Posts about: "TCAS (All)" [Posts: 152 Page: 7 of 8]¶

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 .
.

I appreciate the invitation to comment. With first acknowledging there are several technical factors involved here as to which I have limited understanding (and also that I've commented several times on legal issues likely to be presented by the accident regardless), the legal picture probably is best understood if it is described in two contexts. The fact that the most clearly responsible entities - the Army and the FAA - are both parts of the federal government means that sovereign immunity must be taken into account. (Sikorski, mentioned as a potential defendant by one of the attorneys involved in the case already, has no significant legal risk here, in my view. The reason is its protection by a judicial doctrine known as the "military contractor defense." The specifications given to Sikorski for its design and manufacture were reasonably precise and it met them. See Boyle v. United Technologies Corp. (1989), if more depth and detail is desired.)

As for the airline, to fault the pilots when they were on short finals and expected to concentrate on flying - as others have expressed here numerous times - seems very ill-founded. Whether the airline company could be alleged to have responsibility for not having spoken up more effectively to cause the airspace design and procedure to be redone also strikes me as far too oblivious to the actual operation of the NAS, and the FAA and Congressional processes, to have any validity as an approach to liability. The airline and even Sikorski could still be named as defendants but, to reiterate, this would be just for leverage and not because there is any real pathway to liability for either one.

That having been set as background, the first context ignores the existence of sovereign immunity issues and looks just at what happened and who was responsible. As a rubric for this, "normalization of deviance" seems very accurate. This includes the fact that over time, ignoring Conflict Alerts came to be routine. It includes the practice of confirming "traffic in sight" or related proper terminology, for visual separation even though no traffic had been sighted yet - because it had become routine that the traffic would come into view and be properly identified as the traffic ATC had called out. The testimony about "just make it work", as I heard it, similarly was very concerning; iirc an overall very credible FAA witness acknowledged that the "just make it work" attitude also resulted in decreased safety margins. As did the medical helicopter operator who also had Army helicopter service background. Add in the lack of advanced training, and though I have not practiced law as legal counsel for accident victims' families, the liability theories here appear strong.

Then factor in the use of 3-3 to allievate congestion from high departure rates, rather than slowing or reducing departure slots. Part of the pressure to use 3-3 (as I understood the testimony) was that the Potomac Tracon wanted to increase in-trail separation but DCA instead increased use of 3-3. This was consistent with the attitude, "just make it work".

As to ADS-B on the helicopters, my understanding is that given the roles and missions of the helicopter operations, ADS-B is not equippage the military and its civilian control (in the sense of oversight) could have approved consistent with those roles and missions generally, and especially the continuing-of-government function.

Putting all the causal factors together into a "theory of the case" is perhaps better left to advocates for the accident victims' families (just as defense theories better left to defense counsel in this matter). But since you've impliedly asked, I would not - in this first context - parse out three of the four factors you noted, the lack of ADS-B being the one left out. That leaves the helicopter operating approximately 70 feet too high, the airspace design and procedures including the helicopter routes, and the inaction following the several safety alerts in databases and other reporting functions prior to the occurence of the accident. And including the forced enlistment of DCA for handling more traffic than the widely accepted airspace utilization and safe operation rules and procedures would allow - but they "just made it work." In other words, all of these three factors combine into the most likely theory of liability.

There is a second context, however. Federal government defendants are protected, despite the broad removal (waiver) of sovereign immunity by federal statute, from liability if the alleged negligence resulted from the exercise of discretion. If the actions or omissions being challenged resulted from decisions in which the federal entity weighed economic, social, political and other factors against each other in a form of "policy" decision-making, sovereign immunity remains in place. You can see where this is leading, of course. At what point does the over-use of DCA move out of the protection of "discretionary functions and decision-making" and into the realm of ... just plain negiligence which needs to be addressed in a court action. And likewise, at what point does the Army's set of decisions about how the routes are flown, and how visual separation and traffic sightings are handled, move out of the protection given by discretionary decisions and into the realm of significant negligence not deserving of such protection? Same question for FAA - surely the presence of safety concerns in databases and reporting systems - as unorganized as they may be and as lacking in systematic review as they may be - are matters within the FAA's discretionary functions and decision-making . . . until they're not. (And not equipping PAT helicopters or other D.C.-based Very Important air transport operations by helicopter with ADS-B would have no chance of being ruled not resulting from a discretionary function and decision - it's not even arguable imo.)

