The missteps that led to a fatal plane crash at Reagan National Airport

8 months ago (nytimes.com)

> Warrant Officer Eaves stated that it was at 300 feet and descending to 200 feet — necessary because the maximum height for its route closer to the airport had dropped to 200 feet. But even as it reached that juncture, Warrant Officer Eaves evidently felt obligated to repeat his instruction: The Black Hawk was at 300 feet, he said, and needed to descend

> Not only was the Black Hawk flying too high, but in the final seconds before the crash, its pilot failed to heed a directive from her co-pilot, an Army flight instructor, to change course.

> He told her he believed that air traffic control wanted them to turn left, toward the east river bank. Turning left would have opened up more space between the helicopter and Flight 5342, which was heading for Runway 33 at an altitude of roughly 300 feet. She did not turn left.

As much as the article tries to balance it out that the controllers should have done more it seems that ultimately the pilot flying was distracted and not following instructions from the instructor sitting next to them. It happened at least twice based on the captured recordings.

Was there something in their personal life or career to warrant that - a setback, some family situation? Otherwise they seemed qualified and flew that route a few times already.

  • > As much as the article tries to balance it out that the controllers should have done more it seems that ultimately the pilot flying was distracted and not following instructions from the instructor sitting next to them. It happened at least twice based on the captured recordings.

    I'm a helicopter flight instructor, although I've never flown in the military. There are 5 magic words the instructor can, and I would argue is obligated to, use to fix the situation: "I have the flight controls"

    Knowing they were 100 feet high and flying into the approach corridor with an aircraft on short final and not taking the controls is an enormous failure on the part of the instructor. The student was likely task-saturated and the instructor should have recognized that.

    • > Knowing they were 100 feet high and flying into the approach corridor with an aircraft on short final and not taking the controls is an enormous failure on the part of the instructor.

      Even if they were out of the helicopter airway, based at least on radio transmissions the instructor thought they had the landing aircraft in sight and presumably thought they could stay separated from it visually. I would agree with you if staying at the exact right altitude and position was being thought of as the primary factor keeping them separated from traffic they couldn't see, but it seems different when they were operating under visual separation and thought they could see the aircraft.

      That said, I fly Skyhawks not Blackhawks (or any kind of helicopter), so maybe the expectations are different in the rotary wing world. But my experience is that a 100ft altitude deviation is not an "instructors takes the controls" situation in an airplane unless you're about to run into something. Of course they were in this case, but it's not obvious the instructor knew that.

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    • I was also struck by

      | He told her he believed that air traffic control wanted them to turn left, toward the east river bank.

      Now, I'd love to _hear_ the actual comment/instruction here. He may have been hedging because he was trying to piece together the stepped on "pass behind" direction from ATC. But I also wonder if it's an inherent problem when the student outranks the instructor?

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  • Was there something in their personal life or career to warrant that - a setback, some family situation? Otherwise they seemed qualified and flew that route a few times already.

    Beyond her general lack of flight-time? Her primary role appeared to be some sort of liaison in DC, not flying Blackhawks.

  • I think there is way too much focus on the exact position of the helicopter and the article actually does a pretty good job providing additional details (which it then undermines by ending the article the way it did).

    For me the most consequential factor is that the helicopter pilots (technically the instructor, but I assume both were in agreement) requested visual separation based on their obviously incorrect visual sighting of the landing aircraft, which the controller granted. While perfect adherence to the routes by both helicopter and airplane might have avoided a collision, the margin is so incredibly slim (75 ft) that it seems unlikely the intent was that it would serve as the primary way to separate traffic. Properly executed visual separation would have kept everyone safe, but it seems pretty likely that neither helicopter pilot actually has eyes on the jet, maybe at any point or maybe just prior to the crash.

