Posts by user "Hot 'n' High" [Posts: 34 Total up-votes: 31 Page: 1 of 2]¶

On NVGs, just my thoughts but the can some RW Mil people comment on NGVs in a built-up area? The work to make the cockpit NVG-compatible is very significant (I did get involved with that side - all sorts of lights have to be replaced) and, when flying in trail on NVGs, only the rear aircraft had it's Nav lights on so the aircraft in front does not blind the crew behind. IR cameras in a built-up area is one thing (as in the police chasing down crims!) but NVG in a heavily built-up area? That's a whole new ball-game. With the stuff I dealt with that was impossible! Things may have changed. Be interested to know!

The events of the actual night backs you up OBD . I noted the CRJ (BS5342) had company traffic(?) (BS5347) joining behind the 2 x AAs (3130 and 5472 ) which checked in with Twr literally seconds after the accident took place so they had no idea anything was up. Their opening call was along the lines of "BS5347, is on final, request 33 ... circle for 33." - a request they even made a second time on their 3rd call attempt. That implies that 33 was quite a regular event (maybe just to cut the taxi time down at the end? Don't know......) so I'd be surprised if the accident crew hadn't used it before as well - maybe a number of times. Certainly the accident crew accepted the Twr request to switch to 33 quite quickly suggesting it was "no sweat" to them. What was sad is the following company traffic (BS5347) checked in 3(?) times trying to get Twr's attention but, of course, Twr was busy with the 2 x G/As ahead of them on 01. Even after they probably realised people are executing G/As from 01, they still don't know whats happened ahead of them and, on their 3rd call, ask for "33" again ..... only to then be sent around themselves.

On the general subject of the 2nd Twr call to PAT25 and issuing avoidance instructions from BS5342, my take would be that maybe Twr saw it so late and simply didn't have an accurate mental picture of the precise trajectories of the helo and the CRJ to actually formulate a plan to deconflict safely. The only hope was that the helo crew "still" had the aircraft in sight (as they had already stated they had) and were still going to pass behind the CRJ............. Sadly, by then, that was just wishful thinking. At that late stage, all ATC probably knew was that ordering an evasion maneuver was just as likely to turn a near-miss into an accident as it was to turn an accident into a near-miss. A "Rock and a hard place springs" to mind....... One can only feel for the ATCO ...............

Sorry - Bluestreak!!!!! I should maybe have said JIAxxxx. My apologies............

Doing commercial stuff (talking UK here) I was often cleared by Approach for a visual join, say, downwind and then handed to Twr. Twr would then deconflicted me from, say, faster traffic on the ILS. If I had the traffic in sight it was "Extend downwind to join Final as #2 behind the 737 currently on a 3 mile Final. Caution wake turbulence. Report Final." If I didn't have the traffic in sight, or was at all unsure, it was something like "Extend downwind. Report when you have that traffic in sight." after which I'd get onwards clearance on from Downwind to Final. Same at at least 5 other UK regional airports, day or night. Clearly, if the weather was poor I'd be on the ILS anyway so Approach did the sequencing under IFR but mostly Twr had the job. But, as people say, other places have other rules but that was what used to happen to me as standard practice several times a day.

This sort of ties in with EasyStreet s comments on UK ATC in Class D ops which I used extensively. The key is being sure you really can see the actual aircraft ATC want you to see. In many cases, it is easy - it was SOPS for my time travelling about with my pax or when enjoying myself doing a bit of private flying. I'd say this happend (commercially) 80% of the time - otherwise I was IFR. The real difference between my experience and what happened here is 2-fold:-

- Traffic density.
- Routing configurations.

