Posts about: "Probable Cause" [Posts: 16 Page: 1 of 1]ΒΆ

West Coast
January 30, 2025, 20:08:00 GMT
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Post: 11817608
Originally Posted by PerPurumTonantes
Yes ATC could have done better, and heli pilots could have done better. But they were in high pressure time critical nighttime environment with seconds to make decisions.
The people who design the charts and procedures have days and weeks to think things through, in a nice safe office, on the ground, going 0kts with good lighting.
Unless I'm missing something, it would seem that route 4 design is the main culprit here .
There\x92s a reason an in-depth investigation will be conducted by folks whose job is to get to the probable cause.

Subjects ATC  Probable Cause  Route 4

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sudden twang
January 31, 2025, 10:53:00 GMT
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Post: 11818101
Quote from an NTSB report

\x94 The NTSB determines that the probable cause of the accident was the failure of the flight crew to comply with the provisions of a maintain visual separation clearance including the requirement to inform the controller when they no longer had the other aircraft in sight.
Contributing to the accident were the air traffic control procedures in effect which authorized the controllers to use visual separation procedures to separate two aircraft on potentially conflicting tracks when the capability was available to provide either lateral or vertical radar separation to either aircraft. \x93

That was of course PSA 182 I\x92m not entirely sure that after a lengthy investigation the report won\x92t say something similar.

Subjects ATC  NTSB  Probable Cause  Radar  Separation (ALL)  Visual Separation

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ATC Watcher
February 17, 2025, 21:32:00 GMT
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Post: 11830196
@ Fullwings : No rotary pilot I know would knowingly pass that close under/behind a jet transport as the wake could literally be the end of you at 200’AGL.
Absolutely . Lack of Wake turbulence separation is something that immediately came to my mind when discovering the procedure . That should have been another red flag in the Safety assessment , but I assume initially the H routes were designed with RWY 1 OPS in mind and 33 only for departures. Combining 33 Arrivals with route 4 is the initial issue .
@ Lascaille : ​​​​​​​ I very strongly doubt that the US govt would do a 'technically we're immune so tough luck' here. The optics would be dire.
Indeed , and there is a precedent : the 1986 Cerritos collision : the NTSB found no responsibility to ATC as the pilot of the PA28 that hit the DC9 had entered Los Angeles Terminal Control Area airspace without the required clearance. However a judge found the FAA partly responsible to make sure the families of the pax , mostly Mexicans , would be compensated , as the responsible private pilot's wealth would not have been able to cover those.
Here if you want to learn or just refresh your memory ; https://www.latimes.com/archives/la-...%20government.

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

​​​​​​​The NTSB determined "that the probable cause of the accident was the limitations of the air traffic control system to provide collision protection, through both air traffic control procedures and automated redundancy."In addition to the inadvertent and unauthorized entry of the PA-28 into the LA Terminal Control Area, another factor at play was the limitations of the "see and avoid" concept to ensure traffic separation.
Yes history often repeats itself . just like the PATCO history...






Subjects ATC  DCA  FAA  NTSB  Probable Cause  Route 4  See and Avoid  Separation (ALL)

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WillowRun 6-3
January 26, 2026, 20:56:00 GMT
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Post: 12027659
NTSB meeting January 27 - probable cause determination

According to reporting published today by The Air Current - one of its periodic articles reporting on air safety which are not paywalled - the NTSB will meet on January 27. The meeting will include revealing and voting on the probable cause determination produced by its investigation into the DCA midair collision 29 January 2025.

The reporting indicates that the Board's final report is expected within two weeks.

Various safety recommendations also are anticipated to be on the agenda for the NTSB's January 27 meeting.

Of particular interest, among many other factors involved in this horrifically senseless accident (my characterization, not found in TAC reporting as such), is whether the NTSB's meeting which will mark the end of its official investigatory process will touch upon the controversial section of the NDAA, Section 373 (subject of previous posts at the time of passage, upthread).

Subjects DCA  Final Report  NDAA  NTSB  Probable Cause  Safety Recommendations  Section 373 of the FY26 NDAA

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DaveReidUK
January 27, 2026, 21:12:00 GMT
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Post: 12028223
Originally Posted by WillowRun 6-3
A bit off-topic, but nothing I heard today makes it any less interesting to contemplate the question: in the continuing lawsuit, who speaks for the Bluestreak 5342 pilots? They're blamed by the plaintiffs for what they did and what they didn't do, but they are every bit as much victims of this systemic breakdown as the passengers and flight attendants. I would also ask, who speaks for the Army aviators? who also are victims of the systemic breakdown. It all makes me kind of wish Chair Homendy was in the legal profession, tbh.
That's about to be partly answered, with the caveat that it's never in the NTSB's remit to assign blame to individuals. Currently at around #20 of 71 Findings, which will presumably be followed by the Probable Cause statements.

