The document summarizes the 2009 "Miracle on the Hudson" incident where US Airways Flight 1549 was forced to land in the Hudson River after experiencing a bird strike that disabled both engines. It discusses how the pilot Sullenberg's decision to land in the river rather than attempt to return to an airport was aided by the airline's culture of collective mindfulness and safety practices like crew resource management training. This culture emphasized preoccupation with failure, sensitivity to operations, commitment to resilience, and deference to expertise, which helped the pilot and crew successfully evacuate all 150 passengers without any loss of life. The document attributes the major improvements in aviation safety over decades to such safety culture practices rather than any "miracles".

1. HUDSON RIVER PLANE LAND –MIRACLE OR NOT
By: Jeremiah Afang (GradIosh,Msc, IdipNebosh)
• As reported by National Transport Safety
Board, NTSB, [1], on January 15 2009, the US
Airways flight 1549 took off from LaGuardia
airport NY with 150 passengers and 5 crew. 3
minutes later at a speed of 250mph and
altitude of 3000 feet, the plane had contact
with a flock of Canadian Geese.
• The contact resulted in flame and failure of
• both airplane engines.
• Pilot and co-pilot immediately contacted
control room.
• Air traffic Controller, Harten, gave 2 landing
locations.
• Traffic control landing options:
• LaGuardia runway
• Tertaboro runway

2. PILOT’S DECISION
Sullenberg, the pilot of flight 1549,
decided the best option he had is to
land the aircraft in the Hudson River
and communicated same to control
room and crew.
Travelling at 150mph with its nose, the
aircraft completes an unpowered
ditching in the Hudson River.
After landing, 3 and half minutes after
take-off, Pilot gave evacuation
command and the crew removed all
passengers to the wings until rescue
team arrived. All passengers were
saved.

3. MIRACLE OR NOT
Miracle as defined by the Oxford
Dictionary [2], is an extraordinary
event that is unexplainable by natural
or scientific laws, hence an attributed
to divine powers.
An example is one recorded in the
Holy book, Bible where a prophet of
God parted the seas.
Does this define the happening of the
Hudson River? Clearly, not.

4. INVESTIGATION FINDINGS
• Bird strike on planes was not a new incident at this period of time.
• the aircraft engine is designed to withstand bird strike.
• The birds that struck weighed more than expected.
• The plane had several functions and procedures to keep the aircraft in
limited control by the crew.
• He was not pressured by the superiors/ control room operators to
turn the plane around or land at the Tertaboro runway.
• He understood the River was the best option, He went for it.
• The pilot had recently trained for such emergency 2 weeks before.
• That was no miracle, its preparedness, improvisation, deference to
expertise.

5. COLLECTIVE MINDFULNESS & SAFETY CULTURE
Major accidents have been investigated to be issues with management
systems and despite several recommendations and improved designs,
systems still fail. Reason [6] added that what organisations need is to
develop a “robust safety culture”.
He [6] further four (4) features of safety culture which includes:
1. Reporting culture
2. Just culture
3. Learning culture
4. Flexible culture
These practices are collective rather than individual focus.

6. COLLECTIVE MINDFULNESS
Collective mindfulness was advocated by Karl Wieck during a research
on High Reliability Organisations, HRO, like airline, chemical, oil and gas
industries etc. which require a high level and strong safety culture to
prevent accidents.
Collective mindfulness is described by Hopkins [5] as an organisation or
group with mindful individuals, hence a mindful organisation.
This characteristics makes the HRO mindful of danger and risk, hence
reducing chances of accidents and swift response in case of any.
He [5] further mentions the fundamental point, which is for the
organisational level to establish processes of mindfulness, as this will
make all individuals mindful.

7. PROCESS OF A MINDFUL ORGANISATION
Weick et al. [7] identified the 5 processes of a mindful organisation.
1. Preoccupation with failure;
2. Reluctance to simplify;
3. Sensitivity to operations;
4. Commitment to resilience and;
5. Deference to expertise

8. Relationship of Collective mindfulness Process
in the Hudson River incident.
The processes of mindful collectiveness was evident in the Hudson
river plan land incident earlier discussed.
This was no miracle. The organisation was mindful of risk and so are
the individuals.
This practice saved all lives and crew also the plane was not badly
damaged.

