374 NTSB Preliminary Report Out for Reagan National Midair Collision over Potomac River
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Hello again and welcome to a Newsmakers Edition where we talk about people making the news. Earlier today, the NTSB released the preliminary report regarding the U.S. Army Black Hawk helicopter in a PSA Airlines regional jet that collided over the Potomac River in late January. In addition, both the NTSB and the Department of Transportation held press conferences about the accident.

Today I'll be talking about the new information found in that preliminary report, and you'll hear audio clips from both of those press conferences. So please stick around because this Newsmakers Edition starts now. Hello again and welcome to Aviation News Talk, where we talk general aviation. My name is Max Truscott. I've been flying for 51 years. I'm the author of several books and the 2008 National Flight Instructor of the Year. And my mission is to help you become the safest possible pilot.

Last week in episode 373, we talked with Ron Ferry-Donova about what pilots need to know about flying a small plane to Mexico and to other countries. So if you didn't hear that episode, you may want to check it out at aviationnewstalk.com slash 373. And if you're new to the show, please touch either the subscribe key or the follow key in whatever app that you're listening to us on so that next week's episode is downloaded for free. And if you've been listening to the show for a while and feel that you're getting value from it,

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Now let's start with some clips of NTSB Board Chairman Jennifer Homendy speaking at the NTSB press conference today. Later, you'll hear clips from Department of Transportation Secretary Sean Duffy. And then finally, I'll share some of the new pieces of information in the NTSB's preliminary report. Here's the first clip. Information gathered from voluntary safety reporting programs and the FAA is

regarding encounters between helicopters and commercial aircraft near DCA show that from 2011 through 2024, a vast majority of reported events occurred on approach to landing.

Initial analysis found that at least one Traffic Alert and Collision Avoidance System, or TCAS, resolution advisory was triggered per month from 2011 through 2024 at DCA due to proximity to a helicopter.

TCAS resolution advisories, or RAs, unlike traffic advisories or TAs, are recommended escape maneuvers. For example, climb or descend, level off.

Keep in mind that a TA is issued when the intruding aircraft is about 20 seconds from the closest point of approach or 0.3 nautical miles, whichever occurs first. They are advisory. RAs indicate a collision threat and require immediate action.

In over half of the encounters we reviewed again from 2011 through 2024, the helicopter may have been above the route altitude restriction. Two-thirds of the events occurred at night.

We then reviewed commercial operations at DCA and found that between October 2021 and December 2024, there were a total of 944,000

179 commercial operations at DCA. These are instrument flight rules or IFR departures or arrivals. Again, that number is 944,179 commercial operations at DCA.

During that time, again October 2021 through December 2024, there were 15,214 occurrences or close proximity events between commercial airplanes and helicopters in which there was a lateral separation distance of less than one nautical mile

and vertical separation of less than 400 feet. There were 85 recorded events that involved a lateral separation of less than 1,500 feet

and vertical separation of less than 200 feet. So this means a little more than two times a month and mostly at night, helicopters and aircraft got closer than 1,500 feet, which is a quarter of an nautical mile, and less than 200 feet vertically from each other. When you consider how operations are conducted at most airports in the U.S., that is a stunning revelation.

And this is an excellent example of normalization of deviance. You may recall that we interviewed Mike Goulian about his experience in his own flying with normalization of deviance in episode 153, which you can find at aviationnewstalk.com slash 153.

Normalization of deviance occurs when individuals or organizations gradually accept risky behaviors as normal due to repeated success without negative consequences. Over time, deviations from standard procedures become routine, which increases the likelihood of failure or even disaster.

Here are some factors that can lead to normalization of deviance. One, prior success despite risky behavior. When deviations from standard procedures don't immediately lead to failure, people begin to believe the risks are lower than they actually are.

2. Organizational and cultural pressures. Pressures to meet deadlines or reduce costs can encourage cutting corners. And if senior personnel or colleagues normalize a deviation, new members quickly adopt the same behaviors. 3. Lack of negative feedback. If errors or deviations don't result in immediate failure, organizations may assume that no harm is being done. 4. Erosion of standards over time.

