[Senate Hearing 119-455]
[From the U.S. Government Publishing Office]
S. Hrg. 119-455
THE NTSB FINAL REPORT
ON THE DCA MIDAIR COLLISION
=======================================================================
HEARING
before the
COMMITTEE ON COMMERCE,
SCIENCE, AND TRANSPORTATION
UNITED STATES SENATE
ONE HUNDRED NINETEENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 12, 2026
__________
Printed for the use of the Committee on Commerce, Science, and Transportation
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available online: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
64-071 PDF WASHINGTON : 2026
SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION
ONE HUNDRED NINETEENTH CONGRESS
SECOND SESSION
TED CRUZ, Texas, Chairman
JOHN THUNE, South Dakota MARIA CANTWELL, Washington,
ROGER WICKER, Mississippi Ranking
DEB FISCHER, Nebraska AMY KLOBUCHAR, Minnesota
JERRY MORAN, Kansas BRIAN SCHATZ, Hawaii
DAN SULLIVAN, Alaska EDWARD MARKEY, Massachusetts
MARSHA BLACKBURN, Tennessee GARY PETERS, Michigan
TODD YOUNG, Indiana TAMMY BALDWIN, Wisconsin
TED BUDD, North Carolina TAMMY DUCKWORTH, Illinois
ERIC SCHMITT, Missouri JACKY ROSEN, Nevada
JOHN CURTIS, Utah BEN RAY LUJAN, New Mexico
BERNIE MORENO, Ohio JOHN HICKENLOOPER, Colorado
TIM SHEEHY, Montana JOHN FETTERMAN, Pennsylvania
SHELLEY MOORE CAPITO, West Virginia ANDY KIM, New Jersey
CYNTHIA LUMMIS, Wyoming LISA BLUNT ROCHESTER, Delaware
Brad Grantz, Republican Staff Director
Nicole Christus, Republican Deputy Staff Director
Lila Harper Helms, Staff Director
Melissa Porter, Deputy Staff Director
C O N T E N T S
----------
Page
Hearing held on February 12, 2026................................ 1
Statement of Senator Cruz........................................ 1
Statement of Senator Cantwell.................................... 3
Statement of Senator Moran....................................... 5
Statement of Senator Duckworth................................... 6
Statement of Senator Wicker...................................... 66
Statement of Senator Klobuchar................................... 72
Statement of Senator Sullivan.................................... 74
Statement of Senator Lujan....................................... 76
Statement of Senator Budd........................................ 78
Statement of Senator Markey...................................... 79
Witnesses
Hon. Jennifer Homendy, Chairwoman, National Transportation Safety
Board.......................................................... 8
Prepared statement........................................... 11
Appendix
Response to written questions submitted to Hon. Jennifer Homendy
by:
Hon. Jerry Moran............................................. 83
Hon. Maria Cantwell.......................................... 88
Hon. Tammy Duckworth......................................... 93
Hon. John Hickenlooper....................................... 101
Hon. Andy Kim................................................ 105
THE NTSB FINAL REPORT
ON THE DCA MIDAIR COLLISION
----------
THURSDAY, FEBRUARY 12, 2026
U.S. Senate,
Committee on Commerce, Science, and Transportation,
Washington, DC.
The Committee met, pursuant to notice, at 10:17 a.m., in
room SR-253, Russell Senate Office Building, Hon. Ted Cruz,
Chairman of the Committee, presiding.
Present: Senators Cruz [presiding], Wicker, Fischer, Moran,
Sullivan, Blackburn, Budd, Sheehy, Lummis, Cantwell, Klobuchar,
Markey, Duckworth, Lujan, and Fetterman.
OPENING STATEMENT OF HON. TED CRUZ,
U.S. SENATOR FROM TEXAS
The Chairman. Good morning. The Senate Committee on
Commerce, Science, and Transportation will come to order.
Before I begin my opening statement, today marks the 17th
anniversary of the Colgan Air Flight 3407 accident in New York.
We remember the 50 lives lost as we somberly meet to discuss
another deadly aviation accident.
Aviation safety relies on the Swiss cheese model to
mitigate and manage risk. Layers upon layers of human
intervention and technology are meant to close any
vulnerabilities or figurative holes left by the previous layer.
Unfortunately, just over 1 year ago, that safety system failed
just 3 miles from here at Ronald Reagan Washington National
Airport. For more than 15 years, pilots, controllers, and reams
of aviation data detected at least one near mid-air collision
each and every month at National Airport.
In 2013, after a helicopter and plane on approach to DCA
nearly crashed into each other, controllers and helicopter
operators formed a working group to improve coordination in the
local airspace. That group met often, and at some point, even
elevated recommendations to revise and improve mapped flight
routes to show known hotspots, but their suggestions were
ignored. That's one of the many failures uncovered by the NTSB
that, had people responded differently, tragedy would have been
avoided last year.
I want to commend NTSB Chairwoman Jennifer Homendy and all
of the NTSB staff for their efforts. They did yeoman's work to
complete the DCA crash investigation in just 12 months. In
addition to examining the causes of the DCA accident, the NTSB
made 50 recommendations to improve aviation safety. One of
those recommendations, arguably the most impactful one, should
be familiar. For the 18th time, let me repeat that, for the
18th time, the NTSB is urging aircraft in busy airspace to have
ADS-B on board.
Had the Black Hawk and Bombardier CRJ been equipped to
receive ADS-B location signals on January 29, 2025, the pilots
would have been warned of each other's exact position nearly
one minute before impact, and 67 people would still be alive
today. Instead, the CRJ's pilots didn't see the helicopter
until a split second before impact, while the helicopter crew,
it appears, never saw the CRJ.
The NTSB review revealed another major safety loophole.
Military aircraft were routinely ignoring rules that required
aircraft flying in busy airspace to transmit ADS-B signals.
Although planes don't share locations with each other via ADS-
B, they must broadcast such information to air traffic control,
but the Army uses a special carve-out so that it didn't have to
consistently comply with the broadcast mandate. Moreover, the
NTSB discovered that this particular helicopter's ADS-B Out
wasn't even configured correctly. After the January crash, the
FAA eliminated the military's blanket exemption, but just a few
weeks ago, a brand-new loophole was tucked into the annual
Defense Authorization Bill, making it easier for the military
to continue flying without ADS-B around DCA.
If we learned anything from the DCA crash, it's that you
can't have a safe airspace when operators are following
different sets of rules. That's why our committee authored and
passed the bipartisan ROTOR Act. The ROTOR Act, which passed
the Senate unanimously in December, rescinds that new Defense
bill loophole and enacts the central NTSB recommendation of
this investigation.
The ROTOR Act requires all aircraft in congested airspace
to broadcast their location to each other via ADS-B. The ROTOR
Act ensures a commercial airliner landing in a major airport
has visibility, in daytime or darkness, to any nearby aircraft,
whether it's a military helicopter or a general aviation pilot,
and vice versa. No more flying blind. The ROTOR Act will begin
to protect the flying public now, which is why the House should
pass it, and put it on the President's desk for his signature.
Now, I've heard some faint grumbling from stakeholders and
others who want to put the same kind of loopholes into the
ROTOR Act that caused the DCA crash. Some want exemptions for
private jets, while a few airlines quietly carp about the cost
of safety-enhancing technology. These criticisms aren't valid,
and they are, frankly, disturbing. Flying can only be safe when
everybody follows the same standards. Why would we want to
exempt regional airlines from ADS-B given that Flight 5342 was
a regional airline?
I hope my House colleagues don't wait for another accident
or for the NTSB to have to come back and recommend ADS-B for
the 19th time before acting. And the notion that somehow
private jets should receive a blanket exception makes no sense
whatsoever. I don't know how anyone can look in the eyes of the
victims' families and justify that argument. I also hope the
House doesn't try to resolve the dozens of other safety
recommendations from the NTSB, because we know this particular
one on ADS-B can start now and save lives.
Today, there are planes taking off from Ronald Reagan
National Airport. Today, there are planes landing at Ronald
Reagan National Airport. There are planes that may have your
loved ones on them or my loved ones on them, and every single
day we delay we are putting our families in danger for no
reason whatsoever.
In the room with us today, are loved ones of the 67 men,
women, and children who were killed in last January's crash.
I'm encouraged and inspired by your tireless advocacy for safer
skies. It pains all of us to know that your lives have been
irreparably changed. There's nothing we can do to bring back
your spouses, your children, your parents, your cousins, or
your friends, but I hope that we can turn your grief into
action. Thank you for working so hard to make sure that no
other family has to suffer the kind of tragedy that you're
feeling, the pain of each and every day.
I now turn to Ranking Member Cantwell.
STATEMENT OF HON. MARIA CANTWELL,
U.S. SENATOR FROM WASHINGTON
Senator Cantwell. Thank you, Mr. Chairman, and this is a
very important hearing this morning. I feel like it's almost a
culmination of years to finally get a report so crisp and clear
about the failures of the FAA, and what it needs to do to
change its culture.
I, too, want to remind and remember the individuals here
about the Colgan Air crash. Our heart still goes out to the
families affected by that incident, including people from
Seattle. I also want to say that the Colgan families have been
a constant presence in this room, and while that is not the way
the political system is supposed to work, where the victims
have to come and be the biggest advocates for safety, that is
certainly what the Colgan Air families have done. So, we
certainly remember them today.
And I want to also just say, Mr. Chairman, that yesterday's
incident at El Paso reminds me of why this interagency
coordination is so important. If we can get into this kind of
conflict where the FAA is saying that we're going to shut down
airspace for 10 days, and then another agency is saying
something different, and there's concern about what is
happening in the airspace, it just seems to me that we have a
real problem of coordination between DOD and FAA, so we need to
resolve that. I hope that your calls for an interagency
briefing will be heeded, and that we will get to the bottom of
this. Not one more day needs to go by without that kind of
information and oversight for the public.
But we are here today to thank Chair Homendy and the NTSB,
and to thank them for their recommendations and findings after
a thorough, long investigation into the tragic crash in DCA
last year. The loss of 67 souls when an Army helicopter
collided with American Airlines 5342 has weighed heavily on
many of us, but certainly the families who are most affected.
Our hearts go out to you.
Many of the family members are here today, and I know they
will be following today's discussion very closely. You have
stood with us to make our aviation system safer, including your
support for the ROTOR Act, which was critical in trying to push
this legislation through the U.S. Senate, and, hopefully, to
get it to the President's desk.
I want to thank Chair Homendy again for her work with her
team tirelessly delivering answers to these families. I know
that you deliver a lot of answers and information to us. I
think no one knows how hard that is in delivering the
information to the families. I know from our own air accidents
with the seaplane in Seattle, how trying to find the victims of
that crash, there's just so much work that goes into
communicating with the families, and so we thank you for that
as well. These answers demonstrate that this tragedy was a
result of many systematic failures and that that failed
everyone on Flight 5342, and the Army helicopters, and the air
traffic controllers. And so, this is part of a larger trend
where we have to be the ones that put a stop to this finally.
We have witnessed multiple near misses between commercial
airline flights and military flights, including a helicopter
flying too close to DCA traffic last May, exposing
communication failures between the Pentagon air traffic control
tower and the DC tower, and a near mid-air collision between an
Air Force tanker and JetBlue flying from Curacao back to the
United States.
These incidents are just unacceptable. So, we look forward
to the 14 recommendations that you are making today, especially
the issue of NTSB and the larger FAA reforms. I am concerned
that the NTSB found that the FAA and Army are dangerously over-
reliant on pilots to see-and-avoid. How can a congested
airspace rely on see-and-avoid other traffic around the
National Capital Region?
The NTSB found these practices created an unacceptable
risk, especially without the help of a key safety technology
that we've already implemented in so many other aspects of our
airspace: ADS-B In and ADS-B Out. NTSB has also emphasized
having TCAS is not enough. Not enough. The CRJ pilots did not
get air traffic alerts at lower altitudes below 900 feet, and
pilot alerts are more limited if ADS-B In data is not feeding
into the system.
Last week, the NTSB issued their 18th recommendation in 20
years on this type of technology: ADS-B In and Out. That
basically is the alert system that we expected in the digital
age to be implemented 20 years ago. So, recommending that all
aircraft are required to fly in a controlled airspace with this
to ensure pilots have real-time awareness and traffic alerts
both in the air and on the ground is just the last piece of an
aviation safety system safeguard that has been recommended for
years, and the question is why hasn't someone been doing it?
Money cannot be the answer because the cost of lives has
been too great. The bipartisan ROTOR Act also is key in the
NTSB recommendations and it will help to save and strengthen
the oversight. NTSB reinforced that the FAA and Army had access
to safety data in years leading up to the crash that warned of
heightened risk of mid-air collisions in D.C., but the FAA
failed to act on that, as did the Army.
So, NTSB's investigation of the DCA collision and the Air
Alaska door plug accident showed that the FAA's Safety
Management System has been superficial at best. While the FAA
has mandated SMS, a Safety Management System, which means when
you have a safety problem, you have to stop and fix it, that's
all that safety management system means. It means you have to
stop and fix it. It means don't keep going on production, don't
keep going on your system until you fix the safety risk. But if
you don't have a real SMS, then it really doesn't stop to fix
the safety concerns.
That is why the legislation we passed this morning is a
start. We will hear from experts about why the FAA needs to do
this, similar to the expert witnesses that provided us so much
information about the MAX crashes. With the Committee's vote on
this today, I think we are one step closer, and we certainly
know that controllers who voiced safety concerns about
helicopter routes and stressful controller workloads were also
ignored by FAA managers. So, we have to fix this as well.
Mr. Chairman, I stand ready to work with you on getting the
ROTOR Act onto the President's desk. This is critical
legislation that will help now, and we also have more work to
do because this sequence of events and the events at El Paso
show us that we have real communication issues, and we must do
our oversight role. So, thank you, Mr. Chairman, and I look
forward to Chair Homendy's important testimony this morning.
The Chairman. Thank you. I now recognize Chairman Moran for
an opening statement.
STATEMENT OF HON. JERRY MORAN,
U.S. SENATOR FROM KANSAS
Senator Moran. Mr. Chairman, thank you, and I join in
supporting and commending your opening statement, you, and the
Ranking Member. I appreciate the demands and sentiments that
you both expressed. I appreciate the way that you both have
carried out this--conducting the hearings of allowing our
subcommittee to take a significant role in pursuing safety
measures, and really directing the leadership, providing the
leadership to this committee to take concrete actions to
prevent other accidents from occurring in the future.
We continue to mourn the losses of the victims. We express
our condolences on behalf of citizens of my state. We express
our condolences to the members of the family who are present
here today and those who are not. We remember the heroism that
was displayed on the night of January 29 at DCA at Reagan
National Airport as the heroic efforts were made to find and
save lives.
And I commend NTSB Chair Homendy and her team for their
significant and diligent work, the calls for action that have
been made by the Chairman and the Ranking Member. It seems to
me that I can't remember the circumstance in which we had the
factual basis to be more unified in a response than what we
have with the presence of what Chair Homendy and her team have
provided us.
In so many instances in Congress, we get this point of
view, and this point of view, and then we try to hash out who's
telling us the truth and what matters in the conversation. And
Chairman Homendy, I can't find a circumstance in which NTSB
didn't do its job in a way that none of us should have doubts
about the conclusions you reached and the recommendations you
have provided. There is no excuse for us not to achieve the
goal of those recommendations by passing legislation, and
perhaps as important, maybe even more importantly, to insist
that once we pass legislation, that legislative effort is
rewarded by action by the FAA and others so that it is
implemented fully in a way that makes a difference.
I've been in Congress enough to see the circumstances in
which we often pass legislation. We issue the press release and
say we've done something, but we haven't done anything until
we've done something. And that means the administration, the
execution of those laws have to be fully fulfilled. It's our
responsibility, our responsibility in this committee and as
members of the U.S. Senate, to turn the conclusions of the NTSB
report into action. Congress must determine what steps we need
to take following those recommendations, and we need to make
sure that the FAA, the Army, and all others are following those
recommended and enacted safety measures.
Following a yearlong investigation, NTSB has affirmed again
that passing and implementing the ROTOR Act could have, and I
would say, would have, saved lives on January 29, 2025. The
passage and implementation of the ROTOR Act is critical to
achieving the safety of our skies. I urge the House not to
delay in its passage.
The Chairman made the point that every day that goes by
creates a greater risk for others. If there's something that
needs to be addressed in the ROTOR Act, don't delay. Let's have
the conversation and fix something. If there's something
missing or wrong, that doesn't mean watering it down. It means
fully implementing the ROTOR Act as passed just as soon as we
make certain we've got it right.
Additionally, Congress must continue to provide the funding
that is necessary to further modernize our aviation system,
advance new technologies. At the FAA, the FAA Administrator was
in front of us with a roundtable discussion yesterday about
implementation of advanced technologies in the system, and we
must continue to recruit, train, and support air traffic
controllers. No steps back. Moving forward. Act on the
recommendations and make sure that January 29 never occurs
again. Mr. Chairman, I thank you. I appreciate the opportunity
I've had to work with you, Senator Cantwell, and Senator
Duckworth in this regard.
The Chairman. Thank you. Ranking Member Duckworth.
STATEMENT OF HON. TAMMY DUCKWORTH,
U.S. SENATOR FROM ILLINOIS
Senator Duckworth. Thank you, Mr. Chairman. Thank you also
to Ranking Member Cantwell, and to my Chairman of the
Subcommittee, Senator Moran, who has been a joy to work with as
a partner on this issue.
Chair Homendy, I want to thank you and the entire team at
the NTSB for carrying out your mission without fear or favor to
independently investigate the DCA mid-air collision. You
provided FAA, DOD, Congress, and most importantly, the families
of the victims of Flight 5342, clear answers explaining how
this deadly crash happened, and you've given us a framework to
ensure such utterly preventable tragedies never happen again.
Many of the NTSB's findings from the DCA mid-air collision
point to issues that have persisted for years: the urgent need
to address the air traffic controller shortage, the need for
advanced safety technology, and the unacceptable lack of
coordinated communications between the FAA and the DOD. I've
repeatedly sounded the alarm on these issues and I haven't been
the only one. The NTSB found that in prior years, rank-and-file
controllers working in the DCA tower sought spacing of at least
4 miles in trail, while Potomac TRACON controllers asked for a
decrease in DCA's dangerous airport arrival rate. Yet, FAA
management failed to act on the warnings being raised by an
understaffed and overworked controller workforce that was
clearly struggling to manage the busiest, most congested runway
in the United States.
FAA's failure in the face of blaring alarm bells screaming
out that it was a matter of when, not if, one of the near
misses at DCA would become a deadly tragedy is, unfortunately,
emblematic of a chronic crisis that's plagued FAA for years
under multiple administrations. An unacceptable culture of
complacency.
Chair Homendy, 826 days ago, you sat in that very chair in
this very room to testify alongside FAA at a hearing I convened
on addressing close calls to improve aviation safety. That day,
your message could not have been clearer as you warned
everyone, and I'm quoting you, ``The concerning uptick in such
incidents is a clear warning sign that the U.S. aviation system
is sharply strained. We cannot wait until a fatal accident
forces action. We must act before there is a tragedy.'' And
your message was embraced by many in this chamber in a
bipartisan way.
As I recall, I opened that hearing by stating that our
Nation is experiencing an aviation safety crisis. Near misses
are happening way too frequently, and I refuse to be complacent
in waiting to act until the next runway incursion becomes a
fatal collision. Eight hundred and twenty-six days ago, we had
that exchange.
That recognition is why I fought so hard to protect the
1,500-hour rule, and to stop Congress from adding more flights
to DCA. Unfortunately, on that latter fight, I and the members
of Virginia and Maryland delegations were soundly defeated. And
as the NTSB report found, the intense traffic demand in the
region forced Potomac TRACON to routinely reduce the trail
spacing between aircraft, which increased the workload on DCA
air traffic controllers.
Tragically, the one audience that refused to hear these
messages was the one entity with the authority to act: the FAA.
And it seems as if the FAA's complacency has only hardened over
time, regardless of which political party controls the White
House. Again, this is a bipartisan failure.
The NTSB report showed that the FAA failed to conduct
annual reviews of helicopter routes in the DCA airspace leading
up to the DCA mid-air collision, reviews that would have shown
the helicopter route was too close to an approach runway. A
review of helicopter routes would have also potentially
prevented some of the 15,000 close calls between airplanes and
helicopters in the DCA airspace that took place between October
2021 and December 2024.
We have long known about the mounting strain on air traffic
controllers. That is why I will continue to reiterate that any
investment in our ATC system must be informed by and prioritize
the most important asset of the ATC system: its people.
The FAA needs to improve how it reviews relevant safety
data on hotspots, how critical feedback from frontline
controllers is funneled to decisionmakers, and most
importantly, how to ensure enough rested, well-trained
employees are at work every day with all the tools that they
need.
The House must also act to pass the ROTOR Act so we can
codify many of the NTSB's recommendations. But even if that
happens, there is more work to do because the bottom line is
that any system that repeatedly forces pilots to take emergency
evasive actions to save lives is a broken system. We need to
prevent the conditions that will lead to even a near miss.
So, I thank you again, Chairwoman Homendy. You have been a
wonderful resource to this committee. I also thank the
leadership of the Committee, the Chairman, the Ranking Member,
and again my partner on the Subcommittee, Chairman Moran.
Thank you, I yield back, Mr. Chairman.
The Chairman. Thank you. I now want to introduce our
witness, Ms. Jennifer Homendy, the Chairwoman of the National
Transportation Safety Board. The NTSB investigates all civilian
aviation accidents and other major roadway, pipeline, rail, and
marine accidents. We thank Chairwoman Homendy and the NTSB
staff for their work to complete the investigation of the D.C.
mid-air collision in one year.
Chairwoman Homendy, you're recognized for five minutes.
STATEMENT OF HON. JENNIFER HOMENDY, CHAIRWOMAN, NATIONAL
TRANSPORTATION SAFETY BOARD
Ms. Homendy. Chairman Cruz, Ranking Member Cantwell,
Chairman Moran, Ranking Member Duckworth, and members of the
Committee, thank you for the opportunity to be here today to
discuss our investigation of the mid-air collision that
occurred just over a year ago near Ronald Reagan Washington
National Airport.
As we discuss NTSB's thorough fact-finding, extensive
analysis, and comprehensive safety recommendations, I want to
make one thing abundantly clear. We should not be here today.
In this room, sitting with us or watching online, are family
members of the 67 people who died on January 29. We are so
sorry for your loss. You should not have to be here, because as
I've said many times, this was 100 percent preventable. It was
preventable.
In fact, now that our investigation has concluded, I can
say without a shadow of a doubt that we've seen this before.
We've investigated similar mid-air collisions going back
decades, and we've issued safety recommendations like ADS-B In
over, and over, and over again aimed at preventing just these
kinds of collisions, recommendations that have been rejected,
sidelined, or just plain ignored.
As Chairman Cruz and Congressman Onder recently wrote,
``Last year's crash was not an isolated incident. It was the
fatal result of years of unheeded warnings.'' Years.
Fifty-seven years ago, in 1969, we investigated a mid-air
collision between Allegheny Airlines Flight 853 and a small
Piper Cherokee outside Shelbyville, Indiana. Eighty-three
people died. Soon after, the Board held a hearing and issued 14
recommendations aimed at preventing future mid-air collisions,
including our first ever recommendation for FAA to
expeditiously develop and implement a collision avoidance
system in all civil aircraft.
For perspective, that same year we put a man on the moon,
and yet, it took another two decades and a congressional
mandate for FAA to finally implement TCAS. TCAS didn't prevent
this accident, but there are technologies that are readily
available that could have. If I could pull up my slide--while
that's coming up, with ADS-B In and what I'm--maybe I'll give
it a second. With ADS-B In--hopefully it'll come up: technical
difficulties. I'll continue on and when it comes up, I'll
explain.
With ADS-B In----
Senator Cruz. I don't do the AV.
Ms. Homendy. Yes, me, too. There we go. So, on the left
side is the PAT25, and on the right side is Flight 5342. We did
a laser scan of exemplar aircraft, and so the gray around is
the structure, and then, of course, you see the night vision
goggles on the left side.
With ADS-B In, the helicopter pilots would have gotten an
audible alert, if it was in their headset, at 48 seconds prior
to collision when they were over Hains Point, allowing them to
take action. They never got a single alert. They had no idea
that it was--that 5342 was coming from the left, and we can
talk about that in the hearing, if you'd like.
On the right side, outside--looking out of 5342, the CRJ
would have gotten their first alert with ADS-B In at 59 seconds
prior to collision. Instead, they got a TCAS alert that just
said, ``Traffic, traffic,'' and what they need to do is look
out, and figure out where that traffic is, and take action,
which is very difficult to see in many circumstances. And we
can talk about why that is, too.
But, ``Traffic, traffic,'' 19.5 seconds prior to collision.
They didn't actually recognize that the helicopter was there
until 1 second, 1 second prior to collision. Had they gotten
ADS-B In, they would have gotten something more along the lines
of, ``Traffic 12 o'clock, 2 nautical miles, 500 feet below,''
then they could have taken action. What we're talking about
here is lifesaving information for pilots. It's information.
In 2008, we again called on the FAA to implement ADS-B In.
We stated, ``The Safety Board believes that the benefits of
ADS-B technology warrant rapid adoption,'' and that, ``the
equipage of aircraft with ADS-B In capability will provide an
immediate and substantial contribution to safety underline,
especially in and around airports.'' We said that in 2008. What
if the FAA had acted?
I want to be clear though: What happened at DCA could
happen anywhere in our airspace. The NTSB has for years, long
before this tragedy at DCA, been sounding the alarm about the
safety risks of see-and-avoid. Yet we continue to rely on see-
and-avoid to separate traffic throughout the national airspace
when technology is available to provide pilots with the
situation awareness they need and deserve to ensure safety.
See and avoid is exactly what it sounds like. A pilot has
to visually acquire an approaching aircraft, recognize a
collision course, decide on action, execute the control
movement, and allow the aircraft to respond in a matter of
seconds.
Since 2008, we've investigated 211 aviation accidents and
incidents resulting from a mid-air collision or loss of
separation, which killed 281 people and injured 12 others. In
almost half, we raised concerns with see-and-avoid. These
include many in your home states. And I know not all the
Senators are here, but I'm going to pretend they are because we
have--we investigated since 2008 where we stated our concerns.
Sixteen in Texas, one in Kansas, 15 in Alaska, including
the 2019 tragedy in Ketchikan where six people died and 10 were
injured, and I was the Board Member on scene. And we discussed
at length in that report, ``the lack of ADS-B In requirements
for Part 135.'' Two in North Carolina, one in Missouri, two in
Utah, one in Ohio, one in Wyoming, one in Michigan, two in
Wisconsin, one in Illinois, 12 in Nevada, seven in Colorado,
two in Pennsylvania, four in New Jersey, and now, one in D.C.
The fact is, our aviation system is the safest in the world
for a reason. Thanks to the work of you all, the work of the
entire Congress, our work at NTSB, the work of our partners at
FAA, redundancy has been built into the system to prevent
catastrophe, but that doesn't mean system flaws don't exist.
Our aviation system is complex. The National Airspace
System is complex, but it is generally safe, which means many,
many things have to go wrong for a tragedy like this to occur,
and we have an obligation to fix those vulnerabilities.
The question before us is: How many more people need to die
before we act? How many more people need to die before we act?
I've heard others say it can't be done. It's too expensive. The
technology isn't available. The risk is only at DCA. None of
that is true. Absolutely none of it. The technology is
available with an iPhone, or an iPad, a headset--this is mine--
and a cable, and a few hundred dollars for a receiver. That's
what this is: ADS-B In receiver. Even the oldest general
aviation planes can be outfitted with ADS-B In.
The gentleman behind me who is the Director of our Office
of Aviation Safety has no electricity in his plane. This is
what he has. He has ADS-B In with an iPad. In commercial
aviation, American Airlines has equipped its entire fleet of
more than 300 Airbus A321 aircraft with ADS-B In. I was in the
cockpit to look at it. Flew to Phoenix from here. Do you know
how much it cost them? I asked the COO: less than $50,000 per
plane to retrofit.
Boeing offers it on new planes. Airbus offers it on new
planes. Gulfstream includes it. It is possible the technology
is available so we can solve this problem and save lives. We
should not have to be here, and we wouldn't be if the NTSB's
warnings had been heeded.
Exactly 17 years ago, Colgan Air Flight 3407 crashed in New
York. 50 people died. In response to that accident, we issued
25 new safety recommendations to the FAA. Ten were closed,
unacceptable action, because they weren't going to do anything
about it. In the letters they told us don't ask anymore. One is
open, unacceptable.
We cannot allow this to happen again. Every single one of
the 50 safety recommendations we issued in response to the DCA
catastrophe must be acted on immediately. The FAA has had
multiple, multiple opportunities to implement NTSB
recommendations. Time after time, they've declined. Now, we
need action. Whether that's through the FAA--and they can
implement a lot of the recommendations we just issued, some of
them are simple, and we can talk about that--Army, Department
of War, or an Act of Congress.
We cannot accept having to be here years from now lamenting
yet more inaction. Not only must we do this for the 67 people
who died on January 29, we must do this for all those who lost
their lives in accidents that the NTSB has investigated. We
must do this for their families. We must do this for future
generations, lives we can still save.
Chairman Cruz, Ranking Member Cantwell, Chairman Moran,
Ranking Member Duckworth, I am immensely grateful to you and
the members of this committee for your robust advocacy via the
bipartisan ROTOR Act. Not only do I want to thank you for your
incredible leadership, but I mean this from the bottom of my
heart: thank you for your willingness to stand up and do what's
right for safety.
I look forward to working with you to create a future where
no family ever has to endure such tremendous loss. Thank you.
[The prepared statement of Ms. Homendy follows:]
Prepared Statement of Jennifer Homendy, Chairwoman,
National Transportation Safety Board
Good morning. My name is Jennifer Homendy, and I'm honored to serve
as Chairwoman of the National Transportation Safety Board (NTSB).
As you know, the NTSB is an independent Federal agency charged by
Congress with investigating and establishing the facts, circumstances,
and cause or probable cause of all civil aviation accidents and serious
incidents in the United States and defined accidents in all other modes
of transportation, including roadway accidents, grade crossing
incidents, railroad accidents, pipeline accidents, major marine
casualties occurring on or under the navigable waters, internal waters,
or the territorial sea of the United States, and other accidents
related to the transportation of individuals or property when the Board
decides the accident is catastrophic, the accident involves problems of
a recurring character, or the investigation of the accident would carry
out our statutory requirements. In addition, the NTSB carries out
special studies concerning transportation safety and coordinates the
resources of the Federal government and other organizations to aid
victims and their family members impacted by major transportation
disasters.
Thank you for the opportunity to appear before you today to discuss
our investigation of the midair collision between a Sikorsky UH-60L
helicopter, operated by the U.S. Army under the callsign PAT25, and an
MHI (Mitsubishi Heavy Industries) RJ Aviation (formerly Bombardier) CL-
600-2C10 (CRJ700), N709PS, operated by PSA Airlines as American
Airlines flight 5342. These aircraft collided in flight about 0.5 miles
southeast of Ronald Reagan Washington National Airport (DCA),
Arlington, Virginia, about 8:48 pm eastern standard time on January 29,
2025.
The 2 pilots, 2 flight attendants, and 60 passengers on board the
airplane and all 3 crewmembers on board the helicopter died. Flight
5342 was operating under the provisions of Title 14 Code of Federal
Regulations Part 121 as a scheduled domestic passenger flight from
Wichita Dwight D. Eisenhower National Airport, Wichita, Kansas, to DCA.
PAT25 originated from Davison Army Airfield (DAA), Fort Belvoir,
Virginia, for the purpose of the pilot's annual standardization
evaluation flight with the use of night vision goggles (NVGs). Night
visual meteorological conditions prevailed in the area of DCA at the
time of the accident.
PAT25 departed DAA and landed at sites in Virginia and Maryland
before the crew turned south toward Washington, DC, and was cleared by
the DCA tower controller (who was working combined local control and
helicopter control positions) to transition the DCA airspace via
helicopter Routes 1 and 4 before proceeding back to DAA. The helicopter
joined Route 1 near Cabin John, Maryland, and followed the Potomac
River southbound at low altitude, passing the Key Bridge, Memorial
Bridge, Tidal Basin, and Hains Point before continuing onto Route 4.
At the same time, flight 5342 was approaching DCA on an instrument
flight rules flight that had been uneventful during departure, cruise,
and initial descent. The airplane was inbound from the south on a
visual approach to runway 1 when the DCA tower controller asked the
flight crew if they could accept runway 33 instead.
Our final investigation report is being formatted for an
anticipated public release date of February 17, 2026. To enable the
Committee to adequately prepare for the hearing, we are providing the
analysis section of the report in full here:
Analysis
Introduction
The accident occurred when PAT25, which was transiting southbound
on Helicopter Route 4, impacted flight 5342, which had just turned onto
final approach for runway 33 at DCA. At the time of the accident, the
DCA local control (LC) controller was working both the LC and
helicopter control (HC) positions. About 5 minutes before the
collision, the first officer (FO) of flight 5342 contacted the tower
while inbound on approach for landing on runway 1. The LC controller
asked if they could switch to runway 33. After deliberation, the crew
determined that they could accept the runway change and the FO informed
the controller, who then instructed the flight crew to circle to runway
33 and issued a landing clearance.
About 2 minutes before the collision, when the aircraft were about
6.5 nautical miles (nm) apart, the LC controller issued a traffic
advisory to PAT25, informing them of a ``C-R-J just south of the Wilson
Bridge circling to runway three three''; however, the helicopter's
cockpit voice recorder (CVR) captured this transmission as, ``PAT two
five traffic just south of Wilson Bridge is a C-R-J at one thousand two
hundred feet for runway three three,'' indicating that the PAT25 crew
did not receive the word ``circling'' as part of the advisory due to
degraded radio reception. At this time, PAT25 was crossing the Tidal
Basin, and flight 5342 was one of five airplanes approaching DCA in
darkness from the south. The PAT25 instructor pilot (IP) stated to the
controller that they had the traffic in sight and requested visual
separation, which the controller approved.
The LC controller contacted the helicopter crew again about 20
seconds before the collision and asked the crew if they had the CRJ in
sight, followed by instructions to ``pass behind that C-R-J''; however,
the helicopter CVR indicated that the ``pass behind that'' portion of
the transmission was blocked by a 0.8-second mic key from within the
helicopter. The IP indicated that they had the airplane in sight and
requested visual separation, which the controller again approved. About
6 seconds before the collision, the IP stated to the pilot, ``alright
kinda come left for me ma'am, I think that's why he's asking . . .
we're kinda . . . out towards the middle.'' The pilot acknowledged and
the helicopter subsequently started to move left. The aircraft collided
at an altitude about 278 feet mean sea level (msl) about 2,500 feet
from the runway 33 threshold.
The analysis discusses the accident sequence and evaluates the
following safety issues:
the extensive use of pilot-applied visual separation and the
inherent limitations of the see-and-avoid collision avoidance
concept;
controller workload, position combining, and communications
practices;
the design of the Washington, DC, area helicopter routes and
operators' awareness and interpretations of route structure and
limitations;
the limitations of the traffic awareness and alerting
systems on both aircraft;
shortcomings in Federal Aviation Administration (FAA) and
U.S. Army safety assurance and risk management processes;
including lack of proactive data sharing and analysis to
identify and mitigate midair collision risk; and
deficiencies in FAA safety culture and postaccident drug and
alcohol testing procedures.
The NTSB investigation's comprehensive review of the accident
circumstances determined that the following factors did not contribute
to the cause of the accident:
Flight 5342 crew qualifications. The pilots of flight 5342 were
certificated and qualified in accordance with Federal regulations.
[FINDING 1]
Flight 5342 crew medical factors. The pilots of flight 5342 were
medically qualified for duty, and available evidence does not indicate
that they were impaired by effects of medical conditions or substances
at the time of the accident. [FINDING 2]
Flight 5342 crew fatigue.\1\ Review of the flight 5342 pilots' time
since waking and sleep opportunities in the days before the accident
indicated that the pilots were unlikely to have been experiencing
fatigue. [FINDING 3]
---------------------------------------------------------------------------
\1\ In this report, ``fatigue'' is used consistent with human
performance science to describe performance impairment associated with
insufficient sleep, circadian disruption, and/or extended time awake.
Operational factors such as high workload, sustained attention demands,
stress, and task saturation can also degrade vigilance and situational
awareness, but these effects are analytically distinct from fatigue and
are addressed separately in the report.
---------------------------------------------------------------------------
PAT25 crew qualifications. The pilot, IP, and crew chief onboard
PAT25 were qualified and current in their positions as designated by
the unit commander in accordance with Army regulations. [FINDING 4]
PAT25 crew medical factors. The pilot, IP, and crew chief of PAT25
were medically qualified for duty, and available evidence does not
indicate that they were impaired by effects of medical conditions or
substances at the time of the accident. [FINDING 5]
PAT25 crew fatigue. Review of the PAT25 three crewmembers' time
since waking and sleep opportunities in the days before the accident
indicated that the crew were unlikely to have been experiencing
fatigue. [FINDING 6]
Airplane mechanical factors. The airplane was properly
certificated, equipped, and maintained in accordance with 14 Code of
Federal Regulations (CFR) Part 121. The airplane was operated within
its weight and balance limitations throughout the flight. Examination
of the airplane revealed damage consistent with an in-flight collision
and subsequent impact with water, and there was no evidence of any
structural, system, or powerplant failures or anomalies. Review of
surveillance videos indicated that the airplane's wing navigation,
landing/taxi, and anti-collision strobe lights were operating at the
time of the collision. [FINDING 7]
Helicopter flight controls, rotor system, and powerplants. The
helicopter was properly certificated, equipped, and maintained in
accordance with U.S. Army regulations. Review of helicopter maintenance
records did not reveal any open discrepancies or anomalous trends that
contributed to the accident. The helicopter was operated within its
weight and balance limitations throughout the flight. Examination of
the helicopter revealed damage consistent with an in-flight collision
and subsequent impact with water, and there was no evidence of any
structural, main or tail rotor system, flight control system, or
powerplant failures or anomalies. Review of surveillance videos
indicated that the helicopter's right and tail position lights, the
landing light, as well as both upper and lower anti-collision lights,
were operating at the time of the collision. [FINDING 8]
Air traffic controller qualifications and tower staffing. The
operations supervisor (OS) and four controllers who were working in the
DCA airport traffic control tower (ATCT) cab at the time of the
accident were properly certified, qualified in accordance with Federal
regulations and facility directives, and current. [FINDING 9] Although
the DCA ATCT facility was not staffed to its target level at the time
of the accident, the number of staff in the tower at the time of the
accident was adequate and in accordance with FAA directives. [FINDING
10] Therefore, the NTSB concludes that the decision to combine the HC
and LC positions was not the result of insufficient staffing, and
personnel were available to staff the HC and LC positions separately
had the OS chosen to do so. [FINDING 11]
Controller medical factors. The LC controller, assistant local
control (ALC) controller, and OS were medically qualified for duty, and
available evidence does not indicate they were impaired by effects of
medical conditions at the time of the accident. [FINDING 12]
Controller fatigue. Review of the LC and ALC controllers' and OS's
time since waking and sleep opportunities in the days before the
accident indicated that the controllers, including the OS, were
unlikely to have been experiencing fatigue. [FINDING 13]
Weather conditions. Visual meteorological conditions prevailed in
the area at the time of the accident. A review of observations recorded
throughout the night of the accident revealed no evidence of any local
atmospheric pressure anomalies that would have impacted barometric
altimeter readings. [FINDING 14]
Airport response. Metropolitan Washington Airports Authority (MWAA)
aircraft rescue and firefighting (ARFF) and airport operations staff
responded immediately and in accordance with applicable emergency plans
and regulatory requirements, deploying land-and water-based resources,
and coordinating mutual aid under complex nighttime and on water
conditions. [FINDING 15]
Accident Sequence
Controller Performance
Workload and Resource Management
Because the LC and HC positions were combined on the night of the
accident, the LC was not only responsible for providing services to the
arriving and departing fixed-wing aircraft, but had the added
responsibility of providing services to numerous helicopters that were
transitioning the airspace. In the 20 minutes before the accident, the
total number of aircraft that the LC controller was handling fluctuated
between 7 and 12 aircraft. In a postaccident interview, the LC stated
that he felt ``a little overwhelmed'' about 10 to 15 minutes before the
accident, and that he felt the volume was manageable when ``one or two
helicopters'' left the airspace. This statement was consistent with a
peak in observed traffic volume of 10 aircraft around this time (5
helicopters and 5 airplanes); 1 helicopter subsequently departed the
airspace at 2040:28, or 7:31 before the collision. The LC controller
reported that he would have asked to have the HC and LC positions
staffed separately if he received two more helicopters.
In the 2 minutes before the accident, there were a total of 29
transmissions between the LC controller and airplanes/helicopters on
his frequency, and about 90 seconds before the collision, the number of
aircraft on the LC controller's frequency increased to 12. During that
time, the controller spoke to or received communications from six of
those aircraft: three inflight helicopters, one inflight airplane, and
two airplanes on the ground. The other six aircraft, with which the
controller did not directly communicate during the 2 minutes before the
accident, but which he was still responsible for maintaining awareness
of, included two inflight helicopters, two inflight airplanes, and two
airplanes on the ground.
Human factors research has consistently shown that in air traffic
control (ATC) operations, voice communications reliably capture and
direct controller attention toward the aircraft involved. Several
studies have shown that auditory communication events--including
issuing clearances and receiving pilot readbacks--function as
attentional anchors that trigger cognitive focus and updates to the
controller's mental representation of that aircraft's trajectory and
status (Endsley and Rogers 1997; McGee, Mavor, and Wickens 1997).
Therefore, the LC controller's moment-to-moment subject attention
allocation can be reasonably inferred from the aircraft with which he
was communicating at any given point in time.
The complexity of the airspace and limited airfield surface area at
DCA require controllers to carefully coordinate the flight paths and
timing of aircraft taking off, landing, and transitioning through the
airspace and to issue instructions and clearances as necessary to
efficiently facilitate these various flight operations. The LC
controller's communications in the 2 minutes before the accident are
consistent with his continuous shifting of priorities between airborne,
ground, and transitioning aircraft.
After initially approving PAT25's request to maintain visual
separation from flight 5342, he turned his attention to an airplane
waiting to depart, informing them about traffic three miles out
circling to runway 33 (flight 5342) and additional traffic on a six-
mile final approach for runway 1, and instructing them to line up and
wait on the runway. At 2046:29.1 (about 1:30 before the collision), an
Air Force helicopter checked in on the frequency, along with a
simultaneous transmission from an inbound American Airlines airplane.
The LC controller instructed the Air Force helicopter to standby, then
instructed a landing airplane to continue their landing roll to
``taxiway November.'' A medical transport helicopter then contacted the
tower. The LC controller cleared the airplane waiting to depart runway
1 for an ``immediate takeoff,'' as the airplane needed to be clear of
the intersection of runways 1 and 33 before flight 5342 crossed the
runway 33 threshold for landing. About 2046:58, the LC controller
replied to the Air Force helicopter, which was west-southwest of the
airport, and approved their requested route of flight. About 45 seconds
before the collision, the American Airlines airplane that had attempted
to contact the tower at the same time as the Air Force helicopter
transmitted their location on the runway 1 approach; however, that
transmission was stepped on by the medical transport helicopter's
second transmission to tower. The LC controller then approved the
medical transport helicopter's request to transition through the Class
B airspace. A conflict alert was audible during two brief mic keys from
the controller at 2047:37.8, and would have been visible on the
controller's control tower radar display (CTRD). Less than 2 seconds
later, about 20 seconds before the collision, the LC controller asked
PAT25 if they had the CRJ in sight. Three seconds later, the LC
instructed PAT25 to pass behind the CRJ. PAT25 said it had the aircraft
in sight and requested visual separation; the LC controller stated,
``vis separation.'' The American Airlines airplane inbound on the
runway 1 approach then contacted the tower a third time, and the LC
controller was communicating with that airplane when the collision
occurred.
Given the LC controller's statement that he felt ``a little
overwhelmed'' with a traffic volume of ten aircraft, it is likely he
began to feel overwhelmed again in the 2 minutes before the accident
when traffic volume increased. A review of the DCA ATCT standard
operating procedures (SOPs) and training documents did not indicate any
guidance specifically related to controller workload and how and when
controllers should ask for relief.
Where a controller's attention is focused can influence the amount
of time it takes to recognize and respond to an unexpected event. A
study that evaluated scanning patterns and detection times of expert
tower controllers to abnormal events found that the controllers'
average detection times, beginning from the onset of the abnormal
event, ranged from 14 seconds to 204 seconds (Crutchfield et al.,
2021), which could lead to adverse outcomes for time-critical safety
events. The conflict alert system acts as a safety net to assist
controllers responding to traffic conflicts in a timely manner. During
the 2 minutes before the accident, the LC controller was communicating
with aircraft located primarily south and west-southwest of the
airport; therefore, his attention would have been focused in that
direction. Just before the conflict alert activated, the LC controller
was communicating with a medical transport helicopter located about 16
miles west of the airport. The LC controller likely would have looked
at the CTRD to confirm that helicopter's location. The LC controller
recalled that he noticed the conflict between PAT25 and flight 5342
during his scan and queried PAT25 to ensure that they still had the
airplane in sight, which PAT25 confirmed.
Situation awareness forms a basis for decision-making and is
defined as the ``perception of the elements in the environment within a
volume of time and space [Level 1], the comprehension of their meaning
[Level 2], and the projection of their status in the near future [Level
3]'' (Endsley, 1988).\2\ Figure 1 presents an illustration of the
situation awareness concept. Situation awareness is not only what the
controller is perceiving in the current air traffic situation (level 1)
but how they interpret that information (level 2) and use it to project
the future state of air traffic (level 3) moving in their airspace.
Levels 2 and 3 are especially critical in the air traffic environment
because it is dynamic and constantly changing.
---------------------------------------------------------------------------
\2\ These three levels of situation awareness, which are
sequential, are followed by decisions and performance of actions.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Recognizing an impending collision requires information to be
perceived from the environment, stored in working memory, and
interpreted against knowledge stored in long term memory, allowing
controllers to identify familiar situations, predict future events, and
determine an appropriate response (Wickens, Mavor, and McGee, 1997).
