Posts about: "CRJ" [Posts: 363 Page: 16 of 19]¶

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.

Refer to ATCDumbo Question 1!!

ATCWatcher Thank you…It’s like pulling teeth but we will get there eventually ….

No thanks to the NTSB for the selective choice of facts…What should I expect in a country of fake news and alternative facts?

As for your comments re if the CRJ had ADSB_IN; exactly ….welcome to my nightmare!

Shock horror The Holy Grail turned out to be the holy hand grenade!!!

Re all lawyers reading… Put that one in your pipes and smoke it!

Always look on the ….. Now what pizza to order tonight

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

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.

ATCDumbo Question 4: In three parts

BugBear : In your post above you appear to imply that the LC had to work 2 different radar screens. (Memories of Uberlingen?)

Are you sure about that?

And to manage two discrete VHF frequencies. What, two different ?headsets? Is that what you are implying?

And where do you think the ADS-B information from the CRJ was displayed in the TWR Cab, on one or more of the radar screens?

BugBear ": In your post above you appear to imply that the LC had to work 2 different radar screens. (Memories of Uberlingen?)" "And to manage two discrete VHF frequencies. What, two different ?headsets? Is that what you are implying?"

Yes. LC could hear both Heli and AA. Neither AA Nor helo could hear the other ....."
From ATCDumbo......
"And where do you think the ADS-B information from the CRJ was displayed in the TWR Cab, on one or more of the radar screens?"
One hopes. If not to both pilots, then eyes on by LC ?? How are two conflicted aircraft that close in not aware of each other ?? Doesn't AA get a chance to look for traffic??

Even if traffic is changing orientation from Four 0'clock to12 in ten seconds????

Hiya WR 6-3 , always worth discussing so no worries.

The baseline is that a TA on it's own is not enough and can even lead to issues if reacted to without knowing exactly where that contact is and what it is doing. You should, if you have the time (hence my comment re workload for the RJ crew at that point), try and get visual on the traffic but, tbh, it's very difficult to do, especially at low level at night against backlighting. You don't even really have time to "debate" a "shall we react (against SOP) to (yet another?) TCAS alert at DCA?" with all else that is going on at that point of a flight. SOP/Training says "fly on"! You need compelling evidence to go against that. I fact, IIR, the NTSB noted that the CRJ had full "up" elevator at the time of impact - that implies the crew finally saw the helo and reacted ..... but with no time to change their flight path.

If you want to "do" the airline - I feel a much better case could be made based on the fact the evidence of issues for that approach at DCA was sat in the Safety Databases for anyone who went looking, that maybe even crews had raised the issue themselves through internal reporting in the Airline, and/or there was no process in place within the Airline to review operations into DCA - or any other airport. This is promoted by the FAA who state that "The [airline] SMS promotes a defined structure and a \x93learning culture\x94 within an aviation organization that continually seeks and analyzes information, then turns that information into action that eliminates or mitigates safety risks, before they become unwanted events.". The full ref is here. And that also applies equally to the Metropolitan Washington Airports Authority who I believe operate DCA as an independent organisation. How the MWAA fit in to US Government - I'm not sure!

Anyway, hope this helps. Cheers, H 'n' H

Good points Sailvi767 . What's your thoughts on if somewhere has a reputation for being a "TA Mecca" where, due to the airspace design, it leads to a high number of TAs from safely (but proximate!) crossing traffic as seems to be the case with DCA going back in this Thread?

I guess that dampens the urge to figure out what's going on with a TA, especially when on a relatively short Final where workload is high/time is in short supply/city lighting makes it very difficult. We don't know re this specific crew but it seems the Company regularly used 33 so that could be a factor - "Here we go again...... another TA........". As someone said, the "boiled frog" scenario.

I still think that, while it's a valid thought of "what if they did......", I think it masks the more important aspect in that the overall design of that bit of airspace was rubbish - as was so eloquently put by the NTSB.

Basically, the design stitched up the CRJ crew, the helo crew, the ATCO and the poor pax. Where else are there similarly wilting frogs? Thats the big question.

Yup,

the pilot flying screwed up in multiple ways but it is all the instructor\x92s fault.

Just like the pilot in the CRJ in YYZ obviously is incompetent when it comes to landing but no fault of her own.

I really struggle to comprehend why the helicopter not transmitting ADS-B Out is relevant to the accident. What benefit would the other two parties - the CRJ and the TWR Controller gained?
The CRJ didn't have ADS-B IN, and the ATC Surveillance system (radar) doesn't process the data.

DM as required to convince me otherwise.

Pretty clear the Army helicopter was too high, a little off course, and certainly did not have the plane in sight the controller wanted them to have in sight. Controller busy and separation left to helicopter crew.

So may 'what ifs' could change the outcome. A "caution - VFR helicopter traffic below - southbound along river" call out to the CRJ crew by ATC could of made the difference. The helciopter crew staying at or below 200 could of made the difference.

Its amazing that this was considered "the norm" in that area.

