Posts about: "Normalization of Deviance" [Posts: 63 Page: 2 of 4]¶

On rare occasion (for my civilian flying) I have been given a VFR clearance at an unusually low altitude (flying along Miami Beach being one example), and occasionally a routing I consider more risky (over water or a built up area with no where to go if the engine quits). Usually, I have accepted and flown the cleared routing, though there have been times I have requested a variation to reduce risk. These have been occasional for me, therefore I treated them as such, and my awareness went up considerably. To me, a situation which deviates from my "normal" requires heightened vigilance I'm a little nervous doing something I would not normally do.

So if the Blackhawk pilots either flew this low altitude route regularly, or it was an operational norm for that pilot group/operation, pilots would begin to relax with it - it's "normal" I opine that it is never normal to fly at 200 feet AGL in a built up area, nor close to the approach path for a busy airport. So if the training and operational norms of this routing lead pilots to think it is normal, they treat it that way, and vigilance goes down. This was an accident waiting to happen, because of normalization of deviance form established norms of flying.

I've learned the hard way that when ATC asks if you have X aircraft in sight, once you think you do, mentally map the path of that aircraft, then start looking for the one you have not seen yet - particularly with two pilots! You get a clearance to pass at 200 AGL under the approach path of a busy airport at night - that's unusual, and spidy senses should be tingling lots! This hyper awareness should be being trained into the operation - a preflight briefing from the lead "On this flight, we could expect this routing and clearance. This will be unusual, and we're going to be extra aware by doing the following....".

So it's easy to blame the Blackhawk pilots, and yes, they wear some of this, but the military let the pilots down by not categorizing this flight as "high risk", and ATC let the pilots down by clearing a routing which had the potential to provide only a hundreds of feet vertical separation, rather than insisting on both vertical, lateral, and projected path separation, and thereafter, telling the Blackhawk pilots all of the airplanes they should be seeing, not just the one, which seems to have been misunderstood.

I have been instructed to orbit to allow for a passing aircraft to clear in front of me, why not this time? Maybe that low altitude air route is too small for a normal orbit? Another red lag about that route not being a good idea!

It\x92s anecdata, but I have noticed a trend over the years for US pilots to sometimes call visual with the airfield or other traffic when they may not be as a kind of reflex when asked. This is likely perceived as being on the ball, helping ATC, keeping the flow up but it falls smack under normalisation of deviance.

Last time I operated into LAX there was a cloud layer from 7,000\x92 down to ~2,500\x92, really thick and solid, bit of drizzle, no breaks until you suddenly came out of the bottom of it into a different airmass. A few people were calling visual from 10-15 miles out which raised eyebrows as it was highly unlikely to be the case. Yes, they were going to be visual at some point but not right then.

Would be interested in opinions from FAA-land as to whether this is isolated and/or very abnormal or they\x92ve noticed it as well...

I have noticed this and it really hosed me one night. Coming home to KMTN from KVKX (right next to DCA actually) I was VFR in the Class B at 2000 feet. The ceilings were dropping going north, but traffic at KBWI was all going along with calling the field in sight at 2500 feet. BWI wanted me above their landing traffic, so I was told to climb to 2500, which put me in IMC. There was NO WAY anyone was visual at 2500, but they didn't want to deal with a pop-up IFR flight in the middle of a busy push, so I got "You will be in the clear at 2500, everyone is reporting airport in sight". The message was very clear, don't screw the whole thing up! At least they didn't ask me if I could see any specific airplane, I guess they knew what the answer would be.

Interesting and quite shocking, coming from a former standards/instructor pilot, re— normalisation of deviance.
eg. If you don’t catch all of a radio call meant for you, just reply with what you think the controller wants to hear you say and then comply with that — not, ‘Say again…’ and confirm your clearance. Also (implicitly while discussing LED lights) confirmed that the helicopter crew would not have been able to visually identify the correct conflicting traffic, yet made the habitual call, ‘Traffic’s visual, request visual separation’ and ok to proceed, with ATC complicit in the arrangement. Also don’t beat yourself up too much if you bust your altitude restriction right under where your route intersects with landing jets, while confirming this as the most safety critical part of the route.

But that's actually the correct flow of events. If you weren't 100% sure but you readback what you think you heard and you don't get a correction then you did, actually, hear it correctly.

