Posts about: "NTSB" [Posts: 232 Page: 9 of 12]¶

To be candid I "cut class" and missed Panel 5, so thanks for noting all that.

As Panel 5 was getting set, there were follow-up questions about the post-accident testing. At least two witnesses weren't familiar with previous revisions of the relevant FAA written rules (iirc they're referred to as "orders" but I wouldn't swear to that). FAA testified that the agency is revising that order, in light of things not having been done properly at DCA on the night ofJanuary 29 into January 30. Member Inman hit a towering home run, I thought. He noted that he was with DoT when FAA set to work on revising a previous iteration of the pertinent order ..... many years ago. Deja vu, all over again.

NTSB Youtube channel links:

After having completed three days of its formal proceedings - which I'll predict will long be remembered for the Board Chair ordering witnesses from FAA to turn off their cellular devices and to relocate because one had been seen elbowing another during the latter's testimony - the Board may be about to enter a new kind of Washington ball game.

Twelve billion dollars here, eighteen billion dollars additional there, pretty soon you're talking real money (with apologies to anyone who recalls the originator, Illinois Senator Everett McKinley Dirksen). With all that federal largesse provided by the American taxpayer destined to be spent on the so-called "new ATC system", I have a question. Isn't it necessary to know what conclusions the Board reaches in this investigatory process before committing to - and I'm going to use my own phrase - the "new National Airspace Architecture"?

The United States needs a new FAA organization, on two fronts at least. One, separate the ANSP from the regulator (as probably hundreds of real-life aviation industry worthies have long advocated). Second, a new organizational structure, ethos, culture, set of career pathways, and everything else that is not fit for purpose for the immient and dramatic changes dead-ahead (such as automation, Advanced Air Mobility, environmental pressures, and oh yeah, increased traffic correlated with increased demands from the traveling public for the precise kind of bag of peanuts to which they believe they're entitled). Is it not the case that FAA has failed in its fundamental mission, because under no ConOps should it have been possible for this accident to take place? (Of course, there will never be a guarantee against one or more persons conducting relevant activities with gross negligence - but if that harsh judgment is levied against the Black Hawk, nonetheless the system should have provided stronger procedural separation.)

And all this is before decisions are made about what technologies to build into the new Nat'l Airspace Arch., what vendors, what geographic arrangement, and what connectivity the entire system will have with ATM in Europe and globally (and European ATM especially is moving rapidly into the future).

But the Board final report is what, 12 months away? 18 months perhaps?

And as the new National Airspace Architecture is supposed to be undergoing definition and development, what assurance is there that the upcoming 42nd Triennial Assembly of ICAO in Montreal will not take action which will seriously impact the U.S. process? Or set ICAO on further intitiatives which would constrain U.S. plans, and not necessarily for the better? Recall that the United States has not had a designated Permanent Representative to ICAO since Capt. Sully abruptly resigned (July 2022), and while the career Foreign Service officials heading up the U.S. Mission undoubtedly are fine and excellent public servants, they are not ( afaik ) aviation industry professionals.

None of this is to say that the NTSB should speed up its process and deliberations. But at the same time, if during this Assembly the Secretary of Transportation shows up - as happened during the previous Assembly - to speak on behalf of the United States, I hope the Secretary has very, very good speechwriters because it will be hard to say anything meaningful when the state of affairs is in such disarray.

Edit:
On July 17 the White House nominated former Delta Airlines Capt. and U.S. Navy aviator Jeffrey Anderson to the position of Permanent Representative to ICAO with the rank of Ambassador. Timing of Senate confirmation hearing is presently unknown.

Yes, radar alt was a recorded parameter on the accident helocopter FDR. See the Flight Data Recorder (Helicopter) Factual Report in the NTSB docket.

NTSB Overview/Updates
https://www.ntsb.gov/investigations/...CA25MA108.aspx
The docket is linked at the bottom of that page.

NTSB Public Docket
https://data.ntsb.gov/Docket/?NTSBNumber=DCA25MA108
The docket contains evidence related to the investigation. Many NTSB investigations have public dockets; often they're released with the final report.