Controllers must routinely monitor the current state of an aircraft and
predict its future location in relation to other aircraft (Endsley,
1995). Conflicts that develop slowly, particularly at night, are
inherently difficult for people to recognize due to reduced visual cues
and the fact that gradual change can reduce situation awareness and
delay recognition.
Controllers must maintain awareness of each aircraft they are
managing (to include, for example, location, altitude, and airspeed)
and anticipate where that aircraft will be in the seconds and minutes
to follow. A controller's ability to maintain situation awareness is
impacted by their workload and divided attention. As remaining
cognitive resources are reduced with increasing workload (such as
increasing traffic complexity, traffic volume, and/or radio
communications), a controller's ability to maintain situation awareness
is reduced. Because the LC was working the combined LC and HC
positions, he was required to manage and maintain awareness of fixed-
wing aircraft arrivals and departures as well as the movements of
helicopters in the airspace, which required dividing his attention
between airborne, ground, and transiting traffic. The NTSB concludes
that keeping the HC and LC positions continuously combined on the night
of the accident increased the LC controller's workload and negatively
impacted his performance and situation awareness. [FINDING 16]
It is also likely that the controller was using expectation-driven
processing, which directs a person's attentional focus. When events
occur as expected or are routine, such as a pilot correctly reading
back a clearance or adhering to a published flight path, information
processing occurs rapidly with minimal effort. This expectation can
lead to errors if a pilot or aircraft does not behave as expected. In
this case, the controller expected that PAT25 would remain clear of
flight 5342 because the PAT25 IP stated that they had the airplane in
sight and would maintain visual separation. The frequent use of pilot-
applied visual separation reinforces the expectation that the pilot of
one aircraft will maintain separation from another aircraft, and
because it has repeatedly worked as expected, it can be more difficult
for a controller to notice deviations, especially when workload is
high. It is likely that the controller did not expect the conflict
between PAT25 and flight 5342 to occur, and felt comfortable dividing
his attention between the accident aircraft and the numerous other
aircraft under his control at the time of the accident.
The primary duties of the ALC control position were to alert the LC
controller of any unusual situations or traffic conflicts, maintain
surveillance of the local traffic pattern and landing area, and assist
the LC controller with monitoring of aircraft on final via the CTRD.
These duties would be accomplished by scanning the airspace as well as
the tower displays. When the HC and LC positions were combined, the ALC
position had the additional duty of monitoring the helicopter and
airplane frequencies. In a postaccident interview, the ALC controller
recalled that she was ``writing down what the different helicopters
were doing'' when she heard the conflict alert and the LC controller
asking PAT25 if they had the CRJ in sight, then instructing PAT25 to
pass behind the CRJ.\3\ Monitoring traffic is a workload-intensive
task, and, like the LC, the ALC was also subject to high workload in
the minutes before the accident. If the LC and HC positions had been
staffed separately, the LC and ALC would have only been working fixed-
wing traffic, and another controller would have been working helicopter
traffic. This would have reduced the number of aircraft the LC and ALC
were controlling and monitoring--for example, about 90 seconds before
the accident, the LC/ALC would have been handling 7 airplanes while a
separate helicopter controller handled the 5 helicopters on frequency
at the time. This would have reduced cognitive loading and enabled the
HC controller to more easily keep track of the movement of the
helicopters and their potential conflicts with arriving airplanes. It
is possible that if the positions had been staffed separately, a
standalone HC controller could have detected the potential conflict
between PAT25 and flight 5342 earlier, enabling an earlier and more
effective traffic advisory to PAT25. The NTSB concludes that had the HC
and LC positions been staffed separately, PAT25 might have received a
more timely and effective traffic advisory. [FINDING 17] The NTSB
further concludes that the LC and HC positions should have been
separated at the time of the accident given traffic volume and
complexity. [FINDING 18]
---------------------------------------------------------------------------
\3\ Note taking and recording aircraft information are routine
components of local and assistant local controller duties, along with
radio communications, coordination, and traffic sequencing. Such tasks
require temporary shifts of attention between displays, communications,
and the out-the-window visual scan.
---------------------------------------------------------------------------
The NTSB also concludes that in the 2 minutes before the accident
when traffic volume was increasing, the ALC should have prioritized
surveillance of aircraft in the air in order to assist the local
controller, rather than diverting her attention to the lower priority
task of documenting helicopter information, which could have been
completed when traffic volume and complexity had subsided. [FINDING 19]
The primary duties and responsibilities of the OS included
providing operational supervision, directing the tower operation to
ensure efficiency, and determining when the HC and LC positions should
be combined or separately staffed. The DCA ATCT SOP stated that the OS,
as the watch supervisor, must maintain situation awareness of traffic
activity and operational conditions in order to provide timely
assistance to controllers and ensure that available resources are
deployed for optimal efficiency. To do this, the OS must not only
maintain a general awareness of traffic volume and complexity within
the airspace, but also continuously assess the risk of the operation to
determine when a controller needs assistance and when the HC/LC
positions should be separately staffed. The OS should also scan the
airspace and CTRD to identify any potential conflicts.
The HC and LC positions were combined when the OS came on duty
earlier on the day of the accident. Why the positions were combined
earlier that day was not determined, as facility SOP had been revised
in June 2024 to remove the requirement for documentation of the reason
for combining. Some controllers interviewed felt that combining the HC
and LC positions resulted in better situation awareness and reduced
workload, because they did not have to coordinate with another
controller the way they did when the positions were separately staffed.
Controllers stated that the benefits to staffing the positions
separately were having another set of eyes scanning traffic, less
frequency congestion, and a controller dedicated to helicopters only.
In other words, duties and responsibilities would be divided between
two controllers, allowing for more focused attention to aircraft on
their respective frequencies to recognize the development of a
potential conflict. Although the DCA ATCT SOP specified hours during
which the HC position ``should normally be de-combined,'' the SOP
allowed the OS to combine or separately staff the position at their
discretion after considering factors such as staffing, weather
conditions, and traffic volume. The LC controller stated he was feeling
a little overwhelmed about 10 to 15 minutes before the accident and had
thought about asking for the HC/LC positions to be staffed separately,
but did not because a helicopter left the airspace. Helicopter and
airplane traffic volume subsequently increased again in the 2 minutes
before the accident; however, the OS stated in a postaccident interview
that there was no need to staff the positions separately in the hour
before the accident, as they only had one helicopter at a time.
The OS had been working multiple control positions for over 4 hours
and had been working the OS position for over 2 hours at the time of
the accident. From the OS position in the tower, he was listening to
the LC controller's transmissions, which were broadcast on a speaker in
the tower cab, and ``look[ing] out the window.'' He could not recall
the specifics of the traffic situation at the time of the accident, and
did not recall the conflict alert activating, but witnessed the
collision.
To provide timely assistance to controllers and ensure that
available resources are deployed for optimal efficiency, the OS should
continuously assess the risk of ongoing factors in the operation,
including traffic volume and complexity, controller experience, time on
position, nighttime conditions, and any other factors deemed relevant.
However, given his extended time on position, it is likely that the OS
was experiencing reduced alertness at the time of the accident, which
decreased his ability to effectively assess operational risks. Research
in a simulated air traffic control room showed that extended time on
task (over 90 minutes) increased detection latency for complex events
such as two aircraft at the same altitude on the same flight path
(Thackray and Touchstone, 1989).
The OS's reduced alertness and attentiveness would be consistent
with his extended time on position at the time of the accident and his
not recognizing the increases in traffic volume that occurred 10 to 15
minutes before the accident and again in the 2 minutes before the
accident. In addition, he did not recognize the developing traffic
conflict as PAT25 continued toward flight 5342. The NTSB concludes that
due to extended time on position at the time of the collision and his
complacency, the OS was likely experiencing reduced alertness and
vigilance, which decreased his awareness of the operational environment
and reduced his ability to proactively assess the risks posed by the
traffic and environmental conditions at the time of the accident.
[FINDING 20]
FAA Order 7210.3DD, ``Facility Operations and Administration''; the
collective bargaining agreement (CBA) between the National Air Traffic
Controllers Association (NATCA) and the FAA; and DCA ATCT SOPs outline
the duties and responsibilities of supervisors, including the
requirement to ensure that adequate relief opportunities are provided
to all operational staff. However, none of these documents detail how a
supervisor is expected to manage the supervisor's own relief periods
throughout the duty day or shift. The CBA states that employees should
not be required to spend more than 2 consecutive hours performing
operational duties without a break from operational areas.\4\ While
breaks for controllers in accordance with the collective bargaining
agreement (CBA) are closely monitored and strictly enforced, the CBA
does not cover supervisory personnel such as operations supervisors and
controllers-in-charge; therefore, individuals performing these duties
are not subject to the same break requirements.
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\4\ A break is defined in the CBA as, ``a period of time during
which no duties are assigned and offer employees opportunities to
attend to personal needs or rejuvenate their mental acuity.''
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A supervisor's duties are extensive, and providing oversight in an
operational environment can be as mentally taxing as working a control
position. Under current rules, supervisors are often conducting
supervisory duties for hours, and in some cases, entire shifts, but are
not provided the same relief periods as operational personnel. The NTSB
concludes that the lack of mandatory relief periods for supervisory air
traffic control personnel is contrary to human factors research that
shows clear performance deterioration in situations of prolonged time
on task. [FINDING 21] Therefore, the NTSB recommends that the FAA
develop and implement time-on-position limitations for supervisory air
traffic control personnel, including guidance for district and facility
level management to adapt these limitations to account for their own
staffing and local standard operating procedures. [RECOMMENDATION 1]
Traffic Advisories
The LC controller's first advisory to PAT25 regarding flight 5342
occurred about 2 minutes before the collision. This advisory was
consistent with air traffic policy. In response to the controller's
traffic advisory, the PAT25 IP stated that they had the traffic in
sight and requested visual separation. The controller did not issue a
corresponding traffic advisory to the crew of flight 5342.
The controller later stated that he had other priority duties at
the time he issued the initial advisory to PAT25 and that he intended
to go back and issue an advisory to flight 5342. However, because he
was attending to other priority tasks, he did not return to the
airplane before the conflict alert activated about 1 1/2 minutes later.
Although the crew of flight 5342 had other contextual clues about the
presence of PAT25 (see discussion in section 0), they never received an
advisory from the controller about the helicopter, which would have
increased their situation awareness. The NTSB concludes that, although
the LC controller provided an initial traffic advisory to the crew of
PAT25 in accordance with FAA Order JO 7110.65, he did not provide a
corresponding advisory to the crew of flight 5342 regarding PAT25's
location and intention, which could have increased situation awareness
for the crew of flight 5342. [FINDING 22]
FAA Order JO 3120.4, ``Air Traffic Technical Training,'' conveys
instructions, standards, and guidance for the administration of air
traffic technical training (FAA, 2024c). The order lists ``positive
control'' as a job subtask, which it defined, in part, as taking
command of control situations and not acting in a hesitant or unsure
manner. The LC controller reported that, after the conflict alert
activated, he noted that the helicopter was ``way closer'' to the
airplane than it was supposed to be. In response, the controller
contacted the crew of PAT25 and stated, ``PAT two five do you have that
C-R-J in sight?'' The controller then instructed PAT25 to ``pass behind
that C-R-J.'' The PAT25 IP replied that they had ``a-aircraft'' in
sight and again requested visual separation, which the controller
approved.
FAA Order JO 7110.65AA, ``Air Traffic Control,'' paragraph 5-1-4,
Merging Target Procedures, stated that controllers must provide traffic
information to any turbojet aircraft whose target appears likely to
merge with another aircraft, unless those aircraft are separated by
more than the appropriate vertical separation minima. Safety alert
procedures and phraseology requirements, contained in paragraph 2-1-6,
stated that controllers should immediately issue a safety alert to an
aircraft that is in unsafe proximity to another aircraft, and to offer
the pilot an alternative course of action if feasible, ending the
transmission with the word ``immediately.''
When the LC controller recognized that the two aircraft were in
unsafe proximity, the most appropriate action would have been to issue
safety alerts to both aircraft regarding the other aircraft's position
and distance, and to issue positive control instructions to the pilots
that would have prevented their courses from converging, such as climb,
descend, or turn, as appropriate. However, the controller's traffic
call to PAT25 at this time provided no information that could have
assisted the crew in visually locating and positively identifying the
airplane, nor did it contain positive control instructions that the
crew could have taken to resolve the conflict. Additionally, the
controller did not issue a safety alert to flight 5342, contrary to
merging target procedures. Timely issuance of positive control
instructions by the controller and subsequent compliance with those
instructions by the flight crew(s) could have averted the impending
collision. The NTSB concludes that if the LC controller had issued a
standard safety alert to the flight crews of either aircraft as
prescribed in FAA Order JO 7110.65, providing the conflicting
aircraft's position and positive control instructions, the crew of
either aircraft could have taken immediate action to avert the
impending collision. [FINDING 23]
Threat and Error Management
The primary purposes of the ATC system are to prevent a collision
between aircraft operating in the system and to provide a safe,
orderly, and expeditious flow of traffic. FAA Order 7110.65, Air
Traffic Control, paragraph 2-1-2, ``Duty Priority,'' states, that
controllers should ``give first priority to separating aircraft and
issuing safety alerts as required in this order. Good judgment must be
used in prioritizing all other provisions of this order based on the
requirements of the situation at hand.''
Because there are many variables involved, it is virtually
impossible to develop a standard list of duty priorities that would
apply uniformly to every conceivable situation. Controllers must
evaluate each on its own merit, and when more than one action is
required, exercise their best judgment based on the facts and
circumstances known to them. According to FAA Order JO 7110.65AA,
``That action which is most critical from a safety standpoint is
performed first.'' One way that controllers may do this is to use
recognition primed decision making, which allows for quick and
effective decision making in complex situations. Recognition primed
decision making relies on pattern matching of the current situation
with past experiences to identify a course (or courses) of action, and
mental simulation of how the course(s) of action will play out (Klein,
1998).
In this accident, when the LC controller recognized that PAT25 and
flight 5342 were converging after the conflict alert activated, he
should have issued a safety alert to both aircraft; however, the LC
controller asked PAT25 if they had the airplane in sight. Under high
workload and time pressure, controllers have reduced cognitive capacity
for responding to unusual situations (Damos, 1988). The LC controller
knew he had to resolve the conflict, but had limited time and capacity
to do so. Asking if PAT25 still had the CRJ in sight, then instructing
PAT25 to pass behind the CRJ, required less processing load than
issuing a safety alert, which should include a clock position or
location of the traffic, distance, and an action for the pilot to take.
In November 2016, the NTSB issued Safety Recommendation A-16-51,
asking the FAA to provide initial and recurrent training for air
traffic controllers on controller judgment, vigilance, and/or safety
awareness with specific reference to two midair collisions that
occurred in 2015 to be used as case studies.\5\ The FAA responded that,
in July 2017, it delivered instruction to controllers on threat and
error management (or TEM, which the FAA described as the practice of
applying controller judgment, vigilance, and safety awareness) as part
of instructor-led recurrent training and stated that the training would
also be required training for future controllers. The FAA also stated
that they delivered a web-based ``Emergencies'' training in July 2017
to highlight accidents similar to the two midair collisions cited in
the recommendation. After reviewing this training, the NTSB determined
that the materials did not highlight the safety issues identified in
the 2015 midair accidents, nor did the training provided discuss those
or similar accidents as recommended. When the FAA indicated that it did
not plan to take further action, Safety Recommendation A-16-51 was
classified Closed--Unacceptable Action in 2023.
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\5\ Additional information about the two accidents and the findings
that led to our recommendations may be found, respectively, in the
reports of the investigations (ERA15MA259A/B and WPR15MA243A/B) and the
safety recommendation report (ASR-16-6).
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A vast majority of the time, controllers perform very effectively
and reliably; however, human vulnerabilities such as fatigue, increased
workload, time pressure, and biases can increase errors. A controller's
ability to anticipate, detect, and mitigate risks is essential. TEM
provides a strategy to combat these vulnerabilities. TEM is a process
for identifying safety risks--threats, errors, and undesired states--in
the environment and mitigating those risks. In the context of air
traffic control, threats include many of the complexities faced by
controllers, such as airspace congestion, pilot errors, terrain or
obstacles near the airport, and adverse weather conditions. Some
threats can be anticipated, while others occur unexpectedly. Errors are
actions or inactions by the controller that result in a deviation from
the controller's intention or expectation, such as instructing an
aircraft to taxi across an occupied runway, not detecting a pilot
readback error, or providing an incorrect clearance, heading, or
altitude. Undesired states are operational conditions where the margin
of safety is reduced. An undesired state often results from mismanaged
or missed threats and errors and is often considered the ``last stage''
before an accident or incident. To restore the margin of safety, a
controller must act to mitigate the risk by addressing the undesired
state rather than the error (ICAO 2005).
In an observational study performed by the FAA at two air traffic
control centers, they found that communication was the most frequent
threat identified, resulting primarily from frequency congestion,
simultaneous transmissions, incorrect pilot readback, or failure of a
pilot to respond. On average, 15 percent of threats lead to an error
and 13 percent of errors lead to an undesirable state (Eurocontrol,
2011). A review of United Kingdom incident data identified controller
scanning patterns of radar and flight strips to be a primary
contributor.
None of the controllers involved in this accident were familiar
with the term ``threat and error management'' during postaccident
interviews, nor were they familiar with the concepts that would be
included in such training, suggesting that they did not receive
training on this method of safety management. The NTSB requested and
received controller training materials related to identifying and
mitigating risk. Review of this material did not reveal any formal TEM
training other than the 2017 workshop, and there was no evidence to
indicate that the workshop or the subject matter it contained had been
offered in any training since 2017.
Adequate training on the use of TEM can strengthen situation
awareness by teaching controllers to continuously monitor their
environment to more quickly identify threats; promote team
communication to ensure that communications are clear, timely, and
assertive; emphasize effective scanning habits; recognize patterns in
the development of adverse events; and enhance decision making under
stress by developing habits that balance procedural compliance with
problem solving to mitigate the risks of threats and errors. TEM would
have likely improved the situation awareness of all controllers in this
event, which may have allowed for earlier conflict recognition or
encouraged the OS to conduct a risk assessment of the steady helicopter
traffic and its resulting workload on the LC and ALC controllers.
The NTSB continues to believe that including case studies in
initial and annual air traffic controller training and highlighting
situations in which controller judgment, vigilance, and safety
awareness could be improved would enhance controllers' ability to
identify and manage threats and errors. FAA guidance on the use of good
judgment is vague, and case studies provide the opportunity to examine
a real chain of events that had resulted in an accident, imparting
valuable lessons without exposing participants to the potential risk of
adverse outcomes inherent to on-the-job training, which the FAA often
relies upon for controller training. The NTSB also believes that
providing controllers the opportunity to discuss and practice applying
TEM using scenario-based training is critical, as repetition of skills
through training leads to automaticity of behaviors (Wickens et al.,
2004), thus freeing up working memory.\6\ Automaticity has been
demonstrated to improve speed and accuracy (Wickens et al., 2004),
situation awareness (Endsley, 2010), and decision making (Haith and
Krakauer, 2018). Therefore, the NTSB concludes that initial and
recurrent scenario-based training in threat and error management would
help controllers identify and mitigate risks and strengthen situation
awareness. [FINDING 24] Therefore, the NTSB recommends that the FAA
develop instructor-led, scenario-based training on threat and error
management that trains controllers to continuously monitor their
environment to more quickly and accurately identify threats; promote
team communication to ensure that communications are clear, timely, and
assertive; emphasize effective scanning habits; recognize patterns in
the development of adverse events; and enhance decision-making under
stress by developing habits that balance procedural compliance with
problem solving to mitigate the risks of threats and errors, and
provide this training to all air traffic controllers annually.
[RECOMMENDATION 2]
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\6\ ``Automaticity'' refers to highly learned skill performance
driven by schemas that does not require much controlled attention.
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TEM training would also benefit controllers performing supervisory
duties, who are responsible for overseeing facility operations and
making operational decisions, such as when to combine or de-combine
control positions, provide additional monitoring of a position or
frequency, or rotate controller positions to allow for adequate break
opportunities. When making these decisions, OSs must balance safety and
risk management with the operational demands of the facility, which are
continually changing based on factors such as traffic flow and weather
conditions. Other than the list of factors that the accident OS was to
consider when combining the HC and LC positions, there was no guidance
or tool available in the DCA ATCT SOP to support supervisors in
identifying risk, analyzing the potential impact of that risk on
individual controllers or the overall operation, prioritizing risks
based on likelihood and impact, or developing strategies to reduce or
eliminate the identified risks. Additionally, no such tool or guidance
was available in the Air Traffic Organization (ATO) ATO SMS Manual or
in FAA Order 7110.65, which prescribes air traffic control procedures.
There were several factors that increased risk to DCA ATCT operations
on the night of the accident, including nighttime conditions, the
steady volume of helicopter traffic, and the lack of requested miles-
in-trail spacing from Potomac TRACON that resulted in offloading
airplanes to runway 33. The NTSB concludes that a risk assessment or
decision making tool would likely have benefited the accident OS in
identifying and mitigating the operational risk factors that were
present on the night of the accident. [FINDING 25] A risk assessment
tool that could be tailored to the operational needs of each facility
would benefit supervisory air traffic control personnel throughout the
National Airspace System (NAS). Therefore, the NTSB recommends that the
FAA ATO develop and implement a risk assessment tool for supervisors
that incorporates the principles of threat and error management to
assist in risk identification, mitigation, and operational decision
making. [RECOMMENDATION 3]
PAT25 Operations
Helicopter Radio Quality
Review of recorded ATC communications on the night of the accident
revealed that the transmissions made by PAT25 were accompanied by
static interference, which likely made intelligibility of their
transmissions difficult for both ATC and other aircraft. The
helicopter's CVR also captured a conversation between the pilots
earlier in the flight regarding the poor quality of the transmissions
received from the controller, many of which were incomplete or broken.
Most critically, the portion of the controller's initial traffic
advisory regarding flight 5342, in which he stated that the airplane
would be ``circling runway 33,'' was not received in its entirety by
the PAT25 crew; radio interference characteristic of that experienced
by the helicopter crew throughout the flight caused the transmission to
sound like, ``for runway 33'' inside the helicopter, omitting the word
``circling.'' \7\
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\7\ This instance of interference was different from the subsequent
0.8 second mic key that resulted in the PAT25 flight crew not hearing
``two five pass behind that.''
---------------------------------------------------------------------------
If the PAT25 crew had heard the word, ``circling,'' it possibly
would have served as a salient cue alerting the crew to the airplane's
intended flight path and allowed the IP to better anticipate its
subsequent movement. Without hearing the word ``circling,'' the IP had
to infer the circling pattern from the airplane's stated destination of
runway 33. Interviews with other The Army Aviation Brigade (TAAB)
pilots indicated that they were not very familiar with fixed-wing
approaches to runway 33. Although the IP likely knew that airplanes
landing on runway 33 approached from the southeast due to the runway's
orientation, and although this implied that traffic landing on runway
33 had to cross over Route 4, anticipating this would have required the
IP's deliberate thought and attention. The NTSB concludes that, due to
degraded radio reception, the crew of PAT25 did not receive salient
information regarding flight 5342's circling approach to runway 33.
[FINDING 26]
Clear and effective communication is essential for safe air traffic
control operations and pilot situation awareness. When radio quality is
degraded, pilots and controllers can miss important information, and
having to repeat control instructions can result in time lost for other
safety-critical tasks. Given the importance of clear radio
communications and the evidence presented in this accident, in which
poor radio reception quality may have affected the PAT25 crew's
awareness of flight 5342's position and intentions, the NTSB recommends
that the Department of War Policy Board on Federal Aviation conduct a
study to evaluate the quality of radio transmissions and reception for
those aircraft operated within the National Airspace System (NAS) to
identify factors that degrade communications equipment performance and
adversely affect the safety of civilian and military flight operations.
[RECOMMENDATION 42] The NTSB further recommends the Department of War
implement appropriate enhancements, based on the findings of the study
recommended in Safety Recommendation [42],to remediate identified
deficiencies in air-ground radio communications performance.
[RECOMMENDATION 43]
Flight Crew Performance
Visual meteorological conditions prevailed in the DCA area on the
night of the accident, and the recorded wind about the time of the
accident was from 300+ at 14 kts with gusts to 23 kts, with the wind
direction varying between 270+ and 330+. These wind conditions would
constitute a right quartering tailwind for the accident helicopter,
which was traveling on a southerly course at the time of the collision.
The helicopter's CVR captured several comments between the pilots
throughout the accident flight regarding the wind and turbulence. The
comments suggested that maintaining helicopter trim, altitude, and
heading required the flying pilot's close attention.
During a postaccident simulator observation, investigators asked a
current and qualified Army pilot with over 600 hours of flight
experience in the UH-60L to retrace the accident helicopter's flight
path in conditions programmed to simulate those present on the night of
the accident. When asked to rate the workload, he reported that he had
insufficient capacity for ``easy attention'' to additional tasks due to
the conditions.
It is likely that the accident pilot, as the pilot flying, was
experiencing similar workload during the accident flight and was
relying on the IP, as the pilot monitoring, to respond to the
controller and look for traffic. The IP's prompt reply to the
controller that he had the aircraft in sight likely further reassured
the pilot that he had visually acquired the airplane, although there
was no discussion between the crew to confirm this.
At the time of the controller's initial traffic advisory to PAT25,
four other airplanes were approaching runway 1 for landing, and flight
5342 would have appeared among them when viewed from the helicopter.
None of these airplanes would have been discernable from PAT25's
position at the time of the initial traffic advisory as anything other
than a point of light in the distance. These airplanes were about 3,
7.5 (flight 5342), 11, 15, and 20 statute miles from PAT25. In the
investigative hearing, an Army standardization instructor pilot stated
that, when he was flying over Cabin John, Maryland, at night when
wearing NVGs, he was able to see airplanes ``lined up'' at the Wilson
Bridge, a distance of about 14 miles. He also stated that it was
difficult to discern any individual aircraft's sequence in a group of
airplanes, because the brightest landing or position light did not
necessarily correspond to the closest aircraft. NTSB observations of
airplane traffic at DCA from the roof of a building on the southwest
Washington, DC, waterfront (near the location where PAT25 received the
first traffic advisory) confirmed that investigators were able to see
airplanes over 16 miles away when using NVGs. It is likely that the
accident IP was able to see at least four, and possibly five, airborne
targets on the horizon in the direction of the Wilson Bridge when the
controller issued the initial traffic advisory. The NTSB visibility
study determined that these targets would have appeared as lights in a
tight cluster near the horizon south of the airport.
During the NTSB NVG observation, investigators found it difficult
to determine which of several tightly spaced approaching airplanes was
closest to the Wilson Bridge; thus, the IP's task of identifying the
``CRJ just south of the Wilson Bridge,'' would have been challenging.
However, despite the ambiguous visual scene at the time, the IP
responded almost immediately that he had the traffic in sight and
requested visual separation. The speed of the accident IP's reply
suggests a rote response that occurred without positively identifying
flight 5342. This also seems likely because the IP never pointed out or
discussed the traffic with the pilot, despite extensive discussions of
other nearby targets earlier in the flight. This issue will be
discussed further in section 0. The NTSB concludes that the PAT25 IP
did not positively identify flight 5342 at the time of the initial
traffic advisory despite his statement that he had the traffic in sight
and his request for visual separation. [FINDING 27] The NTSB further
concludes that, with several other targets located directly in front of
the helicopter represented by points of light with no other features by
which to identify aircraft type, and without additional position
information from the controller, the IP likely identified the wrong
target. [FINDING 28]
Several other reasons support the plausibility that the IP's
response to the initial traffic advisory was automatic and that he
likely did not fully realize the implications of the controller's
message. First, the IP was busy. In the 47 seconds before the
controller's transmission, the IP made a position report to the
controller, instructed the pilot to apply additional right pedal,
advised the pilot to begin a turn, corrected the pilot's altitude, and
called out a nearby obstacle (a crane). Second, at the time of the
initial traffic advisory, the IP knew that the airplane was at the
Wilson Bridge, a distance that did not pose an immediate conflict.
Finally, the IP understood that accepting visual separation was the
most efficient means of transitioning the DCA Class B airspace. This
factor will be discussed in additional detail in section 0.
The NTSB visibility study indicated that, from the IP's point of
view, the airplane would have been visible in the right windshield for
most of the 2 minutes before the collision, except for brief periods
when it was obscured by aircraft structure, and would have appeared as
a small dot of light low on the horizon among an area of bright
cultural lighting. As the helicopter neared the approach path of runway
33, the lights of flight 5342 would have appeared in the helicopter's
center windshield, outside the IP's NVG field of view when looking
straight ahead. Spotting the airplane in the 30 seconds before the
collision would have required the IP to turn his head to the left and
perform a focused visual search of the sky in the approach area for
runway 33. That he did not see the airplane at that time suggests that
he did not scan the area in the center windshield, which in turn
indicates that it did not occur to him that the airplane might be to
his left. In the absence of a focused search in the proper area, it is
unlikely that the PAT25 pilots would have spontaneously noticed the
airplane because it was outside the NVG field of view in an area of
very low visual acuity and would have appeared against a complex
background of ground lighting. Further, because the airplane was on a
collision course with the helicopter, it would have exhibited little
relative motion.
The IP's visual search for traffic was likely hindered by the
informational content of the LC controller's second traffic callout. If
the controller had provided information about the location of the
airplane in relation to the helicopter (for example, ``ten o'clock''),
the IP would have known where to look; however, the controller merely
asked if the PAT25 crew had the ``C-R-J in sight.''
Review of the helicopter's CVR indicated that the IP did not
verbally discuss with the pilot the location of flight 5342 after the
controller's initial advisory about 2 minutes before the collision nor
after the second call from the controller about 20 seconds before the
collision. The helicopter CVR recording suggests that his attention was
subsequently focused on coaching the pilot on the use of the rudder
pedals to compensate for a quartering tailwind and on monitoring radio
conversations between the local controller and two other helicopters.
His instruction to the pilot to ``kinda come left'' following his final
interaction with the controller just before the collision occurred
reinforces the idea that he believed the ``CRJ'' referenced by the
controller was among the airplanes approaching runway 1; however, he
was likely unsure which of those airplanes was the airplane in
question. Thus, the IP did not positively identify the location of the
airplane and he did not communicate his uncertainty about its location
to the pilot.
Information provided by the Army indicated that the accident IP and
pilot received aircrew coordination training during Army Helicopter
Flight School in 2019 and 2021, respectively. The crew also received
annual aircrew coordination training. A TAAB standardization pilot
stated that the 2024 aircrew coordination training involved the
discussion of several class A mishaps (as defined by the Army,
occurrences that are fatal or cause permanent disability or more than
$2.5 million in damage) and what each accident crew could have done to
improve the situation. Additionally, the accident IP was an aircrew
coordination instructor and, according to the B Company safety officer,
had provided aircrew coordination training 5 days before the accident.
The Army's H-60 Series Aircrew Training Manual, chapter 7, Aircrew
Coordination Training, stated that crews ``must use clear, concise
terms that can be easily understood and complied with in an environment
full of distractions,'' and further defined preferred terms for
communicating about traffic. Terms included, ``visual'' to indicate
that a target, traffic or obstacle was seen or identified; ``traffic,''
indicating an aircraft that presented a collision hazard, followed by
clock position, distance, and reference to altitude; and ``no joy,''
indicating that a target, traffic or obstacle was not positively seen
or identified. As an aircrew coordination training instructor, the
accident IP would have been familiar with these terms.
Additional guidance was available in chapter 4, H-60 Crewmember
Tasks, which stated that aircrews should ``immediately inform other
crewmembers of all air traffic or obstacles that pose a threat to the
aircraft'' using the ``clock, altitude, and distance method.'' Although
the IP could have used other methods to point out the airplane to the
pilot, he most likely did not do so because he was uncertain about the
airplane's position and assumed that it was one of the airplanes in
front of the helicopter on approach to runway 1, as evidenced by his
lack of a verbal affirmation to the pilot that he had located the
airplane.
Another factor that contributed to the PAT25 crew not positively
identifying flight 5342 was the lack of an integrated traffic awareness
and alerting system in the helicopter that could have provided aural
alerts to the crew's headsets and depicted traffic information on an
instrument panel display in the pilots' primary field of view as part
of their normal instrument scan. Although the crew had the capability
to display ADS-B In traffic information on a moving map display on
portable tablets using the ForeFlight application, The Army Aviation
Brigade (TAAB) pilots told investigators that they did not typically
monitor their tablets during low-level operations on the DC helicopter
routes because the flying task was too demanding. They also stated that
any aural alerts from the device could not be heard because of the high
level of ambient noise in the helicopter and because their helmets were
not equipped to receive audio from the tablets.
In the absence of an accurate mental model of the airplane's
expected flight path to runway 33, the lack of instruction from the
controller to direct his visual scan, and without an integrated traffic
awareness system, the IP's baseline expectations about traffic flow in
the DCA area likely drove his visual search. Aggregated flight tracking
data from the FAA showed that, in the year before the accident, only 5-
7 percent of northbound arrivals at DCA had landed on runway 33.
Anecdotal statements from other TAAB pilots indicated that some had
never encountered an airplane landing on runway 33 while traveling on
Route 4.
Thus, the more common flight path for airplanes during a north
operation at DCA was, by far, a straight-in approach to runway 1, and
the IP's baseline expectation would have been for conflicting traffic
to approach from the south for runway 1 (to the right of the
helicopter) rather than from the southeast (to the left of the
helicopter) for runway 33. The numerous airplanes on approach for
runway 1 likely reinforced this expectation, making it likely that the
IP considered one of them as the conflicting traffic. This scenario
would be consistent with his statement to the pilot just before the
collision, ``alright kinda come left for me. . .I think that's why he's
asking,'' because moving left would have increased the helicopter's
separation from traffic approaching runway 1.
Expectations drive attention, and people sometimes have difficulty
noticing a variance between what they usually see and the actual state
of things. When expectations are strong, people tend to seek out and
attend to confirmatory visual information while overlooking indications
that the current situation is different. This phenomenon, known as
expectation bias, not only influences perception in the present, it
also influences perception of past events by promoting recollections
that conform more closely to typical patterns. Expectation bias is a
well-known vulnerability in human performance. In this case,
expectation bias likely played a role in the IP's ineffective scan
following the controller's traffic callouts. The NTSB concludes that
interference that obscured the controller's ``circling to'' call, the
microphone keying that blocked the PAT25 crew from receiving the
instruction to ``pass behind,'' ambiguous visual cues, and the lack of
an integrated traffic awareness and alerting system likely reinforced
the PAT25 crew's expectation bias that the airplane was among the
traffic approaching runway 1 and did not pose a conflict. [FINDING 29]
It could not be determined whether the PAT25 pilots received
specific training addressing DCA runway use and traffic patterns,
including fixed-wing approach and departure procedures. However, given
the proximity and routine interaction of published helicopter routes
with DCA fixed-wing traffic flows, additional airspace-specific
training on DCA arrival and departure corridors and runway
configurations would likely have improved the PAT25 crew's
understanding of the risks inherent in the Army's routine mission-
related operations in this environment. Therefore, the NTSB concludes
that the absence of documented training on DCA fixed-wing procedures
and the mixed-traffic operating environment represented a safety
vulnerability for Army flight crews operating in the DCA Class B
airspace. [FINDING 30] As a result, the NTSB recommends that the U.S.
Army revise training procedures for flight crews assigned to operate in
the Washington, DC, area to ensure that they receive initial and
recurrent training on fixed-wing operations at DCA, including approach
and departure paths, runway configurations, and the interaction of
those traffic flows with published helicopter routes. [RECOMMENDATION
34]
Helicopter Altimetry
Aircraft pitot-static systems and barometric altimeters have
defined performance specifications. These include allowable instrument
errors, which are tolerances for allowable errors after manufacture and
during operation. They also include tolerances for position errors,
which are errors caused by external aerodynamic effects from the
airflow over the aircraft and (on helicopters) the main rotor downwash.
Although cockpit instruments are designed to be accurate, in general it
is not feasible to design barometric altimeters to be perfectly
accurate in all flight conditions or throughout their entire service
life. Older design mechanical barometric altimeters, such as those on
the accident helicopter, have multiple types of allowable errors that
can accumulate while still remaining within design and performance
criteria. Additionally, changes to the aerodynamic shape of the
aircraft, such as adding external stores support system (ESSS) tanks,
change the pressure effects on the pitot-static system and can increase
the position error. Altimeter testing showed that the 100-ft pressure
altitude discrepancy seen in the flight data recorder data for the
accident flight was observed on three other UH-60L helicopters operated
by the 12th Aviation Battalion. These altimeter testing results also
showed that the pressure altitude data recorded by the helicopters'
FDRs, when corrected for local conditions, was representative of what
was indicated on the right side altimeter. Therefore, the FDR pressure
altitude data for the accident helicopter, when corrected for local
conditions, was likely representative of what was indicated on the IP's
barometric altimeter during the accident flight.
The allowable tolerances are additive, with the total error having
the potential of exceeding 100 ft. These tolerances are not unique to
military aircraft; they apply to civil aircraft as well. While a
difference of 100 ft would have little consequence at higher altitudes,
given the low altitudes prescribed along portions of the DC helicopter
routes and Army procedures that stated that flight should be conducted
no lower than 100 ft agl, such a discrepancy resulted in the increased
likelihood of altitude exceedances along these routes.
Although the instrument error specific to the accident helicopter
could not be determined, disassembly and examination of the internal
components did not reveal any anomalous wear that would have prevented
normal operation. Additionally, the CVR recording did not capture any
conversations between the flight crew regarding any malfunction of the
barometric altimeters during the accident flight. It is likely that the
behavior of the accident helicopter's static system position error and
barometric altimeter instrument error were similar to that observed on
other 12th Aviation Battalion UH-60L helicopters. The NTSB concludes
that, due to additive allowable tolerances of the helicopter's pitot-
static/altimeter system, it is likely that the crew of PAT25 observed a
barometric altimeter altitude about 100 ft lower than the helicopter's
true altitude, resulting in the crew erroneously believing that they
were under the published maximum altitude for Route 4. [FINDING 31]
The accident helicopter's FDR should have contained a radio keying
parameter; however, these data were not present on the accident
helicopter's recorder. The radio keying parameter is needed to
synchronize timing between the FDR and CVR, and accurate parametric
data from the FDR is crucial for accident investigation purposes as
well as for flight operations quality assurance (FOQA) programs used to
support a safety management system (SMS). The investigation found that
after the initial installation of the helicopter's FDR, there was no
scheduled recurrent task to verify the continued accuracy of the
recorded data. FAA Advisory Circular (AC) 20-141B recommends that
operators of aircraft equipped with a digital FDR perform a
``reasonableness check'' at an interval not to exceed 18 months (FAA,
2010). The NTSB concludes that a recurrent task to verify the continued
accuracy of recorded flight data for U.S. Army aircraft would help
ensure the data integrity needed to support quality assurance and
safety programs and accident investigations. [FINDING 32] Therefore,
the NTSB recommends that the U.S. Army develop and implement a
recurring procedure, at an interval not to exceed 18 months, to verify
the continued accuracy of recorded flight data. [RECOMMENDATION 35]
The Washington, DC, helicopter route altitudes, particularly the
low altitudes specified for Routes 1 and 4 in the vicinity of DCA, did
not account for the errors inherent to barometric altimeters, nor did
they account for human error tolerances--both Army standards and FAA
commercial pilot standards require pilots to maintain altitude within
100 ft while in flight. Review of aggregated aircraft
flight track information for helicopters on the DC helicopter routes
from January 1, 2024, through January 30, 2025, indicated that
helicopters regularly exceeded published maximum route altitudes. For
the northern segment of Route 4, which included the area of the
collision, of the 523 flights analyzed, 260 flights (49 percent) were
identified as exceeding route altitude limitations at some point during
the flight. Had the error tolerances of barometric altimeters been
considered during design of the helicopter route maximum altitudes, the
incompatibility of a 200-ft ceiling and barometric altimeter errors may
have been identified. Although the data did not attribute an exact
number or rate of altitude exceedances specifically to Army
helicopters, the data indicated that military users comprised about 79
percent of the helicopter flight track data; therefore, it is
reasonable to assume that at least some Army helicopters were exceeding
maximum route altitudes. The NTSB concludes that the FAA and the Army
failed to identify the incompatibility between the helicopter routes'
low maximum altitudes and the error tolerances of barometric
altimeters, which contributed to helicopters regularly flying higher
than published maximum altitudes and potentially crossing into the
runway 33 glidepath. [FINDING 33]
Despite helicopter manufacturer flight testing that showed
increased barometric altimeter position errors with the ESSS installed,
the Army's UH-60L operator's manual did not contain an altimeter
correction chart for the ESSS configuration. The lack of this
information in the operator's manual would result in UH-60L pilots
being unaware that the ESSS could result in a greater-than-anticipated
position error in flight. Neither maintenance checks nor the pilot's
preflight check against local field elevation would detect this error,
as these checks are not performed with the helicopter's main rotor
turning.
The U.S. Army issued Standardization Communication message 25-02 to
inform pilots of the potential for increased position error in UH-60
helicopters equipped with ESSS.\8\ This message included instructions
to maintain a minus 50-ft margin when flying with a clearance with a
maximum altitude to ensure the maximum altitude is not exceeded.
However, at the time of this report, the U.S. Army has not incorporated
information into the UH-60 series operator's manuals to inform pilots
of the increased position error with the ESSS configuration. The NTSB
concludes that pilots need all available information on the potential
total error, allowed by design, that could occur in flight on an
airworthy barometric altimeter. [FINDING 34] Therefore, the NTSB
recommends that the U.S. Army incorporate information within the
appropriate operator's manual for all applicable aircraft on the
potential total error allowed by design that could occur in flight on
an otherwise airworthy barometric altimeter, including the increased
position error associated with the ESSS configuration. [RECOMMENDATION
36]
---------------------------------------------------------------------------
\8\ The message was signed by the Director of the U.S. Army
Aviation Center of Excellence's Evaluation and Standardization
Directorate on August 5, 2025.
---------------------------------------------------------------------------
Helicopter Transponder
Postaccident examination of the helicopter's transponder revealed
that it was transmitting the incorrect aircraft address during the
accident flight due to a broken solder connection, which was the result
of an incomplete bond at the time of the unit's manufacture. This
incorrect address was not a factor in the accident flight, because no
other aircraft in the geographic area was transmitting an identical
address, but it could pose a safety risk if two aircraft in the same
vicinity were to broadcast the same address.\9\ The examination also
revealed that the transponder Automatic Dependent Surveillance--
Broadcast (ADS-B) squitter was off and the time source was incorrectly
set, which prevented the transponder from broadcasting ADS-B Out. Given
that there was no historical ADS-B data for the accident helicopter
following the installation of the transponder in April 2023, it is
likely that either the squitter or time source setting, or both, were
incorrectly set at the time of installation. A functional check of the
transponder that was required after its installation should have
detected that ADS-B Out was not broadcasting. Therefore, the NTSB
concludes that the Army's post-installation functional check of the
transponder on the accident helicopter was insufficient to detect that
it was not broadcasting ADS-B Out. [FINDING 35] Inspection of other
helicopters from the 12th Aviation Battalion found incorrect time
source settings on several aircraft equipped with APX-123A
transponders, resulting in the Army directing a one-time inspection of
transponders to verify ADS-B Out functionality. It could not be
determined how or why the time source setting was changed following
installation of the transponders. At the time of the accident, the Army
had no established recurrent procedure for verifying transponder ADS-B
functionality or confirming that it was transmitting the correct
address. The NTSB concludes that the Army's lack of a recurrent
transponder inspection procedure resulted in the incorrect aircraft
address being transmitted by the accident helicopter's transponder, and
the incorrect ADS-B settings on several other helicopters being
undetected. [FINDING 36] As of the date of this report, the Army has
not yet developed a recurring procedure for this task, and it is
possible that future ADS-B Out or aircraft address issues could go
undetected. Therefore, the NTSB recommends that the U.S. Army develop
and implement a transponder inspection procedure on all aircraft with
transponders capable of transmitting Mode S and ADS-B and operated in
the NAS, at least annually and upon each aircraft's entry into service
in the NAS, that ensures
---------------------------------------------------------------------------
\9\ Although there is a very low probability that two aircraft in
the same geographical vicinity and covered by the same radar may
broadcast the same aircraft address, the scenario is not impossible.
---------------------------------------------------------------------------
1) the transponder ADS-B settings are correct,
2) the transponder is transmitting ADS-B, and
3) the transponder is transmitting the correctly assigned address.
[RECOMMENDATION 37]
Additionally, the NTSB concludes that, because the APX-123A
transponder is designed for use on multiple aircraft platforms, it is
possible that incorrect settings may be present on other aircraft used
throughout the Department of War armed services. [FINDING 37]
Therefore, the NTSB recommends that the Department of War Policy Board
on Federal Aviation require the Department of War to verify on all
aircraft with transponders capable of transmitting Mode S and ADS-B and
operated in the NAS, at least annually and upon each aircraft's entry
into service in the NAS, that
1) the transponder ADS-B settings are correct,
2) the transponder is transmitting ADS-B, and
3) the transponder is transmitting the correctly assigned address.
[RECOMMENDATION 44]
Flight 5342 Operations
FDR and CVR information from the airplane indicated that the
airplane's control columns rapidly moved aft and the crew indicated
surprise and alarm about 1 second before the impact; these actions are
consistent with the crew of flight 5342 not detecting the helicopter
until it was too late to avoid a collision. The limitations of see-and-
avoid, discussed in section 0, likely explain the crew's late
detection. Factors particularly relevant in this case include a complex
background of dense cultural lighting behind the helicopter until about
10 seconds before impact, which would have made the helicopter's
external lighting inconspicuous, and the helicopter's minimal relative
motion in the flight 5342 crew's field of view, which also would have
made it difficult to spot. The crew's moderate to high workload during
the final stage of the circling approach, as shown in simulator studies
conducted as part of this investigation, likely also reduced the odds
of the flight crew detecting the helicopter.
