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

Hiya WR 6-3 , the fact the RJ crew had a TA (IIR) has been mentioned/discussed a few times in this Thread - it's easy to forget!!! There is a problem with this tho.....

To briefly reiterate what has been said before, in such a complex airspace environment TA's (which is a step down from an RA, which requires mandatory action on the part of a crew, but RA's are inhibited by TCAS at that low level) can happen fairly frequently due to the proximity of adjacent aircraft which are not necessarily a threat - such as when helo traffic is close but is due to be avoiding you. You could get a TA and yet the helo will pass, say, just behind/below you - and all is well. If you recall, the number of TA's noted in the various Safety Databases has also been discussed and points to issues with 33 and R4 being fairly frequent - the warning bells re the 33/R4 airspace configuration had been ringing in the months/years leading up to this sad event - even if it had always ended OK ......... until this time.

The problem really comes when you regularly get such warnings; they become almost "normal". Normally, if you execute a go-around (not mandatory) against such traffic which ATC has specifically organised to miss you, ATC would rightly ask why plus, if you can't see it, you could go-around into it. Here the RJ crew were involved in the execution of the side-step on to 33 and were fully concentrating on rolling out on quite a short Final and would be expecting ATC to keep traffic away from them. So they would likely have noted the TA (I only use "likely" as I can't recall any facts on that) but now you have a highly split focus; flying the last bit of the approach where you have to monitor the PF/aircraft on the approach, ensure you remain stable to touchdown, keep a check that the a/c on 01 was not moving...... etc, etc and trying to see TA traffic - at low-level against a sea of lights. High workload, a belief/trust that ATC has you covered, and a rubbish environment to pick up the helo which is also not an uncommon event at DCA.................... Not a good hand of cards to hold at all.................. That's a polite way to put it!

So, this was definitely not a case of "Well, they had the traffic info so they should have avoided it!" - it's wayyyyyy more subtle and complex than that. That last bit of the cheese, if not having an actual hole in it, was so thin as to effectively be useless......... On your "legal culpability" point (where I have absolutely no quals!!!) I did mention, during discussions of the reports on the Safety Databases, that airlines and airports have a duty of care and so they could (should?) have been conducting Safety Audits which may have highlighted this Risk. Maybe they did and people picked the Risk up but continued to assess it as being "safe". Who knows..........................

Hiya WR 6-3 , always worth discussing so no worries.

The baseline is that a TA on it's own is not enough and can even lead to issues if reacted to without knowing exactly where that contact is and what it is doing. You should, if you have the time (hence my comment re workload for the RJ crew at that point), try and get visual on the traffic but, tbh, it's very difficult to do, especially at low level at night against backlighting. You don't even really have time to "debate" a "shall we react (against SOP) to (yet another?) TCAS alert at DCA?" with all else that is going on at that point of a flight. SOP/Training says "fly on"! You need compelling evidence to go against that. I fact, IIR, the NTSB noted that the CRJ had full "up" elevator at the time of impact - that implies the crew finally saw the helo and reacted ..... but with no time to change their flight path.

If you want to "do" the airline - I feel a much better case could be made based on the fact the evidence of issues for that approach at DCA was sat in the Safety Databases for anyone who went looking, that maybe even crews had raised the issue themselves through internal reporting in the Airline, and/or there was no process in place within the Airline to review operations into DCA - or any other airport. This is promoted by the FAA who state that "The [airline] SMS promotes a defined structure and a \x93learning culture\x94 within an aviation organization that continually seeks and analyzes information, then turns that information into action that eliminates or mitigates safety risks, before they become unwanted events.". The full ref is here. And that also applies equally to the Metropolitan Washington Airports Authority who I believe operate DCA as an independent organisation. How the MWAA fit in to US Government - I'm not sure!

Anyway, hope this helps. Cheers, H 'n' H

As I noted in my last post.......

Every organisation should have an SMS which should include such key areas in relation to their own operations. Now, whether they do or not......................................................... ........

As you say galaxy flyer , it is down to the individual airline, airfield operator or other "deliverer" in the aviation world what they track and exactly how they do it. Most of my Safety stuff was in the Mil and a while back so I'm not sure what happens today. I did get an MSc out in Safety Engineering for one role I did!