Small deviations can slowly escalate, so what starts as a one-time exception can turn into a common practice. 5. Cognitive biases and human nature

One of those biases is optimism bias, where people believe bad outcomes won't happen to them. And another is confirmation bias. If past deviations didn't cause harm, people assume they never will. Six, insufficient oversight and accountability, weak safety culture, and lack of internal audits allow bad habits to go unnoticed or uncorrected.

And seven, in dynamic environments like aviation, evolving conditions can lead to gradual shifts in how rules are applied. Here's our next clip from Chairman Hamadi. As a result of the accident, U.S. Department of Transportation Secretary Sean Duffy took swift action.

to ensure safety and restrict helicopter traffic from operating over the Potomac River at DCA until March 31st. And I want to commend him for that and commend the work of the FAA to also take swift action.

As that deadline nears, we remain concerned about the significant potential for a future midair collision at DCA, which is why we are recommending a permanent solution today. On the chart to my right is a cross-section of the airspace that extends from runway 33's center line, spanning from the runway to the east bank of the Potomac River.

The figure shows the separation distance that would exist according to FAA charts, with a helicopter on Route 4 and an airplane descending on the glide slope to Runway 33.

As stated in my last press conference and confirmed by the FAA, helicopter routes established by the FAA have no lateral boundaries. And the Baltimore-Washington helicopter route chart includes no warning for helicopters to operate a defined distance from the shoreline. So this shaded region right here represents an approximation of the area in which helicopters could be flown.

We know that the helicopter on the accident date was not in this area. It was to the west. But at the maximum altitude here of just 200 feet, a helicopter operating over the eastern shoreline of the Potomac River would have just 75 feet of vertical separation from an airplane approaching runway 33. 75 feet.

that distance decreases if the helicopter is operated farther from the shoreline. And again, this helicopter, the Black Hawk, was operated farther to the west. We've determined that the 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 mid-air collision at DCA. Let me repeat that. They pose an intolerable risk to aviation safety. We're therefore recommending today that the FAA permanently prohibit operations on helicopter Route 4 between Haines Point and the Wilson Bridge when Runways 1-5

and 3-3 are being used for departures and arrivals at DCA. And now we're going to skip ahead a little to the NTSB's second recommendation. So we are also recommending that the FAA designate an alternative helicopter route that can be used to facilitate travel between Haines Point and the Wilson Bridge when that segment of Route 4 is closed.

So in the first of those two clips, the chairman said that there is approximately 75 feet separation between the routes. It appears the helicopter was flying higher than 200 feet. You may recall that I said in a prior episode that it's easy to try to blame a pilot if

or a controller for this crash, but that a new safety approach would look at the systemic conditions that led to the crash and not assign blame to an individual. As I said previously when talking about this accident, if pilots always got killed whenever they're 100 feet high, we'd all be dead. So it's clear that the margins were too small. I mean, it's absurd to think that 75 feet is adequate separation between routes.

So given the root structure that was in place, this was an accident that was bound to happen someday. It was just waiting to happen. All pilots and all controllers make mistakes. So we have to have margins in our systems that are big enough to accommodate these normal variations that occur. Now let's listen to this clip from Department of Transportation Secretary Sean Duffy. I want to also talk about another point that Chair Homany brought up.

that over the last two and a half years there have been 85 near misses or close calls. And that is close calls that are within 200 feet of vertical separation and 1500 feet of lateral separation. Incredibly close for aircraft. 85 of them. I think the question is when this data comes in, how did the FAA not know? How did they not study the data to say, hey, this is a hotspot.

We're having near misses and if we don't change our way, we're going to lose lives. That wasn't done. Maybe there was a focus on something other than safety. But in this administration, we are focusing on safety. And so what the FAA has deployed is AI tools to make sure we can sift through the data

and find hotspots in our airspace at our airports. So if there's another DCA-esque situation out there, our AI tools will help us identify those and take corrective actions preemptively as opposed to retroactively.

Sean raises a good question. How did the FAA not know that this many near misses were occurring at the DC airport? And I think the answer is that many people knew that there was an issue here, including the FAA. The TCAS data was available since for a number of years, pilots have been required to report whenever their TCAS generates an RA or resolution advisory. In challenging situations, pilots and controllers tend to suck it up to try to make things work out.