In my experience at UK regionals, there is usually just not the taffic density we see here (tho it can be busy at times at certain "rush hours"!) and, also, the ergonomics of the flightpaths were such that you weren't looking back up a busy approach path with many aircraft "in stream" thus making "picking the one" almost impossible. If I had to join a stream I was either changed to IFR for the ILS to "avoid an excessive delay" (which was ATC basically saying to me "we can't do this safely under VFR" which got my vote each time) or, if a smaller stream, I'd be extended downwind by App who effectively then handed Twr a workable solution which App had "engineered". At no time was I given anything more than a simple "pick 1 out of 1"-type or, very rarely, a "1 out of 2" scenario and never where the Twr were "trying to wallpaper a room, tile a bathroom and re-wire the main fuse box" at the same time. In the odd "1 out of 2" situations I was always asked "Do you see the 2 aircraft on Final?" and, unless I saw both, it was "Negative, only 1 in sight!".

The takeaway is that what's "legally allowed" is sometimes "not practically wise" and that seems to have been the undoing here.

Hi WR 6-3 , I've been following discussion about immunity etc - I'll steer clear of that legal discussion if I may. I have no idea \x96 I\x92ll leave it to you bright legal folks!!! However, with a humble background in Safety Engineering, and having been on a few Flight Safety Committees, and even run a large UK Database used by Equipment Engineers (I just ran the system \x96 a very important point as you\x92ll see later!) to identify Engineering issues with their kit, my thoughts. I\x92ve no idea how things (a) should have worked at DCA and, (b) actually worked there. But what follows is how I\x92ve seen it working countless times when I\x92ve been part of that process at different levels in the UK. Just some thoughts really\x85\x85 and you\x92ll see why I\x92ve underlined the bit above shortly.

Personally, the reference to ASIAS and it forming a key player here is, IMHO, a bit of a "red herring". It's not how Flight Safety should work in my experience of over some 40 years. Flight Safety ethos comes from the top and works down. Flight Safety activity starts at the bottom works up. In other words, it is the guys and gals on the Line, in the Tower, in the Hangar, in the Cockpit day-to-day who should actively spot and flag up issues relevant to where they are working - encouraged and supported all the way by the ethos from on high. After all, they (and only they) know exactly what is happening in their airspace, on their flight deck, in their hangar.

So the \x93DCA Flight Safety Organisation\x94 (we had Flight Safety Committees as Sqdn and Stn level to manage this \x96 similar in Industry \x96 so does DCA have a similar group? Please tell me it does!) should have been alerted to, possibly, initially unquantified issues with near misses along Route 4 by ATC staff. Local DCA Safety Management and ATC staff would then quantify the issue using the data available directly from such sources as the FAA AIDS and the NASA ASRS databases, all freely available via the ASIAS site. A good overview of ASIAS can be found here and an example of a search screen is the AIDS search form. This is all driven \x93bottom up\x94 . I personally used AIDS and ASRS during my MSc when writing a research paper many years ago \x96 sat at my PC in the UK so it\x92s really easy to use if I could master it! Juan probably got his stuff from there too.

Once the \x93DCA Flight Safety Organisation\x94 has looked at the data sources, either you have no issue or it needs wider investigation. In this case, clearly it was an issue, so (a) Route 4 should have had temporary mitigation put in place by DCA and (b) the "corporate" FAA (for want of a way to describe it) should have been requested to carry out a full "independent" Safety Review. Finally, (c), the ASIAS organisation could have been asked to flag this up to other Airfield Safety Organisations in their \x93Communication\x94 role in case they had similar issues to DCA. Again, local Safety Management at those fields would then investigate.

The FAA Safety Review should decide, with justification , what the next steps are - the justification being called the revised Safety Case (\x93revised\x94 as there should already be an initial \x93Safety Case\x94 supporting the operation of Route 4! Mmmm, an initial Safety Case? Was that a pig I\x92ve just seen fly past here???????!!!!!!!!). The outcome could be (as in this case) to close Route 4 down. If it were to be kept open, the revised Safety Case must support that by adding further mitigation and, vitally, the situation should be then be formally reviewed at defined intervals to ensure such mitigation is actually working before it becomes \x93normal business\x94. The FAA could also order a much wider formal review to see if other airfields are similarly affected and, if so, similar Safety Case reviews should be conducted at such locations if required.