I almost included with this (already lengthy) post the "syllabus" of the U.S. Supreme Court's decision in the United States v. Varig Airlines case, which I think is the most pertinent aviation case in which the discretionary function rule is fundamentally involved....but this isn't a legal forum. Still, the U.S. S. Ct. opinion (467 U.S. 797 1984) gives me uncertainty about how any court of competent jurisdiction will draw the line between what would in a case against a not-federal defendant definitely appear to be negligence, and the actions and omissions of the federal defendants here. (My personal view is that the federal defendants acted with such severe negligence that the discretionary function protection has been lost - but that is a gut reaction to the "this accident never should have happened" idea and not legal analysis.)

Finally and last for a reason, I am not commenting about the motives of legal counsel who are representing or advising clients involved in this matter. I have not practiced law a single day, or a single billable hour, or otherwise, on behalf of the families or representatives of aviation accident victims, or the defendants in such matters. As a result, in participation as a guest on this forum I think it's much wiser to let the members of the bar who do have clients and who do practice in this area let their conduct in their professional capacities speak for itself.

The CRJ crew was aware of the traffic. They received a Traffic alert from TCAS 18 seconds prior to impact.

Depends how you define "aware". Clearly, they weren't "aware" enough to realise they were about to run into it until the last second. I must admit that, if I got a TA at less than 500ft on final at a controlled airport, I would have a good think about it before doing anything. It's night, they'd have to look at the TCAS return to see where it actually was, work out what it was doing, then start looking out. And guess what, just before they collided, the CRJ crew started pulling up, so they probably did all that and it took that long to react.

If your comment was intended to be a criticism, which I interpret it was, I think you're being unrealistic and unfair.

Trying to understand how the individuals and organizations responsible for the operation of the DCA airspace and associated helicopter routes expected it all to operate safely. Also not exactly trying to anticipate lines of inquiry to be conducted by the Dep't of Transportation Inspector General, although I think Sailvi767's comment points to a key area that will be examined.

My understanding is that TCAS RA's are inhibited below some specified altitude, in order to reduce or minimize nuisance alerts. Is it a correct statement to say that when the CRJ received the TCAS TA's referenced by Sailvi767's comment, it already was below the altitude at which RA's were inhibited?

If that is correct, then doesn't it follow that the CRJ crew - intently focused on the approach to and landing on 33 - were following procedure that has long been acknowledged for DCA Rnwy 33 - the LC will keep helicopter traffic from becoming conflicting traffic? It is (I think, but only as a non-pilot and non-ATCO) obviously true that in this instance, there were a number of inputs (and lackof inputs) by ATC, and likewise several acts and omissions by PAT25 which led to the procedure failing badly, with the tragic result. In other words, the clearest root cause is the fact that the acknowledged procedure over a period of years was that the LC (and sometimes a helicopter position in the tower) would keep the helicopters from becoming conflicting traffic - and through normalizationi of deviance, when this procedure eventually failed, it failed all the way.

In a previous post I mentioned that one of the attorneys representing the families of accident vicitims has said that claims against the airline would be investigated and possibly included in the forthcoming lawsuits. I suppose it is not talking like a stark raving lunatic to point to the many reports filed about overly close encounters in the airspace, especially in light of information found and then released by NTSB soon after January 29 which detailed many close encounters (as a non-frivolous basis to assert claims against the airline). But wait. They are going to argue that, during the last few hundred feet on final approach to Runway 33 at night, after having been more or less directed by ATC to switch from Runway 1, running through all the steps outlined (by Capn Bloggs) to look for the possibly conflicting traffic took priority over flying the approach - especially in light of the long-acknowledged procedure at DCA? I'm admittedly shouting from down in the cheap seats but this attack by plaintiffs on the CRJ pilots, as an means to advance claims against the airline, strikes me as a legal obscenity.