Up to 205 documents now in the docket, including composite CVR transcript. Couple of things jumped out:

1. PAT25 PF started to turn right at Cabin John (American Legion Bridge), which would have taken them toward Great Falls; i.e., up the Potomac. IP had to tell PF to turn left, which would start track down Potomac River (helo route 1). Odd. Not the best SA by PF.

2. No discussion in the PAT25 cockpit about the called CRJ traffic.

3. PSA Captain/PF expressed to PM a preference for continuing to runway 1 but accepted runway 33. Media will make a big deal out of this. I don\x92t think it is.

I have flown that route a handful of times during my time in the Marine Corps (admittedly it's been more than 20 years ago). I recall being asked to do a 360 turn over the Wilson Bridge for spacing (we were northbound) for traffic landing on 33.

In regards to your other comment about them not seeing the CRJ, I have believed from the time that the radio traffic was public that the controller was not specific enough when he asked PAT 25 "do you have the CRJ in sight?" Something along the lines of "PAT 25, CRJ on final for RWY 33 is at your 10 o'clock less than a mile, pass behind that traffic" should have drawn the helo crews eyes to the left to hopefully see the traffic. Even better would have been to have the helo do a left 360 over Hains Point.

Yes , but for me more important is the fact that a single controller was handling 2 frequencies that were not really coupled, the CRJ did not hear the RAT and vice versa, both only heard what the controller said not the questions asked , The single controller was also busy doing 2 jobs and quite busy with Runway 1 OPS , so probably that is why he did not find the time top pass essential traffic info to the CRJ . 2 controllers might have changed something, yes, but only " might" because in that case , both would have been on 2 separate frequencies , if traffic info was not passed to the CRJ , the result could have been the same .

For me the key point of this accident is the 100 ft procedural separation planned between a Heli route and a non precision ( e.g visual) approach path . The rest are just more holes in the cheese.

I\x92ve been listening to the NTSB hearings while doing other things last couple of days. All I can say is the FAA testimony is wild .

Normalisation of deviance doesn\x92t even come close.

- Airspace design. The heli route stepping down to 200ft max lead some army pilots to believe it gave clearance from DCA traffic. Spoiler. It did not.
- Controller workload \x93Just make it work\x94 was a common attitude at DCA
- FAA not actively tracking TCAS RA \x93incidents\x94 as it could skew data.. maybe it was correctly applied visual separation etc. Need to look at the background etc. Yeah. But it generated an RA 🤬
- FAA refusing requests for traffic \x93hot spots\x94 on low level VFR charts as \x93hot spots\x94 are on ground charts only.
- PAT25 wanted visual separation from the CRJ. ATC was required to inform the CRJ crew another aircraft was applying visual separation to them. They didn\x92t.

Honestly from a European perspective. It\x92s quite bone chilling.

I feel this was a systemic failure. Airspace design and Risk Normalisation.

And my heartfelt condolences for the pilots, of both aircraft, and everyone else involved including the ATCOs. Not that there weren\x92t issues\x85 but in the Swiss cheese model, the FAA bought the cheese, drilled holes in it, and invited everyone to take a look inside.

Slightly surprised by some NTSB comments as well\x85 they were presented that the heli was straight ahead on the CRJ TCAS simulation presentation. But in actual fact the CRJ was circling in a left turn for runway 33. It was stable at 500ft but in a left turn to line up with the runway\x85 wings level at 300ft. It was challenged by the airline/ALPA but I would hope the NTSB would have picked up on that.

Low point of the whole hearing was Jennifer Homendy halting proceedings and moving witnesses to different seats, as one of the FAA managers elbowed a colleague while she was giving testimony - at which point she went quiet. Infernce being she was being reminded to stop talking.

TCAS gave a TA just prior to that, why should TCAS have lost track?
That's why I don't understand all the fuzz about ADS-B in the UH60. TCAS in the CRJ worked as designed, including RA inhibit down low.
the CRJ crew getting a visual on the UH60 some seconds earlier could have saved them as well, one of many items on the 'could have saved them' list.


I've wondered a couple of times, what if.... the CRJ crew had failed to spot the UH60 all together. Now a left-banking evasive manoeuver was started, and only the left wing was substantially shredded by the rotor.
If they would has kept wings level, maybe both wings would have narrowly escaped major damage, only MLG and belly at risk of the main rotor.
But it all doesn't matter, really. 'Fate is the hunter' and they got caught.

From 10-AIR-A FLIGHT DATA RECORDER - AIRPLANE - GROUP CHAIRMAN'S FACTUAL REPORT :

You can see that the pitch-up reduced the airspeed, and the vertical speed was mostly unaffected. This would have had a net effect of making the descent steeper (as the Radio Alt suggests).

If the CRJ crew had remained unaware, we would've learned how the downwash of a helicopter affects the wings of a jet.

The ultimate point is that a situation where a helicopter scrapes by the underside of a jet is not supposed to occur. At this point, all bets are off anyway, and rather than pondering what to do in such a situation, the focus should be on how to prevent it in the first place.

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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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?