Posts about: "ATC" [Posts: 614 Page: 25 of 31]¶

Since we\x92re discussing the DCA accident, let\x92s be clear about U.S. terminology as specified by 7110.65.

There is tower-applied visual separation . That is not relevant to the DCA accident.

There is also pilot-applied visual separation . That is what PAT25 requested and the LC approved.

As for the perfectly-safe visual separation, the DCA accident might have been avoided had the LC applied all of the elements of pilot-applied visual separation; i.e.

I'm applying SLF/attorney license here (hey, there's poetic license, so why not?) of repeating - with some editing - a post I placed on the R&N thread about testing at DCA.

1) Regarding ADSB-Out being turned off, what is the reason there was such emphasis placed on this at the recent Congressional hearing (and just scoring media points per usual in Committee hearings doesn't qualify as a "reason" in this context). Is the reason that there are objections to running the kinds of tests in question (per the R&N thread) in or near DCA airspace? Is it valid to say there is no connection to the chain of causes-and-effects which led to the midair collision on Janaury 29 (but if there is, what is that connection, specifically)? Is the reason some connection with the occurence of TA's and RA's on TCAS as documented by NTSB? (although other posts on the R&N thread indicate that ADSB-out isn't connected to TCAS advisories . . . that is, if I understood those other posts). Or something else? I'm dismissing the mere fact that FR24 doesn't provide information to enthusiasts as the reason for such emphasis in the hearing.

2) If the Army operates certain "missions" with ADSB-Out turned off, and it conducts these operations based on national security concerns, my initial thought about this practice is, . . . . . . . hey, isn't there a discretionary function involved in deciding what avionics (or electronics system if this isn't within the technical definition and scope of "avionics") to operate based on national security concerns? So the Senator declaring that there is "no justification" seems to deliberately overlook the existence in the Federal Tort Claims Act of the exception. (I realize there has not been, to my knowledge at least, any lawsuits filed yet. But they're certainly going to happen.)

Of course, this all said, the indictment of the structure and operation of the portion of the NAS in which DCA is situated might (as suggested previosly) itself be adjudged inconsistent and non-compliant with basic standards of aviation safety. The only not-crazy-sounding justification for that state of affairs would seem to be "but we have to move traffic in volume." As a legal wrangle over whether that obvious judgment of a "policy" nature is or is not a proper basis for keeping federal immunity in place in a particular matter . . . I am quite skeptical such a legal wrangle would ever make it as far as an actual courtroom proceeding. But will Congress not try to manuever itself into the issue for all the usual reasons - some people want actually to address the problem constructively, some just want to please their donors, and some just follow the crowd, or so it always appears.

3) Something about discovery in civil litigation was underscored by the exchange in the video clip: there's an Army memo, dated Aug. 9, 2024 as referenced by Sen. Cruz, about operating in the NAS with ADSB-Out turned off. And the Army so far declines to turn it over to the Committee. (Applying the rough equivalent of a pre-snap read by a QB, the manner in which the Army witness replied to Sen. Cruz's questions gave the impression that the Army and DoD will strongly resist the memo in question becoming public.)

[Okay, I'll refrain from speculating how much fun it would be to decide which officer or officers would be presented as the Person(s) Most Knowledgeable about the matters discussed in this memo (on the Army side, receiving the Rule 30(b)(6) deposition notice), or similarly, how much fun would be had by counsel describing the "subject matter(s)" which must be specifically iterated in a Rule 30(b)(6) deposition notice (on the plaintiffs' side).]

4. I'm very determinedly hoping this won't be read or even misinterpreted as an offensive point. In the YT video produced by "Mover" in which he interviewed a former Army helicopter aviator (post 1228), it was possible to draw the impression that Army helicopter pilots operating in the airspace in which DCA is situated have a certain attitude toward FAA ATC. That is, the Army operates - one could get the impression - in its own "airspace system" and deals with FAA ATC only as much and only as quickly as necessary. Listening to the pertient Jan. 29 ATC R/T, and knowing the visual difficulties presented by the basic facts of nighttime in that specific area of the DCA airspace, plus NVGs, an observer could get the impression that the Army aviator handling the R/T was doing so in a perfunctory manner on Jan. 29.

