Highest Duty: My Search for What Really Matters

3. THOSE WHO CAME BEFORE ME

AS HUMAN ENDEAVORS go, aviation is a very recent one. The Wright brothers first flew in 1903. That’s just 106 years ago. I’m fifty-eight years old, and I’ve been flying for forty-two of those years. Aviation is so young that I’ve been involved in it for almost half of its history.

Through the efforts of many people in the past 106 years—their hard work, their practice, their engineering breakthroughs—aviation has quickly gone from its dangerous infancy to being so commonplace that there is little tolerance for any risk at all. We may have made it look too easy. People have forgotten what’s at stake.

I’m not saying passengers shouldn’t feel comfortable flying. It’s just that it’s easy to become complacent when our nation can sometimes go a year or two between major airline accidents involving fatalities. When things are going well, success can hide inefficiencies and deficiencies. And so it takes constant vigilance.

Long before I found myself in the cockpit of Flight 1549, I had closely studied other airline accidents. There is much to be learned from the experiences of pilots who were involved in the seminal accidents of recent decades. I have soberly paged through transcripts from cockpit voice recorders, with the last exchanges of pilots who didn’t survive.

I studied these accidents partly because, in the early 1990s, I had joined a couple dozen other US Airways pilots to help develop an air-safety course looking at CRM—crew resource management. Before Flight 1549, my proudest professional contribution was my work in CRM. My fellow facilitators and I helped change the culture of our airline’s pilot group by improving cockpit communication, leadership, and decision making. As First Officer Jeff Diercksmeier, my friend on the CRM team, said, “It was a time when a few people who really believed in what they were doing made a difference.”

My interest in air safety goes back to my first flights as a teenager. I’ve always wanted to know how some pilots handled challenging situations and made the best decisions. These were men and women worth emulating.

And so I tried to understand, intimately, the full stories behind each of these pilot’s actions. I’d ask myself: If I had been there, would I have been as successful?

A few years ago, I was invited to speak at an international conference in France focused on safety issues in a variety of industries. Given the comparatively ultrasafe record of commercial aviation, I was asked to appear on two panels to discuss how airline safety efforts might be transferable elsewhere. I talked about how other industries are recognizing that they can benefit by adopting some of our approaches.

This degree of safety requires tremendous commitment at every level of an organization and a constant diligence and vigilance to make it a reality.

Those of us who are pilots worry about the financial issues now weighing down airlines. Most passengers today select carriers based on price. If one airline’s fare is five dollars less than a competitor’s fare, the airline with the less costly ticket gets the booking. The net effect is that airlines are under intense pressure to lower their costs so they can offer competitive fares. This has cheapened the experience of flying; we’ve all seen the cutbacks in amenities offered in coach. But passengers don’t see other ways in which the airlines are cutting back. For instance, some of the smaller regional airlines have lowered the minimum requirements for pilot recruitment, and they’re paying some pilots $16,000 a year. Veteran pilots—those who have the experience that would help them in emergencies—won’t take these jobs.

I have 19,700 flight hours now. Back when I had, say, 2,000 or 4,000 hours of experience, I knew a lot of things, but I did not yet possess the depth of understanding I have now. Since then, I’ve sharpened my skills and learned from many situations that tested and taught me. Regional airlines will now take someone with 200 hours of flying experience and make him or her a first officer. These new pilots may have exceptional training, and they may have a high degree of ability. But it takes time, hour after hour, to master the science and art of flying a commercial jet.

Another issue: Airlines used to have more large hangars in which their planes were repaired and maintained by their own mechanics. The mechanics would overhaul component parts, radios, brakes, engines. They knew the specific parts and systems in each aircraft in their fleet. Now many airlines have outsourced their maintenance and component work. Are these outside mechanics as experienced and knowledgeable about a particular aircraft? If a part is sent overseas to be overhauled, does it come back as reliable?

It’s fair to say that when jobs are outsourced, and the work is done in a remote location, an airline has to work much harder to control the entire process, and to have the same level of confidence in the part or repair.

Every choice we in the airline industry make based solely on cost has ramifications and should be evaluated carefully. We have to constantly consider the unintended consequences for safety.

An airline accident is almost always the end result of a causal chain of events. If any one link was different, the outcome may have been different. Almost no accident was the result of just one problem. In most cases, one thing led to another, and then there was too much risk and a bad outcome. In aviation, we need to keep looking at the links in the chain.

