Posts about: "ATC" [Posts: 614 Page: 27 of 31]¶

Repeated for emphasis, but further comment I won't make as it may cross too far into politics. How to manage the air space around National/Reagan will certainly get the FAA's attention, but it is worth recalling that no matter what the NTSB recommends after a given investigation, the FAA will assess each recommendation as regards implementation, or not.
(I am sure that you are aware of that, but some of our participants need to have that spelled out).

Not that the NTSB are going to apportion blame in their report, that isn\x92t their function. But it\x92s quite clear there were (and are) unsafe practices going on among controllers and operators in FAA/DOD land. Read the docket testimony here from page 463 onwards to about 468 or until you get bored.

https://data.ntsb.gov/Docket/Documen...dacted-Rel.pdf

Clearly Army pilots are calling visual on very distant traffic which they haven\x92t actually identified and can\x92t see, and controllers are believing them and contracting responsibility for collision avoidance to them. The Standards pilot being interviewed here (the most experienced Army pilot NTSB spoke to) even says \x91..I know it\x92s bad\x85\x92 but condones the practice because otherwise the PAT helos would have to hold!

The logic displayed here is totally crazy.

If ATC have taken the trouble to issue a traffic advisory to a helo, why does the helo pilot think it\x92s reasonable to assume the traffic (which they haven\x92t seen!) will be no factor. The Controller has called out that particular traffic to the helo pilot for a reason he\x92s become aware of, like the traffic\x92s intended flight path will shortly become a collision risk to the helo.

Because, due to the proximity of Route 4 to runway 1 traffic, 12th AB pilots much more frequently received traffic calls for runway 1 traffic coupled with visual separation, traffic for which there would never be a collision threat. And if there was 33 landing traffic, ATC would just issue a hold. I\x92m still reading through the interviews, but have yet to find an example of a 12th AB pilot that, while on Route 4 with visual separation for 33 landing traffic, actually had to track the aircraft and maneuver to avoid.

Yes, it was functional and activated during the accident sequence. The DCA CA system is discussed extensively in the ATC interviews.

In this interview at pages 97 and 112 the pilot says he has operated south on Route 4, and with traffic circling to 33, both accepted \x91hold at Haines Point\x92 and also accepted \x91visual, pass behind\x92 clearances literally dozens of times. Admittedly he wasn\x92t 12th AB. (This is a PSA line check captain who was formerly military UH-1N helicopter pilot operating in the area with USAF at Andrews AFB). Very interesting interview.

https://data.ntsb.gov/Docket/Documen...dacted-Rel.pdf

That is ultimately the call of the crew. ATC only gives the option, it's the PICs responsibility to assess whether it is feasible and safe. I don't personally know any ATCo who would be comfortable offering that in this particular scenario, but that's coming from the European perspective where we have nothing even close to the proximity of military/civilian mixed traffic. I only did a little approach familiarization and no tower work, but just talking to colleagues who did, I don't think I'd be comfortable to offer visual separation in that environment. But then again threat normalization is a pretty effective thing.

Just went ,very selectively of course, through the thousand of pages of to the dockets and they give a clearer picture , to me at least . of the huge normalization of deviance that took place from both the DCA control staff and the RAT pilots.. I went mainly thought the interviews and the TCAS dockets.
What I learned:
Interestingly the Local controller involved was also a CPL pilot
Pressure to use 33 for landing during high departure rates was there to avoid the queue blocking the taxi ways for arriving aircraft : ( my comment : when you get to that situation traffic should be reduced by departure slots , that what we do in Europe with the Network manager CTOTs..)
No reaction to Conflict alert because visual acquisition was prioritized , i.e if you saw the helicopter passing behind you disregarded the CA. and this was almost always the case so CA with helicopters became disregarded
Advanced training was poor or non existent ( e.g Threat/Error management training).
On the PAT pilots interviews the most flagrant normalization of deviance is requesting visual separation with an aircraft you do not see ( yet) I realize that was declared by pilots other that the one operating that flight , but gives a good indication of the local " best practices " in that area.
Finally on the TCAS issue, one of the screenshots shows other traffic, and we can see that there were 2 TAs one in front -2 and one behind +6 , that could ( emphasis on could) have been one of the reason the CRJ crew missed the urgency of the -2 , but also probably were more focusing on the PAPI so both looking outside instead of at the display .