And in this case, that worked for many years. And the FAA probably tolerated these many close calls because it was the nation's capital. There is a tremendous amount of helicopter traffic, almost all of it from one government agency or another. And I'm sure that the FAA wanted to help out their federal partners as much as possible. So everyone just grew to accept a situation that probably wouldn't have been tolerated if all these helicopters were from a local flight school.

Now, it's ironic that the FAA has pushed the adoption of safety management systems, or SMS, into airlines and now Part 135 charter companies, and it has its own internal SMS systems. Yet, this accident is exactly the kind of problem that SMS systems are designed to detect as part of their normal hazard assessment processes before an accident occurs.

Undoubtedly, there will be a lot of changes in the future, and Secretary Duffy alludes to that in this next clip. And a lot of promises have been made from DOT and the FAA about upgrades to the system that have never happened. Again, this should have happened...

Four years ago, 10 years ago, 15 years ago. But right now we're at a point where we can actually do it and we can do it really fast. Again, we're thinking, you know, three and a half, four years, we can get this completed. A brand new air traffic control system, gold plated, envy of the world. And so what we're looking at doing is some...

They're not simple. This is high-tech stuff, but we are going to move from copper wires. We're going to go to fiber, wireless, and satellite, right? A combination of those three in our system. We have radar. Again, it works, but this is from the 1970s or early 80s as the newest radar that we use. We are going to get state-of-the-art brand new radar

to feed into our cabs, into our towers, into our scopes. We need state-of-the-art new terminals for our air traffic controllers so they have all the right screens with all the best technology behind it that gives them the best data to analyze as they give instructions to air travel, air traffic. And finally, we're going to...

deploy resources for runway safety, new technology that will allow our air traffic controllers not to use binoculars in the tower to see where aircraft are at, but to actually have ground radar or sensors at our airports that will allow air traffic controllers to see where airplanes are at and better control their movements. We've heard a lot of news stories of just near misses on the tarmac.

And how do you alleviate that? Take away the binoculars and give them technology so they can see on their screens where every aircraft is at. And I think by doing this, we are going to greatly improve our safety in the system, but it's also going to improve the efficiency that we have in American air travel, which I think will mean less delays, less cancellations, and again, better safety. Now, just a real quick point. This is going to cost money.

And we're in an environment where there's a lot of cost cutting. We're looking for savings everywhere in government. And that's appropriate. I think we have a government that is far too bloated, far too fat. We can go on a diet. But that doesn't mean we don't see points that need investment. And this is a place that we need investment. So in the next couple of weeks, I'm going to come out with this plan. I'm going to share it with the Congress, get their feedback, let them put their fingerprints on it.

But then I'm going to come back and I'm going to ask the Congress for all the money up front so we can expedite this process of building out this system. One of the problems is it takes too long.

If you go 6, 8, 15 years, Congresses change, money changes, priority changes, administrations change, technology changes, and they do fits and starts. They start to upgrade technology and it never gets completed. It's not that the Congress never gave any money. It's not that the FAA didn't want to do the upgrades. It just takes too long. So they have to give us the money. We're going to lay out our plan to actually do it really quickly. And again,

This is the time when you lose 67 lives. I think we can honor those who lost their lives by paying this forward and saying, you know what? We're going to make sure we've learned from this air disaster and we're going to pay it forward. So there's not other families that have to go through the pain and anguish of losing a loved one like these families had to go through.

AND I THINK THAT'S HOW WE HONOR THEM, THAT'S HOW WE PAY IT FORWARD, AND WE DO IT BY FIXING THE SYSTEM AND MAKING IT BETTER AND MAKING IT WORK. SO AGAIN, TO THE RECOMMENDATIONS THAT THE NTSB HAVE GIVEN US OFF THIS CRASH,

We are adopting. We accept them. We were actually doing them 36 hours after the crash. And we'll look forward to hearing more from the NTSB as their recommendations and investigations continue. So FAA infrastructure is getting a lot of attention now, and hopefully something good will come of this accident.

Now let's look at the preliminary NTSB report released at the same time as the press conference. And if you'd like to read the report yourself, I've included a link to it in our show notes at aviationnewstalk.com slash 374.

The report runs 20 pages, which is long for a preliminary report. And much of what is in the report was either known to us before or was discussed by NTSB Chairman Hominy in the audio clips I just played. But here are a few nuggets buried in the report that may be new. First is the crew's experience. Both crew members of Flight 5342 held ATP certificates with type ratings for the CL-65.

