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| galaxy flyer
February 02, 2025, 03:16:00 GMT permalink Post: 11819484 |
I agree completely.
It almost seems backwards to me. Late runway changes should only be applied in quiet environments, allowing plenty of room for manoeuvring without separation issues. The same for visual separation, where only one or two aircraft in the area make misidentification of traffic an improbability. Unfortunately the reverse is true. The busier and more congested the airspace, the more likely these procedures are to be used. From a risk identification and management perspective, I just don't see how operating like this can ever have been deemed acceptable. Again though, it's used because it's the only way to squeeze an extra 1% out of an over burdened system. And worse of all, everyone involved, from pilots to ATC, think they're the worlds best for making it "work". All that said, the plan for DCA, particularly the helicopter ops, were hazardous in the extreme. The Route 4/33 operations is just plain dangerous, nothing less. The politics of DCA are going to drive a band-aid fix is my prediction. Visual separation won\x92t go away. FAA will get crucified over manning. DCA may lose some significant service, if we closed 33 permanently. If I read the NOTAM correctly, closing 4 and 33, the pain will become known, interestingly, I read elsewhere that the helicopter altitudes were raised to 200\x92 in 2023 due to noise complaints. Subjects
ATC
DCA
FAA
Separation (ALL)
Visual Separation
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| island_airphoto
February 02, 2025, 03:33:00 GMT permalink Post: 11819493 |
I’m not in job of defending the US system, but there needs to be some perspective. The US airspace operates about 40%-50% of all global aviation. Only half of daily flights are air carrier. For lot of reasons outside this discussion, air carriers are the default transport, trains and buses are a tiny fraction of long distance transport. Apply EASA aviation standards and the US network would grind to halt or create huge gaps in service. We’ve gone 16 years without a fatal US carrier major accident, which isn’t different than the rest of the world, especially when the US has a 50% share. Our economy would suffer greatly and passengers revolt at what would required.
All that said, the plan for DCA, particularly the helicopter ops, were hazardous in the extreme. The Route 4/33 operations is just plain dangerous, nothing less. The politics of DCA are going to drive a band-aid fix is my prediction. Visual separation won’t go away. FAA will get crucified over manning. DCA may lose some significant service, if we closed 33 permanently. If I read the NOTAM correctly, closing 4 and 33, the pain will become known, interestingly, I read elsewhere that the helicopter altitudes were raised to 200’ in 2023 due to noise complaints. And yes, trying to do EU IFR for everything all the time would create some epic traffic jams. * IMHO they need the dedicated helicopter controller on at ALL times the helicopters are flying and they need to be held for crossing traffic. They also all need ADS-B, no private pilot that wasn't totally skint would be running around with the lack of situational awareness the helos seem to have in an area like that. Subjects
ADSB (All)
ATC
DCA
FAA
IFR
Separation (ALL)
Situational Awareness
Visual Separation
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| galaxy flyer
February 02, 2025, 04:02:00 GMT permalink Post: 11819500 |
The area is extraordinarily sensitive to noise complaints. I muffed a landing at KVKX just a few miles away after the takeoff curfew and someone called the cops on me for going around and I got a bit annoyed with them and told them they weren't the air police.
And yes, trying to do EU IFR for everything all the time would create some epic traffic jams. * IMHO they need the dedicated helicopter controller on at ALL times the helicopters are flying and they need to be held for crossing traffic. They also all need ADS-B, no private pilot that wasn't totally skint would be running around with the lack of situational awareness the helos seem to have in an area like that. Subjects
ADSB (All)
ATC
DCA
IFR
Situational Awareness
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| Bratchewurst
February 02, 2025, 05:50:00 GMT permalink Post: 11819530 |
That\x92s the kind of information that the NTSB will discover from interviews. Subjects
ATC
CRJ
DCA
NTSB
Separation (ALL)
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| fdr
February 02, 2025, 07:24:00 GMT permalink Post: 11819550 |
Well, that's interesting. You seem to be saying that "the system" worked as designed? FDR notes immediately before your reply:
Did ATC do all of that? Having listened to the ATC comms (including the UHF) a few times, I believe they did, for the most part? They mentioned CRJ (of what use is mentioning the type at night, I have no idea, but they did), they mentioned where it was and where it was headed, and they received two acknowledgments... So that means this collision occurred entirely within all established protocls? These aircraft crashed, as per the system specifications. So the system is, to put it plainly...FUBAR? That's not good.