Engine manufacturers know, for example, that their engines might someday encounter and ingest a flock of birds, causing severe damage. To learn what they’re up against, the manufacturers use farm-raised birds to test their engines. These preslaughtered birds are fired into the spinning blades from pneumatic cannons—sacrificed in the name of research that might save human lives. Given the growing population of birds near many airports, this testing is crucial.

Birds certainly are entitled to their wide piece of the sky, but if we humans are to continue joining them there in ever larger numbers, we’ll need to have a better understanding of the risks and remedies of bird strikes. In the wake of Flight 1549, investigators will likely consider whether an improvement in engine certification standards is needed.

Historically, safety advances in aviation often have been purchased with blood. It seems sometimes we’ve had to wait until the body count has risen high enough to create public awareness or political will. The worst air tragedies have led to the most important changes in design, training, regulations, or airline practices.

Airline disasters get massive media coverage, and the public’s reaction in response to these tragedies has helped focus government and industry attention on safety issues.

People have incredibly high expectations for airline travel, and they should. But they don’t always put the risks in perspective. Consider that more than thirty-seven thousand people died in auto accidents in the United States last year. That was about seven hundred a week, yet we never heard about most of those fatalities because they happened one or two at a time. Now imagine if seven hundred people were dying every week in airline accidents; the equivalent of a commercial jet crashing almost every day. The airports would be shut down and every airliner would be grounded.

In aviation, we should always aim for zero accidents. To come closer to accomplishing this, we must have the integrity to always do the right things, even if they cost more money. We have to build on all the hard work of the last 106 years, and not assume we can just rely on the progress made by previous generations. We need to keep renewing our investments in people, systems, and technologies to maintain the high level of safety we all deserve. It won’t happen by itself. We have to choose to do this. This same prescription applies to many other industries and occupations.

Commercial aviation is one of several professions in which knowledge, skill, diligence, judgment, and experience are so important. With the lives of hundreds of passengers in our care, pilots know the stakes are high. That’s why, long before Flight 1549, I read about and learned from the experiences of others. It matters.

WHEN I arrived in the cockpit of Flight 1549, I would be aided by the courageous efforts of pilots who had come before me.

There were the two unheralded test pilots who, on September 20, 1944, risked their lives by landing their B-24 Liberator in Virginia’s James River. This was a voluntary ditching, considered the first test on a full-size aircraft. As the plane hydroplaned for several hundred feet, which almost completely severed the bomber’s nose section, engineers watched from a nearby boat, collecting data on how it fared. The pilots survived.

The following day, the Daily Press in Newport News had this headline: B-24 “DITCHED” TO EXPERIMENT ON STRUCTURES—JAMES RIVER TEST DESIGNED TO SAVE LIVES IN THE FUTURE.

By that day in 1944, the Allies had already ditched scores of bombers in World War II, often in the English Channel. Most filled with water and sank quickly; hundreds of crew members drowned. Better procedures for ditching were desperately needed.

As a recent Daily Press story explained, it took thirteen more years after that test in Virginia for a full report to be written on how best to attempt a water landing while piloting a distressed aircraft. That report called for landing gear to be retracted rather than extended. It described why an airplane should fly as slowly as possible, and why wing flaps should be down for impact. It also called for the nose to be up in most cases. These procedural guidelines remain in use today, and were in my head on Flight 1549.

As a student of history, I am awed when I read of the actions taken by these pilots in earlier eras. They didn’t have all the data that now aids us in our decisions. They didn’t have the benefit of all the additional decades of trial and error in aircraft design. They acted with the mental and physical tool kits available to them.

Perhaps the most famous water landing prior to Flight 1549 happened on October 15, 1956. It was Pan American Airways Flight 943, bound from Honolulu to San Francisco with twenty-five passengers. There were also forty-four cases of live canaries in the cargo hold.

In the middle of the Pacific, in the middle of the night, the Boeing 377 Stratocruiser lost two engines, and its remaining two engines were under strain, consuming large amounts of fuel.

Captain Richard Ogg, forty-two years old, knew he was too far into the trip to turn back to Hawaii. San Francisco was too far ahead. And so he opted for a water landing. He circled for several hours, burning off fuel and waiting for daylight, above a U.S. Coast Guard cutter that was in position to rescue passengers and crew.

Just before 8 A.M., the captain attempted his landing. The tail snapped off and the nose was shattered on impact, but all the passengers and crew were rescued. Captain Ogg went through the plane twice, making sure he didn’t leave anyone behind. The plane took twenty-one minutes to sink below the surface of the Pacific.

The circumstances of Flight 943 were different from my experience on Flight 1549, mostly because Captain Ogg had hours to work on his plan and Jeff and I didn’t even have minutes. Also, he was landing on the open ocean, not on a river. But I had long admired Captain Ogg’s ability to safely land on water. I knew that not all pilots could have successfully equaled his effort.

