Posts about: "NTSB Chair Jennifer Homendy" [Posts: 27 Page: 1 of 2]¶

Yesterday Bill Inman was the \x93Board member on site. \x93 He gave the conference. Mrs Homendy was working behind the scenes. Mr Inman was joined by a few NTSB persons but these were not introduced by name. No IIC name was forwarded. Suppose that becomes clear in the next few days.

The location of the crash gives the much discussed \x93midair accidents waiting to happen\x94 immediate exposure to Congress. It was reported that Congress had already started its own investigation.

So next to one NTSB, two military and one Congressional investigation we appear to have already four investigations running in parallel. Plus whitehouse statements on events and investigation.

Hope Pprune moderators can keep us informed about what is within scope of our exchanges here.
Just thinking \x85 Maybe an idea to focus on factual, not using words like blame etc, so in line with Annex 13.
For me information from a congressional hearing will be part factual and part political.

he was named at the very start of the very first press conference (standing on the far left of the screen)

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

Yes I agree. But it's also possible that the maintenance of such 'procedures' in the face of the growing body of evidence of their unsafety is actually part of a policy stance of expediting traffic, particularly given the highly political nature of the helicopter operator.

I've asked a question over on Rotorheads to see if anyone knows the actual clearance and service given to helicopters entering the DCA Class Bravo on the 'routes', and I'm happy to repeat it here. In London it's Radar Control ie. separation provided by ATC supported by radar. That's one part of the picture. The other is this startling revelation from Jennifer Homendy that there are no lateral limits to the 'routes', so in one sense they are not really 'routes' at all just guidelines with defined altitude limits. I can't find even altitude limits on the NY and Boston charts.

In other words, the way the 'routes' are used is quite possibly defined locally by custom and practice rather than designed with safety baked in by the authority, and that may be the way the authority intended things to be. In the UK every towered field has its own safety management system, as does the CAA. If these exist here at DCA and the FAA it would be instructive to have those examined as part of the investigation, because either they are not being used, or they're being ignored. Nobody could maintain that the risks on this 'route' were As Low As Reasonably Practicable (ALARP).

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.

I don't recall seeing this specific Blancolirio segment previously - and thank you AirScotia for putting it up here.

SLF/attorney as I am, I've looked up some information about ASIAS. Not to bury the lede, the legal issues about whether or not the entities within the federal government which are likely to become defendants in the inevitable litigation will be able to defend successfully on the basis of sovereign immunity will draw, and perhaps draw heavily, on information about ASIAS. This just is my view as (for lack of a better label) an observer, and I'm not part of any legal group or practice currently involved with the matters arising from the accident.

1) Juan overstated one point which could become significant in what I think is the impending legal wrangle over sovereign immunity. The Executive Board of the ASIAS isn't comprised of all the stakeholders shown in one of the slides in the video. The Exec. Board "has representation" from all or substantially all of the stakeholder groups. (Source: portal.asias.aero) Didn't find (or invest more time in looking for) the actual roster of members of that board.

2) skybrary.aero has an interesting page about ASIAS. It notes the involvement of Eurocontrol, ICAO, and Flight Safety Foundation and includes further information about the ASIAS purpose and functions.

3) Most of the slides Juan included in the video appear to have been taken from (or at least those slides appear identical to slides in) a 2007 deck on the Voluntary Information Sharing System Working Group. I won't include the individual's name (just being cautious) but the deck is attributed to the Director, FAA Aviation Safety Analytical Services Division AVP-200. (The slides are marked (in fine print - no irony intended) as "ASIAS Proprietary". Yes, and 67 people were killed in a midair collision in the airspace of our Nation's Capital, so, I'll keep my "fair use" arguments ready if necessary.)

The slides in this deck include a chronological look-back at the genesis and iterations of efforts leading up to ASIAS, from 1995-96 through 2007.

The slide displayed in the video which grabbed my attention was the one indicating that ASIAS is governed by formal principles. Why this is so interesting (imho) is that the legal issue of whether sovereign immunity does or does not apply to FAA and (though it is more complicated) to the Army depends on whether the "discretionary function exception" applies. (That is, a federal statute removes sovereign immunity for negligence in general, but it also includes exceptions where sovereign immunity remains in place as a defense . . . or an affirmative defense, but this isn't law school or actual representation). I'm not drilling into the potential arguments and counters at this time. That being said, I'm quite inclined to think that it will be difficult to prevail on an argument defending the way FAA continued to run DCA because that way was based on policy choices or judgments instead of defined rules - in other words, that FAA exercised discretion in a matter of judgment about policy issues. To reduce this to some absurdity, "show me the policy decision memo that was written about a choice between tolerating the risk, now revealed as obvious - and didn't Board Chair Homendy say it was "intolerable" - of midair collisions, instead of applying all the safety principles embedded in the very existence of ASIAS itself." I'm not waiting for such a memo to surface, but if it exists, surely it will be found in discovery.

