On 29 January 2025 an Army Black Hawk and an airliner on final approach to Reagan National collided over the Potomac. Sixty-seven people died. A year later the National Transportation Safety Board adopted its report, and its finding of probable cause begins with the Federal Aviation Administration.
It's a lot of data that they request. They say they're data-driven. ATO did a top five every year, and it says they're data-driven. I would say they are not.
I was stunned, absolutely stunned, when Senators Jerry Moran and Duckworth held a closed-door briefing and invited me, invited the Army, invited FAA, and was asking us for an update and asking us questions, and data came up. And I talked about our 15,214 events that we've identified, the 210, the 85. And FAA said, actually, it's five. My five.
On the twenty-ninth of January, twenty twenty-five, at about eight forty-eight in the evening, a US Army Black Hawk helicopter and a passenger jet on final approach to Reagan National Airport collided about half a mile from the runway and fell into the Potomac River. Sixty-seven people died. Two pilots, two flight attendants and sixty passengers aboard the airplane, and all three crew aboard the helicopter. There were no survivors.
One year later the National Transportation Safety Board adopted its report. Four hundred and nineteen pages. The sentence that says why it happened begins with the Federal Aviation Administration.
Thank you, Chair. Today is a heavy day, and I do not think that is lost on any of us. This has been an incredibly difficult year for our agency and our investigators, the first responders to this accident, and the aviation community as a whole as we have mourned the loss of 67 lives nearly one year ago from an accident and tragedy that never, ever should have happened. As difficult as this year has been for so many, though, I know it has been most difficult for the family and friends who lost loved ones in this accident.
Whether you're here today with us, or online, or watching at a later date, please know that I, my fellow board members, and our entire agency mean it when we say we have not let a day go by when we are not thinking about your loved ones. They have been on our minds and in our hearts at each and every step of this process. Our investigation has been a grueling and challenging process, but I cannot imagine having to endure all of this in the eyes of the public. I will continue to pray for each and every one of you.
I imagine there will be some difficult moments today for all of us as we try to provide answers to how a multitude of errors led to this tragedy. There will be some times where individual errors may be noted throughout the course of the day in relation to this accident, but I want to make it crystal clear, any individual shortcomings were set up for failure by the systems around them. We are not here today to place blame on any individual or any organization, but we are here to ensure those systems that failed to protect 67 people on January 29th, 2025 never fail again. To that end, I remain steadfast in my commitment to forcefully advocate for all the safety recommendations we adopt today moving forward.
Thank you, Chair. Flight fifty-three forty-two was a scheduled passenger flight from Wichita, Kansas, operated by PSA Airlines for American Airlines. It had left Wichita at six thirty-eight that evening. The helicopter, call sign PAT twenty-five, had come from Davison Army Airfield at Fort Belvoir, Virginia, on a training flight - the pilot's annual standardisation evaluation, flown with night vision goggles.
Tragically, there were no survivors. The two pilots, two flight attendants, and 60 passengers aboard the airplane, and three crew members aboard the helicopter were fatally injured. I want to take a moment to address the families and friends of the 67 people who died. that day.
I imagine every day since January 29th has been incredibly difficult, and I imagine that today is even more difficult, and Thursday as we mark one year since this tragedy occurred, since you lost your loved ones. as a mom, I can only imagine all that you've been through. You are in our daily prayers. I pray for you every single day.
And on behalf of everyone at the NTSB, our entire agency, please accept our heartfelt condolences and our deepest, deepest sympathies. Unknowingly, you are also an inspiration to so many of us. You have, in the wake of absolute devastation, shown remarkable selflessness, courageously advocating for important reforms in aviation safety to save lives for others. I have no doubt that the information uncovered by our investigation will support all of your efforts to make aviation safer, to work towards a future where no family endures such tremendous loss.
Our Family Assistance Team and the American Red Cross are here today to provide support for anyone, The weather was clear. The tower had cleared the helicopter to cross the airport's airspace along two published helicopter routes and go home. It was a routine night, flown by a route that existed on a chart, at an altitude that was printed on that chart. The report prints the last minutes in three columns against a single clock.
The helicopter's cockpit voice recorder on the left, the tower's recording in the middle, the airplane's recorder on the right. This is the end of it. Nothing is read over these pages.