Musings: "The system" includes all of us that are involved in aviation at all levels, everyday. Thee are a lot of flights that go into DCA every day, each crew observing the same conditions, and conducting briefings of the arrivals, approaches and departures. Same out of LAX etc. How many of us, as stakeholders in the system have raised our concerns to the system by the means available, the ASRS, company safety reporting systems, the squadron SMS systems. How many safety managers have bothered to go and do an operational route survey/audit? Without our active participation, then we are relying on some person long retired who designed a procedure that survives to this point in time, and due to our collective indifference to the common users safety we remain broadly mute, until something falls off the perch. At this point we feign surprise, shock and some horror, yet, search inside, how many of us are surprised by this event, or Jeju Air in Muan, or the Russians shooting down yet another civil aircraft, Instead, we pontificate, (myself possibly more than most) and point the bone at all others in the system, SMS systems only work if they have data that is meaningful. Each airline may seem to be swamped in data, that however is not the case for dealing with extremely low incidence, but high consequence events. There is not enough data generally to do a damned thing with, for just UAL, DAL, AAL etc or other operators. To be able to understand fully a system behavior there has to be adequate data, At present the only aggregated data of any note is that with NASA under the ASRS, and with ICAO at the reportable event level. Each ICAO state safety plan is supposed to provide data to the extent it can to its own community and to ICAO, and that is generally the last that is seen of the data. The airlines and operators dont get feedback, ICAO may or may not apply that data towards rule making, but that is years hence, and does not meet the needs of the user or the public today. Without the data being available to all, it is diminished in its utility. SMS systems have limited effectiveness that is IMHO glossed over universally, as actually getting data that is useful takes effort, and then evaluating that data takes critical analysis. By squandering the opportunity to have the data to evaluate, it should be no surprise that occasionally, we have SA-1, SA-2 and SA-3 type situational awareness failures of biblical proportions. Aerospace suffers from frequent events that are normal in most respects. Functional resonance is a reasonable paradigm to assess how the system is really working, to give the system the understanding of how large the slip between assumptions and real system behavior is. The means of doing that is available from the flight data, and from operational audit aimed at understanding how expectations of process match with the real world. Alternatively, we can sit back and blame the victims of the most recent mishaps, chasing those that should take responsibility for this, which to an extent falls on all of us that use the system and don't bother to raise concerns to the system. Complacency works well though, until it doesn't. Subjects
ATC
CRJ
DCA
ICAO
Situational Awareness
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| Easy Street
February 02, 2025, 10:30:00 GMT permalink Post: 11819666 |
Apply EASA aviation standards and the US network would grind to halt or create huge gaps in service ... Our economy would suffer greatly and passengers revolt at what would required.
... The politics of DCA are going to drive a band-aid fix is my prediction. Visual separation won\x92t go away. FAA will get crucified over manning. DCA may lose some significant service, if we closed 33 permanently. [I think of the Austin investigation, which did not even mention, let alone question the practice of issuing runway clearances to multiple aircraft at the same time, which IMHO is the root cause of most of the recent near misses.] Last edited by Easy Street; 2nd February 2025 at 10:50 . Subjects
ATC
Close Calls
DCA
FAA
Separation (ALL)
Visual Separation
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| ATC Watcher
February 02, 2025, 10:42:00 GMT permalink Post: 11819672 |
I the idea that while the extra airspace capacity afforded by visual separation at night may come at the price of occasional accidents such as this, that price is worth paying for passenger, government and economic benefit. Those kind of ideas don't tend to be well received or understoood by the public, or by extension by elected representatives, so a prediction of my own: every single agency and authority involved will go out of its way to avoid acknowledging that idea, and instead will pretend that visual separation at night is a fundamentally sound practice let down by poor procedure design and/or ATC at DCA.