4) Not least, Juan walks through some specific reports of previous aircraft-helicopter encounters at DCA. At about 8:50, no. 1458911, he relates an incident with chilling parallels to the fateful night of January 29. I mean, if our court and legal system in the United States still has any meaningful relationship to "the interests of justice" . . . this will be (imho) powerful and effective evidence. And it's not from a distant past - just 2015. If my notes are accurate, the incidents just after this one (a Captain who calls DCA the most dangerous airport he's familiar with or words to that effect), and the previous incident also (a TCAS RA, complied with, but then a GPWS from the tower was triggered, incident 1558721 at about 8:15) - when was a specific policy judgment made to shrug off incidents such as these, and what were the alternatives then considered? Or was it "system drift, this is the way we've always done things, National is close to the Hill you know" .... these explanations do not constitute policy, in my view, but rather negligence that can and should be held to adjudicated responsibility and accountability in the United States District Court.

One last point is that Juan's calling attention to the swift and unequivocal actions taken by the Secretary of Transportation is something everyone involved with aviation safety and operations ought to concur with. Not even a month in the role yet - and this tragic calamity occurs. Salute!, Mr. Secretary!

Hi WR 6-3 , I've been following discussion about immunity etc - I'll steer clear of that legal discussion if I may. I have no idea \x96 I\x92ll leave it to you bright legal folks!!! However, with a humble background in Safety Engineering, and having been on a few Flight Safety Committees, and even run a large UK Database used by Equipment Engineers (I just ran the system \x96 a very important point as you\x92ll see later!) to identify Engineering issues with their kit, my thoughts. I\x92ve no idea how things (a) should have worked at DCA and, (b) actually worked there. But what follows is how I\x92ve seen it working countless times when I\x92ve been part of that process at different levels in the UK. Just some thoughts really\x85\x85 and you\x92ll see why I\x92ve underlined the bit above shortly.

Personally, the reference to ASIAS and it forming a key player here is, IMHO, a bit of a "red herring". It's not how Flight Safety should work in my experience of over some 40 years. Flight Safety ethos comes from the top and works down. Flight Safety activity starts at the bottom works up. In other words, it is the guys and gals on the Line, in the Tower, in the Hangar, in the Cockpit day-to-day who should actively spot and flag up issues relevant to where they are working - encouraged and supported all the way by the ethos from on high. After all, they (and only they) know exactly what is happening in their airspace, on their flight deck, in their hangar.

So the \x93DCA Flight Safety Organisation\x94 (we had Flight Safety Committees as Sqdn and Stn level to manage this \x96 similar in Industry \x96 so does DCA have a similar group? Please tell me it does!) should have been alerted to, possibly, initially unquantified issues with near misses along Route 4 by ATC staff. Local DCA Safety Management and ATC staff would then quantify the issue using the data available directly from such sources as the FAA AIDS and the NASA ASRS databases, all freely available via the ASIAS site. A good overview of ASIAS can be found here and an example of a search screen is the AIDS search form. This is all driven \x93bottom up\x94 . I personally used AIDS and ASRS during my MSc when writing a research paper many years ago \x96 sat at my PC in the UK so it\x92s really easy to use if I could master it! Juan probably got his stuff from there too.

Once the \x93DCA Flight Safety Organisation\x94 has looked at the data sources, either you have no issue or it needs wider investigation. In this case, clearly it was an issue, so (a) Route 4 should have had temporary mitigation put in place by DCA and (b) the "corporate" FAA (for want of a way to describe it) should have been requested to carry out a full "independent" Safety Review. Finally, (c), the ASIAS organisation could have been asked to flag this up to other Airfield Safety Organisations in their \x93Communication\x94 role in case they had similar issues to DCA. Again, local Safety Management at those fields would then investigate.

The FAA Safety Review should decide, with justification , what the next steps are - the justification being called the revised Safety Case (\x93revised\x94 as there should already be an initial \x93Safety Case\x94 supporting the operation of Route 4! Mmmm, an initial Safety Case? Was that a pig I\x92ve just seen fly past here???????!!!!!!!!). The outcome could be (as in this case) to close Route 4 down. If it were to be kept open, the revised Safety Case must support that by adding further mitigation and, vitally, the situation should be then be formally reviewed at defined intervals to ensure such mitigation is actually working before it becomes \x93normal business\x94. The FAA could also order a much wider formal review to see if other airfields are similarly affected and, if so, similar Safety Case reviews should be conducted at such locations if required.