TOWER: PAT two five do you have that C-R-J in sight? [sounds of rapid beeping consistent with conflict alert audible in background] TCAS: traffic. traffic. [automated voice] TOWER: PAT two five pass behind that C-R-J.
[sounds of rapid beeping consistent with conflict alert audible in background] HELO: PAT two five has a— aircraft in sight request visual separation. [loud static in background] CREW: alright kinda come left for me ma'am I think that's why he's asking CREW: we're kinda EGPWS: plus hundred. [automated voice] CREW: oh-kay. fine TOWER: American four seventy two Washington Tower winds are three two zero at one seven— [sounds of rapid beeping audible in background consistent with conflict alert.
audible reaction in background before transmission cut off] CREW: [sound similar to mumbling] CREW: oh # CREW: ohhhh ohhhh. [louder voice] SOUND: [sounds consistent with impact]
analysis to identify and mitigate midair collision risk. Early in the investigation, the NTSB found insufficient separation between helicopter traffic on Route 4 and aircraft landing on runway 33, and recognized an alternate route for helicopters was needed to prevent a midair collision. As a result, the NTSB issued two urgent safety recommendations on March 11, 2025. The first recommendation asked to prohibit operations on helicopter route 4 between Hains Point and the Wilson Bridge when Runways 1-5 and 3-3 were being used at DCA.
The second recommendation asked to designate an alternative helicopter route that could be used to facilitate travel between Hains Point and the Wilson Bridge when that segment of Route 4 was closed. Immediately following the accident, the FAA implemented temporary airspace restrictions around DCA. Helicopter Route Four runs along the eastern shore of the Potomac, past the end of runway thirty-three. The report measures it.
At an altitude of two hundred feet, a helicopter over the eastern shoreline would have about seventy-five feet of vertical separation from an airplane approaching runway thirty-three. And that distance decreases the further west of the shoreline the helicopter is flown. you want to put it, stuck in red tape and bureaucracy of a very large organization somehow didn't make it up. Repeated recommendations over the years, so much so that DC Tower took it upon themselves to create a helicopter working group because they had concerns.
How is it that no one, absolutely no one, in the FAA did the work to figure out there was only 75 feet, at best, 75 feet of vertical separation between a helicopter on Route 4 and an airplane landing on runway 33? how is it nobody until we did this investigation? That's a great question and we've asked the same question among staff and that's precisely why we have recommended the assessment of these helicopter routes not just what was there at the time but everything that exists today for this airport they've conducted others but we're focused on this one right here so we have recommended that in our recommendations. Yeah in fact in our in our findings of urgent recommendation report.
We stated existing separation distances between helicopter traffic operating on Route 4 and aircraft landing on runway 33 are insufficient and pose an intolerable risk to aviation safety by increasing the chances of a midair collision. I'm going to ask Mr. Banning and Mr. LeBaron, your pilots, is there anywhere in our airspace that 75 feet of vertical separation is acceptable?
I'd say not to me, as a pilot. Yeah, not that I'm aware of. Absolutely not, absolutely not. The routes the Administration established have no lateral boundaries.
The chart does not say how far from the shoreline to stay, because there is no line to stay inside of. Army pilots interviewed after the accident said they flew at or below two hundred feet, along the east bank. That is the width of the margin: seventy-five feet, above a route with no edges. The Board's investigators reconstructed what each cockpit could see.
Not what was there - what was visible, from those two seats, at those angles, at that time of night. That study is the next eight minutes, as the Board published it. This animation presents a simulated view from the right seat of the helicopter. A dark gray structural mask generated from a three-dimensional laser scan of an exemplar aircraft is overlaid on the scene.
A light gray mask depicts the mounting structure of the night vision goggles positioned for the instructor pilot looking straight ahead. The green tint mimics a green phosphor visual effect, but the actual behavior of the night vision goggles has not been simulated. Crew communications transcribed from the cockpit voice recorder are shown as text at lower left. Audio recordings of air traffic control communications on the helicopter frequency are synchronized with the animation.
with corresponding transcript text displayed in the center. Radio interference blocked some transmissions from the local controller and other helicopters. Transmissions that were blocked are indicated by striking through words in the transcript. A moving map depicting the locations of PAT25 and Flight 5342 and synchronized with the view from the cockpit will be shown at lower right.