There will follow a raft of Safety Recommendations (I haven't been keeping count of how many have been referred to), though it's not clear whether they will be explicitly listed during the hearing.

Subjects Findings  NTSB Chair Jennifer Homendy  Probable Cause  Safety Recommendations

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DaveReidUK
January 27, 2026, 22:35:00 GMT
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Post: 12028253
Originally Posted by Undertow
The FAA ignored them
Strictly speaking, the FAA as regulator doesn't "ignore" NTSB Safety Recommendations.

It responds to them, with either acceptance or rejection, and in the latter case provides its reasons for doing so. It may also suggest alternative means of compliance with the Board's wishes, and in some cases this leads to quite a bit of to-and-froing between the two organisations until a final position is reached.

The hearing is about to start on the Probable Cause statements, having had a prolonged debate on proposed amendments to several of the Findings (which are now all agreed).

Subjects FAA  Findings  NTSB  Probable Cause  Safety Recommendations

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DaveReidUK
January 27, 2026, 23:09:00 GMT
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Post: 12028272
Probable Cause Statement:

The NTSB determines that the probable cause of this accident was the FAA's placement of a helicopter route in close proximity to a runway approach path.

Their failure to regularly review and evaluate helicopter routes and available data, and their failure to act on recommendations to mitigate the risk of a mid-air collision near Ronald Reagan Washington National Airport, as well as the air traffic system's overreliance on visual separation.

In order to promote efficient traffic flow without consideration for the limitations of the see and avoid concept.

Also causal was the lack of effective pilot applied visual separation by the helicopter crew, which resulted in a mid-air collision.

Additional causal factors were were the tower team's loss of situational awareness and degraded performance due to a high workload of the combined helicopter and local control positions, and the absence of a risk assessment process to identify and mitigate real time operational risk factors, which resulted in miss prioritization of duties, inadequate traffic advisory advisories, and the lack of safety alerts to both flight crews.

Also causal was the Army's failure to ensure pilots were aware of the effects of air tolerances on barometric altimeter in their helicopters, which resulted in the crew flying above the maximum published helicopter route altitude.

Contributing factors include the limitations of the traffic awareness and collision alerting systems on both aircraft, which precluded effective alerting of the impending collision to the flight crew's.

An unsustainable airport arrival rate, increasing traffic volume with a changing fleet mix and airline scheduling practices at DCA, which regularly strain the DCA Atct workforce and degraded safety over time.

The Army's lack of a fully implemented safety management system, which should have identified and addressed hazards associated with altitude exceedances on the Washington, D.C. Helicopter routes.

The FAA's failure across multiple organizations to implement previous NTSB recommendations, including Ads-b in and to follow and fully integrate its established safety management system, which should have led to several organizational and operational changes based on previously identified risk that were known to management and the absence of effective data sharing and analysis among the FAA aircraft operators and other relevant organizations.

Subjects Altimeter (All)  Barometric Altimeter  DCA  FAA  NTSB  Probable Cause  Route Altitude  See and Avoid  Separation (ALL)  Situational Awareness  Visual Separation

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Ver5pen
January 27, 2026, 23:15:00 GMT
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Post: 12028277
Originally Posted by DaveReidUK
Probable Cause Statement:
weird that they don\x92t even mention the Blackhawk PF\x92s straying from altitude constraints, the IP repeatedly tells her about her deviations multiple times as per the transcript, baro altitude limitations or not they were both aware she wasn\x92t meeting the limits of the corridor (that the margins are so fine in that airspace is absurd of course)

Additionally this would\x92ve been sapping the IP/PM\x92s capacity to an extent no doubt as he had to monitor her deviations

wasn\x92t this a currency flight for her and she\x92s already blown a segment of it? Clearly her recency/skill level is at least a factor?

ditto they don\x92t mention the limitations of VFR separation under night vision

Subjects Blackhawk (H-60)  Probable Cause  Separation (ALL)  VFR

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DaveReidUK
January 27, 2026, 23:38:00 GMT
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Post: 12028289
Originally Posted by Ver5pen
weird that they don\x92t even mention the Blackhawk PF\x92s straying from altitude constraints, the IP repeatedly tells her about her deviations multiple times as per the transcript, baro altitude limitations or not they were both aware she wasn\x92t meeting the limits of the corridor (that the margins are so fine in that airspace is absurd of course)

Additionally this would\x92ve been sapping the IP/PM\x92s capacity to an extent no doubt as he had to monitor her deviations

wasn\x92t this a currency flight for her and she\x92s already blown a segment of it? Clearly her recency/skill level is at least a factor?

ditto they don\x92t mention the limitations of VFR separation under night vision





Those are addressed in some of the 75-odd Findings statements.