The captain had 3,950 total hours of flight experience, of which 3,024 hours were in the accident airplane make and model. The first officer, or FO, had 2,469 total hours of flight experience, of which 966 hours were in the accident aircraft make and model. The captain was the pilot flying, and the FO was the pilot monitoring for the entirety of the accident flight.

The flight crew of the helicopter, PAT-25, consisted of an instructor pilot or IP, pilot, and a crew chief. According to information provided by the U.S. Army, both pilots were current and qualified in the helicopter.

The IP held the rank of Chief Warrant Officer 2 and had accumulated 968 total hours of flight experience, of which about 300 hours were in the accident helicopter make and model. The pilot held the rank of Captain and had accumulated about 450 total hours of flight experience, of which about 326 hours were in the accident helicopter make and model.

The crew chief held the rank of staff sergeant, which sergeant is spelled wrong in this report. Hopefully they'll fix that. And had accumulated about 1,149 total flight hours, all of which was in UH-60 helicopters. The cockpit voice recorder, or CVR audio from the helicopter, indicated that initially the IP was the pilot flying and the pilot was the pilot monitoring and transmitting on the radio.

Following the initial contact with DCA Tower, the crew conducted a change of control. The pilot became the pilot flying and the IP became the pilot monitoring and transmitting on the radio for the remainder of the flight.

PAT-25 first checked in with the DCA tower controller at 8.32 p.m. The controller issued the altimeter setting of 29.89 inches of mercury, and the PAT-25 crew acknowledged by correctly reading back the altimeter setting. Later, PAT-25 was about 1.1 miles west of the key bridge. According to Helicopter CVR, at that time the pilot indicated they were at 300 feet. The IP indicated that they were at 400 feet.

Neither pilot made a comment discussing an altitude discrepancy. At 8.45 and 30 seconds, PAT-25 passed over the Memorial Bridge. CVR data revealed that the IP told the pilot that they were at 300 feet and needed to descend. The pilot said that they would descend to 200 feet.

At 8.46 and 2 seconds, a radio transmission from the tower was audible on Flight 5342's CVR, informing PAT-25 that traffic just south of the Wilson Bridge was a CRJ at 1,200 feet circling to Runway 33.

CVR data from the helicopter indicated that the portion of the transmission stating that the CRJ was circling may not have been received by the crew of PAT-25. The word circling is heard in ATC communications as well as on the airplane's CVR, but not on the helicopter's CVR.

At 8.47 and 39 seconds, which was 20 seconds before impact, a radio transmission from the tower was audible on both CVRs, asking the PAT-25 crew if the CRJ was in sight. A conflict alert was audible in the background of the ATC radio transmission. One second later, the crew of Flight 5342 received an automatic traffic advisory from the airplane's TCAS system stating, "'Traffic, traffic.'"

At this time, the aircraft were about 0.95 nautical miles apart.

Two seconds later and just 17 seconds before impact, a radio transmission from the tower was audible on both CVRs directing PAT-25 to pass behind the CRJ. CVR data from the helicopter indicated that the portion of the transmission that stated pass behind the may not have been heard by the PAT-25 crew as the transmission was stepped on by a .8 second microphone key from PAT-25.

Fifteen seconds before impact, the crew of PAT-25 indicated to ATC that the airliner was in sight and requested visual separation, which was approved by DCA Tower. Following this transmission, the IP told the pilot they believed ATC was asking for the helicopter to move left toward the east bank of the Potomac River.

Seven seconds before impact, Flight 5342 rolled out onto the final approach for Runway 33. The airplane was at a radio altitude of 344 feet and 143 knots. One second before impact, Flight 5342 began to increase its pitch. Flight data recorders showed that the airplane's elevators were deflected near their maximum nose-up travel.

The PAT-25 FDR, or flight data recorder, indicated that the radio altitude of the helicopter at the time of the collision was 278 feet and had been steady for the previous five seconds. The helicopter's pitch at the time of the collision was about 0.5 degrees nose up with a left roll of 1.6 degrees.

PAT-25 was equipped with a Multipurpose Flight Recorder, or MPFR, Cockpit Voice and Flight Data Recorder. The MPFR captured the entirety of the accident flight and contained about 70 flight data parameters. By design, the MPFR does not record date information, time information, or helicopter position information.

