February 26, 2025, 16:35:00 GMT
permalink Post: 11836479
Also is 'normalisation of deviance' written down on a whiteboard somewhere? People keep saying it. It doesn't seem very organic.
Subjects
ATC
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February 26, 2025, 19:10:00 GMT
permalink Post: 11836579
When you say 'it' can you please be specific about what you're talking about? Because this discussion started with a theoretical ('If you don’t catch all of a radio call meant for you') i.e. a general case of 'people' replying with 'what they want to hear' but you seem to be now talking about a specific occurrence...?
At 8:47:42 the helicopter pilot stepped on the latter part of ATC’s transmission to the Blackhawk which was an instruction to ‘…pass behind the…’ The helicopter crew could not possibly have heard that instruction because they stepped on it themselves. Read back is required to an en-route clearance. Afterwards there was an intercom discussion between the helicopter pilots about whether they were to move further east.
Seems that two consecutive radio calls to the helicopter got corrupted which led to a breakdown in SA onboard the helicopter. Probably they had no idea that they needed to look left over the city lights to see the CRJ and were convinced their traffic was in the line up of jets on 01 extended centreline and therefore no factor.
Subjects
ATC
Blackhawk (H-60)
CRJ
Situational Awareness
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February 28, 2025, 16:43:00 GMT
permalink Post: 11837889
Did something change about this?
Subjects
ATC
TCAS (All)
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February 28, 2025, 22:48:00 GMT
permalink Post: 11838179
Yes that as the old way , the JAL/JAL encounter and Ueberlingen changed that to : forget visual acquisition just follow the RA, The traffic you see might not be the one giving the RA and even if you do the maneuver you might take will increase the risk , as in the 2 cases I mentioned.
Subjects
ATC
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February 28, 2025, 23:15:00 GMT
permalink Post: 11838203
It was about the difficulty of being able to visually identify traffic beyond approximately 3 miles, and therefore the lack of useful information when ATC tells me I have traffic at 6 o clock and 10 miles. I don\x92t have a rear view mirror in this particular aircraft and I can\x92t see that far.
What percentage of day VMC traffic point-outs can you typically get a visual on? I\x92d estimate 50-50 for me.
Subjects
ADSB (All)
ATC
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March 01, 2025, 09:36:00 GMT
permalink Post: 11838415
IMO the fact that the helo crew didn't readback/acknowledge "pass behind" is irrelevant. Twice before, they told the LC that they had the CRJ in sight and requested visual sep, which was granted. Surely you don't specifically need to be told to not hit the CRJ after you've reported it in sight?
I think the LC saw what was unfolding and said that because he had concerns that the chopper didn't actually have the CRJ. He was right.
I think the LC saw what was unfolding and said that because he had concerns that the chopper didn't actually have the CRJ. He was right.
PAT25 says (for the second time), “Traffic visual, request visual separation”,
which is not true, evidently they were not visual at all because they crashed into the CRJ.
LC responds, “Visual separation approved, [pass behind the] CRJ,”
which clearance was issued on the false premise that PAT25 was visual. But PAT 25 only hears, “Visual separation approved…[pause]…CRJ,” because they briefly stepped on the LC’s transmission themselves. No read back is forthcoming; the LC should be expecting one but he fails to chase it up, because he’s too busy.
If PAT 25 realised he’s stepped on the middle part of the LC’s transmission to himself (which likely could have included an instruction) then he ought to be professional enough to say, “Stepped on, say again,” etc and make absolutely sure he knows what the clearance may have been. That was standard practice a long time ago, but no longer, it seems.
My original point was that in the Mover/Gonky video (post #1228) it was suggested that it’s perfectly OK to second guess what ATC might have said to you, reply to that, and then if no correction is forthcoming you can comply with your guess. As others have pointed out implicitly, that works if there’s only one error involved, but here there were three: an untrue statement, leading to a wrongly issued clearance, and a missing read back.
System broken.
Last edited by Stagformation; 2nd March 2025 at 23:42 .