In the docket:
10-HELO-A FLIGHT DATA RECORDER - HELICOPTER - GROUP CHAIRMAN'S FACTUAL REPORT
https://data.ntsb.gov/Docket/Documen...0L_FDR-Rel.pdf

The transcript of NTSB interview with the local controller is available as one of the articles. Part way through it but was it most obvious, perhaps with the benefit of hindsight, is how poorly constructed some of the questions are - ambiguous and at times, leading.

On the relationship between the in-progress NTSB investigation and the "new ATC system" (or, new National Airspace Architecture), my previous assertion of "necessity" was over-stated, and work not only can be started (as you noted) but it has started, i.e., the funds authorized and appropriated in the recent U.S. federal government budget legislation. Although I haven't read the line items in detail, my understanding is that the funds are assigned for specific projects and activities.

But, that having been said, the Board's investigation appears primed to result in recommendations, supported by factual findings and analysis, for arguably significant changes in certain basic aspects of the ATM architecture. I'm relying here on the fact that the Board issued, very soon after January 29, an emergency directive to FAA with regard to the design of the DCA airspace and specifically the use of the helicopter routes. While I would not wish to assert familiarity with the actual world of ATC, the tenor and content of the Board's actions to date as well as of the three days of hearings strongly suggest that the Board will make recommendations for significant change in at least certain areas. Among these are the structure of airspace in which helicopters (civil, law enforcement, and military) interact with commerical traffic - it should be noted that a review of these airspace structures was ordered after the accident. Also, the way in which military aviation is conducted in Class B airspace especially adjacent to airports (of a certain size, presumably) appears likely to be covered by recommendations. None of this is to say that the new ATC system cannot be undertaken unless and until the Board report is issued (again, "necessary" was imprecise) but to the degree that recommendations for particular substantial reconfigurations of the NAS design are coming, the architects of the new ATC system certainly will not want to have to backtrack and redo their work.

On the drive to bring "FAA 2.0" into being, I would not associate myself with any claim that the United States ATM should "copy" European activities. I think the Memorandum of Cooperation between the SESAR authorities on one hand, and the FAA on the other, is the correct framework. And under that framework, "harmonization" appears to be the principal objective. It happens to be the case that although three formal joint reports on the status of harmonization have been completed and published over the past couple of decades, the most recent one was published several years ago. It is not as if nothing much has changed or advanced in the intervening years, but no further report is anywhere to be found.

When one takes into account the many and varied data-gathering and reporting functions of EUROCONTROL, the activities of the FABs, the ATM Master Plan, and informed expert groups such as the Wise Persons Group, at least from the cheap seats from which I see these it appears clear that European ATM is advancing quickly into the future. Whereas, in the United States, despite good people in certain technical roles in agencies and supporting organizations, the sorry state of the overall system speaks for itself. So to learn from our European allies and partners (and I do continue to view those States as allies and partners despite the view being out of vague in certain ignoramus precincts here) is not just wise, but necessary. But not to copy, rather to learn and adapt what will work best on this side of the transatlantic air-bridge.

On ICAO and the nomination of Mr. Anderson - and I do not know the gent either. Perhaps frustration with ICAO's immutable process of seeking consensus is what drove Sullenberger from Montreal, but I have my doubts. An experienced and by-then famous airline captain would be expected to have enough sophistication to realize, in advance, the unsurprising fact that ICAO is part of the UN. It should not have been any surprise, and that is without wondering whether the lucrative guest-speaker circuit was also a major factor.

I don't agree (respectfully) that each and every Member State, even small States lacking an airline, have equal voice. In Assembly votes, yes, they do. But not in the Council, given its three levels of membership and the process by which States gain membership on Council. And, though I am not an ATC professional (as you know), my understanding is that in the Air Navigation Commission, there are States with the experience and credibility to understand evolving state-of-the-art, even though they may disagree on how to proceed with it. And not every Member State has that level of experience and credibility. It's impolitic perhaps to say this out loud but that does not negate its validity or truth.

