Posts about: "Probable Cause" [Posts: 13 Page: 1 of 1]¶

There\x92s a reason an in-depth investigation will be conducted by folks whose job is to get to the probable cause.

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.

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 .
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 !)

Yes history often repeats itself . just like the PATCO history...

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).

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.

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).

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

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"

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.

"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?

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?