Posts about: "NTSB" [Posts: 232 Page: 5 of 12]¶

I believe radalts are configured to display height above gear; so add ≈16' height of Blackhawk to 278' yielding 294'. Then there's rotor bowing, and how much higher will the tail rotor arc be at the speed the helo was flying?

Likely the Kollsman settings will be recoverable. Barometric altimeters used in VFR can be way off, but transponder calibration depends on a calibrated altimeter. The NTSB will be looking at maintenance records.

Excerpt from Feb 14 NTSB Briefing Points on Mid-Air Collision near DCA So nothing yet reported on the CRJ CVR when maximum elevator was applied.
I was once stopped at a red light, began rolling when the light turned green - and suddenly found myself on the brakes before I was conscious of the car running the red light. Possibly a CRJ pilot similarly caught the helo in peripheral vision and reacted subconsciously.
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I agree that the DC controllers should not be scapegoated. At the same time, the concept of professionalism must be addressed. The concept that professionals in a field must alone (without management, without lawyers, without the public) maintain the best practices of the given professional discipline.

In the US, physicians who work for "Health Maintenance Organizations" are asked to practice medicine, at times, in a "basically unsafe" manner...to keep patients moving. On occasion, such practices will bite a patient (and sometimes the physician). As a whole, HMO physicians do not enjoy the best reputation.

From my perspective, there is practically no difference between the plight of an American air traffic controller and an American HMO physician. Both are expected to "squeeze one more in." Both fields are staffed by above-average capable individuals who thrive on challenges. Both are managed in such a manner that they cannot say "no" and also keep their job. In this regard, at least physicians have job portability.

But the take home point is that one cannot admit to knowing a practice is fundamentally unsafe, yet do it anyway. The public, rightfully, should not accept this. I have no solution except more staff and/or more airports (and not some next-gen whizzbang computer system).

In a prior briefing the NTSB said that the crew of the CRJ \x93had a verbal reaction\x94 to something, and flight data showed the plane beginning to increase its pitch. A second later there was a sound of the collision.

Sad to see the NTSB reporting PAT25 was between 278" and 313' in the seconds before the collision instead of 'at or below' 200' OK, PAT25 seems to attract much of the blame for the impact, but that doesn't detract from the unsuitability of Route 4 in the broader sense.

The route doesn't provide safe clearance, is the answer. Even if they didn't collide, I can't imagine the ride being particularly gentle after something that size passes ~50ft overhead. Even the near miss might have resulted in a critical loss of control.

Let's see if I have understood "plug and chug" correctly!

If we took the FAA to be undertaking "plug and chug" regulatory and procedural activities, unburdened by political considerations and at risk of having EASA or UK CAA regulations and procedures held up as comparators in negligence cases against it, then I think it is highly unlikely that FAA regulations would be as permissive as they are in respect of visual separation and runway occupancy (the two most obvious and frequently cited points of difference, at least where airline operations are concerned), or that DCA\x92s helicopter routes would have existed. So why such a difference in approach? Economic factors are usually held up as the reason, and I fear this takes us away from "plug and chug" regulation into policy territory where immunity would seemingly apply.

I very much doubt that any politician, corporate lobbyist or general would explicitly advance the argument that occasional accidents are a tolerable price for the traffic capacity enhancements enabled by visual separation. It'll be interesting to see whether the NTSB forces that argument into the open, or enables it to be avoided by distracting itself with altimetry and other such matters.

No, at this point foaming at the mouth might be a better descriptive.
While the intent was for them to "pass behind" (and thus not be on/under final when the RWY 33 traffic is on final) there was a missed opportunity to get the spacing (in time) needed.

When the NTSB has more to share it will be interesting (to me) to see what a balanced mitigation strategy is.

The diagram shows the route up the east ~half of the river, solidly over water. The inset seems to show it within perhaps the east quarter, but still 100% over water. Asking crews to follow the riverbank therefore seems to be a direct contradiction.

You could reasonably define the bank as the water's edge, and therefore expect crews to fly along an infinitesimally narrow path. Or as the space between the water's edge and the [edge of the flood plain | first flat area | something else], which would imply that the western boundary changes with the water level. Both imply the route is substantially above land.

Neither are useful for precise navigation, but the map and the description are probably 'close enough' if they are only needed for general route guidance and knowing that structures on the east bank need to be NOTAMed for helicopters, but probably not the west bank.

A good reminder that measurements/specifications without tolerance are often worse than useless.

If it quacks like a duck... this kind of "It can't be an X because we can't do it, so we'll call it a Y" leads to a culture that gets used to massaging the truth for convenience. Did we hear more on the Alaska door plug that was an 'opening' not a 'removal'?