Subjects
ATC
DCA
Separation (ALL)
Visual Separation
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| island_airphoto
February 02, 2025, 13:57:00 GMT permalink Post: 11819813 |
and from island air photo :
Spot on, but there is no EU or EASA IFR there are IFR rules and agreed global aviation standards ,Period What is ( or should I say was ) done in DC , or in SFO or with LAHSO, etc are all deviations to allow more traffic outside of the rules. Expedition taking over our good old "safety first" mantra . Now , is delegating visual separation to an Helicopter ,at night ,( with pilots wearing NGV ) on an aircraft cleared off the ILS doing a circle visual NPA at 500 ft with 4 eyes most probably locked on the PAPI something safe ? with a 150- Ft margin of error designed on the chart ? But it is how the system was built and local controllers trained on doing this , since years. Normalization of Deviance. I wish good luck to the NTSB and the FAA is trying to reverse this . 1.The bat-s### crazy way they run helicopters around DCA. 2. The usual practice of visual approaches and spacing in good weather. It has been that way for as long as I have been flying and I am having a hard time even visualizing all IFR spacing to the pavement on a clear day. Maybe asking an American about this is like asking a fish if water is wet? The OTHER unrelated (?) issue of sorting out ground traffic. I was one on the same trip cleared to take off with an aircraft on short final and then cleared to land with an airplane just pulling out onto the active. To make that one better, I knew the person flying that plane and couldn't resist being snarky: "Ah XYZ tower, we'll be going around, Bob says not to wreck his airplane by landing on it". Subjects
ATC
DCA
FAA
IFR
Land and Hold Short
NTSB
Separation (ALL)
Visual Separation
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| galaxy flyer
February 02, 2025, 14:29:00 GMT permalink Post: 11819828 |
Mere SLF here - I work in risk management (in a different industry) and so have an interest here, along with a lifelong interest in aviation - fully ready to be modded if I'm talking out of turn!
I accept the point regarding the likely economic impact. However I think its worth making the point that in the context of that '16 years without a fatality' record. there have been a number of potentially serious near-misses on the ground (JBU at BOS, AAL/DAL at JFK, SWA/FDX at AUS, etc etc) that are indicative of a system operating beyond its capacity and implementing procedures that are deemed to be of an acceptable risk profile in order to stretch that capacity. It was fortunate that those previous incidents were narrowly avoided. Wednesday night was where that luck, sadly, ran out. Subjects
DCA
FAA
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| DespairingTraveller
February 02, 2025, 15:04:00 GMT permalink Post: 11819846 |
I'm struggling to make sense of the numbers being bandied about here. Apparently the NTSB has said that the CRJ was at 375 feet,
But from the beginning, various plots have shown the collision occurring in mid-river. A little work with Google Earth will show that the extended 33 centre line reaches mid-river about 3,300 feet from the aimpoint of runway 33. A 3 degree glideslope and some trig will put it at 175 feet at that range, with obvious implications. 375 feet would be a big error with not much more than half a mile left to run. What am I doing wrong? Also, helicopter route 4 hugs the eastern bank of the Potomac until Goose Island and doesn't cross to the western bank until Wilson Bridge. So why did the Black Hawk perform a 45 degree right turn while still abeam DCA? (See, e.g., post #25) Was it intending to route direct to Fort Belvoir, ignoring the heli routes? (I think I've seen it was operating out of Joint Base Anacostia en route to Fort Belvoir, so the fact it was still abeam DCA must have been more than obvious.) Puzzled. Last edited by DespairingTraveller; 2nd February 2025 at 15:24 . Reason: edited to correct typo Subjects
Blackhawk (H-60)
CRJ
DCA
NTSB
Route 4
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| NIBEX2A
February 02, 2025, 15:41:00 GMT permalink Post: 11819865 |
Once again, looking at the safety reports below. How many of these may have been caused by the helicopter having the wrong aircraft in sight when applying visual separation?