The CVR recording indicated that the crew did not verbally
communicate about the traffic alert and collision avoidance system
(TCAS) traffic advisory (TA) they received 19.2 seconds before the
collision. Guidance provided by PSA Airlines did not specify standard
callouts pilots were required to make in response to a TA. PSA's Flight
Operations Manual (FOM) stated that, upon receiving a TA, a crew should
``attempt to see the reported traffic'' and ``should not maneuver based
on a TA alone.'' The FOM referred to FAA AC 120-55, which contained
guidance indicating that crews should ``respond to TAs by attempting to
establish visual contact with the intruder aircraft and other aircraft
which may be in the vicinity.'' The AC also included the statement,
``coordinate to the degree possible with other crewmembers to assist in
searching for traffic. Do not deviate from an assigned clearance based
only on TA information.'' Thus, crew members were advised to search for
the conflicting traffic and coordinate with each other as workload
allowed, but were not permitted to maneuver in response to a TA without
seeing a target that posed a collision risk.
The TA aural alert activated when the airplane was 1.05 nm from the
helicopter and as the captain was turning the airplane left to align it
with the runway 33 final approach path about 450 ft radio altitude.
Simulator observations with current and qualified PSA CRJ pilots
indicated that this was a visually demanding task that required the
captain to control the airplane's lateral path, thrust, airspeed, and
glidepath (as indicated by the precision approach path indicator or
PAPI). It is unlikely that he had spare capacity to perform an
extensive visual search for traffic at this time. The FO was also
performing visually demanding tasks, such as monitoring the airplane's
lateral alignment, glidepath, and energy state to ensure that the
approach remained stable, and monitoring the position of an airplane
that had been cleared for takeoff on runway 1 to ensure that it would
not pose a conflict. That airplane was still on or near the surface of
the runway at the time the TA occurred, and it did not cross the
centerline of runway 33 (thus no longer posing a conflict) until 4
seconds after the TA. The FO also would have been required to adjust
the airspeed indicator bug for the airplane's final approach speed as
soon as the captain had aligned the airplane with the runway. Thus,
both pilots were busy and had limited opportunity to search for traffic
in response to the TA.
If, despite this workload, the FO had promptly reacted to the TA,
it is likely that he would have glanced at the multifunction display
(which was set to show traffic within a 5 nm radius) to determine the
traffic's location. This would have revealed a traffic icon 1 nm mile
in front of the airplane at a relative altitude of -200 feet. He would
then have looked directly in front of the airplane. For 9 seconds after
the TA occurred, the helicopter was surrounded by, and likely
indistinguishable from, a dense array of both steady and flashing
lights that stretched along the horizon to the right of the airport.
Given the complexity of this background and the helicopter's lack of
apparent motion when viewed from the airplane, it is likely that the FO
would have been unable to spot it during a brief search. Even if the
crew was unsuccessful in visually locating the helicopter, they were
trained not to maneuver unless they received an resolution advisory
(RA). Many of the PSA pilots interviewed were unaware of the altitude
below which RAs were inhibited.
It is also possible that the radio transmissions audible to the
flight crew reduced the extent of their visual search for the
helicopter. Although the crew could not hear PAT25's transmissions to
the controller, they could hear the controller's transmissions to the
helicopter. These transmissions would have been reassuring if the crew
heard them and recognized their airplane as the ``CRJ'' being
referenced. One second before they received the TA aural alert, they
would have heard the LC controller transmit, ``PAT two five you got the
C-R-J in sight?'' followed by, ``PAT two five pass behind the C-R-J.''
A few seconds later, they would have heard the LC controller transmit
``vis sep.'' The crew of flight 5342 undoubtedly understood the
terminology associated with approving visual separation. Thus, these
transmissions (if listened to) would have indicated to the crew that
the helicopter had their airplane in sight and intended to avoid them.
The fact that the controller did not issue them any advisories or
instructions would also have been reassuring, because it would have
indicated that the responsibility for deconfliction had been assigned
to the helicopter. If heard and attended to, the radio communications
audible to the flight 5342 crew could have reassured them that the
helicopter was not a significant threat and that they could focus their
attention on completing their approach and landing. However, because
the CVR did not contain any discussions between the crew about these
transmissions or the potential of a conflict with the helicopter, their
level of awareness of the transmissions and their involvement in the
traffic conflict could not be determined.
The NTSB concludes that the crew of flight 5342 did not see the
helicopter until it was too late to avoid a collision because of the
high workload imposed during the final phase of their approach, and due
to the helicopter's low conspicuity and lack of apparent motion.
[FINDING 38]
DCA Air Traffic Control Tower Facility
Traffic Management, Volume, and Flow
Postaccident interviews and investigative hearing testimony
provided by DCA ATCT and Potomac terminal radar approach control
(TRACON) personnel, as well as FAA Air Traffic Organization (ATO)
leadership, indicated that managing the flow of traffic at DCA had been
a longstanding challenge that could be attributed to several factors,
one of which was DCA's airport arrival rate (AAR).
Potomac TRACON and DCA ATCT personnel stated in interviews and
investigative hearing testimony that managing the rate of arrivals into
DCA while providing adequate MIT spacing between arriving aircraft was
a continual issue. Potomac TRACON and DCA ATCT had agreed that aircraft
would arrive at the runway threshold at DCA with a spacing of 4 miles
in trail (MIT); however, the FAA found through a systematic review
conducted after the accident that DCA ATCT controllers were provided
with less than 4 MIT about 40 percent of the time. This spacing was
critical because it allowed adequate time for departures to take place
between arriving aircraft, thereby reducing backups on DCA's limited
taxiway surface area.
In 2023, Potomac TRACON requested a decrease to the existing AARs
due to changes to the mix of aircraft types serving DCA over the
previous decade, flight schedule increases that did not allow for use
of reduced separation of aircraft on final approach, airspace and
weather constraints, and an inability to regulate traffic flow based on
time, also referred to as ``metering.'' The Potomac TRACON air traffic
manager (ATM) stated in postaccident interviews that the request to
reduce DCA's AARs was not forwarded to higher levels because it was
``too political.'' The FAA's denial of the documented request to change
the AAR at DCA without feedback to the requester effectively eliminated
what could have been an important operational safety improvement and
violated their established review process.
Another factor that DCA ATCT controllers cited as contributing to
traffic complexity was that airlines often grouped their allotted
departures or arrivals for a given 2-hour period into the last 30
minutes of the first hour and the first 30 minutes of the second hour
rather than spreading them evenly throughout the hour, which resulted
in times of ``compacted demand'' on controllers to accommodate traffic
surges. The NTSB concludes that times of compacted demand as a result
of air carrier scheduling practices increased operational complexity
and required mitigations by controllers to maintain spacing and surface
movement. [FINDING 39] Other airports, including New York's LaGuardia
Airport, have mitigations in place to prevent this practice through
Federal regulations contained in 14 CFR 93 Subpart K, which prescribes
air traffic rules for aircraft operating to and from high density
traffic airports. The regulation specifies the number of operations
that can occur during any 30-minute period or any two consecutive 30-
minute periods. In order to alleviate the effects of compacted demand
at DCA, the NTSB recommends that the FAA initiate rulemaking in 14 CFR
Part 93 Subpart K, High Density Traffic Airports, that prescribes air
carrier operation limitations at DCA in 30-minute periods, similar to
those imposed at LaGuardia Airport, to ensure that the airport does not
exceed capacity and to mitigate inconsistent air carrier scheduling
practices. [RECOMMENDATION 4]
A time-based flow management (TBFM), or metering, system had been
in place at Potomac TRACON for at least 10 years before the accident
and controllers had been trained in its use; however, the system was
never activated. The core function of TBFM is the ability to schedule
aircraft to reach a defined point at a specified time, creating a time-
ordered sequence of traffic.
According to testimony provided in the investigative hearing by the
FAA's Washington District traffic management officer, TBFM would allow
for better management of the compacted demand at DCA. A representative
of American Airlines testified that TBFM was in use at several of the
airline's other hub airports and that it ``smooths out the volume'' of
traffic while providing more accurate MIT. Information provided by the
FAA indicated that, as of February 2025, the TBFM project at Potomac
TRACON was on hold until further notice due to budget constraints. A
manager at Potomac TRACON testified that they had ``not seen it yet,
and it is supposed to come in March of [20]26.''
In interviews with DCA ATCT personnel, as well as review of ATC
audio and personal observation by investigators, ``offloading''
arrivals to another runway was common practice at DCA to build spacing
between aircraft, particularly during times of heavier traffic flow and
when the airport was in a north configuration (airplanes landing on
runway 1).
The DCA ATCT operations manager at the time of the accident stated
that controllers routinely offloaded traffic on approach to runway 1 by
having them circle to runway 33. Although other methods were available
to DCA controllers to build additional spacing between aircraft, the
operations manager stated that offloading traffic to runway 33 was a
preferred mitigation at DCA ATCT because it continued the flow of
arrivals and departures during compacted demand times.\10\ In contrast,
having an airplane decrease airspeed on final approach to increase
separation would cause traffic buildup behind that aircraft that would
also affect Potomac TRACON.
---------------------------------------------------------------------------
\10\ During the NTSB's investigative hearing, the ATO's acting
deputy COO testified that other methods included slowing aircraft after
check-in on final approach, instructing aircraft to perform S-turns on
final approach, and ``demand[]'' that Potomac TRACON provide a certain
MIT interval between aircraft, if needed.
---------------------------------------------------------------------------
Many of the factors that contributed to DCA's uniquely complex
traffic situation were present on the night of the accident and
contributed to high controller workload. The LC controller stated in a
postaccident interview that a traffic ``push,'' or compacted demand,
had begun about 2000 that night, but he believed that traffic was
decreasing around the time of the accident. He also stated that the
tower ``wasn't getting spacing on final'' at the time of the accident,
referring to the 4 MIT agreement with Potomac TRACON. Further, he had
traffic on the ground waiting to depart. As a result, he was asking
pilots of aircraft inbound for landing whether they could switch to
runway 33 as a means of increasing space between arrivals to allow for
departures. The NTSB concludes that DCA ATCT routinely received less
than the requested miles in trail spacing from Potomac TRACON, which
increased controller workload by requiring them to generate additional
spacing to prevent delays or gridlock. [FINDING 40] The NTSB also
concludes that the practice of ``offloading'' arrival traffic on
approach to runway 1 by asking pilots if they could accept a circling
approach to runway 33 was a routine mitigation strategy for DCA
controllers to generate spacing that was not provided by Potomac
TRACON. [FINDING 41] The NTSB further concludes that TBFM, or metering,
would provide Potomac TRACON and DCA ATCT with a consistent flow of
traffic with more accurate spacing and greater predictability, thereby
reducing controller workload. [FINDING42]
The NTSB recognizes that, according to the FAA, Potomac TRACON
began limited operational use of TBFM in October 2025; however, TBFM
had not yet been implemented at the Potomac TRACON or the DCA ATCT at
the time of the accident, and full implementation and operational use
of TBFM in both facilities is expected by March 2026. Therefore, the
NTSB recommends that the FAA fully implement operational use of the
TBFM system at Potomac TRACON and its associated air traffic control
towers. [RECOMMENDATION 5] The NTSB also recognizes that FAA also made
a temporary adjustment to the AAR following this accident, which
remains in effect as of the date of this report. In order to fully
address the traffic management, volume, and flow issues in the DCA
airspace, the NTSB recommends that the FAA reassess the DCA AAR with
special consideration to its airspace complexity, airfield limitations,
mixed-fleet operations, and traffic volume. [RECOMMENDATION 6]
The NTSB is concerned also that the spacing issue observed in this
accident may exist elsewhere in the NAS. Therefore, the NTSB also
recommends the FAA require each Class B or Class C ATCT facility to
evaluate its existing MIT procedures or agreements to ensure that the
spacing provided is appropriate for operational safety, and make the
results publicly available. [RECOMMENDATION 7]
During the course of the investigation, the NTSB learned that the
DCA ATCT had been downgraded from a level 10 facility to a level 9
facility in 2018. Facility level is a factor that determines controller
compensation, and controllers stated that the downgrade at DCA ATCT
impacted employee morale and resulted in the loss of experienced
controllers, who left for higher paying facilities. Despite several
requests from the NTSB during this investigation, the FAA did not
provide documentation of the criteria or formula it used in its
determination to downgrade DCA ATCT's facility level.
The NTSB is concerned about the impacts of the downgrade on the DCA
ATCT's long-term facility health and by the FAA's lack of transparency
regarding the metrics used to define facility levels throughout the
NAS. Although the DCA ATCT's facility level downgrade could not be
directly correlated to the circumstances of this accident, the NTSB
concludes that DCA ATCT has significant airspace, airfield, mixed
fleet, and operations complexities that appear to be inconsistent with
its current facility level classification. [FINDING 43] Therefore, the
NTSB recommends that the FAA define objective criteria for the
determination of air traffic facility levels considering traffic and
airspace volume, operational factors unique to each facility, and cost
of living. [RECOMMENDATION 8] Using this criteria, determine whether
the classification of the DCA ATCT as a level 9 facility appropriately
reflects the complexity of its operations. [RECOMMENDATION 9]
Visual Separation
The FAA's Pilot-Controller Glossary states that visual separation
is a means employed by ATC to separate aircraft in terminal areas and
enroute airspace in the NAS. In the terminal, or airport, area, visual
separation can be either tower-applied, in which the tower controller
sees the aircraft involved and issues instructions to effect
separation; or pilot-applied, in which a pilot sees the other aircraft
involved and provides their own separation by maneuvering as necessary
to avoid it. Visual separation does not require a certain minimum
separation distance between aircraft; therefore, pilots are permitted
to determine their own spacing. In the absence of visual separation at
DCA, Class B radar separation minimums would apply, which require 1 1/2
mile lateral or 500 ft vertical distance between IFR (airplane) and VFR
(helicopter) traffic.
Postaccident interviews with controllers and testimony provided in
the NTSB investigative hearing revealed that visual separation was the
primary means of separating helicopter and fixed-wing traffic in the
DCA area when weather conditions permitted. One controller testified
that the use of visual separation was ``paramount'' to efficient
operations at DCA given the volume of traffic and the complexity of the
airspace. Due to the proximity of the helicopter routes and zones to
the approach and departure corridors for fixed-wing traffic, applying
standard Class B separation minimums at all times would likely require
controllers to frequently issue holds to helicopter traffic and,
depending on traffic priority, could also result in controllers
frequently issuing go-around instructions to fixed-wing traffic, all of
which would increase controller workload and contribute to additional
airspace congestion and traffic complexity. To avoid these
difficulties, controllers were motivated to provide a traffic advisory
and authorize visual separation for helicopters transiting DC airspace
as early as possible, and interviews with controllers indicated that
this practice had become the norm.
Previous external compliance verifications (ECVs) at the DCA ATCT
identified issues such as shortcutting standard phraseology, instances
in which the HC position was combined or de-combined without required
documentation in the facility logs, and occurrences in which
helicopters flew in close proximity to arriving fixed-wing aircraft and
traffic information was not issued to either aircraft. The team also
observed occasions where fixedwing traffic was not advised regarding
helicopters operating in close proximity to the final approach course.-
wing traffic was not advised regarding helicopters operating in close
proximity to the final approach course.
During a November 2024 ECV, the ECV team noted ``a few
occurrences'' in which the LC controller advised aircraft on final
approach that helicopters operating near the final approach course had
them in sight and were maintaining visual separation. However, at the
time these transmissions were made, the helicopter had not reported the
traffic in sight and had not been advised to maintain visual
separation. The LC controller appeared to be anticipating that the
helicopters would visually acquire the arrival traffic, report traffic
in sight, and then be instructed to maintain visual separation.
A retired FAA air traffic specialist who was subsequently employed
as a contractor to perform ECVs at DCA ATCT stated that, during his 9
months at the facility, he had concerns about potential conflicts with
the helicopter routes, which he raised to the ATM at the time.
In the NTSB's investigative hearing, the DCA ATCT operations
manager (OM) at the time of the accident stated that the controllers at
DCA would ``just make it work'' by utilizing all available tools to
compensate for the traffic volume.
Because DCA was a high volume, complex airport with ``not a lot of
real estate,'' controllers had to ``keep things moving'' in order to
provide safe and efficient service. He stated that this ``make it
work'' mentality had become normalized at DCA ATCT before the accident
and that, ``it can be taxing on a person. . .constantly having to give,
give, or push, push, push in order to efficiently move traffic.'' He
further stated that, ``Whenever the controllers at DCA just make it
work, they are going above and beyond to approach the limit of the
rules and regulations. They're pushing the limits of what can be done
to safely and efficiently move the aircraft and/or helicopters at DCA.
. .you're pushing the line.''
The issues identified by previous ECVs at DCA should have served as
symptoms of a controller workforce under constant pressure to ``make it
work.'' Controllers relied on the use of pilot-applied visual
separation in order to accommodate helicopters operating on the routes
and zones while moving a high volume of aircraft through complex
airspace into and out of an airport with limited surface area. The NTSB
concludes that the FAA ATO failed to recognize ECV results as
indicators of systemic traffic management, volume, and flow issues at
DCA for which controllers were required to compensate. [FINDING 44]
Interviews and testimony from helicopter operators in the DCA area
indicated widespread understanding that visual separation allowed more
efficient traffic flow and that requesting and receiving approval for
visual separation was normal practice. Helicopter operators reported
receiving traffic advisories at distances that made it difficult to
identify specific targets. Nevertheless, they were generally
comfortable using pilot-applied visual separation, particularly on
clear nights and when using NVGs, which allowed aircraft lights to be
seen from long distances.
The expectation that helicopter crews would maximize use of visual
separation to facilitate traffic flow likely promoted a pattern of
automatic responses when flight crews received traffic advisories. An
Army standardization instructor pilot stated in a postaccident
interview that he sometimes responded to traffic advisories before
visually acquiring the traffic if he knew that it was far away and was
not an imminent threat. The accident IP's significant experience flying
on the DC helicopter routes and the speed of his reply to the
controller's traffic advisory support the likelihood that he had also
developed this habit. This practice was contrary to FAA requirements
that a crew should visually identify aircraft before requesting visual
separation.
The acceptance of a gap between typical operating practices and
formal operating requirements has been described as normalization of
deviance. Coined after the Space Shuttle Challenger disaster in 1986,
``normalization of deviance'' refers to the gradual shift away from
standards or acceptable practices (Vaughan 1996). Such deviations
originate from frontline personnel trying to manage conflicting goals,
such as maximizing production, protection, and minimizing workload
(Rasmussen, 1999). When such gaps develop, they can become
incrementally larger if they persist without negative consequences, and
this can lead to systemic safety vulnerabilities.
In this case, controller expectations that a helicopter crew would
have a specific aircraft in sight before requesting and receiving
approval for visual separation were not necessarily valid. As a result,
there was potential for controllers to overestimate the level of
traffic awareness a helicopter crew had, following a traffic advisory,
and to underestimate the level of information and assistance they might
subsequently require to ensure collision avoidance.
The NTSB concludes that the longstanding practice of relying on
pilot-applied visual separation (see-and-avoid) as the principal means
of separating helicopter and fixed-wing traffic in the Washington, DC,
area by DCA tower, the Army, and other helicopter operators led to a
drift in operating practices among controllers and helicopter crews
that increased the likelihood of a midair collision. [FINDING 45]
There are inherent limitations to seeing and avoiding other
airborne traffic. These include the limited field of view from the
cockpit, including the obscuring effects of aircraft structures or, in
this accident, the limited field of view provided by NVGs. Even the
positioning of aircraft in a pilot's field of view near the cockpit
structure reduces the odds of detection due to the effect of nearby
objects on visual accommodation (Chong and Triggs 1989).
In this accident, both aircraft were located adjacent to or within
a field of background lights when viewed from the other's perspective.
Aircraft superimposed on or adjacent to complex backgrounds are more
difficult to detect (Steedman and Baker 1960). Although aircraft
lighting may improve the conspicuity of aircraft flying at night, the
effect of a complex background of ground lighting may offset the
advantages of such lighting. An Army standardization instructor pilot
testified during the investigative hearing that, although it was easy
to identify airplanes on approach to runway 1, it would be much more
difficult to maintain visual contact with an airplane circling for
runway 33, particularly as the helicopter descended to 200 ft. He also
testified to the challenges inherent to NVG use, including the limited
field of view and the difficulty in identifying aircraft operating near
or below the horizon against dense cultural lighting.
Attentional limitations also play a role. Research indicates that
fixed-wing pilots spend, on average, 30 percent to 35 percent of their
time scanning outside, and even less time when engaged in tasks that
demand their attention inside the cockpit (Wickens et al., 2001). When
pilots do scan outside for traffic, they are biased toward the area
directly in front of them, or toward outside features most pertinent to
their current task (Colvin et al., 2005). Aircraft on a collision
course lack relative motion in a pilot's field of view, which makes
them less likely to attract visual attention because peripheral vision
is more sensitive to motion than fine detail (Gibb et al., 2010).
These and other factors contribute to delays in detection that can
lead to a midair collision when crews are visually self-separating.
Research involving actual test flights indicates that most unalerted
visual acquisitions of conflicting aircraft occur after two aircraft
have closed to within 1 to 2 nm of each other. Mathematical modeling of
the probability of visual acquisition based on these studies has
indicated that, for a closure rate of 120 kts, the probability of
detecting an intruder aircraft in the daytime does not reach 85 percent
until 12 seconds before a collision (Andrews 1991). In this accident,
CVR and FDR data indicate that the crew of flight 5342 detected the
helicopter about 1 second before the collision, and that the crew of
PAT25 had no awareness of the impending collision.
The NTSB has highlighted the limitations of see-and-avoid in
previous investigations and argued that these limitations cannot be
overcome by recommending greater pilot diligence and scanning for
traffic. Traffic awareness and alerting technologies with aural alerts,
however, can significantly improve detection and reaction times
(Andrews 1991). This underscores the importance of such technology in
airspace with a high concentration of commercial air traffic.
This accident, in which neither the crew of PAT25 nor the crew of
flight 5342 detected each other in time to avoid a collision, amplifies
the serious inherent limitations of the see-and-avoid concept, a
primary means of separation between helicopters and commercial
airplanes at DCA. The NTSB concludes that reliance on pilot-applied
visual separation (see-and-avoid) as a primary means of separating
mixed traffic introduced unacceptable risk to the DCA Class B airspace.
[FINDING 46]
Although this accident occurred in the uniquely complex DCA Class B
airspace, the underlying limitations of pilot-applied visual separation
are inherent to human performance and are present wherever see-and-
avoid is used as a means of aircraft separation in the NAS. Because
controllers nationwide routinely apply visual separation in mixed-
traffic environments, mitigating this risk requires consistent,
systemwide training that emphasizes the limitations of see-and-avoid
and the conditions under which its use may introduce unacceptable risk.
Therefore, the NTSB recommends the FAA develop a new and comprehensive
instructor-led, scenario-based training on the proper use of visual
separation, both tower-and pilot-applied. This training should include
information on the inherent limitations of see and avoid,
responsibilities when applying visual separation, and guidance for
controllers on factors, such as current traffic volume, workload,
weather or environmental factors, experience, and staffing, that should
be considered when applying visual separation. Require this training
for all controllers and include on a recurrent basis thereafter in
annual simulator refresher training. [RECOMMENDATION 10]
Radio Frequency Management
The DCA air traffic control tower utilized a discrete frequency for
communicating with helicopters to avoid interference and frequency
congestion. When the HC and LC positions were combined, it was normal
practice to keep helicopters on their own frequency rather than
directing all traffic to use the same frequency. This also made the
process of de-combining the helicopter and local control positions
easier. When the HC and LC positions were combined, all pilots could
hear all transmissions made by the controller; however, the use of
separate frequencies meant that transmissions made from helicopters
were not audible to airplanes and transmissions made from airplanes
were not audible to helicopters. Pilots indicated that there were
advantages and disadvantages to this practice. The advantages included
reducing non-pertinent transmissions that could impede communication
between crewmembers and alleviating frequency congestion; however,
pilots reported that being able to hear transmissions from all other
aircraft would be an asset to flight crew situation awareness. Had the
accident crews been able to hear each other's transmissions to the
controller, PAT25 would have heard flight 5342's acceptance of the
runway 33 circling approach and their subsequent readback of the
landing clearance. Flight 5342 would have heard PAT25's position report
at the Memorial Bridge. These transmissions contained additional
salient information regarding each aircraft's position and intentions,
which may have increased the crews' awareness of the potential for a
traffic conflict. The NTSB concludes that DCA tower's procedure of
maintaining a discrete helicopter frequency when the local and
helicopter control positions were combined decreased overall situation
awareness for pilots operating in the area. [FINDING 47] Therefore, the
NTSB recommends the FAA conduct a comprehensive evaluation, in
conjunction with local operators, to determine the overall safety
benefits and risks to requiring all aircraft to use the same frequency
when the helicopter and local positions are combined in the DCA ATCT.
[RECOMMENDATION 11]
The very high frequency (VHF) radio communications used by air
traffic control do not allow for simultaneous transmissions. If a pilot
or controller attempts to broadcast on the same frequency at the same
time as another pilot, one or both transmissions may be garbled,
incomplete, or blocked from reception entirely. This leads to missed
control instructions, lack of clarity, loss of situation awareness, or
readback errors; however, there is currently no system in use that
allows controllers to know when a simultaneous broadcast has occurred.
Review of the helicopter's CVR indicated that the controller's
instruction 17 seconds before the collision, which stated, ``PAT two
five pass behind that C-R-J,'' was interrupted by a 0.8-second
microphone key from one of the helicopter crewmembers, which resulted
in much of the transmission being interrupted, and the crew did not
receive the instruction to ``pass behind.''
In 1984, the FAA was petitioned to enact rulemaking requiring two-
way radio communication systems employing anti-blocking and stuck
microphone protection circuitry. In response, the FAA issued Technical
Standard Order (TSO) C128, which provided standards for preventing
blocked channels used in two-way radio communications due to
unintentional transmissions, and TSO C122, which provides standards for
equipment designed to prevent blocked channels in two-way radio
communications caused by simultaneous transmissions. TSO-C128 and its
subsequent revision has proven effective and popular with VHF radio
manufacturers; however, only one manufacturer had been issued a letter
of TSO design approval under TSO-C122 since its original issuance in
1994. In June 2012, the FAA issued a Notice of Intent to Cancel C122a,
the current revision, citing the lack of design approvals and ``the
eventual obsolescence of TSO-C122a equipment''; however, the FAA has
not finalized the cancellation of the TSO. In July 2025, citing the
circumstances of this accident, the FAA announced that it was
withdrawing its previous intent to cancel TSO-C122a and was reopening
the associated comment period. The FAA stated that it welcomed comments
on whether TSO-C122a and the standard it references, RTCA/DO-209, are
obsolete, as well as input to identify current technologies that may
have replaced these standards.
The NTSB recognizes that implementing same-frequency communications
for airplanes and helicopters in a high traffic volume area such as DCA
increases the risk of simultaneous radio transmissions that prevent
critical information from being transmitted or received by both pilots
and controllers. Therefore, the NTSB recommends that the FAA implement
anti-blocking technology that will alert controllers and/or flight
crews to potentially blocked transmissions when simultaneous
broadcasting occurs. [RECOMMENDATION 12]
Conflict Alert System
The conflict alert system is designed to draw the controller's
attention to a potential conflict and is presented in three ways, an
aural alert, a flashing conflict alert ``(CA)'' on the display, and a
conflict list on the display, which indicates in red the aircraft
involved. The activation criteria comprises three algorithms that each
detect conflicts independently, sensing potential linear, maneuver, and
proximity conflicts. Some of these logics predict where the aircraft is
going, while others consider where the aircraft is located at that
time; however, the CA presented to the controller is the same
regardless of which algorithm is activated. This requires the
controller to identify and interpret the severity of the conflict and
evaluate the action they should take based on other available
information. Interviews with DCA ATCT personnel indicated that CAs were
heard ``often'' and were ``pretty common'' at DCA. In the 30 minutes
before the accident occurred, the conflict alert could be heard in the
background during 18 controller transmissions.\11\ Controllers reported
that they often received CAs for non-conflicts, such as when aircraft
were on diverging paths, or that the CA would continue to activate even
after the controller had taken action to mitigate the conflict. In this
accident, the controller responded about 6 seconds after the alert
activated. There was a slight delay in the LC controller's response, as
he was completing a transmission with another helicopter when the CA
activated, and he did not query PAT25 until after the other helicopter
had responded.
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\11\ As previously noted in section 1.7.8.4, these instances did
not necessarily represent 18 distinct CA activations. Review of
available radar display replay data for the final 18 minutes before the
accident identified five separate CA activations, several of which
persisted long enough to be audible across multiple transmissions.
---------------------------------------------------------------------------
Allendoerfer et al., (2007) analyzed 607 CAs from 5 enroute and 17
terminal ATC facilities and categorized controller responses to the
alerts and the timing of the responses. Their research indicated that
the majority of CAs (44 percent in the terminal area) received no
response from controllers; many are so brief that controllers have
resolved the situation before the alert activated, or that the
situation resolved itself without any controller input. They noted that
no operational errors nor deviations occurred in these instances.
Alerts that activate and require no controller action may increase
workload, as the alert directs the controller's attention away from
their current tasks and toward the aircraft involved in the alerting
event. Of the alert situations where controllers acted, they most often
acted before the alert activated (67 percent of the time). This
suggests that, while many alerts are valid according to the alert
algorithms, they do not provide useful information to controllers; that
nuisance alerts are common (81-87 percent of CAs are estimated to be
nuisance alerts); and that high nuisance alert rates may desensitize
controllers and lead to poor responses to critical alerts.
The current system displays all CAs in the same manner regardless
of the algorithm that triggered the alert. In the absence of any
salient information conveying the severity of the conflict, controllers
must make their own determination regarding whether the conflict alert
requires immediate action, thus increasing cognitive load. The FAA's
Human-Systems Integration Branch manager stated during the NTSB's
investigative hearing that improvements are available to the CA
software that could provide color coding or various aural alerts
depending on which of the three conflict alert algorithms was
activated. The NTSB concludes that providing controllers with
additional salient cues regarding the perceived severity of a potential
conflict would reduce controller cognitive load and would likely
improve reaction time to the most critical conflict alerts. [FINDING
48] Therefore, the NTSB recommends that the FAA develop and implement
improvements to the conflict alert system to provide more salient and
meaningful alerts to controllers based on the severity of the conflict
triggering the alert. [RECOMMENDATION 13] Once the improvements to the
conflict alert system discussed in Safety Recommendation [13] are
implemented, provide training to controllers on its use.
[RECOMMENDATION 14]
Postaccident Drug and Alcohol Testing
The LC controller, ALC controller, and OS underwent U.S. Department
of Transportation (DOT) workplace postaccident drug testing about 18
hours, 20 hours, and 18 hours after the accident, respectively. This
testing did not detect any tested-for substances indicative of
prohibited drug use. They did not undergo alcohol testing.
The 14 tested-for substances on the DOT workplace drug testing
panel in effect at the time of the accident may be detectable in urine
for a day or more after last drug use. As such, the testing was
worthwhile, although it was less sensitive for identifying pre-accident
prohibited drug use than it would have been if it was conducted sooner
after the accident. There was no evidence to indicate that any of the
controllers were under the influence of alcohol at the time of the
accident; however, had timely postaccident alcohol testing been
conducted, controller alcohol use might have been definitively excluded
as a factor in the accident. Unfortunately, postaccident alcohol
testing was not conducted, so there was no toxicological evidence
available to support such a determination. The NTSB concludes that
there was no evidence that the LC controller, ALC controller, or OS
were under the influence of alcohol or prohibited drugs at the time of
the accident; however, evidence was substantially limited by the lack
of postaccident alcohol testing, and evidence was of somewhat lower
quality than it would have been if drug testing had been conducted
sooner following the accident. [FINDING 49]
DOT Order 3910.1D, ``Drug and Alcohol-Free Departmental Workplace
Program,'' stated that air traffic controllers must undergo
postaccident drug and alcohol testing as soon as possible after a fatal
accident, any accident that involved a need for medical treatment away
from the accident site, or following an accident which resulted in
substantial damage to aircraft or other vehicles or property. The order
also required that, whenever possible, alcohol testing must take place
within 2 hours after the accident, and drug testing within 4 hours
after the accident. Review of documentation provided by the FAA
indicated that the drug and alcohol testing determination was not made
until almost 3 1/2 hours after this accident, when the FAA ATO
determined that there was a requirement to test the LC controller, ALC
controller, and OS. By that time, the controllers had left the
facility. Although DOT Order 3910.1D permitted alcohol testing for
another 4 1/2 hours after the determination was made and stated that
controllers must remain readily available for testing, the ATO decided
to test for drugs only, and the testing was scheduled for late the
following afternoon. Thus, the NTSB concludes that the FAA ATO's drug
and alcohol testing determination did not meet DOT timeliness
requirements; furthermore, the ATO's decision to not conduct drug
testing as soon as possible after the testing determination, and to not
conduct alcohol testing at all, violated DOT requirements. [FINDING 50]
FAA Order JO 1030.3B, ``Initial Event Response,'' outlines ATO
procedures following an accident, to include the postaccident/incident
drug and alcohol testing determination being made concurrently with the
ATO's Services Rendered Telephone Conference (SRT), which is a
management review to assess air traffic services associated with an
event (FAA, 2014a). However, initiating an SRT requires multiple
initial notifications and preliminary review of the event, to include
preparing audio and radar display recordings of the event for playback.
These administrative and investigative actions take time. When
possible, SRTs are convened the administrative day following the
accident to allow time for such actions to be completed, though major
air carrier accidents or fatal accidents involving air traffic control
services require an SRT to be convened no later than 3 hours following
initial notification. However, an SRT conducted 3 hours after an
accident is already outside the 2-hour postaccident alcohol testing
window outlined by the DOT, and an SRT conducted the next
administrative day is likely to fall outside both the 4-hour
postaccident drug testing window and the 8-hour maximum time for
alcohol testing.
Additionally, there was evidence that ATO staff lacked a complete
understanding of DOT postaccident drug and alcohol testing
requirements. First, the testing determination itself violated DOT
requirements. Also, a DOT-required memorandum as to why testing was not
performed in a timely manner was not prepared, which an ATO
representative attributed to staff's lack of awareness of this
requirement.\12\
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\12\ This accident was not the only recent NTSB investigation to
identify delayed drug testing and missed alcohol testing of an air
traffic controller who was providing services during a serious safety
event. The NTSB's investigation of a 2023 runway incursion involving a
Southwest Airlines passenger airplane and a Federal Express cargo
airplane identified that the controller who had been communicating with
both airplanes had not undergone postincident alcohol testing, and did
not undergo postincident drug testing until the day after the event. In
response to NTSB queries about the drug testing determination in that
event, the FAA provided a copy of an FAA e-mail request to ``please
test'' the controller that had been sent more than 8 hours after the
event, by which time the window for alcohol testing had closed.
---------------------------------------------------------------------------
The NTSB concludes that the delayed and inappropriate drug and
alcohol testing determination was due in part to the ATO's
determination process being inadequately designed to routinely meet DOT
requirements for timely testing, and in part to ATO staff's incomplete
understanding of those requirements. [FINDING 51]
A primary intended purpose of DOT workplace drug and alcohol
testing is to deter and identify abuse of alcohol and use of certain
illegal drugs by individuals performing security-and safety-sensitive
duties, with the recognition that those substances may have impairing
effects on the performance of those duties (US Congress, 1991).
Systemic obstacles to accomplishing timely and appropriate postaccident
and postincident testing weaken the ability of such testing to serve
its intended safety purpose. Accordingly, the ATO's inadequately
designed determination process presents a public safety risk that
extends beyond any single accident investigation.
The ATO representative testified at the NTSB's investigative
hearing that the FAA had begun efforts to revise the initial event
response procedures outlined by FAA Order JO 1030.3B. As of the date of
this report, those initial event response procedures have not been
revised. In this process, the FAA could consider the example of drug
and alcohol testing requirements for FAA-regulated employers such as
airlines, which are closely related to the requirements for FAA-
employed air traffic control specialists.
The DOT requires the FAA to conduct postaccident testing of FAA-
employed controllers whose performance is thought to have contributed
to an accident or cannot be completely discounted as a contributing
factor, and the FAA imposes similar requirements on its regulated
employers. FAA regulations contain language clarifying the permissive
intent of the requirement imposed by the FAA on regulated employers,
stating that the employer's decision not to administer a test must be
based on a determination, using the best information available at the
time of the determination, that the employee's performance could not
have contributed to the accident.\13\
---------------------------------------------------------------------------
\13\ For corresponding DOT/FAA workplace testing language, see DOT
Order 3910.1D, Chapter III, paragraph 6.i(2). For corresponding
language pertaining to safety-sensitive employees of FAA-regulated
employers, see 14 CFR 120.109(c) and 14 CFR 120.217(b)(1).
---------------------------------------------------------------------------
There is no requirement in the DOT's workplace drug and alcohol
testing program, or in DOT/FAA regulations for regulated employers, for
each drug and alcohol testing determination to be based on upper
managerial consensus after investigation. DOT's own workplace drug and
alcohol testing guidance states, ``the decision to subject an employee
to a postaccident test shall be made using the best information that is
reasonably available to management at or about the time of the
accident.'' DOT's guidance to DOT/FAA-regulated employers is more
explicit:
The supervisor at the scene of the accident/event should know the
testing criteria and make a good-faith effort decision to test or not
test based on the information available at the time [emphasis in
original]. The supervisor may consult with others, but the supervisor
is the person who has to make the decision.
If the FAA were to adopt a process whereby on-site supervisors are
empowered to make postaccident/incident testing determinations using
available information independently from SRTs, this would not only
remove many of the barriers to timely decision making but also would
achieve parity with DOT's guidance on best practices for DOT/FAA-
regulated employers. Any such process change would need to be
effectively communicated throughout the ATO, including by revising FAA
Order JO 1030.3B, leveraging existing training procedures, and possibly
developing new tools, to ensure that ATO staff possess a strong
understanding of associated requirements. This institutional
understanding would need to be resilient to workforce turnover, and to
the relative infrequency of events triggering postaccident and incident
testing. Therefore, the NTSB recommends that the FAA revise the Air
Traffic Organization's initial event response procedures so that an
appropriate on-site supervisor makes each postaccident and postincident
drug and alcohol testing determination, based on their assessment of
whether the event meets testing criteria and which controllers had
duties pertaining to the involved aircraft, without needing to wait for
investigation or approval. [RECOMMENDATION 15]
The NTSB additionally recommends that the FAA at least annually,
provide training on the revised postaccident and postincident drug and
alcohol testing determination procedure discussed in Safety
Recommendation [15] to all staff who have responsibilities under that
procedure; this training should include a post-learning knowledge
assessment. [RECOMMENDATION 16]
FAA ATO procedures that limit the timeliness of postaccident/
incident testing determinations also limit opportunities to evaluate
potential downstream barriers to timely testing. It is possible that
successful revision of ATO procedures might expose other weaknesses--
for example, in contractor availability to conduct timely testing once
a timely drug and alcohol testing determination is made. The DOT,
including the Assistant Secretary for Administration and the
Departmental Drug Office (DDO), has the responsibility to oversee FAA
adherence to DOT workplace drug and alcohol testing requirements and
associated required training of supervisors. To enforce its workplace
drug testing requirements effectively, the DOT should ensure that the
FAA systematically identifies and addresses barriers to timely
postaccident and postincident drug and alcohol testing at its
facilities. Importantly, addressing these barriers likely would require
administrative support from the DOT DDO, not just oversight.
Accordingly, the NTSB recommends that the DOT require the FAA to
demonstrate at least annually that each air traffic control facility it
operates has the routine capability to accomplish required postaccident
and postincident drug and alcohol testing within the U.S. DOT's
specified timeframes of 2 hours for alcohol and 4 hours for drugs, and
implement a process to ensure that any facility without such capability
will demonstrate timely remediation. [RECOMMENDATION 47]
Helicopter Route Design and Information
Preliminary investigative findings of this accident revealed that,
when flown at the recommended maximum altitude of 200 ft, a helicopter
operating over the eastern shoreline of the Potomac River on Helicopter
Route 4 would have about 75 ft of vertical separation from an airplane
approaching runway 33. This vertical separation decreases the farther
west of the shoreline the helicopter is flown, or if the airplane is
operating below the 3+ visual glidepath provided by the runway 33
precision approach path indicator (PAPI).
In an urgent safety recommendation report published on March 11,
2025, the NTSB concluded that the separation distances between
helicopter traffic operating on Route 4 and aircraft landing on runway
33 that existed at the time of the accident were insufficient and posed
an intolerable risk to aviation safety by increasing the chances of a
midair collision. The NTSB also concluded that it was critical for
public safety helicopter operators to have an alternate route available
for operating in and around Washington, DC, without increasing
controller workload.
As a result of our findings, we issued two urgent safety
recommendations to the FAA. Urgent Safety Recommendation A-25-1 asked
the FAA to prohibit operations on Helicopter Route 4 between Hains
Point and the Wilson Bridge when runways 15 and 33 were being used for
departures and arrivals, respectively, at DCA. Urgent Safety
Recommendation A-25-2 asked the FAA to designate an alternative
helicopter route that could be used to facilitate travel between Hains
Point and the Wilson Bridge when that segment of Route 4 was closed.
Immediately following the accident, the FAA implemented temporary
airspace restrictions around DCA. On March 14, 2025, the FAA removed
from helicopter route charts the section of Helicopter Route 4 between
Hains Point and the Wilson Bridge. Additionally, the FAA prohibited use
of runways 15/33 and 4/22 at DCA during ``specific, limited helicopter
operations'' in the vicinity of DCA. The NTSB responded that these
actions exceeded the intent of Safety Recommendation A-25-1 and
classified it Closed--Exceeds Recommended Action.
In correspondence dated March 26, 2025, the FAA stated that it
would collaborate with stakeholders to develop a new helicopter route
connecting the Wilson Bridge to the Anacostia River and would provide
updates on the alternative route designation process as it progresses.
The NTSB stated that this planned work was responsive to Safety
Recommendation A-25-2 and, pending its completion, the recommendation
was classified Open--Acceptable Response.
FAA Order JO 7210.3DD listed criteria and procedures for the
development and modification of helicopter route charts. One of the
listed criteria was that, ``Care should be exercised to avoid
recommending altitudes or flight ceilings/floors which would cause
helicopters operating on a designated route to encounter inflight wake
turbulence generated by large, fixed-wing traffic.'' The order stated
that Terminal Operations Service Area Directors were responsible for
reviewing and approving new or revised helicopter route chart proposals
and assuring that they complied with all prescribed criteria. These
directors were also responsible for conducting annual reviews of
existing visual flight rules (VFR) helicopter route charts to determine
their accuracy and continued utility; however, the FAA was unable to
provide documentation of the required annual reviews for the Baltimore-
Washington Helicopter Route Chart. As of the date of this report, no
information has been provided regarding annual reviews conducted,
including criteria used, if such reviews were conducted. The NTSB
concludes that annual reviews of helicopter route charts as required by
FAA Order 7210.3DD would have provided an opportunity to identify the
risk posed by the proximity of Route 4 to the runway 33 approach path,
but there is no evidence to support that these reviews were being
performed at DCA. [FINDING 52] The NTSB is concerned that the lack of
documentation of annual reviews for the Baltimore-Washington Helicopter
Route Chart may be an indication that these annual reviews are not
occurring at other locations throughout the NAS. Therefore, the NTSB
recommends that the FAA ensure that annual reviews of helicopter route
charts are being conducted throughout the NAS as required by FAA Order.
[RECOMMENDATION 17]
Although the FAA took immediate action following this accident to
remove the portion of Route 4 between Hains Point and the Wilson
Bridge, the NTSB remains concerned about the potential for other areas
of conflict within this airspace. Following the accident, the FAA
published a NAS Helicopter Operations Helicopter Route Analysis, which
summarized the ATO's safety analysis of domestic airports with charted
helicopter routes. Using Performance Data Analysis and Reporting System
(PDARS), TCAS events, and Near Midair Collision System (NMAC) data, the
FAA reviewed charted routes and high-traffic-volume areas for possible
conflicts with traffic patterns and reviewed the descriptions for
charted and agreement-established routes. The analysis identified
hazards in the airspace encompassing the routes and proposed actions to
address priority concerns. This analysis, however, did not include DCA.
The NTSB reviewed PDARS data provided by the FAA regarding
encounters between fixed-wing airplanes and helicopters operating on
Routes 1 or 4 from January 2018 to February 2025. During this time,
there were 4,067 encounters (65.6 encounters per month) in which
separation was less than or equal to 1,000 ft and 348 encounters (5.6
encounters per month) in which separation was less than or equal to 500
ft. A heat map depicting the frequency of these events showed several
areas where encounters between helicopters and fixed-wing aircraft were
concentrated, including the area of the accident site, as well as north
of DCA, consistent with encounters with aircraft on approach to runway
19, and south of DCA, consistent with encounters with aircraft on
approach to runway 1.
In unofficial correspondence dated January 16, 2026, the FAA
reported that it had conducted an in-depth analysis of the helicopter
operations within DCA's airspace and made additional changes to the
Baltimore-Washington Helicopter Route Chart. As of the date of this
report, that analysis has not been provided to the NTSB. Therefore, the
NTSB recommends that the FAA conduct an SRM process to evaluate whether
modifications to the remaining DCA helicopter route structure are
necessary to safely deconflict helicopter and fixed-wing traffic and
provide the results to the NTSB. [RECOMMENDATION 18] In addition, the
NTSB recommends that the FAA amend their helicopter route design
criteria and approval process to ensure that current and future route
designs or design changes provide vertical separation from airport
approach and departure paths. [RECOMMENDATION 19] Once the criteria and
approval process referenced in Safety Recommendation [17] are developed
and implemented, review all existing helicopter routes to ensure
alignment with these updated criteria. [RECOMMENDATION 20]
According to testimony provided by personnel from the FAA's
Aeronautical Information Services office during the NTSB's
investigative hearing, the routes depicted on a helicopter chart do not
have lateral limitations unless explicitly outlined on the chart's
route description. The routes were described as ``recommended paths''
that served to streamline traffic flow and facilitate easier
communication between pilots and controllers regarding expected flight
paths, reporting points, and area ingress and egress locations.
According to the FAA, helicopter routes were not specifically designed
to provide separation between helicopters and fixed-wing traffic.