    I also think it's hasty to discount the controller's role. At least based on the article, it's not clear the controller provided enough information that the helicopter pilots could have determined if they had visually identified the right aircraft. Given how busy the airspace is, making sure the helicopter was tracking the right landing aircraft is pretty critical. And while it's the pilots' job, the controller can certainly give them every advantage.

    I think the statement in the article about many things going wrong all at the same time is likely the right one, although of course we should wait for the final NTSB report to say for certain. I feel like people want the satisfaction of identifying one single primary cause, but most aircraft accidents don't really work like that. And we should want to understand all the factors to plug as many holes in the swiss cheese as we can going forward.

    • > the margin is so incredibly slim (75 ft) that it seems unlikely the intent was that it would serve as the primary way to separate traffic.

      At that level a few hundred feet (since the helicopter is already supposed to be flying 200 or so feet above the ground) can make all the difference.

      > I think the statement in the article about many things going wrong all at the same time is likely the right one, although of course we should wait for the final NTSB report to say for certain. I feel like people want the satisfaction of identifying one single primary cause, but most aircraft accidents don't really work like that. And we should want to understand all the factors to plug as many holes in the swiss cheese as we can going forward.

      There can be contributing factors but the just because there are many factors doesn't mean they are equally weighted. At least with the pilot with have at least two indications they were confused. The instructor next to them tried to correct them a few times already.

      > At least based on the article, it's not clear the controller provided enough information that the helicopter pilots could have determined if they had visually identified the right aircraft. Given how busy the airspace is, making sure the helicopter was tracking the right landing aircraft is pretty critical.

      I think at least the non-flying pilot, the instructor, had understood and directed the pilot to avoid the collision, but the pilot didn't listen. The ATC in a busy airspace like don't have the time to have a long discussion with pilots ensuring they are good pilots and know what aircraft they are seeing "do you see 3 lights on it, one is red?", "how many engines do you see?". That just not very likely. They assume a helicopter pilot on that kind of an airspace configuration will know what they are doing. If they request visual separation they assume a hefty responsibility.

  • The warrant officer was the instructor and was training her. Few times doesn't make someone qualified. I think it was because of military egos and ranks, the warrant officer didn't force corrected the Captain.

    Also why is training happening in such dangerous path where even if the instructions were followed the aircrafts could get as close as 30 m apart.

    • Coincidentally, Nathan Fielder is currently doing an entire season of The Rehearsal based on the premise that a number of flight crashes occurred after the co-pilot failed to contradict or take controls from the pilot.

      > Nathan Fielder studies airliner black box transcripts in which the first officer feels too intimidated to challenge the captain, leading to fatal crashes due to pilot error. He discusses this with John Goglia, a former National Transportation Safety Board member, who had once recommended roleplay simulation to improve pilot communication.

      Really good season so far!

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    • > Also why is training happening in such dangerous path where even if the instructions were followed the aircrafts could get as close as 30 m apart.

      Forget training, why is this happening under any circumstances ever? If a military transport mission is ever so critical that you're willing to fly it within 30 meters of a civilian airlines it seems to me that you should just close the airspace to civil air traffic at that point.

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    • While I can’t speak to their individual temperaments, this is not an issue in the Army. Warrant officers are probably the least likely to worry about rank being confused with authority. They have the military experience from serving in the enlisted ranks as an NCO, with the protection of being officers that are above enlisted but still fall outside the commissioned officer ranks. They aren't untouchable but are highly insulated from petty tyrants.

      I don’t know why the instructor didn’t take a more forceful/active role leading up to the crash, but I don’t think rank was a contributing factor.

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    • I don’t know if the US shares a great deal with UK armed forces, but an officer ignoring a senior NCO, especially one training them, does so very much at their own peril.

      It is far more likely to be something like cognitive overload rather than a clash or personalities - you don’t get to be in that position in the first place if you have a tendency to disregard instructors.

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    • I've personally never met a warrant officer afraid of (or even the least bit timid about) correcting a commissioned company-grade officer (O-3 in this case).