Subjects
ATC
CRJ
PAT25
Pass Behind
Pass Behind (All)
Separation (ALL)
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March 01, 2025, 16:24:00 GMT
permalink Post: 11838685
No this has not changed, my remark was on RAs not TAs, If I induced confusion my bad ..
There are however also issues with visual acquisitions on TAs , all very well described here , if you want to go further : https://skybrary.aero/sites/default/...shelf/2051.pdf
There are however also issues with visual acquisitions on TAs , all very well described here , if you want to go further : https://skybrary.aero/sites/default/...shelf/2051.pdf
Subjects
ATC
TCAS RA
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March 04, 2025, 14:56:00 GMT
permalink Post: 11840670
Listening to the tower and helo local controller audio files, here\x92s what I come up with from shortly before up to the time of the accident:
Fixed wing
AAL1630, departed 1, waiting handoff to departure
JIA5305, holding short 1, #2
DAL832, holding short 1 #3
JIA5342, cleared to land 33
AAL3130, cleared to land 1
AAL472, cleared visual 1
JIA5347, cleared visual 1, requested 33
Rotary wing
PAT25
helo, Zone 4
helo, callsign Blackjack 1, freq change approved just prior
helo, callsign Muscle 12, handed off to ADW prior
helo, request Route 3, Zone 6
helo, Zone 7
Medevac AirCare helo, proceeding to Inova Fairfax
Some of the helo\x92s on above list may be duplicates due to poor audio quality.
At the time of the accident, runway 4/22 was not in use.
Fixed wing
AAL1630, departed 1, waiting handoff to departure
JIA5305, holding short 1, #2
DAL832, holding short 1 #3
JIA5342, cleared to land 33
AAL3130, cleared to land 1
AAL472, cleared visual 1
JIA5347, cleared visual 1, requested 33
Rotary wing
PAT25
helo, Zone 4
helo, callsign Blackjack 1, freq change approved just prior
helo, callsign Muscle 12, handed off to ADW prior
helo, request Route 3, Zone 6
helo, Zone 7
Medevac AirCare helo, proceeding to Inova Fairfax
Some of the helo\x92s on above list may be duplicates due to poor audio quality.
At the time of the accident, runway 4/22 was not in use.
pretty sure I was the circled aircraft that night, AA1855 from CLT. We were just about to be cleared onto the MTV1 when it happened. Did not see it happen but pretty sure we heard JIA5342 being handed off to tower. We were then vectored off the approach and eventually diverted to IAD. Tragic night.
Subjects
ATC
PAT25
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March 05, 2025, 02:07:00 GMT
permalink Post: 11841017
LC says, “PAT25, do you have the CRJ in sight?”
PAT25 says (for the second time), “Traffic visual, request visual separation”,
which is not true, evidently they were not visual at all because they crashed into the CRJ.
LC responds, “Visual separation approved, [pass behind the] CRJ,”
which clearance was issued on the false premise that PAT25 was visual. But PAT 25 only hears, “Visual separation approved…[pause]…CRJ,” because they briefly stepped on the LC’s transmission themselves. No read back is forthcoming; the LC should be expecting one but he fails to chase it up, because he’s too busy.
If PAT 25 realised he’s stepped on the middle part of the LC’s transmission to himself (which likely could have included an instruction) then he ought to be professional enough to say, “Stepped on, say again,” etc and make absolutely sure he knows what the clearance may have been. That was standard practice a long time ago, but no longer, it seems.
My original point was that in the Mover/Gonky video (post #1228) it was suggested that it’s perfectly OK to second guess what ATC might have said to you, reply to that, and then if no correction is forthcoming you can comply with your guess. As others have pointed out implicitly, that works if there’s only one error involved, but here there were three: an untrue statement, leading to a wrongly issued clearance, and a missing read back.
System broken.
PAT25 says (for the second time), “Traffic visual, request visual separation”,
which is not true, evidently they were not visual at all because they crashed into the CRJ.