And to reply to a question earlier by DIBO on the discussion about ADS-B out not avail on the RAT, and its relevance for TCAS, well it would have influenced the degree of accuracy of the Tau calculation ( with Alt returns every 25 ft instead of 100 feet) and could ( again emphasis on could) have changed the alert logic/timing of the TA. Non installation of ADS-B and flying 70 ft too high are probably one of the points the lawyers are going to get into to prove negligence from the military to get more money for their clients , possibly shadowing the real causes. ; which for me are still the design of the procedure and routes, and the failure of the Regulator to act on the alerts. . Love to hear Willow-Run 6-3 comment on this .
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Absolutely, but the other side of the normalisation of unsafe practices coin is Local Controllers conveniently believing that pilots have instantly picked up distant traffic visually and granting their request!

I appreciate the invitation to comment. With first acknowledging there are several technical factors involved here as to which I have limited understanding (and also that I've commented several times on legal issues likely to be presented by the accident regardless), the legal picture probably is best understood if it is described in two contexts. The fact that the most clearly responsible entities - the Army and the FAA - are both parts of the federal government means that sovereign immunity must be taken into account. (Sikorski, mentioned as a potential defendant by one of the attorneys involved in the case already, has no significant legal risk here, in my view. The reason is its protection by a judicial doctrine known as the "military contractor defense." The specifications given to Sikorski for its design and manufacture were reasonably precise and it met them. See Boyle v. United Technologies Corp. (1989), if more depth and detail is desired.)

As for the airline, to fault the pilots when they were on short finals and expected to concentrate on flying - as others have expressed here numerous times - seems very ill-founded. Whether the airline company could be alleged to have responsibility for not having spoken up more effectively to cause the airspace design and procedure to be redone also strikes me as far too oblivious to the actual operation of the NAS, and the FAA and Congressional processes, to have any validity as an approach to liability. The airline and even Sikorski could still be named as defendants but, to reiterate, this would be just for leverage and not because there is any real pathway to liability for either one.

That having been set as background, the first context ignores the existence of sovereign immunity issues and looks just at what happened and who was responsible. As a rubric for this, "normalization of deviance" seems very accurate. This includes the fact that over time, ignoring Conflict Alerts came to be routine. It includes the practice of confirming "traffic in sight" or related proper terminology, for visual separation even though no traffic had been sighted yet - because it had become routine that the traffic would come into view and be properly identified as the traffic ATC had called out. The testimony about "just make it work", as I heard it, similarly was very concerning; iirc an overall very credible FAA witness acknowledged that the "just make it work" attitude also resulted in decreased safety margins. As did the medical helicopter operator who also had Army helicopter service background. Add in the lack of advanced training, and though I have not practiced law as legal counsel for accident victims' families, the liability theories here appear strong.

Then factor in the use of 3-3 to allievate congestion from high departure rates, rather than slowing or reducing departure slots. Part of the pressure to use 3-3 (as I understood the testimony) was that the Potomac Tracon wanted to increase in-trail separation but DCA instead increased use of 3-3. This was consistent with the attitude, "just make it work".

As to ADS-B on the helicopters, my understanding is that given the roles and missions of the helicopter operations, ADS-B is not equippage the military and its civilian control (in the sense of oversight) could have approved consistent with those roles and missions generally, and especially the continuing-of-government function.

Putting all the causal factors together into a "theory of the case" is perhaps better left to advocates for the accident victims' families (just as defense theories better left to defense counsel in this matter). But since you've impliedly asked, I would not - in this first context - parse out three of the four factors you noted, the lack of ADS-B being the one left out. That leaves the helicopter operating approximately 70 feet too high, the airspace design and procedures including the helicopter routes, and the inaction following the several safety alerts in databases and other reporting functions prior to the occurence of the accident. And including the forced enlistment of DCA for handling more traffic than the widely accepted airspace utilization and safe operation rules and procedures would allow - but they "just made it work." In other words, all of these three factors combine into the most likely theory of liability.

There is a second context, however. Federal government defendants are protected, despite the broad removal (waiver) of sovereign immunity by federal statute, from liability if the alleged negligence resulted from the exercise of discretion. If the actions or omissions being challenged resulted from decisions in which the federal entity weighed economic, social, political and other factors against each other in a form of "policy" decision-making, sovereign immunity remains in place. You can see where this is leading, of course. At what point does the over-use of DCA move out of the protection of "discretionary functions and decision-making" and into the realm of ... just plain negiligence which needs to be addressed in a court action. And likewise, at what point does the Army's set of decisions about how the routes are flown, and how visual separation and traffic sightings are handled, move out of the protection given by discretionary decisions and into the realm of significant negligence not deserving of such protection? Same question for FAA - surely the presence of safety concerns in databases and reporting systems - as unorganized as they may be and as lacking in systematic review as they may be - are matters within the FAA's discretionary functions and decision-making . . . until they're not. (And not equipping PAT helicopters or other D.C.-based Very Important air transport operations by helicopter with ADS-B would have no chance of being ruled not resulting from a discretionary function and decision - it's not even arguable imo.)

