The Janus of Close Calls: A Tale of Two Mishaps

By now everyone in the world has heard about the heroic actions of the Captain and crew of US Airways Flight 1549 – now simply referred to as the “Miracle on the Hudson.”

But I doubt that most readers are aware that an eerily similar accident occurred in the spring 1999 in Eastern Europe, when TransGlobal Airlines Flight 1144 experienced dual engine failure shortly after takeoff out of Chelyabinsk International Airport after flying through a flock of migrating birds. The IL–113 aircraft – a clone of the Airbus 320/319 series – was forced to ditch in Lake Ostrovo four miles off the end of the Runway 33. The aircraft was successfully brought to rest in the lake and initially stayed afloat for about twenty minutes, but the pilot’s failure to activate the pre-ditching switch on the overhead panel resulted in the aircraft’s outflow valves remaining open, eventually sinking the aircraft before help could arrive and resulting in the drowning and exposure deaths of 78 passengers and all five members of the flight crew. Forty three passengers survived in emergency and make shift life rafts until they were rescued by fishing boats only moments after the aircraft sank.

In the subsequent investigation by the Eastern European Aviation Investigation Board (EEAIB), multiple factors were identified as contributing causal factors including (1) poorly designed procedures that required the pilots to go deep into a confusing automated checklist to find the emergency procedure that required the pre-ditching switch activation, and (2) the failure of TransGlobal Airlines to adequately train emergency ditching procedures in the simulator. While these factors were contributory, the proximate causal factor was pilot error. In a statement issued from the EEAIB lead investigator, the Captain was singled out as “being put in a very difficult situation, but one that was survivable for all on board, if the procedures had been followed.” The local prosecutor stated that he would have seriously considered charging the Captain with manslaughter had he survived, and was now looking at the potential culpability of the airline and aircraft manufacturer. "With a tragedy of this magnitude, someone has to be held accountable," the prosecutor said.

In both of these cases (if the NTSB early reports on Flight 1549 are accurate), the pilots failed to activate the "ditching switch" prior to a water landing. The major difference between these two accidents was not the skill or expertise of the Captain or crew, but rather the circumstantial factors that surrounded them. In one case, rescuers were on the scene in a matter of minutes, in the other, they could not reach the aircraft until it went under.

Another major difference is that one mishap actually occurred and the other is purely the work of my imagination. There is no TransGlobal Airlines, IL-113, EEAIB, Lake Ostrovo or Runway 33 at Chelyabinsk. This was written merely to prove a very important point about performance and lessons learned. Outcomes should not be used to evaluate our need to improve or make changes. Please understand that this is not intended to take anything away from the stellar crew of Flight 1514. It is intended to cut through the media fueled hype to take advantage of some free lessons.

In Roman mythology, Janus is the god of gates, doors, beginnings and endings. He is typically seen as having two faces looking in opposite directions, representing moments of choice. The lessons of Flight 1549 will take time to sort themselves out but had it ended differently, the drum for “someone to be held accountable” would be beating loudly and the FAA would be holding hearings on pending rulemaking. Let’s not be blinded by success or failure in our search for opportunities to improve. If checklist modifications and/or training improvement opportunities come out of this recent success – we have two great stories to tell.

So let me summarize this flight of fancy with three main points. First, life itself a mission simulator. Second, free lessons are there for the taking every day and everywhere if we will just look for them and not be blinded by outcome bias, and finally, not all mandates for improvement need to be written in blood.

By the way, nice job Captain Sullenberger and crew.