LC responds, “Visual separation approved, [pass behind the] CRJ,”
which clearance was issued on the false premise that PAT25 was visual. But PAT 25 only hears, “Visual separation approved…[pause]…CRJ,” because they briefly stepped on the LC’s transmission themselves. No read back is forthcoming; the LC should be expecting one but he fails to chase it up, because he’s too busy.
If PAT 25 realised he’s stepped on the middle part of the LC’s transmission to himself (which likely could have included an instruction) then he ought to be professional enough to say, “Stepped on, say again,” etc and make absolutely sure he knows what the clearance may have been. That was standard practice a long time ago, but no longer, it seems.
My original point was that in the Mover/Gonky video (post #1228) it was suggested that it’s perfectly OK to second guess what ATC might have said to you, reply to that, and then if no correction is forthcoming you can comply with your guess. As others have pointed out implicitly, that works if there’s only one error involved, but here there were three: an untrue statement, leading to a wrongly issued clearance, and a missing read back.
System broken.
Good points, especially the first, Keep in mind that no readback was required, and that type of instruction doesn't require a readback and according to the AIM is not even a type that "should" be read back, so the controller wouldn't be surprised if he didn't get one. Agree with Capn Bloggs;even if PAT25 didn't get the particular "pass behind" transmission, visual separation, which came up twice, carries the implicit instruction "Don't hit the other aircraft" ( no sarcasm intended), regardless of the method employed.
Last edited by Commando Cody; 5th March 2025 at 02:45 . Reason: Add reference to another post
Subjects
ATC
CRJ
PAT25
Pass Behind
Pass Behind (All)
Separation (ALL)
Visual Separation
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March 05, 2025, 10:44:00 GMT
permalink Post: 11841182
https://www.faa.gov/air_traffic/publ...section_4.html
Para 2-4-3 note 2 says it all really.
Last edited by Stagformation; 5th March 2025 at 11:55 .
Subjects
ATC
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March 05, 2025, 11:58:00 GMT
permalink Post: 11841230
Originally Posted by
Stag
simply confirms the helicopter crew had no idea of the imminent danger they were in.
Now if the controller had said "you look to be tracking very close to the CRJ are you sure you can pass behind?" or similar, then maybe the helo crew would have got excited. A call like that might have even triggered a "holy sh1t" moment about the TCAS "Traffic". But as far as they were concerned, they knew they had the traffic in sight and could do the visual sep thing and even if they had heard "pass behind" they would have said/thought "well, obviously". Except they had the wrong aircraft. ATC had an idea they had the wrong aircraft but didn't get the message across.
As for the reference, same thing. The helo crew could have read-back "pass behind" but it wouldn't have achieved anything.
Subjects
ATC
CRJ
Pass Behind
Pass Behind (All)
Separation (ALL)
TCAS (All)
Traffic in Sight
Visual Separation
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March 05, 2025, 19:00:00 GMT
permalink Post: 11841477
In this scenario, there is zero information in the call to "pass behind" that indicates any imminent danger. All it does is further legitimise the previous two approvals for visual separation.
Now if the controller had said "you look to be tracking very close to the CRJ are you sure you can pass behind?" or similar, then maybe the helo crew would have got excited. A call like that might have even triggered a "holy sh1t" moment about the TCAS "Traffic". But as far as they were concerned, they knew they had the traffic in sight and could do the visual sep thing and even if they had heard "pass behind" they would have said/thought "well, obviously". Except they had the wrong aircraft. ATC had an idea they had the wrong aircraft but didn't get the message across.
As for the reference, same thing. The helo crew could have read-back "pass behind" but it wouldn't have achieved anything.
Now if the controller had said "you look to be tracking very close to the CRJ are you sure you can pass behind?" or similar, then maybe the helo crew would have got excited. A call like that might have even triggered a "holy sh1t" moment about the TCAS "Traffic". But as far as they were concerned, they knew they had the traffic in sight and could do the visual sep thing and even if they had heard "pass behind" they would have said/thought "well, obviously". Except they had the wrong aircraft. ATC had an idea they had the wrong aircraft but didn't get the message across.
As for the reference, same thing. The helo crew could have read-back "pass behind" but it wouldn't have achieved anything.