9. Collective Mindfulness In The Hudson River
Incident
Mindfulness Process US Airways Hudson Incident
Preoccupation with failure Reports [4] shows that the engine had been
built to withstand bird-strike, but not one of
4kgs.
Sensitivity to operations Pilot had train 2 weeks before for such
emergency. This is not a usual training for
pilots, but the mindful culture had prompted
him to prepare for future.
Commitment to resilience Crew and control room did not panic. Pilot
was aware of emergency preparedness
procedures and communicated clearly.
Control room group themselves to provide
advice to pilot.
Deference to expertise The air traffic controller advised landing on
runways but pilot who was more competent
to decide. He decided, they adhered and
called in for emergency rescue on the river.

10. CAUSES OF AVIATION ACCIDENTS
Allianz Global Corporate & Specialty, AGSC, [8] reported that the major
causes of aviation accidents are related to human factors and
behaviour in the cockpit.
These are issues with organisational safety culture which was as a
result of several issues such as; pilot fatigue; errors; insufficient
trainings; decision making issues;

11. Improvements of Safety Culture in Aviation
Industries
In recent decades, the aviation industry has experienced improvement
in safety culture with the launching of Crew Resource Management,
CRM.
Its benefits includes [8]:
1. Promotes open communication and teamwork by all in operation.
2. Provides training.
3. Improves decision making process;
4. Emergency preparedness and team adaptation in critical situations.
5. A tool to combat accident when teamwork is deficiency is a possible
factor.

12. Improvements of Safety Culture in Aviation
Industries Contd.
Another method in the aviation industry to improve safety culture is Air
Navigation Service Providers, ANSP, who advocate a “Just Culture”
system where air-traffic controllers are encouraged to report safety
issues without fear of punishment.
These systems allow the aviation industry to improve its safety culture
and collective mindfulness.

13. Aviation Fatality Statistics Over Decades
• The report [8] shows the following statistics;
Death Per 100 million passengers
1961 - 1971 133
2001 - 2013 2

14. Legal Requirement to Improve a Just Culture in
Aviation Industry
The Civil Aviation Authority [10] defines a just culture as one which front
operators are not punished for actions, opinions and decisions taken by
them, but wilful violations, gross misconduct etc is not accepted. Hence a
Directive was issued on same, EC Regulation 376/2014.
The Directive encouraged reporting by including mandatory compliance for
airlines by:
1. Organisations must analyse and follow-up on reports. Feedback must be
provided to reporter.
2. Permitting whistle blowing: employees or contracted workers may report
any infringement.
3. Introduced time-frame for reporting safety issues to the concerned
authority.

15. References
1. National Transportation Safety Board. Loss of Thrust in Both Engines After Encountering a
Flock of Birds and Subsequent Ditching on the Hudson River, US Airways Flight 1549, Airbus
A320-214, N106US, Weehawken, New Jersey, January 15, 2009. Aircraft Accident Report
NTSB/AAR-10 /03. Washington, DC. 2010
2. Oxford Dictionary (2019). [online] Available at:
https://en.oxforddictionaries.com/definition/miracle [Accessed 2 May 2019].
3. Seidenman P, Spanovich D. How Bird Strikes Impact Engines. Available at: https://www.mro-
network.com/maintenance-repair-overhaul/how-bird-strikes-impact-engines. 2016.
4. Paries J. Lessons from the Hudson. In Resilience Engineering in Practice 2017 May 15 (pp. 49-
68). CRC Press.
5. Hopkins A. Safety Culture, Mindfulness and Safe Behaviour: Converging Ideas? 2002.
6. Reason J. Beyond the Limitations of Safety Systems. Australian Safety News. 2000 Apr;194.
7. K Weick & K Sutcliffe, Managing the Unexpected: Assuring High Performance in
An Age of Complexity, (San Francisco: Jossey-Bass, 2001), p 3.

16. References. Contd.
8. Corporate AG. Specialty SE: Global Aviation Safety Study–A review of 60 years
of Improvement in Aviation Safety. 2014
9. Marshall D. Crew Resource Management: From Patient Safety to High
Reliability. Safer Healthcare Partners, LLC; 2009.
10. Civil Aviation Authority. Just Culture. 2015. Available at:
https://www.ibe.org.uk/userassets/events/20180306_ibe_webinar_handout_caa_f
wm20160629_just%20culture.pdf