Also is 'normalisation of deviance' written down on a whiteboard somewhere? People keep saying it. It doesn't seem very organic.

In describing the phrase, \x91normalization\x85\x92, etc., it\x92s unclear to me what you meant by the term, \x93doesn\x92t seem very \x91organic\x92 \x94.

The \x91normalization\x85' term was originated in 1996 by Diane Vaughan, a sociologist who wrote, " The Challenger Launch Decision; Risky Technology, Culture, and Deviance at NASA University of Chicago 1996\x94. It\x92s wide use reflects the essential notion behind group behaviours when assessing risk and consequences.

Normalization of deviance?

Prescriptive safety; do as I say not as I do.

Safety via regulation, an illusion of control.

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.

Hi WR 6-3 , thanks for that - I think I've finally got the idea here! I've been particularly slow on the uptake and, on that basis, you are correct to reject my "on high" example. I've said much so time for me to sit back - there seem to be so many issues with this case and this "immunity" question is just one aspect to it and which I found difficult as a non-US and non-lawyer to understand. Engineering (my first "life") is far easier - if it doesn't work, you hit it - if it still doesn't work, you just hit it harder! Simples!!!!!

My closing thoughts. It seems ATC were simply trying to run a routing system, the layout of which was handed to them, to the best of their ability. As moosepileit said at Post #1176, "These charted routes are Pre 9/11/01. ATC workload and growth of route, ahem, users, too. How do you boil a frog? Just like this. One degree at a time. This is the B-17/P63 crash - dumb orchestration, no one spoke up." . The ATCO involved seems to be a victim of this - a process of "normalisation" over time and pushing rules to, or beyond, their sensible limits - something I said a few Posts back. Similarly, the helo crew were as much victims - again, possibly a process of "normalisation" over time meant they were a bit too happy to say that they had an a/c in sight which they genuinely thought was 5342 but wasn't - "normalised complacency" if such a term exists - I guess it does now!

My own concerns relate more to the "human factors" involved (as per my Safety Engineering experience) and why someone, somewhere, didn't call "Time-out, Folks! We seem to be having a lot of near-misses here! Time to revisit the Safety Case!" - if there was ever one in the first place....... Interestingly, I've already mentioned the Airport Management team in this context - but how come the airlines, where some of their pilots are calling DCA, what was it, "the most dangerous airport in the USA" (it's somewhere back in this Thread!), didn't call a halt? They also have a responsibility to conduct safe operations. OK, they have less exposure to the rate of TCAS warnings at DCA but someone, somewhere would review all TCAS incidents involving their aircraft, where it was and, importantly, why it occurred........

I hope that, once complete, the detail of their findings are written up and presented formally to the Aviation Community. The ultimate irony is that your fellow legal-beagles will be doing work which should have been done by Flight Safety people in the first place ! The only difference is why they are doing it! As someone who has had a formal background in Flight Safety, that is really quite embarrassing!

To close - I was involved in one "incident" (actually, it was a complete "non-incident" as you will see!) when crossing the overhead of Luton at 3000ft S - N one day. A jet on the runway went tech so the next aircraft on approach, after some discussion between ATC, the stranded aircraft on the r/w and the aircraft on approach, had only one option - to go around as the runway was blocked ...... certainly for a while. Standard missed approach for LTN is (simplified) "climb to 3000ft" - exactly where I was. But The reason I'd been given that crossing clearance was the ATCO had clearly pre-planned for the eventuality of me being overhead at 3000ft and a possible go-around to 3000ft. His instruction was quite straight forward, immediate and totally relaxed. "Airline XYZ, go around - stop climb at 2000ft - traffic crossing in my overhead at 3000ft.". Even so, I did pay very close personal attention to the go-around a/c, checking it actually leveled off at 2000ft ...... to see that it all went according to the "Plan"! Oh, in case you wondered, the big difference between my LTN and LCY crossings was that I couldn't get high enough at LCY for ATC to safely slot just this sort of go-around in underneath me! At LCY, the London TMA limited me to 2500 ft max (well, 2400ft with 100ft to allow for height-keeping errors on my part!).

But at LTN, I did have a great view of a 737 climbing towards me, leveling off and then passing safely below! If only the outcome on that fateful night at DCA had been the same for 5342 and PAT25.........

