Posts about: "NTSB" [Posts: 232 Page: 6 of 12]¶

From what I understand the delegation of separation used in the US is based on the "see and avoid ", It is basically delegating the positive control (ATC separation instructions ) from the controller to the pilot , who has to acquire the traffic visually and maintain visual contact and maneuvers to avoid it . = traffic info from ATC + See and avoid. . I do not think the ICAO forefathers designing the airspace classifications had this in mind when defining class B.
Listening to the NTSB , the only ATC instruction given : to " pass behind " was not received , and therefore not acknowledged by the crew , so we are here 100% in the good old "see and avoid" scenario I would say

There you go. A bit of work with google is never time wasted. I offered an opinion about the extent to which the NTSB might be incentivised to explore issues of the mission of the FAA, and like all opinions, it resides in the domain of politics. That's a possible reason why the NTSB might not choose to go there. However an ex-Inspector General of the Dept of Transportation had strong views on the subject, and I give a lot of weight to her opinion, supported as it is by her personal experiences of dealing with the FAA.

I'm fairly certain that, because Annex 13 and all else pursuant to the Chicago Convention of 1944 applies to international civil aviation, the statutory as well as practical jurisdiction and responsibility of NTSB are matters dealt with by federal statute and regulations. This is not to say that the Board will or should ignore Annex 13 or declare it irrelevant - but it is to say -
first, the NTSB's authorization and processes are set by federal law and not by Annex 13 (although as the excerpt you quoted also says, Ann. 13 does apply where the case is international civil av.); and
second, the DCA midair is not within international civil aviation (sorry to find it necessary to state the obvious).

I cannot cite anything specific to support it but I'm strongly inclined to think Chair Homendy, at this point in her public service career, will insist on a report and supporting analysis that leaves, if you will, political niceties on the bottom of the Potomac shy of the Rny 3-3 threshold -- where they belong. We will see, time will tell.

Having quite a few questions:

At what distance and light conditions should any average (heli) pilot be able to identify specifically a \x93CRJ\x94 ?

That stand alone, or after having been told what other traffic was in range and view. For example another being a biz jet or A320.

And this question for both daytime and at night.

Would that performance improve when ATC would supply them with say \x93at your 11 o\x92clock and 1,500 ft and 150 kt and intent (visual to rwy33)?

And would that performance improve at say 3 o\x92clock?

Amazed that visual separation responsibility ended up in the lap of the \x91least able\x92 party involved that some here describe as being \x91clinically\x92 blind !

On the NTSB - as far as I have understood it, they can study and recommend on anything. They could for example start an SS parallel to this investigation addressing this wider issue.

That was made pretty clear in the NTSB update over a week ago, yes. If your mental map is that the active runway is 01 (which it was) then unless you have the information that someone is landing on 33 and that's your traffic, you'll be looking for traffic approaching 01... particularly if you are familiar with flying in this area due to your mission requirements. If you know that your traffic is approaching RWY 33, then you look for it in a different direction, particularly if you are familiar with the local flying area.

(Not sure why this little hamster wheel is still spinning, but this is PPRuNe).

NTSB Aviation Investigation Preliminary Report - N709PS, PAT25

From NTSB interim report on DCA aircraft / helicopter collision.

"Near Midair Collision Events at DCA
Review of information gathered from voluntary safety reporting programs along with FAA data regarding encounters between helicopters and commercial aircraft near DCA from 2011 through 2024 indicated that a vast majority of the reported events occurred on approach to landing. Initial analysis found that at least one TCAS resolution advisory (RA) was triggered per month due to proximity to a helicopter. In over half of these instances, the helicopter may have been above the route altitude restriction. Two-thirds of the events occurred at night.

A review of commercial operations (instrument flight rules departures or arrivals) at DCA between October 2021 and December 2024 indicated a total of 944,179 operations. During that time, there were 15,214 occurrences between commercial airplanes and helicopters in which there was a lateral separation distance of less than 1 nm and vertical separation of less than 400 ft. There were 85 recorded events that involved a lateral separation less than 1,500 ft and vertical separation less than 200 ft."



What is seen - reported; and what is dismissed … diminishes the value of reporting.
A system broken: a broken safety management system at the national level.

NTSB press conference up on YT -

Normalization of deviance?

It won't be the last time I'll think it compulsory to say this about this accident - I'm not trying to provoke the inevitable lawsuits into higher intensity (despite status as simple SLF/attorney).