A review of the dataset revealed that the error data source for a parameter listed in provided documentation as barometric altitude was actually a recording of pressure altitude. Review of the recorded pressure altitude values revealed that they were inconsistent with other available data, and the pressure altitude parameter was declared invalid.

Further work will determine if the invalid data for pressure altitude was limited to only what was recorded on the MPFR and whether it may have affected other helicopter systems that use pressure altitude as a data source.

The tower was staffed with five controllers at the time of the accident, working five open positions. And by the way, when ATC refers to local, they're talking about what pilots would typically call the tower controller. The five open positions were assistant local control, ground control, clearance delivery, local control, and operations supervisor. The helicopter control and local control positions were

were combined at 3:40 p.m. on the day of the accident, and the flight data and clearance delivery positions were combined. Flight 5342 was communicating with the DCA tower controller via the published control tower frequency of 119.1. PAT-25 was communicating with the tower via the published helicopter frequency of 134.35. Because the aircraft were on different frequencies, the crews of Flight 5342 and PAT-25

were not able to hear each other's transmissions to the controller, but the controller's transmissions to each aircraft would be audible to both flight crews.

According to post-accident information obtained from FAA aeronautical information specialists, helicopter routes have no defined lateral boundaries and are drawn to depict linear paths along defined surface features in a manner legible to flight crews. Any applicable altitude and lateral distance restrictions are typically documented in the chart specifications or in warning boxes displayed on the chart.

The airliner's fuselage was recovered in 13 major sections, comprising the entire length of the airplane from radome in the nose to the aft fuselage and tail cone. Two areas of damage were noted to the lower right side

fuselage wing-to-body fairing. There was a puncture in the right side of the fairing, about 10 inches by 8 inches, and a slash through the lower surface of the fairing, internal structure, and lavatory access door, about 29 inches long by 2 inches wide. An approximate 2-foot-long section of one of the helicopter's tail rotor blades was embedded in the slash. The helicopter's cockpit area was heavily fragmented.

The left seat pilot's barometric altimeter and HSI were found separate from the cockpit area. The left barometric altimeter Colesman window read between 29.88 and 29.89. A portion of the right seat pilot's instrument cluster was found separated from the cockpit structure but remained connected via hoses and cables. The right barometric altimeter Colesman window was set to 29.87.

The report also noted that Runway 33 accounted for just 4% of all arrivals. So if the helicopter crew operated in the area a lot and knew that few airplanes ever land on Runway 33, they may have been looking in the wrong place for the aircraft.

The report says that for whatever reason, the word circling was not heard on the helicopter's CVR, so they may not have internalized that the airplane they were looking for was heading to their left versus heading to the right where they'd look for aircraft landing on the more commonly used runway 1.

So that's a quick summary of the new information in the preliminary report. From here, the NTSB has probably another year of investigation and analysis ahead of them before we get the final NTSB report. And as I discussed with NBC analyst and former NTSB investigator Jeff Gazzetti in episode 368, now that the preliminary report has been issued, we don't expect to hear much more about this investigation until the final report is released.

Now, a key takeaway from this accident is that we all need to be diligent in our flying and in our efforts to identify potential hazards. And when you find a hazard, report it to the responsible organization. And if you work for an aviation company, actively participate in their safety program. Report even small issues. And if you work on the safety side of the house, do the analysis to find areas where safety margins are smaller than they can be.

Now, I can't help but think about how easily this accident could have been just another near miss. The helicopter rotor blades, which are at the top of the helicopter, contacted the underside of the airliner. Had the airliner started its climb even a second earlier, or the helicopter had been just 10 or 15 feet lower, this might have been just another of the thousands of near misses near DCA in the past few years. But when you have thousands of near misses, you're bound to have an accident someday.

Keep this in mind as you scan your operation and try to identify any near misses that might become an accident someday.

And just a reminder that I love hearing from you and I read many of your emails on the show. If you'd like to send me a message, just go out to aviationnewstalk.com, click on contact at the top of the page. That's absolutely the best way to send me a message. And of course, I also want to thank everyone who supports the show in one of the following ways. We love it when you join the club and sign up at aviationnewstalk.com support.

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your side Baby sliding upside down You can always