The Baltimore-Washington Helicopter Route Chart included depictions
of each helicopter route and associated altitudes; however, it provided
inconsistent guidance on route altitudes, showing the depicted
altitudes as both ``maximum'' and ``recommended'' in the chart legend,
textual route description, and additional information sections. The
chart did not describe any lateral boundaries associated with the
helicopter routes nor were the visual depictions of each route on the
chart associated with any specific measurement or scale. The
description of Route 4 stated that pilots should fly ``via east bank of
Potomac River'' between the Anacostia River north of DCA and the Wilson
Bridge south of DCA. The version of the Baltimore-Washington Helicopter
Route Chart effective October 2, 2025, removed language in the route
descriptions that stated, ``All Route Altitudes are Maximum.''
Three pilots from the 12th Aviation Battalion stated in
postaccident interviews that they assumed that the published helicopter
route altitudes provided separation from the flow of fixed-wing
aircraft, and, as long as they remained at or below the published
altitude, they would be deconflicted from fixed-wing traffic. In
testimony provided at the NTSB investigative hearing, a standardization
instructor pilot stated that the battalion did not have written
guidance regarding the proximity to the east bank that they were
required to maintain, but that ``tribal knowledge'' was to ``hug the
shoreline'' along this portion of the route unless it was necessary to
deviate for traffic avoidance.
Given the low altitudes of the routes, the fact that these route
altitudes decreased nearer to DCA, and that the battalion's letter of
agreement with the DCA ATCT required adherence to the published route
altitudes, it is understandable that helicopter pilots would conclude
that the purpose of the route altitudes was to separate fixed-wing and
helicopter traffic; and the FAA provided no warnings or advisories on
the helicopter route chart to ensure that they understood this was not
the case. The NTSB concludes that the information published by the FAA
regarding Washington, DC, area helicopter routes was insufficient to
provide helicopter and fixed-wing operators with a complete
understanding of the helicopter route structure and its lack of
procedural separation from fixed-wing traffic. [FINDING 53]
Interviews with four DCA-based PSA pilots revealed that only one of
the pilots, who was previously a military pilot in the area, had
specific knowledge of the helicopter routes, locations, and altitudes.
Another pilot was aware that there were helicopter routes but was not
aware of their associated lateral or altitude limitations. The other
two pilots had no knowledge of the helicopter routes. FAA-published
terminal procedures did not contain any information to inform fixed-
wing pilots operating at DCA about the presence or location of the
helicopter routes, and DCA-specific airport and approach information
published by PSA also did not include information about the helicopter
routes.
Without this information, fixed-wing pilots were left uninformed to
the potential that they may come in close proximity to or conflict with
helicopters utilizing visual separation on published helicopter routes
underlying the DCA approach and departure corridors. The NTSB concludes
that current aeronautical charting does not provide information on VFR
helicopter routes that may conflict or come in close proximity to
approach and departure corridors, which reduces pilot situation
awareness. [FINDING 54] Although the flight 5342 crew's awareness of
the helicopter routes could not be determined, other PSA pilots
interviewed displayed a varying level of knowledge about the routes.
Including helicopter route information on approach procedure charts
would increase pilot situation awareness of the operating environment
and potential risk. Therefore, the NTSB recommends that the FAA
incorporate the lateral location and published altitudes of helicopter
routes onto all instrument and visual approach and departure procedures
to provide necessary situation awareness to fixed-wing operators of the
risk of helicopter traffic operating in their vicinity. [RECOMMENDATION
21]
ADS-B and Collision Avoidance Technologies
The accident helicopter was equipped with a transponder that could
transmit ADS-B Out information. This capability was tied to the Mode S
function of the transponder such that, when Mode S was selected, the
helicopter should have broadcasted ADS-B Out information. As of January
1, 2020, all aircraft operating above 10,000 ft msl or in Class B and C
airspace are required to transmit ADS-B Out; however, Federal
regulations exempt Department of War aircraft from broadcasting ADS-B
Out when performing sensitive government missions.
Due to the routes and landing sites used during the accident
flight, the Department of War considered PAT25's flight path sensitive
and, therefore, the helicopter was not required to be broadcasting ADS-
B Out at the time of the accident. Radar data indicated that the
helicopter's transponder switched from Mode 3/A and C to Mode S near
Cabin John, Maryland, before proceeding south along the Potomac River
about 8 minutes before the accident, but the helicopter was not
broadcasting ADS-B Out despite the crew's selection of the Mode S
function. Although the helicopter's CVR did not capture any crew
conversation about activating Mode S, it is likely that the crew turned
on the transponder's Mode S function before flying south on Helicopter
Route 1 toward the high-traffic airspace near DCA in order to provide
ADS-B Out data to air traffic control and other aircraft; however, the
crew's activation of Mode S during the flight was contrary to Army SOP,
which stated that flight crews should not change transponder modes
during flight.
The TAAB commander testified during the NTSB's investigative
hearing that the reason for the prohibition on changing transponder
modes during flight was due to the amount of ``heads down'' time
required to change the transponder mode; however, the UH-60L operator's
manual, as well as testimony by a former TAAB standardization pilot at
the NTSB's investigative hearing, indicated that activating Mode S
required just two button pushes.
Although the helicopter was not transmitting ADS-B Out, its
position and speed was available to the DCA local controller because
its transponder was responding to Mode S interrogations, and ADS-B Out
information would not have appreciably changed the timing of the
conflict alert the controller received before the collision. Flight
5342 was not equipped with ADS-B In, nor was its TCAS II system capable
of receiving ADS-B In information as part of its activation algorithm.
The NTSB concludes that the lack of ADS-B Out from the accident
helicopter did not contribute to this accident, as the helicopter was
still being tracked by radar, and ADS-B Out would not have provided
improved traffic alerting for the DCA controller or the crew of flight
5342, because the airplane was not equipped with ADS-B In. [FINDING 55]
Although the lack of ADS-B Out information from the accident
helicopter did not change the circumstances of this accident, collision
avoidance technologies that leverage ADS-B In information are most
effective if all aircraft broadcast ADS-B Out at all times. The NTSB
concludes that the Army's standard operating procedures that prevent
flight crews from enabling ADS-B Out while in flight, when not
performing sensitive missions that require ADS-B to be disabled, limit
the visibility of military aircraft on collision avoidance technologies
that leverage ADS-B information. [FINDING 56] Therefore, the NTSB
recommends that the Department of War Policy Board on Federal Aviation
require armed services to amend their operational procedures to allow
flight crews to enable ADS-B Out while in flight. [RECOMMENDATION 45]
The accident airplane was equipped with TCAS II, and information
obtained from the airplane's FDR and CVR indicated that the crew
received a TA regarding PAT25 about 20 seconds before the collision,
which was within TCAS system alerting specifications. This TA remained
active until the collision occurred; however, the crew had been trained
not to maneuver based solely on a TA, and their workload at the time
they received the TA was high, resulting in limited available capacity
to look for and visually acquire the traffic. The TCAS system did not
generate a subsequent RA even though the two aircraft continued to
converge, because TCAS II inhibit logic was designed to suppress RAs
below 900 ft above ground level during descent. A known limitation of
TCAS II is that it often issues RAs during some normal and routine
operations, including when visual separation is being applied. The TCAS
II RA inhibit altitude threshold was established based on the
technological limitations available at the time it was developed to
maximize effective alerting while minimizing these types of nuisance
alerts.
PSA crews were trained to respond promptly to RAs and maneuver as
indicated by the advisory, even if such a maneuver conflicted with ATC
instructions. Therefore, it is probable that the crew of flight 5342
would have maneuvered in accordance with the instructions provided by
the RA had they received one, which may have prevented the collision.
The NTSB concludes that although the airplane's TCAS operated as
designed, it was ineffective in preventing the collision because of
current activation criteria and resolution advisory inhibit altitudes.
[FINDING 57]
The NTSB has previously advocated for the FAA to require ADS-B In
technology on the basis that equipping aircraft with ADS-B In
capability would provide an immediate and substantial contribution to
safety, especially near airports. Simulations using the circumstances
of this accident reaffirm this conclusion and demonstrate the value of
ADS-B In-derived traffic information in improving pilots' situation
awareness and supporting earlier identification of potential traffic
conflicts.
ADS-B traffic advisory system (ATAS) is an ADS-B application
intended to reduce the number of midair collisions and near midair
collisions involving general aviation aircraft. ATAS utilizes ADS-B
information to generate verbal alerts indicating the clock position,
relative altitude, range, and vertical tendency of proximate traffic.
In this accident, the TA that the flight 5342 crew received
consisted simply of the annunciation, ``Traffic, traffic.'' No
information about the location of the traffic threat relative to the
airplane was annunciated, and the crew would have had to refer to the
TCAS display to determine the relative position of the threat before
directing their visual scan in the appropriate area. Given the crew's
high workload at the time they received the TA, it is unlikely that
they performed a focused visual search for the helicopter at this time.
The NTSB performed a simulation to determine how an ADS-B based
system capable of providing ATAS-style alerts would have performed in
the accident scenario. The simulation indicated that the crew of flight
5342 would have received two alerts concerning PAT25 had it been
equipped with such a system. The first aural and visual alert would
have occurred 59 seconds before the collision, annunciating ``Traffic,
12 o'clock, low, three miles, descending.'' A second aural alert would
have occurred 35 seconds before the collision, annunciating ``Traffic,
12 o'clock, low, two miles.'' These two alerts would have occurred 40
and 16 seconds, respectively, before the TCAS TA that the crew received
before the collision, providing the crew with additional awareness of
the helicopter.
While TCAS TAs provide a verbal annunciation that a potential
traffic conflict exists, the annunciations do not include the position
and range of the target, requiring the pilot to first refer to the TCAS
display inside the cockpit to determine the direction in which they
need to direct their visual search. An ATAS-style TA indicating the
clock position, relative altitude, range, and vertical tendency of
nearby traffic would allow pilots to immediately direct their visual
search in the proper direction outside the aircraft. The NTSB concludes
that TA aural alerts that include additional information about the
location of traffic could reduce the time pilots need to visually
acquire target aircraft. [FINDING 58] The NTSB recommends that the FAA
modify airborne collision avoidance system (ACAS) TA aural alerts to
include clock position, relative altitude, range, and vertical
tendency. [RECOMMENDATION 22]
The crew of flight 5342 could have intervened in the accident
sequence if they had more knowledge about the level of the threat posed
by the traffic that triggered the TCAS TA. While a TCAS display does
depict traffic targets, a pilot must monitor the display over time to
determine in what direction the target is moving. By leveraging ADS-B
In traffic information, an ACAS display can depict the ground track of
traffic targets, increasing pilots' awareness of the movements of
nearby traffic and providing more timely information to help a pilot
determine whether that target may become a collision threat. The NTSB
concludes that had the airplane been equipped with an airborne
collision avoidance system that used ADS-B In information to show
directional traffic symbols, the crew of flight 5342 would have
received enhanced information about the risk posed by the helicopter,
which could have enabled them to take earlier action to avert the
collision. [FINDING 59] Therefore, the NTSB recommends that the FAA
require existing and new TCAS I, TCAS II, and ACAS X installations to
integrate directional traffic symbols. [RECOMMENDATION 23]
The helicopter was not equipped with an integrated cockpit display
of traffic information (CDTI), nor was it required to be under current
regulations. As previously discussed, the pilot and IP onboard PAT25
had tablets that were capable of displaying ADS-B traffic information
from other aircraft and providing visual and aural alerts.\14\ A
simulation of the ForeFlight CDTI display available on the tablets
indicated that the application would have generated a visual and aural
alert concerning the airplane at 2047:11, or 48 seconds before the
collision. The tablets, which would likely have been strapped to the
pilots' thighs, were normally referenced in flight by the pilot
monitoring (in this accident, the IP); however, statements from Army
helicopter pilots indicated that it was unlikely that the accident crew
were referring to the tablets for traffic information at the time of
the accident given the demands of visual, low-level flight at night
under NVGs. Simulator testing indicated that, when using a tablet
secured to a thigh, a pilot would be required to divert their attention
below a normal scan of the cockpit instruments in order to view the
tablet screen. Additionally, the aural alerting that could have been
provided by the tablets was not integrated into the crew's helmets and
would not have been heard by the crew over the ambient noise inside the
helicopter, even if the application had been configured to provide
aural traffic alerts. At the time of the accident--and still as of the
date of this report--the DOW had no requirement for military aircraft
to receive ADS-B In, or to be equipped with any integrated cockpit
display of traffic information derived from ADS-B In data. The NTSB
concludes that, although the pilot and IP onboard PAT25 were equipped
with tablets that had the ability to display traffic transmitting ADS-B
Out, it is unlikely that the pilots were using the tablets to monitor
or identify traffic at the time of the accident due to the workload
associated with low-altitude flight. [FINDING 60]
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\14\ Although tablets and other portable traffic-display devices
can provide helpful supplementary awareness, they are not a functional
substitute for an integrated CDTI within the normal instrument scan or
for timely ATC traffic advisories and safety alerts--particularly in
complex Class B environments.
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The NTSB has investigated numerous midair collision accidents that
occurred within controlled airspace or in which air traffic control was
in contact with at least one of the involved aircraft. In many of these
investigations, the NTSB noted that a CDTI with ADS-B In information
would enhance pilots' situation awareness by providing information
regarding traffic conflicts that may otherwise go undetected due to the
numerous documented limitations of see-and-avoid.\15\
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\15\ Examples include ERA09MA447, CEN19MA141AB, ANC20LA074,
ERA22FA318, CEN22FA081, and ERA23FA142.
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Following the investigation into a midair collision between two air
tour airplanes in Ketchikan, Alaska, in 2019, the NTSB issued several
safety recommendations to the FAA, asking them to identify areas with a
high concentration of air tour traffic and to require that CFR Parts 91
and 135 air tour operators which operate within those areas be equipped
with an ADS-B Out-and In-supported traffic advisory system that
includes visual and aural alerts (NTSB, 2021). We also recommended that
the FAA require all aircraft operating within those high density
traffic areas, not just those conducting air tours, be equipped with
ADS-B Out.
In an October 24, 2023, follow-up letter regarding Safety
Recommendation A-21-17, the NTSB emphasized that the absence of an ADS-
B In requirement for Part 135 passenger-carrying operations fails to
take advantage of the demonstrated safety benefit of ADS-B In traffic
awareness and alerting and is inconsistent with the ``appropriate level
of public safety'' the FAA itself expects for operations in which
passengers bear no responsibility for the aircraft's operation (NTSB,
2023). In a response dated November 2024, the FAA stated that they had
determined that, ``current ADS-B requirements continue to adequately
address the needs of aviation safety,'' and that they would ``not
pursue additional ADS-B operator requirements at this time'' (FAA,
2024e).
During the NTSB's investigative hearing for this accident, the FAA
ATO's acting deputy chief operating officer (COO) stated that the
agency supported requiring that newly manufactured aircraft in the
United States be equipped with ADS-B In. He also stated that the agency
supported requiring that aircraft operating in airspace where they are
required to transmit ADSB Out, also be required to install and operate
ADS-B In.-B Out, also be required to install and operate ADS-B In.
The circumstances of this accident illustrate that the additional
information provided by an ACAS system supplemented with ADS-B In
information, including ATAS alerts and directional traffic displays,
further enhance the safety benefit provided by ACAS. For all pilots,
ADS-B In information provided on a CDTI with alerting that is audible
to the pilot would provide critical situation awareness to help
mitigate the risk of midair collisions, even if their aircraft are not
equipped with an ACAS. In order to take full advantage of the safety
benefits provided by ADS-B, the NTSB recommends that the FAA require
all aircraft operating in airspace where ADS-B Out is required to also
be equipped with ADS-B In with a cockpit display of traffic information
that is configured to provide alerting audible to the pilot and/or
flight crew. [RECOMMENDATION 24] In order to provide the same situation
awareness advantages to military flight crews, the NTSB recommends that
the Department of War require all military aircraft operating in the
NAS be equipped with ADS-B In with a cockpit display of traffic
information that is configured to provide alerting audible to the pilot
and/or flight crew, and that such requirement apply wherever in NAS the
FAA requires any aircraft to operate with ADS-B Out. [RECOMMENDATION
46]
Advances since the development of TCAS II standards allow ACAS X,
the next generation of airborne collision avoidance systems, to provide
improved alerting. Among other enhancements, ACAS X systems utilize
ADS-B In information in addition to transponder interrogations, and
include improved algorithms to more accurately reflect actual collision
risk.
A series of simulations conducted using the circumstances of this
accident showed that the crew of flight 5342 would have received a TA
about 8 seconds earlier if the airplane had been equipped with ACAS Xa,
an ACAS X variant for airplanes, even though ADS-B information from the
helicopter was unavailable. However, although ACAS Xa can deliver
earlier and more accurate alerts than TCAS II, the current RA inhibit
altitudes under ACAS Xa are the same as those of TCAS II, and would
also have prevented ACAS Xa from issuing a RA under the accident
circumstances. The results of the simulation indicated that the risk of
a NMAC was reduced by more than 90 percent when the ACAS Xa logic was
modified to allow RAs down to 300 ft, because it is possible that the
crew would have taken the action prescribed by the RA to avoid the
collision. The NTSB concludes that technological advances since the
development of TCAS II operating standards may allow ACAS Xa with
reduced inhibit altitudes to have an expanded alerting envelope while
reducing nuisance alerts. [FINDING 61] Furthermore, the NTSB believes
that ACAS X, as the standard is currently defined, would improve the
safety of aircraft that are currently required to be equipped with
TCAS. Therefore, the NTSB recommends that the FAA require the use of
the appropriate variant of ACAS X on new production aircraft that are
subject to TCAS equipage regulations [RECOMMENDATION 25] and that the
FAA require existing aircraft that are subject to TCAS equipage
regulations be retrofitted with the appropriate variant of ACAS X.
[RECOMMENDATION 26] Given the results of the TCAS and ACAS X simulation
study, which showed a significant reduction in the risk of a NMAC when
the RA inhibit altitude was lowered, the NTSB also recommends that the
FAA evaluate the feasibility of decreasing the TA and RA inhibit
altitudes in ACAS Xa to enable improved alerting throughout more of the
flight envelope. [RECOMMENDATION 27] If the FAA's evaluation resulting
from Safety Recommendation [27] finds that inhibit altitudes can be
safely decreased, the NTSB further recommends that the FAA require
retrofitting of the applicable ACAS X variant incorporating the reduced
TA and RA inhibit altitudes on all aircraft that are subject to TCAS
equipage regulations. [RECOMMENDATION 28]
The ACAS simulations using the circumstances of this accident also
showed that, had the helicopter been equipped with ACAS Xr, a version
of ACAS X that is still under development and intended specifically for
rotorcraft, the risk of a NMAC was reduced by more than 50 percent,
with no changes to the TCAS or ACAS Xa inhibit altitudes. This
information would have been provided to the crew via a cockpit display
that would have been part of their normal instrument scan and also
would have provided aural alerting integrated with the helicopter's
internal communications system. Therefore, the NTSB concludes that,
although not yet commercially available, had the helicopter been
equipped with ACAS Xr with integrated aural alerting, the crew could
have received an alert regarding flight 5342 and could have taken
action to avert the collision. [FINDING 62]
Given the significant reduction in the risk of a NMAC as shown in
the simulations when the helicopter was equipped with ACAS Xr, the NTSB
recommends that the RTCA Program Management Committee finalize and
publish the minimum operational performance standards for ACAS Xr for
rotorcraft. [RECOMMENDATION 50] The NTSB also recommends that the FAA
require that all rotorcraft operating in Class B airspace be equipped
with ACAS Xr technology once the ACAS Xr standard has been published.
[RECOMMENDATION 29]
Safety Management Systems and Safety Data
Indicators of Midair Collision Risk
Multiple safety occurrence reporting systems contained reports from
pilots and controllers about close calls between airplanes and
helicopters in the vicinity of DCA in the years before the accident,
some of which included airplanes on approach to runway 33.\16\ Several
of those reports described issues similar to those found in this
investigation, including airspace complexity, problems with ATC
communications, challenges associated with combining helicopter and
local control positions, and helicopters flying above recommended
altitudes. An Aviation Safety Information Analysis and Sharing (ASIAS)
review of Aviation Safety Action Program (ASAP) reports filed by pilots
from February 2020 through October 2024 found 85 reports, or about 18
reports per year, that contained information on close calls between
helicopters and airplanes near DCA.\17\ Reports of close calls near DCA
were also found in other safety occurrence reporting systems, including
Air Traffic Safety Action Program (ATSAP), Aviation Safety Reporting
System (ASRS), NMACS and mandatory occurrence reports (MORs). Although
it is possible that some of the reports in these systems described the
same events, it is reasonable to conclude that there were more than 18
close calls per year, or more than 1 close call per month on average,
reported in the 4 years before the accident.
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\16\ These included a NMAC (1070511144 in the NMAC database) for
the May 2013 near-miss between an airplane and a military helicopter
that was the catalyst for the formation of the HWG at DCA ATCT; an ASRS
report from July 2015 that involved a near miss between an airplane on
a circling approach to runway 33 and a helicopter (ACN 1283693); and an
ASRS report from June 2013 in which an airplane on the River Visual
approach to runway 19 received a TCAS RA due to a helicopter passing
below (ACN 1095485).
\17\ The term ``close calls'' commonly refers to events in which
the proximity between two aircraft was perceived as potentially unsafe.
See, for example, Ending Serious Close Calls (FAA). Other terms, such
as near misses, close proximity events, and airborne encounters have
been used by different groups to describe similar types of events.
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Safety occurrence reporting systems rely on subjective self-reports
with varying submission criteria and are therefore unlikely to capture
all safety events (Dy and Mott, 2024).\18\ By comparison, objective
aircraft position data, such as TCAS RA data captured by ground-based
receivers, indicated that there were about 15 TCAS RAs per month, on
average, within 10 nm of DCA between April 2023 and March 2025.
Aviation Risk Identification and Assessment (ARIA) data showed that
airplanes and helicopters came within 1 nm laterally and 400 feet
vertically 390 times per month, on average, between October 2021 and
December 2024. PDARS data identified an average of 5.6 instances per
month between 2018 and 2025 in which helicopters flying on Routes 1 or
4 came within 500 ft of airplanes arriving or departing DCA.
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\18\ Additionally, pilots may not be aware of close proximity
events or may have been successfully applying visual separation, which
would not result in safety reporting in instances when objective
measures indicated close proximities.
---------------------------------------------------------------------------
Some objective measures of aircraft proximity that were examined
after the accident were not used for safety assurance before the
accident occurred. For example, postaccident review of PDARS radar-
based data identified close encounters between aircraft in the vicinity
of airports and revealed instances of helicopters flying above maximum
route altitudes; however, the FAA had not previously used those data to
track such metrics. Additionally, ARIA proximity data and TCAS RA data
from ground-based receivers were available to ASIAS, but those data
were also not actively monitored by ASIAS or widely available before
the accident.\19\
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\19\ TCAS TA and RA data were available through an operator's FOQA
and could have provided useful information, but those data are
proprietary and only represented information from, and were only
available to, operators who participated in ASIAS.
---------------------------------------------------------------------------
The Army and PSA had varied knowledge of and limited access to
safety data systems. The Army did not participate in ASIAS, did not
request FAA data, and did not routinely use information that the FAA
made publicly available. The Army did not have a robust safety
occurrence reporting system, nor did it collect and aggregate safety
data from their helicopters. PSA had an SMS, as required by 14 CFR Part
5, and participated in the ASIAS program. Although PSA reported
reviewing safety occurrence reports from its pilots and FOQA-based TCAS
data provided by the ASIAS program, PSA did not have access to
objective proximity data from PDARS or ARIA. As a result, their safety
assurance and safety risk management processes did not identify a
heightened risk of midair collision at DCA.
The FAA ATO had access to many sources of data, including ASIAS,
PDARS, ARIA, ATSAP, MORs, ASRS, and NMACs, as well as limited access to
ASAP and TCAS RA information. Although the ATO reported that they
reviewed a large number of data sources as part of their safety
assurance process, they also did not identify the risk of a midair
collision between helicopters and fixed-wing traffic at DCA. In the
investigative hearing, FAA officials acknowledged that the ATO had
missed these indicators of risk.
The ARIA system was designed specifically to use objective criteria
to automatically identify air traffic operations that represented
potential safety risks and generate reports known as preliminary ARIA
reports, or PARs. However, ATO's subsequent reviews of PARs were
subjective and largely focused on regulatory compliance rather than
potential risk. For example, ARIA generated 874 PARs for the area
surrounding DCA between June 2022 and May 2025, but ATO classified none
of them as NMACs, even though pilots and controllers made multiple
reports of close calls during that period. Additionally, the safety
group manager for the FAA's Eastern Service Area noted that their
Quality Assurance Office reviewers did not normally search for
voluntary reports and acknowledged that, ``from one validator to
another, or from somebody that's looking at that report, their
perception of what is the possibility of collision may be different.''
As a result of these subjective reviews, potentially valuable objective
risk-based safety data were not tracked. The NTSB concludes that
multiple data sources provided evidence of midair collision risk
between fixed-wing aircraft and helicopters at DCA, including on
approach to runway 33, before this accident; however, the limited
access to and use of available objective and subjective proximity data
hindered industry and government stakeholders' ability to identify
hazards and mitigate risk. [FINDING 63]
In its Safety Risk Management Policy, the FAA recognized the value
of objective data, stating, ``While any data is better than no data,
when available, analytical data is preferred, followed by empirical,
and finally, judgmental. This is due to the margin of error associated
with each type of data. Analytical data typically has the lowest margin
of error; the margin of error of empirical data can be controlled by
sample size; and judgmental data has the largest margin of error due to
human biases and subjective experience'' (FAA, 2023d).
Since the accident, the FAA ATO has used objective proximity data
to identify areas of potential conflict between airplanes and
helicopters in the NAS. It conducted a helicopter route analysis using
multiple data systems to count ``close proximity'' events with
objective measures based on parameters such as vertical/horizontal
proximity, slant range, or time to contact. In addition to identifying
near midair collisions, analyses of objective proximity data can
identify areas of high traffic density and potential routing conflicts,
and depict areas with a high concentration of encounters involving
distances less than those provided by standard IFR separation, which
could have shown evidence of the dependence on visual separation to
manage traffic in the DCA airspace before the accident.\20\
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\20\ During the investigative hearing, the FAA ATO acting deputy
COO cited the dependence on visual separation between helicopters and
IFR traffic at DCA as an example of risk that was missed prior to the
accident.
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Although there is value in using multiple data sources to
understand a problem, the lack of standard proximity metrics or indexes
to signify when aircraft are ``too close'' results in difficulty
comparing the risk levels of different locations or tracking the
incidence of events over time. The NTSB concludes that improving
stakeholder access to standardized and objective information about
aircraft close proximity encounters for use in safety assurance
processes would increase the likelihood of detecting and mitigating
hazards before accidents occur. [FINDING 64] Therefore, the NTSB
recommends that the FAA create an objective definition of close
proximity encounter and a public database of those encounters and their
locations that can be used to monitor their prevalence and identify
areas of potential traffic conflict for safety assurance and safety
risk management. [RECOMMENDATION 30]
Safety Information Sharing
Most of the stakeholder groups involved in the investigation
described internal processes for evaluating and addressing safety
occurrence reports. That the midair collision between PAT25 and flight
5342 occurred despite these reported activities raises the question of
why they did not lead to more meaningful risk mitigations at DCA. Some
evidence suggests that safety occurrence reports were used at DCA tower
to identify hotspots, including a hotspot in the same location as the
midair collision, and propose changes to helicopter route charting
through the safety risk management panel (SRMP) process; however, these
efforts met with resistance from ATO, yielding little success.
The investigation also revealed that, although helicopters
routinely triggered TCAS RAs for airplanes on approach to DCA and were
the subject of many voluntary pilot reports, helicopter operators were
largely unaware of their involvement in these events. Upon learning of
its involvement in TCAS RA events involving airplanes on approach to
DCA, one helicopter operator made changes to its standard operating
procedures to help mitigate such events. Additionally, an Army
representative stated in the investigative hearing that learning of
Army helicopter involvement in TCAS RAs would be valuable for risk
mitigation.
FAA regulations (see 14 CFR Part 5.57) state that, if a hazard is
identified through an operator's SMS, that operator must provide notice
to anyone involved that could address the hazard or mitigate the risk.
Additional guidance in FAA Order JO 1000.37C states that safety
promotion activities include actively sharing safety-related
information with other external parties, such as industry stakeholders,
air navigation service providers, and other Federal agencies.
Despite this guidance, this investigation revealed that reviews of
close proximity events around DCA appeared to have occurred in
isolation rather than involving all relevant parties. For example,
preliminary ARIA reports were only reviewed by FAA ATO Quality
Assurance Office staff and did not incorporate the operators involved
in the events. PSA Airlines reported reviewing TCAS RAs involving its
aircraft, but noted that there was often a delay of several months
between the occurrence and the review. Additionally, PSA relied on the
Confidential Information Share Program (CISP) or the FAA to identify
other aircraft that triggered TCAS RA activations on PSA aircraft.
When two TCAS-equipped aircraft come into conflict, both aircraft
receive RAs that alert the pilots and are captured on flight data
recorders. However, when a TCAS RA is triggered by an aircraft without
TCAS, the pilot of the unequipped aircraft may never become aware of
the event. If timely steps are taken to identify the threat aircraft,
the pilots or operators can be notified of their involvement in the
event. However, as this investigation showed, it may be difficult to
identify aircraft that triggered TCAS RAs if not attempted until months
or years after the event, particularly if they are not broadcasting
ADS-B Out. The NTSB concludes that the FAA's lack of an established
process to inform parties about their involvement in events such as
NMACs or TCAS RAs reduces the likelihood of fully understanding and
mitigating future midair collision risk. [FINDING 65] Therefore, the
NTSB recommends that the FAA develop and implement a process that will,
in a timely manner, notify involved parties after events such as NMACs
or TCAS RA activations, such that notification occurs while relevant
data remain available and before meaningful safety analysis, reporting,
or corrective action is no longer practicable. [RECOMMENDATION 31]
FAA Air Traffic Organization Safety Management System
Safety Risk Management and Safety Assurance
At the time of the accident, the FAA had an established SMS for
several of its organizations, including the ATO and ATO facilities
(such as DCA ATCT). FAA policy required that each organization
establish and maintain each of the four components of SMS--safety
policy, safety risk management, safety assurance, and safety promotion.
However, despite the ATO's established and well documented safety
policy, this investigation indicated significant gaps in its safety
risk management, safety assurance, and safety promotion processes and
procedures.
FAA guidance for SMS implementation clearly establishes
responsibility and requirements for operators and external service
providers to coordinate safety risk management and safety assurance
activities with external parties to collect and share safety hazard
information and monitor safety risk controls. For example, the FAA
stated that airport operators, tenants, and users should coordinate SMS
efforts to the fullest extent possible, and that a method of data
sharing and reporting among the separate SMSs be included in the safety
risk management process. The FAA also required that air traffic
managers coordinate with local airport operators to increase awareness
and understanding of local operations and safety challenges, including
convening conferences to discuss and clarify operations.
By contrast, the FAA ATO Order on identification and mitigation of
hazards at the local level does not require external stakeholder
involvement. Participation is limited to bargaining unit
representatives and management at FAA air traffic facilities (FAA,
2020b). Although the 2021 GAO report called on the FAA to develop a
mechanism to exchange information with operators in the DC area, there
was no formal process in place at DCA for operators and the FAA to
share information about helicopter route traffic, TCAS RAs, or
potential traffic conflicts. In the absence of a formal process,
formation of helicopter working groups in the Washington, DC, area
demonstrated recognition by local controllers and operators of safety
risks and attempted coordination of the diverse helicopter operations
in the DCA Class B airspace. However, these groups were described as
informal, did not include a mission statement or statement of work, and
their attempts to recommend changes were met with resistance from, and
little action by, the ATO.
As an example of informal collaboration, the DCA ATCT helicopter
working group (HWG) identified areas of increased collision risk
between airplanes and helicopters, and proposed changes to the charted
helicopter route and zone altitudes to mitigate those risks. One of the
proposed changes included relocating or eliminating the section of
Route 4 adjacent to DCA due to the risk posed by the proximity of that
route to fixed-wing approach and departure paths. A near midair
collision between a military helicopter and a regional jet in 2013
(which occurred in the same vicinity as this accident) was the catalyst
for this initial proposal, and the DCA ATCT HWG made additional
recommendations to move Route 4 in the years after; however, members of
the group recalled a lack of feedback from management at higher levels
within the ATO regarding why their suggestions to move or eliminate
Route 4 were not adopted.
The group also proposed the addition of ``hotspots'' to the
Baltimore-Washington Helicopter Route Chart to highlight areas that
posed an increased risk of potential conflicts between airplanes and
helicopters to increase pilot and controller vigilance in those areas.
However, the FAA also rejected the proposal to chart these hotspots
because, ``hotspots are associated with ground or surface movement and
are not within the VFR aeronautical chart specification.'' The HWG
comprised DCA ATCT controllers--the individuals most familiar with the
flow and separation of helicopter and fixed-wing traffic around DCA and
with the greatest insight into its vulnerabilities and areas of highest
risk; however, the FAA repeatedly failed to act on proposals provided
by the group and rejected changes that would have raised pilot
awareness of areas of increased midair collision risk and increased
separation between Helicopter Route 4 and fixed-wing approach and
departure paths.
In addition, the investigation did not identify evidence showing
that the ATO conducted annual, documented reviews of helicopter route
charts in the Washington, DC, area as required by FAA Order JO
7210.3DD. Further, review of FAA data programs did not indicate that
the ATO routinely used available data to evaluate separation risk
between fixed-wing traffic and helicopter operations at congested
airports, including DCA.
The NTSB concludes that, given their access to a wide range of data
sources and information, the FAA ATO was made aware of, and had
multiple opportunities to identify the risk of a midair collision
between airplanes and helicopters at DCA; however, their data analysis,
safety assurance, and risk assessment processes failed to recognize and
mitigate that risk. [FINDING 66] The NTSB further concludes that the
FAA ATO's application of its safety management system did not
effectively coordinate safety assurance and safety risk management
activities with external stakeholders in the DCA Class B airspace.
[FINDING 67]
The FAA established the Air Traffic Safety Oversight Service (AOV)
in 2004 as the safety oversight authority to ensure effective and
independent safety oversight of ATO and to enforce safety regulations
related to air navigation services, including ATO SMS functions (FAA,
2024a). However, in December 2025, the FAA Administrator announced that
the FAA was implementing a single, agencywide SMS, stating in testimony
before the House Committee on Transportation and Infrastructure's
Subcommittee on Aviation that, ``This unified approach will help the
FAA detect, analyze, and mitigate risk more consistently and ensure
that lessons from accidents, incidents, and near misses are acted upon
quickly across the agency'' (FAA, 2025f). Additionally, in a document
titled, ``FAA Flight Plan 2026'' the agency stated its intent, as part
of creating one FAA SMS, to establish a Safety Integration Office and
implement an FAA-wide safety risk management process (FAA, 2026).
Therefore, the NTSB recommends that the U.S. Department of
Transportation Office of Inspector General complete an audit of the FAA
ATO SMS functions and data sharing activities at all air traffic
control facilities and determine whether these activities are conducted
in collaboration with all relevant external stakeholders, ensuring that
the audit's results are documented, reported to the Secretary of
Transportation and the FAA Administrator, and made available to the
public. [RECOMMENDATION 49] Additionally, the NTSB recommends that the
FAA, based on results of the audit, ensure that all SMS functions and
data sharing activities at all air traffic control facilities are
conducted in collaboration with all relevant external stakeholders.
[RECOMMENDATION 32]
At the NTSB's investigative hearing, the DCA ATCT OM at the time of
the accident testified that controllers would routinely compensate for
the conditions provided by reduced MIT spacing and compacted demand
times by ``making it work,'' and using ``all available tools.'' The
``make it work'' mindset had become normalized and ``routine'' at DCA
ATCT.
Although processes were in place to conduct risk assessments of
hazards at the facility level, existing procedures did not provide
robust guidance to assist controller and supervisor risk assessment and
decision making in real-time, day-to-day operations. For example, the
DCA ATCT SOP contained a list of seven factors that an OS should
consider when deciding to combine or de-combine the HC position, but
did not provide additional information on how to effectively evaluate
the impact of those factors on the control position(s). Changes to the
DCA ATCT SOP in 2023 removed the requirement for the OS to document the
time and reason for combining or de-combining the HC position in the
facility log. Requiring this information to be recorded made it more
likely that the OS would consider and evaluate the risks associated
with combining or de-combining the position under the existing
operational and environmental conditions, and it is likely that the
removal of this requirement normalized combining the positions without
a thorough evaluation of the associated risk factors. Maintaining this
record could also provide background information for safety assurance
processes to determine whether the positions were being combined and
de-combined appropriately. The NTSB concludes that changes to DCA ATCT
SOPs prior to the accident removing the requirement for the OS to
document the time and reason for combining or de-combining the HC
position in the facility log made it less likely that the OS would
consider and evaluate the risks associated with combining or de-
combining the position. [FINDING 68] Because operational position-
combining decisions are made routinely at towers throughout the NAS
under time pressure and with similarly limited documentation
requirements, establishing a standardized, nationwide requirement to
record the time and rationale for combining or de-combining positions
would strengthen real-time risk-based decision making and provide
consistent safety assurance inputs across facilities. Therefore, the
NTSB recommends that the FAA establish a requirement across all ATCT
SOPs that the OS or controller in charge (CIC) document in the daily
facility log when any control position is combined with the LC
position, or when the OS/CIC position is combined with a control
position, along with a rationale for doing so. [RECOMMENDATION 33]
A number of hazards existed within the DCA ATCT at the time of the
accident. Nighttime operations reduced visibility and made
identification of aircraft more difficult; traffic volume was
increasing with reduced MIT, which increased controller workload and
required the use of runway 33 to build additional spacing; helicopter
traffic was present; and the HC and LC positions were combined, which
increased workload for the LC and ALC controllers. The DCA ATCT SOP
stated that the OS was responsible for maintaining situation awareness
of the operation, providing assistance to controllers, and deploying
available resources for optimal efficiency; however, there was no
guidance provided by the ATO or the ATCT SOP that would have assisted
the OS in assessing, anticipating, or alleviating controller workload.
Because concerns about potential conflicts between airplanes and
helicopters had been identified in previous ECVs at the tower facility,
the night conditions, helicopter traffic on Route 4, and use of runway
33 at the time of the accident should have raised an additional level
of awareness and vigilance, particularly on the part of the OS, as all
of those factors increased the likelihood that an airplane and
helicopter may come in close proximity. However, the guidance available
to the OS was insufficient to help him evaluate these factors and apply
operational risk management in a manner that could have more
effectively mitigated these hazards.
It is apparent that controllers in the DCA area were under pressure
to accommodate more traffic volume, and in response, developed their
own methods of traffic management in order to maintain operational
efficiency. A functional SMS should have identified and addressed these
locally accepted operational practices, the ``make it work'' mentality
described by controllers, and the lack of a robust process for day-to-
day risk assessment and mitigation. The NTSB concludes that safety risk
management practices were not fully integrated into DCA ATCT operations
and did not identify or mitigate the operational challenges faced by
controllers or the lack of guidance regarding operational risk
assessments for controllers and supervisors. [FINDING 69]
Safety Promotion and Positive Safety Culture
According to ICAO, safety promotion is how an organization builds
and sustains a positive safety culture and the foundation for an
effective SMS. It does this by actively communicating safety
information, policies, priorities, and lessons learned. The goal is to
ensure that everyone understands their shared responsibility for
safety, feels supported by leadership, and has the awareness, tools,
and motivation to manage safety risks effectively. During the
investigative hearing, the ATO acting deputy COO stated that there was
no formal SMS training for controllers, though he believed that
facility management would be familiar with the ATO SMS Manual. Ensuring
that every employee is familiar with their organization's SMS through
training and consistent, transparent communication is essential for
building trust and collaboration. FAA AC 120-92D stated that
organizations are required to provide initial safety training for
employees so that they can perform their SMS-related duties, and that
recurrent training may be necessary to maintain employee competencies.
The FAA's previously discussed failure to deliver recurrent TEM
training highlights a missed opportunity to reinforce controllers'
abilities to recognize and mitigate hazards, which are critical skills
that they can apply not only in their day-to-day duties of managing air
traffic, but also in providing feedback through established safety
reporting systems to foster continuous improvement of the SMS.
At the facility level, ATO utilized and encouraged use of formal
safety reporting systems, such as ATSAP, to collect safety concerns
from tower personnel without fear of punishment. However, the practice
of a just culture was not consistently followed by ATO management.
Interviews with some ATO staff indicated that there was a fear of
retaliation for raising safety issues, and some individuals would only
speak to investigators because they were close to retirement or had
retired. An air traffic safety specialist, who would not speak to
investigators until after her retirement was finalized, discussed
multiple occasions where mandatory reporting events went unreported as
well as harassment for pushing back on unsafe practices. Following this
accident, DCA ATCT management personnel were reassigned, an action that
appeared inconsistent with the characteristics of a positive safety
culture defined by the ATO acting deputy COO. During the NTSB's
investigative hearing, ATO management witnesses had to be separated
from subordinate witnesses due to concern that answers were being
influenced due to their close proximity. Organizations involved in the
investigative hearing were asked to confirm that there would not be any
retaliation against the witnesses participating in the hearing, and all
affirmed this commitment. Additionally, interviews with current and
former DCA ATCT personnel indicated that morale had been low for years
before the accident due to the 2018 facility level downgrade and the
FAA's lack of transparency regarding the metrics used to support that
decision.
DCA ATCT controllers were familiar with the ATSAP program for
reporting safety concerns. As previously discussed, between January
2011 and August 2023, a total of 520 ATSAP reports (approximately 40
reports per year) were filed related to DCA, supporting controller
statements that they felt comfortable reporting safety concerns through
the system. If a safety concern did not warrant filing an ATSAP report,
controllers stated they also felt comfortable expressing their concerns
to facility management.
Although there were multiple indicators of the risk of a midair
collision in the DCA airspace from numerous objective and subjective
data sources, such as ATSAP, ASRS, MORs, ARIA and NMACs, these risks
were not identified by ATO safety assurance processes. The FAA also
lacked an established process for informing parties about their
involvement in NMACs and TCAS RAs. Without adequate awareness that such
risks exist, ATO and parties were unable to take adequate mitigations
and the DCA airspace remained vulnerable to the risk of a midair
collision.
Although traffic flow volume and management issues had been
longstanding challenges at DCA, ATO management did not adequately
respond to concerns expressed by frontline personnel. For example,
suggestions from personnel who were involved in efforts to reduce DCA's
AAR were often met with resistance and a lack of communication from ATO
management. Instead, controllers were required to adopt a ``make it
work'' mindset and compensated for these conditions by relying on
mitigations such as extensive use of pilot-applied visual separation
and offloading arrivals to runway 33. Potomac TRACON personnel stated
that they also employed workarounds for dealing with the high volume of
traffic in the DCA airspace. Proposals from the DCA ATCT HWG to move
Route 4 and add ``hotspots'' to the helicopter route chart were
rejected despite their identification of risks in these areas.
Finally, on numerous occasions during the course of this
investigation, the FAA failed to provide the NTSB with requested
investigative information, even after agreeing to do so, or provided
incomplete responses to information requests.
The lack of flexibility in adapting procedures to changes in air
traffic, the dismissal of safety improvements suggested by frontline
personnel, the fear of retaliation expressed by some former employees,
and the ATO's actions following this accident all suggest an
organization that does not embrace the principles of open
communication, just culture, and continuous improvement inherent to a
positive safety culture. The NTSB concludes that FAA ATO management did
not follow the tenets of SMS to support its workforce, encourage open
communication, identify and mitigate risks, or foster a just culture,
which eroded the overall safety culture within ATO. [FINDING 70] The
NTSB recognizes that the FAA's postaccident initiative to introduce a
single, agencywide SMS presents an opportunity to identify and correct
inconsistencies between ATO SMS guidance and its other SMS policies and
guidance. Therefore, the NTSB recommends that the Secretary of
Transportation work with the FAA Administrator to convene an
independent panel to conduct a comprehensive review of the safety
culture within the FAA's ATO, and use the findings to enhance the ATO's
existing SMS and integrate it into all levels of the organization.
[RECOMMENDATION 48]
US Army Safety Assurance
Although helicopters and airplanes had routinely experienced close
encounters in the DCA area, the organizations involved appeared to lack
awareness of how common such encounters were, or the safety-related
implications. Aside from the DCA ATCT controllers who recommended the
relocation of Helicopter Route 4 away from the runway 33 approach path,
neither FAA or Army was effectively monitoring the risk of a midair
collision between military helicopters and civilian fixed-wing aircraft
in the area.
The NTSB's review of the Army's safety management processes
revealed deficiencies in safety assurance that were not in compliance
with DOW requirements and that left the Army unaware of the potential
for a midair collision in the DCA area (DOD, 2019b). For example, the
Army lacked a flight data monitoring program that could have detected
deviations above the published altitudes on Route 4. Flight data
monitoring programs have been used by commercial operators,
manufacturers, and the FAA to identify, evaluate, and monitor the risks
of specific categories of accidents and design and implement safety
enhancements to mitigate such risks; however, these programs depend on
the collection of relevant operational data, which the Army was not
collecting.
Flight data monitoring programs analyze data from a variety of
sources, such as flight recorders, dedicated quick access recorders,
and ADS-B. If Army safety professionals had been analyzing operational
data from its helicopters, it is likely they would have identified
altitude exceedances on the helicopter routes adjacent to DCA and would
have taken steps to understand why the exceedances were occurring at
such a high rate. This may have also raised their awareness about
cumulative errors in the UH-60s barometric altimetry system, and the
lack of compatibility between the narrow acceptable range of operating
altitudes on Route 4 and the acceptable range of error in the
barometric altimeters. The NTSB concludes that the Army did not have a
flight safety data monitoring program for helicopters, and as a result,
was unaware of routine altitude exceedances and related risks in the
DCA terminal area. [FINDING 71] Given the density of civil air traffic
in close proximity to the helicopter routes, this was an unacceptable
oversight. Class B airspace surrounds the busiest airports in the
country used by passenger-carrying airlines. The Army must take
extraordinary care that it does not routinely introduce unacceptable
risk to civil aircraft operations in such areas. A 2020 report from the
National Commission on Military Aviation Safety found that, if all
military services fully employed FOQA, Line Operations Safety Audit
(LOSA), and ASAP programs, ``the Department of Defense and services
would have an invaluable collection of data that would support the
development of predictive analysis safety programs'' (National
Commission on Military Aviation Safety, 2020). Therefore, the NTSB
recommends that the Secretary of the Army establish a flight data
monitoring program for rotary-wing aircraft the U.S. Army operates in
the NAS. [RECOMMENDATION 38]
Another limitation in the Army's safety assurance capability was
the absence of a mature, front-line incident reporting program capable
of capturing first-hand accounts of close encounters between aircraft.
