My apologies for not writing more (and sooner) but I will just say (again?) that the theology course I’m taking is like drinking out of a fire hose. While it will be a few weeks yet before the final report is out on the DCA crash, the items that are going into the report are now released.
I’m going to start with the Safety Data report, which frankly is damning to the FAA and now-former tower management. Short version is that DCA has had problems for years, including the perception that reporting issues would lead to retaliation. There are multiple recommendations in the report for the FAA, and a few for the Army, as leadership at both agencies (and the DoT) was abysmal.
The human performance report is a good overview of the human operations and interactions with onboard technology that is supposed to help prevent collisions. If you want to understand what was happening in each place, the information available, factors that limited the use of technology and prevented adequate warnings, and more, this is it.
The report notes early something I had “seen” early on: the call-out of the CRJ operated by PSA (Piedmont) for American Airlines lacked critical information. There were several planes in the area called out by the controller, and there was no way for the helicopter crew to know which one was being pointed out. There is evidence that they mistook another aircraft for the one they were supposed to be watching. I may not have many hours as a pilot, but every time I had other traffic called out it always specific, as in “you have X aircraft at your Y o’clock high/low/same (altitude). SOP was to locate, then call back and read-back “I have X aircraft in sight at Y o’clock high/low/same” to verify the information.
As a side note, so long as the object was moving relative to you, life was good. It was when things were a dot that you needed to act as the lack of movement meant it was coming straight at you. Therefore you dove or climbed and/or changed course as well. Doesn’t matter if it was a bird (birds can take out a plane and/or pilot) or a plane — by the time it starts to get visually larger it usually is too late to avoid.
There is a lot more in that particular report, and it is well worth reading carefully. As I said earlier, the only people who come out of this pretty much in the clear are the Piedmont crew who were never warned about the helicopter.
Here is the helicopter operations report, and the medical report. On the latter, the controllers on duty that night should have recourse against management for failing to do the proper drug and alcohol tests. While there is no evidence of such, the failure to follow SOP unfairly puts a cloud over them as they have no way to prove they weren’t impaired. On the former, it is worth reading and re-reading. There are a number of issues with Army aviation leadership and operations that need to be addressed. One of which is that a number of the helicopters in the unit involved had altimeters that were/are not giving correct altitude. There’s more, but the altimeter issue is an ongoing major issue that needs to be addressed.
The airplane systems group report is a good primer on ADS-B and collision avoidance — and the limits of technology. This is a good read and I suspect a number of changes may come out of it.
Now, keep in mind that the area around DCA is some of the most congested in the United States. Fact is, there have been a number of efforts to shut down Reagan because of volume, runway length, location, and other issues. Congress has not only prevented closure, but expanded normal operating hours over the expert advice given it simply because it is convenient for them. And make no doubt it is highly convenient. I’ve flown in and out of there more times than I can count because it is right there at the Pentagon, close to downtown DC, etc.
Also keep in mind that there is a lot of military traffic in the area. There have been efforts made to limit military traffic, primarily helicopters, from the area around DCA because of the congestion and safety issues. Those were ignored/overridden on the basis of national security (and convenience as well).
In an ideal world, the helicopter should have been to one side and gone behind the Piedmont CRJ at a safe distance. It should not have been coming up under it as it was landing.
The NTSB has already heavily hinted/indicated that a majority of the blame for the accident resides with the FAA, and I think they are correct. The lack of leadership, poor management (at all levels including the DoT) failed to address a number of issues, technical and human. I would put among them the long-standing failure to upgrade critical systems, a push for DEI over competence in hiring, and other efforts that inhibited recruitment. When you look at all the problems, the FAA failed at every level.
But, there is plenty of blame to go around. I suspect the controllers are going to take a few hits even with staffing/overwork as mitigating factors; and, the instructor pilot in the helicopter is probably going to take a hit or two despite the fact that without an accurate altitude neither he nor the instructee had no way of knowing they were not at the right altitude. Those of you who know aviation also already know that even if the instructee did make one or more mistakes, the failure to correct them (in time) lies with the IP.
As for all the wild speculation that the instructee kamakazied the Piedmont CRJ; that she failed to obey the commands of the IP; that she wasn’t competent as a pilot and shouldn’t have been flying; and all the other junk: the cockpit recorders and radio transmissions (nor her official background) in no way support those claims. In fact, if you look at the voice recordings, it sounds like a fairly typical learning flight. The IP issued guidance as needed, encouraged the instructee, and seemed to have no major issues with the instructee. Yes, the instructee was green in many respects, but that’s sorta the point of doing training flights. And again and again, without accurate altimeter readings in such a congested area bad things are going to happen.
From the reports, along with photos and diagrams released by the NTSB, it is quite possible that the helicopter and the CRJ may not have seen each other until the last second (if at all). The only people who seem to have done everything right and by the book are the crew of the CRJ. When finally did get warning, they did their best to avoid the crash. It is in no way their fault that they were not able to do so.
So, again, I suspect that the FAA is going to get the lion’s share of the blame (deservedly) for failures of leadership and gross incompetence; whether they get called out or not, DoT should catch some of that too; Army Aviation as a whole, along with senior leadership above them, bear a good bit of blame as well; the controllers on duty will be called out; and, it is likely that the IP will take a hit as well. Not named, though they should be, will be Congress who not only continued operations at DCA but expanded them against all informed advice.
Right now, one of my hopes is that the efforts begun in the wake of the crash to finally modernize the FAA systems using Commercial Off The Shelf technology (COTS) are indeed still underway. Elon and some of the DOGE team were providing advice and assistance and I hope his leaving government did not hamper those efforts (which a lot of entrenched interests in DC are opposed to since COTS doesn’t allow for as much graft and power). I also heard that recruiting efforts for controllers and other critical positions had DEI and other hobbles removed and there were a number of people looking to enter the field. Again, I hope that is continuing as it was and is desperately needed.
I agree with the NTSB assessment that this was one hundred percent avoidable. Had FAA management addressed issues and concerns instead of retaliating against those pointing out problems, this would never have happened. If Army aviation and other entrenched interests had not kept the helicopter route open despite strong advice not to, and if they had properly functioning aircraft, this would not have happened. If Congress hadn’t kept DCA open and expanded operations, this would not have happened. I could go on, but what happened is far more the result of an absolute failure of multiple leadership on multiple levels than anything else.
One of the other things I hope does come out of this is improved collision avoidance systems. We need what we have to work, and part of that lies with setting minimums and standards for lower altitudes. We need newer systems that can and will integrate and operate as noted in the report(s). We also need to be sure military and civilian systems will interoperate, especially in areas such as DC and DCA where there is heavy traffic in close proximity. Again the reports make some good points on that.
I hope some good can come out of this tragedy. I also hope that the final report, along with these reports and previous releases, will put to rest the unfounded and reprehensible speculations of a deliberate crash and/or an out-of-control helicopter trainee.
Getting hit by lightning is not fun! If you would like to help me in my recovery efforts, and to start a truly new life, feel free to hit the fundraiser at A New Life on GiveSendGo, use the options in the Tip Jar in the upper right, or drop me a line to discuss other methods. If you want to know some of what it is going for, read here. There is also the Amazon Wish List in the Bard’s Jar. It is thanks to your gifts and prayers that I am still going. Thank you.