As for Mr. Anderson, the profile he has up on LinkedIn indicates that he has had quite significant labor relations experience. And governement relations responsibilities for the pilots' labor organization as well. His military career was, it appears, where he learned to aviate, and is not the approach the White House expects him to apply at ICAO. (In my view, sovereignty of every Member State's airspace is so fundamental, not only as reality of international flying but also under the Chicago Convention that a military career actually is fabulously relevant background for ICAO Permenent Rep, but reasonable minds can differ.) The labor relations experience could well turn out to be just what the doctor ordered for dealing with - as you say - the sometimes infintesimal pace of ICAO efforts to actually do something.

Of course, with ALPA having promptly denounced the nomination, because Mr. Anderson split from the labor organization over raising the age limit, perhaps the Senate confirmation process will not be accelerated before the Assembly convenes in third week of September. Whether the U.S. will be represented by a proper Permanent Representative, even one without Senate confirmation as Ambassador, is just not clear on the scope yet.
[...apologies for thread drift, but right now the NTSB DCA midair investigation is "the only game in town" in U.S. aviation policy - town as in Washington that is, not Montreal, QC, CA. ]

Repeated for emphasis, but further comment I won't make as it may cross too far into politics. How to manage the air space around National/Reagan will certainly get the FAA's attention, but it is worth recalling that no matter what the NTSB recommends after a given investigation, the FAA will assess each recommendation as regards implementation, or not.
(I am sure that you are aware of that, but some of our participants need to have that spelled out).

From the Seattle Times today https://archive.ph/7td29

@WillowRun6-3 : First a couple of replies to your earlier comments :
No the FAA cannot copy Europe, in fact the initial Single sky (SES) plan was the other way around, copying what the US had, based on a biased report that the US system was better and more productive than Europe . a single airspace structure under a single authority, When they realized it would not be possible, they then invented the FABs ( airspace blocks) that did not work either , so they went for technical harmonization , that is how SESAR grew . . Yes the current US-Europe discussions are about harmonization between NextGen ( what is left of it ) and SESAR . No-one wants to "copy" the other today but I suspect that the FAA 2.0 will most probably "copy" the technological path of Europe , with an ambitious master plan etc...Do not rock the boat just believe technology/ automation, now AI, will eventually solve all the problems.
on the NTSB powers :
As Lonewolf 50 correctly said and reminded us, the FAA does not have to follow NTSB recommendations . In fact they mostly don't , I have been told or read some time ago that over the last decades there were a few hundreds NTSB recommendations that remained open unactioned., But that is not a US alone issue, same in many other countries. An Investigation Board is not a Regulator, which is what is missing in the US.
as to how ICAO works :
I have been attending ICAO meetings . part of Panels and various working group ( still do it today ) The ANC is where the decisions are voted but not when the work is done and proposals are made. . There is not like in the UN , no State has a priority seat there, all equals , big and small.. And that causes difficulties My example was correct , for instance in Europe there are 2 large non-EU States both with very large international airlines and a dozen smaller ones , also both aircrfat manufacturers which are constantly blocked by very small countries with no airline but members of the EU. ( PM me if you want the names)
Military background, no use for me because we do not discuss Military matters in ICAO ( the "C" in ICAO is sacred ) and over-playing the sovereignty card is creating opposition , not consensus . Some States think it is is a nice retirement present to send a former Air Force General to ICAO : big mistake . You lose influence, not gain any, in my experience at least , but I will give Mr Anderson my full attention and will judge him on his actions , not his past .He might prove to be excellent in that role , who knows,
now about retaliation :
Not sure if this is the case., In Europe we do not do this .We suspend people involved in accidents, this is standard , some need retraining ,some come back to work ( almost always in the same facility) and some want to change jobs, but they are generally seen more as victims than culprits.
Here from what we know so far, the controllers and their supervisors were trained to work on local procedures made long before they came to the facility . Those procedures were or became unsafe but if this is how they were trained to work , you can't blame the operators for faulty procedures . OK but what about supervision ? 10 managers in 10 years, 5 in the last 5 years , show that some possibly felt vey uncomfortable with what they were seeing. But for me they also were kind of victims of the system

Each of those individuals testified with apparently sincere and candid demeanor (I watched most all of that day) even seen and heard just through livestream.