The Army's framework for hazard identification, reporting, and analysis
consisted of operational hazard reports (OHRs) and the Army Safety
Management Information System (ASMIS) ``mishap and near miss
reporting'' module; however, participation in these programs was
limited, and they had not yet matured into full operational use.
The TAAB safety manager stated that ASMIS 2.0 was being used to
record monthly inspection results, mishaps, and near-misses, but
described these as company-level safety inputs rather than individual
pilot submissions. TAAB pilots similarly described company safety
officers as responsible for most safety paperwork and data entry. Pilot
interviews gave no indication of flight crew-initiated OHRs, and no
interviewee described pilots directly logging events in ASMIS.
According to the brigade safety manager, no ASMIS near-miss reports
or OHRs related to near mid-air collisions between aircraft had been
filed, and no OHRs had been filed about near midair collisions in the
DCA area. The brigade safety manager stated that no OHRs had been
submitted by brigade pilots for any reason in the year preceding the
accident. This low utilization could explain, in part, the Army's lack
of awareness about the prevalence of close proximity events in the DCA
area. The NTSB concludes that the Army's safety reporting systems for
pilots were not well utilized and did not provide the organization with
information about close encounters between Army helicopters and other
aircraft that were later found to have occurred frequently. [FINDING
72]
Given the number of close encounters between helicopters and fixed-
wing aircraft in the DCA area revealed by postaccident analysis of
safety data, the NTSB believes that it is important for the Army to
improve its capability in this area. Interviewed pilots did not offer
reasons for their lack of utilization of the safety reporting systems.
Research literature suggests that common reasons for underreporting
cited by pilots include the effort required to file a safety report,
concern over negative consequences, and disbelief that safety reporting
will lead to safety improvements (Haslbeck, Schmidt-Moll, and Schubert,
2015, 596-601). Such barriers might be addressed by reducing the effort
required to file a report, cultivating a supportive (``just'') culture,
or providing feedback to pilots about changes resulting from safety
reports. The first step in addressing this issue would be for the Army
to identify the specific reasons for the low utilization of safety
reporting systems among its pilots. Therefore, the NTSB recommends that
the Secretary of the Army survey U.S. Army helicopter pilots to
identify barriers to the utilization of flight safety reporting
systems, develop a plan to address the identified barriers, and
implement that plan across Army aviation units. [RECOMMENDATION 39]
The deficiencies noted above likely existed because the Army had
yet to fully implement best practices for safety management. Based on
testimony from the TAAB commander during the investigative hearing,
TAAB was in the beginning stages of implementing the Army's version of
SMS (Army Safety and Occupational Health Management System, or ASOHMS)
and had not yet reached the point where it was focused on the
development of effective safety assurance capabilities.
The Army's slow progress in implementing ASOHMS could stem from
several causes. First, responsibility for different aspects of safety
management was widely distributed across various Army organizations.
Second, the program was designed to address the full range of safety
issues that a commander might seek to manage, both on-and off-duty, not
only safety of flight operations. Third, the Army encountered resource
issues, as evidenced by comments made at the NTSB's investigative
hearing by the director of the Data Analysis and Prevention Directorate
that the military flight operations quality assurance (MFOQA) mandate
was unfunded. Fourth, TAAB safety personnel indicated that staffing was
an issue. Until shortly before this accident, TAAB had only one full-
time safety manager, who was responsible for five battalions and a
variety of different functions. Due to his broad range of
responsibilities, only half of his time was available for working on
flight safety issues, and only a portion of that time was spent
specifically on helicopter safety. The 12th Aviation Battalion safety
officer, who was also a pilot, spent about 75 percent of his time on
ground safety and occupational health matters and 25 percent on
aviation safety. B Company's safety officer, also a pilot, estimated
that 80 percent of his time was spent on occupational health and safety
matters. By comparison, a Part 121 airline typically employs several
individuals working full-time on flight safety management-related
functions.
A 2023 GAO study of Army National Guard helicopter units found that
workload and staffing imbalances hindered the scope of safety officer
efforts in the Guard's aviation units. Safety officers interviewed by
the GAO described struggling to address the broad scope of their ground
and flight safety responsibilities and their roles as pilots. This
impeded their ability to do such things as ``coordinating with other
safety organizations; using data systems to perform hazard analysis;
communicating with unit personnel for aircraft-specific insights; and
overseeing the quality of hazard and accident reporting processes.''
Evidence from this investigation suggests that TAAB and the 12th
Aviation Battalion faced similar challenges with safety-related
staffing and workload allocations.
At the NTSB's investigative hearing, the director of safety and
occupational health for the U.S. Army Secretariat acknowledged the
existence of these challenges and said that the Army was updating its
``manpower evaluation'' model to address the issue. Although updating
the manpower evaluation model was an annual requirement, past updates
did not result in adequate safety staffing. The NTSB concludes that the
Army's process for allocating resources to aviation safety management
did not ensure the development of a robust SMS for helicopter
operations in the Washington, DC, area. [FINDING 73] This accident
demonstrates the importance of having the capability for, at a minimum,
implementing safety assurance processes to monitor the safety of Army
aviation operations in densely utilized airspace with a high
concentration of commercial air traffic. Therefore, the NTSB recommends
that the Secretary of the Army revise the method for allocating
resources to ensure the development of a robust SMS that will, at a
minimum, identify and monitor the potential for midair collisions
between Army aircraft and civil air traffic operating in the NAS.
[RECOMMENDATION 40]
US Army Safety Culture
Our investigation identified several characteristics of the Army's
safety culture relevant to this accident.
Just culture: At the operational unit level (brigade and
battalion), investigators found evidence of a generally non-punitive
and non-repressive safety climate. Frontline personnel reported feeling
comfortable expressing safety-related concerns to safety officers and
to their chain of command. The absence of a repressive climate did not
appear to be a limiting factor in safety information flow.
Reporting culture: Although formal safety reporting systems
existed, including OHRs and ASMIS near-miss reports, their utilization
by flight crews was low. As a result, the organization had limited
visibility into emerging operational risks, including the frequent
close proximity of helicopters to jet aircraft arriving at DCA. This
gap reflects a reporting culture that was formally established but not
functionally embedded in routine operations.
Informed culture: The Army's ability to maintain an informed
understanding of operational risk was constrained by organizational
structure and priorities. Safety professionals who might otherwise
analyze safety reports and operational data were largely consumed by
ground safety and occupational health responsibilities mandated at the
Army level. In combination with the low volume of flight safety reports
and the absence of flight data monitoring capability, these constraints
limited the organization's capacity to synthesize available information
and maintain awareness of hazards, such as routine altitude exceedances
on Washington, DC, helicopter routes.
Flexible culture: The Army's safety system lacked the structural
flexibility and analytical capability necessary to adapt its safety
focus in response to changes in the operational environment.
Consequently, safety oversight did not adjust to the increasing density
of aircraft arrivals at DCA, the reliance on visual separation to
maintain traffic flow, or the infrequent use of runway 33, which made
encounters between helicopters on Route 4 and low-flying airplanes
approaching from the southeast atypical and less anticipated.
Learning culture: Organizational learning within the Army was
primarily reactive, occurring in response to mishaps rather than
through anticipatory identification of weak signals and emerging
trends. The Secretary of the Army had mandated adoption of the ASOHMS
in 2024, and the Army Combat Readiness Center had developed tools to
support hazard tracking and analysis; however, these capabilities were
not effectively utilized due to the structural and cultural limitations
described above.
Although Army leadership had recently initiated policy changes
intended to shift aviation safety management in a more proactive
direction, these efforts were constrained by limitations in
organizational capacity and safety culture. Specifically, Army aviation
exhibited an underdeveloped reporting culture, limited informed
awareness of operational hazards, insufficient flexibility to adapt
safety oversight to changing risk, and a learning culture oriented
toward reactive rather than anticipatory risk management.
The NTSB concludes that the Army's aviation safety system failed to
consistently detect, interpret, and act on signals of latent hazards,
resulting in degraded safety assurance, organizational learning, and
safety culture. [FINDING 74]
The NTSB believes that addressing the identified safety culture
limitations described above would require the Army to take several
interrelated, system-level steps. First, the Army would need to ensure
that flight safety management functions are adequately staffed and
resourced, including the assignment of competent safety professionals
with the expertise and time necessary to cultivate a robust reporting
culture and to identify weak signals of risk through effective
analysis.
Second, the Army would need to structurally protect these personnel
from collateral duties unrelated to aviation safety that dilute their
capacity to perform proactive safety oversight.
Third, the Army would need to provide flight safety personnel with
objective data collection and analysis tools, such as a funded and
institutionalized MFOQA capability, to support the detection of
emerging risk trends during normal operations.
Finally, the Army would need to ensure that flight safety personnel
are empowered, through organizational authority and access to
leadership, to effectively advocate for safety-related changes based on
the risks they identify.
As a result, the NTSB recommends that the U.S. Army develop and
maintain a flight safety management capability that is independently
resourced and functionally separate from its occupational and
environmental health management system, and ensure that this capability
is both culturally and functionally integrated with units conducting
sustained flight operations in the NAS. [RECOMMENDATION 41]
Attachment:
NTSB Findings, Probable Cause, and Recommendations List
Findings
1. The pilots of flight 5342 were certificated and qualified in
accordance with Federal regulations.
2. The pilots of flight 5342 were medically qualified for duty, and
available evidence does not indicate that they were impaired by
effects of medical conditions or substances at the time of the
accident.
3. Review of the flight 5342 pilots' time since waking and sleep
opportunities in the days before the accident indicated that
the pilots were unlikely to have been experiencing fatigue.
4. The pilot, instructor pilot, and crew chief onboard PAT25 were
qualified and current in their positions as designated by the
unit commander in accordance with Army regulations.
5. The pilot, instructor pilot, and crew chief of PAT25 were
medically qualified for duty, and available evidence does not
indicate that they were impaired by effects of medical
conditions or substances at the time of the accident.
6. Review of the three PAT25 crewmembers' time since waking and
sleep opportunities in the days before the accident indicated
that the crew were unlikely to have been experiencing fatigue.
7. The airplane was properly certificated, equipped, and maintained
in accordance with 14 CFR Part 121. The airplane was operated
within its weight and balance limitations throughout the
flight. Examination of the airplane revealed damage consistent
with an in-flight collision and subsequent impact with water,
and there was no evidence of any structural, system, or
powerplant failures or anomalies. Review of surveillance videos
indicated that the airplane's wing navigation, landing/taxi,
and anti-collision strobe lights were operating at the time of
the collision.
8. The helicopter was properly certificated, equipped, and
maintained in accordance with U.S. Army regulations. Review of
helicopter maintenance records did not reveal any open
discrepancies or anomalous trends that contributed to the
accident. The helicopter was operated within its weight and
balance limitations throughout the flight. Examination of the
helicopter revealed damage consistent with an in-flight
collision and subsequent impact with water, and there was no
evidence of any structural, main or tail rotor system, flight
control system, or powerplant failures or anomalies. Review of
surveillance videos indicated that the helicopter's right and
tail position lights, the landing light, as well as both upper
and lower anti-collision lights, were operating at the time of
the collision.
9. The operations supervisor and four controllers who were working
in the Ronald Reagan Washington National Airport air traffic
control tower cab at the time of the accident were properly
certified, qualified in accordance with Federal regulations and
facility directives, and current.
10. Although the Ronald Reagan Washington National Airport air
traffic control tower facility was not staffed to its target
level at the time of the accident, the number of staff in the
tower at the time of the accident was adequate and in
accordance with Federal Aviation Administration directives.
11. The decision to combine the helicopter control and local control
positions was not the result of insufficient staffing, and
personnel were available to staff the helicopter control and
local control positions separately had the operations
supervisor chosen to do so.
12. The local control controller, assistant local controller, and
operations supervisor were medically qualified for duty, and
available evidence does not indicate they were impaired by
effects of medical conditions at the time of the accident.
13. Review of the local control and assistant local control
controllers' and operations supervisor's (OS) time since waking
and sleep opportunities in the days before the accident
indicated that the controllers, including the OS, were unlikely
to have been experiencing fatigue.
14. Visual meteorological conditions prevailed in the area at the
time of the accident. A review of observations recorded
throughout the night of the accident revealed no evidence of
any local atmospheric pressure anomalies that would have
impacted barometric altimeter readings.
15. The Metropolitan Washington Airports Authority Airport Rescue
and Firefighting and airport operations staff responded
immediately and in accordance with applicable emergency plans
and regulatory requirements, deploying land-and water-based
resources, and coordinating mutual aid under complex nighttime
and on-water conditions.
16. Keeping the helicopter control and local control positions
continuously combined on the night of the accident increased
the local control controller's workload and negatively impacted
his performance and situation awareness.
17. The local control and helicopter control positions should have
been separated at the time of the accident given present
traffic volume and complexity.
18. In the two minutes before the accident when traffic volume was
increasing, the assistant local controller should have
prioritized surveillance of aircraft in the air in order to
assist the local controller, rather than diverting her
attention to the lower priority task of documenting helicopter
information, which could have been completed when traffic
volume and complexity had subsided.
19. Had the helicopter and local control positions been staffed
separately, PAT25 might have received a more timely and
effective traffic advisory.
20. Due to extended time on position at the time of the collision
and his complacency, the operations supervisor was likely
experiencing reduced alertness and vigilance, which decreased
his awareness of the operational environment and reduced his
ability to proactively assess the risks posed by the traffic
and environmental conditions at the time of the accident.
21. The lack of mandatory relief periods for supervisory air traffic
control personnel is contrary to human factors research that
shows clear performance deterioration in situations of
prolonged time on task.
22. Although the local control controller provided an initial
traffic advisory to the crew of PAT25 in accordance with
Federal Aviation Administration Order Job Order 7110.65, he did
not provide a corresponding advisory to the crew of flight 5342
regarding PAT25's location and intention, which could have
increased situation awareness for the crew of flight 5342.
23. If the local control controller had issued a standard safety
alert to the flight crews of either aircraft as prescribed in
FAA Order Job Order 7110.65, providing the conflicting
aircraft's position and positive control instructions, the crew
of either aircraft could have taken immediate action to avert
the impending collision.
24. Initial and recurrent scenario-based training in threat and
error management would help controllers identify and mitigate
risks and strengthen situation awareness.
25. A risk assessment or decision making tool would likely have
benefited the accident OS in identifying and mitigating the
operational risk factors that were present on the night of the
accident.
26. Due to degraded radio reception, the crew of PAT25 did not
receive salient information regarding flight 5342's circling
approach to runway 33.
27. The PAT25 instructor pilot did not positively identify flight
5342 at the time of the initial traffic advisory despite his
statement that he had the traffic in sight and his request for
visual separation.
28. With several other targets located directly in front of the
helicopter represented by points of light with no other
features by which to identify aircraft type, and without
additional position information from the controller, the
instructor pilot likely identified the wrong target.
29. Interference that obscured the controller's ``circling to''
call, the microphone keying that blocked the PAT25 crew from
receiving the instruction to ``pass behind,'' ambiguous visual
cues, and the lack of an integrated traffic awareness and
alerting system likely reinforced the PAT25 crew's expectation
bias that the airplane was among the traffic approaching runway
1 and did not pose a conflict.
30. The absence of documented training on Ronald Reagan Washington
National Airport's fixed-wing procedures and the mixed-traffic
operating environment represented a safety vulnerability for
Army flight crews operating in the Ronald Reagan Washington
National Airport Class B airspace.
31. Due to additive allowable tolerances of the helicopter's pitot-
static/altimeter system, it is likely that the crew of PAT25
observed a barometric altimeter altitude about 100 ft lower
than the helicopter's true altitude, resulting in the crew
erroneously believing that they were under the published
maximum altitude for Route 4.
32. A recurrent task to verify the continued accuracy of recorded
flight data for U.S. Army aircraft would help ensure the data
integrity needed to support quality assurance and safety
programs and accident investigations.
33. The Federal Aviation Administration and the Army failed to
identify the incompatibility between the helicopter routes' low
maximum altitudes and the error tolerances of barometric
altimeters, which contributed to helicopters regularly flying
higher than published maximum altitudes and potentially
crossing into the runway 33 glidepath.
34. Pilots need all available information on the potential total
error, allowed by design, that could occur in flight on an
airworthy barometric altimeter.
35. The Army's post-installation functional check of the transponder
on the accident helicopter was insufficient to detect that it
was not broadcasting Automatic Dependent Surveillance-Broadcast
Out.
36. The Army's lack of a recurrent transponder inspection procedure
resulted in the incorrect aircraft address being transmitted by
the accident helicopter's transponder, and the incorrect
automatic dependent surveillance-broadcast settings on several
other helicopters being undetected.
37. Because the APX-123A transponder is designed for use on multiple
aircraft platforms, it is possible that incorrect settings may
be present on other aircraft used throughout the Department of
War armed services.
38. The crew of flight 5342 did not see the helicopter until it was
too late to avoid a collision because of the high workload
imposed during the final phase of their approach, and due to
the helicopter's low conspicuity and lack of apparent motion.
39. Times of compacted demand as a result of air carrier scheduling
practices increased operational complexity and required
mitigations by controllers to maintain spacing and surface
movement.
40. Ronald Reagan Washington National Airport air traffic control
tower routinely received less than the requested miles in trail
spacing from Potomac Consolidated Terminal Radar Approach
Control, which increased controller workload by requiring them
to generate additional spacing to prevent delays or gridlock.
41. The practice of ``offloading'' arrival traffic on approach to
runway 1 by asking pilots if they could accept a circling
approach to runway 33 was a routine mitigation strategy for
Ronald Reagan Washington National Airport controllers to
generate spacing that was not provided by Potomac Consolidated
Terminal Radar Approach Control.
42. Time-based flow management, or metering, would provide Potomac
Consolidated Terminal Radar Approach Control and Ronald Reagan
Washington National Airport air traffic control tower with a
consistent flow of traffic with more accurate spacing and
greater predictability, thereby reducing controller workload.
43. Ronald Reagan Washington National Airport air traffic control
tower has significant airspace, airfield, mixed fleet, and
operations complexities that appear to be inconsistent with its
current facility level classification.
44. The Federal Aviation Administration Air Traffic Organization
failed to recognize external compliance verification results as
indicators of systemic traffic management, volume, and flow
issues at Ronald Reagan Washington National Airport for which
controllers were required to compensate.
45. The longstanding practice of relying on pilot-applied visual
separation (see-and-avoid) as the principal means of separating
helicopter and fixed wing traffic in the Washington, DC, area
by Ronald Reagan Washington National Airport air traffic
control tower, the Army, and other helicopter operators led to
a drift in operating practices among controllers and helicopter
crews that increased the likelihood of a midair collision.
46. Reliance on pilot-applied visual separation (see-and-avoid) as a
primary means of separating mixed traffic introduced
unacceptable risk to the Ronald Reagan Washington National
Airport Class B airspace.
47. Ronald Reagan Washington National Airport air traffic control
tower's procedure of maintaining a discrete helicopter
frequency when the local and helicopter control positions were
combined decreased overall situation awareness for pilots
operating in the area.
48. Providing controllers with additional salient cues regarding the
perceived severity of a potential conflict would reduce
controller cognitive load and would likely improve reaction
time to the most critical conflict alerts.
49. There was no evidence that the local control controller,
assistant local control controller, or operations supervisor
were under the influence of alcohol or prohibited drugs at the
time of the accident; however, evidence was substantially
limited by the lack of postaccident alcohol testing, and
evidence was of somewhat lower quality than it would have been
if drug testing had been conducted sooner following the
accident.
50. The Federal Aviation Administration Air Traffic Organization's
(ATO) drug and alcohol testing determination did not meet
Department of Transportation (DOT) timeliness requirements;
furthermore, the ATO's decision to not conduct drug testing as
soon as possible after the testing determination, and to not
conduct alcohol testing at all, violated DOT requirements.
51. The delayed and inappropriate drug and alcohol testing
determination was due in part to the Air Traffic Organization's
(ATO) determination process being inadequately designed to
routinely meet Department of Transportation requirements for
timely testing, and in part to ATO staff's incomplete
understanding of those requirements.
52. Annual reviews of helicopter route charts as required by Federal
Aviation Administration Order 7210.3DD would have provided an
opportunity to identify the risk posed by the proximity of
Route 4 to the runway 33 approach path, but there is no
evidence to support that these reviews were being performed at
Ronald Reagan Washington National Airport.
53. The information published by the Federal Aviation Administration
regarding Washington, DC, area helicopter routes was
insufficient to provide helicopter and fixed-wing operators
with a complete understanding of the helicopter route structure
and its lack of procedural separation from fixed-wing traffic.
54. Current aeronautical charting does not provide information on
visual flight rules helicopter routes that may conflict or come
in close proximity to approach and departure corridors, which
reduces pilot situation awareness.
55. The lack of Automatic Dependent Surveillance-Broadcast (ADS-B)
Out from the accident helicopter did not contribute to this
accident, as the helicopter was still being tracked by radar,
and ADS-B Out would not have provided improved traffic alerting
for the Ronald Reagan Washington National Airport controller or
the crew of flight 5342, because the airplane was not equipped
with ADS-B In.
56. The Army's standard operating procedures that prevent flight
crews from enabling Automatic Dependent Surveillance-Broadcast
(ADS-B) Out while in flight, when not performing sensitive
missions that require ADS-B to be disabled, limit the
visibility of military aircraft on collision avoidance
technologies that leverage ADS-B information.
57. Although the airplane's traffic alert and collision avoidance
system operated as designed, it was ineffective in preventing
the collision because of current activation criteria and
resolution advisory inhibit altitudes.
58. Traffic advisory aural alerts that include additional
information about the location of traffic could reduce the time
pilots need to visually acquire target aircraft.
59. Had the airplane been equipped with an airborne collision
avoidance system that used Automatic Dependent Surveillance-
Broadcast In information to show directional traffic symbols,
the crew of flight 5342 would have received enhanced
information about the risk posed by the helicopter, which could
have enabled them to take earlier action to avert the
collision.
60. Although the pilot and instructor pilot onboard PAT25 were
equipped with tablets that had the ability to display traffic
transmitting Automatic Dependent Surveillance-Broadcast Out, it
is unlikely that the pilots were using the tablets to monitor
or identify traffic at the time of the accident due to the
workload associated with low-altitude flight.
61. Technological advances since the development of traffic alert
and collision avoidance system II operating standards may allow
airborne collision avoidance system Xa with reduced inhibit
altitudes to have an expanded alerting envelope while reducing
nuisance alerts.
62. Although not yet commercially available, had the helicopter been
equipped with airborne collision avoidance system Xr with
integrated aural alerting, the crew could have received an
alert regarding flight 5342 and could have taken action to
avert the collision.
63. Multiple data sources provided evidence of midair collision risk
between fixed-wing aircraft and helicopters at Ronald Reagan
Washington National Airport, including on approach to runway
33, before this accident; however, the limited access to and
use of available objective and subjective proximity data
hindered industry and government stakeholders' ability to
identify hazards and mitigate risk.
64. Improving stakeholder access to standardized and objective
information about aircraft close proximity encounters for use
in safety assurance processes would increase the likelihood of
detecting and mitigating hazards before accidents occur.
65. The Federal Aviation Administration's lack of an established
process to inform parties about their involvement in events
such as near midair collisions or traffic alert and collision
avoidance system resolution advisories reduces the likelihood
of fully understanding and mitigating future midair collision
risk.
66. The Federal Aviation Administration Air Traffic Organization was
made aware of, and had multiple opportunities to identify the
risk of a midair collision between airplanes and helicopters at
Ronald Reagan Washington National Airport; however, their data
analysis, safety assurance, and risk assessment processes
failed to recognize and mitigate that risk.
67. The Federal Aviation Administration Air Traffic Organization's
application of its safety management system did not effectively
coordinate safety assurance and safety risk management
activities with external stakeholders in the Ronald Reagan
Washington National Airport Class B airspace.
68. Changes to Ronald Reagan Washington National Airport air traffic
control tower's standard operating procedures to the accident
removing the requirement for the operations supervisor (OS) to
document the time and reason for combining or de-combining the
helicopter control position in the facility log made it less
likely that the OS would consider and evaluate the risks
associated with combining or de-combining the position.
69. Safety risk management practices were not fully integrated into
Ronald Reagan Washington National Airport air traffic control
tower operations and did not identify or mitigate the
operational challenges faced by controllers or the lack of
guidance regarding operational risk assessments for controllers
and supervisors.
70. Federal Aviation Administration Air Traffic Organization (ATO)
management did not follow the tenets of safety management
systems to support its workforce, encourage open communication,
identify and mitigate risks, or foster a just culture, which
eroded the overall safety culture within ATO.
71. The Army did not have a flight safety data monitoring program
for helicopters, and as a result, was unaware of routine
altitude exceedances and related risks in the Ronald Reagan
Washington National Airport terminal area.
72. The Army's safety reporting systems for pilots were not well
utilized and did not provide the organization with information
about close encounters between Army helicopters and other
aircraft that were later found to have occurred frequently.
73. The Army's process for allocating resources to aviation safety
management did not ensure the development of a robust safety
management system for helicopter operations in the Washington,
DC, area.
74. The Army's safety system failed to consistently detect,
interpret, and act on signals of latent hazards, resulting in
degraded safety assurance, organizational learning, and safety
culture.
Probable Cause
We determined that the probable cause of this accident was the
FAA's placement of a helicopter route in close proximity to a runway
approach path; their failure to regularly review and evaluate
helicopter routes and available data, and their failure to act on
recommendations to mitigate the risk of a midair collision near Ronald
Reagan Washington National Airport; as well as the air traffic system's
overreliance on visual separation in order to promote efficient traffic
flow without consideration for the limitations of the see-and-avoid
concept.
Also causal was the lack of effective pilot-applied visual
separation by the helicopter crew, which resulted in a midair
collision. Additional causal factors were the tower team's loss of
situation awareness and degraded performance due to the high workload
of the combined helicopter and local control positions and the absence
of a risk assessment process to identify and mitigate real-time
operational risk factors, which resulted in misprioritization of
duties, inadequate traffic advisories, and the lack of safety alerts to
both flight crews. Also causal was the Army's failure to ensure pilots
were aware of the effects of error tolerances on barometric altimeters
in their helicopters, which resulted in the crew flying above the
maximum published helicopter route altitude.
Contributing factors include:
The limitations of the traffic awareness and collision
alerting systems on both aircraft, which precluded effective
alerting of the impending collision to the flight crews;
An unsustainable airport arrival rate, increasing traffic
volume with a changing fleet mix, and airline scheduling
practices at DCA, which regularly strained the DCA ATCT
workforce and degraded safety over time;
The Army's lack of a fully implemented safety management
system, which should have identified and addressed hazards
associated with altitude exceedances on the Washington, DC,
helicopter routes;
The FAA's failure across multiple organizations to implement
previous NTSB recommendations, including ADS-B In, and to
follow and fully integrate its established safety management
system, which should have led to several organizational and
operational changes based on previously identified risks that
were known to management; and
The absence of effective data sharing and analysis among the
FAA, aircraft operators, and other relevant organizations.
What We Recommended
On Mar. 7, 2025 we issued an urgent recommendation report (AIR-25-
01) with two urgent recommendations on mitigating the risk of midair
collisions at DCA.
To the Federal Aviation Administration:
Prohibit operations on Helicopter Route 4 between Hains
Point and the Wilson Bridge when runways 15 and 33 are being
used for departures and arrivals, respectively, at Ronald
Reagan Washington National Airport (DCA). (Urgent)
Designate an alternative helicopter route that can be used
to facilitate travel between Hains Point and the Wilson Bridge
when that segment of Route 4 is closed. (Urgent)
As a result of this investigation, we made the following new safety
recommendations.
To the Federal Aviation Administration:
1. Develop and implement time-on-position limitations for
supervisory air traffic control personnel, including guidance
for district and facility level management to adapt these
limitations to account for their own staffing and local
standard operating procedures.
2. Develop instructor-led, scenario-based training on threat and
error management that trains controllers to continuously
monitor their environment to more quickly and accurately
identify threats; promote team communication to ensure that
communications are clear, timely, and assertive; emphasize
effective scanning habits; recognize patterns in the
development of adverse events; and enhance decision-making
under stress by developing habits that balance procedural
compliance with problem solving to mitigate the risks of
threats and errors, and provide this training to all air
traffic controllers annually.
3. Develop and implement a risk assessment tool for supervisors
that incorporates the principles of threat and error management
to assist in risk identification, mitigation, and operational
decision making.
4. Initiate rulemaking in 14 Code of Federal Regulations Part 93
Subpart K, High Density Traffic Airports, that prescribes air
carrier operation limitations at DCA in 30-minute periods,
similar to those imposed at LaGuardia Airport, to ensure that
the airport does not exceed capacity and to mitigate
inconsistent air carrier scheduling practices.
5. Fully implement operational use of the time-based flow
management system at Potomac Consolidated Terminal Radar
Approach Control and its associated air traffic control towers.
6. Reassess the Ronald Reagan Washington National Airport's airport
arrival rate with special consideration to its airspace
complexity, airfield limitations, mixed-fleet operations, and
traffic volume.
7. Define objective criteria for the determination of air traffic
facility levels considering traffic and airspace volume,
operational factors unique to each facility, and cost of
living.
8. Using the criteria established by Safety Recommendation [7],
determine whether the classification of the Ronald Reagan
Washington National Airport's air traffic control tower as a
level 9 facility appropriately reflects the complexity of its
operations.
9. Conduct a comprehensive evaluation, in conjunction with local
operators, to determine the overall safety benefits and risks
to requiring all aircraft to use the same frequency when the
helicopter and local positions are combined in the Ronald
Reagan Washington National Airport air traffic control tower.
10. Implement anti-blocking technology that will alert controllers
and/or flight crews to potentially blocked transmissions when
simultaneous broadcasting occurs.
11. Develop and implement improvements to the conflict alert system
to provide more salient and meaningful alerts to controllers
based on the severity of the conflict triggering the alert.
12. Once the improvements to the conflict alert system discussed in
Safety Recommendation [11] are implemented, provide training to
controllers on its use.
13. Revise the Air Traffic Organization's initial event response
procedures so that an appropriate on-site supervisor makes each
postaccident and postincident drug and alcohol testing
determination, based on their assessment of whether the event
meets testing criteria and which controllers had duties
pertaining to the involved aircraft, without needing to wait
for investigation or approval.
14. At least annually, provide training on the revised postaccident
and postincident drug and alcohol testing determination
procedure discussed in Safety Recommendation [13] to all staff
who have responsibilities under that procedure; this training
should include a post-learning knowledge assessment.
15. Ensure that annual reviews of helicopter route charts are being
conducted throughout the National Airspace System as required
by Federal Aviation Administration Order.
16. Conduct a safety risk management process to evaluate whether
modifications to the remaining helicopter route structure in
the vicinity of Ronald Reagan Washington National Airport are
necessary to safely deconflict helicopter and fixed-wing
traffic and provide the results to the National Transportation
Safety Board.
17. Amend your helicopter route design criteria and approval process
to ensure that current and future route designs or design
changes provide vertical separation from airport approach and
departure paths.
18. Based on the criteria and approval process established by Safety
Recommendation [17], review all existing helicopter routes to
ensure alignment with these updated criteria.
19. Incorporate the lateral location and published altitudes of
helicopter routes onto all instrument and visual approach and
departure procedures to provide necessary situation awareness
to fixed-wing operators of the risk of helicopter traffic
operating in their vicinity.
20. Modify airborne collision avoidance system traffic advisory
aural alerts to include clock position, relative altitude,
range, and vertical tendency.
21. Require existing and new traffic alerting and collision
avoidance system (TCAS) I, TCAS II, and airborne collision
avoidance system X installations to integrate directional
traffic symbols.
22. Require all aircraft operating in airspace where Automatic
Dependent Surveillance-Broadcast (ADS-B) Out is required to
also be equipped with ADS B In with a cockpit display of
traffic information that is configured to provide alerting
audible to the pilot and/or flight crew.
23. Require the use of the appropriate variant of airborne collision
avoidance system X on new production aircraft that are subject
to traffic alert and collision avoidance system equipage
regulations.
24. Require existing aircraft that are subject to traffic alert and
collision avoidance system equipage regulations be retrofitted
with the appropriate variant of airborne collision avoidance
system X.
25. Evaluate the feasibility of decreasing the traffic advisory and
resolution advisory inhibit altitudes in airborne collision
avoidance system Xa to enable improved alerting throughout more
of the flight envelope.
26. If the evaluation resulting from Safety Recommendation [25]
finds that the inhibit altitudes can be safely decreased,
require retrofitting of the applicable airborne collision
avoidance system X variant incorporating the reduced traffic
advisory and resolution advisory inhibit altitudes on all
aircraft that are subject to traffic alert and collision
avoidance system and equipage regulations.
27. Require that all rotorcraft operating in Class B airspace be
equipped with airborne collision avoidance system (ACAS) Xr
technology once the ACAS Xr standard has been published.
28. Create an objective definition of close proximity encounter and
a public database of those encounters and their locations that
can be used to monitor their prevalence and identify areas of
potential traffic conflict for safety assurance and safety risk
management.
29. Develop and implement a process that will, in a timely manner,
notify involved parties after events such as near midair
collisions or traffic alert and collision avoidance system
resolution advisory activations, such that notification occurs
while relevant data remain available and before meaningful
safety analysis, reporting, or corrective action is no longer
practicable.
30. Based on the results of the audit completed in accordance with
Safety Recommendation [49], ensure that all safety management
system functions and data sharing activities at all air traffic
control facilities are conducted in collaboration with all
relevant external stakeholders.
31. Establish a requirement across all air traffic control tower
standard operating procedures that the operations supervisor
(OS) or controller-in-charge (CIC) document in the daily
facility log when any control position is combined with the
local control position, or when the OS/CIC position is combined
with a control position, along with a rationale for doing so.
32. Develop a new and comprehensive instructor-led, scenario-based
training on the proper use of visual separation, both tower-and
pilot-applied. This training should include information on the
inherent limitations of see and avoid, responsibilities when
applying visual separation, and guidance for controllers on
factors, such as current traffic volume, workload, weather or
environmental factors, experience, and staffing, that should be
considered when applying visual separation. Require this
training for all controllers and include on a recurrent basis
thereafter in annual simulator refresher training.
33. Require each Class B or Class C air traffic control tower
facility to evaluate its existing miles-in-trail procedures or
agreements to ensure that the spacing provided is appropriate
for operational safety, and make the results publicly
available.
To the U.S. Army:
34. Revise training procedures for flight crews assigned to operate
in the Washington, DC, area to ensure that they receive initial
and recurrent training on fixed-wing operations at Ronald
Reagan Washington National Airport, including approach and
departure paths, runway configurations, and the interaction of
those traffic flows with published helicopter routes.
35. Develop and implement a recurring procedure, at an interval not
to exceed 18 months, to verify the continued accuracy of
recorded flight data.
36. Incorporate information within the appropriate operator's manual
for all applicable aircraft on the potential total error
allowed by design that could occur in flight on an otherwise
airworthy barometric altimeter, including the increased
position error associated with the external stores support
system configuration.
37. Develop and implement a transponder inspection procedure on all
aircraft with transponders capable of transmitting Mode S and
automatic dependent surveillance--broadcast (ADS-B) and
operated in the National Airspace System (NAS), at least
annually and upon each aircraft's entry into service in the
NAS, that ensures 1) the transponder ADS-B settings are
correct, 2) the transponder is transmitting ADS-B, and 3) the
transponder is transmitting the correctly assigned address.
38. Establish a flight data monitoring program for rotary-wing
aircraft the U.S. Army operates in the National Airspace
System.
39. Survey U.S. Army helicopter pilots to identify barriers to the
utilization of flight safety reporting systems, develop a plan
to address the identified barriers, and implement that plan
across Army aviation units.
40. Revise the method for allocating resources to ensure the
development of a robust safety management system that will, at
a minimum, identify and monitor the potential for midair
collisions between Army aircraft and civil air traffic
operating in the National Airspace System.
41. Develop and maintain a flight safety management capability that
is independently resourced and functionally separate from its
occupational and environmental health management system, and
ensure that this capability is both culturally and functionally
integrated with units conducting sustained flight operations in
the National Airspace System.
To the Department of War Policy Board on Federal Aviation:
42. Conduct a study to evaluate the quality of radio transmissions
and reception for those aircraft operated within the National
Airspace System to identify factors that degrade communications
equipment performance and adversely affect the safety of
civilian and military flight operations.
43. Implement appropriate enhancements, based on the findings of the
study recommended in Safety Recommendation [41], to remediate
identified deficiencies in air-ground radio communications
performance.
44. Require the Department of War to verify on all aircraft with
transponders capable of transmitting Mode S and automatic
dependent surveillance--broadcast (ADS-B) and operated in the
National Airspace System (NAS), at least annually and upon each
aircraft's entry into service in the NAS, that 1) the
transponder ADS-B settings are correct, 2) the transponder is
transmitting ADS-B, and 3) the transponder is transmitting the
correctly assigned address.
45. Require armed services to amend their operational procedures to
allow flight crews to enable Automatic Dependent Surveillance--
Broadcast Out while in flight.
46. Require all military aircraft operating in the National Airspace
System (NAS) be equipped with Automatic Dependent Surveillance-
Broadcast (ADS-B) In with a cockpit display of traffic
information that is configured to provide alerting audible to
the pilot and/or flight crew, and that such requirement apply
wherever in the NAS the Federal Aviation Administration
requires any aircraft to operate with ADS-B Out.
To the Department of Transportation:
47. Require the Federal Aviation Administration to demonstrate at
least annually that each air traffic control facility it
operates has the routine capability to accomplish required
postaccident and postincident drug and alcohol testing within
the U.S. Department of Transportation's specified timeframes of
2 hours for alcohol and 4 hours for drugs, and implement a
process to ensure that any facility without such capability
will demonstrate timely remediation.
48. Work with the Federal Aviation Administration (FAA)
Administrator to convene an independent panel to conduct a
comprehensive review of the safety culture within the FAA's Air
Traffic Organization (ATO), and use the findings to enhance the
ATO's existing safety management system and integrate it into
all levels of the organization.
To the Department of Transportation Office of Inspector General:
49. Complete an audit of the Federal Aviation Administration (FAA)
Air Traffic Organization safety management system functions and
data sharing activities at all air traffic control facilities
and determine whether these activities are conducted in
collaboration with all relevant external stakeholders, ensuring
that the audit's results are documented, reported to the
Secretary of Transportation and the FAA Administrator, and made
available to the public.
To the RTCA Program Management Committee:
50. Finalize and publish the minimum operational performance
standards for airborne collision avoidance system Xr for
rotorcraft.
The Chairman. Thank you, Madam Chair. In just a moment,
Chairwoman Homendy is going to play a short video simulation
that the NTSB produced that includes the transcript of the
cockpit voice recordings along with air traffic control
transmission. And I will say right before this hearing began,
the Chairwoman played for the members of this committee, in the
back conference room, the video along with the audio of the
cockpit voice transmissions.
Under Federal law, we're not allowed to play the actual
voice transmissions publicly. But I will tell you, watching and
listening, and for any members that did not see that, I'm
certain that Chairwoman would be happy to give you the
opportunity to see it and listen to it. It is positively
horrifying. And watching it and listening to the voices of the
pilots makes you sick to your stomach.
After watching, it is indisputable that ADS-B In and Out
could have prevented, and likely would have prevented, this
accident, and we have an obligation to prevent the next
accident. I do want to give a moment if any of the family
members wish to step out and not watch the video. We certainly
understand that, and so, I want to give you an opportunity if
you would prefer not to watch it.
And, Madam Chair, you can play the video now.
[Video shown.]
Ms. Homendy. So, it I think it stopped here because that--
it says 47 seconds, but at 48 seconds, the helicopter crew
had--they did have ADS-B In on an iPad that was strapped to
their thigh, but they also had NVGs on, and it was a high night
vision goggles on, and it was a high workload environment.
And so, they didn't look down. You don't look down
constantly in this airspace with NVGs on to--it would be very
difficult. Had--the problem is that they would have received an
oral alert from their iPad at 48 seconds had that been
connected into their headsets, but their headsets aren't able
to receive those oral alerts.
And so, an oral alert, had that been connected and
integrated into their headset, which was one of our
recommendations to do that so that they can get those alerts,
it would have been 40--they would have been at 280 feet. The
aircraft would have been at 640 feet. They would have been
miles apart and could have taken evasive action because, at
this point, they're at Hains Point, in plenty of time to take
action. But that was the first time they would have received an
alert, but didn't because they couldn't hear. It doesn't come
across their headset.
[Video shown.]
Ms. Homendy. At 59 seconds, this is where Flight 5342, had
they had ADS-B In, would have gotten their first alert. That
would have been their first alert had there been ADS-B In, and
I know there has been statements made, but the helicopter
wasn't transmitting ADS-B Out. Even if this aircraft had ADS-B
In, it wouldn't have mattered because at DCA you have something
called TIS-B, it's Traffic Information Service-Broadcast. They
have ground radar stations that take information from
transponders and other aircraft in the air that have ADS-B, and
relay it back up to aircraft that have ADS-B In.
So, they would have gotten their first alert and it would
have sounded something like, ``Traffic 12 o'clock, 2 nautical
miles, 500 feet below,'' or, ``low altitude.'' What you're
going to hear in a minute--in just a few seconds, at 19 and a
half seconds, is what they actually did here, and that's--we'll
go ahead and play.
[Video shown.]
Ms. Homendy. Yes, sorry, you didn't hear, ``Traffic,
traffic,'' at 19 and a half seconds because the CVR audio isn't
on there, but that would have been 19 and a half seconds. And
then at that point at, ``Traffic, traffic,'' you're looking
out, trying to figure out where the traffic is. Helicopters
down in the lights. Pilots are told when it's a traffic
advisory, you're not to take any sort of evasive action because
you need to be looking at and acquiring that traffic.
Resolution advisories, which is part of TCAS that you can
get, resolution advisories would have provided them with a
climb/descend. Except, below 900 feet, across our entire
airspace, resolution advisories are inhibited, meaning they are
quiet, all you get is, ``Traffic, traffic.'' What we're talking
about is timely information for pilots.
The Chairman. Thank you, Madam Chair. The NTSB conducted a
thorough investigation into this accident. What did the NTSB
investigation show about what would have happened if both
aircraft had been equipped with ADS-B In?
Ms. Homendy. The accident wouldn't have happened. At 48
seconds, the helicopter crew would have gotten an oral alert,
they could have taken evasive action, and the flight crew of
5342, at 59 seconds, could have had an alert that allowed them
to take evasive action. So, we have recommended ADS-B In
everywhere there is ADS-B Out for all aircraft.
The Chairman. As you know, the bipartisan ROTOR Act, which
passed out of this committee and which is passed to the Senate
unanimously, every Republican, every Democrat has voted for it,
mandates ADS-B In and Out on aircraft flying into congested
airspace. In your professional judgment, if the ROTOR Act had
been the law at the time of this accident, would the accident
have occurred?
Ms. Homendy. No, it wouldn't have occurred. Though, this
helicopter route shouldn't have existed, but that's another
story. No, I don't believe it would have occurred.
The Chairman. Well, and as you know, that's another
component of the ROTOR Act is mandating a reassessment of
helicopter----
Ms. Homendy. Absolutely.
The Chairman.--routes as well. ADS-B Out and In is not new
technology. Today, the FAA only requires ADS-B Out, which sends
signals directly to air traffic control. In 2010, the Agency
chose not to require ADS-B In, which would have given pilots
those same signals. Nonetheless, some aviators voluntarily use
ADS-B In, receiving weather, traffic, and other information in
the cockpit. American Airlines, for example, has equipped
nearly 30 percent of its fleet with ADS-B In. More than 80
percent of private pilots use some form of ADS-B In. It is
clearly a popular technology.
I've heard a handful of special interest groups, however,
want carve outs from the ADS-B In requirement. I don't think a
private jet or a charter flight flying into DCA, or Dulles, or
DFW, should be able to adhere to a lower safety standard than a
passenger airline. Special treatment for them would put
everyone else's lives at a risk. Others have said that all of
general aviation should be exempt, even though pilots in rural
areas are already exempted, and the ROTOR Act protects general
aviation's ability to use portable transponders. In your
judgment, should different aircraft be flying into congested
area using different ADS-B safety rules?
Ms. Homendy. No, absolutely not. It's a shared airspace.
The Chairman. Those same skeptics like to claim that ADS-B
In is too costly. Major airlines like American Airlines have
figured out how to install ADS-B In. Every new Gulf Stream has
ADS-B In, and, of course, the ROTOR Act only requires ADS-B In
for planes flying into busy airspace. A crop duster flying in
Arkansas isn't going to need it and won't be affected, but if
that crop duster decides to land at DCA Reagan, then it should
have the technology and not be endangering the lives of
passengers flying into and out of Reagan every day. In your
judgment, is it too expensive for planes to install ADS-B In?
Ms. Homendy. Four hundred dollars. Everybody's got a phone.
Everybody's got a headset. Four hundred dollars. Maybe you get
an iPad, it's a little more expensive, but that isn't costly.
American Airlines, less than $50,000 a plane to retrofit. The
plane was out of service. They told me one or two days when
they retrofitted it--each plane.
The Chairman. So, I want you to repeat that because one of
the concerns people are raising is this is some onerous
government mandate. A private pilot can get the equipment
necessary, A, to keep himself or herself safer, B, to keep
everyone else flying into that congested airspace safer. They
can get that equipment for $400.