Subjects
ATC
CRJ
Pass Behind
Pass Behind (All)
Separation (ALL)
TCAS (All)
Traffic in Sight
Visual Separation
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March 06, 2025, 13:29:00 GMT
permalink Post: 11841979
Assuming they correctly received/understood that the object they were to pass behind was landing runway
33
, not runway 1. That seems to be in some doubt.
Because without that information, they could IMHO quite happily look at the A319 approaching runway 1, intend to pass behind it to head south down-river until the A319 was no longer over the river, and loiter around the runway 33 approach until that happens.
Shift the times by ten seconds and the same accident could have still occurred.
Visual simply doesn't work at the required level of safety if there are multiple aircraft to be visual with.
Because without that information, they could IMHO quite happily look at the A319 approaching runway 1, intend to pass behind it to head south down-river until the A319 was no longer over the river, and loiter around the runway 33 approach until that happens.
Shift the times by ten seconds and the same accident could have still occurred.
Visual simply doesn't work at the required level of safety if there are multiple aircraft to be visual with.
Reading this thread since the night of the accident, many have noted the "wrong-thinking" (for lack of a better term) underpinning the way traffic was managed by FAA and ATC.
I'm not enthused about the litigation that almost certainly will be intense once it commences. But reading the thread I've started to wonder.....
What would a chronological reconstruction of each incremental decision by FAA about the operation of DCA look like, a chronology that would (of course) include each Congressional enactment requiring or allowing further intensity of operations? The airport did not go from a nominal operational environment, with typically safe procedures and airspace usage rules very similar to or the same as any other major urban airport in the country, to the situation which obtained on January 29, overnight - or so it would seem.
(Yes, reconstructing the facts to build such a chronology would involve quite a lot of discovery activities in the presumably forthcoming lawsuits, but I'm not veering off into any further comment about why that would matter or which party or parties it would help or hurt..... other than to say, very often, cases are won and lost in discovery.)
Some years ago, on a trip to Capitol Hill hoping to find gainful employment on a Congressional staff somewhere, on the return flight from what then was Washington National, the aircraft's cockpit door was open as the boarding process was being completed (it was 1987). I recall being seated close enough to the flight deck - leaning a little into the aisle (a Midway Airlines DC-9 iirc) - to be able to see the pilot in the LHS and part of the D.C. skyline through the cockpit's front windows. Maybe that is why my mind somehow can't quite comprehend the recollections from kidhood of reading about the midair collision over New York City which is featured prominently in the book Collision Course , together with the events of the night of January 29.
Added: Wall Street Journal, March 6: "Air-Traffic Staff Rules Tightened After Crash." Also reports previous "close call" incident. Highly recommended reading (and I didn't see anything to contradict the above post, WR 6-3).
Last edited by WillowRun 6-3; 6th March 2025 at 13:46 .
Subjects
ATC
Circle to Land (Deviate to RWY 33)
Close Calls
DCA
FAA
Pass Behind
Pass Behind (All)
Separation (ALL)
Visual Separation
Wall Street Journal
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March 06, 2025, 14:12:00 GMT
permalink Post: 11842012
Yes that as the old way , the JAL/JAL encounter and Ueberlingen changed that to : forget visual acquisition just follow the RA, The traffic you see might not be the one giving the RA and even if you do the maneuver you might take will increase the risk , as in the 2 cases I mentioned.
Subjects
ATC
TCAS (All)
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March 08, 2025, 13:43:00 GMT
permalink Post: 11843428
By the time the H60 realized the lights on the CRJ were too high too fast and too bright to be on final for #1, it was a half second too late... does the tail on the helo seem to drop just before impact, ?? Think they wanted to climb?
Congressional perks in this case make me "see" red. All of Congress should be made to Uber from DCA for a full year or until changes are made. By FAA, not by Congress.
...selfish dolts.
Last edited by BugBear; 8th March 2025 at 14:14 .