Facts of life: at one time or another pilots will set incorrect QNH values, altimeters will fail, flights will end up above or below a glideslope, lateral boundaries will be breached, pilots will fail checkrides, radio transmissions will be blocked, visual illusions will occur, air traffic controllers will get distracted. So any procedure that depends on all those things never happening is flawed. We are not living in some utopic la-la-land.

So I wouldn\x92t call the altimeter discussion a distraction per se - not yet, anyway. It\x92s just one tiny fact in a complex picture, but still an important fact nevertheless. It is a concrete example of one (or more) of those, by itself insignificant, real-life deviations from perfection occurring. I expect (hope) that the NTSB will use this issue just to illustrate the point that relevant traffic procedures at KDCA were largely based on wishful thinking.

The more posts I've read on this thread, the more I'm anticipating that court actions seeking compensation for the families of the people killed in this accident will encounter very tough barriers.

This is an excerpt from a website of an actually well-known, very accomplished, and respected group of lawyers who specialize in (among other things) aviation matters. I'm not using their name and I don't have any approval, express or implied, to use information from their website - but if justice is to be sought for the victims' families, public discussion is - or should be - encouraged.

"A discretionary function is an action of a governmental nature exercised by a federal employee, but in order for that action to be considered a discretionary function, it must pass a two-part test:

There must be an element of judgment or choice. That is, if a federal statute or regulation prescribes a course of action for an employee to follow, there is no discretion.
That judgment or choice must be susceptible to policy analysis.
The Federal Tort Claims Act contains a discretionary function exception that says the U.S. cannot be held liable for any employee\x92s failure to exercise or perform a discretionary duty.

Within the legal field of aviation accidents, discretionary duties for which the U.S. is not liable include the following:

Aircraft \x93spot check\x94 certifications
Weather forecasting
Failure to install equipment
The FAA\x92s design of flight procedures
The types of actions that are considered not discretionary, and therefore, open the U.S. government to litigation are:

The failure to issue air traffic control manual warnings
If air traffic control fails to warn of weather dangers
The failure to maintain equipment
Relaying incorrect instructions to pilots."
END OF EXCERPT [not intended as legal advice here or on its original internet page]

So to return to ATC Watcher's point...... the more posts I read about this midair collision (plus other information such as NTSB briefings) the more I am anticipating that it will require an act of Congress to provide for compensation for the families of the victims. Isn't it the obvious fact that convenience for people who work in Washington and travel "back home" generally speaking on weekends and when Congress isn't convened, is a prime and central reason for the way DCA airspace has been constructed and managed? Is it really going to be the case that because the lawsuits will - in all likelihood - fail to overcome the "discretionary function" exception, that the 67 families will be without a remedy? Is that how it works, then?

In case anyone thinks my sense of being horrified at this accident is clouding reason or logic, consider this - the book Collision Course discusses the PATCO union's genesis, the strike, and so on. PATCO's earliest stirrings resulted in large part from the 1960 midair over New York. Is the United States aviation sector willing to accept an outcome of this accident that in effect travels back over six decades? The point is, given the long-term shortage of ATCOs in this country . . . I don't think a court is capable of ruling that the situation, allowed and in fact enabled by Congress and successive White House presidential administrations, is subject to "negligence" analysis in the currently applicable legal sense. All this being said, this is how I arrive at thinking that in the interests of justice, some other means of providing for the loved ones of 67 souls who were on board needs to be determined and implemented.

Absolutely . Lack of Wake turbulence separation is something that immediately came to my mind when discovering the procedure . That should have been another red flag in the Safety assessment , but I assume initially the H routes were designed with RWY 1 OPS in mind and 33 only for departures. Combining 33 Arrivals with route 4 is the initial issue .
Indeed , and there is a precedent : the 1986 Cerritos collision : the NTSB found no responsibility to ATC as the pilot of the PA28 that hit the DC9 had entered Los Angeles Terminal Control Area airspace without the required clearance. However a judge found the FAA partly responsible to make sure the families of the pax , mostly Mexicans , would be compensated , as the responsible private pilot's wealth would not have been able to cover those.
Here if you want to learn or just refresh your memory ; https://www.latimes.com/archives/la-...%20government.

As an aside , the NTSB conclusions of that collision are interesting compared to our DCA accident : ( exactly 40 years ago !)

Yes history often repeats itself . just like the PATCO history...

Another case is the 1971 midair between Hughes Airwest Flight 706 (DC-9) and a USMC F-4. The backstory of the maintenance status of the Phantom is a mess.

airplanecrazy , This is a good image, and I hope this analysis is done in the accident report, with the level of detail that the NTSB can gather. I have done a similar analysis with the addition of a statistical analysis for production problems and it allowed a prediction of the expected rate of failure. It looks to me like separating out the dimensions - how the along-course spacing was maintained, the height, and the horizontal offset - would give some estimate for when all 3 overlap at the same time.