But all of those deficiencies arguably added up to the stated Probable Cause: "the lack of effective pilot applied visual separation by the helicopter crew, which resulted in a mid-air collision"


Subjects Blackhawk (H-60)  Findings  Probable Cause  Separation (ALL)  VFR  Visual Separation

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Equivocal
January 27, 2026, 23:50:00 GMT
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Post: 12028296
Originally Posted by NTSB
The NTSB determines that the probable cause of this accident was the FAA's placement of a helicopter route in close proximity to a runway approach path.
I haven't read the report yet but if this is what it concludes, it looks like it's going to be a disappointing read. Aircraft move around and it's not possible to design routes that never intersect....in an environment such as the one in question, ATC should be authorising the aircraft to follow specific routes only when the requisite separation will exist. As I mentioned much earlier in the thread, t he procedures that were applied by ATC immediately before the accident are ‘standard’ and used the world over. None are intrinsically unsafe but their application (as with all the other rules that need to be followed) needs to be appropriate. Visual separation at night is likely to be fine on a clear night with just two or three aircraft in the sky but it’s unlikely to be in any way appropriate in high traffic density environments. Just because there’s a rule that says you can do something doesn’t mean it’s necessarily a good idea. You can have a helicopter route as close to an approach path (or any other route) just as long as you don't allow a helicopter and another aircraft to be in the same place at the same time. Whilst the other mentioned causal and contributory factors are all going to be valid up to a point, fundamentally, the FAA permitted inappropriate application of completely suitable procedures. How and why this situation was allowed to prevail is, I hope, discussed in detail in the report even if it didn't make it into the Probable Cause statement.

Subjects ATC  FAA  NTSB  Probable Cause  Separation (ALL)  Visual Separation

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WillowRun 6-3
January 28, 2026, 03:09:00 GMT
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Post: 12028338
"The NTSB determines that the probable cause of this accident was the FAA's placement of a helicopter route in close proximity to a runway approach path."

The PC statement should be read in its entirety, and at the conscious risk of ripe cliche, context matters. The Board did not assign the probable cause to the intersecting flight routes as such. For one thing, Chair Homendy repeatedly since the early days of the Board investigation has hammered upon the fact that the vertical separation was as little as 75 feet without any procedural separation (such as the helos holding at Haines Point). And also since the start of the investigation, time and again the complexity of the DCA airspace, and the (in my strident opinion) very messed up operation of DCA with regard to - as ATC staff testified - just "making it work", have been emphasized. Plus the refusal of FAA ATO to act upon the input from the helicopter working group several years ago, plus FAA's declining to note "hot spots" on charts. And the staffing issues, and lack of fidelity to SMS on the part of FAA and to some extent the Army as well. And there were, quite obviously, many findings of fact which are necessarily part of the context for reading . . . and understanding, the PC determination.

A person need not be an aeronautical engineer, airspace architect, or civilian or military aviator to understand from the get-go that intersecting flight paths might be found across the NAS. I'll stand to be corrected but I do not think - having watched the entirety of the hearing today - that the criticism of the Probable Cause finding is a valid, fair or accurate assessment of the Board's work in this investigation.
WillowRun 6-3

Subjects ATC  DCA  FAA  Findings  Helicopter Working Group  Hot Spots  NTSB  NTSB Chair Jennifer Homendy  Probable Cause  Separation (ALL)  Vertical Separation

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artee
January 28, 2026, 03:16:00 GMT
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Post: 12028339
Originally Posted by WillowRun 6-3
"The NTSB determines that the probable cause of this accident was the FAA's placement of a helicopter route in close proximity to a runway approach path."

The PC statement should be read in its entirety, and at the conscious risk of ripe cliche, context matters. The Board did not assign the probable cause to the intersecting flight routes as such. For one thing, Chair Homendy repeatedly since the early days of the Board investigation has hammered upon the fact that the vertical separation was as little as 75 feet without any procedural separation (such as the helos holding at Haines Point). And also since the start of the investigation, time and again the complexity of the DCA airspace, and the (in my strident opinion) very messed up operation of DCA with regard to - as ATC staff testified - just "making it work", have been emphasized. Plus the refusal of FAA ATO to act upon the input from the helicopter working group several years ago, plus FAA's declining to note "hot spots" on charts. And the staffing issues, and lack of fidelity to SMS on the part of FAA and to some extent the Army as well. And there were, quite obviously, many findings of fact which are necessarily part of the context for reading . . . and understanding, the PC determination.