PILOT: slowin' American thirty one thirty TOWER: PAT two five traffic just south of the Wilson Bridge is a C-R-J at one thousand two hundred feet circling runway three three HELO: PAT two five has the traffic in sight request visual separation. [loud static during transmission] TOWER: vis separation approved TOWER: American sixteen thirty tower runway one line up and wait traffic three out circling runway three three additional traffic on six mile final PILOT: line up and wait runway one American sixteen thirty PILOT: tower Muscle seven approaching Springfield request route three to zone six PILOT: tower Muscle seven approaching Springfield request route three to zone six. [loud static during transmission, transmission stepped on by simultaneous transmission from airplane frequency] PILOT: American four seventy two by KATRN runway one PILOT: American four seventy two by KATRN runway one. [transmission simultaneous with Muscle 7 transmission] TOWER: Muscle seven stand by ha ha CREW: ha TOWER: Bluestreak fifty three zero seven keep rolling out to november ground point seven good day PILOT: november fifty three zero seven CREW: he's got'em stacked up tonight CREW: (yeah/kinda) busy CREW: alright three three zero so now we've pretty much got a right quartering tailwind going to be pushing you CREW: yeah PILOT: National Tower good eveining AirCare one's with you a single medivac heli— [transmission cut off by next tower transmission] TOWER: American sixteen thirty winds are three two zero at one four gusts two five traffic two mile left base runway three three no delay runway one cleared for immediate takeoff CREW: crabbing CREW: yeah CREW: better not to fight the wind PILOT: number one cleared for takeoff American sixteen thirty CREW: right pedal This animation presents a simulated view from the right seat of the CRJ.
A dark gray structural mask generated from a three-dimensional laser scan of an exemplar aircraft is overlaid on the scene. Crew communications transcribed from the cockpit voice recorder are shown as text at lower left. Audio recordings of air traffic control communications on the airplane frequency are synchronized with the animation with corresponding transcript text displayed at lower right. A movie map depicting the locations of both aircraft synchronized with the view from the cockpit is shown at upper left.
CREW: visual three three SOUND: [sound of cavalry charge consistent with autopilot disconnect] CREW: that's me I got ten plus PILOT: okay cleared to land runway one American thirty one thirty CREW: all checks we're configured yep [sound of switch] what'd ya say? CREW: yeah we are configured. you want me to uh clear the flight director and everything? CREW: uhhh sure why not CREW: all right TOWER: Jazz seven eight nine contact Potomac Departure good day PILOT: have a good day TOWER: American thirty one thirty slow to final PILOT: slowin' American thirty one thirty TOWER: PAT two five traffic just south of the Wilson Bridge is a C-R-J at one thousand two hundred feet circling SOUND: [sound of tone consistent with altitude alert] runway three three HELO: PAT two five has the traffic in sight request visual separation.
[loud static during transmission] CREW: uhhh I gotta level off TOWER: vis separation approved TOWER: American sixteen thirty tower runway one line up and wait traffic three out circling runway three three additional traffic on six mile final CREW: all right PILOT: line up and wait runway one American sixteen thirty PILOT: tower Muscle seven approaching Springfield request route three to zone six PILOT: tower Muscle seven approaching Springfield request route three to zone six. [loud static during transmission, transmission stepped on by simultaneous transmission from airplane frequency] PILOT: American four seventy two by KATRN runway one PILOT: American four seventy two by KATRN runway one. [transmission simultaneous with Muscle 7 transmission] TOWER: Muscle seven stand by Bluestreak fifty three zero seven keep rolling out to november ground point seven good day EGPWS: one thousand. [automated voice] SOUND: [sound of click consistent with verifying spoilers are stowed] thousand feet CREW: stable spoilers stowed confirm missed approach altitude set PILOT: november fifty three zero seven CREW: uh two thousand two hundred set PILOT: National Tower good eveining AirCare one's with you a single medivac heli— [transmission cut off by next tower transmission] TOWER: American sixteen thirty winds are three two zero at one four gusts two five traffic two mile left base runway three three no delay runway one cleared for immediate takeoff PILOT: number one cleared for takeoff American sixteen thirty TOWER: Muscle seven say request and Muscle seven request route three to zone six PILOT: yeah Muscle seven request route three to zone six.