But I'm out of date - tho in my last non-safety related Contract with a major Mil supplier, I was often approached by the Department Safety Officer once he learned of my "safety" past! He just liked to bounce ideas off me as someone with a past involvement!

The issue is that it can be all quite subjective. I'm not sure how prescriptive the likes of the FAA, CAA, EASA et al are when it comes to SMS's these days. Hopefully, such accidents such as this dreadful one cause all those involved to say "Are we doing all we could/should?". I know WR 6-3 naturally concentrates on the legal side - I tend to look to see where the best safety lessons can be learned, acknowledging that all costs \xa3/$/\x80/\xa5.

What's that saying? "If you think Safety is expensive, you try having an accident!"!!!!!

Good points Sailvi767 . What's your thoughts on if somewhere has a reputation for being a "TA Mecca" where, due to the airspace design, it leads to a high number of TAs from safely (but proximate!) crossing traffic as seems to be the case with DCA going back in this Thread?

I guess that dampens the urge to figure out what's going on with a TA, especially when on a relatively short Final where workload is high/time is in short supply/city lighting makes it very difficult. We don't know re this specific crew but it seems the Company regularly used 33 so that could be a factor - "Here we go again...... another TA........". As someone said, the "boiled frog" scenario.

I still think that, while it's a valid thought of "what if they did......", I think it masks the more important aspect in that the overall design of that bit of airspace was rubbish - as was so eloquently put by the NTSB.

Basically, the design stitched up the CRJ crew, the helo crew, the ATCO and the poor pax. Where else are there similarly wilting frogs? Thats the big question.

For a while I was flying schedules which were often conducted SVFR as they were very short legs . I'd often get from Twr on joining the circuit at my various destinations, and having confirmed I'd got traffic XYZ in sight, a clearance "Roger, C/S, keeping that traffic in sight, report Final XX. You are No 2 to the XYZ.". From that point on, my positioning was determined by me based on visual separation with the other traffic - so not totally identical to the DCA accident but the principle was the same - I was responsible for remaining clear of XYZ and positioning appropriately behind them (including accounting for wake/runway occupancy effects etc). Occasionally I'd then get "C/S, new clearance - report ready for L/R base." usually with a reason if there was time - often it was App not leaving TWR a big enough gap to sneak me in between 2 IFR arrivals.

In other words, Twr would delegate separation to me with the initial clearance but, if for whatever reason, they became unhappy - I got issued with a revised, more restrictive, clearance. Similarly, if I lost sight of the traffic at any point after the initial "Report Final" clearance, it was my responsibility to advise ATC that I was no longer visual with XYZ (ie I could no longer comply with the clearance ATC had given me) and ATC would then update my clearance on that basis - "..... report ready for base" or similar until they could visually assure themselves of separation. Indeed, on those occasions, it was not unknown for ATC to say "C/S, I have you both in sight - that traffic is well ahead of you, report Final XX, No 2". I was thus relieved of my responsibility to self-position.

What ATC giveth away in their airspace ATC can taketh back again in their airspace!

Now, "normalised deviation" may skew such a way of working such as PAT routinely expecting to get what they ask for and ATC routinely giving them what they want......... Not saying that happened at DCA but............ Also, I've lost track in the Thread if PAT were visual but with another a/c or the intended one but simply "lost it" at some point........... And whether visual separation at night in such busy airspace was wise ............

Hiya Capt B , true but I sort of see 2 related issues - (a) airspace design and (b) how things are conducted within that airspace.

If the airspace design had been used with positive control (ie holding traffic off R4 while 33 was in use or even holding R4 traffic at bridges or somewhere clear of 33 while it was in use) that would work.

Using that same airspace design with "see and avoid" was far less safe and, as reported, led to quite a few incidents of TA's before this fateful day.

But, as the "see and avoid" system was seen by the users at the coal face at least to work, despite the TA's, the operational use of the design became "normalised" to use "see and avoid".

Sadly, no-one (such as DCA management) seems to have studied the extra issues so this more dangerous way of using the design has became "normalised", particularly where ATC is busy.

That's just my take on it.

You have a point RBF but, ultimately, it's the airline who is responsible to keep their customers, staff and innocent bystanders (ie Joe Public going about their lawful business) safe. They are the operators and their Safety Management organisation is there to reduce all Risks they face to ALARP.