Safety reports, if assessed and promulgated correctly, act as another line of defence. They identify any deficiencies in procedures which may have been overlooked (or underestimated) in the original procedure safety assessment. Hopefully the crash investigation will delve into these aspects to identify what action was taken on receipt of the reports below by the respective organisations. I found it chilling to read how many factors associated with this accident had repeatedly occurred and been reported over the previous 20+ years. I’ve condensed the reports [see spoiler- mods] and highlighted in bold many of these deficiencies, identified by pilots. Common Themes
Spoiler
Last edited by Saab Dastard; 2nd February 2025 at 17:15 . Reason: Make it legible Subjects
ATC
Accident Waiting to Happen
Circle to Land (Deviate to RWY 33)
DCA
FAA
Frequency 119.1
Separation (ALL)
TCAS (All)
TCAS RA
Visual Separation
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| PPRuNeUser134364
February 02, 2025, 16:35:00 GMT permalink Post: 11819905 |
I know I'm fighting a losing battle but here goes.....
I'm struggling to make sense of the numbers being bandied about here. Apparently the NTSB has said that the CRJ was at 375 feet,
But from the beginning, various plots have shown the collision occurring in mid-river. A little work with Google Earth will show that the extended 33 centre line reaches mid-river about 3,300 feet from the aimpoint of runway 33. A 3 degree glideslope and some trig will put it at 175 feet at that range, with obvious implications. 375 feet would be a big error with not much more than half a mile left to run. What am I doing wrong? Also, helicopter route 4 hugs the eastern bank of the Potomac until Goose Island and doesn't cross to the western bank until Wilson Bridge. So why did the Black Hawk perform a 45 degree right turn while still abeam DCA? (See, e.g., post #25) Was it intending to route direct to Fort Belvoir, ignoring the heli routes? (I think I've seen it was operating out of Joint Base Anacostia en route to Fort Belvoir, so the fact it was still abeam DCA must have been more than obvious.) Puzzled. Assuming the NTSB figure of 375ft is correct, you still need more info for it to mean anything. Was that the AGL, AMSL or SPS height/altitude? How accurate are the 'various plots' that indicate the collision occurred mid-river? They may be right; they may not be. Was the CRJ on final or was it still positioning to final? If it wasn't on final then the trigonometric calculations of what height it should be at might not be correct. What official evidence is there that the Blackhawk made a 45 degree turn, or could that be a data error in the publicly available information? In summary what I am saying is that, despite all of the internet sleuths plotting tracking data, none of it is official and it is all subject to various errors. Whilst interesting to form an understanding of the circumstances, it can't be assumed to be accurate to within a few feet (vertically or laterally).
Regarding UH-60L altimeters:
All UH-60 A and L Army aircraft incorporated the APN 209 radar altimeter. Our Sikorsky tech fellow for Avioics/electronis reports the accuracy in this area is 1-2 feet. The radar altimeter position in the instrument panel is just to the right of the attitude indicator and its top matches the top of the attitude indicator. The barometric altimeter is immediately below it. Both pilots have the same setup.
Instead of no RA below 500ft (or whatever the floor is), how about telling one conflict to climb and the other one to \x91not climb\x92? \x91Not climb\x92 could then be understood (and trained) to mean \x91descend a little, terrain/aircraft/wx permitting or fly level\x92. Lots of ifs and buts, spurious warnings, limitations for when 3 or more conflicts, TCAS vs. GPWS considerations etc. but perhaps worth a thought.
Subjects
ATC
Barometric Altimeter
Blackhawk (H-60)
CRJ
DCA
NTSB
Radar
Route 4
TCAS (All)
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| DespairingTraveller
February 02, 2025, 17:19:00 GMT permalink Post: 11819940 |
I know I'm fighting a losing battle but here goes.....