So, from my point of view, I think that ASIAS (and as per the ASIAS overview link earlier) is not in itself responsible for initially identifying issues - it is simply (a) a conduit across users once issues have been identified by a user and (b) it manages some tools for users to use. I managed the RN\x92s Fleet Air Arm Engineering Database with a staff of 3. What we would do is, for example, at the request of Equipment Desk Officers , run additional reports requested by them if they thought, say, there was an increase in issues with a particular type of hydraulic pump or whatever it was. It was not my role in that Post to look for problems - my role was to ensure such data was accessible and ensure the database remained accurate and up to date. As I said earlier, the activity to raise problems and initially scope them is bottom-up as only the worker-bees (in my example, the Desk Officer) see the specific issues where they happen to work. The ethos to ensure that the organisation is in place at each airfield (and the wider FAA) to support the Safety activity should be top-down.

Clearly, it requires suitably qualified/experienced people on the coal face with a mind to safety to actively recognise and flag up such issues, encouraged from the very top by the ethos . That is an important point. If the ethos \x93encourages\x94 the watching of a \x93near miss\x94, sucking one\x92s teeth and saying \x93Sheesh! That was bleep-bleep close!!!!\x94 and moving swiftly on, that is NOT a safety management ethos !!! That is a recipe for disaster! If the ethos exists only in name and the worker-bees are not positively encouraged to raise issues which are then transparently acted on, but is an ethos which is totally subservient to commercial or political pressures then you'll get little or no Safety activity which will lead to\x85\x85\x85.... I\x92m sure you can all fill that ending in\x85\x85\x85!

Just my thoughts FWIW\x85\x85.. and sorry it\x92s so long! Cheers H 'n' H

Well, isn't that razor-sharp, incisive, accident cause analysis?

1. So if an "intolerable risk" is identified by the NTSB Chair, your view is that nonethless the pilot flying the helicopter necessarily was incompetent when that risk finally reached occurrence? The Swiss Cheese model requires accounting for all the holes in the block first of all existing somewhere, and then enough of them lining up - but not necessarily all of the holes lining up. The pilot might have been fully competent and might not have been - but the intolerable risk present in the airspace design makes it necessary to know a lot more relevant facts in the record to supoort a logical conclusion.

Or perhaps you'll next assert that Chair Homendy is just covering for DEI.

2. Any second-year associate in a firm of more than three lawyers who has done nothing more than watch five depositions would raiload your argument to the extent it is based on the NYT's twisting of the summary of the CVR about turning left. Directive? Among other things, if the pilot flying was being "directed" then to the extent there is responsibility, it has to be mutual.

3. Whenever I read pieces like the one published in the NYT I wonder if one of the reporters has a close friend working on one of the lawsuits and is just trying to shape public opinion. Even if that speculation is merely a cheap shot, I didn't read anything in the piece which changed the level of "complexity" of the accident. Perhaps it was deeply hidden and required more reading between the lines. Regardless, its publication is a sorry excuse to jump far ahead of the investigations.

I\x92ve been listening to the NTSB hearings while doing other things last couple of days. All I can say is the FAA testimony is wild .

Normalisation of deviance doesn\x92t even come close.

- Airspace design. The heli route stepping down to 200ft max lead some army pilots to believe it gave clearance from DCA traffic. Spoiler. It did not.
- Controller workload \x93Just make it work\x94 was a common attitude at DCA
- FAA not actively tracking TCAS RA \x93incidents\x94 as it could skew data.. maybe it was correctly applied visual separation etc. Need to look at the background etc. Yeah. But it generated an RA 🤬
- FAA refusing requests for traffic \x93hot spots\x94 on low level VFR charts as \x93hot spots\x94 are on ground charts only.
- PAT25 wanted visual separation from the CRJ. ATC was required to inform the CRJ crew another aircraft was applying visual separation to them. They didn\x92t.

Honestly from a European perspective. It\x92s quite bone chilling.

I feel this was a systemic failure. Airspace design and Risk Normalisation.

And my heartfelt condolences for the pilots, of both aircraft, and everyone else involved including the ATCOs. Not that there weren\x92t issues\x85 but in the Swiss cheese model, the FAA bought the cheese, drilled holes in it, and invited everyone to take a look inside.

