Posts about: "NTSB" [Posts: 232 Page: 4 of 12]¶

Hi Bill , understood, I was a bit too harsh maybe, but I get upset to continuously read what the controller should have done. Remember he was trained like this , to follow procedures that were basically unsafe in order to move the traffic . I can say unsafe because they were removed immediately after the accident , not waiting for the NTSB to recommend it . No everyone is stupid in the FAA , they knew this route was in conflict with 33 Visual arrivals. And did not pass any safety case, but the procedure was kept , most probably due political or military pressures , relying on controllers and pilots to mitigate the risks.

Now on the Conflict alert on the BRITE display . I have no first hand info on the SOPs in DCA on how a TWR controller uses the BRITE and if STCA are even displayed . `, but if they are, seen the charts and the routes , I guess STCA alerts are very common .especially when you delegate separation and you then play with a couple of hundred feet, vertical separation Too many unnecessary alerts equals normalization of deviance, . Look at the Haneda preliminary report , same ..

Finally since you mention TCAS RAs , there is a major difference with STCA , it is not the same as a TCAS RA . With an RA , as a pilot you have to react and follow , it is mandatory , for a controller a STCA is just an alert , just like a TCAS TA , if in your judgement it will pass you will not do anything , and if you have already issued a correcting instruction ( heading, level , etc,,) or here delegate visual separation , the STCA just becomes a nuisance. .

I sincerely hope the DC Controller will not be made the scapegoat of this accident . Not so sure it will not.

Concur. Scapegoating stochastically guarantees a repeat incident/accident of the same kind under "rhyming" circumstances.

Rarely does the "bad apple" theory of accident causation survive the scrutiny of a robust, honest investigation.

Long version of Wall Street Journal article about changing DCA airspace use rules, from WSJ website (summary in print edition Feb. 12):
__________

Federal air-safety officials want to permanently keep helicopters away from commercial jets taking off and landing at a busy Washington, D.C., airport after the deadliest U.S. aviation accident in more than two decades.

The move, under consideration by senior Federal Aviation Administration officials, would be part of a long-term plan to improve safety at Ronald Reagan Washington National Airport, according to people familiar with the discussions.

Helicopters have been temporarily barred from flying in a corridor used by the U.S. Army Black Hawk that collided on Jan. 29 with an American Airlines regional jet, killing 67 people. The chopper routes have been used to ferry senior military officials around the region and to train for a \x93continuity of government\x94 mission in the event American political leaders need rapid evacuation from Washington. Other government agencies have also used the routes.

Federal officials have said they would revisit the helicopter restrictions once the National Transportation Safety Board issues a preliminary report on the accident in the coming weeks. Preliminary indications from the probe point to multiple factors potentially contributing to the crash, including the design of the airspace, as well as actions by the helicopter pilot and air-traffic controller, according to people familiar with the investigation.

The NTSB said it would examine how far apart planes and helicopters are supposed to be while flying in the airspace.

Transportation Secretary Sean Duffy has criticized the Pentagon\x92s operation of helicopters near the airport. \x93If we have generals who are flying in helicopters for convenience through this airspace, that\x92s unacceptable,\x94 he said last week. \x93Get in a damn Suburban and drive. You don\x92t need to take a helicopter.\x94

The Army said it would continue to comply with FAA requirements and restrictions to enhance flight safety. The service said it was reassessing its aircraft operations near the airport and that it gave priority to the safety of the public and military personnel. The current restrictions allow certain critical flights.

Duffy also suggested certain military missions can be done at a different time of night. The Jan. 29 crash occurred around 9 p.m. Eastern time.

Defense officials have assumed that the helicopter routes would be closed in the coming months amid several ongoing investigations, but have privately said that the routes should be reopened. Adjustments under consideration if routes are reopened include limiting hours for training and test missions.

Reagan\x92s convenient location, a few miles from Capitol Hill, has made the nearly 84-year-old airport a favorite among politicians, business executives and tourists.

Space is tight at the airport. Reagan\x92s longest runway, Runway 1, is the nation\x92s busiest, airport officials have said, and it has two smaller runways. Routes into and out of the airport are constrained by no-fly zones around sensitive government buildings.