[loud static during transmission] TOWER: Muscle seven you say route three to zone six? a-firm Muscle seven PILOT: a-firm Muscle seven. [loud static during transmission] TOWER: Muscle seven approved Muscle seven PILOT: Muscle seven. [loud static during transmission] American four seventy two Mount Vernon Visual ...
one PILOT: American four seventy two Mount Vernon Visual one. [transmission stepped on by simultaneous transmission from helicopter frequency] PILOT: National Tower good evening AirCare one is with you single medivac helicopter one thousand feet two niner niner one on the altimeter requesting zone six for Fairfax. [transmission made during previous airplane transmission] TOWER: medivac AirCare one Washington Tower National altimeter two niner niner zero. approved through Washington class bravo airspace report landing assured at Fairfax EGPWS: five hundred.
[automated voice] CREW: five hundred feet on top of the bug sinking seven stable two niner— two niner niner zero for AirCare one copies CREW: checks CREW: I got two white two red cool TOWER: [two brief mic keys with rapid beeping audible in background consistent with conflict alert] TOWER: PAT two five do you have that C-R-J in sight? [sounds of rapid beeping consistent with conflict alert audible in background] TCAS: traffic. traffic. [automated voice] TOWER: PAT two five pass behind that C-R-J.
[sounds of rapid beeping consistent with conflict alert audible in background] HELO: PAT two five has a— aircraft in sight request visual separation. [loud static in background] TOWER: vis separation PILOT: American four seventy two by BADDN Mount Vernon Visual EGPWS: plus hundred. [automated voice] TOWER: American four seventy two Washington Tower winds are three two zero at one seven— [sounds of rapid beeping audible in background consistent with conflict alert. audible reaction in background before transmission cut off] SOUND: [sound of click] oh # ohhhh ohhhh.
[louder voice] SOUND: [sounds consistent with impact]
in the belief that route four was procedurally separate that if they were on that they would be separated from fixed wing traffic arriving three three departing one five oh yes sir I did you had you had that thing and was that a similar belief across the unit yes sir following the incident I contacted many of my fellow co-pilots that were there and everybody had the same assumption that we were not allowed to cross the departure and approach path one five three three while on route four we were always told to hold at the golf balls down by the sewage treatment plant just northeast of Wilson Bridge or at Hains Point which I'd done 100% of the time when I was on route four and 3315 was active. Okay so that kind of that may have confused a little bit so your so the belief there would have been that you did not believe it was procedurally separated because procedurally separated just so we have an understanding when I say procedurally separated, meaning if you fly that route at the altitude you're supposed to and an aircraft flies that approach the way they're supposed to, they will have appropriate The report states it as a finding. The majority of Army pilots interviewed incorrectly assumed that flying at or below the published route altitudes provided inherent separation from fixed-wing traffic arriving at and departing the airport. They believed the route kept them clear.
The route did not keep them clear. risk of security as paramount. Knowing ADS-B out, the signals it sends out, we assessed that was a risk that could be mitigated. So, the policy the day of the accident was to have ADS-B out, off, any time you are conducting anything related to the mission, i.e.
flying near a mission route or location. And what guidance did you have to develop this policy? At the time of the accident it was Army policy and which we were in compliance with in addition to the MOU between the DoD and the FAA. Thank you.
And when they when the aircraft are operating ADS-B out off are they required to broadcast mode C a 3A and C? Yes they are. And one part of the SOP states the air crews are not to for. So some of this might be redundant, but I think the question will be asked a little bit different, and so I'm interested in your answer.
FAA regulations allow DoD aircraft to turn ADS-B out off when performing sensitive or classified operations in the national airspace. For national defense, homeland security, intelligence, or law enforcement purposes, and when transmitting ADS-B out would compromise the mission or pose a safety risk to the aircraft, crew, or people and property in the air and on the ground. A memo from the Department of Army dated August 9th, 2024 outlines when ADS-B out should be turned off within the national airspace. It states that air crews conducting sensitive or classified operation shall consider during pre-mission planning, operating their transponder collision avoidance, situational awareness, and other onboard systems to emit the least flight information required to meet airspace access and safety requirements.
