The NTSB enumerated more than 70 findings and issued 48 safety recommendations (32 to the FAA) in the meeting held to describe its final report into the collision of an Army Black Hawk helicopter and a PSA (operating as American Eagle 5342) CRJ700 at Washington National Airport on Jan. 29, 2025, that killed all 67 people on both aircraft. Probable cause was the use of a helicopter route that took the Black Hawk too close to the regional jet. Contributing factors included the visual separation granted the helicopter crew and cultural and safety issues with ATC at the airport. The findings and recommendations have been drafted but may change as the NTSB prepares a 500-page document resulting from what Chair Jennifer Homendy said was the board’s most complex investigation ever. The written findings are expected in a few weeks.
The board held a daylong meeting in Washington to release its findings and recommendations, but there were only a few new facts to be gleaned. Most of the material had already been covered in earlier public hearings or media scrums, and they painted the now-familiar picture of systemic and cultural issues within the FAA that seemingly paralyzed its ability to recognize and/or act on what should have been obvious hazards to flight safety. Part of the package is a simulated animation of what the pilots saw that night:
Among the new information was reference to a 2013 loss of separation in the same area as last year’s collision, which resulted in a recommendation from a working group that was formed because of the earlier incident that the helicopter route that the Black Hawk was using be moved or removed, according to testimony heard at the NTSB’s final board meeting on the collision on Tuesday. Among the myriad failings by the FAA, Army, and others directly and indirectly involved in the tragedy was the fact that the helicopter corridor, known as Route 4, had been repeatedly identified as a safety concern because it crossed perpendicular to the final approach for Runway 33 with as little as 75 feet of vertical separation, something found almost unbelievable by NTSB Chair Jennifer Homendy. “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?” she was quoted by People Magazine as saying during the hearing. That route was immediately closed after the Jan. 29, 2025, crash that killed all 67 people on both aircraft.
Another tragic tidbit of information concerned how close this disaster came to being nothing more than an ASRS report. The collision was far from the massive impact that seemed to be shown in the surveillance videos that captured that familiar flash followed by wreckage arcing into the black water below. The only point of contact between the two aircraft was one of the helicopter’s main rotors clipping the left wing of the airliner, which was banking left as it set up for Runway 33.
Other discussions were about concerns with staffing, staff morale, and the procedures to deconflict traffic. Although controllers repeatedly warned the Black Hawk of the presence of the regional jet, NTSB investigator Brian Soper told the meeting a “safety alert” should have been issued, according to the People coverage. It’s now thought the helicopter crew was looking at a different aircraft when it repeatedly assured the tower that it had the RJ in sight. Among the “culture” issues at the DCA tower was reliance on the granting of visual separation for deconfliction in the complex airspace.
The FAA got out ahead of the damning report with a rule that dealt with some of the NTSB’s findings that was released last week. As we reported, the rule made permanent the TFR that closed Route 4 and prevented the Army from running training and proficiency flights over the airport. The agency said Tuesday it will work with the NTSB to address the many issues raised in the forthcoming final report. The Army has not commented.
Yeah, the government posture around this has a strong CYA smell, even if some of the fixes are real. Thank you very much!
NOW given that there was a 2013 incident along with recommendations, I think it’s time that some head(s) roll on this one. There are 67 dead people in cemeteries because no one took appropriate action.
Further, the UH-1 didn’t have ADS-B ‘in’ … a mere Garmin portable in cockpit woulda alerted the crew that they were looking at the wrong traffic airplane.
I forgot that the helicopter was operating without their ADS-B out on, as well. This was a training flight … what logic would allow that … esp. when there were 2013 recommendations ? The FAA, SO fixated on safety — often to the point of excess — fell on its “sword” on this one. Imagine some Cessna driver operating right there without their ADS-B turned on … they’d be making little rocks out of big ones.
ADS-B is a red herring in this…in-close at high angular crossing rates, system lag would have you looking in the wrong spot anyway…and heads down trying to correlate multiple acft is going to cause other issues.
The real problem is stupid procedures that accepted known risk (and the near misses just proved what was evident to anyone who participated). Lumping in future ADS-B use as a “solution” makes it more likely that stupid procedures will survive because “ADS-B will fix it”…but won’t because you’re asking more of ADS-B than it was designed for (resolution, lag).
In a high density critical operating environment such as DCA, EVERY tool available should be used. I don’t disagree that the whole design of the flight patterns was problematic and was a primary cause. ADS-B direct has little lag and resolution can be increased. In my own airplane, I use an Aera 660 on the yoke dedicated to the traffic purpose. One of the things I recommended to the Army folks was to install and train the third crew member (crew chief or ??) in back to use a hard mounted Aera GPS watching for traffic while the pilots are flying. Imagine if that were the case here … while the training was going on, the person in back could have noticed the traffic and even maybe verified it and then notified the pilots.
In THIS case, there’s another “red herring” no one is addressing but ought to. The female officer flying was not normally assigned to flight duties … she was doing ceremonial tasks in the White House, et al. So she wasn’t as proficient as she might have been. They’re essentially retraining her and yakking while a critical phase of flight is occurring. The Warrant Officer instructor was in the left seat and likely looking right at her and DCA and the panel and not watching left where the airliner came from. I’d take a large wager that they never ever saw that airliner due to this. I have not heard any tower recordings that informed the Army crew that traffic was approaching from their left?
I just lost two friends in the crash of a TBM700 in WI while executing a missed approach in hard IFR conditions last November. I bring this up because it has shaken me to my core. I dove into the data heavily and found that ADS-B data is invaluable to establishing what happened second by second. After the fact analysis of same in this situation won’t reverse what happened but its use might have helped beforehand. I now view it similarly to the backup radar on new cars. It’s just one of the tools that are available and ought to be used IMHO. Were I the Commander of the Army unit, I’d order some COTS Garmin stuff for exactly this purpose. One Aera portable might have saved 67 lives, sadly.
Good comment however, ignored is the politics. Pre-GPS work by the Goldmuntz (PATCAC) committee under LBJ and RMN presented a menu of then-current ground-based technology that had accuracy and timeliness close to that of ADS-B. The controllers shied away from anything that might affect their jobs and the radar/transponder manufacturers joined them in ignoring the menu. The same cabal has stymied ADS-B, which FAA said in 2000 would be fully operational by 2010. That plus a watch-size computer could provide everything needed by the pilot, who is after all the real traffic controller. The vast, multi-billion-dollar ATC system exists primarily to provide him with the same info. ATC needs to sit back in backup mode and concentrate on ATM, which looms as the larger, but less stressful, problem.
I use ADS-B regularly, often in high traffic areas, I find it useful for general SA of field is busy or quiet or for long range deconfliction, in close it is a distractor as system has real time lag, and bearing shift or system ghosts become visual traffic distractors…even though you send your position out every second. Using every tool available is good…if it’s used within that tool’s capabilities, otherwise it adds to the problem
…but fix the underlying procedural stupidity (including who, when and where you train), conflicting routes/approaches and endorse/support ATC using the hammer to say “enough” when it gets unsafe.