I almost included with this (already lengthy) post the "syllabus" of the U.S. Supreme Court's decision in the United States v. Varig Airlines case, which I think is the most pertinent aviation case in which the discretionary function rule is fundamentally involved....but this isn't a legal forum. Still, the U.S. S. Ct. opinion (467 U.S. 797 1984) gives me uncertainty about how any court of competent jurisdiction will draw the line between what would in a case against a not-federal defendant definitely appear to be negligence, and the actions and omissions of the federal defendants here. (My personal view is that the federal defendants acted with such severe negligence that the discretionary function protection has been lost - but that is a gut reaction to the "this accident never should have happened" idea and not legal analysis.)

Finally and last for a reason, I am not commenting about the motives of legal counsel who are representing or advising clients involved in this matter. I have not practiced law a single day, or a single billable hour, or otherwise, on behalf of the families or representatives of aviation accident victims, or the defendants in such matters. As a result, in participation as a guest on this forum I think it's much wiser to let the members of the bar who do have clients and who do practice in this area let their conduct in their professional capacities speak for itself.

There have been a number of references above to the woefully inadequate vertical separation provided between helicopter Route 4 and the approach to Runway 33. Given altimeter errors (expected and maybe not so expected) in the helicopter, a helicopter flying high (and possibly offset sideways towards the end of Runway 33) and an aircraft maybe low on approach, there really wasn’t any guaranteed separation.

I strikes me that, from my layman’s point of view, that this is the primary and gaping hole (among numerous others) in the Swiss cheese here.

At the same time, I get the sense that no controller was ever going to intentionally permit a helicopter to pass directly under an approaching aircraft and challenge that limited clearance.

My question is, should this have been (or was it?) formalized as an ATC procedure? Because if this had been proceduralized, I find it hard to believe that just nighttime VFR separation would have been found acceptable in that environment. Rather I would think that lateral separation should have been actively managed by ATC.

For one thing, with the CRJ (or whatever aircraft) pilots making a late switch to 33, turning to line up with the runway, etc., they may not have had the bandwidth to scan for a possibly conflicting helicopter, if they could even have seen it from their cockpit. (IIRC from the inquiry, the NTSB will be investigating that last point.)

I don’t know how difficult it may have been for the helicopter to see the CRJ, but the simple fact is that they did not.



On another subject, one thing that struck me from the inquiry was that the helicopter pilot apparently had very limited recent flight time, yet was assigned a challenging check ride.

This contrasted with the testimony of the leader (?) of one of the local Medivac groups, who discussed how much more experience he and his pilots had flying in that challenging environment (and often single-pilot ops at that).

Is the Army not providing adequate training and flight time to ensure their pilots can operate safely in those conditions?

I wouldn't bother explaining it to laymen as a hole in cheese. In layman's terms it's the same as having two busy roads cross, and no traffic lights.

And to stick with motoring analogies, some of us are used to considering that at a junction another vehicle can be partly obscured by a pillar for one eye, and in the blind spot of our other eye, so we might move our head sideways to help check better. Some aircraft have more windscreen pillars (this helicopter has four) so the aircraft in a constant relative position - which is the one that is the collision risk - may stay behind a pillar unless we move our head.

It's simple; the altitude restriction was never intended to be the sole method of separation. At most, it was an additional layer of protection. The controller wouldn't have cleared the Blackhawk to continue if they hadn't said they had the traffic in sight. But they did say that, whether it was true or not. ATC is a service provided to pilots, not an authority. Pilot-applied visual separation essentially overrides any procedure used by ATC. When you say "Traffic in sight," you are saying "I don't need your help maintaining separation, I have it under control and I take full responsibility."

The IFR aircraft wouldn't be required to have the traffic in sight.

And yet as we saw, this approach failed. So something has to be wrong with it.

Yet was not the controller required to inform the CRJ of the helicopter, which (as the inquiry noted) he failed to do? Thus a possible cross-check was lost.

