PURPOSE

This case study is intended to provide a useful tool for the 

U. S. Nuclear Regulatory Commission (NRC) staff as it interacts 

with their stakeholders. It will also enable the regulated 

community to identify with, and learn from the findings made 

by the National Transportation Safety Board (NTSB) regarding 

the forced landing on the Hudson River by US Airways Flight 

1549. The positive safety culture traits that contributed to the 

successful outcome of this event parallel those traits the NRC 

has incorporated into its Safety Culture Policy Statement. 

WHAT HAPPENED?

On January 15, 2009, at approximately 3:27 p.m., US Airways 

Flight 1549 departed LaGuardia Airport heading to Charlotte 

Douglas International Airport. Less than 2 minutes after 

takeoff, the captain told the control tower there was an emergency. There were bird strikes in both engines. With both engines dead 

and unable to complete the engine dual failure checklist, the captain started the auxiliary power unit and took control of the aircraft. 

Initially, he informed the control tower of his intent to return to LaGuardia; however, he quickly realized that he was unable to 

return to the runway and informed the controller that he had no other alternative but to land on the Hudson River. He announced 

on the public address system, “This is your captain, brace for impact.” The plane started quickly losing altitude and the captain 

glided the aircraft, tail first, into the Hudson River. Although the airplane was substantially damaged, all 155 passengers and crew 

members evacuated safely. 

Evidence of Strong Safety Culture Traits Evidence of Positive Safety Culture Traits

Leadership Safety Values and Actions in 

which leaders demonstrate a commitment 

to safety in their decisions and behaviors. 

Even after the successful landing on the Hudson River, the captain’s commitment 

to the safety of others was evident. Before leaving the cabin, he walked up and 

down the aisle twice to make sure everyone was out. Once he was out of the cabin, 

he instructed the rescue boats to take care of the people on the wings first because 

those in the rafts were already safe. His commitment to the safety of others before 

thinking of himself is a reflection of his strong leadership skills.

Problem Identification and Resolution in 

which issues potentially impacting safety 

are promptly identified, fully evaluated, 

and promptly addressed and corrected 

commensurate with their significance.

Both pilots identified issues potentially impacting the safety of the passengers and 

crew. They fully evaluated and quickly addressed the corrective measures needed. 

Each pilot adhered to his role and responsibilities while the captain planned the 

landing – wings exactly level, nose slightly up, survivable descent rate; touch down 

just above minimum flying speed but not below it. All of these things needed to 

happen simultaneously.

Personal Accountability in which all 

individuals take personal responsibility 

for safety.

From the captain to the co-pilot, flight attendants, passengers and emergency 

responders, everyone’s contribution was critical to the success of the emergency 

landing and rescue. Everyone was accountable for their actions which played a 

significant role in maintaining safety for the passengers and crew.

Work Processes in which the process of 

planning and controlling work activities is 

implemented so that safety is maintained.

Having just recently completed training, the first officer recognized the warning 

signs of the abnormal event. He, therefore, located the quick reference handbook 

and followed its processes, which gave him greater control of the situation to 

maintain safety for all passengers. 

Safety Culture Communicator 

Case Study 2 August 2011

US Airways Flight 1549: Forced Landing on Hudson River
Continuous Learning/Training in which 

opportunities to learn about ways to ensure 

safety are sought out and implemented.

In order to ensure safety, US Airways Crew Resource Management (CRM) and 

Threat Error Management (TEM) training was integrated into all aspects of the US 

Airways mandatory training plan. The captain stated that the training gave them 

the skills and tools needed to build a team quickly, open lines of communication, 

share common goals and work together

Environment for Raising Concerns in 

which a safety conscious work environment 

is maintained where personnel feel free 

to raise safety concerns without fear of 

retaliation, intimidation, harassment or 

discrimination.

An important component in the CRM training program includes techniques 

that teach everyone how to clearly express concerns and problems, after which 

everyone commits to a solution. Research has shown that subordinates hesitate to 

correct their supervisors out of a traditional, but sometimes dangerous, respect for 

authority. The CRM training encourages everyone to raise safety concerns without 

fear of retaliation. 

Effective Safety Communication in which 

communications maintain a focus on safety.

The National Transportation Safety Board (NTSB) report states that the cockpit 

voice recorder data indicated that the communication between the captain and first 

officer were excellent. In addition, the flight crew made only pertinent callouts to 

the air traffic controller in order to manage the workload and focus on safety. 

Respectful Work Environment in which 

trust and respect permeate 

the organization.

The National Transportation Safety Board (NTSB) concluded that the 

professionalism of the entire flight crew and their excellent CRM training during 

the accident sequence contributed to their ability to maintain control of the 

airplane, configure it to the extent possible under the circumstances and fly an 

approach that increased the survivability of the impact.

Questioning Attitude In which individuals 

avoid complacency and continuously 

challenge existing conditions and activities 

in order to identify discrepancies that might 

result in error or inappropriate action.

In the CRM training, everyone learns to articulate a discrepancy between what is 

happening and what should be happening. After the bird strike, the captain quickly 

realized there was an emergency and took control of the aircraft. Although the 

Air Traffic Controllers were clearing the way for Flight 1549 to land at LaGuardia 

Airport, the captain analyzed the existing conditions, questioned the guidance to 

land at LaGuardia and instead made the decision to land on the Hudson, which was 

the safer option.

WHAT CAN WE LEARN FROM THIS 

ACCIDENT?

“The lessons that can be taken from the remarkable story of 

Flight 1549 are many, and from a corporate management standpoint, 

a question to be asked might be, “If my company, my management 

team, my employees were put into a situation that difficult, can we 

respond?” 

—Crisis Management Best Practices: 

“Miracle on the Hudson” by Jay Silverberg, 

http://xenophonstrategies.com/blog/posts/crisis-managementbest-practices-miracle-hudson.

The story of US Airways flight 1549 contains the same threads of 

leadership, training, planning and preparation required for any 

corporation to be sufficiently able to respond when a crisis strikes. 

This incident reinforces the importance of promoting a positive 

safety culture by demonstrating how the strong safety culture traits 

aided the crew in protecting the safety of the passengers. 

Sources of Information:

Accident Report:

NTSB Number AAR-10/03

NTIS Number PB2010-910403

Crew Management Processes Revitalize Patient Care, Health 

and Medicine, Originating Technology/NASA Contribution, 

http://www.sti.nasa.gov/tto/Spinoff2009/hm_6.html

Leadership Crucible | Kevin & Jackie Freiberg, 

http://www.freibergs.com/resources/articles/leadership/

the-leadership-crucible/

This Safety Culture Case Study was developed by NRC, Office 

of Enforcement (OE). If you have any questions, please contact 

David Solorio, Branch Chief, at 301-415-0149 or by email 

at Dave.Solorio@nrc.gov.

Case Study developed by Marge Sewell on detail to OE.

Evidence of Strong Safety Culture Traits Evidence of Positive Safety Culture Traits