    • > I think it was because of military egos and ranks, the warrant officer didn't force corrected the Captain.

      I think they should prohibit such type of flights when ranks are reversed. Let's imagine he would have yanked the controls and avoided the crash. Now the Captain could have said "you're insubordinate and tanked my qualification flight, there will be a price to pay".

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    • > Also why is training happening in such dangerous path where even if the instructions were followed the aircrafts could get as close as 30 m apart.

      I'm not sure that's a correct understanding of how the approach path to the runway and the helicopter route are supposed to interact. So far as I understand, the intent was never that a helicopter and airplane were supposed to be able to happily barrel along their respective paths within worrying about running into each other. That kind of thing happens a lot in aviation, but the separation distance is much, much larger.

      Instead, one was supposed to see the other and use their eyes to visually stay away (ideally by much more than 100 ft). That's what was supposed to happen here, and what the instructor pilot in the helicopter said they were doing. Visual separation is also used a lot in aviation, often in places where there are no narrowly defined paths at all, but it carries the risk of aircraft not seeing or misidentifying each other, which could be what happened here.

    • That's actually the crux of the matter - not only shouldn't they have done training (at night, with night vision goggles) in conditions where aircraft could be only 30 m apart, this construct of a helicopter flight corridor being within an altimeter's tolerance of the glide path for an airport runway shouldn't have been allowed to happen at all! It's unfortunate that the article focuses on who made what missteps and doesn't mention this systemic issue.

    • even if the instructions were followed the aircrafts could get as close as 30 m apart

      This doesn't match with how I understood the ATC's instructions. The helicopter was instructed to "pass behind" the landing airliner, not pass below. I think the controller's intention was for the helicopter to hold short of passing the runway 33 flight path, and not to enter that space until the plane had crossed the river.

    • With regards to training for high tolerance situations. Places and times where a small error can have large consequences.

      Yes you ease into it, the first level of training is done in a safe environment, however as the person gains competence the training moves into the domain in question, the person gains experience at doing the thing in question while being supervised. Or to put it another way.

      What? You expect that their first flight through that tight corridor at night should be done alone?

      In conclusion, I think it is fine in general that they were doing training on that flight path. However the fact that the both pilot and the trainer erred so badly indicates the need for better low level training and a reevaluation of the need for such a tight flight path in a civilian zone.

      Update: unrelated thought, I could not decide if low or high tolerance was the term i wanted, after waffling a bit I went with high tolerance. as that is the correct engineering meaning, but really the term is ambiguous and means the different things in different domains, he has a high tolerance for alcohol means the opposite of he made a high tolerance part.

  • It seems like both the pilot and instructor misidentified the plane they were supposed to be separated from, otherwise the instructor would have taken the controls and performed the maneuver himself if he knew a collision was imminent.

    Maybe visual flight separation is a bad idea when there are a bunch of lights from the ground and a busy airspace. A plane on a collision course with you will just look like a static light, like many many other lights in the area.

    • > It seems like both the pilot and instructor misidentified the plane they were supposed to be separated from, otherwise the instructor would have taken the controls and performed the maneuver himself if he knew a collision was imminent.

      I think eventually they figured out and instructed the pilot to avoid but the pilot didn't listen. But that was the second mishap of the flight. The pilot was failing to maintain a proper altitude before that.

      > Maybe visual flight separation is a bad idea when there are a bunch of lights from the ground and a busy airspace. A plane on a collision course with you will just look like a static light, like many many other lights in the area.

      To me, at least in this case, it seems the pilot was not adequately prepared. They were either distracted or rusty. The instructor should have taken controls and flown back at the first sign of not being able to maintain a proper altitude. However, the pilot outranked the instructor; taking controls away and failing the qualification / training flight could have resulted in some retribution or more hassles. Also, I think they should instead let pilots do this kind of qualification in similar but more remote or less busy area, longer, until they get more hours under their belt and not allow rank reversals to train like that. They should have found someone outranking her who wouldn't have though twice about grabbing the control.