So, from my point of view, I think that ASIAS (and as per the ASIAS overview link earlier) is not in itself responsible for initially identifying issues - it is simply (a) a conduit across users once issues have been identified by a user and (b) it manages some tools for users to use. I managed the RN\x92s Fleet Air Arm Engineering Database with a staff of 3. What we would do is, for example, at the request of Equipment Desk Officers , run additional reports requested by them if they thought, say, there was an increase in issues with a particular type of hydraulic pump or whatever it was. It was not my role in that Post to look for problems - my role was to ensure such data was accessible and ensure the database remained accurate and up to date. As I said earlier, the activity to raise problems and initially scope them is bottom-up as only the worker-bees (in my example, the Desk Officer) see the specific issues where they happen to work. The ethos to ensure that the organisation is in place at each airfield (and the wider FAA) to support the Safety activity should be top-down.

Clearly, it requires suitably qualified/experienced people on the coal face with a mind to safety to actively recognise and flag up such issues, encouraged from the very top by the ethos . That is an important point. If the ethos \x93encourages\x94 the watching of a \x93near miss\x94, sucking one\x92s teeth and saying \x93Sheesh! That was bleep-bleep close!!!!\x94 and moving swiftly on, that is NOT a safety management ethos !!! That is a recipe for disaster! If the ethos exists only in name and the worker-bees are not positively encouraged to raise issues which are then transparently acted on, but is an ethos which is totally subservient to commercial or political pressures then you'll get little or no Safety activity which will lead to\x85\x85\x85.... I\x92m sure you can all fill that ending in\x85\x85\x85!

Just my thoughts FWIW\x85\x85.. and sorry it\x92s so long! Cheers H 'n' H

Hiya WR 6-3 , firstly, please do accept my apologies if I came over a bit harshly re ASIAS. I always read you input as, while the detailed legal nitty-gritty is generally way beyond me, you always provide a refreshing viewpoint which is good to read! The aim of my Post, based on my interpretation of the above quote, was just to emphasise the existence of ASIAS is just as a tool or, rather, a set of tools but which has no real "proactive function" in itself. Yes, it represents a very small part of the Flight Safety chain - but as a resource in the main. As you say, there were loads of examples of what happened at DCA and my post was an explanation as to who, I believe, should have been looking at it. Maybe they did - and just ignored it? No idea!

In the UK, the airport operator is totally responsible for the safety of operations on or above their field out to 4000 ft on approach and departure - about 12 miles. The CAA who regulates aviation here, along with the Dept of Transport, but in conjunction with other stakeholders such as NATS (our en-route ATC organsiation), airlines and airfield operators etc, designs the airspace and sets the generic rules for it's use. As you said, the main rule is "Don't crash anything into anything else!". However, at the airfield, it is the airport operator who needs to ensure that the generic rules work in their environment. If a particular rule is legal but, if applied in their location, is unsafe, they can't apply that rule! That's what the Safety Case should say.

A relevant example? I used to regularly (for work) transit London S > N and N > S along the red dotted line below - at 2400ft as it kept me just out of the London TMA but as high as possible so, if it had all gone quiet on the engine front, I'd have the best chance to get the plane onto the ground with me alive and no-one else hurt. As part of the transit, I had to cross the final approach into London City (green line). So, say heading N, I'd chat to Thames Radar while over South London and would ask for a London City crossing. They'd chat to City ATC to co-ordinate and take me to the Thames before handing me to City Tower. My route over the Approach has aircraft at 1200 ft descending on the ILS and so I would have crossed anything landing at 1200 ft above that. So, while on first glance, it was fine I never, ever got that clearance with an aircraft landing - and for very good reasons. If the aircraft on the ILS had had to do a go-around, life could have become interesting very quickly. I was always held until the landing aircraft was well clear (ie ATC could see it was almost at the airfield) before they cleared me across. Indeed, legally, they could have given me a "You see the landing? Pass behind that"! But, no - always positive clearances. Got my vote ....... + gave me chance to enjoy the views of Greenwich and the City of London and "delayed" me a couple of minutes. OK, a bit unfair as LCY is "sleepy hollow" compared to DCA but, despite that, they were very friendly ..... but very strict!!!!!