What you are doing wrong is making guesses based on incomplete/inaccurate data that is in the public domain. Assuming the NTSB figure of 375ft is correct, you still need more info for it to mean anything. Was that the AGL, AMSL or SPS height/altitude? How accurate are the 'various plots' that indicate the collision occurred mid-river? They may be right; they may not be. Was the CRJ on final or was it still positioning to final? If it wasn't on final then the trigonometric calculations of what height it should be at might not be correct. What official evidence is there that the Blackhawk made a 45 degree turn, or could that be a data error in the publicly available information? In summary what I am saying is that, despite all of the internet sleuths plotting tracking data, none of it is official and it is all subject to various errors. Whilst interesting to form an understanding of the circumstances, it can't be assumed to be accurate to within a few feet (vertically or laterally). Similarly, given that both aircraft did sadly end up in the river, there's limited margin for error in the position of the impact as well. The Potomac is narrow near DCA as a glance at a chart will show. Anyway, I have no expectation of solving anything. Just trying to understand the information that's out there. Subjects
Blackhawk (H-60)
CRJ
DCA
NTSB
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| island_airphoto
February 02, 2025, 18:39:00 GMT permalink Post: 11819989 |
Subjects
DCA
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| T28B
February 02, 2025, 19:09:00 GMT permalink Post: 11820017 |
Greetings, esteemed colleagues.
Before Monday arrives and the posting rate increases, I will repeat the guidance that Pilot DAR provided a few days ago.
AA5342 Down DCA
The moderators have had a background discussion about this situation, and agreed to stand by the exclusion of political discussion as is the policy of PPRuNe. That said, this accident, and the investigation and introspection to come are going to run the ragged edge of political discussion. We want the aviation safety discussion, we don't want it lost in discussion and emotion about politics - we just don't have the page space! (and it's a lot of work to moderate!). Posts referencing actual facts, reported from authoritative sources, and primarily on the topic of the accident, the investigation, and associated safety are welcomed here. If in doubt, just leave out the political part of what you're thinking to write, we all know that you have an opinion, we don't need to read it here. If your post touches to role of a government official as a factor of the event, without inflaming discussion, the moderation team will do it's best to find a favourable interpretation. Thanks for working with the moderation team on this... Pilot DAR If you are (as many PPRuNe members are) a fixed wing civil aviator, or air transport pilot, I'll ask you not to post about (1) helicopter operations and (2) military flying unless you also have experience in both of those areas of endeavor that relates to this tragic accident. There are a number of our members who have that experience, so let's not let our noise drown out their signal.
We've had to remove some noise. I have received a few well founded complaints about the uninformed commentary about both rotary wing flying, and military flying. Please do not play the role of the sciolist, but instead speak from your own actual professional experience and knowledge. If you have something to critique about the mixing of helicopter and fixed wing operations at and around civil airports, please be temperate and professional in your language. Thank you all in advance for your cooperation in keeping this discussion professional. Subjects
AA5342
DCA
Thread Moderation
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| Lost in Saigon
February 02, 2025, 19:19:00 GMT permalink Post: 11820026 |
I have 2 questions regarding DCA ATC procedures.(they are probably related)
1) If PAT25 had said they were unable to identify the inbound CRJ, how would ATC have dealt with it? 2) Why was PAT25 requesting \x93Visual Separation\x94? What advantage did that give to PAT25? Subjects
ATC
CRJ
DCA
PAT25
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| makobob
February 02, 2025, 19:39:00 GMT permalink Post: 11820037 |
DCA Mishap
Hello fellow flyers, I am a 65 y/o retired pilot. I served 20 years in the Navy flying P-3C and trainers then served another 20 years flying for Southwest Airlines, nine of those years as Captain. Also, I am a graduate of the Naval Post Graduate Aviation Safety School with extensive hands on experience in military mishap investigation.