A person need not be an aeronautical engineer, airspace architect, or civilian or military aviator to understand from the get-go that intersecting flight paths might be found across the NAS. I'll stand to be corrected but I do not think - having watched the entirety of the hearing today - that the criticism of the Probable Cause finding is a valid, fair or accurate assessment of the Board's work in this investigation.
WillowRun 6-3
I find it interesting that the actions of the crew of PSA5342 were not included as Probable Cause. How do you think this will affect the lawsuit against them?

Subjects ATC  DCA  FAA  Findings  Helicopter Working Group  Hot Spots  NTSB  NTSB Chair Jennifer Homendy  Probable Cause  Separation (ALL)  Vertical Separation

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WillowRun 6-3
January 28, 2026, 03:39:00 GMT
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Post: 12028346
Originally Posted by artee
I find it interesting that the actions of the crew of PSA5342 were not included as Probable Cause. How do you think this will affect the lawsuit against them?
Uh, yes, very conspicuous by its absence.

First, I have taken something posted on this thread some time ago as a deeply important article of faith. It was (I'm not quoting it exactly but from memory) "they owned the airspace of the last several hundred feet of the final approach to 3-3." The effort to paint them as negligent by the (estimable and highly successful) plaintiff lawyers frankly makes me want to puke. And I don't care one iota that some or several of those lawyers own their own aircraft and have pilot licenses. They didn't build hours, did they? And, .... it's one thing to try build a case against the airline company, but something else to assail the deceased pilots.

Relatedly, and second, I tend to think the NTSB sees this in somewhat the same way. But the NTSB really excoriated the FAA, and it richly deserved it too. This was - it cannot be said too often AFAI-am concerned - a systemic failure. So between being revolted by the effort to invade the ownership of those last few hundred feet of airspace or flight path of Bluestreak 5342 on final to 3-3 on the night of 29 January 2025, and gunning for bear in the form of a complacent, ridiculously evasive if not obstructionist if not dishonest FAA, the Board had zero-decimal-zero tolerance or inclination for assigning causal factors to two dead pilots on final to 3-3. And that's EVEN IF the airline company should have done more.

Third, and I don't know if it would be viable, but to the extent that the accountability for this accident lies mostly with FAA, and somewhat with the Army pilots and Army, then aren't the pilots victims too, rather than negilgent party-defendants? Shouldn't their estates have legal representation, as a party-intervenor in the case? That is what I meant earlier, who speaks for them? As we all know, the Board does not find fault. I somewhat think the lawyers seeking their contingency fee will probably, I guess, be talking about "fault." But the Army pilots are a bit different. It is distasteful and unseemly to criticize them, as they were in service, and just as much victims of the systemic failures as Bluestreak 5342's two pilots. And Uncle Sam, why, he's already admitted fault.

Fourth and last, yes, the airline company will get raked over the coals for not having outsmarted the failures of the FAA. Jackpot justice, what a way to improve the architecture and operation of the NAS. (With apologies to a very estimable and deservedly highly well-respected airline industry attorney - a real one - who at a conference in Paris oh, a couple three years or so ago, made the point that plaintiff lawyers should not be the ones setting aviation policy through liability lawsuits.)

What good is a lawyer clodding around a pilot's forum on the internet without a rant now and again, eh?

Subjects Accountability/Liability  FAA  NTSB  Probable Cause

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paulross
January 29, 2026, 12:41:00 GMT
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Post: 12029104
This Thread Re-Mixed

As new information has emerged I have just rebuilt the website that re-organises this long thread by subject.
You can find it here: https://paulross.github.io/pprune-th...DCA/index.html

All 1,829 posts are organised into 68 subjects.

Changes:
  • Added link to NTSB findings, probable cause and final recommendations.
  • Added subjects: 'Accountability/Liability', 'Findings', 'NTSB Docket', 'Barometric Altimeter', 'Route Altitude', 'Hot Spots', 'Final Report', 'Probable Cause', 'Safety Recommendations', 'Helicopter Working Group'.
Around 20% of the posts on the thread are excluded because I can't pick up a subject from that post so please contact me if you feel that you contribution has been excluded.