Are you sure about that? My understanding of Class B airspace is that all aircraft proceed only on the basis of an ATC clearance. So to re-parse your statement\x85When a pilot says \x93Traffic in sight\x94 it just means he can see it, nothing more. It\x92s when he then says, \x93Request visual separation\x94 that he\x92s suggesting to the Local Controller he doesn\x92t need help with separation. And then it\x92s only when the Local Controller says, \x93Visual separation approved\x94 that the pilot takes on the responsibility for separation.

The CRJ crew was aware of the traffic. They received a Traffic alert from TCAS 18 seconds prior to impact.

No, they're exactly the same. If you say "traffic in sight" then the controller will immediately say "Maintain visual separation."

"Request visual separation" is non-standard.


https://www.faa.gov/air_traffic/publ...section_2.html

For most of its flight, PAT25 was operating outside Class B but in contact with PCT. At Cabin John with PAT25 operating right at the Class B floor of 1500 ft, the DCA LC approved PAT25’s request to proceed Route 1, Route 4, to DAA. That was PAT25’s clearance into Class B.

Two interesting events noted on the recordings:

At about 20:00L, PCT calls helicopter traffic to PAT25. I count at least 12 statements between the two pilots regarding the called traffic in addition to radio transmissions to PCT regarding the traffic. Contrast this to the CRJ called traffic which generates zero discussion between the PAT25 flight crew.

At about 20:37L, there’s a traffic interaction between MUSL13 and BLJK1 (two helicopters) that generates a conflict alert. The DCA LC provides multiple traffic alerts to both aircraft, including direction, range, and altitude of the conflicting aircraft, even after visual separation is approved for BLJK1. Contrast this with the accident sequence where PAT25 is provided with a single traffic alert and the CRJ gets bupkis.

Trying to understand how the individuals and organizations responsible for the operation of the DCA airspace and associated helicopter routes expected it all to operate safely. Also not exactly trying to anticipate lines of inquiry to be conducted by the Dep't of Transportation Inspector General, although I think Sailvi767's comment points to a key area that will be examined.

My understanding is that TCAS RA's are inhibited below some specified altitude, in order to reduce or minimize nuisance alerts. Is it a correct statement to say that when the CRJ received the TCAS TA's referenced by Sailvi767's comment, it already was below the altitude at which RA's were inhibited?

If that is correct, then doesn't it follow that the CRJ crew - intently focused on the approach to and landing on 33 - were following procedure that has long been acknowledged for DCA Rnwy 33 - the LC will keep helicopter traffic from becoming conflicting traffic? It is (I think, but only as a non-pilot and non-ATCO) obviously true that in this instance, there were a number of inputs (and lackof inputs) by ATC, and likewise several acts and omissions by PAT25 which led to the procedure failing badly, with the tragic result. In other words, the clearest root cause is the fact that the acknowledged procedure over a period of years was that the LC (and sometimes a helicopter position in the tower) would keep the helicopters from becoming conflicting traffic - and through normalizationi of deviance, when this procedure eventually failed, it failed all the way.

In a previous post I mentioned that one of the attorneys representing the families of accident vicitims has said that claims against the airline would be investigated and possibly included in the forthcoming lawsuits. I suppose it is not talking like a stark raving lunatic to point to the many reports filed about overly close encounters in the airspace, especially in light of information found and then released by NTSB soon after January 29 which detailed many close encounters (as a non-frivolous basis to assert claims against the airline). But wait. They are going to argue that, during the last few hundred feet on final approach to Runway 33 at night, after having been more or less directed by ATC to switch from Runway 1, running through all the steps outlined (by Capn Bloggs) to look for the possibly conflicting traffic took priority over flying the approach - especially in light of the long-acknowledged procedure at DCA? I'm admittedly shouting from down in the cheap seats but this attack by plaintiffs on the CRJ pilots, as an means to advance claims against the airline, strikes me as a legal obscenity.

Bit of confusion here . TCAS is not a separation tool , it is a last minute anti collision system . You are not obliged to monitor the screen, definitively not at 300ft on finals Not sure the CRJ crew noticed it . . Fact is the CRJ crew was not passed the traffic info . the reason why has been covered in the NTSB docket ( interview of the controller)
In class B , controllers will provide separation between IFR and VFR however they can delegate separation to an aircrfat visually following a strict procedure and phraseology .and issuing an ATC Instruction : " maintain visual separation "

As I posted on here before I had that exact same scenario happen to me on runway 33 in DCA. Traffic closing on a collision course on TCAS. Tower reported the traffic had us in sight. When the traffic closed to \xbd mile with no vector change apparent We went around from 400 feet. We never saw the traffic. Tower chewed my butt saying the traffic had us in sight. I didn\x92t care.