Bit of confusion here . TCAS is not a separation tool , it is a last minute anti collision system . You are not obliged to monitor the screen, definitively not at 300ft on finals Not sure the CRJ crew noticed it . . Fact is the CRJ crew was not passed the traffic info . the reason why has been covered in the NTSB docket ( interview of the controller)
In class B , controllers will provide separation between IFR and VFR however they can delegate separation to an aircrfat visually following a strict procedure and phraseology .and issuing an ATC Instruction : " maintain visual separation "

WR 6-3 : our posts crossed each other :
when you say : Correct .
Yes , but the CRJ did not receive one TA but 2 , one ( the PAT ) 200ft below , and the other 600 above , most probably the aircraft on finals for runway 1 . , it is quite normal to receive TAs on that kind of tight sequence scenario,. Finally a TA is not an RA. Pilots do not have to react on a TA. In fact some airlines Training programs specify that no horizontal maneuvers are to be made based solely on information shown on the TCAS traffic display. (TAs)

Correct, they received an alert only to the traffic. RA would have been inhibited. The traffic then tracked in on the TCAS display to the collision. Some are posting that their company policy prohibits taking action. Watching an aircraft track in on a collision course and doing nothing takes a lot of courage. At my airline and most others what the policy means is that you should not deviate until you get a RA to avoid other issues or conflicts. When you know you are below the altitude a TA will function on final a go around is always acceptable for anything the PIC deems a potential safety hazard. Your airspace is protected. The policy deals with most other situations where you might create another hazard.

As I posted on here before I had that exact same scenario happen to me on runway 33 in DCA. Traffic closing on a collision course on TCAS. Tower reported the traffic had us in sight. When the traffic closed to \xbd mile with no vector change apparent We went around from 400 feet. We never saw the traffic. Tower chewed my butt saying the traffic had us in sight. I didn\x92t care.

Actually, it's not the exact same scenario.

In the case you quote, Tower reported the traffic had you in sight. In the case in question, AA5342 was not provided traffic by the DCA LC.
In the case you quote, did Tower say that the traffic was going to maintain own separation? Did Tower provide a bearing/direction and distance to this traffic? Did Tower provide the height of the traffic?

Re ATC assigning own separation, that happens here in Oz. IIRC, it went like this: "Report sighting the 737 on final"..."Traffic sighted"..."Follow as number two". Although critically, Our Oz AIP states:
Re TCAS, my Boeing manual states
Change 7 came in some years ago. I wonder if the CRJ's TCAS was the same and the TA was inhibited a few seconds before the collision, which was below 500ft?

Re "normalised deviation", I'm not sure this applies here. Normalised deviation means deviating from published (perportedly safe) procedures, with no adverse consequences, so the deviations continue. In this case, it's pretty obvious that the "published procedures" were flawed in the first place.

Not so much slackness and cutting corners, it's a failure of the FAA's Safety Management System that allows this dangerous stuff to continue. Reports would have been put in routinely I suspect; even the TCAS events should have triggered some SMS action.

Is the FAA ISO9001 approved?

In my ( European) world Procedures are written down and yes they can be altered with a pilot request and controller approval. but it is adherence first .
Taking a road procedure similarity : . at a crossroad you can have a stop sign or a triangle giving priority , or nothing
The written procedures are : at a stop sign you must stop even if there is no traffic.

:Transposing this to DCA route 4 map l the procedure should have been in Europe at least ;
1) hold ay golf balls until you get a clearance to proceed . (so that in case of loss of comms , blocked freq, etc.. you can't proceed ).
2) pilot or controller can request visual separation if all t he following conditions re met : typically VMC, and in daylight and traffic is in sight and maintained in sight and both aircrfat pilots are informed. of each other position
3) lateral deviations by the helicopters to fly over built up areas of the city at 200ft will; not be permitted.

Big differences .

Now a pilot can request visual separation at any time but Controller can refuse at any time to .. To my knowledge requesting visual a night using NVG is not covered in the definition of " visual acquisition " in ICAO, so legally it could be challenged I guess . Same as when a pilot reports "visual" on his TCAS display . It is not valid , and for good reasons .
But KDCA is not in Europe, and ICAO SARPs do not apply to military aircrfat , so the outcome of all this is quite uncertain .In fact i would not be surprised if nothing dramatic changes as far as procedures are concerned, Route 4 will be permanently removed I guess, but other than that ? business a usual with visual separations at night ? .