The FAA has said it is also reviewing airspace around airports aside from Reagan that also have high volumes of helicopter and airplane traffic.

Discussions about Reagan airport have also focused on a small runway known as Runway 33, people familiar with the matter said. The American Airlines regional jet was attempting to land there when it collided with the Army helicopter. Some government and industry aviation officials believe that there isn\x92t a problem with planes using the runway if helicopters aren\x92t near the traffic lanes.

Warning signs existed for years about risks facing commercial passengers, with planes sharing the skies closely with helicopters zipping up and down the Potomac River.

The path the American Airlines regional jet took toward Runway 33 required it to turn toward the right and then bank left to line up for its landing. That route crosses over a lane for helicopters at a relatively low altitude.

There have been at least 35 events involving conflicts between helicopters and flights into and out of the airport that have been flagged since the 1980s, according to a Wall Street Journal analysis of anonymous reports to a system overseen by the National Aeronautics and Space Administration.

In one instance, in July 2018, a helicopter and small plane came within roughly 580 feet of each other while the plane was approaching Runway 33. The helicopter pilot had to maneuver to avoid the plane and questioned the air-traffic controller about it after, according to an internal FAA report on the incident viewed by the Journal.

Neither aircraft had received traffic advisories or safety alerts, the report said. The helicopter pilot reported the incident as a near midair collision. \x93I\x92m sorry for the confusion,\x94 the controller told the helicopter pilot, according to an audio recording of air-traffic-control communications following the incident.

Nearly two weeks after the deadly crash over the Potomac, the FAA has lifted some of the constraints put on Reagan airport in the wake of the accident.

The FAA on Tuesday boosted the airport\x92s arrival rate from 26 to 28 aircraft an hour, after temporarily reducing it to ease the strain on controllers still dealing with the aftermath of the crash, according to an email viewed by the Journal and earlier reported by other news outlets. The current rate is still lower than the airport\x92s typical maximum of 32 arrivals an hour.

Reagan\x92s two smaller runways, which had been closed due to search and recovery efforts, have been reopened.
________

Just heard NTSB briefing. It seems that the scapegoat will not be any of the humans involved, nor even the procedures, but the altimeter system of the black hawk (a 100 ft discrepancy) and the radio (they did not hear "circling" and "pass behind")

Landing flap, 9 deg pitch up, and full up elevator! That is what I heard NTSB report at today's briefing.

No one in the assembled press made any comment and so likely no one understood that was not normal or what it most likely indicated.

deltafox44
Not at all. The briefing indicated there may be a possibility that the altimeter in the BlackHawk displayed an inaccurate altitude reading and that the discrepency was in the order of approx 100' given the height at which the collision is known to have occurred.
Briefing the RT comms, NTSB stated that a portion of the ATC instruction to the BlackHawk to 'pass behind the CRJ' was received in the Blackhawk (according to the CVR), truncated due to the BlackHawk keying the mic at the same time. Apparently, the words 'pass behind the' were missing from the BlackHawk CVR.

(my bold in quote) well.... that doesn't surprise me.
For a couple of days now, was thinking about posting something on an "extra noise" I keep hearing in the R/T comms, when TWR gives the ' pass behind ' instruction. Was wondering whether TWR's Tx wasn't stepped over by someone.
My first impression was that the extra noise came from an radio call from a turbine helicopter (given the typical background noise often heard in radio calls from turbine helicopters). And was wondering if it wasn't PAT25 that started replying to TWR's first ' in sight? ' call, effectively blocking part of TWR's second call, the ' pass behind ' part of the instruction.

In attached mp3 (in .zip per forum attachment requirements) around 00:05 I hear this 'extra noise'.


Edit:
well, this seems to confirm my initial impression:

No, hence the tower telling the Blackhawk to pass behind.
Seems to me like a reaction to seeing the Blackhawk right before impact and a reflex/reaction with intent to avoid.

The subtext for me is that the Blackhawk crew never saw them...but there's more for the NTSB to sort out, as the lady was VERY CLEAR about.