My inquiry was meant to refer to an internal investigation process, possibly with witness testimony. Or does the NTSB investigation in effect preempt any internal Army investigation and reporting functions which presumably are conducted when there is no civilian involvement in an Army aviation accident?

It wasn't mentioned ( afaik ) in the NTSB hearings but does the Policy Board on Federal Aviation (which I understand is situated within DoD) have any investigation role in this accident? Or in deciding upon and possibly implementing recommendations the NTSB presumably will make when its report is complete, to the extent the recommendations are directed to Army aviation specifically (or other types of military aviation generally) as these operate in the NAS?

Not that the NTSB are going to apportion blame in their report, that isn\x92t their function. But it\x92s quite clear there were (and are) unsafe practices going on among controllers and operators in FAA/DOD land. Read the docket testimony here from page 463 onwards to about 468 or until you get bored.

https://data.ntsb.gov/Docket/Documen...dacted-Rel.pdf

Clearly Army pilots are calling visual on very distant traffic which they haven\x92t actually identified and can\x92t see, and controllers are believing them and contracting responsibility for collision avoidance to them. The Standards pilot being interviewed here (the most experienced Army pilot NTSB spoke to) even says \x91..I know it\x92s bad\x85\x92 but condones the practice because otherwise the PAT helos would have to hold!

The logic displayed here is totally crazy.

If ATC have taken the trouble to issue a traffic advisory to a helo, why does the helo pilot think it\x92s reasonable to assume the traffic (which they haven\x92t seen!) will be no factor. The Controller has called out that particular traffic to the helo pilot for a reason he\x92s become aware of, like the traffic\x92s intended flight path will shortly become a collision risk to the helo.

If such an internal investigation happens it won't be public. Just look at how sparse accident investigations are when the NTSB/civilians aren't involved.
I've not seen a public release for the AH-64 that crashed in Galveston Bay Dec 2016. I know a few ASAMs were issued late 2017/early 2018, basically some pre and post flight inspections. Apache helicopter down in Galveston Bay, Texas

And that's about par for the course, particularly the Army.

I doubt they have an investigative role. They probably will be involved with policy changes once the report is final, though we likely won't hear much about it.

The DOD has its own investigation process which is detailed and regulated by each service. Any fatal serious injury accident or substantial damage is investigated in a Safety Investigation Board (SIB) usually under a O-6 or O-7 grade officer. Just like an NTSB investigation the Board President can accredit subject matter experts, outside contractors, JAGs to interview, gather data, etc. The SIB runs under a tighter timeline than an NTSB investigation, usually the report is due within 90 days, but obviously that’s subject to the complexity of the mishap. The report is “privileged” releasable only within the service, generally only within the Major Command in the USAF. It is NOT public released. The SIB recommendations do not include disciplinary or administrative actions for DoD members. It cannot be used in the courts. The MAJCOM commander is usually briefed in a meeting without coffee or cookies. It’s a tense briefing.

At some point during the SIB, the command convenes an Accident Investigation Board (AIB), also run by a senior officer. The AIB can use factual data from the SIB, but must conduct its own interviews, on scene investigations, etc, to ensure its independence from the SIB. The AIB report is releasable, may recommend disciplinary or administrative actions, may have recommendations to outside contractors or suppliers. Being public, it can be used in court actions, FEB or courts martial.

The Congressional “privileged” status came out in the 50s when the military accident was astronomical and needed a process to establish what happened and what actions could prevent a repeat mishap. The privilege took away anyone’s Article 31 rights, basically everyone had immunity in the SIB process but not in the AIB process. You get “rights” read to you in a AIB and a Defense Counsel is offered.

I would guess the Army is or will run an AIB as there’s, at least, the possibility of disciplinary actions or specific recommendations for regulatory changes that must come out of a military process, as the NTSB cannot issue recommendations to the military authority. It might just be an echo of the NTSB report.