I have mostly enjoyed my latest years of not sitting at the front end of a jet. During my 40 years of flying people, I never really felt the stresses of being responsible for the well being of so many. Now that I spend most of my days on my boat fishing or growing tomatoes in my garden, life's pressures are minimal. This has opened my eyes to the gravity of the enormous responsibility I held on my shoulders, for the safety and well being of so many. I have always had the mindset not to "arm-chair" quarterback any aviation mishap, regardless of how tempting it may be. But the aviation mishap that occurred at DCA on the evening of Wednesday, January 29 has compelled me to speak out. Was it preventable? Sadly, It was entirely preventable. How did it happen you may ask. After all both aircraft were clearly operating normally up until impact. First lets clear up one detail both the President and our news media has consistently made error. Elevation refers to the height above sea level of the ground. These two aircraft were flying altitudes, not elevations. Aircraft fly altitudes and above 18,000 feet they are called flight levels. Example, flight level 180 is 18,000 feet. The ill-fated regional jet was at approximately 325 feet when it was impacted by the Army UH-60 helicopter. I have flown into Washington National since the first days Southwest began operations at DCA. I was already a Captain at this point, and I can tell you this airport is one of the most technically challenging of any I have flown. However, that is not why this disaster happened. I would be very surprised if the RJ black box revealed either of the two young PSA pilots were aware up until the moment of impact. Why you may ask? Because when you are flying a jet on short final, at 325 feet, you are focused on the flare and touch-down point on the runway. Perhaps the young First Officer may have seen the UH-60 just with enough warning to make a call-out, just prior to impact. From the angle of impact, very unlikely the more seasoned Captain would have even been able to see anything at all. If the First Officer was making the landing, it is most certain that neither of them saw it coming and there was nothing said on the microphone. I have no doubt, the pilots on the regional jet will be completely vindicated. In any aviation mishap, there is a chain of events that lead up to the accident. If any one of the links in the chain are broken, the accident will not happen. In this case, there are two remaining main causal factors. DCA control tower: Tower controller made a fatal error in communicating with the Army UH-60. Time was clearly critical and was wasted by asking the H-60 if they had jet traffic in site. Clearly, they did not. What should have been said in a very assertive voice, "PAT25 (UH-60's callsign), IMMEDIATE TURN TO XXX HEADING, CLIMB AND MAINTAIN XXX ALTITUDE TO AVOID COLLISION. Tower was no help at all. First they cleared the RJ for a last minute change to 33, and then failed to ensure their approach corridor was clear of traffic. In my view, the tower controller could have easily prevented this fatal collision. Army UH-60 crew: In military aviation training, we have always have preached the importance for pilots to maintain situational awareness. That philosophy by the way is also a cornerstone to commercial aviation safety. Were the pilots tuned up to tower when the controller gave the RJ clearance to land runway 33? Had they been aware the commuter jet was going to track over the ground through their intended flight direction, something should have been said. Request vector, due to traffic! One H-60 pilot responded, yes we have traffic in site, we will maintain VFR (visual flight rules) which means "see and avoid" yes even at night. Clearly he was looking at the wrong traffic which by the way is a very common occurrence, especially at night. No doubt the Army crew was engaged in training, which may have been a distractor to situational awareness. In the end, the chain of events were allowed to happen as did this horrible accident that took the lives of sixty-seven beautiful souls. The President is totally correct in that we need to hire pilots and air-traffic controllers based on merit and experience, nothing else! I have witnessed first hand, the failed attempts to ensure diversity while training pilots, at the expense of safety. That practice, both military and commercial aviation, needs to stop! The current administration has their hands full but I have complete confidence they will make significant headway. Clearly we need to train and educate more air traffic controllers! The shortage and perhaps poor training standards are likely the primary cause of this mishap. I have no doubt our new Transportation Secretary is on it with both feet running. We need to maintain pilot standards also. The pilot shortage resulted in the FAA reducing the flight hours required to be hired to fly commercially. Why didn't they allow experienced pilots age 65-67 to work? In this country, we have effectively dumbed down just about everything, in the name of getting everyone through. Just like on the operating table, you want the most experienced individuals in the most demanding jobs! Last edited by T28B; 3rd February 2025 at 02:17 . Reason: formatting and paragraph breaks Subjects
ATC
DCA
FAA
PAT25
President Donald Trump
See and Avoid
Situational Awareness
VFR
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| Peristatos
February 02, 2025, 19:42:00 GMT permalink Post: 11820039 |
What is US Congress' role in the DCA chaos?
Since 1966, DCA has operated under a federally mandated **"perimeter rule"** (enacted by Congress) that limits most nonstop flights to destinations within 1,250 miles of the airport. This was designed to reduce congestion and prioritize short-haul travel.