Sure, the FAA have that same responsibility in ensuring their airspace is safe and operates safely. However, that does not absolve the airline of their own Safety responsibilities. Just to say "Well, the FAA say it's OK so it's fine!" is not enough. Aviation is littered by 1000's of cases where the National rules say one thing but an airline will be even more restrictive. For eg, the ILS minima for an approach to R/W 24 at ABC may be, let's say, 100ft, but Airline XYZ itself says only Captains may fly down to that on this particular approach - their 1st Officers can't even fly the approach at all (for whatever reason)! Obviously, you can't go less restrictive than the Regs but you can go more restrictive.

The data in the various databases is freely available (I've used them myself for research back in the day) so the airline should be doing it's own "due diligence" around their operation rather than blindly accepting what the FAA say. However, and there always is one of these, the "downside" is that it may well be more expensive to operate within the more restrictive case which will upset the Finance Department who will cite the regs.....

And so it goes on......... The only certainty is that the lawyers will do well out of this (appols to Willow-Run !).......

I can see exactly where you are coming from Capn Blogs so I don't blame you at all for your comment above! After all, you can say exactly the same for Aircraft Certification too....... This is my take on it which I put out there...............

This is where a SMS needs to look again at things and then decide what else, if anything, needs to be done. Part of my background is from Safety Engineering (where I was put through a SE MSc in the 1990's by my then employer) and processes such as Hazard Analysis takes into account both material failure as well as operational failure - and here we have "airspace design" and then the "operation of that airspace". When designing a bit of kit you apply the Regs as part of the design hazard analysis. But that is the minimum (tick VG) - after that we then ask "And is it actually safe?". Regs generally provide for a "minimum safe standard" which, all being well, will see us through - 100%. If not, we'd have aircraft falling out the sky with regular abandon! But that's assuming that those who write the Regs have got it right (or, in this case "designed the airspace" and then created the "operational rules" for that design). They can make mistakes as much as anyone else. One would hope for rigorous QA checks and so on ......... but this is where even organisations such as the FAA can, over time, become institutionalized with poor practices/cost cutting/etc/etc.

On an operational side of things, I've often, as an Engineer, reduced servicing intervals to less than those recommended where I've had issues with a bit of kit on a particular airframe*. I've released the aircraft back into service with an Engineering Limitation which has called for more frequent inspections than the Rules ask for while we try and ascertain what the issue is and if there really is a trend starting. If as an operator you believe something to be unsafe, you must address it. How did I know to reduce the servicing intervals? Sometimes it was a Maintenance Engineer calling me over and saying "Hey, Boss, have you seen this? What do you think?". Other times it's because trawling through Stats, a trend has started to show which, in the noise of day-to-day operations, was invisible - but look back over 6 months in a Spreadsheet and, hey, what have we here? We used to get regular print-outs from our Maintenance databases for just this reason - in the 1980's!

The FAA, in the wake of this accident I suspect, has issued this on the considerable extension of SMS's - but only in Apr 2024. But this is not new stuff - SMS's have been around for years. My first brush with it all was way back in 1980 - we called it something different then but that's what it was! Here in the UK, the CAA published CAP 795 - Safety Management Systems - Guidance to Organizations back in 2015, the purpose of which " .......... is to provide guidance on the implementation of Safety Management Systems (SMS). It has been developed to give sufficient understanding of SMS concepts and the development of management policies and processes to implement and maintain an effective SMS. It applies to Air Operator\x92s Certificate (AOC) holders, continuing airworthiness management organisations, maintenance organisations, air navigation service providers, aerodromes and approved training organisations. ".

Now, this is where you are absolutely spot on and is also what I said in my previous post - such additional "safety nets" will almost inevitably cost more so the Finance Director is none to keen. The usual "Operations/Engineering vs Finance" standoff.......! The long-debated issues at Boeing is also being blamed on exactly this over in "Rumours & News". What's that saying? "If you think safety is expensive, wait till you have an accident!".

Anyway, that's my take FWIW and hopefully it explains why I said what I did! Cheers, H 'n' H

WR 6-3 , again, my apologies and please rest assured my comment was very tongue-in-cheek hence my initial apology! That those who suffered from this tragic accident receive recompense as a very poor substitute to not still having their loved ones with them is absolutely essential! My comment was more along the lines that it looks like determining culpability will be quite convoluted...... hence the "lawyer" quip. If it came across as otherwise I, again, unreservedly apologise!