Ms. Homendy. You already have a headset. Everybody has a
phone. Some people have iPads. Four hundred dollars. This is
the receiver.
The Chairman. Another objection that has been raised is the
claim that somehow the military should be exempt, that the
military should be able to fly in congested airspace and not be
subject to the rules everyone else is. Does that make any
sense?
Ms. Homendy. No, it does not.
The Chairman. Well, 100 members of the U.S. Senate agree
with you. The Secretary of War agrees with you. The Secretary
of Transportation agrees with you, and I am hopeful that within
the next two weeks, the House of Representatives will put the
ROTOR Act on the floor, will pass it, and will put it on
President Trump's desk for signature. We owe it to the families
of those who lost their lives, the 67 souls who should be with
us today if only Congress had listened to the first 16 times
the NTSB recommended ADS-B In. Thank you.
Ms. Homendy. I know you don't have any more time, but can
I----
The Chairman. Sure.
Senator Cantwell. He's the Chair.
Ms. Homendy. I know you--yes. Can I have one thing to point
out?
The Chairman. You could have two.
Ms. Homendy. OK. Thank you. In 2001, the FAA had a
rulemaking on fractual ownership, and they stated in there that
passengers who are transported under Parts 121 and Part 135,
``Exercise no control over and bear no responsibility for the
airworthiness or operation of the aircraft aboard which they
are flown.''
I would also say that applies to Part 91, Revenue
Generating Passenger Operations. The FAA concluded that, ``The
appropriate level of public safety is provided by very
stringent regulations and oversight under Part 121 and Part
135.'' In Ketchikan in 2019, we stated that, ``Aircraft without
ADS-B do not demonstrate the appropriate level of safety for
passenger-carrying operations conducted under Part 135
Regulations,'' and we also stated that there's shared airspace
between 121, 135, and GA.
We've conducted numerous investigations between Part 121
airlines and GA aircraft, or GA aircraft carrying passengers
who paid for a service with other GA aircraft, or between 135s
and 121s, or 135 and GA. The fact is everyone should be under
the same rules, one level of safety, because it doesn't matter
if you're in a private plane, a commercial jet is also
operating in your airspace.
The Chairman. Thank you. Ranking Member Cantwell.
Senator Cantwell. Thank you, Mr. Chairman. Chair Homendy,
you, in my opinion, have become a sentry for aviation safety.
And that means that you're standing guard over our system,
which, I believe, should be standing guard over by the FAA, and
you should play a role on the details that then, jointly, this
works together.
But somehow, the industry has too much influence over this
process, and I don't know if the FAA just thinks that it can't
keep up technologically. I don't know, but these
recommendations have been on the table for a long time, and
they've never been implemented. And so, I want to ask several
questions about your 14 key recommendations.
But, first, on this issue of ADS-B In, you just talked
about the issue of what it would take to implement. But isn't
there a cost? General aviation is saying this is too expensive
and you just refuted that, but isn't there a cost for not doing
it? NTSB data showed that between 2006 and 2025, they
investigated 153 mid-air collisions involving general aviation
operators compared to one mid-air collision and four near mid-
air collisions involving commercial jets. So, these general
aviation accidents have cost 198 lives. So, there is a huge
cost to general aviation for not doing this. Isn't that
correct?
Ms. Homendy. That's correct. Unfortunately, when you do
rulemaking, the DOT puts the price of a life at $11.6 million.
The NTSB considers all life priceless. You can't put a price
tag on a life.
Senator Cantwell. How many times did you or your
individuals listen to the audio tapes here?
Ms. Homendy. Quite a number of times.
Senator Cantwell. Hundreds?
Ms. Homendy. If I combined everyone. Yes.
Senator Cantwell. So, I think that's the difference. You're
listening to this, analyzing this, and you are steadfast in
your recommendations, and somehow, these guys are listening to
other voices and saying we don't have to do it because there's
a cost. And I got news for the FAA: in the digital age that's
not going to stand because we all can see this information, and
we need an FAA that basically is on top of this, and will push
through the regulations to implement.
So, on this issue, a safety management system, which is
basically part of the requirements, you're basically saying
that they didn't integrate a system. Would a safety management
system with the number of near misses that you said were alarm
bells going off in the cockpit, demanded that this run--this
route no longer exist?
Ms. Homendy. A safety management system--a properly
implemented safety management system should have identified the
risk. But it is pretty clear from our investigation----
Senator Cantwell. Well, would have----
Ms. Homendy.--that did not occur.
Senator Cantwell.--not only identified it, but would have
required, once identified, to fix it.
Ms. Homendy. Yes, once you identify, then you look at your
mitigations, and then you implement those mitigations, and
monitor those mitigations, and reevaluate for change. But in
this case, there were numerous warning signs from people within
the FAA saying we have a problem here. Then, there was their
own data that they weren't even looking at: 15,214 close
proximity events.
I can tell you this much, the FAA requires a lot of data.
They've got 10 different systems just for mid-air collisions,
but they don't actually have a definition for what they
consider is a mid-air collision, a near miss, not one single
definition. So, then, you have people who aren't looking at the
data. Then, you have the tower who is trying to raise concerns
over and over again, year after year, and not being heard, told
to go away. And I have to tell you, this same scenario that
occurred on January 29, also occurred in 2013 between a
military aircraft and a private commercial jet. It was averted.
Same thing happened.
Senator Cantwell. So, we need an aggressive FAA in this air
traffic control office and safety office on aviation safety to
actually collect data, report on data. And my guess is we're
going to have to get some of this data, and review it, and
require hearings because, otherwise, this job isn't getting
done. It appears to be.
Ms. Homendy. Yes.
Senator Cantwell. So, if you would just comment on San
Antonio--I mean El Paso, for us about this newest event.
Ms. Homendy. I don't know a lot. I don't know anything
about El Paso other than what I read. It's not something that
we handle. However, you know, from the--what little I know, I
will say there has been miscommunication or no communication
between--at least, the Army and FAA for years. Now, the Army
participated--the 12th Battalion participated in the Helicopter
Working Group, but in general, they weren't having
conversations.
Senator Cantwell. Which this--is in this accident, the key
issue as well. The conversation should have been happening, and
we, obviously, had a rule that somehow got changed that allowed
this to happen, and it wasn't an accurate assessment even after
the rule was changed, so.
Ms. Homendy. Yes. And if you don't mind me mentioning,
the--listen, the reason why the NTSB has the party system, when
we do an investigation, we invite entities who are technical
experts into our investigation, like FAA, like the Army, like,
you know, a number of others, PSA, you name it, in order for us
to get the evidence we need to conduct our investigation.
They're not part of the analysis, right? But during that time--
it has been a year--during that time, parties get that
information in real time and can make change immediately. They
don't need to wait for our final investigation to come out with
50 recommendations.
You know what the best result of an investigative report
is? It's the best thing that has happened in years at the NTSB,
in Missouri, actually. I wish Mr. Schmitt was here to hear it.
We had at the end of a terrible train derailment, I was on
scene, went to meet with a farmer in his barn who said he had
been talking about, you know, this terrible accident that could
occur for years on Facebook, doing videos. I met with him in
his barn and said, ``What's going on,'' for, like, 2 hours, and
he said to me--I said, ``I'm going to fix this before we
leave,'' and he's like, ``Sure you are.'' I don't blame him.
You know, he had been facing a government bureaucracy for
years. So, I got everybody together before we left. I said, you
name it, and I said, ``We are fixing this crossing.'' And you
know what happened? A year later, we issued our final report on
a deadly train collision at this terribly designed grade
crossing. And Governor Parson not only fixed that crossing, he
fixed 49 others, and we issued no recommendations.
The failure in this report is that we had to issue
recommendations. Now, I'm going to get a briefing from FAA on
the reorganization, but we can't be just shifting around the
deck chairs. ATC didn't contribute to this. We need reform.
Senator Cantwell. Well, other people here need to listen.
Thank you, Mr. Chairman.
The Chairman. Thank you. Senator Wicker.
STATEMENT OF HON. ROGER WICKER,
U.S. SENATOR FROM MISSISSIPPI
Senator Wicker. Thank you, Mr. Chairman. And also, thank
you, Ranking Member Cantwell, and former Chairman Cantwell, for
asking that question about El Paso.
Senator Cantwell and I were leading this committee during
the time when we were investigating the 737 MAX 8 tragedies,
and this is the most heartrending and gut-wrenching issue that
we could possibly ever investigate. And I just don't have the
words to tell the families how awful this is, and how terrible
I realize they must feel. Thank you, Chairwoman Homendy, for
your leadership in this.
Since the accident in January of last year, what has
changed at Reagan National Airport between the FAA, the towers,
and the National Guard, in the interim, before our Act can be
passed by the House?
Ms. Homendy. Well, one thing that did change is that
within--we issued two urgent safety recommendations for
immediate action in March of this past year, just a couple of
months after the accident occurred, calling on the Secretary of
Transportation to take action about the helicopter route
itself, Route 4.
And within two hours--it's the fastest we have ever had an
entity implement our recommendation. Within two hours, he did
so. He prohibited mixed traffic between Hains Point and Wilson
Bridge, which is now in an interim final rule before him. But
he's continued that prohibition on mixed traffic, and has
required ADS-B Out in the airspace. He has authorized
additional personnel in the tower. However, the tower is facing
some challenges. The numbers are lower because a lot of people
are going through training, but a number of other measures need
to be--need to take place.
Senator Wicker. Sure----
Ms. Homendy. But he's done a great job.
Senator Wicker. I understand that, but things have been
done within weeks of this accident based on your
recommendations.
Ms. Homendy. Yes. And I have to say, this was his first day
on the job.
Senator Wicker. Right. Yes.
Ms. Homendy. It was his first day on the job. He did--this
will forever stay with him, which is why he is so committed to
aviation safety, and he has been an excellent partner on this
with us.
Senator Wicker. When you speak to skeptical members of the
other body, is it the cost to general aviation that they
mention as the only reason they're skeptical about the bill?
What other reasons do they give for not readily passing what
has been passed unanimously over here?
Ms. Homendy. I've heard a number of things. I've heard
cost. I've heard aircraft----
Senator Wicker. That would be the cost to the general
aviation owners?
Ms. Homendy. I've heard for everybody. Cost for general
aviation, 135, 121 regional airlines, major airlines. I've
heard difficulty in retrofitting, planes being out of service.
I've heard privacy concerns. I've heard--and I'm sure Senator
Budd is going to raise this, I've heard concerns about tracking
aircraft with ADS-B Out where some airports and third-party
entities are tracking aircraft, especially GA aircraft, to
charge them landing and ramp fees, which is something you-all
can address. Those are the main issues I've heard about.
Senator Wicker. Let me ask you--let me ask you this. On the
headsets, it just strikes me as so inconceivable that this
helicopter had the ADS-B, but the two pilots could not hear it
on their headsets. Why was that, and how readily could that be
fixed?
Ms. Homendy. So it can be fixed. We have issued a
recommendation for them to have an integrated headset so that
they can hear any sort of alerting, but we've also recommended
better technology on the helicopters so they're not relying on
iPads on their legs while they're in a night vision goggle,
high workload environment.
I will say the Army has been very responsive. They have
completely replaced their helicopters at the 12th Battalion,
from the old Lima models to the new MIC models, and they have
stated they're going to implement that technology. They're
still working on the headset issue and haven't quite committed
to that, but implement better technology for ADS-B In and Out
by the third quarter of 2027, though, they're asking for $500
million. So, since you're in charge of that, I will ask for
$500 million.
Senator Wicker. And if the Chair will indulge me, should
the House pass this bill that has now passed unanimously in the
Senate, should they pass it next week, how soon could it be
implemented?
Ms. Homendy. I think certain measures can be implemented
immediately. Some measures will take a little bit of time. I
don't know how much time, but it would take a little bit of
time, and FAA would have to sort some of it out through a
rulemaking in that amount of time, like ADS-B In. But in that
amount of time, the risk still is in our airspace. So, every
day that goes by, we face the potential for another catastrophe
to occur.
Senator Wicker. Well, thank you for your stewardship of
this issue.
Ms. Homendy. Thank you.
The Chairman. Senator Duckworth.
Senator Duckworth. Thank you, Mr. Chairman. As our
committee conducted oversight and aftermath of the tragic DCA
crash, I've noticed that the stories from FAA and the Army have
gradually evolved over time. Specifically, my sense is that the
information provided have come to resemble more of a telling of
what should have happened rather than what actually happened,
and I fear this pattern is yet another symptom of a complacent
culture.
For example, NTSB is now officially recommending that FAA
and the Army engage in proactive data sharing. The lack of
coordination between the FAA and the Army was on full display
in May of last year when it was reported that the dedicated
direct access line connecting the Pentagon tower with the DCA
tower had not worked since 2022, meaning that for more than
1,000 days--1,000 days--not a single soul ever used the hotline
directly connecting the DCA tower and the Pentagon's Army
heliport. Now, in the aftermath of this scandal, which itself
occurred only months after the preventable deadly DCA crash,
FAA issued statements downplaying the impact, implying that the
inoperable hotline was really no big deal because, look,
controllers could just ``call each other on the telephone.''
But FAA cannot hand-wave away the scandal because FAA's
Deputy Chief Operating Officer publicly admitted that FAA had
no idea that the dedicated hotline was not working for 3 years.
FAA had no idea until another Army helicopter incident less
than 4 months after the DCA crash forced two commercial flights
to abort landings at DCA. Meaning, that after the tragedy of
Flight 5342 civil military collision, not one FAA employee
thought, ``Hmm, maybe we should test our direct communications
line to the Army heliport from the DCA Tower?''
Chair Homendy, does the fact that the FAA's dedicated
direct access line to the Pentagon was literally inoperable for
years without anyone noticing, serve as an apt metaphor for the
sheer amount of work that must be done to improve
communications between DOD and FAA?
Ms. Homendy. That one's still under investigation by NTSB,
but, yes, I would agree with that.
Senator Duckworth. Just yesterday, the FAA announced a 10-
day temporary flight restriction in El Paso, then abruptly
reversed it hours later. The conflicting reports that emerged
do not inspire confidence that the FAA and DOD have improved
their communications either with each other or within their own
organizations. In fact, the FAA Administrator yesterday in
response to the Chairman Cruz's question about what happened in
El Paso said that Secretary Duffy's tweet about drug cartel
drones was absolutely correct, that they knew about the
impending--the request for closure of the airspace, but he did
not know why FAA actually closed the airspace for 10 days.
Chair Homendy, the DCA collision, and now we're hearing
it's a party balloon that they shot down. So, I'm still waiting
to hear what's happening. But Chair Homendy, the DCA collision,
the May Pentagon go rounds, the B52 incident in South Dakota,
and now, El Paso, showcases a severe lack of coordination.
What must change at the FAA, DOD to prevent future
coordination failures? What is at risk if there is no
improvement, and has NTSB been included in some of these
meetings with--and coordination between FAA and DOD because
they were keeping you out for a while there?
Ms. Homendy. No, we are not part of that, but we would not
necessarily be part of that. But FAA, we can talk about
separately because I do have some concerns there. Army actually
worked really well with us. What we investigated was between
the Army and the FAA, and there was no communication. I mean,
the Army participated, the 12th Battalion participated in a
helicopter working group that was formed by the tower because
the tower was saying, hey, we've got a serious safety issue
here and nobody's doing anything about it. Let's try to
coordinate. But Army wasn't asking for data. They had their own
safety management system problems and there was lack of
coordination.
Look, I'm going to tell you, I worked 15 years on Capitol
Hill, and we talk about this all the time. When you go to an
agency, the lack of communication, even within a large agency
and between agencies is terrible. I don't understand it. People
can't talk. It's astounding to me, but it's not surprising from
what we've seen from the investigation.
Senator Duckworth. Would it be safe to presume that you
would support Congress elevating the NTSB recommendations
following the DCA mid-air collision into a statutory
requirement?
Ms. Homendy. Yes. And you can do that simply by requiring
the entities to adopt the recommendations, and reference our
report without actually having to do language everywhere. What
I will say, though, is we shouldn't wait to move the provisions
in the ROTOR Act. This isn't a wait on ROTOR move, this
legislation. This is a yes, and. Congress can move many pieces
of legislation every day, so it's a yes/and.
Senator Duckworth. Thank you.
The Chairman. Thank you. Senator Moran.
Senator Moran. Senator Cruz, thank you. I intended in my
line of questioning to reemphasize the importance of ROTOR Act,
but perhaps that has been accomplished in this hearing,
although one would have thought that 17 other times it may have
been accomplished. So, maybe it can't be said enough, but I
reaffirm my commitment to seeing the passage of the ROTOR Act a
bit along the lines of Senator Duckworth about--and you talked
about communication.
One of the things, and I don't have any of the details in
front of me, so you'll have to refresh my memory. But the
number of near misses you mentioned in your opening statement
that were reported at DCA in regard to potential collisions,
but you also, in an earlier testimony or in our conversations,
talked about the number of times that somebody at DCA reported
a problem that they thought needed to be fixed, but it never
worked its way up the chain of command. And I think, as I
recall, like nothing ever made it to the folks who actually
could implement changes recommended by air traffic controllers
or others involved in air traffic safety. Am I saying enough to
refresh your memory about what I'm talking about?
Ms. Homendy. Yes. First of all, the data which we actually
obtained from the FAA, in coordination with them, showed 15,214
close proximity events over about 10 years, 85 of which were
near misses, and----
Senator Moran. But you also indicated today something I
didn't realize. There's no real definition because those have
been dismissed as unimportant, but to me or to Kansans and
Americans, you hear a near miss, that means something. But
apparently there's no definition that would awake somebody
within the FAA.
Ms. Homendy. Yes. They need a common definition because you
all--you brought together FAA, NTSB, and the Army at one point
behind closed doors, and I talked about the near miss numbers
that we had received from FAA. And all of a sudden FAA spoke up
and said, no, it's five. And I looked over, where'd you get
five? You somehow whittled down 15,214 to five because there's
no common definition. Ten different data sources, and it's
whatever you choose it to be that day, a definition. And, you
know--so, you know, from my standpoint, that is just one of
many areas that they could have fixed before we even got to a
recommendation.
Senator Moran. You fill in spaces on my other aspect of my
question----
Ms. Homendy. Yes.
Senator Moran.--about that, where things were reported time
and time again, but never did anyone in the hierarchy ever hear
of the complaints because there was timidity in complaining.
Ms. Homendy. Well, one, I would probably--I would say the
hierarchy at the air traffic organization did understand----
Senator Moran. Yes.
Ms. Homendy.--what was going on, which was a problem. I
mean it was push it down, make it go away, not an issue. Too
political. Too political was from one of the interviews, not my
phrasing. The leadership of the FAA probably were totally
unaware. So, you have the tower--that's the ultimate
bureaucracy, by the way. I think at one point, we counted the
steps from the tower to get something all the way up to
leadership. It was like 10 or 12 steps. It's ridiculous.
Senator Moran. Almost nothing made it the 10 or 12 steps--
--
Ms. Homendy. No.
Senator Moran.--if you recall what you----
Ms. Homendy. No. It made it to the district level and made
it nowhere else. So, what happened was the air traffic control
tower said, you know what, we're going to have to take things
into our own hands. So, we're going to create this Helicopter
Working Group. So, they did, not just with the military, but
all the private operators, police, you name it, law
enforcement, and they pulled together the working group. They
did some work. They proposed to their hierarchy, hey, you know,
we should move helicopter Route 4. Another time they said, we
think we should put some hotspots, you know, on the helicopter
charts, including at the end of Runway 33, which we've seen is
an area where we have a great concern for risk if there's a
mid-air collision. And FAA's response----
And then, they had numerous reports just coming from the
tower, written reports. They also had a report saying, we're
getting too many requests from Potomac TRACON to reduce spacing
between aircraft landing. There were so many reports, and each
time it was nope, or no--and this is the ultimate in
bureaucracy when the response to the hotspot was, yes, we don't
put hotspots on maps. Oh, the only hotspots we do on maps is
for ground movement. Come on.
At our hearing, we raised this issue. Why didn't you do
anything? The person who showed up from FAA said, well, they
could have raised it at a symposium. Really? They were raising
it so many times in writing, verbally. If that happens at DCA,
you know it's happening everywhere else in our airspace.
Senator Moran. Thank you for refreshing my memory and
putting that on the record today. Let me ask you, if there's
any indication or what are the indications that the FAA, the
Department of Transportation are taking aggressive action to
implement recommendations, past and present? Has anything
changed since January 29 of last year? I think you made a
really important point that you don't--I think there's a
tendency, I can see myself thinking the same thing: we'll wait
for the recommendations, and then we'll know what to do when we
know there are things to be done today.
Ms. Homendy. And that's perfectly reasonable for you-all,
but for those that were parties to our investigation, the
reason why you are parties is because you're privy to factual
information so you can take early action. None of that
occurred. In fact, the entire time--we work for FAA, and I'm
going to be honest with you, I met with the DOT IG at one point
to talk about whether we should write a letter about
obstruction to our investigation, because we weren't--we were
repeatedly denied data we requested. What we kept hearing from
FAA was, well, you're not asking for it properly. We did. I
audited it, but here's what I'll say on the changes. I don't
know of any other than what the Secretary did, and that isn't
right.
Senator Moran. Message received. I wrote on my notes today
that our subcommittee, this committee, we ought to rely--I
guess, request GAO Inspector General, constant oversight on the
Department of Transportation, and the FAA in particular.
Ms. Homendy. Yes.
Senator Moran. Thank you, again.
Ms. Homendy. And on DOT IG, one thing I will say, sometimes
they don't get access to their data systems. That's something
you should chat with them about, because they aren't getting
the data. They're relying on people giving them the data.
Senator Moran. Thank you.
The Chairman. Thank you. Senator Klobuchar.
STATEMENT OF HON. AMY KLOBUCHAR,
U.S. SENATOR FROM MINNESOTA
Senator Klobuchar. Thank you very much, Senator Cruz. And,
thank you, Chairwoman. Not only do you bring this incredible
expertise--you know I've always been a supporter of yours, but
you also bring the passion and the anger that I know so many of
the families and the loved ones in this room are feeling over
what happened. I want to thank your dedicated NTSB staff for
all of their hard work. And I want to acknowledge the 67 people
who lost their lives, including Wendy Jo Schaffer, a mom of two
from Mahtomedi, Minnesota.
So, this committee, as you noted, has worked in a
bipartisan fashion to advance the ROTOR Act, and I thank the
Chairman and the Ranking Member for their work on this, as well
as Senator Moran and Senator Duckworth. So, my questions are,
first of all, on air traffic control staffing, we have a
shortage of air traffic controllers. Former Senator Braun and I
pushed to address staffing shortages by requiring the FAA to
conduct maximum hiring of air traffic controllers.
While the number of the staff at the time in the tower, as
you've noted in the report, was adequate, and in accordance
with FAA directives, the facility was staffed below its target
level. How can lower staffing levels impact controller
performance and awareness? Has the FAA increased staffing at
DCA to mitigate some of the issues raised today?
Ms. Homendy. So, it impacts staff--we didn't find a concern
with staffing on that day, as you noted, but it does impact
safety because it impacts their workload. In this case, you can
see two people should have been on position, one on helicopter
control, one on local control. And what happened was the local
controller was doing two jobs. People were at the--in the tower
and on staff, and available, but he was forced to do two jobs
and taking--and handling between seven and 12 aircraft.
What I will say, as far as staffing today, there are
staffing challenges, and that is an significant impact on
safety. They are authorized at DCA to have pretty high numbers,
but they're not at those numbers. On January 6, right before
our board meeting, I checked--we checked the numbers at DCA.
There's authorized numbers, but then you have to ask any day,
what's operational, who's out, who's on medical leave, who's on
military leave? It was lower than it was on January 29.
Senator Klobuchar. OK. Thank you. The NTSB report showed
that the flight path for helicopter Route 4 comes within 75
feet of the approach to Runway 33, and that video was chilling
to watch. Are there any circumstances in which 75 feet of
vertical separation is safe?
Ms. Homendy. Absolutely not. Not safe, anywhere in our
airspace.
Senator Klobuchar. The FAA is required to annually review
these helicopter flight routes. Who was tasked with reviewing
helicopter routes, and why hadn't this risk been identified
previously?
Ms. Homendy. I'm only laughing a little bit because it's so
sad, because DCA has existed since 1940s. Runway 33, 1940s,
traffic certainly has changed, but helicopter Route 4 has been
there since 1986. FAA is required to do an annual review of
those routes. Not a single annual review was done. Not a single
one. In fact, they couldn't--at first, when we asked who was
responsible for doing those annual reviews----
Senator Klobuchar. I think we asked NTSB or FAA. Have they
been able to identify who has that role?
Ms. Homendy. They finally--they did finally tell us who it
was. It was like a terminal operations director, but nobody
knows who specifically that is.
Senator Klobuchar. And do you know if they've changed this
now?
Ms. Homendy. No, I do not.
Senator Klobuchar. OK. Well, that's a good question for us
to ask. Could you talk about how you did this report and got
this thorough analysis, through all the grief? And as I was
watching the video, I was thinking about the hard work of your
staff, and I was thinking about the grief of the families. And
I was thinking about how every single day they had to come to
work, your staff, feeling that weight of what had happened to
these families and then still do their jobs. How many staff
contributed to this investigation? How many hours? And what is
the funding status for NTSB? And you can put it in writing
later if you don't have it. Exactly.
Ms. Homendy. It's probably about 50 or 60 staff. I mean,
we're only about 415 right now. It's significant. How were we
able to do this? The people behind me. I can only advocate like
I do, and know the facts that I do, and do a good job because
of them. We are a team, and they put together--they gathered
19,000 pages of evidence. It's my duty to read every single
word of that evidence because that's their hard work. I mean,
it's a lot--a lot of work, while they also have about 15 to 20
other cases. Mr. Chin here, who's behind me, did all the
helicopter work: helicopter systems, barometric altimeters,
you'll name it, on this investigation. He's also leading the
UPS crash as the investigator in charge.
Senator Klobuchar. Thank you, Mr. Chin.
Ms. Homendy. So, the personnel, it has been difficult. I
mean, it's a difficult year for them, and the shutdown was
difficult. It's a strain on all of them, but I have never been
more proud of the team than I was on January 27, and every day
since I came to the NTSB. Thank you.
Senator Klobuchar. Thank you. I just think this--the
findings and the fact that on a bipartisan basis, the Chairman
and Ranking Member have worked on this, as you noted, focused
on this, along with Senator Moran, Senator Duckworth. I just
don't detect partisanship here when it comes to this, and it is
such an example of why we're never going to be able to make
things better if we don't get to the bottom of what went wrong.
And as I understand already, some changes have been made that
you've recommended, and must continue to be made, every single
one of them. Thank you.
Ms. Homendy. Thank you. And I'll also add for the Chairman,
this is the same team behind me that helped us--helped me
evaluate NDAA before we even did anything. We got to--we get
together as a group and make decisions as a team.
Senator Klobuchar. Thanks.
The Chairman. Senator Sullivan.
STATEMENT OF HON. DAN SULLIVAN,
U.S. SENATOR FROM ALASKA
Senator Sullivan. Thank you, Mr. Chairman, and, Madam
Chair, it's good to see you again, and I want to thank you as
well. You're doing an exceptional job, and you're--your whole
team. I want to begin by, of course, expressing my deepest
condolences to the families and loved ones of those we lost in
the American Airlines Flight 5342 tragedy at DCA.
As you know, Madam Chair, also around the same time, we had
another airplane crash in Alaska, the Bering Air crash over
Norton Sound. One year later, these losses remain deeply felt
throughout our country with witnesses here, in my state in
Alaska, where, as you know, aviation is not a luxury, it's a
lifeline. And I want to thank the NTSB for its thorough work,
and I appreciate the work you've done on the latest Bering Air
crash--or not, or that latest crash in Alaska. We are grateful
for your commitment. We're grateful for you going up to Alaska
so soon after that crash, and aviation safety is particularly
important in my state, where communities depend on reliable air
service, for healthcare, for commerce. We have over 230
communities in my state that are not connected by roads, and
so, it really, really matters.
So, I want to broaden the aperture here. It has been 6
years since the February 2020 NTSB report that found over a 10-
year period, Alaska's aviation crash rate was almost two and a
half times higher than the national average, and the fatality
rate was 1.3, almost 1.4 times higher. That led me and the FAA
Administrator at the time, Steve Dixon, and you, to push for
what we now refer to as the Alaska Aviation Safety Initiative,
the FAASI Initiative.
I was able to get that initiative codified in the FAA
Reauthorization Act of 2024, ensuring that it would be in law
with the goal that we would reduce fatal aviation accidents in
Alaska by 90 percent by 2033, require the FAA to improve
maintenance and reliability of weather equipment, and to
reauthorize $25 million, at a minimum, annually, through 2028,
to carry out this work.
We've made significant progress on that. As you know, the
Working Families Tax Cuts Act had a huge investment in aviation
safety, ATC reform. A lot of that, about $180 million so far,
is going to Alaska. So, given the substantial work and funding
we've had since 2020 in the NTSB report, would you agree with
me that it's time to take a more comprehensive look at where we
are with the state of aviation safety in Alaska? And can I get
your commitment to work with me on this?
Ms. Homendy. Yes. In fact, I will offer, if you'd like,
we'll come back to Alaska, and would certainly welcome having a
robust conversation with you and others about aviation safety
and your needs, which are very unique.
Senator Sullivan. Good. Well, I appreciate that. Mr. Chair,
one of the things I'm going to be working on, and hopefully
with the Chair's--you know, and the Committee's help, is
possibly a field hearing with the Chairman of the NTSB, who
again, I think is doing a great job with the FAA on the state
of where we are in the FAASI Initiative. Because what we're
trying to do----
The Chairman. Can the field hearing coincide with salmon
fishing season?
Senator Sullivan. If you come, it can. But what we're
trying to do is preempt, you know, what Senator Duckworth
actually said, which is see our challenges. You know, I did
notice, Madam Chair, in your opening statement, you mentioned
Alaska with regard to 15 potential near collisions. We did have
a collision in 2019 in Ketchikan. Six people died, you know, in
that collision.
So, yes, I'd like to get to have you up and have my
constituents see, because I think there's progress, but there
are still gaps. And would you agree with that? And you know,
the President, Secretary Duffy, did announce a huge investment
in AWA systems in Alaska. I think the President actually
announced 170 for my state, which would be fantastic, but we
need to work on all elements of that. Can I get your commitment
again on that? And are there any things that, from the
preliminary look at the Bering Air investigation, or your other
areas of expertise that relate to Alaska, that you could kind
of lay out right now here?
Ms. Homendy. Well, we're still collecting--well, first of
all, yes, you have my commitment on that.
Senator Sullivan. Great. Thank you.
Ms. Homendy. I was the Board Member on scene for Ketchikan.
It was really devastating.
Senator Sullivan. Yes.
Ms. Homendy. And Brice Banning was also on that
investigation. He's our investigator in charge for DCA. Yes, so
we're still conducting the investigation on Nome. We hope--I
need to check in with the team on what the--when that will be
completed.
But you have a lot of needs in Alaska, infrastructure for
one of them, resources. I mean, just to see how different
aviation is, that you're relying on aviation from everything
from mail, to prescriptions, lifesaving medicine, to food.
Senator Sullivan. Yes.
Ms. Homendy. And you need to have that infrastructure there
so you can get all of that in, whether it's weather, whether
it's runway lights, or anything else.
Senator Sullivan. Good. Well, I look forward to that. And
Mr. Chairman, I look forward to maybe getting you up there and
your team, but that'll be an important hearing. And again,
thank you for your work. Thank you for your work on the FAASI
Initiative. I want to thank the Committee on that. We made some
really good progress on the Alaska Safety Initiative here in
the last FAA reauthorization, and the Working Families Tax Cuts
Act, which we passed in July. And your work on this, I know
it's difficult. And again, to the families who have lost loved
ones, we are very focused on making sure this doesn't happen
again, either in D.C. or in Alaska. Thank you.
The Chairman. Thank you. Senator Lujan.
STATEMENT OF HON. BEN RAY LUJAN,
U.S. SENATOR FROM NEW MEXICO
Senator Lujan. Thank you. Mr. Chairman. To all the families
that are here, thank you for being here. Not just lifting the
memories and names of those that you lost personally, but of
all 64 that we lost, for reminding us that behind policy,
behind these decisions, that there are people. And I want to
thank you all for being here.
Chair Homendy, one of the many findings and recommendations
in this report, one that stood out to me, is how the lack of
communication and coordination between the FAA and the Army
contributed to this crash. What's even more concerning is that
this lack of coordination apparently has not been resolved.
Just yesterday, we saw how the lack of coordination between
the FAA and the Department of Defense can lead to widespread
confusion. Flights were delayed, canceled for many of my
constituents, Senator Cruz's constituents, and others
throughout the United States. But it's more than those fights
being canceled. It's the worry and the uncertainty that also
came from this.
There has still been no answer from the President, from the
U.S. Government, from the Department of Transportation, from
the Department of Defense. And now, we're learning the
Department of Homeland Security, they've all been quiet and
they stand behind what Secretary Duffy said, that it was about
a drone incursion. Well, what's being reported now is that it
was a laser that was on loan from the Department of Defense to
the Department of Homeland Security, Border Patrol, and that
they were--that they shot a party balloon.
I thought that was a technical term for some craft. A party
balloon is a balloon any one of you would buy for someone's
birthday party, and they shut down--they said they were going
to shut down air traffic for 10 days without calling the White
House, without calling the Department of Defense. Do you all
know how long the airspace was shut down over Venezuela when
the full force of the United States military went down there?
Twenty-four hours.
Further, what's being reported is that the FAA and DOD have
said that this technology was safe for air travel. It also says
that there are accounts that there were DOD personnel on the
ground there with Border Patrol. I appreciate Senator Cruz and
Senator Cornyn making it abundantly clear that there needs to
be a briefing in a SCIF. I don't know why there needs to be a
briefing in a SCIF shooting a party balloon.
But it's not just the Department of Defense that needs to
be there. The Department of Transportation, the FAA, as part of
the Department of Transportation, the Department of Homeland
Security, and the Border Patrol, and the people that were on
the ground that did this, and I want to know why they're not
communicating.
So, my question to you is, are you going to investigate
this?
Ms. Homendy. Our mandate is to investigate after a tragedy
occurs.
Senator Lujan. I appreciate that. Let me ask you a
different question. Yes or no, is a lack of Federal
coordination harmful to the safety of our airspace?
Ms. Homendy. Yes.
Senator Lujan. Will the--well, I just asked that as well.
My other questions around this, Ms. Homendy, is with--what
Congress needs to do to make sure that the crash that you are
here to share information about does not happen again. The
question that Senator Moran asked about how many communications
have there been throughout the years, whether it's under a
Republican or a Democratic President, it doesn't matter, from
air traffic controllers or from anyone else, have been
silenced?
I certainly hope that we're able to demand that that
information be shared to this committee to oversight, and that
we have a real conversation about what it takes to implement
those changes, because no administration has been willing to do
this by rule. Clearly, from the point that Senator Duckworth
made, that even a phone that should be used to communicate is
not even being utilized.
A few years ago, I was in New Mexico at a site for aircraft
that was used to put out forest fires at one of the command
centers that is under, I believe, the jurisdiction of the
United States Department of Agriculture. When I was in there
looking at this particular tower, they told me the Internet
didn't work inside the tower, and they were hesitant to tell
me.
Well, I started calling everyone that I could, and we got a
bunch of folks on board. Chairman, I think your office might
have even helped with this one. Well, now that tower has access
to the Internet, and the people in that air traffic tower are a
little more safe than they were before it was out. If it's
little things like that that are getting in the way of this
because someone's being told you have to stay quiet, shame on
all of us.
And so, as I close here, I know I didn't ask many questions
in this area. I just certainly hope that we can get to the
bottom of this, and that, Chairman, we truly can make things
safer, and that we don't forget the names of those that have
been lost. Not just on this horrific crash, but on the others
as well, and that we do something significant in this space,
and I look forward to working with you and doing my part. You
let me know how we can make this better.
But in the case of what's happened in El Paso, Southern New
Mexico, it's not just a briefing in a SCIF. I don't want to
hear the spin. I don't want to hear the cover up. I want to
hear the facts. I want to hear the truth. I certainly hope that
that briefing doesn't have to take place in a SCIF. There
should be information that's shared with the American people as
to what happened there, because that can't happen anywhere
else. We need people coordinating. I'm not suggesting we don't
go after bad people or bad things. It's not what I'm saying,
but we need to make sure that we're keeping people safe as
we're also going after bad things throughout the United States
that are endangering all of our constituents as well. Thank you
for the time, Mr. Chairman.
The Chairman. Thank you.
Ms. Homendy. May I have 10 seconds?
The Chairman. Sure.
Ms. Homendy. Just--and I don't know, we're not involved in
El Paso, but what I will say is we did note the poor safety
culture within the Air Traffic Organization, and throughout our
investigation, we found numerous people were afraid to talk to
us. They didn't want to be formally interviewed. Some people
actually came directly to me and that would not be appropriate
for me to talk to them in an investigation.
So, I--over time, with--our investigators were able to gain
trust, their trust, to then interview them, but some people
wouldn't provide their names. They were scared. I can't tell
you the number of people who were just scared to speak up
because they were worried about retaliation. At our own
hearing, I had to get everyone to commit to not to retaliate.
Still, that occurred, but it's not a good culture right now.
Senator Lujan. I appreciate that. Thank you, Chairman.
The Chairman. Senator Budd.
STATEMENT OF HON. TED BUDD,
U.S. SENATOR FROM NORTH CAROLINA
Senator Budd. Thank you, Chairman. You know, Flight 5342
was a Charlotte-based flight crew. A North Carolina pilot was
in the Blackhawk. But wherever folks were from, even outside
North Carolina, we never want this to happen again. Thanks for
your work on this and that of your team behind you. Chair
Homendy, I think you had this in your written testimony, but
would you agree that ADS-B In information is most effective
when all aircraft are broadcasting ADS-B Out?
Ms. Homendy. Yes, sir.
Senator Budd. Should policymakers address incentive
structures that discourage the installation and use of ADS-B
Out?
Ms. Homendy. We don't have a formal position on that, but I
will say yes.
Senator Budd. You know, as you mentioned a few moments ago,
a couple questioners ago, some airports are now contracting
with third-party companies to use ADS-B Out data to assess
landing fees on operators. Would you say that this aligns with
the intent of ADS-B?
Ms. Homendy. Absolutely not. ADS-B is a safety tool, and it
should be used for safety, not to--not as a revenue generator
to charge, certainly, general aviation pilots and others, ramp
fees, or landing fees. That's not how it should be used. It's a
safety technology.
Senator Budd. Do you think using it in a manner that you
just described, like to generate fees, would encourage pilots,
aircraft owners to have them turned off?
Ms. Homendy. Yes. They turn them off, or just not install
it at all, or use it. That would be--that would discourage
their use. So, I would--and I believe you have legislation on
this. I hope it moves because I think it should be prohibited.
Senator Budd. Well, to address the issue, I introduced the
Pilot and Aircraft Privacy Act, which would prevent airports
from using ADS-B to assess fees on aircraft operators for that
very reason that you just mentioned. I think it harms safety.
You know, you noticed--as you noted in your testimony, if
both the helicopter Flight PAT25 and Flight 5342 had been using
ADS-B, a collision avoidance system, the crew of 5342 would
have had nearly a minute more, advanced warning than they
received from the TCAS. Now, it may not have prevented the
tragedy, but it would have been another layer in this so-called
Swiss cheese model.
Chair Homendy, I do appreciate the time today, time you
gave today. I appreciate your team, and I look forward to
working with you and with this committee to ensure as many
aircraft as possible use the ADS-B system and other critical
safety technologies. Thank you so much.
Ms. Homendy. Thank you.
The Chairman. Thank you. Senator Markey.
STATEMENT OF HON. EDWARD MARKEY,
U.S. SENATOR FROM MASSACHUSETTS
Senator Markey. Thank you, Mr. Chairman. First of all,
Madam Chair, I just want to say that you are one of America's
great public servants. You're fearless, and you're very smart,
and very needed at this time. So, I just wanted to tell you
that publicly.
Ms. Homendy. I'm only as good--I'm only that good because
of them behind me.
Senator Markey. But we need people like you to make them
good, because there are other people who have positions in our
government who, as you're saying, they put even their own
personnel in a code of omerta where they're afraid to speak the
truth, afraid to say the right thing, and you create the right
culture to protect the American people. I just want to tell you
how grateful I am, and I think our Nation is whenever they hear
you speak because they know you're speaking the truth.
And I want to begin just by taking a moment to honor the 67
individuals who lost their lives when American Eagle Flight
5342 crashed into the Potomac River. In Massachusetts, this
tragic crash hit us especially hard. Six individuals associated
with the Skating Club of Boston, as well as Massachusetts
native, Chris Collins, were on board Flight 5342. Chris's
brother, Matt Collins, is in the audience at today's hearing.
To Matt and all of the families here, and watching, we are
committed to honoring your loved ones with more than just
words, with actions that we are going to take.
And it is because of you, the families, who have turned
unimaginable grief into determined advocacy, that the Senate
unanimously passed the bipartisan ROTOR Act in December. Change
does not happen without your bravery, without your
perseverance, without the families standing up and demanding
that something be done.
And even as we speak, Maxim Naumov, the son of two of the
members of the Skating Club of Boston, and a Norwood,
Massachusetts resident, is honoring his parents' memory right
now on the world stage at the Winter Olympics, skating with
extraordinary strength, extraordinary grace, which is what all
the families are showing right now. So, it's time for Congress
that it takes inspiration from Max's courageous performance and
enacts the ROTOR Act into law in our Nation. This legislation
is the action needed to honor the crash victims and prevent
future tragedies so hearings like this are not necessary in the
future.
Now, I'd like to talk about airline accountability. The
NTSB's final report concludes that it is vital that all
commercial aircraft are equipped with crash avoidance
technology called ADS-B In. Despite the importance of this
technology, the airline industry has repeatedly said that it
would be too costly to implement. So, Chair Homendy, is it true
that this technology is too costly to implement?
Ms. Homendy. Not by the evidence. American Airlines
outfitted--retrofitted over 300 Airbus A321s for less than
$50,000 an airplane, and only had them out of service for 1 or
2 days.
Senator Markey. Yes. It reminds me when the auto industry
used to say it's too expensive to have airbags, it's too
expensive to have seat belts, we just can't afford it makes the
car too unaffordable. You know what the American public said?
Build in the safety. And it turns out, the more you do it, is
the lower the cost is. We have to get it done for our airline
industry as well.
Ms. Homendy. And that's the cost.
Senator Markey. Without question. It's just an unacceptable
price that we have to pay because the industry wants to cheap
out in terms of building in the protections that the families
of our country deserve. So, I believe that an industry that
rakes in billions in profits every year, can afford lifesaving
technology for a very small cost.
And I want to turn to one final issue: FAA staffing. Soon
after the crash, the NTSB examined flight data and identified
over 15,000 close proximity events between airplanes and
helicopters here at the Washington airport. If an FAA employee
had been analyzing this data, they may have identified the risk
in this DCA airspace before the tragic crash.
Rather than bolstering FAA staffing capacity, the Trump
administration responded by cutting the very FAA staff needed
to conduct this life-saving analysis, and that's why last July,
I sent a letter to the FAA demanding answers about its staffing
levels and capacity to identify similar risk at other airports
in our country. And it's also why I fought for and won an
amendment in the ROTOR Act to ensure the FAA Administrator
maintains the necessary staffing levels to analyze safety
trends before a disaster happens.
Unfortunately, over a year later, according to NTSB's
report, the FAA is still not analyzing these trends to catch
close calls before they occur. It's a year later. This is
unacceptable. Chair Homendy, do you agree that the FAA is still
not proactively acting to identify these risks at U.S.
airports?
Ms. Homendy. They are not doing what we have recommended,
and we have been urging them to do the entire time, which is to
not only evaluate their data, which they're starting to do now,
but to develop a simple definition of what a close call is.
They have 10 different types of data sources coming in for a
near miss and not one single definition that everyone can get
around on what is a near miss. And then, even the information
and data they collect, isn't shared with the airlines until
about 3 to 6 months later.
Senator Markey. Yes. You recommend that there be the
creation of an office to collect the data and then to
disseminate the information. And that still has not happened.
Ms. Homendy. We had recommended that they develop a
standard definition for what a close proximity event is, and to
improve their data analysis, and to share that data with
external stakeholders, including Federal agencies and the
airlines in a very timely manner.
Senator Markey. You recommended the creation of an office
in order to track and publicly report this data, and that has
not happened.
Ms. Homendy. I don't think we recommended an office, but--
--
Senator Markey. That was in the NTSB report, so I'll
double-check on that, but that's how I read the report.
Ms. Homendy. We did mention an office about doing a safety
management system review of Air Traffic Organization. That is
one area that we did mention that we needed some work done.
Senator Markey. Thank you, Mr. Chairman, and we must pass
this legislation. It's absolutely critical.
Ms. Homendy. Thank you.
The Chairman. Thank you, Chairwoman Homendy, for your
testimony here today, and thank you for the hard work of your
team who does a consistently excellent job.
Senators will have until the close of business on February
19 to submit questions for the record. The witnesses will have
until close of business on March 5, to respond to those
questions.
That concludes today's hearing. The Committee stands
adjourned.
[Whereupon, at 12:19 p.m., the Committee was adjourned.]
A P P E N D I X
Response to Written Questions Submitted by Hon. Jerry Moran to
Hon. Jennifer Homendy
Question 1. As part of its investigation, the NTSB simulated the
flight paths of American Airlines Flight 5342 and Priority Air
Transport 25 with and without the most advanced position broadcast and
traffic collision avoidance technologies, including ADS-B In-enabled
Cockpit Display of Traffic Information--or ``CDTI''--and Airborne
Collision Avoidance System X--or ``ACAS-X''--respectively. The
investigation concluded that installation and use of ADS-B In--and the
suite of more advanced cockpit alerting technologies it enables--would
have provided the commercial jet with its first indication of the
potential hazard posed by the helicopter nearly one minute before the
collision, rather than just 19 seconds before the collision using older
traffic collision avoidance technology. Similarly, the investigation
concluded that the installation and use of ADS-B In and ADS-B In-
enabled technologies would have provided the helicopter with its first
indication of the hazard posed by the commercial jet 48 seconds before
the collision. The NTSB's investigation attested to the difference that
ADS-B In and ADS-B In-enabled technologies could have made in this
circumstance. Would you elaborate on how installation and use of ADS-B
and comparable technologies would impact air safety?
