Posts about: "Route 4" [Posts: 113 Page: 5 of 6]¶

Hi layman54 , I think it's much more subtle than that. As you say, other bits of the system may put the pilots into danger but you then need to fully understand why the Pilot(s) didn't save the day. You sort of start off with the premise that the crew of PAT25 took off that evening and certainly didn't want to fly into the CRJ - so, why did they?

To say so-and-so got it wrong is often obvious ........ but why did they get it wrong? That's often very complex and can involve a lot more people and a raft of other factors and that's where the really valuable lessons are to be found. That's the real reason behind any "bias" - it's so we don't simply stop at that first person (or persons) who got something wrong, but look at what led to them doing what they did and what other factors contributed to the end result . That is the real way Safety is improved. You can then look at appropriate mitigation to try and prevent that same scenario from setting up another crew to fail in the same way at a later date.

As others have said, height and track is a red herring TBH as the deal with ATC was for PAT25 to "see and avoid" so they could have quite safely passed behind the CRJ at the same altitude or even above it - but not too close due to things like wake effects. If you can't manage "see and avoid" safely, you need to build in much, much bigger safety margins - such as holding PAT until the CRJ had landed. Many, including me, have asked how on earth the PAT25 crew (or, indeed, anyone) could reliably be expected to pick out the CRJ in that scenario especially at that range. For vertical/horizontal separation, relying on a few 10's of feet up/down or left/right is simply worthless given errors with altimeters and piloting accuracy in such a high-workload situation where it's "eye's out" navigating and looking for traffic all at a couple of hundred feet above land/water which is quite unforgiving if you get too low (I know ex helo crew who are no longer here because they inadvertently hit the sea) - not to mention any issues with NVGs (no idea, never used them!). What the NTSB implied was that, by suggesting that such a set-up as Route 4 passing under the approach to 33 was intrinsically safe through vertical/lateral separation, was madness. The route was pulled almost immediately pretty much on that basis.

So, for example, based on the difficulty in picking out the correct aircraft from the inbound stream, one of the many questions I've been asking myself is "Why were the PAT25 crew so willing to say they had the CRJ in sight (twice they said that) in that environment?". Had that become "normalised" on the Sqdn, or were the risks of miss-IDing a/c not being adequately highlighted in Local Orders, particularly given the geometry of that specific set-up? There may be several reasons - that's for the NTSB to dig out. I used to do a lot of visual separation stuff Commercially and I was nervous as hell - and that was in wayyyyyyyy simpler scenarios in way better conditions usually involving just one other aircraft. ATC were the same - they were very pointed in making sure I'd really seen the a/c in question. Any doubts in my mind or the ATCs mind and it was either an orbit till traffic was well clear or, if busier, it was "Contact Approach ....... lets chat again when they hand you back to me on the ILS.". OK, the ILS bit is not applicable to PAT25 but you get my drift!

There is no one reason why this accident happened - there will be quite a list with each one contributing to the final outcome. Any one of those things, had they been different decisions by those involved on the night, or, for example, by those who designed and approved Route 4 way back when, would have saved the day. So correct not just the 1st issue you find, find out and correct ALL the issues! That's what we really need to do to stop similar things happening again, not just at DCA, but anywhere.

Anyway, hope the above helps with the context of the word "bias". It was not that long ago it was "Hang the crew! Erm, oh no! Someone else has done it now! Hang them too!" Rinse & repeat! Thankfully, we are much better at digging out all the issues these days. But we have to constantly remind ourselves to "Look for everything, not just the 1st thing you find!". Cheers, H 'n' H

Although the data in post 1346 does distinguish between day time and night time, it doesn't (nor probably can't) highlight which flights were adjusted by ATC, e.g. track this, sight that, pass behind, track direct, etc. If the use of Route 4 was simply pilots doing their own thing ie a single direction route without any ATC inputs then the tracking difference might be interesting. In this case, it could highlight an issue, perhaps not.

I've no insider knowledge but, given how the first AA accepted it and the following AA asked for it specifically, it may have been common practice within AA. Not all line pilots may fully appreciate the potential issues linked with, say, that particular sidestep.

I raised the airline responsibility bit more as "idle thoughts" to illustrate that everyone can play their part in making things safer in cases such as this - including airlines. However, it does need (a) identification of the issue, (b) then good analysis to scope it all and, finally, if there is a "real" potential issue after that analysis, (c) to work out a formal policy (here with AA and DCA) so everyone knows what's what and, importantly, appreciates any knock-on issues that such a policy may generate - such as maybe cutting down on ATC's flexibility on occasion.

So, for eg, it could have been a joint AA/DCA policy that AA would not be placed on the sidestep, or accepted on the sidestep, while something was on Route 4. Irrelevant here now as Route 4 has gone ..... but the above concept can be applied to other potential issues at other airfields.

