Learning from the Hudson River landing

After watching the film Sully, which is based on the real-life investigation into a water landing of US Airways Flight 1549 in 2009, our columnist once again notes the importance of putting people first

The plane (an Airbus A320) was en route from New York City to North Carolina when it struck a flock of Canadian Geese (an event known as a bird strike) shortly after take-off from LaGuardia airport. As a result, both of the aeroplane’s engines failed.

Captain Chesley Sullenberger and his first officer, Jeffrey Skiles, were in the cockpit that day. Sullenberger made a Mayday call, during which he was informed that they were cleared to land at a nearby airport in New Jersey. The two pilots soon realised that they would not be able to reach the assigned runway safely, and therefore decided to conduct an emergency landing in the Hudson River.

All 155 passengers and crew on board survived the incident and Sullenberger and Skiles, as well as three crew members, were awarded the Masters Medal of the Guild of Air Pilots and Air Navigators, as well as numerous other recognitions for their deeds.

The film opens with a scene in which a team from the National Transportation Safety Board is conducting the initial investigation, which reflects all the things that safety and health teams should not be doing in an investigation of any incident …

The members of the investigation team came in with a certain bias, and it was clear that the objective of the enquiry was to apportion blame.

The stricken aircraft in the Hudson River.

The pilots were accommodated in a hotel and not allowed to return to their homes. No counselling was provided for them after the incident or during the subsequent enquiries. The body language of the investigation panel was authoritative as well and, at times, they even grinned and made jokes amongst themselves.

There was no regard for the psychological impact of the event, nor did the panel show any signs of concern or give any support to the pilots. The investigation was mainly focused on workspace elements, including systems, checks, experience and simulations. No consideration was given to issues such as conscious and unconscious decision-making or the actions taken in real time, when an emergency situation was playing out in the plane.

The film reminded me of the importance of treating people with respect and dignity during incident investigations. Although there is a lot to consider when discussing incident investigation techniques and fundamentals, for the sake of this article, let us as leaders challenge ourselves with three fundamental questions.

What is the correct make-up of an investigation team?
It is not uncommon for companies to require that their safety and health professionals chair incident investigations, whether it be a small or serious incident. Although we say that safety is a line responsibility, is this always the case in industry? It definitely isn’t always the case in incident investigations.

I understand that incidents resulting in minor injuries could be chaired by a safety and health department. However, investigations into serious incidents, including incidents with minor injuries, but with high-risk potential, should be chaired by someone having line responsibility. This includes investigations into major close calls or near-misses, as they are often referred to in the safety and health industry.

When selecting incident investigation teams, do we consider the biases of those people appointed? Are those chosen, as part of the investigation team, independent from the incident or department in which the incident occurred?

Everyone has a built-in bias and it is therefore important to consider this when setting up and appointing an investigation team. It is also important to ask whether those members can suspend their own agendas and listen to the facts presented without any sort of preconceived ideas.

It is natural for those involved in preparing for an incident investigation to develop their own views on what led up to the incident and, at times, even what caused it. These views are developed by listening to others immediately after the incident or later, in the lead-up to the investigation.

Captain Chesley Sullenberger and first officer Jeffrey Skiles.

The problem here is, if the person believes that the preconceived ideas are accurate, they might not suspend their own agenda and, as a result, direct the discussions to what they think happened.

I have heard of cases where preconceived ideas are discussed prior to an investigation and then, when comments are made during the interviews that are connected to those preconceived ideas, the investigation team believes that they have confirmed their points of view and don’t have to explore any further.

This results in an inaccurate investigation and fails to address the actual contributing factors. If these factors aren’t addressed correctly, whatever is proposed to prevent a recurrence will make no difference whatsoever. Leaders are then surprised when a repeat incident occurs.

It is evident that the team conducting the investigation of the Hudson River landing had strong preconceived ideas. They kept directing their questions to obtain the answers that they were looking for – so much so that that they made accusations. The team began their enquiry with personal questions, which included:

• How much sleep did you get last night, captain?
• When was your last drink and do you do drugs?
• Have you had any personal problems at home lately?

“Why are they looking for something that we did wrong, if all turned out right?” Skiles asks Sully. It is clear that the pilots felt that they were being blamed for their actions. This situation unfortunately happens in far too many investigations throughout all industries, where the questions asked are posed around preconceived ideas, and are aimed at apportioning blame.

The answer provided by someone else in the scene was, “It didn’t end right for the airline or the insurance company.” This reflects that there was no suspension of agenda; and indicates very strongly that the investigation team was biased throughout.

The investigation team at work.

Do we treat people with dignity and respect?
I recall the expression on Skiles’s face when the investigation team asked those three questions: he was shocked by the direct nature of the questions.

Those initial accusation-toned questions placed enormous stress on the two pilots, which affected them and their families.

What should have happened was that the pilots should have been allowed to take the investigation team through the events leading up to the incident and the reason for the decision to land on the Hudson River. This would have been a much more caring and humanising approach and the investigation would probably have been conducted without causing mistrust and stress.

Instead, the team’s body language and aggressive approach were not conducive to a good investigation, which should be based on trust and mutual respect.

After the initial simulations, the investigating officer commented, “A lot of toes were stepped on to arrange the sharing of the simulations; I really don’t know what you two were hoping to get out of it.” Wow, what a terrible comment to make, when the only thing the pilots wanted was to understand how the simulations were conducted and what the outcomes were.

Surely, those chairing an incident investigation should consider all issues, including comments and requests by those involved. If not, we should question whether those in charge have suspended their own agendas. After all, the request by the two pilots for a simulation to be made was valid and, even if they “stepped on toes”, it reflected the truth – they would not have been able to fly the plane safely to any airport.

Are we focusing on the right things?
It is clear in the movie that the investigation team focused on workplace controls, including checklists and procedures. Very little, if any, consideration was given to the human element – including the psychological aspect. It was all about objects and nothing about people.

This emergency landing was all about people, however; it was about the decisions taken by the pilots while an emergency was playing out. It was about how they had been trained; it was also about how to respond to things they had never been prepared for or seen in the safety of simulations. Decisions had to be made in a matter of seconds.
After all, the outcome of the public enquiry confirmed that the decisions of Captain Sullenberger and First Officer Skiles made were brave and correct, and saved the lives of
155 persons that day. Had the investigation team suspended their agendas, focused on the human elements, treated others with dignity and respect and been transparent from the beginning, they might have come to this conclusion much earlier.

This is a lesson for all safety and health practitioners. It is about people, emotions and respect, it is about finding the balance between taking into account the safety controls as well as the human elements; and it is about allowing others to tell their story in front of investigators who have set aside their own agendas.