Before I continue on on that, what is a local orientation, The helicopter carried no integrated traffic display. The crew did have tablets running an application that could show nearby traffic and could have given them a visual and audible alert forty-eight seconds before the collision. Army pilots did not typically use it that way. goggles.
So that's not part of their training? No, ma'am, that's not. Okay. Were you ever, did you have any knowledge, was it a surprise to you that there was a max of 75 feet vertical separation at the bank of the east bank of the potomac where the glide slope for 33.
Yes ma'am that was shocking based on the hundreds and hundreds of hours I flew in this area like like I said I did not think that was allowed for a helicopter to be on that route while landing runway 33, 15. And this might be this might not be a fair question and you're welcome to get back to But how if you did know that before how would that have changed your operations? If I knew that that there was the vertical separation 75 feet I would have I would have told pilots not to Cross the center line of the approach path until you saw the aircraft either take off or land Thank you very much member in men. Well first member Graham member in men I just want to make sure we've got the ability to go as long as we need to, but that we can There is a further problem with the altitude, and it is not the crew's judgement.
The report finds the Army did not ensure its pilots were adequately informed about the error tolerances allowed in barometric altimeters. The crew was flying above the published maximum for the route while reading an instrument that was within specification. The second layer is ATC separation or remain well clear actions by the pilot during the flight. We talked about this a lot yesterday, so our conflict probe, our air traffic control separation support is that middle layer.
And then the last layer is the collision avoidance layer. So this is now the pilot where the middle layer is air traffic control, the last layer is legally, squarely the responsibility of the pilot. And as Dr. Kasner said, this last layer is hard for the pilot to do just by vision.
The see and avoid requirement there is hard. And so over the years, we've developed a large number of systems that support the pilot in the task of the visual acquisition or the avoidance of other aircraft. And those systems, they fall in the two categories. We already mentioned them.
The first category is a traffic alerting system. So this provides alerts to the pilot on where the aircraft is. It's usually what we call a yellow level alert, so it's a caution, which requires immediate attention by the pilot, but the pilot still needs to determine whether an action is actually necessary. And then the second category of systems is a collision avoidance system, which also provides an escape maneuver.
So those are usually red level alerts, immediate attention by the pilot, immediate action by the pilot. And as I mentioned, it's directive. So it tells the pilot how to avoid a hazard or a conflict in midair. So this is all, this existed all before the introduction of ADS-B.
And it used, a lot of the sensors that are used in these systems are effectively 1980s technology. So they ping, they interrogate other aircraft, they wait for a reply, they time how long that takes, that gives you an estimate of range. You watch range over time and you can tell whether the aircraft is getting closer or not. Mind you, when you have range, you don't know if the aircraft is in front of you or behind you or wherever, you just have range.
You have range rate by watching it over time and in the reply from the aircraft, you get altitude. So you have three parameters, range, range rate, and altitude, and that's the information you have to decide whether you're going to avoid or try to do something about this aircraft in your vicinity. And this is where actually a lot of these systems struggle because what you do when And the last protection was already switched off. On an airplane that is descending, the collision avoidance system stops issuing avoidance instructions below nine hundred feet above the ground.
It is deliberate - the alerts would be constant that low, and they would be wrong. Below that height the system will still say there is traffic. It will not say what to do about it. The two aircraft met at roughly three hundred feet.
The controllers, asked at the hearing, said they had not been aware of that. First question is for Mr. Allen Prior to the accident, were controllers aware that aircraft TCAS resolution advisories are inhibited below 900 feet? Not that I'm aware of.
Do they know that today? Anyone on the panel, perhaps? I can't say every controller knows that, but we have distributed some lessons learned and put some of that information out. So now that some, if not all, are aware, first off, can you make them all aware?
Is that a possibility? Yeah, definitely. You've given me some great ideas this week. We're certainly happy to jot some of these information items down this year.
Thank you, sir. And then One person in the tower was working the airplanes and the helicopters at once. The two positions had been combined during a period of heavy traffic, and the report finds there was no structured process for making that decision in real time. Workload degraded the controller's performance and situational awareness.