Answer. The NTSB has previously advocated for the FAA to require
ADS-B In technology on the basis that equipping aircraft with ADS-B In
capability would provide an immediate and substantial contribution to
safety by enhancing pilot and flight crew situation awareness of
surrounding traffic, especially near airports. Simulations using the
circumstances of this accident reaffirm this conclusion and demonstrate
the value of ADS-B In-derived traffic information in improving pilots'
situation awareness and supporting earlier identification of potential
traffic conflicts.
In this accident, the traffic alert (TA) that the flight 5342 crew
received with the installed traffic alert and collision avoidance
system (TCAS) consisted of the aural annunciation, ``Traffic,
traffic,'' with the TCAS display simply depicting a yellow circle in
front of the airplane. Information about the specific location of the
traffic threat relative to the airplane was not announced, and the crew
would have had to watch the TCAS display to determine the threat's
relative position and direction of motion before visually scanning the
appropriate area. Given the crew's high workload during final approach
to land on runway 33 at the time they received the TCAS TA, they would
have had limited capacity to look for and acquire the conflicting
traffic. Notably, the crew of flight 5342 had not received any traffic
information from the DCA local controller of the presence of PAT25 and
were likely unaware of the presence and proximity of PAT25 until a few
seconds before the collision.
The NTSB performed simulations using an ADS-B In application and a
cockpit display of traffic information (CDTI) to determine how an ADS-
B-based system would have performed in the accident scenario. The
simulation indicated that the crew of flight 5342 would have received
two alerts concerning PAT25 had it been equipped with such a system.
The first aural and visual alert would have occurred 59 seconds before
the collision, annunciating ``Traffic, 12 o'clock, low, 3 miles,
descending.'' A second aural alert would have occurred 35 seconds
before the collision, annunciating ``Traffic, 12 o'clock, low, 2
miles.'' These two alerts would have occurred 40 and 16 seconds,
respectively, before the TCAS TA that the crew received before the
collision, providing the crew with early awareness of proximate
traffic, enhancing their situation awareness of the presence of PAT25.
This enhanced situation awareness could have afforded an opportunity
for the crew of flight 5342 to query the air traffic control local
controller regarding the presence of PAT25.
Although TCAS TAs provide a verbal annunciation that a potential
traffic conflict exists, the annunciations do not include the position
and range of the target, requiring the pilot to first refer to the TCAS
display inside the cockpit to determine the direction in which they
need to direct their visual search. A TA indicating the clock position,
relative altitude, range, and vertical tendency of nearby traffic would
allow pilots to immediately direct their visual search in the proper
direction outside the aircraft. The NTSB concludes that TA aural alerts
that include additional information about the location of traffic could
reduce the time pilots need to visually acquire target aircraft.
Consequently, the NTSB recommended that the FAA modify airborne
collision avoidance system (ACAS) aural alerts to include clock
position, relative altitude, range, and vertical tendency (Safety
Recommendation A-26-29 from the DCA investigation). The NTSB also
recommended that the FAA require existing and new TCAS I, TCAS II, and
ACAS X installations to integrate directional traffic symbols (A-26-
30).
We have investigated numerous midair collisions that occurred
within controlled airspace or in which air traffic control was in
contact with at least one of the involved aircraft. In many of these
investigations, we noted that a CDTI--which may be part of the
aircraft's installed avionics, such as on a dedicated navigation
display or multifunction display, or that could be hosted on a portable
device, such as a smartphone or tablet computer--with ADS-B In
information would enhance pilots' situation awareness by providing
information regarding traffic conflicts that may otherwise go
undetected due to the numerous documented limitations of pilot-applied
visual separation (the see-and-avoid concept). The circumstances of
this accident illustrate that the additional information provided by an
ACAS system supplemented with ADS-B In information, including alerts
indicating the clock position, relative altitude, range, and vertical
tendency of the other identified aircraft as well as directional
traffic displays, further enhances the safety benefit provided by ACAS.
For all pilots, ADS-B In information provided on a CDTI with alerting
that is visible and audible to the pilot would provide critical
situation awareness to help mitigate the risk of midair collisions. To
take full advantage of the safety benefits provided by ADS-B, the NTSB
recommends that the FAA require all aircraft operating in airspace
where ADS-B Out is required to also be equipped with ADS-B In with a
cockpit display of traffic information that is configured to provide
alerting audible to the pilot or flight crew (Safety Recommendation A-
26-31). Additionally, to fully realize the benefit of ADS-B In, the
NTSB recommended the following to FAA in our DCA investigation report:
Require the use of the appropriate variant of airborne
collision avoidance system X on new production aircraft that
are subject to traffic alert and collision avoidance system
equipage regulations. (A-26-32)
Require existing aircraft that are subject to traffic alert
and collision avoidance system equipage regulations be
retrofitted with the appropriate variant of airborne collision
avoidance system X. (A-26-33)
Evaluate the feasibility of decreasing the traffic advisory
and resolution advisory inhibit altitudes in airborne collision
avoidance system Xa to enable improved alerting throughout more
of the flight envelope. (A-26-34)
If the evaluation resulting from Safety Recommendation A-26-
34 finds that the inhibit altitudes can be safely decreased,
require retrofitting of the applicable airborne collision
avoidance system X variant incorporating the reduced traffic
advisory and resolution advisory inhibit altitudes on all
aircraft that are subject to traffic alert and collision
avoidance system and equipage regulations. (A-26-35)
Require that all rotorcraft operating in Class B airspace be
equipped with airborne collision avoidance system (ACAS) Xr
technology once the ACAS Xr standard has been published. (A-26-
36)
Question 2. Several of the NTSB's recommendations involve the
installation and use of ADS-B In technology. Last year, the Senate
unanimously passed the ROTOR Act, which Chairman Cruz and I and other
members of this Committee introduced to address the precise gaps in air
safety that the NTSB's identified. I believe that the ROTOR Act aligns
precisely with many of the NTSB's recommendations, particularly as it
relates to installation and use of ADS-B technology. Would you agree
that the ROTOR Act represents a targeted and precise approach to
improving the safety of the National Airspace System?
Answer. If enacted, FAA implementation of the requirements in the
ROTOR Act would directly address 1 of 50 NTSB safety recommendations
from the DCA midair collision investigation: Safety Recommendation A-
26-31, which recommends that the FAA require all aircraft operating in
airspace where ADS-B Out is required to also be equipped with ADS-B In
with a cockpit display of traffic information that is configured to
provide alerting audible to the pilot and/or flight crew. The NTSB has
long believed such equipage would immediately and substantially
contribute to the safety of the National Airspace System (NAS),
especially near airports. The ROTOR Act was introduced prior to the
completion of our investigation, and does address long-standing NTSB-
identified safety issues, but recipients must implement all 50 NTSB
recommendations made in the final investigation report to address all
the safety deficiencies identified in this investigation.
Question 3. The NTSB concluded that one of the chief causes of this
accident was a helicopter route that would have placed rotorcraft
traversing it within 75 vertical feet, at most, of commercial traffic
on approach to DCA's runway 33. Describe how the NTSB determined that
this route presented such a problem to the safety of the airspace
around DCA? Did the NTSB's investigation reveal why this route--and the
problems it presented--was not addressed long before this collision?
Answer. Preliminary investigative findings of this accident
revealed that, when flown at the recommended maximum altitude of 200
ft, a helicopter operating over the eastern shoreline of the Potomac
River on Helicopter Route 4 would have about 75 ft of vertical
separation at maximum from an airplane approaching runway 33. This
vertical separation decreases the farther west of the shoreline the
helicopter is flown, or if the airplane is operating below the 3+
visual glidepath provided by the runway 33 precision approach path
indicator (PAPI).
In an urgent safety recommendation report published on March 11,
2025, we concluded that the separation distances between helicopter
traffic operating on Route 4 and aircraft landing on runway 33 that
existed at the time of the accident were insufficient and posed an
intolerable risk to aviation safety by increasing the chances of a
midair collision.
As a result of our findings, we issued an urgent safety
recommendation to the FAA (Safety Recommendation A-25-1) asking the FAA
to prohibit operations on Helicopter Route 4 between Hains Point and
the Wilson Bridge when runways 15 and 33 were being used for departures
and arrivals, respectively, at DCA. That recommendation has since been
classified Closed--Exceeds Recommended Action.
Our investigation identified multiple factors resulting in the risk
of midair collision between airplanes and helicopters at DCA remaining
unmitigated. One factor was that the FAA Air Traffic Organization's
data analysis, safety assurance, and risk assessment processes failed
to recognize and mitigate the risk of collision, particularly when DCA
air traffic controllers had previously voiced concern about near midair
collision occurrences near DCA. We also found that multiple data
sources provided evidence of midair collision risk between fixed-wing
aircraft and helicopters at DCA, including on approach to runway 33,
before this accident; however, the limited access to and use of
available objective and subjective proximity data hindered industry and
government stakeholders' ability to identify hazards and mitigate risk.
Additionally, the FAA Air Traffic Organization's application of its
safety management system (SMS) did not effectively coordinate safety
assurance and safety risk management activities with external
stakeholders in the airspace around DCA. As a result, we recommended
that the Department of Transportation Office of Inspector General
complete an audit of the FAA Air Traffic Organization's SMS functions
and data-sharing activities at all air traffic control facilities and
determine whether these activities are conducted in collaboration with
all relevant external stakeholders (A-26-56). We also recommended the
following to the FAA:
Based on the results of the audit completed in accordance
with Safety Recommendation A-26-56, ensure that all SMS
functions and data-sharing activities at all air traffic
control facilities are conducted in collaboration with all
relevant external stakeholders. (A-26-39)
Create an objective definition of close proximity encounter
and a public database of those encounters and their locations
that can be used to monitor their prevalence and identify areas
of potential traffic conflict for safety assurance and safety
risk management. (A-26-37)
Develop and implement a process that will, in a timely
manner, notify involved parties after events such as near
midair collisions or traffic alert and collision avoidance
system resolution advisory activations, such that notification
occurs while relevant data remain available and before
meaningful safety analysis, reporting, or corrective action is
no longer practicable. (A-26-38)
FAA Order JO 7210.3DD listed criteria and procedures for developing
and modifying helicopter route charts. One of the listed criteria was
that ``care should be exercised to avoid recommending altitudes or
flight ceilings/floors which would cause helicopters operating on a
designated route to encounter inflight wake turbulence generated by
large, fixed-wing traffic.'' The order stated that Terminal Operations
Service Area Directors were responsible for reviewing and approving new
or revised helicopter route chart proposals and assuring that they
complied with all prescribed criteria. These directors were also
responsible for annually reviewing existing visual flight rule
helicopter route charts to determine their accuracy and continued
utility; however, the FAA was unable to provide documentation of the
required annual reviews for the Baltimore-Washington Helicopter Route
Chart, nor was the FAA able to identify who was responsible for
conducting such annual reviews. As of the date of our final
investigative report, no information has been provided regarding
whether annual reviews have been conducted and, if so, what criteria
were used in the review.
The NTSB concludes that annual reviews of helicopter route charts
as required by FAA Order 7210.3DD would have provided an opportunity to
identify the risk posed by the proximity of Route 4 to the runway 33
approach path, but there is no evidence to support that these reviews
were being performed at DCA. The NTSB is concerned that the lack of
documentation of annual reviews for the Baltimore-Washington Helicopter
Route Chart may be an indication that these annual reviews are not
occurring at other locations throughout the NAS. Therefore, the NTSB
recommends that the FAA do the following:
Ensure that annual reviews of helicopter route charts are
being conducted throughout the National Airspace System as
required by FAA Order. (A-26-24)
Conduct a safety risk management process to evaluate whether
modifications to the remaining helicopter route structure in
the vicinity of Ronald Reagan Washington National Airport are
necessary to safely deconflict helicopter and fixed-wing
traffic and provide the results to the National Transportation
Safety Board. (A-26-25)
Amend your helicopter route design criteria and approval
process to ensure that current and future route designs or
design changes provide vertical separation from airport
approach and departure paths. (A-26-26)
Once the criteria and approval process referenced in Safety
Recommendation A-26-26, review all existing helicopter routes
to ensure alignment with these updated criteria. (A-26-27)
Incorporate the lateral location and published altitudes of
helicopter routes onto all instrument and visual approach and
departure procedures to provide necessary situation awareness
to fixed-wing operators of the risk of helicopter traffic
operating in their vicinity. (A-26-28)
Question 4. The NTSB faulted deficient data sharing practices
across the FAA, Department of Defense, and aircraft operators, citing
this breakdown as a contributing factor to the midair collision of
January 29th, 2025. The ROTOR Act would require the Army Inspector
General, as part of an audit of Army aviation, to assess the Army's
coordination with the FAA. The bill would also establish or designate
an office within the FAA called the Office of FAA-DOD Coordination.
This Office would coordinate the military's airspace usage with
relevant verticals within the FAA--including the Air Traffic
Organization--make certain that employees are empowered to provide
feedback--such as that raised about the dangerous airspace design near
DCA--pursue improved aviation safety data sharing practices between
civil and military airspace users and execute certain safety reviews.
How would a dedicated FAA-DOD coordination apparatus like the one
proposed in the ROTOR Act support improved aviation safety data
sharing? Describe the significance of data sharing among all airspace
users to aviation safety.
Answer. The NTSB investigation found that the FAA's lack of an
established process to inform parties about their involvement in events
such as near midair collisions or TCAS resolution advisories reduces
the likelihood of fully understanding and mitigating future midair
collision risk. While multiple data sources provided evidence of midair
collision risk between airplanes and helicopters at DCA before this
accident, limited access to this data hindered both industry and
government stakeholders' ability to identify hazards and mitigate risk.
The likelihood of detecting and mitigating these hazards and risks
before accidents occur would be increased by improving stakeholder
access to information about close proximity encounters for use in
safety assurance processes. To collaborate effectively regarding these
risks, the NTSB recommends that the FAA create an objective definition
of close-proximity encounter and a public database of those encounters
and their locations that can be used to monitor their prevalence and
identify areas of potential traffic conflict for safety assurance and
safety risk management (Safety Recommendation A-26-37). The NTSB also
recommends that the FAA develop and implement a process that will, in a
timely manner, notify involved parties after events such as near midair
collisions or TCAS resolution advisories such that notification occurs
while relevant data remain available and before meaningful safety
analysis, reporting, or corrective action is no longer practicable
(Safety Recommendation A-26-38). Additionally, we recommend that the
FAA ensure that all SMS functions and data-sharing activities at all
air traffic control facilities are conducted in collaboration with all
relevant external stakeholders (including military NAS users; Safety
Recommendation A-26-39).
The NTSB investigation found that the Army's safety reporting
systems for pilots were not well utilized and did not provide the
organization with information about close encounters between Army
helicopters and other aircraft that were later found to have occurred
frequently. As a result, the NTSB recommends that the Army survey its
helicopter pilots to identify barriers to the utilization of flight
safety reporting systems, to develop a plan to address the identified
barriers, and to implement that plan across Army aviation units (Safety
Recommendation A-26-46).
Question 5. The NTSB, and this Committee, have attested to the
importance of widespread adoption of ADS-B In technology and its
importance to improving safety. How does the NTSB view comparable and
complementary technologies--including, for example, ACAS-X or hybrid
TCAS--that can also utilize ADS-B data to the benefit of aviation
safety?
Answer. Many technologies contribute to aviation safety, and the
NTSB's analysis and recommendations in response to the catastrophe at
DCA address multiple collision avoidance technologies, including TCAS
I, TCAS II, ACAS-X, and ADS-B In and Out. The NTSB's overarching
concern in relation to each of these technologies is to ensure that, on
all aircraft operating in high traffic airspace, they are equipped;
operating properly; configured in such a way as to provide alerts
audible to the pilot and flight crew in their operating environment;
that such alerts to the pilot and flight crew include the clock
position, relative altitude, range, and vertical tendency of the other
identified aircraft; and that cockpit displays of traffic information
integrate directional traffic symbols. In short, we believe pilots and
flight crews should have ready access to the fullest possible dataset
when identifying other traffic in their airspace.
Our recommendations from the DCA investigation to the FAA on these
technologies include the following:
Modify airborne collision avoidance system traffic advisory
aural alerts to include clock position, relative altitude,
range, and vertical tendency. (A-26-29)
Require existing and new traffic alerting and collision
avoidance system (TCAS) I, TCAS II, and airborne collision
avoidance system X installations to integrate directional
traffic symbols. (A-26-30)
Require all aircraft operating in airspace where Automatic
Dependent Surveillance--Broadcast (ADS-B) Out is required to
also be equipped with ADS B In with a cockpit display of
traffic information that is configured to provide alerting
audible to the pilot and/or flight crew. (A-26-31)
Require the use of the appropriate variant of airborne
collision avoidance system X on new production aircraft that
are subject to traffic alert and collision avoidance system
equipage regulations. (A-26-32)
Require existing aircraft that are subject to traffic alert
and collision avoidance system equipage regulations be
retrofitted with the appropriate variant of airborne collision
avoidance system X. (A-26-33)
Evaluate the feasibility of decreasing the traffic advisory
and resolution advisory inhibit altitudes in airborne collision
avoidance system Xa to enable improved alerting throughout more
of the flight envelope. (A-26-34)
If the evaluation resulting from Safety Recommendation A-26-
34 finds that the inhibit altitudes can be safely decreased,
require retrofitting of the applicable airborne collision
avoidance system X variant incorporating the reduced traffic
advisory and resolution advisory inhibit altitudes on all
aircraft that are subject to traffic alert and collision
avoidance system and equipage regulations. (A-26-35)
Require that all rotorcraft operating in Class B airspace be
equipped with airborne collision avoidance system (ACAS) Xr
technology once the ACAS Xr standard has been published. (A-26-
36)
NTSB recommendations to the Department of War Policy Board on
Federal Aviation include:
Require the Department of War to verify on all aircraft with
transponders capable of transmitting Mode S and Automatic
Dependent Surveillance--Broadcast (ADS-B) and operated in the
NAS, at least annually and upon each aircraft's entry into
service in the NAS, that 1) the transponder ADS-B settings are
correct, 2) the transponder is transmitting ADS-B, and 3) the
transponder is transmitting the correctly assigned address. (A-
26-51)
Require armed services to amend their operational procedures
to allow flight crews to enable Automatic Dependent
Surveillance--Broadcast Out while in flight. (A-26-52)
Require all military aircraft operating in the National
Airspace System (NAS) be equipped with Automatic Dependent
Surveillance--Broadcast (ADS-B) In with a cockpit display of
traffic information that is configured to provide alerting
audible to the pilot and/or flight crew, and that such
requirement apply wherever in the NAS the Federal Aviation
Administration requires any aircraft to operate with ADS-B Out.
(A-26-53)
The NTSB also issued one related recommendation to the RTCA Program
Management Committee, as follows:
Finalize and publish the minimum operational performance
standards for airborne collision avoidance system Xr for
rotorcraft. (A-26-57)
Question 6. Last year, I introduced the Aviation Funding Stability
Act, which would allow the FAA to draw from the Airport and Airway
Trust Fund to continue operating when appropriations lapse.
Importantly, my legislation would also make certain that controllers
get paid in the event of a shutdown. Many experts have emphasized that
consistent and uninterrupted funding for the FAA is essential for
maintaining and promoting a safe and efficient National Airspace
System. Would you agree that stable funding for the FAA would enhance
the safety and reliability of our National Airspace System?
Answer. Stable funding for the FAA and the NTSB would enhance the
safety and reliability of our national airspace. The NTSB needs
authorization to operate when appropriations lapse, and the NTSB urges
you to consider that. When an accident occurs, it is incumbent upon the
NTSB to take action immediately to prevent further tragedies in our
airspace; that action can't wait for appropriations and continuing
resolutions.
______
Response to Written Questions Submitted by Hon. Maria Cantwell to
Hon. Jennifer Homendy
NTSB Recommendations for Air Traffic Control. It's clear Congress
should swiftly pass the ROTOR Act so that the FAA must begin
implementing many of the key requirements we discussed during the
hearing. However, that does not mean our work stops there. Several of
the NTSB's findings and recommendations related to the FAA providing
air traffic controllers with proper training and support should be
considered in additional legislation.
Question 1. One of these recommendations says the FAA should
develop new annual training for controllers on how to better manage
scenario-based threats and decision-making in high stress situations.
How would this annual training improve controllers' ability to identify
and mitigate safety risks?
Answer. In November 2016, the NTSB issued Safety Recommendation A-
16-51, asking the FAA to provide initial and recurrent training for air
traffic controllers on controller judgment, vigilance, and/or safety
awareness with specific reference to two midair collisions that
occurred in 2015 to be used as case studies. The FAA responded that, in
July 2017, it instructed controllers on threat and error management (or
TEM, which the FAA described as the practice of applying controller
judgment, vigilance, and safety awareness) as part of instructor-led
recurrent training and stated that the training would also be required
for future controllers. The FAA stated that it delivered a web-based
``Emergencies'' training in July 2017 to highlight accidents similar to
the two midair collisions cited in the recommendation. After reviewing
this training, the NTSB determined that the materials did not highlight
the safety issues identified in the 2015 midair accidents, nor did the
training discuss those or similar accidents, as recommended. When the
FAA indicated that it did not plan to take further action, Safety
Recommendation A-16-51 was classified Closed--Unacceptable Action in
2023.
A vast majority of the time, controllers perform very effectively
and reliably; however, human vulnerabilities such as fatigue, increased
workload, time pressure, and biases can increase errors. A controller's
ability to anticipate, detect, and mitigate risks is essential. TEM
provides a strategy to combat these vulnerabilities. TEM is a process
for identifying safety risks--threats, errors, and undesired states--in
the environment and mitigating those risks.
The controllers involved in this accident stated they were not
familiar with the term ``threat and error management'' during
postaccident interviews, nor were they familiar with the concepts that
would be included in such training, suggesting that they did not
receive training on this method of safety management. The NTSB
requested, and received, controller training materials related to
identifying and mitigating risk. This material did not reveal any
formal TEM training other than the 2017 workshop, and there was no
evidence to indicate that the workshop or the subject matter it
contained had been offered in any training since 2017.
Adequate TEM training can strengthen situation awareness by
teaching controllers to continuously monitor their environment to more
quickly identify threats; promote team communication to ensure that
communications are clear, timely, and assertive; emphasize effective
scanning habits; recognize patterns in the development of adverse
events; and enhance decision-making under stress by developing habits
that balance procedural compliance with problem solving to mitigate the
risks of threats and errors. TEM would have likely improved all
controllers' situation awareness in this event, which may have allowed
for earlier conflict recognition or encouraged the operations
supervisor (OS) to conduct a risk assessment of the steady helicopter
traffic and its resulting workload on the local control (LC) and
assistant local control (ALC) controllers.
The NTSB continues to believe that including case studies in
initial and annual air traffic controller training and highlighting
situations in which controller judgment, vigilance, and safety
awareness could be improved would enhance controllers' ability to
identify and manage threats and errors. FAA guidance on the use of good
judgment is vague, and case studies provide the opportunity to examine
a real chain of events that had resulted in an accident, imparting
valuable lessons without exposing participants to the potential risk of
adverse outcomes inherent to on-the-job training, which the FAA often
relies upon for controller training. The NTSB also believes that
providing controllers the opportunity to discuss and practice applying
TEM using scenario-based training is critical, as repeating skills
through training leads to behavioral automaticity, thus freeing up
working memory. Automaticity has been demonstrated to improve speed and
accuracy, situation awareness, and decision-making The NTSB
investigation found that initial and recurrent scenario-based training
in threat and error management would help controllers identify and
mitigate risks and strengthen situation awareness. Accordingly, the
NTSB recommends that the FAA develop instructor-led, scenario-based
training on threat and error management that trains controllers to
continuously monitor their environment to more quickly and accurately
identify threats; promote team communication to ensure that
communications are clear, timely, and assertive; emphasize effective
scanning habits; recognize patterns in the development of adverse
events; and enhance decision-making under stress by developing habits
that balance procedural compliance with problem solving to mitigate the
risks of threats and errors, and provide this training to all air
traffic controllers annually (Safety Recommendation A-26-9).
Question 2. In the FAA Reauthorization law, we required FAA to
deploy advanced tower simulation systems nationwide to help train
controllers to prevent near misses. Should FAA use these systems for
this new annual training?
Answer. Yes.
Question 3. Other key recommendations call for FAA to implement
more useful alerts for controllers that better flag the severity of
issues triggering the alert, and to install technology in towers to
alert controllers when their transmissions have been blocked. If
implemented, how would these safety recommendations have mitigated
risks and prevented the strained conditions at DCA Tower that
contributed to the accident?
Answer. The current conflict alerts (CA) system operates in the
same manner regardless of the algorithm that triggered the alert. In
the absence of any salient information conveying the severity of the
conflict, controllers must determine on their own if the conflict alert
requires immediate action, thus increasing the controller's cognitive
load. Available improvements to the CA software could provide color
coding or various aural alerts, depending on which conflict alert
algorithms were activated. Providing controllers with additional
salient cues regarding the perceived severity of a potential conflict
would reduce controller cognitive load and would likely improve
reaction time to the most critical conflict alerts.
Regarding blocked radio transmissions, the very high frequency
(VHF) radio communications used by air traffic control do not allow for
simultaneous transmissions. If a pilot or controller attempts to
broadcast on the same frequency at the same time as another pilot, one
or both transmissions may be garbled, incomplete, or blocked from
reception entirely. This leads to missed control instructions, lack of
clarity, loss of situation awareness, or readback errors; however,
there is currently no system in use that allows controllers to know
when a simultaneous broadcast has occurred.
Antiblocking technology would alert controllers and/or flight crews
to potentially blocked transmissions when simultaneous broadcasting
occurs.
Strong ADS-B In Performance Standard. It's crucial for the safety
of the flying public that aviation operators, especially the commercial
passenger fleet--which moves over 2 million passengers each day, are
equipped with ADS-B In technology, and not alternatives that don't
deliver on safety.
Importantly, not every type of ADS-B In performs the same way and
delivers the same benefits. That's why our bipartisan DCA safety
legislation requires ADS-B In that boosts situational awareness for
pilots and delivers real-time traffic advisories and alerts to ensure a
robust additional layer of safety on the flight deck.
Question 1. What are the benefits of pilots having ADS-B In that is
integrated with avionics on the flight deck?
Answer. The NTSB has previously advocated for the FAA to require
ADS-B In technology because equipping aircraft with ADS-B In capability
would immediately and substantially contribute to safety, especially
near airports. Simulations using the circumstances of this accident
reaffirm this conclusion and demonstrate the value of ADS-B In-derived
traffic information in improving pilots' situation awareness and
supporting earlier identification of potential traffic conflicts.
Pilots and flight crews (not the airplane) need to receive the rich
alerting information, including cockpit displays of traffic information
with directional traffic symbols and audible traffic and resolution
advisories.
In this accident, the TA that the flight 5342 crew received
consisted simply of the annunciation, ``Traffic, traffic.'' No
information about the location of the traffic threat relative to the
airplane was annunciated, and the crew would have had to refer to the
TCAS display to determine the relative position of the threat before
visually scanning in the appropriate area. Given the crew's high
workload at the time they received the TA, it is unlikely that they
performed a focused visual search for the helicopter at this time.
The NTSB performed a simulation to determine how an ADS-B-based
system capable of providing alerts would have performed in the accident
scenario. The simulation indicated that the crew of flight 5342 would
have received two alerts concerning PAT25 had it been equipped with
such a system. The first aural and visual alert would have occurred 59
seconds before the collision, annunciating ``Traffic, 12 o'clock, low,
3 miles, descending.'' A second aural alert would have occurred 35
seconds before the collision, annunciating ``Traffic, 12 o'clock, low,
2 miles.'' These two alerts would have occurred 40 and 16 seconds,
respectively, before the TCAS TA that the crew received before the
collision, providing the crew with additional awareness of the
helicopter.
Although TCAS TAs provide a verbal annunciation that a potential
traffic conflict exists, these annunciations do not include the
target's position and range, requiring the pilot to first refer to the
TCAS display inside the cockpit to determine the direction in which
they need to direct their visual search. A TA indicating the clock
position, relative altitude, range, and vertical tendency of nearby
traffic would allow pilots to immediately direct their visual search in
the proper direction outside the aircraft. The NTSB concludes that TA
aural alerts that include additional information about the location of
traffic could reduce the time pilots need to visually acquire target
aircraft. Consequently, the NTSB has also recommended that the FAA
modify airborne collision avoidance system (ACAS) TA aural alerts to
include clock position, relative altitude, range, and vertical tendency
(Safety Recommendation A-26-29).
The circumstances of this accident illustrate that the additional
information provided by an ACAS system supplemented with ADS-B In
information, including alerts and directional traffic displays, further
enhances the safety benefit provided by ACAS. For all pilots, ADS-B In
information on a CDTI with alerting that is audible to the pilot would
provide critical situation awareness to help mitigate the risk of
midair collisions, even if an aircraft is not equipped with an ACAS. To
take full advantage of the safety benefits provided by ADS-B, the NTSB
recommends that the FAA require all aircraft operating in airspace
where ADS-B Out is required to also be equipped with ADS-B In with a
cockpit display of traffic information that is configured to provide
alerting audible to the pilot and/or flight crew (Safety Recommendation
A-26-31).
Question 2. Do you agree that ADS-B In that is integrated with an
aircraft's avionics on the flight deck would provide the strongest
safety benefit for commercial passenger flights?
Answer. Improving pilots' situation awareness of surrounding
traffic and potential traffic conflicts in busy airspace, such as near
airports, is important for preventing midair collisions. Ensuring
pilots receive effective aural and visual alerts to potential traffic
conflicts enhances safety. Having a CDTI that uses ADS-B data to show
surrounding traffic, and its directionality increases pilots' awareness
of the movements of nearby traffic. The information provided to the
pilot is equally, if not more important than the method of display.
Therefore, the NTSB recommended that the FAA require all aircraft
operating in airspace where ADS-B Out is required to also be equipped
with ADS-B In with a CDTI that is configured to provide alerting
audible to the pilot and/or flight crew.
For currently installed airborne collision avoidance systems on
commercial passenger aircraft, the traffic display may only show a
nondirectional target, requiring pilots to watch the display to infer
the direction of movement of the traffic target relative to their own
aircraft. Using ADS-B data to show the directionality of surrounding
traffic provides more timely information to help pilots determine if
certain targets may become collision threats. The NTSB recommended that
the FAA require existing and new airborne collision avoidance system
installations to integrate directional traffic symbols (Safety
Recommendation A-26-30). Additionally, ensuring that aural alerts to
potential traffic conflicts can be both heard by the pilots and contain
additional information about the location of traffic, such as clock
position and distance, could reduce the time pilots need to visually
acquire these targets before they become a collision threat. Therefore,
NTSB recommended that the FAA modify aural alerts in airborne collision
avoidance systems (ACAS) to include clock position, relative altitude,
range, and vertical tendency (Safety Recommendation A-26-29).
By adding directional traffic symbols and information-rich aural
alerting into an installed ACAS, information would be immediately
available to pilots in their normal visual scan of cockpit instruments
and flight displays, pilot situation awareness of surrounding traffic
would be enhanced, and the time for pilots to visually acquire a
potential traffic conflict would be reduced, providing a strong safety
benefit by preventing midair collisions.
Question 3. Do you agree that ADS-B In technology and ACAS-X
technology are two separate technologies with different capabilities?
Answer. ACAS-X (including ACAS-Xa and ACAS-Xr) is a family of
technologies intended to serve as a successor to TCAS technologies.
ACAS-X technology is intended to include, and have the capabilities to
utilize, ADS-B data (referred to as ``ADS-B In'') as an integrated
feature of the ACAS-X system. ACAS-X also receives information about
nearby aircraft by interrogating their transponders. ACAS-X uses these
data to provide both traffic advisories and resolution advisories.
However, ADS-B In may also be utilized on aircraft without ACAS-X
systems via other technologies. For example, a general aviation
airplane may be equipped with a portable ADS-B receiver and a tablet
that receives ADS-B data from the receiver to display information about
surrounding traffic and alert the pilot of potential traffic conflicts.
Question 4. If so, do you agree that ACAS-X is not an alternative
means of compliance to NTSB's recommendations on ADS-B In issued in
response to the Board's investigation of the January 29, 2025 mid-air
collision near DCA?
Answer. ACAS-X uses ADS-B and interrogator data. If Congress is
concerned, it should charge the FAA with mandating the use of that data
and ACAS-X and ACAS-Xr.
Limitations of Collision Avoidance Technologies.
Question 1. Do you agree that collision avoidance technologies like
TCAS and ACAS-X depend on ADS-B In data for maximum performance and
safety benefits?
Answer. Yes.
Older generation ACAS technologies typically do not leverage ADS-B
data; however, newer technologies, such as ACAS-X, do use ADS-B In data
for optimal performance.
In addition, although a TCAS display does depict traffic targets, a
pilot must monitor the display over time to determine in what direction
the target is moving. By leveraging ADS-B In traffic information, an
ACAS display can depict the ground track of traffic targets, increasing
pilots' awareness of the movements of nearby traffic and providing more
timely information to help a pilot determine if a target may become a
collision threat.
Question 2. Do you agree that ADS-B In provides pilots with better
situational awareness at lower altitudes where Traffic Alert and
Collision Avoidance System (TCAS) does not activate?
Answer. Pilots using ADS-B In have improved situation awareness,
especially when integrated with ACAS. Currently, TCAS I or II is only
required for about 4 percent of aircraft registered in the United
States. For the other 96 percent, there is a gap in regulations that
ADS-B In would fill.
The circumstances of this accident illustrate that the additional
information provided by an ACAS supplemented with ADS-B In information,
including ADS-B alerts and directional traffic displays, further
enhance the safety benefit provided by ACAS. For all pilots, ADS-B In
information provided on a CDTI with alerting that is audible and
visible to the pilot would provide critical situation awareness to help
mitigate the risk of midair collisions, even if their aircraft are not
equipped with an ACAS.
To take full advantage of the safety benefits provided by ADS-B,
the NTSB recommends that the FAA require all aircraft operating in
airspace where ADS-B Out is required to also be equipped with ADS-B In
with a CDTI that is configured to provide alerting audible to the pilot
and/or flight crew. To provide the same situation awareness advantages
to military flight crews, the NTSB recommends that the Department of
War require all military aircraft operating in the NAS be equipped with
ADS-B In with a CDTI that is configured to provide alerting audible to
the pilot and/or flight crew, and that such requirement apply wherever
in the NAS the FAA requires any aircraft to operate with ADS-B Out.
Question 3. In NTSB's view, why should FAA require aircraft
operating in busy airspace to fly with both safety enhancing ADS-B In
and ACAS-X? What is the safety benefit to pilots by having both of
these technologies while flying in busier airspace?
Answer. ADS-B In is required as an input of surveillance data to
ACAS-X systems for TSO certification; however, if ADS-B In data are
invalid, ACAS-X systems can still alert by using the other surveillance
input, which is transponder interrogations and replies. Per the minimum
operational performance standards, ACAS-X uses ADS-B information for
optimal performance.
Clear Timeline for ADS-B In Requirement.
Question 1. Do you agree with how the ROTOR Act sets a clear
compliance date for aviation operators to equip with safety enhancing
ADS-B In? How will this help ensure aviation safety benefits can be
delivered in a timely manner to pilots across the National Airspace
System?
Answer. The Board's longstanding position is that the FAA should
require ADS-B In as soon as possible. A clear, definitive deadline for
compliance would provide certainty and accountability for the FAA and
industry to move forward to implementation as soon as possible. We are
concerned that negotiating rulemaking could water down the final rule.
Question 2. How would a clear compliance date for operators to
equip with ADS-B In help foster regulatory certainty for the aviation
industry?
Answer. As noted above, a clear, definitive deadline for compliance
would provide certainty and accountability for the FAA and industry to
move forward to implementation as soon as possible.
Aircraft Separation and Pilot Workload.
Question 1. In your estimation is ADSB-In primarily a safety
technology to improve pilot situational awareness?
Answer. ADS-B is a data source that can be used by numerous
technologies. The NTSB has previously advocated for the FAA to require
ADS-B In technology because equipping aircraft with ADS-B In capability
would immediately and substantially contribute to safety, especially
near airports. The NTSB has investigated numerous midair collisions
that occurred within controlled airspace or in which air traffic
control was in contact with at least one of the aircraft involved. In
many of these investigations, the NTSB noted that a cockpit display of
traffic information with ADS-B In information would enhance pilots'
situation awareness by providing information on surrounding traffic as
well as alerting to traffic conflicts that augment the pilots' see-and-
avoid task. In these accidents, the investigation found that these
conflicts went undetected, which confirms the numerous documented
limitations of see-and-avoid.
Question 2. Would you have concerns with efforts to use ADSB-In to
transfer primary responsibility for separation and traffic flow
throughput from air traffic controllers to pilots?
Answer. This is beyond the scope of our investigation.
Question 3. Would transferring primary responsibility for
separation to pilots create higher pilot workloads and human factors
issues for pilots in en route and terminal areas? Do you see this
posing any issue for air traffic controllers who are exercising
positive control of separation?
Answer. This is beyond the scope of our investigation.
Army Safety Management System. The investigative record indicates
the Army's aviation safety system failed to consistently detect and act
on altimeter altitude exceedances and other operational factors
concerning Army aviation flights in the National Capitol Region
environment.
Question 1. On top of ensuring an effective safety management
system at the Army, what structural safety management changes should
Congress require from the military to prevent future mismanagement of
safety risks?
Answer. The NTSB issued eight safety recommendations to the U.S.
Army as part of our DCA investigation.
Revise training procedures for flight crews assigned to
operate in the Washington, DC, area to ensure that they receive
initial and recurrent training on fixed-wing operations at
Ronald Reagan Washington National Airport, including approach
and departure paths, runway configurations, and the interaction
of those traffic flows with published helicopter routes. (A-26-
41)
Develop and implement a recurring procedure, at an interval
not to exceed 18 months, to verify the continued accuracy of
recorded flight data. (A-26-42)
Incorporate information within the appropriate operator's
manual for all applicable aircraft on the potential total error
allowed by design that could occur in flight on an otherwise
airworthy barometric altimeter, including the increased
position error associated with the external stores support
system configuration. (A-26-43)
Develop and implement a transponder inspection procedure on
all aircraft with transponders capable of transmitting Mode S
and Automatic Dependent Surveillance--Broadcast (ADS-B) and
operated in the National Airspace System (NAS), at least
annually and upon each aircraft's entry into service in the
NAS, that ensures 1) the transponder ADS-B settings are
correct, 2) the transponder is transmitting ADS B, and 3) the
transponder is transmitting the correctly assigned address. (A-
26-44)
Establish a flight data monitoring program for rotary-wing
aircraft the U.S. Army operates in the National Airspace
System. (A-26-45)
Survey U.S. Army helicopter pilots to identify barriers to
the utilization of flight safety reporting systems, develop a
plan to address the identified barriers, and implement that
plan across Army aviation units. (A-26-46)
Revise the method for allocating resources to ensure the
development of a robust safety management system that will, at
a minimum, identify and monitor the potential for midair
collisions between Army aircraft and civil air traffic
operating in the National Airspace System. (A-26-47)
Develop and maintain a flight safety management capability
that is independently resourced and functionally separate from
its occupational and environmental health management system,
and ensure that this capability is both culturally and
functionally integrated with units conducting sustained flight
operations in the National Airspace System. (A-26-48)
______
Response to Written Questions Submitted by Hon. Tammy Duckworth to
Hon. Jennifer Homendy
Question Topic: Improving Aviation Safety Across the National Airspace
System
Question 1. The National Transportation Safety Board (NTSB) report
on the DCA Midair Collision issued dozens of recommendations. Which of
the recommendations from the report would make the most significant
impact on aviation safety if implemented across the entire National
Airspace System?
Answer. Every one of the NTSB's 50 recommendations in response to
the DCA tragedy is crucial and, if implemented, will help save lives.
Question 2. The Federal Aviation Administration (FAA) is in the
process of a $32.5 billion overhaul of the air traffic control (ATC)
system.
A. To date, the FAA has focused on upgrading equipment as a key
pillar in the Brand New Air Traffic Control System (BNATCS). However,
as the NTSB report showed, Terminal Radar Approach Control controllers
repeatedly overrode DCA tower controllers, increasing the strain on the
system. Management failed to appropriately address the issue. An
overhaul of the ATC system does not only require new equipment, but
significant change to the safety culture. What recommendations does the
NTSB have to ensure the BNATCS addresses deeper cultural issues that
contribute to strain on the system?
Answer. Numerous recommendations from the DCA final report call for
ATC reforms related to operational practices, safety culture, and
technology, including those listed below. Broadly, the FAA must ensure
controllers are properly trained and supported by effective management
practices, effective procedures, and the best available technology.
To the FAA: Develop and implement time-on-position
limitations for supervisory air traffic control personnel,
including guidance for district and facility level management
to adapt these limitations to account for their own staffing
and local standard operating procedures. (A-26-08)
To the FAA: Develop instructor-led, scenario-based training
on threat and error management that trains controllers to
continuously monitor their environment to more quickly and
accurately identify threats; promote team communication to
ensure that communications are clear, timely, and assertive;
emphasize effective scanning habits; recognize patterns in the
development of adverse events; and enhance decision-making
under stress by developing habits that balance procedural
compliance with problem solving to mitigate the risks of
threats and errors, and provide this training to all air
traffic controllers annually. (A-26-09)
To the FAA: Develop and implement a risk assessment tool for
supervisors that incorporates the principles of threat and
error management to assist in risk identification, mitigation,
and operational decision making. (A-26-10)
To the FAA: Define objective criteria for the determination
of air traffic facility levels considering traffic and airspace
volume, operational factors unique to each facility, and cost
of living. (A-25-15)
To the FAA: Using the criteria established by Safety
Recommendation A-26-15, determine whether the classification of
the Ronald Reagan Washington National Airport's air traffic
control tower as a level 9 facility appropriately reflects the
complexity of its operations. (A-26-16)
To the FAA: Develop a new and comprehensive instructor-led,
scenario-based training on the proper use of visual separation,
both tower-and pilot-applied. This training should include
information on the inherent limitations of see and avoid,
responsibilities when applying visual separation, and guidance
for controllers on factors, such as current traffic volume,
workload, weather or environmental factors, experience, and
staffing, that should be considered when applying visual
separation. Require this training for all controllers and
include on a recurrent basis thereafter in annual simulator
refresher training. (A-26-17)
To the FAA: Conduct a comprehensive evaluation, in
conjunction with local operators, to determine the overall
safety benefits and risks to requiring all aircraft to use the
same frequency when the helicopter and local positions are
combined in the Ronald Reagan Washington National Airport air
traffic control tower. (A-26-18)
To the FAA: Implement anti-blocking technology that will
alert controllers and/or flight crews to potentially blocked
transmissions when simultaneous broadcasting occurs. (A-26-19)
To the FAA: Develop and implement improvements to the
conflict alert system to provide more salient and meaningful
alerts to controllers based on the severity of the conflict
triggering the alert. (A-26-20)
To the FAA: Once the improvements to the conflict alert
system discussed in Safety Recommendation A-26-20 are
implemented, provide training to controllers on its use. (A-26-
21)
To the FAA: Revise the Air Traffic Organization's initial
event response procedures so that an appropriate on-site
supervisor makes each postaccident and postincident drug and
alcohol testing determination, based on their assessment of
whether the event meets testing criteria and which controllers
had duties pertaining to the involved aircraft, without needing
to wait for investigation or approval. (A-26-22)
To the FAA: At least annually, provide training on the
revised postaccident and postincident drug and alcohol testing
determination procedure discussed in Safety Recommendation A-
26-22 to all staff who have responsibilities under that
procedure; this training should include a post-learning
knowledge assessment. (A-26-23)
To the FAA: Establish a requirement across all air traffic
control tower standard operating procedures that the operations
supervisor (OS) or controller-in-charge (CIC) document in the
daily facility log when any control position is combined with
the local control position, or when the OS/CIC position is
combined with a control position, along with a rationale for
doing so. (A-26-40)
To the Department of Transportation (DOT): Require the
Federal Aviation Administration to demonstrate at least
annually that each air traffic control facility it operates has
the routine capability to accomplish required postaccident and
postincident drug and alcohol testing within the U.S.
Department of Transportation's specified timeframes of 2 hours
for alcohol and 4 hours for drugs, and implement a process to
ensure that any facility without such capability will
demonstrate timely remediation. (A-26-54)
To the DOT: Work with the Federal Aviation Administration
(FAA) Administrator to convene an independent panel to conduct
a comprehensive review of the safety culture within the FAA's
Air Traffic Organization (ATO), and use the findings to enhance
the ATO's existing safety management system and integrate it
into all levels of the organization. (A-26-55)
To the DOT Office of the Inspector General: Complete an
audit of the Federal Aviation Administration (FAA) Air Traffic
Organization's safety management system functions and data
sharing activities at all air traffic control facilities and
determine whether these activities are conducted in
collaboration with all relevant external stakeholders, ensuring
that the audit's results are documented, reported to the
Secretary of Transportation and the FAA Administrator, and made
available to the public. (A-26-56)
B. How can the FAA more broadly implement the recommendations in
the report to improve the ATC system through its ongoing effort to
modernize?
Answer. The FAA needs to implement every recommendation resulting
from this investigation. Safety recommendations from this investigation
regarding the ATC system would work together with our other
recommendations to the FAA to ensure the FAA is building safeguards at
multiple levels of operations to prevent future tragedies.
C. What would be an appropriate timeline for the implementation of
recommendations that address ATC?
Answer. Many NTSB recommendations on ATC from the DCA report could
be acted upon immediately by the FAA. The NTSB designates parties to an
investigation so they can take early action to improve safety, and the
FAA is mandated to be a party to all our aviation investigations. The
agency has access to all the factual information we do, and it should
have taken action even before we issued our final recommendations in
this report.