To explain further, upthread (in post 1261) in the context of a Mover/Gonky YT video (post 1228) someone much more knowledgeable than myself observed that the way in which the Army pilot interviewed in the video described communications with FAA ATCOs in DCA airspace was as if Army chopper pilots view FAA ATCOs somewhat as a nuisance. Far be it from me to fault any pilot over any practice or custom in anything, including comms with ATCOs. But faulting any pilot is not the point. The point is that in that YT video, as related that other poster, --
"it was suggested that it\x92s 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\x92s only one error involved, but here there were three: an untrue statement, leading to a wrongly issued clearance, and a missing read back."

It is known that ADSB-Out is not active on the Army and other certain missions in the relevant airspace. Is there also a pattern or practice of operating with a mindset that FAA ATC is a necessary nuisance, to be indulged but not focused upon as closely as other airspace users? If any reader asserts this question accuses the Army pilots or any one of them in the helicopter on January 29 of negligence - that would be incorrect. The way in which the airspace had been designed, managed and operated handed those pilots a pre-determined normalization of complacency - so it appears, does it not?. They operated their flight within the system they had been given, which does not constitute negligence. The designers, managers, and operators of that system . . . well, it will be for the courts to sort out whether the exception to the removal of federal immunity to tort claims applies to those systemic level actions, or not. If it were not for the existence of the discretionary function exception, I personally believe the race to the courthouse would already have been a feeding frenzy worthy of the most biting negative stereotypes about lawyers.

Speaking of immunities, wasn't it generally believed that the airspace within the NAS, and especially airspace in which major airports in the United States are situated, was immune to midair collisions, in general and not only collisions sudden, without actionable warning, and with at most two or three seconds' knowledge of impending death and disaster? Mere SLF/attorney as I am, I had believed that. It follows, but only under that mindset, that what occurred was obviously negligence, and even gross negligence. The point is, expect the lawsuits to be, in a word, consistent with the ugliness one feels seeing the wreckage pulled from the Potomac, or reading about the backgrounds of 67 people. Or both.

I really value your contributions, as you bring an analytical and legalistic mind to bear, and help others understand some of the issues. However... from my (simplistic) viewpoint, the helo pilot explicitly requested visual separation. That's explicitly requesting the right? responsibilty? to keep themselves separated from other traffic. This they failed to do. Surely that is negligence.

There were other holes in the cheese, so the pilot was working in a compromised environment.

I'm just an SLF, so no domain expertise at all.

I feel like this ADS-B discussion at political level is just a diversion , either they have been badly briefed by their staff , or they have and are deliberately chosen to raise this in public to shift the blame game somewhere else.
Because , even if the helo had ADSB out and the CRJ an "in " receiver and a CDTI display , what would have happened then ? . The crew would have spotted the Helo, maybe asked ATC what was that , and the reply of the controller would have been something like : " it is a military helicopter on route 4 , has you in sight , passing behind ." and then would you , flying the CRJ , take evasive action or go around after hearing that ? No .
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The primary cause of this collision is airspace design and normalization of deviance over the years. I hope the judges will see that when the trial comes. We should leave the military crew and their grieving families out of this.

I tend to agree with ATC Watchers take on this.
Some people are making out that if the Helicopter had ADSB-out switched on/ activated, then this would never have happened.
Someone correct me if I am wrong but if the Blackhawk has ADSB-out switched on then nothing changes for the CRJ on that night. The TCAS behaves the same, there is no display of the Blackhawk on the CRJ\x92s Nav display\x85..nothing changes. The CRJ crew are still conducting an approach that requires a lot of fast mental processing close to the ground, at night onto a short runway while ensuring checklists/configuration etc is correct. ie they have a high workload. During this high workload phase, \x91the system\x92 has seen fit to allow a single Human ( the helicopter Captain) to be responsible for the separation of the two aircraft visually, at night, in a busy environment while conducting a check, on NVG\x92s.
Is it likey that a single Human, with the sole responsibility, will make a mistake? It\x92s not just likely, it\x92s inevitable, regardless of how sharp and well trained they are, if you run the program long enough their vision, or their SA will fail them and we get what we got here.
The system should never have devolved to the point where one person accepted the responsibility for visual sep 6nm away, at night, in a busy traffic environment while dealing with their own high workload.
The Blackhawk crew had a high workload, the CRJ crew had a high workload, the ATC had a high workload, there was no fat left in the system. Humans make mistakes and any good system will be tolerant of those mistakes.
The system was not tolerant of a mistake, ergo, the system is at fault.