So, when you are discussing (I think!!!) whether ATC elected to give PAT25 a "You visual? Pass behind" or whether it was "ordered" from on-high as it was deemed safe to do, ultimately, it is the ATCOs call on the day. Now, before I get flamed, do I blame the ATCO ? No! Well, why not? After all, he gave PAT permission! And yes, it was a "legal" clearance. But was it a wise clearance? When unpacking that little lot you have to look at a raft of Human Factors which influenced that ATCO on that night. He was on his own so, probably, the only way he could cope with all he had on his plate was to try and shift some responsibility onto PAT25 - one less thing for him to juggle. But even then, he needed to be monitoring which he clearly was - but while very busy with other approaches and departures so he just picked up a concern too late as the audio shows - "Are you sure you see the jet?". Another factor - was the strategy to use Route 4 while 33 was active something ATCers at DCA, over time, started in an effort to cut down radio traffic and speed things up? If so, had it been assessed and then monitored for adverse safety? While anecdotally, it seemed people were aware of "close calls", had any analysis taken place looking at the Databases? In the UK certainly, all the Airport Operator responsibility.

To the final "accountability" part re payments to families, the thing we have here is (and, folks, correct me if I've got this wrong) the FAA set the rules and the operate the Rules. Here, the CAA sets the rules and the Airfield Operator operates the rules. That is important - for eg, huge argument here in the UK about just how independent the UK's Military Flight Safety organisation is ..... as it is part of the Military. IMHO, what we have here are valid generic rules, some of which were simply not suitable in this specific location - just like crossing London City with an aircraft on approach - legal ...... but very unwise. As to who carries the can, well, as you said WR 6-3 , the legal beagles will get to the bottom of that ..... but it will take some time. I'll leave that side to you!!! My main question out of all of this is, why were not these issues flagged up by airport management for further investigation given it was something of an open "secret"? And where else (around the world) is this happening?

And, on that cheerful note...........! H 'n' H

Hiya WR 3-6 , thanks for your reply. A busy day today so I'll give this more time tomorrow if I may! But interesting points again - and I'm a bit clearer too on this "discretionary" aspect - I think!!!!

Hi missy , sorry, what I was trying to say was, and this is from further back in the Thread, it is my understanding that often there is 1 controller handling main arrivals & departures with another controller handling local traffic on the heli routes etc. As is often the case, at quiet times, one position closes and so the 1 controller is now controlling both. That is very common practice both at airports and en-route. The others are, indeed, there in support but things happen (eg the Supervisor is asked a question or gets a phone call - similar with the Assistant.). Not saying that happened here but it illustrates the support aspect of those roles and what can happen.

Now, one could say, "Well, there was a fairly steady flow of (maybe) 10 aircraft landing/taking off. So, 1 extra helicopter is not much more to add in!". True ...... but ...... an example. A mainline train arrives at a major London Station and, at once, all the doors open and several 1000 people all get off together and start heading up the stairs to the ticket barriers. The flow of traffic is heavy but quite ordered as the flow is all in one direction and so, while traffic density up the stairs maybe slows it down a bit, the flow is nicely ordered. Picture now, H 'n' H , being in a rush and so being one of the first off the train arriving at the ticket barrier only to realise - Durrrr - he's left his case back on the train. Being not-too-bright, I decide the quickest way to go back is down the same stairs I came up, and hence back to the train. Of course there's only 1 of me going down and several 1000 coming up. But to an onlooker gazing down, the effect of my single trip back against the several 1000 heading up has had a significant effect. TBH, H 'n' H is causing a fair degree of chaos as he pushes past everyone fighting his way back down the stairs against the flow. A few choice comments are being made by his fellow pax! What we have is a disproportionate effect caused by 1 vs 1000's.

