squad, bird strikes won’t occur below 2,000 feet….
Ah, the arrogance of human beings.
I was a bit surprised they didn’t add a requirement that all bird strikes and engine failures occur within one mile of a smooth body of water. Crew competence notwithstanding, the Hudson River was the ultimate salvation of the plane. Along with dozens of tug/ferry/barge operators, of course.
In any complex situation, thousands of things go right and thousands go wrong. And the fixes that would have worked in the last crisis might actually make things worse the next time disaster strikes. Best intentions notwithstanding, you can’t fine-tune fate.
Every so often, you just have to accept the limitations of human endeavor and be very, very grateful.