- Congress has repeatedly **modified exemptions** to this rule, allowing select long-haul flights (e.g., to Los Angeles, Seattle) through legislation, often driven by lobbying from airlines and lawmakers seeking direct routes to their districts. Congress has the power to **mandate changes to flight caps** at DCA. For example: - In 2023, lawmakers proposed adding 28 more daily flights despite FAA warnings about safety risks. - The 2024 FAA reauthorization bill included provisions to add 10 new round-trip flights, overriding objections from aviation experts. - These decisions are often politically motivated, as DCA\x92s proximity to Capitol Hill makes it a convenient travel hub for lawmakers. Congress *does* decide flight allocations at DCA through statutory mandates and political pressure, often sidelining technical safety guidance. This dynamic underscores a broader issue: when lawmakers act as both regulators and users of a system, public safety can become secondary to political expediency. Subjects
DCA
FAA
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| Sven Sixtoo
February 02, 2025, 19:56:00 GMT permalink Post: 11820054 |
I have 2 questions regarding DCA ATC procedures.(they are probably related)
1) If PAT25 had said they were unable to identify the inbound CRJ, how would ATC have dealt with it? 2) Why was PAT25 requesting \x93Visual Separation\x94? What advantage did that give to PAT25? Subjects
ATC
CRJ
DCA
PAT25
Separation (ALL)
Visual Separation
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| patrickal
February 02, 2025, 23:05:00 GMT permalink Post: 11820185 |
Regarding the collision of American Eagle JIA342 and Army Blackhawk PAT25, I lay the blame squarely on the shoulders of both the FAA and the United States Army Aviation Branch. If the NTSB in any way blame the pilots in the incident, they are not doing their job. Let’s look at all of the holes in this swiss cheese:
1. In an effort to maximize commercial air traffic in and out of DCA, the FAA has created the “deviate to RWY 33 procedure” for air traffic in-bound to RWY 01. This requires a right-hand turn from the RWY 01 approach followed by an immediate hard left-hand turn to line up on RWY 33. FAA criteria for a stabilized approach states that you have to be stable at 500 feet AGL on final in VMC or perform an immediate go-around. But on this particular approach, you will be at or below 400 feet AGL as you come out of the left turn to final. So the FAA has granted an exception to the “stabilized requirements” at DCA to allow for this maneuver. This allows ATC to shorten the distance between arriving and departing aircraft that are utilizing conflicting RWYs. The FAA in essence violates its own safety standards on stabilized approaches for the sake of expediency. 2. The FAA creates the Route 1/4 helicopter route through the DCA airspace as a VFR route with constantly changing altitude requirements. The lowest limit is at 200 ft MSL through the area east of DCA. Any pilot will tell you that flying that low over water at night is a best a tense experience. Try not to break that limit flying at night while also trying to communicate with ATC and simultaneously searching for possible conflicting aircraft. 3. The United States Army Aviation Branch deems it acceptable to allow training missions for Army Reserve pilots with limited flying experience to fly these helicopter routes through this complex and extremely active airspace. Compounding this, training flights at night using night-vision goggles are deemed “safe” in spite of the fact that using said goggles severely limits peripheral vision and makes it difficult if not impossible to perceive any color other than green and white. Picking out particular lights against the background of urban lighting is challenging, as is depth perception. Scanning key cockpit instruments is also made more difficult, making it challenging to accurately maintain altitude. Add to that workload the need to be in constant communication with ATC as well as monitoring all other comms traffic not directed to you but necessary in order to maintain good situational awareness. Given the density of commercial air traffic on this route, common sense would dictate that this route be flown by only the most experienced pilots and only when absolutely necessary. Reasonable logic would understand that conducting training missions should not be using final approach areas with heavy commercial traffic. 4. The Army crew on PAT25 are flying a mission they have been ordered to fly, at night and using night vision goggles. Although they may feel it is difficult and may be anxious about it, their command structure has determined that it is an appropriate training procedure and as such must meet minimum safety requirements. They do not have the authority to question the mission or the orders to fly it. 5. JIA342 is on approach for RWY 01, but is asked at the last minute by ATC to deviate to RWY 33, requiring the “circle to land” maneuver. Therefore, they are now on approach different from what they briefed for. 6. Any aircraft following the “circle to land” approach to RWY 33 will most likely have both pilots focused on RWY 33 as they come out of the left turn to final, especially if it was a last-minute request by ATC. In this case they will be looking to make sure that AA1630, which has just been given clearance to depart from RWY 01, is clear of the intersection with RWY 33 as they complete their final approach, and be ready for a go-around if it is not. In addition, this left bank makes it extremely difficult for the first officer to see any conflicting traffic coming towards them from the 1 to 2 o’clock position, as that traffic will probably be below the right window level. For the pilot, who is on the left side of the cockpit, visibility of such conflicting traffic will be nearly impossible. 