Question 3. If passed into law, the ROTOR Act would codify many of
the NTSB recommendations from the NTSB's report. However, there is work
to be done beyond the ROTOR Act.
A. What key issues are not addressed by the ROTOR Act?
Answer. The ROTOR Act would address 1 of 50 NTSB safety
recommendations from our DCA investigation--Safety Recommendation A-26-
31, which calls on the FAA to require all aircraft operating in
airspace where Automatic Dependent Surveillance--Broadcast (ADS-B) Out
is required to also be equipped with ADS-B In with a cockpit display of
traffic information that is configured to provide alerting audible to
the pilot and/or flight crew. The ROTOR Act does not address many other
safety recommendations from the NTSB's DCA investigation, nor was it
originally intended to. All 50 safety recommendations made in response
to the DCA tragedy are key to improving safety in the NAS and must be
implemented.
B. What are the top ten NTSB recommendations beyond the ROTOR Act
to improve aviation safety and create more redundancy in the system?
Answer. Every one of the NTSB's 50 safety recommendations in
response to the DCA tragedy would improve safety and should be acted on
immediately.
Question Topic: FAA and Department of Defense (DoD) Coordination
Question 1. The NTSB recommendations include multiple areas for
improved information sharing between the FAA and DoD. After the DCA
Collision, there were still several close calls and loss of separation
events between military and civilian aircraft in the National Airspace
System.
A. Please provide a list of events that the NTSB has investigated
or is currently investigating that involve both the FAA and the DoD.
Answer. The following Aviation Safety Investigations in the NAS
since 2001 have also included a branch of the U.S. Armed Services as a
party:
MIA01GA070--Marathon, FL--Coast Guard airplane collision
with water
LAX02FA110--Marana, AZ--Midair collision between U.S. Army
Pilatus UV-20A and Cessna 182C
CHI03IA066--Wichita, KS--Experimental airplane with in-
flight inverter fire
CHI05FA055--Hollister, OK--Midair collision between USAF
military trainer (Cessna T-37B) and Air Tractor AT-502B
DFW05FA244--Pleasanton, TX--Unmarked power line strike
during training flight
DEN06LA004--Truth or Consequences, NM--Failure to maintain
terrain clearance
DEN06GA017--Alpine, WY--Low-level flight maneuver, cable
strike
LAX06GA254--Happy Camp, CA--Tail rotor separation during
fire suppression operation
DEN07FA140--Dayton, WY--Loss of control during in-flight
weather
SEA08FA023--Las Vegas, NV--In-flight collision with terrain
DFW08TA225--Pueblo, CO--Wake turbulence encounter and impact
with terrain
CEN11IA114--Colorado Springs, CO--Parts separation from
aircraft
WPR12FA058--Coupeville, WA--Loss of engine power
CEN14TA126--Fort Carson, CO--Wake encounter and loss of
control in flight
WPR15MA243--San Diego, CA--Midair collisions between Cessna
172 and experimental North American Rockwell Sabreliner
CEN16FA172--North Little Rock, AR--Loss of engine power
CEN16FA278--Fairmont, OK--Loss of control in flight
WPR17LA186--Pacific Ocean, San Diego, CA--Wake turbulence
and loss of control
DCA19MA143--Jacksonville, FL--Runway excursion
WPR21LA070--Heber City, UT--Loss of control in flight
WPR23LA045--San Diego, CA--Midair collision between Sikorsky
UH-60A and Sikorsky MH-60R
ERA23FA256--Montebello, VA--Unknown circumstances leading to
terrain impact
DCA25MA108--Washington, DC--DCA midair collision
OPS25LA034--Washington, DC--Loss of separation between Army
Sikorsky UH60 and Republic Airways Embraer ERJ 170
MIA02LA057--River Ranch, FL--Loss of engine power and forced
landing
LAX04GA051--Big Bear City, CA--Encounter with weather and
collision with terrain
LAX06FA099--Buckeye, AZ--Near collision, loss of control,
and collision with terrain
CEN14FA468--Abilene, TX--Unknown emergency and impact with
trees and terrain
ERA15MA259--Moncks Corner, SC--Midair collision between an
F-16 and Cessna 150M
WPR16FA166--Las Vegas, NV--Loss of engine power
ERA18FA120--Daytona Beach, FL--Aircraft structural failure
WPR22FA094--Glendale, AZ--Fuel exhaustion
OPS25LA052--Minot, ND--Loss of separation between USAF B-52H
and SkyWest Airlines ERJ-170-200; subsequent loss of separation
between same USAF B-52H and Piper PA
B. Please provide a list of any previous recommendations made by
the NTSB involving improved coordination between the FAA and DoD and
the status of those recommendations.
Answer.
To the Department of Defense (DoD; Closed--Acceptable
Action): Coordinate with the Federal Aviation Administration to
ensure oversight, including periodic en route inspections, is
provided at all contractor bases of operation for civilian
contractors that provide aviation transportation to the U.S.
military overseas under 14 Code of Federal Regulations Part 121
or Part 135. (A-06-78)
To the Air Force Rescue Coordination Center (Closed--
Acceptable Action): Work with the Federal Aviation
Administration to develop specific phraseology for
communicating about the location, time, and nature of emergency
locator transmitter signals and emergency beacon codes and
revise your procedures to reflect that phraseology. (A-10-35)
To the DoD (Closed--Acceptable Alternate Action): Develop,
in cooperation with the FAA, a formal document that clearly
defines the roles & responsibilities of each agency regarding
the activation of the special use areas (warning areas), & that
provides for the timely activation of special use areas to
accommodate the users; prior to implementation, these agencies
should also ensure that air traffic control personnel in all
facilities are provided adequate training & formal briefing on
the procedures responsibilities. (A-97-114)
To the DoD (Closed--Acceptable Action): Conduct, in
cooperation with FAA, a formal review of special use airspace
(warning area) procedures to ensure that they are current,
safe, understood, & adhered to by all those involved. Personnel
involved in this review should include air force, navy, FAA
representatives; pilots, controllers & other persons deemed
appropriate. Info generated by the review should be
disseminated to every unit involved in the scheduling, control,
&/or use of special use airspace. (A-97-115)
To the DoD (Closed--Unacceptable Action): Require that
controllers solicit pilot reports of cloud & visibility
conditions from military flights that are operating in special
use areas (warning areas). During periods when the special use
areas have been released to the FAA, the DOD should require
that military controllers confer with the FAA controllers so
that they can maintain an awareness of flight conditions prior
to the start of a scheduled mission. (A-97-116)
To the DoD (Closed--Acceptable Action): Vigorously pursue
upgrading all air traffic control equipment that directly
interfaces with FAA air traffic control facilities to provide
the same level of safety as that provided to civil aircraft by
the FAA & ensure compatibility with automated systems is [sic]
FAA facilities. (A-97-120)
To the DoD (Closed--Acceptable Action): Participate in a
task force, to be convened by the Federal Aviation
Administration, to establish a permanent bird strike working
group to facilitate conflict resolution and improve
communication between aviation safety agencies and wildlife
conservation interests. (A-99-97)
Question 2. The DCA midair collision resulted, in part, from a lack
of coordination between the FAA and the Army. Less than a year later,
an Air Force B-52 aircraft forced a Delta plane to take evasive action
over Minot, South Dakota. Miscommunications between the FAA and DoD
occur across the Department.
A. Should the Senate Commerce, Science and Technology Committee
coordinate with the Senate Armed Services Committee to ensure that the
best practices outlined in the NTSB report are instituted across the
Department, and importantly, that the data gained from the systems is
proactively shared with FAA safety experts?
Answer. Yes.
a. What specific forms of data and information would be the most
critical for DoD and FAA to share? What is the optimal periodicity for
each type of data or information (e.g., instantly, daily, weekly, bi-
weekly, monthly, annually)?
Answer. We only looked at the Army; we would need to look more
broadly at the DoD.
B. In your investigation, what (if any) existing technical systems
did you find currently share relevant data between DoD and FAA? What
was your assessment of the usefulness and functioning of each system
and what recommendations did you have for improvement?
Answer. We only looked at the Army; we would need to look more
broadly at the DoD.
C. Which existing Army or DoD systems could connect easily to or be
compatible with FAA systems or data, or is the NTSB's position that DoD
and/or FAA's systems need to be overhauled in order to speak to each
other?
Answer. We only looked at the Army; we would need to look more
broadly at the DoD.
Question 3. Has the NTSB faced any resistance or obstacles to
observing Safety Reviews conducted by the DoD or FAA? Were there any
barriers to obtaining the information needed to complete the NTSB
investigation of the DCA Midair Collision?
Answer. The FAA refused to give us investigative information in
numerous instances; the DoD provided us with all investigative
information requested.
Question 4. Following the DCA midair collision, FAA announced it is
using artificial intelligence and machine learning to scan incident
reports and mine data sources to identify similar hotspots with high
volumes of mixed helicopter and airplane traffic. Has FAA shared any of
these analyses with NTSB and DoD?
Answer. We have not received this analysis; however, we would like
to, as our Chief Data Officer has concerns about how this practice is
being implemented and that safety concerns identified in our
investigations may be missed.
Question 5. What is the NTSB's assessment of the U.S. Army's
aviation platforms' ability to communicate in real-time with non-
military aircraft or air traffic controllers? Are there any gaps in
communications systems onboard U.S. Army aircraft that prevent real-
time communication?
Answer. Our investigation of the DCA midair collision found that
several of the Army 12th Aviation Battalion's helicopters were not
transmitting ADS-B Out. The battalion did not know this was occurring.
The NTSB determined that the Army's lack of recurrent inspections to
verify the transponder ADS-B settings were correct and transmitting
ADS-B was a factor in this issue remaining undetected by the battalion.
Accordingly, the NTSB recommended the Army and the Department of War
Policy Board on Federal Aviation develop and implement a transponder
inspection procedure on all aircraft with transponders capable of
transmitting Mode S and ADS-B and operated in the National Airspace
System (NAS), at least annually and upon each aircraft's entry into
service in the NAS, that ensures 1) the transponder ADS-B settings are
correct, 2) the transponder is transmitting ADS-B, and 3) the
transponder is transmitting the correctly assigned address (Safety
Recommendations A-26-44 and A-26-51). Verifying functionality of
aircraft transponders will ensure these systems that interface with
TCASs and ground radar stations work properly while flying in the NAS.
Our investigation also found that degraded radio reception resulted
in the crew of PAT25 not receiving salient information regarding flight
5342's circling approach to runway 33. Clear and effective
communication is essential for safe ATC operations and pilot situation
awareness. When radio quality is degraded, pilots and controllers can
miss important information, and having to repeat control instructions
can result in time lost for other safety-critical tasks. Therefore, we
recommended that the Department of War Policy Board on Federal Aviation
conduct a study to evaluate the quality of radio transmissions and
reception for those aircraft operated within the NAS to identify
factors that degrade communications equipment performance and adversely
affect the safety of civilian and military flight operations (Safety
Recommendation A-26-49). We further recommended the DOW implement the
appropriate enhancements based on the findings of this study (Safety
Recommendation A-26-50).
Question Topic: DoD Safety Improvements
Question 1. Should Congress statutorily require the development of
a robust Safety Management System for all Military Services, including
a flight data monitoring system for all aircraft and frontline incident
reporting system, similar to the NTSB recommendations to the Army?
Answer. Yes.
Question 2. What would be a reasonable deadline for the Army to
close out the three recommendations related to development of a Safety
Management System?
Establish a flight data monitoring program for rotary-wing
aircraft the U.S. Army operates in the National Airspace System
(A-26-45)
Revise the method for allocating resources to ensure the
development of a robust safety management system that will, at
a minimum, identify and monitor the potential for midair
collisions between Army aircraft and civil air traffic
operating in the National Airspace System (A-26-47)
Develop and maintain a flight safety management capability
that is independently resourced and functionally separate from
its occupational and environment health management system, and
ensure that this capability is both culturally and functionally
integrated with units conducing flight operations in the
National Airspace System (A-26-48)
Answer. As soon as possible. The team is having ongoing and
productive discussions with the Army.
Question 3. There has been an increase in military-on-military
aircraft collisions. Would the NTSB recommend expanding its
recommendation to identify and monitor potential for midair collisions
between Army aircraft and civil air traffic (A-26-47) to include
aircraft and all other traffic operating in the National Airspace
System?
Answer. Our recommendations have already been made.
Question Topic: Enhance Transparency of NTSB Proceedings
Question 1. Does the NTSB have ex-parte rules prohibiting
communication between entities that would be impacted by an ongoing
NTSB investigation while a given draft is before the board?
Answer. No; however, I have asked our General Counsel to draft a
Board order prohibiting such communications. It would be helpful to
have congressional support for this action because NTSB Board orders
can be changed at will by the Board.
Question 2. To protect NTSB independence, and to enhance public
transparency, would you support Congress passing legislation to codify
such a prohibition on lobbying NTSB members while considering a draft,
and a requirement that amendments proposed by NTSB members be publicly
disclosed?
Answer. Yes, I strongly support this. One of our core values is
transparency, and that should apply to our Board. The Board will work
the Committee on any legislation under consideration.
Question Topic: Air Traffic Controller Training
While the NTSB final report does not explicitly state why the trend
over the previous decade went from always manning the Helicopter
Control (HC) and Local Control (LC) positions separately to both
positions be normally combined, this period coincided with declining
recruitment of air traffic controllers.
Question 1. Does NTSB recommend that the FAA invest in additional
pathways to increase the recruitment and training of air traffic
controllers to minimize towers, resorting to implementing staffing
modifications like combining the HC and LC positions?
Answer. This is beyond the scope of our investigation.
Question Topic: ADS-B In/Out Recommendations
Question 1. Please provide a list of all previous NTSB
recommendations issued on Automatic Dependent Surveillance--Broadcast
(ADS-B) In and ADS-B Out, and the status of these recommendations.
Answer. ADS-B was first discussed in NTSB correspondence related to
Safety Recommendation A-00-66 (Closed--Unacceptable Action), which
resulted from our investigations of four runway incursions that
occurred in 1999, and asked the FAA to require a ground movement safety
system that prevents runway incursions and provides a direct warning to
flight crews.
Safety Recommendation A-00-66 superseded Safety Recommendation A-
91-29, which asked the FAA to develop and implement a system to alert
controllers to pending runway incursion.
ADS-B is not specified in the text of A-00-66; however, it is
discussed in our correspondence. In a 2011 letter, we discussed the
FAA's ADS-B rulemaking and told the FAA that ADS-B might have been a
viable response to A-00-66, but only if ADS-B In were required.
In 2024, as a result of our investigation of a 2023 runway
incursion at JFK airport, we issued Safety Recommendations A-24-4
through -6 to the FAA (all three are classified Open--Unacceptable
Response), which collectively superseded A-00-66.
Collaborate with aircraft and avionics manufacturers and
software designers to develop the technology for a flight deck
system that would provide visual and aural alerts to flight
crews of traffic on a runway or taxiway and traffic on approach
to land. (A-24-4)
Require that the technology developed in response to Safety
Recommendation A-24-4 be installed in all newly certificated
transport-category airplanes. (A-24-5)
Require that existing transport-category airplanes be
retrofitted with the technology developed in response to Safety
Recommendation A-24-4. (A-24-6)
Between 2006 and 2007, we recommended that the FAA require
equipment that could provide increased aircraft identification,
location, and communication capabilities for aircraft operations in the
Gulf of America and remote areas of Hawaii. The following
recommendations have been classified Closed--Acceptable Action:
Ensure that the infrastructure for the National ADS-B
Program in the Gulf of America is operational by Fiscal Year
2010. (A-06-21)
Until the infrastructure for the National ADS-B Program in
the Gulf of America is fully operational, direct POIs to inform
operators in that region about the benefits of commercial
flight-tracking systems and encourage the operators to acquire
such systems. (A-06-22)
Accelerate the implementation of ADS-B infrastructure in
Hawaii to include high-quality ADS-B services to low-flying
aircraft along heavily traveled commercial air tour routes. (A-
07-25)
Require that Hawaii air tour operators equip tour aircraft
with compatible ADS-B technology within 1 year of the
installation of a functional National ADS-B Program
infrastructure in Hawaii. (A-07-26)
FAA Rulemaking on ADS-B
In 2007, the FAA published a notice of advance rulemaking (NPRM)
that only proposed requiring ADS-B Out. The FAA determined ADS-B In was
not needed to maintain the safety and efficiency of the NAS.
In our 2008 NPRM comments, we pointed out that for ADS-B to provide
maximum safety benefits, the system should support both ADS-B Out and
ADS-B In. ADS-B Out provides basic aircraft information, such as
location and altitude, to air traffic controllers to provide traffic
separation. ADS-B In would permit users access to additional services,
such as data-linked weather and traffic information, and would also
provide a means of transmitting conflict warnings directly to pilots
via the ADS-B In communications link.
In 2010, the FAA published a final rule, ``ADS-B Out Performance
Requirements,'' which required, as of 2020, that aircraft flying in
controlled airspace be equipped with ADS-B Out.
The FAA Reauthorization Act of 2018 repealed earlier legislation
that had directed the FAA to initiate rulemaking to issue guidelines
and regulations relating to ADS-B In technology. The repeal language
appears as section 522 of the FAA Reauthorization Act of 2018.
In 2021, because of our investigation of a 2019 midair collision
involving two Part 135 sightseeing tours near Ketchikan, Alaska, we
issued the following safety recommendations to the FAA, which are the
first recommendations to specify the ``Out'' and ``In'' capabilities of
ADS-B. All are classified Open--Unacceptable Response.
Identify areas with a high concentration of air tour traffic
and to require that CFR Parts 91 and 135 air tour operators who
operate within those areas be equipped with an ADS-B Out-and
In-supported traffic advisory system that includes visual and
aural alerts. (A-21-15)
Require that all non-air tour aircraft operating within the
airspace identified as a high-traffic tour area in Safety
Recommendation A-21-15 be equipped with ADS-B Out. (A-21-16)
Require the installation of ADS-B Out and In supported
airborne traffic advisory systems that include aural alerting
functions in all aircraft conducting operations under 14 CFR
Part 135. (A-21-17)
In 2023 correspondence, the FAA said its current ADS-B requirements
and guidance adequately addressed the needs of aviation safety and it
would not pursue additional requirements. The NTSB emphasized that the
absence of an ADS-B In requirement for Part 135 passenger-carrying
operations fails to take advantage of the demonstrated safety benefit
of ADS-B In traffic awareness and alerting and is inconsistent with the
``appropriate level of public safety'' the FAA itself expects for
operations in which passengers bear no responsibility for the
aircraft's operation.
In 2022, because of our investigation of a 2019 helicopter air tour
accident in Hawaii, the NTSB issued the following safety
recommendations to the FAA (both are classified Open--Acceptable
Response):
Implement ADS-B infrastructure improvements in Hawaii, such
as additional ADS-B ground stations, that provide adequate
coverage to enable real-time flight tracking and traffic
advisory services for ADS-B Out-and In-equipped, low-flying air
tour aircraft throughout their entire tour routes. (A-22-12)
As an interim measure until completion of A-21-15, require
Hawaii air tour operators to install ADS-B Out equipment in
their aircraft to enable real-time flight position tracking.
(A-22-13)
Now, with the conclusion of the DCA midair collision investigation,
we have issued additional collision avoidance and ADS-B In
recommendations, as detailed elsewhere.
Question 2. To encourage implementation of NTSB recommendations on
the installation of ADS-B In, would the NTSB be supportive of a public
safety rating system that ranks air carriers on their installation of
ADS-B?
Answer. This is beyond the scope of our investigation.
Question Topic: FAA Complacency
There is a known culture of complacency at the FAA. The NTSB has
issued similar recommendations to those in the DCA report in previous
investigations, but the FAA either failed to act or rejected the
recommendations. The FAA must change its culture and not only implement
the recommendations required by the NTSB but go beyond those
recommendations to create a culture of safety.
Question 1. Please provide a detailed timeline for each
recommendation and explain what mechanism the NTSB will use to track
implementation.
Answer. Title 49 United States Code 1135 requires an initial
recipient response within 90 days for nonurgent recommendations (30
days for urgent) issued to the DOT and all DOT modal administrations.
After the initial response, recipients should update the NTSB on their
progress toward implementing the recommendation whenever a significant
activity has been completed, or every 12 months, whichever occurs
first. The NTSB will attempt to obtain an update from a recipient
through formal or informal means when there has been no update for 12
or more months. If, after 18 months, no update has been received, a
formal letter requesting an update will be sent to the recipient. An
action recommended by the NTSB should be completed within 5 years after
the recommendation is issued. A recommendation over 5 years old may be
kept open if the NTSB determines that the recommendation can be
successfully completed with additional time or that the issue has
significant safety implications, or if the Board votes to keep it open.
Question Topic: NTSB Staffing and Resources
Question 1. What resources were needed to conduct the DCA Midair
Collision investigation?
Answer. Every office across the agency directly supported the
investigation and the investigators who worked on it. Collectively,
agency staff spent over 30,000 hours on the investigation. Fifty
investigators supported the investigation, including four directors and
eight chiefs, along with three dedicated writers. In addition, eight
staff members supported family assistance, five supported media
relations, five supported government affairs, and eighteen staff
members directly supported the investigation and subsequent
investigative hearing and Board meeting. This number does not include
the staff that provided indirect support that ensured investigative
staff had real-time human resources and travel resources, as well as
the technology needed to work on this investigation. The total costs
are estimated to be $3.25 million including labor and mission support
costs.
This number does not reflect the work done by staff who, as part of
their job duties, support all investigations; it is an estimate rather
than the exact monetary cost of this investigation.
Question 2. What is the appropriate level of staffing and funding
necessary to carry out NTSB operations at full capacity?
Answer. Our current budget request is $145 million for Fiscal Year
2027, which will support a staffing level of 450.
______
Response to Written Questions Submitted by Hon. John Hickenlooper to
Hon. Jennifer Homendy
Culture of Safety
The NTSB's DCA crash investigation revealed that aviation safety
personnel had previously raised collision risks to FAA management, yet
these concerns were not addressed in a timely manner. We must always
raise the bar and promote a culture of safety, transparency, and
accountability, especially in aviation, and especially when lives are
at risk.
Question 1. Chair Homendy, could stronger legislative protections
for voluntary safety reporting help promote a stronger culture of
safety across the FAA?
Answer. Yes.
Aircraft Instruments and Spectrum Interference
Aircraft instruments rely on extreme precision, making spectrum
interference a serious safety risk. For example, recent counter-drone
testing by the Navy and Secret Service near DCA triggered dangerous
false alarms for pilots' Traffic Collision Avoidance Systems (TCAS). In
Boulder, the Federal Institute for Telecommunication Science (ITS) has
worked closely alongside the FAA, DOD, and other agencies to study and
minimize spectrum interference to mission-critical systems.
Question 2. Chair Homendy, what specific interagency research and
testing is needed to ensure mission-critical systems aren't compromised
by emerging wireless technologies?
Answer. This is beyond the scope of our investigation.
Question 3. Do you believe the NTSB and FAA's safety concerns are
being given enough weight by the NTIA or FCC before they auction off
spectrum bands--like the ``Upper C-Band''--near sensitive aircraft
frequencies?
Answer. This is beyond the scope of our investigation.
Nationwide Mixed Airspace Review
Following the DCA Crash last year, the FAA confirmed to this
Committee that it was conducting a nationwide review of airspace. The
FAA stated it was examining airspace where commercial aviation traffic
mixed with military airspace activities. The FAA's review is important
to ensure any troublesome areas of mixed airspace traffic are
identified and risks are mitigated.
Question 4. Chair Homendy, how would you characterize the pace and
scope of the FAA's ongoing review of mixed airspace nationwide? Do you
have any further recommendations or findings regarding this airspace
review?
Answer. Because the FAA's review is ongoing, this question is best
posed to that agency.
Runway Incursion
While air traffic controllers perform incredible work, many
airports still lack the technology to prevent ground collisions. At
most airports, safety relies entirely on human eyes and radio calls
rather than automated tracking.
Question 5. Chair Homendy, would expanding ground-based radar and
surveillance systems, including at smaller airports, provide the
additional required situational awareness to help pilots avoid runway
incursions?
Answer. Since 1973, the NTSB has issued numerous recommendations to
the FAA regarding the problems with runway incursions/ground collisions
with aircraft, including the current recommendations from multiple
recent and past incidents and accidents listed below.
Recommendations from a 2017 taxiway overflight at SFO (NTSB
Incident Report AIR-18-01):
Establish a requirement for airplanes landing at primary
airports within Class B and Class C airspace to be equipped
with a system that alerts pilots when an airplane is not
aligned with a runway surface. (A-18-25)
Collaborate with aircraft and avionics manufacturers and
software developers to develop the technology for a cockpit
system that provides an alert to pilots when an airplane is not
aligned with the intended runway surface, and, once such
technology is available, establish a requirement for the
technology to be installed on airplanes landing at primary
airports within Class B and Class C airspace. (A-18-26)
Recommendations from a 2023 runway incursion and rejected takeoff
at JFK (NTSB Aviation Investigation Report AIR-24-01):
Encourage Title 14 Code of Federal Regulations Part 91K,
135, and 121 operators to incorporate into their standard
operating procedures a procedural crosscheck that requires
flight crews to verbalize the number of a runway they are about
to cross, as indicated by runway signs, unless an installed
automated system already provides an aural advisory. (A-24-2)
Collaborate with aircraft and avionics manufacturers and
software designers to develop the technology for a flight deck
system that would provide visual and aural alerts to flight
crews of traffic on a runway or taxiway and traffic on approach
to land. (A-24-4; supersedes A-00-66)
Require that the technology developed in response to Safety
Recommendation A-24-4 be installed in all newly certificated
transport-category airplanes. (A-24-5; supersedes A-00-66)
Require that existing transport-category airplanes be
retrofitted with the technology developed in response to Safety
Recommendation A-24-4. (A-24-6; supersedes A-00-66)
Evaluate the effectiveness of the activation logic for the
runway status light system considering the circumstances of
this incident. (A-24-7)
Using the findings of the evaluation conducted in response
to Safety Recommendation A-24-7, update the runway status light
system activation logic as necessary to improve system
effectiveness. (A-24-8)
Recommendations from a 2023 runway incursion and overflight at AUS
(NTSB Aviation Investigation Report AIR-24-02)
Require air traffic controllers to advise pilots, through
direct communication and automatic terminal information system
broadcasts, when visual contact with aircraft operating on
taxiways and runways cannot be established or maintained and
instruct pilots to provide accurate position reports to aid the
controller in determining an aircraft's location in such
conditions. (A-24-11)
Amend the Aeronautical Information Manual so that it
instructs pilots to inform controllers, before entering an
active runway with the intent to depart, when they need time on
the runway for any reason before beginning the takeoff roll.
(A-24-13)
Require all airports with a Surface Movement Guidance and
Control System plan to ensure that their plans and the
associated letters of agreement correspond with each other and
the stakeholder duties and responsibilities described in
Advisory Circular 120-57, Surface Movement Guidance and Control
System. (A-24-14)
Recommendations from the DCA midair collision investigation:
To the FAA: Develop and implement a risk assessment tool for
supervisors that incorporates the principles of threat and
error management to assist in risk identification, mitigation,
and operational decision making. (A-26-10)
To the FAA: Initiate rulemaking in 14 Code of Federal
Regulations Part 93 Subpart K, High Density Traffic Airports,
that prescribes air carrier operation limitations at DCA in 30-
minute periods, similar to those imposed at LaGuardia Airport,
to ensure that the airport does not exceed capacity and to
mitigate inconsistent air carrier scheduling practices. (A-26-
11)
To the FAA: Fully implement operational use of the time-
based flow management system at Potomac Consolidated Terminal
Radar Approach Control and its associated air traffic control
towers. (A-26-12)
To the FAA: Reassess the Ronald Reagan Washington National
Airport's airport arrival rate with special consideration to
its airspace complexity, airfield limitations, mixed fleet
operations, and traffic volume. (A-26-13)
To the FAA: Require each Class B or Class C air traffic
control tower facility to evaluate its existing miles-in-trail
procedures or agreements to ensure that the spacing provided is
appropriate for operational safety, and make the results
publicly available. (A-26-14)
To the FAA: Conduct a comprehensive evaluation, in
conjunction with local operators, to determine the overall
safety benefits and risks to requiring all aircraft to use the
same frequency when the helicopter and local positions are
combined in the Ronald Reagan Washington National Airport air
traffic control tower. (A-26-18)
To the FAA: Implement anti-blocking technology that will
alert controllers and/or flight crews to potentially blocked
transmissions when simultaneous broadcasting occurs. (A-26-19)
To the FAA: Develop and implement improvements to the
conflict alert system to provide more salient and meaningful
alerts to controllers based on the severity of the conflict
triggering the alert. (A-26-20)
To the FAA: Once the improvements to the conflict alert
system discussed in Safety Recommendation A-26-20 are
implemented, provide training to controllers on its use. (A-26-
21)
To the FAA: Require all aircraft operating in airspace where
Automatic Dependent Surveillance-Broadcast (ADS-B) Out is
required to also be equipped with ADS B In with a cockpit
display of traffic information that is configured to provide
alerting audible to the pilot and/or flight crew. (A-26-31)
To the FAA: Establish a requirement across all air traffic
control tower standard operating procedures that the operations
supervisor (OS) or controller-in-charge (CIC) document in the
daily facility log when any control position is combined with
the local control position, or when the OS/CIC position is
combined with a control position, along with a rationale for
doing so. (A-26-40)
To the United States Department of War, Policy Board on
Federal Aviation: Conduct a study to evaluate the quality of
radio transmissions and reception for those aircraft operated
within the National Airspace System to identify factors that
degrade communications equipment performance and adversely
affect the safety of civilian and military flight operations.
(A-26-49)
To the United States Department of War, Policy Board on
Federal Aviation: Implement appropriate enhancements, based on
the findings of the study recommended in Safety Recommendation
A-26-49, to remediate identified deficiencies in air-ground
radio communications performance. (A-26-50)
NTSB has issued the following additional recommendations to the
FAA, which have been classified Closed--Acceptable Action, calling for
research and development efforts to address the need for cost-effective
alternatives at airports not scheduled to receive Airport Surface
Detection Equipment (ASDE):
Conduct research and development efforts to provide airports
that are not scheduled to receive Airport Surface Detection
Equipment with an alternate, cost-effective system to bring
controller and pilot attention to pending runway incursions in
time to prevent ground collisions. (A-91-30)
Continue research and development efforts to provide
airports that are not scheduled to receive Airport Surface
Detection Equipment with an alternate, cost-effective system,
such as the ground induction loop, to bring controller
attention to pending runway incursions in time to prevent
ground collisions. (A-95-94)
Convene a joint FAA/industry task force on human performance
initiatives to produce human performance-related surface
operation improvements that could be readily implemented during
surface operations by mitigating human error. In identifying
those initiatives, consider the recommendations contained in
the MITRE Corporation study, ``Reports by Airline Pilot Surface
Operations.'' (A-95-96)
Finally, the NTSB has issued the following additional
recommendations to the FAA on this issue over many years that have been
classified Closed--Unacceptable Action:
Establish and publish taxi routes for arriving and departing
aircraft to be used during periods of restricted visibility on
the order of 1/2 mile. (A-73-25)
Require pilots to obtain the controllers' approval before
crossing alighted runway during periods of restricted
visibility on the order of 1/2 mile. (A-73-26)
Require flight crews to read back taxi clearances when
operating in visibilities of less than one-half mile. (A-73-55)
Establish on a trial basis, for the north and for the south
control operations in the Chicago O'Hare international airport
control tower, local control coordinator positions to monitor
and supervise, directly, the local control positions; staff
these positions whenever intersecting runways are in concurrent
operation. (URGENT) (A-86-45)
Amend the air traffic control handbook, 711.65f, paragraph
3-127, to preclude the issuance of multiple landing clearances
to aircraft outside of the final approach fix. Also, establish
a numerical limit so that no more than two landing clearance
may be issued to successive arrivals. (A-91-28)
Retain the national operational position standards as a
separate, independent order and: (a) direct the FAA's human
factors and air traffic service staffs adequacy of redundancies
and incorporate any resultant recommendations into the national
order; (b) expedite the development of chapters 5 through 10 of
the national order. (A-91-107)
Amend FAA Order 7110.65, ``Air Traffic Control,'' paragraph
3-9-4, ``Takeoff Position Hold,'' to discontinue the practice
of allowing departing aircraft to hold on active runways at
nightime or at any time when ceiling and visibility conditions
preclude arriving aircraft from seeing traffic on the runway in
time to initiate a safe go-around maneuver. (A-00-69)
Adopt the landing clearance procedure recommended by
International Civil Aviation Organization Document 4444-RAC/
501, ``Procedures for Air Navigation Services--Rules of the Air
and Air Traffic Services,'' Part V, ``Aerodrome Control
Service,'' Paragraph 15.2. (A-00-70)
Require that all 14 Code of Federal Regulations Part 91K,
121, and 135 operators establish procedures requiring all
crewmembers on the flight deck to positively confirm and cross-
check the airplane's location at the assigned departure runway
before crossing the hold short line for takeoff. This required
guidance should be consistent with the guidance in Advisory
Circular 120-74A and Safety Alert for Operators 06013 and
07003. (Supersedes Safety Recommendation A-06-83) (A-07-44)
Require that all 14 Code of Federal Regulations Part 91K,
121, and 135 operators install on their aircraft cockpit moving
map displays or an automatic system that alerts pilots when a
takeoff is attempted on a taxiway or a runway other than the
one intended. (Supersedes Safety Recommendation A-06-83) (A-07-
45)
Perform a technical review of Airport Surface Detection
Equipment-Model X (ASDE-X) to determine if the capability
exists systemwide to detect improper operations such as
landings on taxiways. (A-11-12)
At those installation sites where the technical review
recommended in Safety Recommendation A-11-12 determines it is
feasible, implement modifications to Airport Surface Detection
Equipment-Model X (ASDE-X) to detect improper operations, such
as landings on taxiways, and provide alerts to air traffic
controllers that these potential collision risks exist. (A-11-
13)
Safety Recommendations
The NTSB deserves bipartisan praise for its timely investigations
and safety recommendations that can save lives. The NTSB has long
called for cockpit voice recorders capable of recording 25 hours of
audio to be installed in aircraft. While the FAA has recently required
new aircraft to include 25-hour cockpit voice recorders, existing
aircraft do not have this equipment retrofitted.
Question 6. Chair Homendy, could you underscore the importance of
all aircraft having cockpit voice recorders in supporting NTSB's safety
investigations? How did this data assist the NTSB in conducting the DCA
investigation and providing its final recommendations?
Answer. Cockpit voice recorders (CVRs) are among the most valuable
tools used for accident investigation. Information, such as flight crew
verbalizations of their intentions and coordination, as well as pilots'
awareness of the state of the aircraft and cockpit information, allows
investigators to more comprehensively assess accident/incident factors.
These factors include flight crews' procedural compliance, distraction,
decision-making, workload, fatigue, and situation awareness.
Ultimately, CVRs provide unique information with which the NTSB can
conduct more thorough investigations to more effectively target safety
recommendations.
CVRs provided critical information during the DCA midair collision
investigation. For example, the CVR on PAT25 revealed that its crew did
not receive salient information regarding flight 5342's circling
approach to runway 33 due to degraded radio reception. Additionally,
the CVR revealed that simultaneous radio transmissions blocked
important information from the controller to PAT25, which reinforced
the PAT25 crew's expectation bias that flight 5342 did not pose a
conflict. Both findings led directly to NTSB safety recommendations.
Although the FAA's recent rulemaking did not require that existing
aircraft be retrofitted with a 25-hour CVR, the FAA Reauthorization Act
of 2024 requires that all aircraft operated under Part 121 and certain
other aircraft be retrofitted with a CVR that retains the last 25 hours
of aircraft operation by 2030.
______
Response to Written Questions Submitted by Hon. Andy Kim to
Hon. Jennifer Homendy
Helicopter Routes Recommendation/Low-Flying Helicopters
Question 1. One of the recommendations made during the NTSB's
January 2026 Board Meeting was that annual reviews should be conducted
on helicopter routes throughout the entire aviation system to ensure
that our airspace is safe. In the New York City region, there are about
80,000 nonessential helicopter flights over this region every year,
which is about 220 flights every day. Not only do these helicopter
flights cause great disturbances for the residents of these densely
populated communities, but they also pose safety risks. There are
minimal guidelines for these helicopters to follow, even in densely
populated residential areas. The fatal April 10, 2025 helicopter crash
in the Hudson River increases concerns of future crashes over these
residential areas being likely. Has the NTSB reviewed safety concerns
of low-flying helicopters and aircraft in crowded residential areas? In
light of the NTSB recommendations from the DCA collision investigation,
what considerations would be most critical to better regulating
nonessential travel to ensure the best safety outcomes?
Answer. All of the NTSB's open recommendations will improve
aviation safety. In addition to the recommendations from the DCA
investigation, the following open recommendations are directed to the
FAA and involved investigations of accidents including helicopters.
In cooperation with Hawaii commercial air tour operators,
aviation psychologists, and meteorologists, among others,
develop a cue-based training program for commercial air tour
pilots in Hawaii that specifically addresses hazardous aspects
of local weather phenomena and in-flight decision-making. (A-
07-18)
Once a cue-based training program that specifically
addresses hazardous aspects of local weather phenomena and
weather-related, decision-making issues is developed (as
requested in Safety Recommendation A-07-18), require all
commercial air tour operators in Hawaii to provide this
training to newly hired pilots. (A-07-19)
Require the installation of a crash-resistant flight
recorder system on all newly manufactured turbine-powered,
nonexperimental, nonrestricted-category aircraft that are not
equipped with a flight data recorder and a cockpit voice
recorder and are operating under 14 Code of Federal Regulations
Parts 91, 121, or 135. The crash-resistant flight recorder
system should record cockpit audio and images with a view of
the cockpit environment to include as much of the outside view
as possible, and parametric data per aircraft and system
installation, all as specified in Technical Standard Order
C197, ``Information Collection and Monitoring Systems.'' (A-13-
12)
Require all existing turbine-powered, nonexperimental,
nonrestricted-category aircraft that are not equipped with a
flight data recorder or cockpit voice recorder and are
operating under 14 Code of Federal Regulations Parts 91, 121,
or 135 to be retrofitted with a crash-resistant flight recorder
system. The crash-resistant flight recorder system should
record cockpit audio and images with a view of the cockpit
environment to include as much of the outside view as possible,
and parametric data per aircraft and system installation, all
as specified in Technical Standard Order C197, ``Information
Collection and Monitoring Systems.'' (A-13-13)
Initiate an aviation weather camera program in Hawaii that
includes the installation and maintenance of aviation weather
cameras at critical locations in Hawaii. Establish public
access to these aviation weather cameras' real-time imagery.
(A-13-25)
Install and maintain aviation weather cameras in those
mountain passes in the continental United States identified in
its research as being high risk. Establish public access to
these aviation weather cameras' real-time imagery. (A-13-26)
Equip flight service station specialists responsible for
Hawaii and the continental United States with the technical
capabilities and training to provide verbal preflight and en
route briefings using aviation weather camera imagery. (A-13-
27)
TO THE FEDERAL AVIATION ADMINISTRATION AND THE EUROPEAN
AVIATION SAFETY AGENCY: After the actions requested in Safety
Recommendation A-17-10 are completed, require operators of
Airbus Helicopters dual-hydraulic AS350-series helicopters to
incorporate changes to the dual hydraulic system to both ensure
pedal control hydraulic assistance and mitigate the possibility
of pilot error during any check of the hydraulic system. (A-17-
11)
Modify the supplemental passenger restraint system (SPRS)
approval process to (1) require letter of authorization (LOA)
applicants to specify a need for and the intended use of an
SPRS for each aircraft; (2) require the Federal Aviation
Administration to evaluate and review, for each specified
aircraft, the need for the SPRS on that aircraft for all
intended uses; all SPRS design, manufacture, installation, and
operational considerations, including, at a minimum, the
potential for passengers to become entangled during emergency
egress; the adequacy of passenger emergency egress briefings;
and the potential for the SPRS to interfere with aircraft
controls; and (3) ensure that each LOA lists the specific
aircraft on which the holder is authorized to use an SPRS. (A-
19-24)
Review the activation system designs of Federal Aviation
Administration-approved rotorcraft emergency flotation systems
for deficiencies that may preclude their proper deployment,
such as a lack of a means to identify high pull forces on
manual activation handles or inadequate guidance on the
intended use of the activation system, and require corrective
actions based on the review findings. (A-19-26)
Revise Miscellaneous Guidance 10 in Advisory Circular (AC)
27 and AC 29 to include design objectives for emergency
flotation systems that consider human factors design
objectives, such as activation handle pull-force
characteristics; provisions for clear, unambiguous, and
positive feedback to pilots to indicate that the float system
was successfully deployed; and inspections to ensure that an
installation of a manual activation system does not preclude a
pilot's ability to deploy the floats, as designed, after it has
been fielded. (A-19-27)
To the FAA: After the actions requested in Safety
Recommendation A-19-32 are completed, require owners and
operators of existing AS350-series helicopters to incorporate
the changes. (A-19-33)
Develop guidance on how to identify intoxicated or impaired
passengers, and distribute it to operators who carry passengers
for hire under Title 14 Code of Federal Regulations Part 91 and
Part 135. (A-19-34)
Require that principal operations inspectors (POI) assigned
to helicopter air ambulance (HAA) operations possess helicopter
and either HAA experience or experience as an assistant POI
under a POI with HAA experience. (A-20-13)
Require the National Weather Service (NWS) to add terminal
doppler weather radar data to the HEMS Weather Tool overlay (as
recommended in Safety Recommendation A-20-19 to the NWS). (A-
20-16)
Require the National Weather Service (NWS) to provide
capability in the HEMS Weather Tool to graphically display
areas of weather radar limitations, including areas where beams
may lack low-altitude coverage, areas that lack radar coverage,
and areas of beam blockages (as recommended in Safety
Recommendation A-20-20 to the NWS). (A-20-17)
Require the use of appropriate simulation devices during
initial and recurrent pilot training for Title 14 Code of
Federal Regulations Part 135 helicopter operations to provide
scenario-based training that addresses the decision-making,
skills, and procedures needed to recognize and respond to
changing weather conditions in flight, identify and apply
mitigation strategies for avoiding adverse weather, practice
the transition to the use of flight instruments to reduce the
risk of spatial disorientation, and maintain awareness of a
variety of influences that can adversely affect pilot decision-
making. (A-21-05)
Install the necessary infrastructure in Hawaii to enable
continuous radio communication between the pilots of low-flying
tour flights and ground support personnel, such as flight
service station specialists and company flight support
personnel, along the most heavily trafficked air tour routes.
(A-22-11)
Implement automatic dependent surveillance-broadcast (ADS-B)
infrastructure improvements in Hawaii, such as additional ADS-B
ground stations, that provide adequate coverage to enable real-
time flight tracking and traffic advisory services for ADS-B
Out-and In-equipped, low-flying air tour aircraft throughout
their entire tour routes. (A-22-12)
As an interim measure until completion of the action to
satisfy Safety Recommendation A-21-15, require Hawaii air tour
operators to install Automatic Dependent Surveillance-Broadcast
Out (ADS-B) equipment in their aircraft to enable real-time
flight position tracking. (A-22-13)
Require air tour operators to have flight support personnel
who are trained to exercise operational control authority,
participate in preflight risk analysis, provide pilots with
weather briefings, monitor the progress of the flights, and
participate in two-way communications with pilots to alert them
of any weather hazards. (A-22-14)
Issue a safety alert for operators to encourage air tour
operators to establish safety assurance processes to routinely
review recorded onboard videos and automatic dependent
surveillance-broadcast (ADS-B) flight tracking data, ideally as
part of a safety management system with an integrated flight
data monitoring program, for the purpose of identifying and
addressing risky trends in weather-related operating practices,
such as encounters or near encounters with instrument
meteorological conditions-related hazards. (A-22-16)
Improve the surveillance of air tour operations in Hawaii
through the use of technologies and innovative approaches,
including but not limited to comparing automatic dependent
surveillance-broadcast (ADS-B) flight position data from air
tour flights with weather camera imagery for the route and
periodically reviewing onboard video recordings, to detect and
correct operating practices that may lead to unacceptable
weather-related risky behavior. (A-22-17)
Issue and periodically update a special airworthiness
information bulletin that lists newly manufactured helicopters
that are equipped with features likely to reduce accidents
resulting from inadvertent encounters with instrument
meteorological conditions, describes retrofit options for
helicopters that do not have such equipment, and encourages the
voluntary integration of these safety features. (A-22-18)
Require operators of Bell 407 helicopters to conduct
subsequent torque checks of the tail boom attachment hardware
and visual inspection of the tail boom attachment fittings as
referenced in Safety Recommendation A-22-28 at an interval
significantly less than the currently required interval to
provide multiple opportunities for detecting any improperly
installed or fractured attachment hardware or fittings. Require
operators to report findings to the FAA. (Urgent) (A-22-29)
Review all experimental exhibition airworthiness
certificates issued to turbine-powered rotorcraft and ensure
that their operating limitations meet the standards of the
latest iteration of Federal Aviation Administration Order
8130.2, Airworthiness Certification of Aircraft. (A-24-20)
Establish periodic reviews for experimental exhibition
airworthiness certificates to ensure that those aircraft are
being inspected and maintained according to the latest
iteration of Federal Aviation Administration Order 8130.2,
Airworthiness Certification of Aircraft. (A-24-21)
Require operators of aircraft equipped with Ozark Aeroworks
T53 series engines to perform recurrent inspections of the rear
bearing cover and the exhaust diffuser inner cone and inner
struts with the exhaust diffuser cover removed. (A-24-22)
Remind operators of experimental exhibition aircraft about
the requirement to submit, to the appropriate flight standards
district office, program letters that list all events at which
the aircraft will be exhibited. (A-24-23)
Develop a method for ensuring that operators of experimental
exhibition aircraft meet their annual obligation to submit
program letters; such a method could include potential
penalties for operators that do not meet this obligation. (A-
24-24)
Revise Federal Aviation Administration Order 8900.1, Flight
Standards Information Management System, to include inspector
guidance requiring routine surveillance of operators of
aircraft with experimental exhibition airworthiness
certificates. (A-24-25)
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