* Re increased servicing, even that has to be approached with care. In the late 1970's, we lost a helo when someone applied more grease then they should have as "....... well, a bit more will be even better!". Murphy's Law can be a right bu&&er!

I may have a dig round on the stats when I get time (currently sorting out heating in the house so quite busy with pipework everywhere!). But I'm sure many in the FAA etc have done exactly that and it's why the NTSB came down on the setup at DCA like a ton of bricks. IIR, they suggested that the FAA look to see if there were other similar risks at other airfields as well.

Also, there were some comments a while back in this Thread that there had been a number of "incidents" (ie TAs) at DCA. Also, it's not how many compared to X, Y or Z. It's not just down to simple numbers - risk assesment is way more than that. It's down to the SME's involved.

Just a few incidents should prompt a much more detailed analysis which then reveals the true risk. If there are more happening elsewhere, all that should do is make you look across the board and ask "Where else is this risk present?" despite no evidence to date - in other words they should have indirectly flagged up DCA.

The danger is an accident can happen the very first time a risk comes home to roost - if you are fortunate, you may get some "near-misses" first as a warning ..... but you may not! But, from what I've read, I'm not sure the NTSB saw this as an "out the blue" event - rather an "accident waiting to happen". Finally, safety is not purely numbers - it's appropriate/intelligent interpretation of those numbers. One event can be more significant than a history of 1000 of similar, but slightly different, events

Anyway, I've had my say and much of this has been said before anyway so I'll return to lurk mode! And my plumbing..... Deep joy!!!!!

Way more likely my inability to express myself clearly ..... plus the dark humour I've been infected with from my Mil days.....

Back on topic, let's hope real good comes out of this dreadful accident..... in many areas.....

Hi WR 6-3 , of course, as you say, the safety of Mil operations is as important a topic as for Civvies, especially when operating in such close proximity. OK, some other strange Mil risks appear such as when someone is deliberately firing rounds or missiles at you to shoot you out the sky or you are conducting refueling between aircraft at FL170 or whatever. Safety should all be part of Mil business - it certainly was when I was Serving.

Here, assuming the original quote is accurate (and nothing suggests it's not!), I suspect my bold highlighting above is key. Given the IG decided not to conduct a review of safety practices himself it looks like someone has just told the IG in no uncertain terms "So you don't want to voluntarily review things? Fine - so now we're ordering you to! Run along now like a good little chap and, by the way, when you report back, we'll be paying very close attention to your conclusions - so don't even think of a white-wash!".

I suspect that this is the unwritten message to the IG given they are even highlighting why they are having to order him to do it!

True, we don't know the reason the IG decided not to conduct a review but, to put it bluntly, there's quite a few innocent civilians no longer with us as a result of the collision with the Mil helo! I suspect, before the instructions were issued, the IG would have been asked "nicely" and any financial/resourcing issues could have been resolved behind closed doors.

Maybe it is just a case of the politicians stamping their authority........ but to "name and shame" in such a clear way rather implies that there's a bit more to it.

Anyway, hopefully it allays WR 's fears and confirms that the Mil usually do take safety seriously. That was the main point I was trying to make.

WR , your Post at #1741 sets out an entirely believable reason why the IG could have been told to keep schtum on the matter and is one I'd not considered - mainly due to the fact that the concept of "discretion" is not one that seems to be prevalent here in the UK. The old "Crown Immunity" was, to me as a layman, possibly our version of "discretion" but that has been reined in over the past few decades.

Here, safety cover-ups (the Mull of Kintyre Chinook fiasco being an immediate example that springs to my mind) seemed more aimed at protecting the reputations of individuals rather than fending off litigation - hence the findings of the RAF's own Board of Inquiry being overturned by Senior Officers to protect those even more Senior Officers above them.

Maybe we live in a simpler legal world here in the UK so your comments are, as ever, quite illuminating to this Brit and highlight things from a different angle which is much appreciated. Whatever the reasons for such obscurification, I do often find myself thinking that the world we live in is not quite as "civilised" and "honest" as we try and make out.

And on that rather depressing observation I'll revert to "lurk mode"!