Traffic advisories were incomplete. No safety alert was issued to either crew.
Flight 5342 was just south of the Wilson Bridge and PAT25 was over the Tidal Basin. PAT25 stated that they had traffic in sight and requested visual separation, which the tower approved. 15 seconds before the collision, DCA tower contacted PAT25 a second time and asked if they had the CRJ in sight. At this time, the aircraft were about one and a quarter miles apart.
Based on information obtained from the CVR, the crew of PAT25 did not hear the controller's instructions to pass behind the CRJ. PAT25 again stated that they had the aircraft in sight and requested visual separation. The controller approved. The collision occurred about 8 47 and 59 seconds p.m.
Eastern Standard Time. At the time of the accident, one controller at DCA tower was managing both airplane and helicopter traffic. During the final two minutes of the accident flight, the controller spoke to six different aircraft, including PAT25. As mentioned in the animation, all aircraft could hear the controller, but helicopters could only hear other helicopters on their frequency, and airplanes only other airplanes.
Air traffic control procedures will be discussed as part of panel three. This photograph from the interior of the DCA air traffic control tower shows the view to the southeast across the Potomac River. Traffic displays can be seen overhead. The traffic displays can be moved to suit the needs of the staff in the tower.
This animation presents a simulated view from the tower. The point of view was based on the local controller's recollection of his position. The local controller could have changed position or orientation slightly on the night of the accident. The underlying animation was produced by the Federal Aviation Administration Target Generation Facility Simulation Branch.
A dark gray structural mask generated from a three-dimensional laser scan of the tower conducted by NTSB staff is overlaid on the scene. Audio recordings of air traffic control communications are synchronized with the animation. Local controller broadcasts are shown in text at lower left. Aircraft broadcasts are shown in text at lower right.
TOWER: American sixteen thirty winds are three two zero at one four gusts two five traffic two mile left base runway three three no delay runway one cleared for immediate takeoff PILOT: number one cleared for takeoff American sixteen thirty TOWER: Muscle seven say request and Muscle seven request route three to zone six PILOT: yeah Muscle seven request route three to zone six. [loud static during transmission] TOWER: Muscle seven you say route three to zone six? a-firm Muscle seven PILOT: a-firm Muscle seven. [loud static during transmission] TOWER: Muscle seven approved Muscle seven PILOT: Muscle seven.
[loud static during transmission] American four seventy two Mount Vernon Visual ... one PILOT: American four seventy two Mount Vernon Visual one. [transmission stepped on by simultaneous transmission from helicopter frequency] PILOT: National Tower good evening AirCare one is with you single medivac helicopter one thousand feet two niner niner one on the altimeter requesting zone six for Fairfax. [transmission made during previous airplane transmission] TOWER: medivac AirCare one Washington Tower National altimeter two niner niner zero.
approved through Washington class bravo airspace report landing assured at Fairfax PILOT: two niner— two niner niner zero for AirCare one copies TOWER: [two brief mic keys with rapid beeping audible in background consistent with conflict alert] TOWER: PAT two five do you have that C-R-J in sight? [sounds of rapid beeping consistent with conflict alert audible in background] TOWER: PAT two five pass behind that C-R-J. [sounds of rapid beeping consistent with conflict alert audible in background] HELO: PAT two five has a— aircraft in sight request visual separation. [loud static in background] TOWER: vis separation PILOT: American four seventy two by BADDN Mount Vernon Visual TOWER: American four seventy two Washington Tower winds are three two zero at one seven— [sounds of rapid beeping audible in background consistent with conflict alert.
audible reaction in background before transmission cut off] The two aircraft were also on different radio frequencies, so neither crew could hear what the other was told. And the aeronautical charts used by airline pilots did not show the helicopter routes that crossed their approach. Seventeen seconds before the collision the controller said: PAT two five, pass behind that C R J. One of the helicopter crew pressed their radio switch for eight tenths of a second while he was speaking, and the words pass behind that never arrived.
The crew answered the half of the sentence they had heard. In nineteen eighty-four the Administration was petitioned to require radios that cannot be blocked this way. That was forty-one years earlier. It's okay, we can always come back.
Mr. Lehman. Direct pressure? No.