The project is here: https://github.com/paulross/pprune-threads .
Issues can be raised here: https://github.com/paulross/pprune-threads/issues or PM me with ideas.

Subjects Altimeter (All)  Barometric Altimeter  Final Report  Findings  Helicopter Working Group  Hot Spots  NTSB  NTSB Docket  Probable Cause  Route Altitude  Safety Recommendations

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WillowRun 6-3
February 06, 2026, 17:52:00 GMT
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Post: 12033392
Legislation in U.S. House of Reps. pending .....

Waiting to see what becomes of the controversial Section 373 in the recent NDAA.
_________________________
Joint Statement of House Transportation and Infrastructure Committee and House Armed Services Committee Bipartisan Leaders on NTSB\x92s Recommendations to Address DCA Crash
For Immediate Release: February 06, 2026
[Committee contacts omitted]

Washington, DC \x96 The bipartisan leaders of the House Transportation and Infrastructure Committee and the House Armed Services Committee today issued a joint statement regarding the National Transportation Safety Board\x92s (NTSB) recently approved recommendations to address the January 29, 2025, midair collision at Ronald Reagan Washington National Airport (DCA).
Joint statement from House Transportation and Infrastructure Committee Chairman Sam Graves (R-MO), House Transportation and Infrastructure Committee Ranking Member Rick Larsen (D-WA), House Armed Services Committee Chairman Mike Rogers (R-AL), and House Armed Services Committee Ranking Member Adam Smith (D-WA):

\x93Now that we have received the approved recommendations and probable cause from the NTSB on the tragic DCA midair collision that claimed 67 lives, and with the NTSB\x92s final report expected in a matter of days, we are working on a comprehensive legislative solution to address what we\x92ve learned. It is our firm belief that meaningful improvements to the safety of our airspace require the full and fair consideration of all of the NTSB\x92s recommendations. We are continuing to evaluate the information and analysis gathered and put forward by the NTSB, and we will work together expeditiously on legislation to ensure a crash like this can never happen again.\x94

Subjects DCA  Final Report  NDAA  NTSB  Probable Cause  Section 373 of the FY26 NDAA

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WillowRun 6-3
February 19, 2026, 23:09:00 GMT
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Post: 12039941
Legislation

From House Transportation and Infrastructure Committee website 19 February 2026

Washington, DC \x96 The comprehensive legislative response to the various aviation safety issues raised by the tragic 2025 midair collision between American Airlines Flight 5342 and a UH-60 Army Black Hawk helicopter at Ronald Reagan Washington National Airport (DCA) was released today by the bipartisan leaders of the House Transportation and Infrastructure Committee and the House Armed Services Committee.
The Airspace Location and Enhanced Risk Transparency (ALERT) Act of 2026 addresses all 50 safety related recommendations issued by the National Transportation Safety Board (NTSB), which concluded its thorough investigation and issued its final report on February 17, 2026.

The ALERT Act considers all of the NTSB\x92s findings of probable cause that contributed to the accident and responds to each of the NTSB\x92s 50 safety recommendations to provide a thorough and holistic legislative solution to improve U.S. aviation safety. Critical safety issues the bill addresses include:

Establishing requirements for equipping collision mitigation, avoidance, and alerting technologies and systems for civil fixed-wing and rotorcraft;
Improving helicopter route design, guidance, and separation;
Preventing loss of separation (near-miss) incidents;
Addressing deficiencies in the FAA\x92s safety culture;
Enhancing air traffic control training and procedures, particularly during high traffic;
Strengthening the safety of the DCA airspace \x96 one of the nation\x92s busiest and most congested airspaces;
Repealing section 373(a) of the last National Defense Authorization Act; and more.
The ALERT Act is led by Transportation and Infrastructure Committee Chairman Sam Graves (R-MO), Transportation and Infrastructure Committee Ranking Member Rick Larsen (D-WA), Armed Services Committee Chairman Mike Rogers (R-AL), and Armed Services Committee Ranking Member Adam Smith (D-WA).

[Quotes from Congressmen omitted]

Link to the text of the ALERT Act: https://transportation.house.gov/components/redirect/r.aspx?ID=486957-71714618

Link to a section by section summary of the ALERT Act:
https://transportation.house.gov/news/email/show.aspx?ID=RFS3V7AWS4PPNV2MA2XZXHULM4


Subjects ALERT Act of 2026  Blackhawk (H-60)  DCA  Final Report  Findings  NTSB  Probable Cause  Safety Recommendations  Separation (ALL)

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