ATC Watcher:
"The primary cause of this collision is airspace design and normalization of deviance over the years. I hope the judges will see that when the trial comes. We should leave the military crew and their grieving families out of this."

Which takes the pertinent legal case right back to the question whether the federal government will be protected by sovereign immunity. Sitting in, say, a conference room discussing in the abstract "airspace design" I don't think a single competent aviation attorney would not reply that design of airspace is a discretionary function (so sovereign immunity applies), and perhaps is a classic illustration of such discretion exercised functionally. Normalization of deviance is likely a closer question on the premise that it occurred through numerous small (or perceived as small at the time) changes and revisions of procedures and airspace design. But operation of the airspace when viewed in such a macro frame of reference looks pretty discretionary as a function, too.

But abstractions lost their meaning as 67 entirely blameless people lost their lives in this catastrophe. I'm not in this matter - not representing or advising anyone - but my mind can't get off outlining the attack on the discretionary function exception (to avoid doubt, I'm saying the exception needs to be argued against and shown not to apply on these facts). It is with hindsight, true, but the situation which existed in the airspace in question on the night of Wednesday 29 January broke, stomped upon, and otherwise disregarded so many basic rules of the aviation safety mindset that ....
like they say, you can take the lawyer out of litigating, but you can't take litigating out of the lawyer.

Here's a new thought. In lawsuits (another poster helpfully noted upthread) under the Federal Tort Claims Act - the statute which takes sovereign immunity away but subject to exceptions - claims for punitive damages are not allowed.

Think about that for half a minute. Just on the facts, forget the legal technicality under the FTCA, would this not FREAKING be a case warranting punitive damages against the federal government for setting the stage of this accident and then putting the players in motion? So, you're an attorney, part of the team representing any one of the families of victims of this CATASTROPHE in the middle of the air ... or some or even all, of the victims' families. What do you do?

I will be neither surprised nor shocked if the lawsuits also name American Airlines, which has no protection obviously under the FTCA. It didn't do anything wrong..... but naming the airline as a defendant gets their insurers involved, and then establishment of a fund and a process to compensate the representatives of the victims can be brought forward and conducted. Skip the courthouse except to get things started, but this matter needs a creative approach. Oh, did I mention, part of the approval for such a fund and compensation process would have to be pretty sweeping reform of how FAA does business and what business it does, and the reform plan had better be down to chapter and verse?
WR 6-3

Hi layman54 , I think it's much more subtle than that. As you say, other bits of the system may put the pilots into danger but you then need to fully understand why the Pilot(s) didn't save the day. You sort of start off with the premise that the crew of PAT25 took off that evening and certainly didn't want to fly into the CRJ - so, why did they?

To say so-and-so got it wrong is often obvious ........ but why did they get it wrong? That's often very complex and can involve a lot more people and a raft of other factors and that's where the really valuable lessons are to be found. That's the real reason behind any "bias" - it's so we don't simply stop at that first person (or persons) who got something wrong, but look at what led to them doing what they did and what other factors contributed to the end result . That is the real way Safety is improved. You can then look at appropriate mitigation to try and prevent that same scenario from setting up another crew to fail in the same way at a later date.

As others have said, height and track is a red herring TBH as the deal with ATC was for PAT25 to "see and avoid" so they could have quite safely passed behind the CRJ at the same altitude or even above it - but not too close due to things like wake effects. If you can't manage "see and avoid" safely, you need to build in much, much bigger safety margins - such as holding PAT until the CRJ had landed. Many, including me, have asked how on earth the PAT25 crew (or, indeed, anyone) could reliably be expected to pick out the CRJ in that scenario especially at that range. For vertical/horizontal separation, relying on a few 10's of feet up/down or left/right is simply worthless given errors with altimeters and piloting accuracy in such a high-workload situation where it's "eye's out" navigating and looking for traffic all at a couple of hundred feet above land/water which is quite unforgiving if you get too low (I know ex helo crew who are no longer here because they inadvertently hit the sea) - not to mention any issues with NVGs (no idea, never used them!). What the NTSB implied was that, by suggesting that such a set-up as Route 4 passing under the approach to 33 was intrinsically safe through vertical/lateral separation, was madness. The route was pulled almost immediately pretty much on that basis.