So, while I'm no expert in how the brain works, usually the ATCO is dealing with a steady flow S - N and is sequencing things in their mind to smoothly land and depart traffic, slotting people in and out of the queue to achieve an orderly, safe, flow. All of a sudden, their "mental flow" now has something working in the other direction which all needs a bit more thought to ensure that everything remains safe. OK, 1 helo is not much, but it requires a disproportionate amount of extra "computing" compared to, say, adding another 1 aircraft into the main flow, to ensure safe separation. Was that why the "Own visual separation" offer was taken up? Now, rather than managing the contraflow, the ATCO only has to "monitor" the singleton swimming against the tide - which they were to a degree. Just a thought.

Spot on! I'm not sure how long such tapes are kept? Usually it is a defined period after which the tape is recycled into the "system". Of course, looking further back, and in a perfect world, you could assess ATC SOPs against the buildup in traffic over the years and see how that's affected things over time. Was it the case of "a death by a 1000 cuts" which WR 3-6 cited? Sadly, I suspect we'd need a crystal ball to study that. But retired Controllers could give a fairly good insight.

I mean the Airport Operator running the airfield. So, in the UK, that could be a company who then employ the Twr controllers to run that side just as they employ or contract Baggage Handlers, Cleaners, etc, etc. The UK ANSP (NATS) generally pick up everything above 4000 ft tho the actual hand-offs vary tactically and there can be local variations to suit specific airspace. So, for example, from memory, the Channel Islands work up to a higher level before en-route takes over. Below that, its up to the Airport Operator to staff their operation and make sure it's all safe and sound.

Anyway, better dash as already late........! Before yet more chaos is caused by H 'n' H !!!!!!

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.........

Hi Chu Chu , admittedly, I'm no legal expert - the opposite really! But, if there have been quite a few "near misses" would that not change matters? Seems, from previous posts, that there's quite a bit of evidence of similar events taking place relating to that route/runway which resulted in official Safety Reports being filed. In a video a little way back in this Thread, a guy called Juan has done some digging in that area. Just my thoughts. Cheers, H 'n' H

Quite so! In fact, if something has a reputation for being, shall we say, extra "difficult", it should attract even more care and attention in it's execution. It's when the "difficulties" go on to become "normalized", and people relax a bit again, that errors start to creep in. Seems to have been quite a few previous close shaves but that, seemingly, didn't trigger a wider managerial review to see what was causing these types of events and so provide extra mitigation (stricter rules?) to prevent further events from happening.

Hiya WR 3-6 , you raise a fair point.

I guess, where I come from is that, too many times, the crews have been blamed and yet the system (stretching flight duty hours, poor rostering, management pressure, skipped maintenance etc, etc) has played a huge part in an accident ..... but those who ran the "system" that allowed this to happen never get "done" - it's easier just to blame the crew. The Mull of Kintyre Chinook Crash is a great example - there was a huge thread in the Mil forum on that.

In that case, the BOI reached the conclusion that no-one knew what had happened especially given the known technical issues with the aircraft. However, two RAF Air Marshalls, Wratten and Day, overturned the BOI findings and placed the blame entirely on the 2 pilots. This was because the aircraft, the Chinook Mk 3, had received an illegal Release to Service (RTS) by the RAF - the aircraft should have been limited to ground running only - not even flying - as the whole fleet was subject to a number of unresolved technical issues. Instead, an illegal RTS was issued against Engineering advice from Boscombe Down and an aircraft that should never have seen daylight under it's wheels unless it were on jacks or lifted by crane, killed 25 VIP passengers and 4 crew on 2nd June 1994.

A guy called David Hill wrote a book entitled "The Inconvenient Truth" which exposed the Air Marshalls and the broken system they presided over which was prepared to ride rough-shod over safety - well worth a read if you have not seen it! The e-book is available via the "Big River" store! I personally saw a similar case of the RAF blatantly breaking it's own rules in 2019 which I took to straight to the Engineering Director of the company I was Contracting for at the time. Being an ex-Mil Engineer, I immediately saw what they were doing was illegal. He simply couldn't believe what I showed him!!!! I could cite other cases - the Shoreham Airshow Hunter crash in 2015.