Anyway, just some thoughts. I'll revert to lurking! Cheers, H 'n' H

It is buried in all these pages of this thread,,,but it seems that tragically so, 2-3 aircrafts before the fatal 5342, ATC requested rwy33 to another crew (same aircraft, same airline iirc) , and they declined ("Unable")

People here and DEI frothers everywhere need to be asking one question:

If this is about one pilot and one operation, and about a single error 15 seconds before a collision on Route 4, why does Route 5 remain almost completely shut down , and not by the FAA?

I have 100% visual and audible on every Route 5 movement from The Lair, even if I'm not at my desk. Seen two operations since the accident.

I suspect that the answer is this: someone reporting to DoD leadership, not Army aviation, came in, took one look at the ops and ops standards, screamed WHISKEY THE ALFA FOXTROT and observed that it was sheer blind luck the accident hadn't happened earlier, and possibly on the 15 approach with a dozen or so teenage soccer players added to the casualty list.

It would appear that while DoD reevaluates its helicopter operations inside the Beltway, it has shifted training flights to outside the Beltway. The only exception appears to be the USCG MH65s as they are based at DCA but even those are now flying more outside the Beltway.

If Route 5 is not being used (and Route 4 is shutdown), how are military helicopters accessing JPN?

Prior to the DCA accident, I don\x92t know that I\x92d ever seen a UH-60 out my way on Route 9 in nearly 3 decades. Now PAT UH-60s are almost a daily occurrence on Route 9 (saw/heard 4 yesterday). The ADW-based UH-1Ns are also flying Route 9 more frequently.

I maintain the the DC helicopter routes (including Route 4) interior to the Beltway are not inherently unsafe if used with appropriate restrictions and ATC-applied separation.

"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."

Because, due to the proximity of Route 4 to runway 1 traffic, 12th AB pilots much more frequently received traffic calls for runway 1 traffic coupled with visual separation, traffic for which there would never be a collision threat. And if there was 33 landing traffic, ATC would just issue a hold. I\x92m still reading through the interviews, but have yet to find an example of a 12th AB pilot that, while on Route 4 with visual separation for 33 landing traffic, actually had to track the aircraft and maneuver to avoid.

In this interview at pages 97 and 112 the pilot says he has operated south on Route 4, and with traffic circling to 33, both accepted \x91hold at Haines Point\x92 and also accepted \x91visual, pass behind\x92 clearances literally dozens of times. Admittedly he wasn\x92t 12th AB. (This is a PSA line check captain who was formerly military UH-1N helicopter pilot operating in the area with USAF at Andrews AFB). Very interesting interview.

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

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

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

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

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

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

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



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

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

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

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

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

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

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

For most of its flight, PAT25 was operating outside Class B but in contact with PCT. At Cabin John with PAT25 operating right at the Class B floor of 1500 ft, the DCA LC approved PAT25’s request to proceed Route 1, Route 4, to DAA. That was PAT25’s clearance into Class B.

Two interesting events noted on the recordings:

At about 20:00L, PCT calls helicopter traffic to PAT25. I count at least 12 statements between the two pilots regarding the called traffic in addition to radio transmissions to PCT regarding the traffic. Contrast this to the CRJ called traffic which generates zero discussion between the PAT25 flight crew.

At about 20:37L, there’s a traffic interaction between MUSL13 and BLJK1 (two helicopters) that generates a conflict alert. The DCA LC provides multiple traffic alerts to both aircraft, including direction, range, and altitude of the conflicting aircraft, even after visual separation is approved for BLJK1. Contrast this with the accident sequence where PAT25 is provided with a single traffic alert and the CRJ gets bupkis.

not intending to be cynical, but it makes the helos blend in nicely with the background, sort of out of the way for rwy 01/19 traffic (=95% of total)
I wonder how many pilots on rwy 01/19 really perceived this section of the routing as unsafe (when flown correctly = hugging the shoreline at max 200ft).
A nuisance, undoubtedly. And the whole helicopter traffic surrounding DCA, pretty unsafe, I can understand.
And then we have nighttime...



taking the nearby airport out of the equation, I wonder if any of the professional operators on this route 4 section, ever felt that this low-level flying was (unnecessarily) unsafe

thank you for your reply!
It looks safe if the jet crews can't see the helicopters?
Good thing they let only professional operators use heli route 4, then.

I take your point that the route was legal (if unsafe).

My impression is that the 500/1000 ft clearance rule exists so when a pilot gets disoriented, or suffers a flight control problem, they don't immediately smash into things; and that they have a chance to find a suitable place to crash land, should the need arise. The latter is obviously solved when the river is right there.

If you don't have that altitude, you're missing a slice of cheese; and of course you won't feel it missing unless you need it, which is often the case with safety.