I disagree. My hackles would be up a bit, probably/hopefully enough, for me to wonder and have a look for it. A traffic headsup call from ATC would also lend more credence to the TCAS TA.

Tower stated helo traffic was transiting the river at 200 feet and had us in sight. When he closed to less than 3000 feet on a constant bearing on TCAS we went around. Probably would have been fine 999 out of 1000 times. Not odds I accept.

I skimmed through the complaint. The defendants are American and PSA (which I will refer to as the airlines) and the USA as responsible for the actions of the air traffic controllers (which I will refer to as the FAA) and for the actions of the helicopter crew (which I will refer to as the army). Perhaps somewhat notable is who is not being sued. This includes the manufacturers of both aircraft and their components and the manufacturer of the night vision goggles.

The best (in my view) argument against the airlines is that it was PSA policy that their pilots should not accept a diversion from runway 1 to runway 33 if they had not already briefed this approach (in addition to briefing the approach to runway 1). The pilot in charge hadn't done this but nevertheless accepted the diversion. This looks bad of course but there is little reason to believe that the omission of the briefing made any difference. It is also argued that the response to the TCAS conflict alert was inadequate which seems only clear in hindsight. Finally there were also insinuations to the effect that airlines should not serve busy airports because they are dangerous that I didn't find convincing.

The argument against the FAA is that the ATCs had actually violated various regulations starting with having one controller handle both helicopters and airplanes and continuing with the specific instructions and information provided to the helicopter and airplane. I suspect these purported violations are not as clear cut as claimed. In any case it is unclear they made any difference.

The argument against the army is that the blackhawk crew violated specific regulations and rules that they were required to observe. Most seriously that they were too high, knew they were too high but didn't correct this in a timely way. This clearly did make a difference and in my view if proven would be sufficient to establish liability.

I didn't notice any references to the discretionary function exception. In general the arguments against the government are based on purported specific violations of established rules and regulations by low level personnel and not on debatable broad policy decisions. The case that an army pilot doesn't have discretion to violate altitude limits seems easy to make to me. Any more than an army driver has discretion to ignore stop signs.

This was a lot of years ago. I believe what was said was, “out of the turn VFR helo traffic will be at your 10 o’clock 1 mile. They have you in sight, cleared to land RWy33”. Don’t recall if a altitude was mentioned. Their altitude was on TCAS as 200’.

I think it is unreasonable. Those crews probably do that runway change often, and would do it blindfolded. As for workload, I agree with Layman; the workload, even if they had briefed it, would have been the same.

Clearly not a pilot, again. Pilots, especially of multi-crew aircraft should NOT have to listen every transmission to every other aircraft to "maintain situational awareness".

This is the problem with enthusiastic amateurs and blood-thirsty lawyers: all these peripheral issues take centre-stage and the real causes are not addressed. Easier to spear the pilots of the CRJ for not doing a unneeded briefing or missing a TCAS alerts than get the FAA and army boffins that approved that sh1tshow in the first place...

Retired airline pilot here and I don't need to hear all ATC transmissions, just the ones that have anything to do with my aircraft.

I did not use the words "maintain situational awareness". I'd be hard pressed to pin down when SA is "maintained" and when it is not. To my understanding, SA is something you can have more or less of, and having more is safer, and has prevented some accidents in the past.

I also don't advocate for that issue taking center stage, but to taboo it and to say we can't talk about it ever doesn't seem right, either. The central issue in this accident is ATC's decision to routinely leave separation in the hands of a heli crew with night vision goggles and less than 75 feet of procedural separation. But we all know this by now if we've watched the NTSB presentation, so please excuse me for not repeating this with every post.

The central issue of the lawsuit is whether the level of safety provided by FAA rules, FAA/ATC procedures, Airline decisions and SOPs, Army decisions and SOPs, and pilot performance on the day are sufficient to legal standards. It's a complex interplay of factors, and even though it's clearly far from the deciding factor, I'm not going to say that a late approach briefing did not matter at all.