So, for example, based on the difficulty in picking out the correct aircraft from the inbound stream, one of the many questions I've been asking myself is "Why were the PAT25 crew so willing to say they had the CRJ in sight (twice they said that) in that environment?". Had that become "normalised" on the Sqdn, or were the risks of miss-IDing a/c not being adequately highlighted in Local Orders, particularly given the geometry of that specific set-up? There may be several reasons - that's for the NTSB to dig out. I used to do a lot of visual separation stuff Commercially and I was nervous as hell - and that was in wayyyyyyyy simpler scenarios in way better conditions usually involving just one other aircraft. ATC were the same - they were very pointed in making sure I'd really seen the a/c in question. Any doubts in my mind or the ATCs mind and it was either an orbit till traffic was well clear or, if busier, it was "Contact Approach ....... lets chat again when they hand you back to me on the ILS.". OK, the ILS bit is not applicable to PAT25 but you get my drift!

There is no one reason why this accident happened - there will be quite a list with each one contributing to the final outcome. Any one of those things, had they been different decisions by those involved on the night, or, for example, by those who designed and approved Route 4 way back when, would have saved the day. So correct not just the 1st issue you find, find out and correct ALL the issues! That's what we really need to do to stop similar things happening again, not just at DCA, but anywhere.

Anyway, hope the above helps with the context of the word "bias". It was not that long ago it was "Hang the crew! Erm, oh no! Someone else has done it now! Hang them too!" Rinse & repeat! Thankfully, we are much better at digging out all the issues these days. But we have to constantly remind ourselves to "Look for everything, not just the 1st thing you find!". Cheers, H 'n' H

Although the data in post 1346 does distinguish between day time and night time, it doesn't (nor probably can't) highlight which flights were adjusted by ATC, e.g. track this, sight that, pass behind, track direct, etc. If the use of Route 4 was simply pilots doing their own thing ie a single direction route without any ATC inputs then the tracking difference might be interesting. In this case, it could highlight an issue, perhaps not.

This raises the question of what fraction of helicopter crews in that situation asked for visual separation. And how often did ATC grant it? According to posts above sometimes helicopters were held at Hains Point so apparently visual separation wasn't universal.

Yep, that question .......... and loads more.

One thing I mentioned earlier is that airlines also have a responsibility for conducting safe operations; safe for their crews, their pax and by-standers. For eg, airlines often have additional rules for certain airfields (eg some require specialist training before crews can operate in there due to say, terrain issues on the approach). As has anecdotally been reported on here, if there have been an above "average" (and someone will need to figure out exactly what that means) number of issues with this particular approach in terms of TA's, irrespective of the outcomes, then the airline has a Duty of Care to have a system which identifies such issues, assesses them and then, if necessary, to put additional mitigation in place - such as, say, banning the use of 33. AA may have looked at this and, if so, their Safety Case should explain why they concluded it was safe. Sadly, even that doesn't guarantee the right decision was reached ...... but at least they'll have formally assessed it. Trouble is, landing on 33 seems to have cut taxi time = fuel = $'s.......

Anyway, just some thoughts! You know, I can be a right cynic at times but, having a background in Safety Engineering in a previous life, that's par for the course!!! Cheers, H 'n' H

If my post is open to misinterpretation, then that's on me. In other words it's not a matter of affirmatively wanting to "drag" the airline into a lawsuit in which it would not be a legitimate party. Rather, in the exercise of forecasting the inevitable lawsuits (or at least applying some analytic foresight), and trying to think like counsel for the victims' families, a non-frivolous claim against the airline could open the case in total to claims for punitive damages. As you note, although in the role of claimant, for its hull loss the airline would likely be involved anyway. And so would its insurers.

Beyond that, and because my referring to making the airline a party is not meant to be trivial, the underlying idea is that establishment of a fund and claims process would be one of two main components of an approach to resolving the matter. The other component would have to be some - and I realize this is perhaps too much magical thinking - hard-truth reform and rework of airspace configuration and usage rules, nationwide. I don't wish to preach or pontificate, but this catastrophic accident happened after the Safety Call to Action, after the National Airspace Safety Team report, after the intense public, political, and international attention to and focus upon FAA in the aftermath of Lion Air and Ethiopian. So the underlying and motivating objective is to follow and apply former U.S. Amb. to Japan Rahm Emanuel's aphorism, "a crisis is a terrible thing to waste."