Indirect pressure. Any type of pressure? I don't get a chance to talk to the airlines directly. I've never met Mr.
Silverman until today. Do I feel the pressure from the command center? Yes, I do feel the pressure from the command center. And I want to add to that, I feel like our ratio of safety to efficiency has gone slightly too far towards efficiency.
Mr. Allen you had your finger kind of raised for a moment. I had a moment I remembered. I was gonna say the pressure would be internal to the agency to maintain the status quo and move the traffic and unless you have a good reason why not to.
So I guess the Between October twenty twenty-one and December twenty twenty-four there were nine hundred and forty-four thousand, one hundred and seventy-nine commercial operations at the airport. In the same period there were fifteen thousand, two hundred and fourteen occurrences in which a commercial airplane and a helicopter came within one nautical mile of each other laterally and four hundred feet vertically. An average of three hundred and ninety a month. Two-thirds of them at night.
I think that these safety reporting systems are vital, and they serve an important purpose, And we would hope and we would like to believe that when a pilot or a controller files a voluntary safety report that it will be looked at and will be considered very seriously. And like I said, there is some evidence that there was some case-by-case analyses of reporting, but I think the pattern was missed. And that's where we've proposed recommendations that we think can get at that. Thank you.
So we looked at, for different separations, less than one nautical mile lateral, less than 400 feet vertical. This is something we worked out with FAA and looking at the data and that gave us the 15,214. Then we looked at less than 600 feet lateral, less than 400 vertical, it gave us 210, and then less than 1,500 feet lateral and less than 200 feet vertical, which gave us 85, right? And so, you know, so the FAA has 10 different sources of data that they're taking in.
It's a lot of data that they request. They say they're data-driven. ATO did a top five every year, and it says they're data-driven. I would say they are not.
I was stunned, absolutely stunned, when Senators Jerry Moran and Duckworth held a closed-door briefing and invited me, invited the Army, invited FAA, and was asking us for an update and asking us questions, and data came up. And I talked about our 15,214 events that we've identified, the 210, the 85. And FAA said, actually, it's five. My five.
And you know, this isn't the first time. Eighty-five of them were closer than one thousand five hundred feet laterally and two hundred feet vertically. This was not gathered afterwards. It is the Administration's own data, recorded as it happened, for three years, before anyone died.
at some of these data through more of the compliance lens. The FAA certainly has the capability to look at data in a more holistic way. We do have evidence that, for example, the ASIAS program is doing that and that it is being done. I don't want to say that it's not being done, but in this instance, with these particular types of data, we did feel like they weren't looking at it in kind of an aggregate or big-picture risk focus, but rather a compliance-based way.
And I think that's a nice way of saying it, probably. But I would offer, again, the same thing. Are we going to five years from now be saying we're seeing something that the data was there again? Because it seems like every two or three years, it's almost whack-a-mole, we continually go back and say, oh, they're looking at it, they're trying, and then we just come back and we have another incident.
Well, one of the recommendations that staff has proposed has to do with establishing, asking F8 to establish a standard measure of close proximity, making that public, and then creating a database so that all of the stakeholders can have access to those data so that people can conduct analyses and be aware of these types of events. So is it the public's responsibility or is it FAA's? Five weeks after the collision, with the investigation nowhere near finished, the Board issued an urgent recommendation: close that segment of Route Four whenever those runways are in use. It called the existing separation an intolerable risk.
The route had been open the night before. or June 11th at a Senate meeting that somehow are 80 out of 15,214 events and then 210 events and then 85 events of 1,500 foot lateral and 200 foot vertical that it's actually five. I actually I had never heard that and we don't even know where that came up okay it came from because this information we got was from you all and the information you provide senators was from actually from I don't know NMAC or whatever you call it. I mean I'm not gonna play the data game with you guys anymore.
It's actually a well-known thing that every time we come out with data you're gonna come out with some other data the night before and that data should have been shared with our IIC according to your order, so I just don't understand. Either we're gonna work together on safety and on this investigation or we're gonna continue to ask for data and you're gonna continue to say no or whittle down data that we received from you. I just don't understand it. It's not helpful.