If the heli route had been higher up, then letting helicopters fly it on visual separation while runway 33 was in use wouldn't be "normalising deviance", it'd be normalising insanity, i.e. the illusion of "safety" that the 200 ft restriction provided would have been absent. The fact that someone at the FAA thought, "it'll be ok if we force the helicopters down to an unsafe altitude routinely" speaks of eroded safety standards to me. There are some disasters (and at least one impressive Space Shuttle fireball) that resulted from eroded safety standards, where managers convinced themselves it would still be ok--until it wasn't.

It does.. About the flawed published procedures , I do not know what standard they use in the US, . Maybe someone here does, because establishing a route a 200ft inside a CTR crossing a runway approach path would not be possible in Europe, First we have SERA ( Standardized European rules of the air ) which mandates a minimum of 500ft , above highest obstacle Then the design : . If I take the Paris TMA as example where heavily helicopters routes exists between the 3 airports and the heliport , the minimum altitude on those routes is 700 ft .and none the routes conflict with any runway approach path .
Then 3rd , if you have to be designing a conflicting route system , it would be procedurally clear that the 2 could not be used simultaneously . In other word , here in DCA, when runway 33 is in use for landing . Route 4 would be closed, and vice versa, when you have an Heli on route 4 you can't use runway 33 for landing.
But it is not only DCA, I have been flying regularly VFR in Vegas a few years back , and what the tourist helicopters companies were allowed to do there was. let's say " amazing " compared to what we are allowed to do in Europe.

Only the PSA CRJ was scheduled. The PAT flight was an ad hoc VFR Class B transition.

Note that the apparently informal procedure of holding helicopters at Hains Pt or golf balls was an effective method of deconflicting Route 4 and 15/33 traffic. However it appears that the use of this \x93procedure\x94 was left to the discretion of the individual controller.

I recall this testimony (and had been avoiding trying to find it in the videotaped record).

If I understand the way the q&a progressed, and especially the definition provided by the examiner during the q&a of the Army pilot, "procedurally separate" means the airspace design is such that if both aircraft adhere to their assigned routes, the Route 4 helicopter operation can safely cross the approach path to 3-3 (and, though it should be obvious, please correct this if I've said it incorrectly or without enough precision). But as the Army pilot as well as the med evacuation group chief testified, they took steps to avoid operating across the approach path if there was DCA traffic - which the examiner referred to as "mitigations".

(The wash machine of my mind is cycling through some further thoughts on how the facts emerging from the hearings and certain items in the (voluminous) docket are likely to interact with the relevant legal issues and, in turn, how that appears likely to impact the looming NAS, FAA, and "new ATC system" reforms.)

It's not the controller's discretion, it's the pilot's discretion. If the pilot calls "traffic in sight" then the pilot is taking on the responsibility of ensuring separation. If the pilot hadn't done that in this case, then I'm sure the controller would've directed them to hold.

One of the Army pilots at the NTSB hearing said he'd always been instructed to hold when there was traffic on approach to 33. I'd be willing to bet that he never called "traffic in sight" in those instances. That's the crucial difference.

Ward Carroll posted some thoughts about the crash following the evidence a couple of weeks ago. He gives a quick summary of the faacts, and looks at the blame game.

He's quite clear that he thinks that ATC alerting the CRJ about the presence of the helo (using visual flight separation) probably wouldn't have changed the outcome.

But he does pick up on the cockpit dynamics on PAT25. He says

"Now, the most important facts to emerge from the hearings this week center on the cockpit exchange between Warrant Officer Eves and Captain Robach that happened just about a minute before the midair. He says to her, " All right, kind of come left for me, ma'am. I think that's why he's asking ." And she replies, " Sure ." He says, " We're kinda.. ." And she cuts him off by saying, " Oh-kay, fine ." And he finishes his statement “… out toward the middle ”, meaning the middle of the river and west of helicopter route 4. So PAT 25 is above and west of where they should have been as the CRJ is properly on final approach for runway 33. Using maritime rules of the road terms, the CRJ was the burden vessel and the Blackhawk was the giveway vessel." He quotes someone (David Cherbonnier) posting:

"In military protocol, referring to a fellow officer as sir or ma'am is the role of a subordinate. It’s use in the cockpit indicated ‘privilege of rank’ as opposed to the typical instructor student relationship. The instructor was a Chief Warrant Officer with over 10 years service as an enlisted person prior to selection as a Chief Warrant Officer and as well as met all criteria to be a check pilot and as such was the person in charge during the entire training/examination exercise. In any other capacity, a Captain represents a person who has been recognized by Congress to have the qualifications to become an officer. In my experience, an examinee’s response in a drawn out “ oh-kay fine ” would have signaled check ride over. In this instance, deference was given to rank. Was that a contributing factor?"