  • > Was there something in their personal life or career to warrant that - a setback, some family situation?

    Why do you focus on that and not many other possibilities for distraction - cognitive overload, lack of sleep, an injury, other distractions in the cockpit, etc.

    • > Why do you focus on that and not many other possibilities for distraction

      Why shouldn't I focus on those? I guess just by asking the question you haven't quite shown why your guess are better. I guess I don't how lack of sleep is a better explainer than, I don't know, a family member dying?

      I guess which one would the investigator be able to figure out? They can read the obituary of the grandmother but how would they figure she didn't sleep well the night before.

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  • A hundred feet in aviation unfortunately just isn't that much. It's the equivalent of driving 3 miles over the speed limit on the highway. I am not sure about rotorcraft but if you are flying a traditional Cessna for training, a bit of wind shear or updraft can easily change your altitude by hundreds of feet.

    • > A hundred feet in aviation unfortunately just isn't that much. It's the equivalent of driving 3 miles over the speed limit on the highway. I am not sure about rotorcraft but if you are flying a traditional Cessna for training, a bit of wind shear or updraft can easily change your altitude by hundreds of feet.

      I would agree in general, but in that particular environment around DC with the restricted WH fly zone, the busy airport, the river and the bridges and the ADSB switched off it can make a huge difference.

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  • idiotic comment. This is literally a training mission - not following an order is not disobeying this is clearly failure of instructor who was not ready to take over. This is a common pattern in like almost any other training situation.

  • I mean maybe instead of patholigizing to that level we maybe need to accept that there is a temporal normal distribution to human attention spans and design our systems around it.

    It feels like semi-autonomous ATC and flight controls were possible as of 5 years ago. Has FAA even started writing initial reports on this?

    • > semi-autonomous ATC

      Yeah, that one has been around as long as there have been computers. It's sort of like the flying car of the ATC world - it's always 5 years away.

      > temporal normal distribution to human attention spans

      Tn this case we had both the ATC and the instructor tell the pilot to do something different and they didn't listen. Not sure if that's an attention span issue, it may be, but it's not clear it's definitely what it is.

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I still don’t understand the policy of the Army at the time to allow disabling of ADS-B Out in civilian airspace. I can understand in wartime.

  • The idea is that you're supposed to train as you fight.

    • The ADS-B transponder tells other planes where you are. It doesn't tell you where the other planes are. Turning it off when there are civilian planes doesn't improve your ability to aviate. it just hurts the situational awareness of the civilian planes who aren't supposed to be learning how to fight.

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    • Within reason, which is why soldiers train with blank-firing adapters and blanks, and not live ordnance when simulating combat.

      Turning ADS-B on/off likely has zero effect on the training/fighting relationship.

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  • > Doing so was Army protocol, meant to allow the pilots to practice secretly whisking away a senior government official in an emergency.

    1: You don't want to do that for the first time in wartime.

    2: In case you've been living under a rock, we are at war with Russia right now. We just haven't declared war.

    • I fail to see how flying untracked in a public airspace 8000km away from Moscow has anything to do with the US being in a new cold war, I don't see what good it brings, especially if it's to play hide and seek around a civilian airport

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    • True, train as you fight. But this was like a check-ride for the young Captain. ADS-B Out didn’t need to be off.

    • If we haven't declared war we're not at War. Words mean things.

      Especially in this era when this administration seems to be gearing up for military action in domestic spaces when Congress has declared no war.

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Why is there a flight path along the Potomac river, right in front of a landing strip, at landing altitudes?

The article claims the helicopter was higher than it should have been, but isn't it safer to fly high across the airport if you're crossing?

  • There's a lot going on in a small area there. Even without helicopters, the main runway (01/19) is the busiest runway in the nation, and it points directly at a no-fly zone over the white house, so the approach has a complicated turn at the last moment. Directly across the river, there's a military base with a heliport. And those helicopters often transport important individuals inside of those areas and to areas up and down the river. Those helicopters aren't just casually flying through, they are doing things in the immediate area.