The discretion involved in the defense against availability of tort claims would not focus on acts or omissions of the Army crew. It would focus on the discretion which went into decisions about construction of the airspace, rules for its usage, and how these changed over time, and this defense could be developed on behalf of both the FAA and Army. Presumably the Army, not just FAA, had significant involvement in airspace management decisions, such as where the helicopter routes were drawn. And how the helicopter aviators are trained certainly involves discretionary judgments.

Where I continue to view the legal playing field differently is that essentially all the elements of the authorities responsible for construction and management of the airspace in question set it up so this accident could occur even if - in this case - the Army pilots followed every rule and procedure they had been trained to follow. To make the point with some absurdity, the way the Army crew was negligent was in refusing to fly the helicopter routes around DCA absent significant modifications in procedures and rules. What other meaning can reasonable minds give to the by-now cliche: it was an accident waiting to happen? Within the airspace as constructed and operated by both the Army and FAA (and any other users who, at an agency and/or interagency level, participated in management of DCA airspace), the helicopter crew could be said to have acted non-negligently - it was the airspace management system which was negligently designed and operated. As another poster noted, there was normalization of complacency.

As I've noted above, I've got no claim for expertise about the DCA airspace (or any airspace) but that does not stop me from asserting that it is hard to understand why you do not see deep liability exposure for FAA in this matter (prior to successful invocation of the discretionary function exception, of course).

I had to delve into Feres in some depth for my student law review article many years ago .... though that's not the only reason I hadn't noted its relevance and applicability. In any event, I recall it being pretty largely without exceptions.... probably you're correct about that aspect.

The trial lawyers I have met would not easily give up on devising a way to get this case in front of a jury and litigating all issues, including punitive damages. Perhaps a claim against the manufacturer and designer of the NVGs? . . . but then we'll see more posts about legal matters, especially the "government contractor defense" and the Boyle decision by the Supreme Court in 1988 (with some oversimplification, if the defense contractor follows reasonably precise specifications for the design of the military equipemt, it is protected against tort claims by, in effect, an extension of the government's immunity).

Conceding liability but without allowance for punitive damages or their equivalent will be tough sledding. Fatalities in this country in airline accidents had, thankfully, become rare. This lends brutal poignancy to descriptions of the lives and imminent futures of passengers on the CRJ. And despite the lingering in American law of the Feres Doctrine, of the Army crew too. Perhaps some fund would be established by the sages and scholars of the United States Congress and an eminence grise (such as the inimitable Mr. K. Feinberg) would hear claims and assign value.

Thanks for assuring that disscussion of (or at least posts about) legal issues on the thread do include proper legal terms and principles. Reasonable care, in particular.

And further as you say, it is possible that a particular crew operating under particular assigned roles and responsibilities, and given knowledge and familiarity with the way DCA ATCOs handle helicopter flights in and near approach corridors - knowledge and familiarity accumulated over time at the levels of both the individual Army aviators and their unit(s) - did in fact exercise care that was reasonable under all those circumstances. I think the second sentence of your post effectively says the same thing.

I cannot adjust my view of this accident to account for a bias against blaming aviators - it's not that I'm unwilling to make such an adjustment where assignment of responsibility is clear and well-established, but as merely an interested outside observer of the aviation sector (whether writ large or down to specific cases in court, or any other rack & stack of it) I have to acknowledge this bias. (The Pakistan 8303 accident, for example, was a situation in which responsibility was clear and well-established, if I followed the accident thread including report correctly). But self-adjustment of bias is unlikely.

So, what was reasonable care in this specific set of physical and procedureal conditions in the relevant moments prior to the midair collision? It might be a logical and factual conclusion to draw that, given (what I think can fairly be called) "normalization of complacency", do the acts and omissions of the crew really amount to negligence? As other posts here have indicated, I'm doubtful of drawing that conclusion. But given the highly aberrational nature of the occurence, what is there to which to assign responsibility, then? Well, the set-up of the airspace and how it was controlled - again, not by the individual ATCOs, rather by the system.

And it is the looming presence of that "system" which gives me pause about whether the invocation of the discretionary function exception would in effect bar the courthouse door.

A friend who sometimes reads threads here asked me recently whether I have any involvement in representing any clients or potential clients with regard to this accident. I definitely do not (just in case anyone reading wonders "what's in it for . . ." WR 6-3).

I'm applying SLF/attorney license here (hey, there's poetic license, so why not?) of repeating - with some editing - a post I placed on the R&N thread about testing at DCA.