After Flight 1549 hit the news, the San Francisco Chronicle contacted Captain Ogg’s widow, Peggy, to ask her about the similarities between my landing in the Hudson and her husband’s 1956 ditching in the Pacific. She spoke of her husband’s sense of duty. He had told reporters at the time: “We had a certain job to do. We had to do it right or else.”

When Captain Ogg was on his deathbed in 1991, his wife was sitting with him and noticed a faraway look on his face. She asked him what he was thinking about. He told her: “I was thinking of those poor canaries that drowned in the hold when I had to ditch the plane.”

THE FIRST major airline accident I ever investigated personally was PSA Flight 1771, which crashed into hilly ranchland near Cayucos, California, on December 7, 1989. It was traveling from Los Angeles to San Francisco.

The specifics of the crash were haunting and disturbing. A former USAir ticket agent named David Burke, thirty-five years old, had been caught on a security videotape allegedly stealing sixty-nine dollars in in-flight cocktail receipts. He was fired, and tried unsuccessfully to get his job back. He then decided to buy a ticket on Flight 1771 because his supervisor was a passenger on it.

In that era before the September 11 attacks, those with airport IDs didn’t necessarily have to go through security. So Burke was able to board the plane carrying a .44 Magnum revolver. Sometime after boarding, he wrote a note on an airsickness bag to his supervisor: “Hi Ray: I think it’s sort of ironical that we ended up like this. I asked for some leniency for my family. Remember? Well, I got none and you’ll get none.”

The plane was at twenty-two thousand feet when the cockpit voice recorder picked up the sound of what appeared to be shots being fired in the cabin. Then a flight attendant was heard entering the cockpit. “We have a problem,” she said. The captain answered: “What kind of problem?” Burke was then heard saying: “I’m the problem!”

The sounds of a struggle and gunshots followed. Investigators believed Burke shot the captain and first officer, and then himself, after which the plane went into a nosedive, probably because a pilot’s body was slumped against the controls. The plane hit the ground at about seven hundred miles an hour and much of it disintegrated on impact. None of the forty-three people on board survived.

As an Air Line Pilots Association safety committee volunteer, I served as an investigator at the crash site as part of the “survival factors” working group, charged with trying to determine what the crew could have done to make that flight survivable. Of course, given the circumstances, there was almost nothing they could have done. The FBI quickly took over and turned the crash site into a crime scene. Over the days of searching, the handgun was recovered with six spent cartridges. So was the note on the airsickness bag, and Burke’s identification badge, which he had used to avoid going through security.

When I got there, the crash site looked like an outdoor rock concert where everyone had left trash all over a hillside. There were hardly any big pieces of the plane besides landing gear forgings and engine cores. It was a very disturbing feeling being at the scene of a mass murder, knowing what had happened in the sky above us. The smell in the air was a mixture of jet fuel and death.

I had known one of the flight attendants on the plane, and it was horrifying to imagine what the crew and passengers went through. Working on this sort of investigation focuses your attention on how to prevent similar tragedies in the future. It renews your dedication to never let it happen again.

In the wake of Flight 1771, some groups of airline workers were subjected to security requirements similar to those set for passengers, better methods of employment verification were instituted, and federal law required employees to turn in their IDs after being terminated from airline jobs. But larger problems with security would still need to be addressed. Standing on that hillside in California, I couldn’t have imagined the way cockpits would be breached on September 11, 2001.

In my role helping with accident investigations, I also was called upon to talk to passengers who survived crashes.

On February 1, 1991, there was a runway collision at Los Angeles International Airport between USAir Flight 1493 and SkyWest Airlines Flight 5569. It happened in part because the local air traffic controller cleared the USAir jet, a 737–3B7, to land while the SkyWest commuter plane, a Fairchild Metro III, was holding in position to take off on the same runway. All ten people on the SkyWest plane died, and twenty-two passengers were killed on the 737. I was given the task of interviewing some of the sixty-seven survivors from the 737.

The NTSB gave us a long questionnaire, with questions such as: What announcements do you recall hearing? Did the emergency exit lights come on? Which exit did you use to escape? Did you help anyone else get out? Did anyone help you get out?

All of these questions were designed to help the airline industry learn from these events and improve the next outcome.

It was not especially pleasant work investigating accidents, but I was grateful for the opportunities to do so. When I talked to survivors, I listened carefully, trying to understand, and I filed away the details, in case I’d ever need to draw on them.