This mishap maybe the first since the Ron Brown accident in FRY where the NTSB was involved, mostly for political reasons. The AIB ripped a bunch of officers new orifices ending their careers. I believe, at least one flag officer retired as a Major or Lt. Col.

BTW, the military uses “mishap” to indicate the crash was preventable whereas “accident” implies God reached down and just took them out. I always laugh cynically at the news of a car accident where it’s written like it was the driver became a passenger and had no agency. Car went out of control. No, the driver was (fill in the blank) and crashed the car.

....@ST Dog
Those replies are appreciated. As the questions I asked probably reveal, I cannot claim any familiarity or experience with U.S. military aviation accident or incident investigations. But I think the course of events following this accident, especially the lawsuits, could lead to more activities becoming public than is usually the case.

Starting with the Army's response to the accident, the likely path the litigation will take could lead to some pressure for its internal inquiry - if an inquiry is conducted and in whatever form - to be disclosed. Apart from classified subjects, parts of the inquiry could be disclosed, even if only as a subject of discovery. Even more so if the case involves all-out legal fighting.

The PBFA also could emerge in a somewhat more public role. As the three days of hearings progressed, at least twice, a former Army helicopter pilot who also later served as an officer in the Air Force, and who works with medical helicopter flights, expressed regret for having to testify about safety concerns about Army and Air Force helicopter operations in the relevant airspace. (He supervises 10 pilots who "frequently fly within DCA airspace as we transport critically ill patients".) Together with several other pieces of testimonial evidence, this testimony showed there are a set of problems in the way the airspace is designed and used.

But the military aviation operations generally involve quite high priority roles and missions, as the letters PAT themselves indicate, even without trying to say anything intellilgent about another helicopter unit which (I read someplace) conducts training flights on a certain grassed-in, lawn area.

So there will be some level of intensity in the litigation. There will be keen Congressional interest, among other reasons because although Senators and Representatives (and their staffs and the cadres of K-Street et cetera) will not say so out loud, the current service level of DCA is something they want to maintain, not reduce. Of course FAA will be the immediate respondent to the investigation result, but in this situation FAA (imo) will not be able to act on its own. Some unit, office, group, or ad hoc assemblage of authorities someplace also will have to pick up the result of the NTSB investigation and do so within the context of intensified public attention.

It should not be assumed that the lawsuit will have proceeded very far in the time it takes for NTSB to reach its conclusions and complete its report. Worse, the discovery process in federal district court can very easily lead to additional pressure for more public involvement (yes, NTSB is thorough, but adversarial litigators do have a way of developing and presenting additional layers of information). None of this is meant as predictions, but there are a lot of unuusal pressures in this situation.

Edit: this post was written before I saw Galaxy Flyer's post. As a guest on this forum, I believe it is expected that I not try to revise content (as opposed to correcting typos) and so I'm leaving this post as written, despite now seeing some gaps in information or understanding.

You're referring to forces of flight. Such is not relevant in a same-altitude broadside collision. The issue here is separation, the subject that dominates this thread and the NTSB investigation.

Otherwise, if you watched the hearing, you'll remember that on day 1 the Army pilots and the medivac helo operator stated that they do not underfly aircraft.

There have been a number of references above to the woefully inadequate vertical separation provided between helicopter Route 4 and the approach to Runway 33. Given altimeter errors (expected and maybe not so expected) in the helicopter, a helicopter flying high (and possibly offset sideways towards the end of Runway 33) and an aircraft maybe low on approach, there really wasn’t any guaranteed separation.

I strikes me that, from my layman’s point of view, that this is the primary and gaping hole (among numerous others) in the Swiss cheese here.

At the same time, I get the sense that no controller was ever going to intentionally permit a helicopter to pass directly under an approaching aircraft and challenge that limited clearance.

My question is, should this have been (or was it?) formalized as an ATC procedure? Because if this had been proceduralized, I find it hard to believe that just nighttime VFR separation would have been found acceptable in that environment. Rather I would think that lateral separation should have been actively managed by ATC.