# 1194 Caley,
"… and yet that is precisely how ICAO stipulates that accident investigation should work. The consequent focus on such things as ‘proximate cause’ and the inherent unwillingness to deal with underlying aetiology work against holistic approaches and generate exactly the outcomes you warn against. "

In part yes, I agree.
However, as you might know, ICAO does not 'stipulate', it provides recommendations and standards of practice (SARPS), e.g. Annex 13, on which nations can base their investigation and reporting.
As such it is the interpretation of by individual nations and their investigators which direct investigation, findings, and recommendations.

Some nations interpret SARPS better than others.

There is an interesting example (amongst many others) of wider investigation and reporting in the Fukushima accident report: Pprune Safety Forum Fukushima Nuclear Accident Investigation

Reforming the regulators
The Commission has concluded that the safety … cannot be assured unless the regulators go through an essential transformation process. The entire organization needs to be transformed, not as a formality but in a substantial way. … regulators need to shed the insular attitude of ignoring international safety standards and transform themselves into a globally trusted entity .

P.S. Re the investigation above, also noting 'Cosmetic Solutions'; if the findings from this DCA investigation warrant it, would the NTSB conclude 'This was a manmade accident, made in the USA'
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My apologies, I tend to regard the conversation here as being reflective of the lounge bar rather than the witness box. You're right, 'recommends' is a better word and I will try to be more pedantic.

Regarding Fukushima, the problem lies not with regulators, but with regulation and its evil twin, compliance. And on your last line, I might add, 'by politics'. The process of sharing draft reports with interested parties is harmful enough to the investigative process, as we have seen with crystal clarity over the Clutha case for example, but is even more damaging in its influence to the jobbing investigator sitting at a word processor, thinking not only of that process, but all the petty politics which are exercised by managers in SIAs. Sometimes the investigator feels charged with writing a benign account of a series of improbable, unfortunate, and unforeseeable coincidences, which aligned with previously unknown holes in otherwise-solid cheese, despite being fully aware that there is much more to it than that.

I'm sure it does, but UK helimeds use the suffix to indicate they are actually on a shout, rather than training or positioning.

That's not called for. PEI 3721 has a respectful and thoughtful response to your post.

I personally don't think there's anything to be gained from going down the ICAO route. The NTSB has it's own charter and that's what dictates what happens in the USA.

I can see several ways the NTSB could take this, first the obvious one. The helicopter assumed responsibility for separation when it was not able to do so, and then found itself on track for collision. That's what I would define as true proximate cause. Then there's a step back from there which says nobody should be allowed to request and receive visual separation responsibilities in Class B airspace. That would be a good result as far as I'm concerned.

And the final step, which I think is more contentious and really hard for the US to accept, is that the culture at the FAA and within the industry is to balance safety and boosterism for the industry, and I think that is a recipe for irreconcilable conflicts. I'm not holding my breath on that one.

I'm surprised that this is your conclusion. I think what I take away from the conversations on the night was that ATC was divesting himself of responsibility, and the helicopter was trying to expedite his sortie, and nothing in the 'system' prevented them from doing that. Removal of visual separation as an option IMHO deals with that hole in the cheese. It seems like you're suggesting that the helicopter might ignore instructions to hold before the tidal basin ?

WMF # 1207,
"… don't think there's anything to be gained from going down the ICAO route. The NTSB has it's own charter and that's what dictates what happens in the USA."

If so then the NTSB (FAA, USA) attitude raises safety concerns.

From systems theory, all systems (i.e. aviation) will change with time, tending towards greater disorder (increasing entropy), often referred to as complexity.
To date, the industry has managed this change and simultaneously improved the level of safety, and with economic benefit.
A contribution to this is the use of world standards (ICAO, UN charter) enabling, aiding, inter-country operations, and refection on one's own, home standards and assumptions

Independent, fixed attitudes may encounter more safety issues as the overall system changes.
Safety minds, thinking, has to change just to keep up with the changes in aviation - what has been done safely before may not apply today or in the future.

I think that's a bit apocalyptic. SARPS are just that, Standards and Recommended Practices. And I'm not saying that the USA is out of line with them, I'm just saying that if you want to understand what the NTSB are doing you should look at their charter, not something that is once removed.

WMF,
… well having searched the usual places and the NTSB, you will have to help with directions and text for reference.

There is a NTSB Charter for data, but nothing which explains the link between ICAO and the USA, and thence to the NTSB and investigation, or the required statement of any USA deviation from the ICAO guidance (Annex 13).
Notwithstanding https://www.ntsb.gov/about/organizat...office_as.aspx
" fulfill U.S. obligations under International Civil Aviation Organization agreements"
"to examine specific aviation safety problems from a broader perspective. "

But back to the thread. Are there any reasons why NTSB might not comment on the wider organisational aspects as indicated in the discussion. Also noting that the NTSB have no powers of enforcement, relying on the FAA; thus if the FAA process were to be identified as deficient, who mandates change.
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