7. For whatever reason, ATC is working with “split frequencies while controlling this airspace, so that although the controller hears both the aircraft on approach and the helo traffic south-bound on “Route 1”, the pilots of those respective aircraft only hear information directed at them. Thus they are not aware of all that is going on around them, and as such their situational awareness is limited by factors outside of their control. 8. ATC informs PAT25 of the conflicting aircraft on approach for RWY 33 at 1200 feet MSL, but at the time, PAT25 is heading almost due east towards the Jefferson Memorial on Helo Route 4 while JIA342 (the CRJ) is executing its right turn departing from the RWY 01 approach and is now heading in a northeast direction as it prepares to make a hard left onto the RWY 33 short final approach. From their respective positions, PAT25 in all likelihood sees the landing lights of AA3130 which is trailing JIA342 and whose landing lights are pointed almost directly in his direction, and mistakenly identifies it as the aircraft approaching RWY 33. At no time does it appear that ATC notifies JIA342 of the conflicting helo traffic. They are most likely focused on their approach to RWY 33, which was just handed to them. 9. As JIA342 rolls out of its left hand turn to final on RWY 33, completing the deviation they were just handed and had not briefed for, it is now approaching the 9-11 o’clock position of PAT25. Since the pilot of PAT25 is on the right-hand side of the Blackhawk, visibility of the CRJ may be limited. Both pilots of PAT25 are now most likely visibly fixated on passing to the rear of AA3130, which is in their 1-3 O’clock position, and which is the conflicting aircraft they perceive as the one ATC initially warned them about. 10. ATC, now receiving a conflicting aircraft warning, asks PAT25 if they have JIA342 in sight. In the absence of any obvious difference from the first mid-identification of the conflicting traffic, confirmation bias raises its ugly head. The voice response from the training pilot is calm and confident in stating that they do have it in sight and claim visual separation, probably proving once again that he mistakenly has AA3130 in sight slightly to his right directly in front of him and more than a mile away. Both pilots are totally unaware of JIA342 which is now arriving in front of them from their left. 11. The collision occurs. In my humble opinion, the crews of both aircraft involved were set up by both the FAA and the Army Department of Aviation through a series of poorly based decisions which focused on expediency and departed from any appropriate utilization of a rational use of risk assessment. Consider the following: 1. Approval of the circling to RWY 33 maneuver which violates normal stabilized approach standards. 2. The establishment of a series of complex VFR helicopter track complex and heavily restricted air space as well as through final approach paths. 3. A 200 foot maximum altitude requirement over water and required even at night, which may result in a less than 200 foot vertical separation between aircraft on approach to RWY 33 and those traveling on Helo Route 1/4. 4. The decision to conduct military training missions in this complex and busy airspace with an abundance of commercial passenger traffic either arriving to or departing from DCA. 5. The use of split frequencies by the FAA which negatively impacts the situational awareness of all of the pilots in the airspace. 6. The use of night vision goggles to place even more limitations on the pilots. Granted, all pilots involved may not have had the thousands of hours senior commercial and military pilot possess. But even the most senior individuals when placed in the task saturated environments these two crews faced would have at the very least felt their “pucker factor” increase through this. And there is probably an equal chance that the lack of common sense and appropriate safety design exhibited by the controlling entities would have resulted in a similar outcome. The odds were significantly stacked against these two flight crews, and unfortunately, against the passengers and flight attendants as well. If ever there were an example of an accident waiting to happen, this is it. Subjects
ATC
Accident Waiting to Happen
Blackhawk (H-60)
CRJ
DCA
FAA
NTSB
PAT25
Route 4
Separation (ALL)
Situational Awareness
VFR
Vertical Separation
Visual Separation
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