Slightly surprised by some NTSB comments as well\x85 they were presented that the heli was straight ahead on the CRJ TCAS simulation presentation. But in actual fact the CRJ was circling in a left turn for runway 33. It was stable at 500ft but in a left turn to line up with the runway\x85 wings level at 300ft. It was challenged by the airline/ALPA but I would hope the NTSB would have picked up on that.

Low point of the whole hearing was Jennifer Homendy halting proceedings and moving witnesses to different seats, as one of the FAA managers elbowed a colleague while she was giving testimony - at which point she went quiet. Infernce being she was being reminded to stop talking.

"Low point of the whole hearing....." (Downwind_Left)

Also a high point - let me explain. ..... First, it was one of a goodly number of instances when Chairwoman Homendy proved all over again why she is an outstanding servant of the public interest.

But most observers of how the Board has operated over the past several years already would have agreed with that (imo).

Personally I didn't observe the elbowing on livestream but when the Chair noted it and that witnesses would be moved, it made sense. Together with the now widely derided rationale (on Wednesday) for not adding a notation on the helicopter route charts - in some terminology or nomenclature if "hot spots" was unavailable - the FAA witnesses in question, as I assessed their statements until that point, had been working mightily to give this accident an air of "excused inevitably." I need to point out this slam on their apparently questionable sincerity-plus-candor explicitly does not include the ATCT supervisor who testified at length and, in my view, honorably.

I don't want to comment yet on whether the accident victims' families will have a valid legal argument about the issue of "in trail" spacing, with regard to which one of the FAA witnesses in question described the matter in quite divergent terms from the way in which the Potomac Tracon official described it. But even reserving further comment, still it appears that if the answer for why the "in trail" memo was not acted upon favorably is that Runway 3-3 was going to be used more frequently, doesn't that answer: (a) mean that the pace of approaching and landing aircraft, in and of itself and also when combined with departures, would remain intense for DCA, and (b) the continued high tempo would also continue to complicate the proper - which is to say safe - control of helicopter flights most especially in the glaring light of the fact that Route 4 intersects the approach path to 3-3? As raw material for the legal argumentation that the FAA's actions and omissions were ministerial, and not matters of policy, this could be another call of, blood in the water.

(Of course all concerned know that the "unwritten policy" choice was to move traffic and hope for safe outcomes only. Maybe that often-criticized approach taken in the United States would prove out in an actual courtroom battle as a regrettable but nevertheless sufficient "policy decision" so as to allow sovereign immunity. But does the United States FAA really want to litigate this issue? Against some of the strongest and most experienced advocates ever to enunciate "Approach" in a courtroom? My understanding is the families, or some of them at least, are rep'd by attorneys and counselors who .... aren't finding time to sit in Starbux and post here.)

There were two other, at least, pieces of FAA testimony that, in my deposition-taking days, would have gone on for some hours more. No one could say what the Assistant LC was doing at the critical times. How could this not have been nailed down in the interviews? Also, what in the world is "debriefing" after training? How and why was that more important than keeping the helicopter position staffed?

I wish not to cast aspersions on any DCA ATCOs whatsoever. The testimony about why FAA did not get both alcohol and drug testing done in accordance with established rules was just another piece of shattered credibility - but as Board Member Inman stated, there is no basis to believe or think those kinds of problems were factors, and so that's not the point here. I mean, it wasn't clear fatalities had occurred very, very soon after the event? Good grief.

Perhaps the contretemps afoot in the investigations - and surrounding public relations affairs - in Korea and India have led me to some misunderstandings, but has it become time to think about whether the U.S. should have an AAIB? and not combine aviation into the general category of Transportation? For now, Member Inman said it well and succinctly: "Do better."

She was really not happy with the FAA more than once.

Was was hoping to rewatch this weekend but for some reason day 1 isn't on YouTube (but day 2 is).

I do have links for the live transcripts but they can be hard to follow.