For one thing, with the CRJ (or whatever aircraft) pilots making a late switch to 33, turning to line up with the runway, etc., they may not have had the bandwidth to scan for a possibly conflicting helicopter, if they could even have seen it from their cockpit. (IIRC from the inquiry, the NTSB will be investigating that last point.)

I don’t know how difficult it may have been for the helicopter to see the CRJ, but the simple fact is that they did not.



On another subject, one thing that struck me from the inquiry was that the helicopter pilot apparently had very limited recent flight time, yet was assigned a challenging check ride.

This contrasted with the testimony of the leader (?) of one of the local Medivac groups, who discussed how much more experience he and his pilots had flying in that challenging environment (and often single-pilot ops at that).

Is the Army not providing adequate training and flight time to ensure their pilots can operate safely in those conditions?

I wouldn't bother explaining it to laymen as a hole in cheese. In layman's terms it's the same as having two busy roads cross, and no traffic lights.

And to stick with motoring analogies, some of us are used to considering that at a junction another vehicle can be partly obscured by a pillar for one eye, and in the blind spot of our other eye, so we might move our head sideways to help check better. Some aircraft have more windscreen pillars (this helicopter has four) so the aircraft in a constant relative position - which is the one that is the collision risk - may stay behind a pillar unless we move our head.

It's simple; the altitude restriction was never intended to be the sole method of separation. At most, it was an additional layer of protection. The controller wouldn't have cleared the Blackhawk to continue if they hadn't said they had the traffic in sight. But they did say that, whether it was true or not. ATC is a service provided to pilots, not an authority. Pilot-applied visual separation essentially overrides any procedure used by ATC. When you say "Traffic in sight," you are saying "I don't need your help maintaining separation, I have it under control and I take full responsibility."

The IFR aircraft wouldn't be required to have the traffic in sight.

Trying to understand how the individuals and organizations responsible for the operation of the DCA airspace and associated helicopter routes expected it all to operate safely. Also not exactly trying to anticipate lines of inquiry to be conducted by the Dep't of Transportation Inspector General, although I think Sailvi767's comment points to a key area that will be examined.

My understanding is that TCAS RA's are inhibited below some specified altitude, in order to reduce or minimize nuisance alerts. Is it a correct statement to say that when the CRJ received the TCAS TA's referenced by Sailvi767's comment, it already was below the altitude at which RA's were inhibited?

If that is correct, then doesn't it follow that the CRJ crew - intently focused on the approach to and landing on 33 - were following procedure that has long been acknowledged for DCA Rnwy 33 - the LC will keep helicopter traffic from becoming conflicting traffic? It is (I think, but only as a non-pilot and non-ATCO) obviously true that in this instance, there were a number of inputs (and lackof inputs) by ATC, and likewise several acts and omissions by PAT25 which led to the procedure failing badly, with the tragic result. In other words, the clearest root cause is the fact that the acknowledged procedure over a period of years was that the LC (and sometimes a helicopter position in the tower) would keep the helicopters from becoming conflicting traffic - and through normalizationi of deviance, when this procedure eventually failed, it failed all the way.

In a previous post I mentioned that one of the attorneys representing the families of accident vicitims has said that claims against the airline would be investigated and possibly included in the forthcoming lawsuits. I suppose it is not talking like a stark raving lunatic to point to the many reports filed about overly close encounters in the airspace, especially in light of information found and then released by NTSB soon after January 29 which detailed many close encounters (as a non-frivolous basis to assert claims against the airline). But wait. They are going to argue that, during the last few hundred feet on final approach to Runway 33 at night, after having been more or less directed by ATC to switch from Runway 1, running through all the steps outlined (by Capn Bloggs) to look for the possibly conflicting traffic took priority over flying the approach - especially in light of the long-acknowledged procedure at DCA? I'm admittedly shouting from down in the cheap seats but this attack by plaintiffs on the CRJ pilots, as an means to advance claims against the airline, strikes me as a legal obscenity.