Here is the text of the prepared remarks from today's NTSB briefing which includes the event timeline: Prepared remarks

I'm not sure they did say that about the altimeter, they said that there was bad pressure altitude data recorded on the FDR. That's not the same as saying the altimeter display was wrong, although it does mean that it's going to be hard to infer what was actually displayed on the Baro Alts. I would have thought a military crew would be pretty solid on altimeter cross checks though so I think that's all a bit of a red herring. The Potomac is (give or take the tide) at sea level so I think we can be pretty confident that the RadAlt figure of 278ft is good for an altitude too.

NTSB did not say (and nobody asked ) if there had been any discussion in the black hawk cockpit about the CRJ (where it was, whether the PF did see it or not) when PM requested visual separation

so I'm not sure what to think of this statement from the NTSB brief:
As they also corrected some previous released information (like PAT25 was on V HF - I know, not really relevant, but it was incorrect when they stated UHF previously), I wouldn't be surprised if they have to come back on this " not using radalt " statement

NTSB didn\x92t mention much in the way of cross cockpit intercom chatter. Must be a lot more that could have been said about the SA on both aircraft, eg altimeter checks, visual lookout, intentions, perceptions, checklists\x85etc.

Jennifer Homendy (NTSB Chair delivering the press conference) stated that the CVR of the Blackhawk had no discussion
relating to seeing the CRJ in the last seconds before impact. The crew didn't see it coming.

They stated the crew was likely wearing NVG, this would explain that

and I expect a lot of attention will go to the NVG aspect, as per NTSB brief, the qualification flight was both 'annual' and 'NVG'....

Didn’t NTSB say today that FDR had ‘data error’ instead of altitude indicating possibility of pitot/static problem? Said they were going to try rebuilding system to test it, which won’t be easy or quick!

absolutely . the altimeter talk is just a distraction or at best contributing factor, Not the cause .. which brings us back to the safety assessment of the procedure , which the NTSB did not mention at all,, but I am sure , or at least I hope they will go into in their final report.
In any case the procedure us currently withdrawn until end of March and I sincerely doubt they will re-install it before the final report is out. ..

A couple of new info points the NTSB clarified : Both aircraft were on VHF , so we can drop this UHF discussion , the Blackhawk had ADS-B equipped but was not transmitting , it was check ride with NVG, and they most probably all had them on .and there was a last second evasive action attempt by the CRJ crew, which go a TA previously . On the TWR, the CAs are displayed in the BRITE even with audio on ..
For the rest we have to wait until the next NTSB briefing

+1 to everything you and Wide Mouth Frog said.

I sincerely hope the NTSB can avoid being distracted by the distractions of altimetry and the missing ATC words on the Blackhawk CVR.

Upthread, Luca Lion calculated the 3 degree PAPI approach path as crossing the eastern riverbank at 270ft. If that's correct, then the CRJ's 313ft radar height 2 seconds before collision puts it at least 43ft above the approach path, so the Blackhawk's radio height deviation of 78ft would have contributed only about 35ft to the erosion of any intended "procedural separation" (*) between the aircraft. Or, to put it another way, the same outcome would have resulted if the Blackhawk had been at 235ft radio and the CRJ on the glide. Height keeping of plus or minus 35ft can only be achieved by instrument flying, which is obviously not compatible with visual separation (or indeed VFR) so cannot be reasonably cited as part of a safety case for the procedure. And of course a landing aircraft could easily be below the glide. Altimetry and height keeping are not the cause of this accident.

Missing the word "circling" wouldn't have influenced the helo crew getting visual with the CRJ at the time of the trasnmission. At best, it would have given them an extra nudge that "runway 33" (which was audible) meant the CRJ would be taking an easterly flight path. Missing "pass behind" with only a few seconds to collision was irrelevant if, as seems likely, the helo crew did not see the CRJ at that point.

(*) The quotes around "procedural separation" are intended to convey a tone of disgust and sarcasm.

Following "5*why", keep asking...
Why did the did miss part of the message
Why was the incomplete read back missed
Why does missing a few words lead to this disaster within seconds.

Does this lead an answer like: helicopter in a very busy airspace, busy controllers (insufficient time to be fully focused on full read backs) being by default too close to (and even needing to cross) the glideslope.
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