1) Regarding ADSB-Out being turned off, what is the reason there was such emphasis placed on this at the recent Congressional hearing (and just scoring media points per usual in Committee hearings doesn't qualify as a "reason" in this context). Is the reason that there are objections to running the kinds of tests in question (per the R&N thread) in or near DCA airspace? Is it valid to say there is no connection to the chain of causes-and-effects which led to the midair collision on Janaury 29 (but if there is, what is that connection, specifically)? Is the reason some connection with the occurence of TA's and RA's on TCAS as documented by NTSB? (although other posts on the R&N thread indicate that ADSB-out isn't connected to TCAS advisories . . . that is, if I understood those other posts). Or something else? I'm dismissing the mere fact that FR24 doesn't provide information to enthusiasts as the reason for such emphasis in the hearing.

2) If the Army operates certain "missions" with ADSB-Out turned off, and it conducts these operations based on national security concerns, my initial thought about this practice is, . . . . . . . hey, isn't there a discretionary function involved in deciding what avionics (or electronics system if this isn't within the technical definition and scope of "avionics") to operate based on national security concerns? So the Senator declaring that there is "no justification" seems to deliberately overlook the existence in the Federal Tort Claims Act of the exception. (I realize there has not been, to my knowledge at least, any lawsuits filed yet. But they're certainly going to happen.)

Of course, this all said, the indictment of the structure and operation of the portion of the NAS in which DCA is situated might (as suggested previosly) itself be adjudged inconsistent and non-compliant with basic standards of aviation safety. The only not-crazy-sounding justification for that state of affairs would seem to be "but we have to move traffic in volume." As a legal wrangle over whether that obvious judgment of a "policy" nature is or is not a proper basis for keeping federal immunity in place in a particular matter . . . I am quite skeptical such a legal wrangle would ever make it as far as an actual courtroom proceeding. But will Congress not try to manuever itself into the issue for all the usual reasons - some people want actually to address the problem constructively, some just want to please their donors, and some just follow the crowd, or so it always appears.

3) Something about discovery in civil litigation was underscored by the exchange in the video clip: there's an Army memo, dated Aug. 9, 2024 as referenced by Sen. Cruz, about operating in the NAS with ADSB-Out turned off. And the Army so far declines to turn it over to the Committee. (Applying the rough equivalent of a pre-snap read by a QB, the manner in which the Army witness replied to Sen. Cruz's questions gave the impression that the Army and DoD will strongly resist the memo in question becoming public.)

[Okay, I'll refrain from speculating how much fun it would be to decide which officer or officers would be presented as the Person(s) Most Knowledgeable about the matters discussed in this memo (on the Army side, receiving the Rule 30(b)(6) deposition notice), or similarly, how much fun would be had by counsel describing the "subject matter(s)" which must be specifically iterated in a Rule 30(b)(6) deposition notice (on the plaintiffs' side).]

4. I'm very determinedly hoping this won't be read or even misinterpreted as an offensive point. In the YT video produced by "Mover" in which he interviewed a former Army helicopter aviator (post 1228), it was possible to draw the impression that Army helicopter pilots operating in the airspace in which DCA is situated have a certain attitude toward FAA ATC. That is, the Army operates - one could get the impression - in its own "airspace system" and deals with FAA ATC only as much and only as quickly as necessary. Listening to the pertient Jan. 29 ATC R/T, and knowing the visual difficulties presented by the basic facts of nighttime in that specific area of the DCA airspace, plus NVGs, an observer could get the impression that the Army aviator handling the R/T was doing so in a perfunctory manner on Jan. 29.

To explain further, upthread (in post 1261) in the context of a Mover/Gonky YT video (post 1228) someone much more knowledgeable than myself observed that the way in which the Army pilot interviewed in the video described communications with FAA ATCOs in DCA airspace was as if Army chopper pilots view FAA ATCOs somewhat as a nuisance. Far be it from me to fault any pilot over any practice or custom in anything, including comms with ATCOs. But faulting any pilot is not the point. The point is that in that YT video, as related that other poster, --
"it was suggested that it\x92s perfectly OK to second guess what ATC might have said to you, reply to that, and then if no correction is forthcoming you can comply with your guess. As others have pointed out implicitly, that works if there\x92s only one error involved, but here there were three: an untrue statement, leading to a wrongly issued clearance, and a missing read back."