    Just as an example, look at a map and take note of where DCA is, where the Marine One hangar is, and where the White House is. All of this stuff is right around the airport.

    • Doesn't fully explain why the military flight path runs right on front of the landing pattern for the main runway. Even with the proximity to each other, i don't see how that was necessary

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  • the military gets what it wants in DC, and the pilots were too comfortable and on different radio systems (helo can’t hear airplanes and vice versa, air traffic control is their intermediary)

    A disaster waiting to happen in retrospect. Similar issues at other airports like runway incursions, especially at crowded small airports like SFO and LaGuardia with antiquated runway layouts.

    • Let's wait for the investigation to complete before we opine on what is or isn't a "disaster waiting to happen." The entire aviation system is a "disaster waiting to happen" unless you assume a baseline level of aircrew competence, and the question will be whether or not the aircrew fell victim to a systematic risk inherent in what they were doing, or whether they just screwed up.

      Sad to say, as a former aviator, I have seen it before where people died and families lost loved ones ultimately because of a systematic risk inherent in what they were doing, but also other times because someone flat-out just screwed up.

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  • Training to evac politicians from what I understand. From wikipedia:

    > "The helicopter was part of the Continuity of Government Plan, with the flight being a routine re-training of aircrew in night flight along the corridor."

    Continuity of Government Plans is what they do when nukes get launched or a 9/11 sort of thing happens.

    • Should the people who had the most ability to prevent a global nuclear war be survivors of one?

      That seems like a misalignment of incentives.

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  • The helicopter did not cross the airport. The helicopter crossed the approach path to the airport, it was supposed to stay low enough not to be in the approach path. Then the pilot steered around the wrong plane and blundered right into the plane that they were supposed to be avoiding.

    Politicians wanting contradictory things, oops.

    • Ironically it would probably be safer if the helicopter crossed directly over the airport. At least then airplanes are usually on the ground, except for the cases where someone has to abort a landing and go around. Still dangerous, but it should happen less often.

  • It's "safer" not to do a lot of things you do in military aviation, for one. And second, the flight path was deliberately plotted out requiring aircrew to maintain certain altitudes and stay within certain lateral boundaries to avoid other traffic. This is no different than any number of corridors like it around the country.

    At some point, it's like saying "isn't it 'safer' not to take the freeway because everyone drives so fast?"

    • The appropriate analogy would be to take the freeway on a unicycle, naked. Otherwise known as inviting disaster.

> He told her he believed that air traffic control wanted them to turn left

This is an interesting sentence. In a very generous interpretation, the pilot (if she had survived) might claim that she wasn't directed to turn, just that the instructor believed ATC wanted her to turn, and thus she still needed to evaluate the situation and decide what to do. In other words, she might claim she didn’t defy an order, because being told an instructor "believes" something is different than being directed to do it.

  • What are the actual words used by the warrant officer? I think you are taking a characterization in the article too literally.

    • Very possible. That's kind of the point of my comment - like you I'm curious what actual words were said and whether they are normal protocol for a training exercise, and at what point does the trainer abandon the exercise and just go "you're about to crash!" either out of urgency or panic?

The helo route was likely instituted decades ago when traffic was lower. The NTSB incident database search turned up a close call between rotary and fixed wing just about every month in the last several years. This was a accident waiting to happen.

This is not by any means the only midair collision where a crew was avoiding a different aircraft.

Why didn't the ATC talk to the airline pilots? Isn't that an egregious error?

  • Some combination of:

    Trying to make sure the 'squeeze play' didn't go awry.

    Being told twice the helicopter could see the CRJ and would maintain visual separation.

    The built-in vertical separation rules.

    A jet in landing configuration isn't in a great position to see and avoid something below it.