Almost invariably lawyers as well as law students and professors, when asked to comment about what is taught in law school, recite the truism that "law school teaches you how to think like a lawyer." Problem is, even quite modest experience in and with the realities and pressures of representing clients - i.e., practicing law - dulls the thinking part and intensifies the hustler mentalities, of which there are many variations. I'm noting this because law school actually trains you how to spot the issues. It sometimes is the case that the standard things lawyers think about a given set of issues are not the most relevant and meaningful things.

With that hopefully not grossly pedantic context out of the way..... in previous comments on this thread I've noted that the federal defendants would be expected to assert sovereign immunity.... more technically, that although the Federal Tort Claims Act waives sovereign immunity in general terms, the statute also contains various exceptions - in other words, the exceptions where they apply keep sovereign immunity in place. The exception relevant here is the "discretionary function" exception, which (pardon the attempt at over-simplifying it) keeps the immunity in place if the allegedly negligent act (or omission) resulted from a federal entity's policy decision or choice.

I previously viewed the discretionary function exception is likely imposing a pretty strong barrier against liability of the (probable) federal defendants. However.

However. However, as I write this somewhere in an aviation law practice a mid-level or even junior associate is pounding their computer keyboard, amassing BASED ON THE ISSUES NOW REVEALED an analysis of how the discretionary function exception has never, never ever ever, been imposed to bar liability for alleged negligence roughly and/or reasonably comparable to the record of "encounters" now documented by NTSB Prelim Report. And that record goes back several years . . . but presumably discovery in United States District Court under the Federal Rules of Civil Procedure could easily reach back to even more past years.

Of course, it will be said that ignoring these many encounters was indeed a policy choice, and so the exception does apply, a forum post like this notwithstanding. But that's just the point. The ISSUE here is that there never was a conscious policy directive which the alleged negligence stemmed from. Or stated another way, if I were in the aviation practice imagined above, I'd be running associates ragged to amass the above-mentioned analysis which establishes, among other things, that GROSS NEGLIGENCE by the FAA can never be, and is not as a matter of law, a predicate for applying the discretionary function exception. (For lawyers out there, somewhat akin to prima facie tort.)

By the way, for all the discovery sports fans out there, just think how much fun it will be to run discovery to amass the facts of what actions - meaning by the aircraft in which the RAs were annunciated - were taken as a result of all the RAs as noted by NTSB's Prelim Report.

The NTSB issued a 10-page report, and the link to said report is contained in the Board's recent press release.
https://www.ntsb.gov/news/press-rele...R20250311.aspx

Shout-out to Blancolirio for including some review and comments regarding the report; as far as I recall the issuance of a separate report was not mentioned in the recent update by the Board in connection with its preliminary accident report.

i believe it’s run by the MITRE Corp for the FAA. When I ran a corporate flight department, our FOQA data went in monthly, anonymously. I’ve gone into the ASIAS website for “meat” for safety briefings, etc. There’s a good pile of data including FOQA, unstable approaches, TCAS, CFIT near misses. Now who and how is the data used, I cannot say.

One example, after the KBED G IV accident, the NTSB went to the NBAA asking for help in better use of FOQA data increase compliance with flight control checks. Remember, this the G IV crew who tried to take-off with locked controls. ASIAS has tens of thousands of flight control checks and compliance data. Focused on that, measure it, problem mostly solved.

GE Digital’s FOQA programs also have a tremendous data bank. For example, KTEB has an easily the highest rate of TCAS encounters for corporate operators. How it compares to KDCA, I again cannot say. The airlines have the KDCA data for their operations. They know how many and where TCAS events occur. More evidence of normalization, I suppose.

Dr David Woods PhD

"\x85 to everyone in safety: look at the DCA midair collision given info in urgent action letter from NTSB. Widespread systems issues, total breakdown of proactive safety; repeats history from Herald of Free Enterprise to Challenger, Columbia etc. see my chapters on (Columbia testimony to Congress, RE book 2006 & 2005 Organization at the Limit book). Highlights real issues of multiple sometimes conflicting goals over multiple jurisdictions/perspectives, signals discounted in the face of ongoing production pressures, etc. Also note the reactions to failure. All well understood in 3 books capturing the new look work of the 80's -- 1990 (Reason) / 1994 (Woods etal) /1997 (Reason)."
Yet here we are all over again. All over again.

https://www.linkedin.com/posts/davidwoods3_to-everyone-in-safety-look-at-the-dca-midair-activity-7307401640821563392-I5Ez/?utm_source=share&utm_medium=member_ios&rcm=ACoAAAizWBQBjDn2 SfSP5os0fcB7hU2U_S8Iv3k

..