It just looks like you're trying to hide things, which I don't think you are. Yes, you can respond. Thank you and you're, thank you for the last part we definitely don't want to hide anything and if anything we want to be transparent with our data. What I'd like to ensure and I'll work with the ATO is if there's a data request that we don't understand or there might be some problems then let's work together to make sure that we can get you or at least articulate exactly what you need so you can complete your investigation.
I feel like everyone that I work The final report goes further back. Contributing to the accident, it finds, was the Administration's failure across multiple organisations to act on previous recommendations, and to follow its own safety management system - the system that was supposed to turn identified risk into change. The risks were known to management. A probable cause is one sentence.
It is drafted by the staff, and then the Board sits in public and decides, clause by clause, what it will say. The draft named the Administration - but not first. It opened: the placement of a helicopter route in close proximity to a runway approach path. A thing that had been placed.
In that clause, nobody had placed it.
are back. Mr. Curtis, can you read the proposed probable cause? Certainly, Chair.
Staff proposes the following probable cause. The NTSB determines that the probable cause of this accident was the placement of a helicopter route in close proximity to a runway approach path with no procedural mitigations to separate helicopter and fixed wing traffic. The FAA's inadequate evaluation and review of data that indicated the risk of a midair collision in that area and their failure to act on recommendations to mitigate that risk. Also causal was the Air Traffic System's over-reliance on visual separation in order to promote efficient traffic flow without consideration for the limitations of the see and avoid concept.
and the Army's lack of a fully implemented safety management system, which should have identified and addressed hazards associated with altitude exceedances on the Washington, D.C. helicopter routes. These systemic failures allowed for a midair collision after the helicopter crew was unable to apply visual separation due to the misidentification of the location of the airplane. Contributing factors include the limitations of the traffic awareness and collision alerting systems on both aircraft, which precluded effective alerting of the impending collision to the flight crews, the high workload of the controllers due to the combination of the local and helicopter control positions, and the absence of effective data sharing and analysis among the FAA, aircraft operators, and other relevant organizations.
Chair. Thank you. Well, we all had some changes, so I'm gonna recognize Member Graham. Thank you, Chair, and I appreciate staff and the individual members of working individually with me on this I I move to amend the probable cause to read and I'm not even gonna write well I guess you got a red line in there that's pretty good I'm just gonna read the whole thing because I can't read through those red lines right now the NTSB my my motion is to amend the and the probable cause to read the NTSB determines that the probable cause of this accident was the FAA's placement of a helicopter route in close proximity to a runway approach path, their failure to regularly review and evaluate helicopter routes and available data, and their failure to act on recommendations to mitigate the risk of a midair collision near Ronald Reagan Washington National Airport, as well as the Air Traffic System's overreliance on visual separation in order to promote efficient traffic flow without consideration for the limitations of the see and avoid concept.
Also causal was the lack of effective pilot applied visual separation by the helicopter crew which resulted in a midair collision. Additional causal factors were the tower team's loss of situational awareness and degraded performance due to a high workload of the combined helicopter and local control positions and the absence of a risk assessment process to identify and mitigate real-time operational risk factors, which resulted in mis-prioritization of duties, inadequate traffic advisories, and the lack of safety alerts to both flight crews. Also causal was the Army's failure to As adopted, it reads: the Federal Aviation Administration's placement of a helicopter route in close proximity to a runway approach path; their failure to regularly review and evaluate helicopter routes and available data; and their failure to act on recommendations to mitigate the risk of a midair collision as well as the air traffic system's overreliance on visual separation in order to promote efficient traffic flow, without consideration for the limitations of see-and-avoid.
have to finish okay there you go perfect any other comment vote vote all right board this is in favor of amendment to recommendation 30 member Graham aye member Inman yes chairman hominy hi all in favor chair great next is I'm finding it I'm going to turn to member Graham Thank You chair I have three new recommendations to the FAA so I'll go one at a time if you could call up amendment 14 please I'll go ahead and start right here we go I move to for a Route Four is closed at the Potomac now. The charts have been redrawn. The recommendations run to dozens, and they go to the Administration, to the Army, and to the makers of the equipment that did not warn anybody. Fifteen thousand two hundred and fourteen times in three years, two aircraft came close enough to be counted.
Every one of them was recorded. Every one of them was recorded by the agency that had drawn the route. The counting was not the hard part.
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