Subjects
ATC
CRJ
DCA
FAA
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March 08, 2025, 21:18:00 GMT
permalink Post: 11843640
As for "do not cross final 33 before CRJ"... that'd still have given too much responsibility to the helo crew, in my opinion. They'd have suffered a crushing breakdown of their mental model as it became clear the lights ahead of them weren't going to land on 33 before they crossed the approach. Would that dawning reality have caused then to widen their search and see the CRJ? Possibly. But I doubt it. Human nature in high pressure situations, like NVG flying over a dark river in a city, is to keep pressing on with a flawed mental model.
"Hold at Hains Point", from a second controller with capacity to keep watch over two converging tracks, was what was needed to save the day here - and to cover up the underlying organisational failings for a while longer.
Subjects
ATC
CRJ
FAA
Night Vision Goggles (NVG)
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March 11, 2025, 03:45:00 GMT
permalink Post: 11845055
Not sure what you mean by this comment. CW3 Roth interview explained the training requirement for Route 1/4 ops. Question is whether these training flights can be conducted safely. I think they can as long as ATC doesn\x92t delegate their primary responsibility for Class B separation. It is politically untenable to resume Route 1/4 PAT training flights at present. I suspect 12th AB and DCA ATC are reviewing their previous policy that VFR visual separation is safe along these routes.
Subjects
ATC
DCA
Route 5
Route 9
Separation (ALL)
VFR
Visual Separation
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March 11, 2025, 20:08:00 GMT
permalink Post: 11845606
AIR-25-01 Deconflict Airplane and Helicopter Traffic in the Vicinity of KDCA
Findings
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.
When Route 4 operations are prohibited as recommended in Safety Recommendation A-25-1, it is critical for public safety helicopter operations to have an alternate route for operating in and around Washington, DC, without increasing controller workload.
To the Federal Aviation Administration:
Prohibit operations on helicopter Route 4 between Hains Point and the Wilson Bridge when runways 15 and 33 are being used for departures and arrivals, respectively, at Ronald Reagan Washington National Airport. (A-25-1) (Urgent)
Designate an alternative helicopter route that can be used to facilitate travel between Hains Point and the Wilson Bridge when that segment of Route 4 is closed. (A-25-2) (Urgent)
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.
When Route 4 operations are prohibited as recommended in Safety Recommendation A-25-1, it is critical for public safety helicopter operations to have an alternate route for operating in and around Washington, DC, without increasing controller workload.
To the Federal Aviation Administration:
Prohibit operations on helicopter Route 4 between Hains Point and the Wilson Bridge when runways 15 and 33 are being used for departures and arrivals, respectively, at Ronald Reagan Washington National Airport. (A-25-1) (Urgent)
Designate an alternative helicopter route that can be used to facilitate travel between Hains Point and the Wilson Bridge when that segment of Route 4 is closed. (A-25-2) (Urgent)
Subjects
ATC
Findings
KDCA
Route 4
Separation (ALL)
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March 12, 2025, 18:31:00 GMT
permalink Post: 11846383
Seems to be a misconception that a published helicopter route must allow for simultaneous ops with fixed wing traffic; e.g., JPN ops and runway 15 landing traffic. While 99% of the published DC helicopter routes are very likely to ensure deconfliction with fixed wing traffic, there are those trouble spots, one of which has recently been in the news. In the case of JPN and runway 15, the obvious answer is that ATC doesn\x92t permit helicopters to land or depart JPN if traffic is landing on runway 15. Or ATC doesn\x92t allow landing traffic for runway 15 while JPN is active.
Subjects
ATC
Route 5
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March 12, 2025, 18:48:00 GMT
permalink Post: 11846398
Seems to be a misconception that a published helicopter route must allow for simultaneous ops with fixed wing traffic; e.g., JPN ops and runway 15 landing traffic. While 99% of the published DC helicopter routes are very likely to ensure deconfliction with fixed wing traffic, there are those trouble spots, one of which has recently been in the news. In the case of JPN and runway 15, the obvious answer is that ATC doesn\x92t permit helicopters to land or depart JPN if traffic is landing on runway 15. Or ATC doesn\x92t allow landing traffic for runway 15 while JPN is active.
Subjects
ATC
Route 5
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