And yes, though it's hopefully non-frivolous, and despite it being a placeholder claim rather than an entirely direct claim, telling ATC "Unable" in re: Rwy 3-3 given the known airspace complications would appear the most viable option.

Yes , this is the word I teach and hammer my students who are afraid to contradict an ATC instruction with which they are uncomfortable with . Very difficult for a under 100 hors student to get this , but I know 10.000 h ATPLs who have the same problem
That said it does not always work , the Lufthansa SFO R/T exchange was an abnormality to stay politically correct . But , back to DCA , I I would be interested to know if previous instructions to circle 33 while on finals 01 was a commonly used procedure , and if it was occasionally refused by some pilots in the past and what was then the reaction of ATC .. divert to Dulles ?

I've no insider knowledge but, given how the first AA accepted it and the following AA asked for it specifically, it may have been common practice within AA. Not all line pilots may fully appreciate the potential issues linked with, say, that particular sidestep.

I raised the airline responsibility bit more as "idle thoughts" to illustrate that everyone can play their part in making things safer in cases such as this - including airlines. However, it does need (a) identification of the issue, (b) then good analysis to scope it all and, finally, if there is a "real" potential issue after that analysis, (c) to work out a formal policy (here with AA and DCA) so everyone knows what's what and, importantly, appreciates any knock-on issues that such a policy may generate - such as maybe cutting down on ATC's flexibility on occasion.

So, for eg, it could have been a joint AA/DCA policy that AA would not be placed on the sidestep, or accepted on the sidestep, while something was on Route 4. Irrelevant here now as Route 4 has gone ..... but the above concept can be applied to other potential issues at other airfields.

Anyway, just some thoughts. I'll revert to lurking! Cheers, H 'n' H

It is buried in all these pages of this thread,,,but it seems that tragically so, 2-3 aircrafts before the fatal 5342, ATC requested rwy33 to another crew (same aircraft, same airline iirc) , and they declined ("Unable")

The geometry of the conflict resembles allowing Right and Left traffic to the very same runway, save two hundred feet (or less) altitude, with one LC to manage two discrete frequencies, two radar screens, neither opposing aircraft privy to the other’s comms. At night in a sea of lights? Oh, and two quite different airframes and maneuvering capabilities....something like that.....??

Not to mention one of the two is not going to turn Final... head on Base Legs? Not foolin here.

The visual (circle) 33 is by far the most commonly used flight path to get aircraft into 33. The infrequently-used RNAV 33 closely tracks the visual 33 flight path. There is also the rare visual straight-in for 33 (see last year\x92s runway incursion with N250AA).

The NTSB preliminary report states that about 4% of DCA\x92s arrivals use runway 33. With 25,000 monthly flights, you can do the math. 33 used more frequently than average in the winter due to the typical strong NW winds seen in the DC area. That was the case on 1/29.

While it may be a wishful narrative that pilots get sent to ATC jail if \x93unable,\x94 doubt that\x92s anywhere close to the truth. I think the reality is if a pilot states \x93unable,\x94 ATC makes the necessary adjustments, which may involve an aircraft being resequenced in the queue. Don\x92t really think ATC has the authority to deny an aircraft a landing clearance out of spite if flight planned for DCA.

And just as the collision was occurring, JIA5347 was checking in on the Mount Vernon Visual specifically requesting 33 . Luck of the draw\x85

I do not intend to make a lecture on how ATC works but you mix up Tower and Radar controller's work . Tower is visual aided by tools to aid determine positions , but it is not issuing instructions ( i.e. vectors) based on those tools ( here a radar display ) Those tools displays might or might not even be in front of the Tower controller working position .
Radar control is done by Approach control , ( Potomac in this case) and here done from another city .

Apart from the IMC non-issue, the cause-and-effect chain of events and omissions in this accident is still under investigation. But I'll try to give some answer to your post - although I doubt my mind will latch onto anything new compared to the volume of this thread to date.

There are unknowns at this point about what information the Army PAT25 crew had in front of them about the altitude at which they were operating. There also are unknowns about the Army crew's visual scan (which, as a non-aviator, sounds to me like a complex subset of facts; I do work on maintaining strong visual scan plying limited access highways and even local streets and roads in my car but the instrument panel of my vehicle is, shall we say, somewhat limited in comparison). Add in the relatively fixed attributes of the physical environment, the background lights of the city and surrounding areas, the river, and so forth. Plus, NVGs, plus experience using same by the particular crew.