It is known that ADSB-Out is not active on the Army and other certain missions in the relevant airspace. Is there also a pattern or practice of operating with a mindset that FAA ATC is a necessary nuisance, to be indulged but not focused upon as closely as other airspace users? If any reader asserts this question accuses the Army pilots or any one of them in the helicopter on January 29 of negligence - that would be incorrect. The way in which the airspace had been designed, managed and operated handed those pilots a pre-determined normalization of complacency - so it appears, does it not?. They operated their flight within the system they had been given, which does not constitute negligence. The designers, managers, and operators of that system . . . well, it will be for the courts to sort out whether the exception to the removal of federal immunity to tort claims applies to those systemic level actions, or not. If it were not for the existence of the discretionary function exception, I personally believe the race to the courthouse would already have been a feeding frenzy worthy of the most biting negative stereotypes about lawyers.

Speaking of immunities, wasn't it generally believed that the airspace within the NAS, and especially airspace in which major airports in the United States are situated, was immune to midair collisions, in general and not only collisions sudden, without actionable warning, and with at most two or three seconds' knowledge of impending death and disaster? Mere SLF/attorney as I am, I had believed that. It follows, but only under that mindset, that what occurred was obviously negligence, and even gross negligence. The point is, expect the lawsuits to be, in a word, consistent with the ugliness one feels seeing the wreckage pulled from the Potomac, or reading about the backgrounds of 67 people. Or both.

I really value your contributions, as you bring an analytical and legalistic mind to bear, and help others understand some of the issues. However... from my (simplistic) viewpoint, the helo pilot explicitly requested visual separation. That's explicitly requesting the right? responsibilty? to keep themselves separated from other traffic. This they failed to do. Surely that is negligence.

There were other holes in the cheese, so the pilot was working in a compromised environment.

I'm just an SLF, so no domain expertise at all.

I feel like this ADS-B discussion at political level is just a diversion , either they have been badly briefed by their staff , or they have and are deliberately chosen to raise this in public to shift the blame game somewhere else.
Because , even if the helo had ADSB out and the CRJ an "in " receiver and a CDTI display , what would have happened then ? . The crew would have spotted the Helo, maybe asked ATC what was that , and the reply of the controller would have been something like : " it is a military helicopter on route 4 , has you in sight , passing behind ." and then would you , flying the CRJ , take evasive action or go around after hearing that ? No .
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The primary cause of this collision is airspace design and normalization of deviance over the years. I hope the judges will see that when the trial comes. We should leave the military crew and their grieving families out of this.

I tend to agree with ATC Watchers take on this.
Some people are making out that if the Helicopter had ADSB-out switched on/ activated, then this would never have happened.
Someone correct me if I am wrong but if the Blackhawk has ADSB-out switched on then nothing changes for the CRJ on that night. The TCAS behaves the same, there is no display of the Blackhawk on the CRJ\x92s Nav display\x85..nothing changes. The CRJ crew are still conducting an approach that requires a lot of fast mental processing close to the ground, at night onto a short runway while ensuring checklists/configuration etc is correct. ie they have a high workload. During this high workload phase, \x91the system\x92 has seen fit to allow a single Human ( the helicopter Captain) to be responsible for the separation of the two aircraft visually, at night, in a busy environment while conducting a check, on NVG\x92s.
Is it likey that a single Human, with the sole responsibility, will make a mistake? It\x92s not just likely, it\x92s inevitable, regardless of how sharp and well trained they are, if you run the program long enough their vision, or their SA will fail them and we get what we got here.
The system should never have devolved to the point where one person accepted the responsibility for visual sep 6nm away, at night, in a busy traffic environment while dealing with their own high workload.
The Blackhawk crew had a high workload, the CRJ crew had a high workload, the ATC had a high workload, there was no fat left in the system. Humans make mistakes and any good system will be tolerant of those mistakes.
The system was not tolerant of a mistake, ergo, the system is at fault.

ATC Watcher:
"The primary cause of this collision is airspace design and normalization of deviance over the years. I hope the judges will see that when the trial comes. We should leave the military crew and their grieving families out of this."