Where did you see the David Woods statement, as quoted? Link, perhaps.

Frankly, a lot of lessons shown in rail accident reports from the 1800s still haven't fully been learnt outside the rail industry. Aviation is unforgiving of mechanical failures but rail is equally unforgiving of procedural failures.

https://en.wikipedia.org/wiki/Clayton_Tunnel_rail_crash

"That's good thinking there, Hot 'n' High." (with apologies to the late Tom Wolfe for my copying the opening line of his 1968 New Journalism book, The Electric Kool-Aid Acid Test)

1) The starting point for any of my thought process about the midair collision is that this accident should never have happened and would not have happened without some parts of "the system" failing to fulfill their assigned responsibilities. Midair collisions in U.S. airspace are an aberation, aren't they? I sense that many aviators and other aviation professionals don't want to say it out loud - their sense of disbelief that this actually occurred.

A few years ago, in response to a question after a guest lecture he had delivered at an ICAO event in Montreal, then-Chair of the NTSB Robert Zumwalt said, "we've already had that accident" . . . the question was about whether an accident caused by certain factors which were, in fact, present in the Colgan Air accident needed to happen, in order for certain rules to be changed. (I don't want to misstate the q&a, although my best recollection was that the question was about fatigue and rest, and commuting time before line service.) In other words, the DCA midair is not an accident the primary causes of which were factors the overall aviation system had not quite learned to do correctly. In comparison, at the time I first began "reading aviation", wind shear accidents were occuring not infrequently (that beginning was December 1974).

I have not represented anyone or anything in air crash litigation and my posting here is not intended as what most lawyers call "client development and prospecting." Despite that, I think the opening statement on behalf of the families of the victims of this accident will be quite a courtroom moment. It's against this backdrop that I've been trying to think through the federal entities' most likely defense. There is some sense, maybe only vague, that how the anticipated lawsuits play out will have some impact or bearing on how the overall aviation system responds to this tragic occurrence.

2) Not for the first time my choice of phrasing was too emphatic and also imprecise. I didn't mean to point to ASIAS as a foundational or ultimate component of decisions about safety of DCA airspace management and usage. Instead, the content of some of the incident reports pointed out by Juan Browne struck me as glaring. They struck me as strong evidence of two things; one - as noted above, this accident was the kind of occurrence caused by some part of the system not fulfilling its responsibilities, and the other, that there were pretty clear statements by "bottom-up" reporters about such responsibilities appearing to be unfulfilled at particular times and in particular situations.

So, from these two foundations, I'm trying to figure out whether the discretionary function exception applies or does not apply. If it applies, the federal court will not have jurisdiction over the claims and the federal defendants will enjoy immunity (irony intended). I apologize in advance for what follows next (it is quoted in full from Congressional Research Service Report (R45732.8, April 17, 2023) "The Federal Tort Claims Act (FTCA): A Legal Overview". I would not clutter up this respected forum with legal material were it not arguably necessary for meaningful discussion of what is likely to happen next in the aftermath of the night of January 29.

CRS:
"[T]to determine whether the discretionary function exception bars a particular plaintiff's suit under the FTCA, courts examine whether the federal employee was engaged in conduct that was (1) discretionary and (2) policy-driven. "If the challenged conduct is both discretionary and policy-driven," then the FTCA does not waive the government's sovereign immunity with respect to that conduct, and the plaintiff's FTCA claim must therefore fail. If, by contrast, an official's action either (1) "does not involve any discretion" or (2) "involves discretion," but "does not involve the kind of discretion\x97consideration of public policy\x97that the exception was designed to protect," then the discretionary function exception does not bar the plaintiff's claim.