Then with all those factual matters still subject to fairly significant unknowns (at least as I am able to follow the developments), your question(s) turn to the acts or omissions of ATC. I am fairly strongly inclined to "stay in my lane" - meaning, there is a lot more about how ATC functions are performed that I don't know, compared to what I might actually have picked up from forum threads and other sources. It stands to reason that the visual separation set-up is subject to formal written rules and procedures, but I don't know to what extent these presumed rules and procedures reach down to very specific operational details. Beyond that, the signal-to-noise ratio of what more I might say would not be too especially good.

I'm reminded of the old saw that some one or another fairly well-versed individual has already forgotten more about a given subject than some smart-aleck will ever be able to master about such subject. I don't want to trip over that . . . altitude restriction.

One other perhaps non-trivial item I can add is that the attorney whose office has filed the preliminary claim (as required pursuant to the federal statute) is very accomplished in this field. I've met him at professional (Aviation Law) conferences. I have enough respect for other members of the bar who have amassed vastly larger public records of accomplishment - even those records which prompt lawyer-bashers to decry the profession and all who practice in it - not to try to pass off forum talk as the equivalent, or even merely reflective of, the serious legal thinking going on in that attorney's conference room. And many other law firm conference rooms. The issues in this matter aren't going to be simple, neat, or pleasant. Perhaps the air has been deflated out of the emotional shock-balloon the midair collision visited upon many folks; it is still my view that this was a catastrophe, wrenching in many respects the NAS all the way back to the skies over New York City in 1960 and the midair which ultimately gave rise to the formation of PATCO. And the strike, which led to, with respect to controller staffing . . . . .

Hiya WR 6-3 , the fact the RJ crew had a TA (IIR) has been mentioned/discussed a few times in this Thread - it's easy to forget!!! There is a problem with this tho.....

To briefly reiterate what has been said before, in such a complex airspace environment TA's (which is a step down from an RA, which requires mandatory action on the part of a crew, but RA's are inhibited by TCAS at that low level) can happen fairly frequently due to the proximity of adjacent aircraft which are not necessarily a threat - such as when helo traffic is close but is due to be avoiding you. You could get a TA and yet the helo will pass, say, just behind/below you - and all is well. If you recall, the number of TA's noted in the various Safety Databases has also been discussed and points to issues with 33 and R4 being fairly frequent - the warning bells re the 33/R4 airspace configuration had been ringing in the months/years leading up to this sad event - even if it had always ended OK ......... until this time.

The problem really comes when you regularly get such warnings; they become almost "normal". Normally, if you execute a go-around (not mandatory) against such traffic which ATC has specifically organised to miss you, ATC would rightly ask why plus, if you can't see it, you could go-around into it. Here the RJ crew were involved in the execution of the side-step on to 33 and were fully concentrating on rolling out on quite a short Final and would be expecting ATC to keep traffic away from them. So they would likely have noted the TA (I only use "likely" as I can't recall any facts on that) but now you have a highly split focus; flying the last bit of the approach where you have to monitor the PF/aircraft on the approach, ensure you remain stable to touchdown, keep a check that the a/c on 01 was not moving...... etc, etc and trying to see TA traffic - at low-level against a sea of lights. High workload, a belief/trust that ATC has you covered, and a rubbish environment to pick up the helo which is also not an uncommon event at DCA.................... Not a good hand of cards to hold at all.................. That's a polite way to put it!

So, this was definitely not a case of "Well, they had the traffic info so they should have avoided it!" - it's wayyyyyy more subtle and complex than that. That last bit of the cheese, if not having an actual hole in it, was so thin as to effectively be useless......... On your "legal culpability" point (where I have absolutely no quals!!!) I did mention, during discussions of the reports on the Safety Databases, that airlines and airports have a duty of care and so they could (should?) have been conducting Safety Audits which may have highlighted this Risk. Maybe they did and people picked the Risk up but continued to assess it as being "safe". Who knows..........................

As earlier mentioned, TAs (Tower and TCAS) may among other incidents and excursions find their way into databases including ASIAS. Once the NTSB dug into the databases, it came up with a long history of losses of separation at a frequency that makes one wonder that such an accident hadn't happened earlier. I suspect that this is not solely a DCA problem.

But who should be watching the data for trends - individual regionals, individual majors, local military, local ATC, individual airport authorities, FAA, NTSB?