Day 1
https://transcript.verbit.co/?transcriptJobId=c8273991-7823-4761-8ab1-95618f517981

Day 2
https://transcript.verbit.co/?transcriptJobId=02727bab-a1a2-4efd-95cb-de7991bdce87

Day 3
https://transcript.verbit.co/?transcriptJobId=42394932-5289-4aa9-b9ea-4a5d3ee725f6

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

NTSB Chairwoman speaks out about legislation to again allow uncontrolled military helicopter flights through Washington D.C. From the New York Times https://archive.ph/7YCHK

((Long pause.....))
1. Facts. The NYT does report the House passed its version of the NDAA. The NYT further reports that the provision at issue does "not appear in the Senate version" of the NDAA which the upper chamber previously passed. Though I have not worked on any Capitol Hill staff, it still is safe to say that there will be a conference between the two bodies to iron out a final version acceptable to majorities in both chambers.
NOTE: the NYT also reports the strong objections of the aviation sector leadership in the Senate, on an actually bipartisan basis. This includes the Chair and Ranking Member of the Senate Commerce Committee (Sen. Ted Cruz (R-Texas) and Sen. Maria Cantwell (D-Wash.), respectively, and the Chair and Ranking Member of the Committee's Aviation Subcommittee (Sen. Jerry Moran (R-Kansas) and Sen. Tammy Duckworth (D.-Illinois)). Doubtless few need to be reminded that Senator Duckworth, currently the Land of Lincoln's junior United States Senator, flew helicopters in the United States Army in armed conflict and actual combat during which she was severely wounded. I don't want to get bumped into blasting jets but I don't see the provision at issue as a wise legislative manuever or that it is wise to make Sen. Duckworth really angry about an aspect of helicopter operations in Washington, D.C. airspace.

Further, NTSB Chair Homendy, per the NYT: "Nobody actually knows what a commercial aviation compatibility risk assessment is". She also reportedly noted that the legislative measure does not task this assessment, whatever it might be intended to cover or what process it might be intended to utilize, to the FAA. Designation of a service secretary and the Secretary of Transportation as authority for issuing the pertinent waiver is not the same thing as tasking the process to FAA, first, as a strictly legal and legislative matter, and second, as a fact of life in the interagency.

2. Interpretation. Cynically, one could assert that this provision is another instance of the drive toward almost unlimited or, as a practical matter, effectively unlimited executive power.

Presumptuously, one could instead assert that somewhere deep inside the national security or intelligence bureaucracy, there is some as yet undisclosed risk or development which requires the Army or any other service to operate helicopter flights in a manner the same or very similar to the procedures allowed prior to the accident.

It may be poor form to transfer the phrase from its original context, but I think the provision at issue produces shock and awe, except that the awe is in the nature of disgust.

https://www.ntsb.gov/news/Documents/...tion%20Act.pdf

Letter to Congressional leaders re: NDAA from NTSB Chair Homendy.
The letter is addressed to the Chair and Ranking Members of the Armed Services Committees in both the House and Senate.

I'm coming to like Jennifer Homendy. It certainly looked like one of the contributory factors to the DCA crash was the military considering themselves to be outside the normal best practises. They now seem to be seeking to make that explicit.

Good language and a strong statement. Too bad she spelled "Department of Defense" incorrectly.

Thank you MechEngr for stating in detail, and explaining, the recommendations made by NTSB and their relation to ADS-B systems, both Out and In.

It appears I had mistakenly thought NTSB had made a recommendation after the accident about ADS-B. That was incorrect.

It would be interesting to try to unearth the document trail with respect to the agreement reached by FAA and the DoD with regard to ADS-B Out usage, which agreement was reached (per the NTSB Chair letter) after the accident. Of course unearthing documents which relate to controversial subjects could well be a fool's errand. .... ..... ...... oh wait, there's such a thing as pre-trial discovery, and the lawsuits are in federal district court.

Senator Cantwell gave two speeches in recent days on the Senate floor about Section 373. I'm not posting links to them, because "politics". Still, something worth noting from them is that the Senator, previously Chair of the Commerce Committe - the Committee with jurisdiction for civil aviation - and currently Ranking Member, stated she does not know who inserted the highly questionable Section 373 into the NDAA. And whether as prevention or preemption, yes, the families of Flight 5342, including the family of the First Officer, are raising a loud objection to Section 373 - but the concerns over the legislative provision are not based on any effort to serve or to please the trial lawyers suing on the families' behalf. Chairwoman Homendy of the NTSB does indeed operate in a political environment, no kidding, but she is conducting her public advocacy as a safety professional and not a politician. (I'm not lauding any Senator's bona fides as aviation safety advocates because, again "politics.")

It was probably brought to his attention after the vote? especially if it was a last-minute addition.

Though in hindsight, his initial comment "This legislation restores our military\x92s focus on lethality" is a bit on the nose.

It's just baffling why the Army doesn't keep the ADS-B equipment on their helicopters operable, it'd be safer at any altitude when they're sharing airspace with civilians.
I can only imagine someone thinking, "well we can't stop doing training flights when the equipment isn't working" (and Homendy glaring at them "then get it fixed").