If you don't address the root causes of an accident, then they remain and, given time, some other luckless aircrew stumble into the exact same situation - and yet more people die!

Sorry to have a rant but.......... well, you know me!!!!! That's why there seems a bias not to blame aircrew - far too many times aircrew have been used as convenient scapegoats for the real villains!

Cheers, H 'n' H

Hiya layman54 , welcome!

Agreed 100%! After all, many air accidents are because pilots are in the wrong place - a good example is the current sister Thread to this one covering a plane which started to take-off from a taxiway - sadly a regular occurrence. Lots of people are asking "How on earth......." - but they did, just as others have done before them! I'll not comment further as the discussion is on that Thread anyway which you can read and the Investigation is early days so far.

However, one of the reasons aviation is so safe today is because the aviation community realised a big driver to improving safety, based on the premise that humans are both ingenious in devising new ways to screw things up - as well as being quite capable of repeating the old ways too - was to understand if additional issues were contributing to those accidents. In particular, anonymous self-reporting of "near misses" provides much valuable information enhancing the understanding of issues before anyone dies. There were many "near miss" reports relating to this route/runway as has been mentioned. But no-one joined the dots........

By understanding how those additional factors contributed to the near miss/accident means further mitigation could be put in place. Maybe one of the most significant - Flight Time limitations - have come about as, after a number of accidents, people realised just how a lack of proper rest significantly degrades human performance and so contributed to poor decision-making, particularly when under pressure. I just use that as an example of "contributory factors" - possibly not relevant here - the full Report is not out yet.

In this case, the helo crew ended up flying into a jet. But why did they do that? Well, when the NTSB recommended that Route 4 be closed, it described it as being "an intolerable risk to aviation safety by increasing the chance of a midair collision.". If the helo crew mistook another aircraft to one they should have been avoiding (a likely mistake) there was little effective mitigation to prevent that mistake leading to catastrophe - hence the recommendation from the NTSB. What there was in terms of mitigation - such as the ATCO - failed. The ATCO suddenly realised all was not quite right but he didn't have the time to come up with a solution to save the day and a collision happened on "his watch". I can't even imagine what he is going through right now every single day.....

Yes, by all means decide liability for recompense to those who lost loved ones on that fateful day - (top tip, go where the money is!). The legal people like our esteemed fellow PPRuNer, WillowRun 6-3 , will do that. What the aviation community itself wants to ensure is that such a mistake (which will happen again - as I said, whilst humans are extremely inventive in finding out new ways to screw up they are also prone to be quite capable of repeating mistakes ad infinitum) - never leads to such deaths in the future. That's why people look, in great depth, behind the obvious cause for the crash to see what more can be done. That's why it's so safe for you to step aboard an aircraft today.

To reiterate, in the words of the NTSB, the aviation world was running a route which provided "an intolerable risk to aviation safety by increasing the chance of a midair collision.". So, one question, who approved that ..... and where is the Safety Case to support that decision? Cue tumbleweed rolling slowly down the road......................

I hope this helps explain why it's wayyyyyy more than "The crew screwed up. End of story!". Cheers, H 'n' H

Hiya Capn , that is precisely what I've been saying in my last few posts (while waiting for various builders and plumbers to get back to me!) - have a look at my last few posts. It's also worth reading Post #1365 by layman54 re aircrew to which I was responding - hence the limited reply I gave concentrating on the topic their post had raised.

My view - they were specifically asked to visually identify a/c A. Now, given the stream of a/c, the distance the a/c were away, the angle of the stream, etc, etc how could they reliably pick out a/c A? Almost impossible I'd say. But they said they had, which then formed the basis of the clearance. But, as you say, they were actually looking at a different a/c, a/c B, not deliberately, but mistakenly thinking it was the one ATC had asked them to look out for and pass behind, a/c A.