Whether the Challenged Conduct Is Discretionary

When first evaluating whether "the conduct that is alleged to have caused the harm" to the plaintiff "can fairly be described as discretionary," a court must assess "whether the conduct at issue involves 'an element of judgment or choice' by the employee." "The conduct of federal employees is generally held to be discretionary unless 'a federal statute, regulation, or policy specifically prescribes a course of action for an employee to follow.'" If "the employee has no rightful option but to adhere to the directive" established by a federal statute, regulation, or policy, "then there is no discretion in the conduct for the discretionary function exception to protect." Put another way, the discretionary function exception does not insulate the United States from liability when its employees "act in violation of a statute or policy that specifically directs them to act otherwise."

Even where a federal statute, regulation, or policy pertaining to the challenged action exists, the action may nonetheless qualify as discretionary if the law in question "predominately uses permissive rather than mandatory language." In other words, where "a government agent's performance of an obligation requires that agent to make judgment calls, the discretionary function exception" may bar the plaintiff's claim under the FTCA. Notably, "[t]he presence of a few, isolated provisions cast in mandatory language" in a federal statute, regulation, or policy "does not transform an otherwise suggestive set of guidelines into binding" law that will defeat the discretionary function exception. "Even when some provisions of a policy are mandatory, governmental action remains discretionary if all of the challenged decisions involved 'an element of judgment or choice'".
[End CRS, all quotations in the excerpt as in original, and all footnotes omitted]

3) Which leads to this essential inquiry: which one - and the answer cannot be "both are involved" - is closer to what happened: the federal entity individuals involved at all levels acted in violation of a statute or policy that specifically directs them to act otherwise", or, the federal entity individuals' "performance of an obligation require[d] that agent to make judgment calls", and "all of the challenged decisions involved an 'element of judgment or choice.'"

On one hand, the imperative of separation of aircraft in controlled airspace is pretty absolute, as far as I have been given to understand. There isn't any discretion or choice to risk a collision at an "intolerable" level of likelihood in order to keep traffic moving, both airline and the military and other helicopter operations in question. And that was the query I was attempted to point out: the midair collision at DCA on Janaury 29 looks like the proverbial death of a thousand small cuts, such that there never was any "judgment" or "choice" as those (admittedly ambigous) terms are employed in the statute and its interpretation. I should have been clearer about only imagining that one of many hypothetical situations where - arguing for the defense - someone was looking at ASIAS and proceeded with the calculating or reasoning which presumably would qualify as "judgment" or "choice." The larger point is that taking account of all the safety information in all the system elements which have been noted and others which might not have been noted here, mark me down as quite skeptical that there ever occurred a time, at a particular place, where anyone acting on behalf of the federal government exercised judgment or discretion that - contrary to the assessment of the NTSB Chair - the risk at DCA was tolerable.

Two caveats to wrap: I don't envy the advocates for the victims' families, as it will be terribly challenging to argue the facts of this case without appearing to cast aspersions on some or all of the pilots and controllers. Nobody wants that, and I certainly don't.

The other is that I do not think that the discretionary function issue will play out in the context of the actions by the pilots of either aircraft or the controllers. Rather it will be litigated with regard to the way FAA (and its parent Cabinet department, DoT) structured, managed, and operated DCA airspace. And this could include staffing policies and procedures (but again, not individuals' actions or inactions on the night of the accident). There may be some involvemenmt of civil-military coordination also at the agency level.

On a somewhat personal note, just a few years ago I traveled by air to a major European capital where a quite substantial and important aviation industry organization has its headquarters; the purpose was to attend a conference hosted by that organization. When the flight ended, because I had not previously traveled on a 787 aircraft, I asked the cabin crew if I could please get an invitation to visit the flight deck to see it, if doing so would not unduly delay the pilots from deplaning. When I got admitted to the flight deck, the captain invited me to sit in the LHS, and then gave me his hat and offered to take my photograph (yes, really). In the snapshots this SLF/attorney looks pretty ridiculous, and I wonder, "what am I, ten years old?" I hope neither this post nor any others look like they were written by that kid.

Hmmm. I'm going to extend your Chicago traffic analogy. Imagine that traffic regulations permitted things known to degrade safety, but which at least some road users wanted: heavily tinted glass, freedom to use handheld cellphones while driving, higher levels of blood alcohol etc. Would the resulting accidents be down to negligence of drivers for being insufficiently skilled to avoid causing accidents under the prevailing regulatory conditions, or down to negligence of the regulators for permitting obviously less safe things to please certain parts of the road user community?