Which takes the pertinent legal case right back to the question whether the federal government will be protected by sovereign immunity. Sitting in, say, a conference room discussing in the abstract "airspace design" I don't think a single competent aviation attorney would not reply that design of airspace is a discretionary function (so sovereign immunity applies), and perhaps is a classic illustration of such discretion exercised functionally. Normalization of deviance is likely a closer question on the premise that it occurred through numerous small (or perceived as small at the time) changes and revisions of procedures and airspace design. But operation of the airspace when viewed in such a macro frame of reference looks pretty discretionary as a function, too.

But abstractions lost their meaning as 67 entirely blameless people lost their lives in this catastrophe. I'm not in this matter - not representing or advising anyone - but my mind can't get off outlining the attack on the discretionary function exception (to avoid doubt, I'm saying the exception needs to be argued against and shown not to apply on these facts). It is with hindsight, true, but the situation which existed in the airspace in question on the night of Wednesday 29 January broke, stomped upon, and otherwise disregarded so many basic rules of the aviation safety mindset that ....
like they say, you can take the lawyer out of litigating, but you can't take litigating out of the lawyer.

Here's a new thought. In lawsuits (another poster helpfully noted upthread) under the Federal Tort Claims Act - the statute which takes sovereign immunity away but subject to exceptions - claims for punitive damages are not allowed.

Think about that for half a minute. Just on the facts, forget the legal technicality under the FTCA, would this not FREAKING be a case warranting punitive damages against the federal government for setting the stage of this accident and then putting the players in motion? So, you're an attorney, part of the team representing any one of the families of victims of this CATASTROPHE in the middle of the air ... or some or even all, of the victims' families. What do you do?

I will be neither surprised nor shocked if the lawsuits also name American Airlines, which has no protection obviously under the FTCA. It didn't do anything wrong..... but naming the airline as a defendant gets their insurers involved, and then establishment of a fund and a process to compensate the representatives of the victims can be brought forward and conducted. Skip the courthouse except to get things started, but this matter needs a creative approach. Oh, did I mention, part of the approval for such a fund and compensation process would have to be pretty sweeping reform of how FAA does business and what business it does, and the reform plan had better be down to chapter and verse?
WR 6-3

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.

That is ultimately the call of the crew. ATC only gives the option, it's the PICs responsibility to assess whether it is feasible and safe. I don't personally know any ATCo who would be comfortable offering that in this particular scenario, but that's coming from the European perspective where we have nothing even close to the proximity of military/civilian mixed traffic. I only did a little approach familiarization and no tower work, but just talking to colleagues who did, I don't think I'd be comfortable to offer visual separation in that environment. But then again threat normalization is a pretty effective thing.

Just went ,very selectively of course, through the thousand of pages of to the dockets and they give a clearer picture , to me at least . of the huge normalization of deviance that took place from both the DCA control staff and the RAT pilots.. I went mainly thought the interviews and the TCAS dockets.
What I learned:
Interestingly the Local controller involved was also a CPL pilot
Pressure to use 33 for landing during high departure rates was there to avoid the queue blocking the taxi ways for arriving aircraft : ( my comment : when you get to that situation traffic should be reduced by departure slots , that what we do in Europe with the Network manager CTOTs..)
No reaction to Conflict alert because visual acquisition was prioritized , i.e if you saw the helicopter passing behind you disregarded the CA. and this was almost always the case so CA with helicopters became disregarded
Advanced training was poor or non existent ( e.g Threat/Error management training).
On the PAT pilots interviews the most flagrant normalization of deviance is requesting visual separation with an aircraft you do not see ( yet) I realize that was declared by pilots other that the one operating that flight , but gives a good indication of the local " best practices " in that area.
Finally on the TCAS issue, one of the screenshots shows other traffic, and we can see that there were 2 TAs one in front -2 and one behind +6 , that could ( emphasis on could) have been one of the reason the CRJ crew missed the urgency of the -2 , but also probably were more focusing on the PAPI so both looking outside instead of at the display .

And to reply to a question earlier by DIBO on the discussion about ADS-B out not avail on the RAT, and its relevance for TCAS, well it would have influenced the degree of accuracy of the Tau calculation ( with Alt returns every 25 ft instead of 100 feet) and could ( again emphasis on could) have changed the alert logic/timing of the TA. Non installation of ADS-B and flying 70 ft too high are probably one of the points the lawyers are going to get into to prove negligence from the military to get more money for their clients , possibly shadowing the real causes. ; which for me are still the design of the procedure and routes, and the failure of the Regulator to act on the alerts. . Love to hear Willow-Run 6-3 comment on this .
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