You are spot on in that there was no way for ATC or the helo crew to verify that the one the helo crew were watching (a/c B) actually wasn't the one that ATC thought they were watching (a/c A). That, as you say, was a very significant weakness. So they were on course to avoid the one they were watching. But that wasn't the one ATC had asked them to watch.

You are dead right in how difficult "see and avoid" is. I'm lucky as I only flew between small UK Regionals and, particularly when in my home patch, I often got from Twr "Visual with a/c A on Final? Join Final as #2 to a/c A!" type stuff. Worked OK when it was only me and a/c A. Any more and usually Approach sequenced me if I'd arrived SVFR by placing me under Radar Control for a short while before then handing me off to Twr to join the cct visually once faster traffic was well ahead of me. That's if they didn't forget me completely .... which happened once ...... but that's another story - they were most apologetic when I reminded them I was still on the last vector they'd given me!!!! "Sorry about that, I'd completely forgotten about you!"! Charming!

Hi MechEng , it's been a while since it was discussed.

Here is the NTSB report/transcript and another transcript here . I couldn't locate the one on Prune way, way back but these 2 will do!). ATC specifically call the a/c sidestepping to 33 as the a/c PAT needs to identify. The ATCO even tells PAT what type it is. PAT then say they have "it" visual. Sadly, "it" wasn't the sidestepping a/c, it was another one. But no-one figured that out ...... till seconds before the crash. This initial exchange, according to the transcript, was about 2 min before the collision. It's only then, on the basis that PAT says they have seen "it" and, by implication, will visually avoid it, that ATC issue the clearance on down Route 4.

There was a lot of discussion earlier on in this Thread about how on earth PAT could be reliably expected to pick out the subject a/c from the rest of the stream of arrivals and at that distance (6 miles rings a bell).

It's only seconds before the crash that it appears that the poor ATCO suddenly starts to suspect the PAT crew are actually looking at a different a/c to the one he had asked them to identify and pass behind. But, by then, it was too late for him to figure out a solution to give to PAT.

As I said, this was all discussed many posts ago so it's easy to forget the details. Hope the links help!

Cheers, H 'n' H

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

Yep, that question .......... and loads more.

One thing I mentioned earlier is that airlines also have a responsibility for conducting safe operations; safe for their crews, their pax and by-standers. For eg, airlines often have additional rules for certain airfields (eg some require specialist training before crews can operate in there due to say, terrain issues on the approach). As has anecdotally been reported on here, if there have been an above "average" (and someone will need to figure out exactly what that means) number of issues with this particular approach in terms of TA's, irrespective of the outcomes, then the airline has a Duty of Care to have a system which identifies such issues, assesses them and then, if necessary, to put additional mitigation in place - such as, say, banning the use of 33. AA may have looked at this and, if so, their Safety Case should explain why they concluded it was safe. Sadly, even that doesn't guarantee the right decision was reached ...... but at least they'll have formally assessed it. Trouble is, landing on 33 seems to have cut taxi time = fuel = $'s.......

Anyway, just some thoughts! You know, I can be a right cynic at times but, having a background in Safety Engineering in a previous life, that's par for the course!!! Cheers, H 'n' H

Who knows, you may be right. I think AA rocking up at DCA and stating that, as "policy", they'd never ever use the sidestep to 33 due to their own safety assessment flagging it up, esp if based on TCAS evidence, would have led to interesting discussions at senior levels. As you say, how that would have ended is anyone's guess. Bit academic anyway as there was no AA ban and the AA flight accepted it when offered it and the next AA asked for it on initial contact ..... not realising what had just happened! That's why I had a $ sign in my earlier post! The cynic that I am........

Hiya WR 3-6 , no nothing grandiose, just a big user of DCA services talking to DCA managers at a working level about concerns they (AA) may have had re operating into the field. Normal business practice really. Of course, that may not be the way it works in the USA........ or elsewhere tbh. Corporations (Govt or Commercial) are skilled in the art of avoiding unpleasant issues as I have seen countless times!

But I doubt AA even did the analysis in the first place to flag up the issue to start with ......................................................... Nuff said in my eyes at least!

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