Of course in this case the thing known to degrade safety is "see and avoid", the regulator is the FAA, and the relevant parts of the user community appear to be "near as damn all of it". Focusing on the Army pilots' failure to achieve it would be a neat distraction from the much more difficult question (for everyone) of whether it is an appropriately safe means of separating from airline traffic. The nice NTSB diagram of Route 4 and the 75 feet spacing dodges the issue that neither the controller nor the Army pilots assumed that procedural separation existed; visual separation was being applied.

The permanent closure of Route 4 could be seen as acceptance that this was an unsafe basis on which to permit operations. However it still misses the point. The route was capable of being operated safely, for instance by holding helicopter traffic or avoiding use of runway 33 when needed to prevent conflictions, but that would have been tacitly to accept that visual separation was unsafe. Closing the route also only fixes the issue on one runway at one airport. Where next?

Since this has been explained numerous times before in this thread, please knock it off with your focus on the word "training."
The vast majority of flights I was on (even when I was not an instructor) were correctly classified as training missions (the post maintenance check flights were not, and the combat missions were not). (I was a Navy pilot for 25 years. The Army follows a similar documentation scheme).
The word "Training" is utterly irrelevant.
This has been explained multiple times in this very thread. Please keep up.

The use of NVG's might or might not have been a contributing factor. (I am hoping that the NTSB can clarify).
To maintain proficiency and currency with a skill You Have To Use It.

I would readily accept the reprimand if I had an any way been trying to imply that being on a training exercise reflected on the abilities of the pilot.

What I was suggesting was that being on a NVG training exercise required (or very strongly recommended) the pilot to use NVGs regardless of their impact on the pilot's performance at the task in hand.

I totally agree with your last two sentences.

Hiya layman54 , welcome!

Agreed 100%! After all, many air accidents are because pilots are in the wrong place - a good example is the current sister Thread to this one covering a plane which started to take-off from a taxiway - sadly a regular occurrence. Lots of people are asking "How on earth......." - but they did, just as others have done before them! I'll not comment further as the discussion is on that Thread anyway which you can read and the Investigation is early days so far.

However, one of the reasons aviation is so safe today is because the aviation community realised a big driver to improving safety, based on the premise that humans are both ingenious in devising new ways to screw things up - as well as being quite capable of repeating the old ways too - was to understand if additional issues were contributing to those accidents. In particular, anonymous self-reporting of "near misses" provides much valuable information enhancing the understanding of issues before anyone dies. There were many "near miss" reports relating to this route/runway as has been mentioned. But no-one joined the dots........

By understanding how those additional factors contributed to the near miss/accident means further mitigation could be put in place. Maybe one of the most significant - Flight Time limitations - have come about as, after a number of accidents, people realised just how a lack of proper rest significantly degrades human performance and so contributed to poor decision-making, particularly when under pressure. I just use that as an example of "contributory factors" - possibly not relevant here - the full Report is not out yet.

In this case, the helo crew ended up flying into a jet. But why did they do that? Well, when the NTSB recommended that Route 4 be closed, it described it as being "an intolerable risk to aviation safety by increasing the chance of a midair collision.". If the helo crew mistook another aircraft to one they should have been avoiding (a likely mistake) there was little effective mitigation to prevent that mistake leading to catastrophe - hence the recommendation from the NTSB. What there was in terms of mitigation - such as the ATCO - failed. The ATCO suddenly realised all was not quite right but he didn't have the time to come up with a solution to save the day and a collision happened on "his watch". I can't even imagine what he is going through right now every single day.....

Yes, by all means decide liability for recompense to those who lost loved ones on that fateful day - (top tip, go where the money is!). The legal people like our esteemed fellow PPRuNer, WillowRun 6-3 , will do that. What the aviation community itself wants to ensure is that such a mistake (which will happen again - as I said, whilst humans are extremely inventive in finding out new ways to screw up they are also prone to be quite capable of repeating mistakes ad infinitum) - never leads to such deaths in the future. That's why people look, in great depth, behind the obvious cause for the crash to see what more can be done. That's why it's so safe for you to step aboard an aircraft today.

To reiterate, in the words of the NTSB, the aviation world was running a route which provided "an intolerable risk to aviation safety by increasing the chance of a midair collision.". So, one question, who approved that ..... and where is the Safety Case to support that decision? Cue tumbleweed rolling slowly down the road......................

I hope this helps explain why it's wayyyyyy more than "The crew screwed up. End of story!". Cheers, H 'n' H