DCA Mishap - Assessment

Aviation
1

I recently viewed a segment from the NTSB investigation of the tragic DCA mishap.

What struck me was the list of causal (contributing) factors for the mishap didn’t include the most obvious one – failure by the helo (PAT) flight crew to “see and avoid.”

This mishap, as tragic as it was, was caused by one (1) primary factor - pilot error. Yes, there were contributing causal factors, including wearing night vision goggles, but the absolute bottom line is the crew didn’t see the CRJ acft and flew into it. Without question, they failed to “see and avoid.”

As a retired P-3C Naval Aviator who holds an ATP (over 10,000 flt hrs.) and was a mishap investigator in the Navy, I would underscore two (2) primary causal factors for this mishap -

(1) Poor situational awareness - electing to wear night vision goggles, ones that restrict vision to some degree, was in poor judgement given the terminal area they were flying in and not comprehending the true nature of impacted airspace. Their awareness in this regard should have been very keen.

(2) Acute Spatial Disorientation - it’s abundantly clear, from the video, that the helo (PAT) flight crew didn’t see the CRJ as they were flying west into the landmass where the acft lights most likely “blended” in with the ground environment. They may have seen and acknowledged another acft to ATC, but not the CRJ.

As we know from training, in VMC conditions, regardless of all other factors, a pilot’s responsibility is to “see and avoid” no matter the situation or circumstances.

Therefore, I’m not only perplexed by the NTSB’s investigative findings, I’m also troubled that they didn’t identify the primary causal factor as - pilot error ( failure to see and avoid). Rather, they provided a litany of factors that have relevance, but are not the factors that caused this tragic mishap. To lay the blame on ATC, altimeter problems, high density airspace, flight path, etc.is to not justifiably assess and identify the true cause of this tragedy.

So, I’m left with the notion that the NTSB is not as credible as they should be and perhaps members don’t have the full breadth and depth of experience they need to perform an investigation like this one. In fact, lambasting ATC, Airborne, etc.is uncalled for as it’s absolutely clear the mishap was at the hands to two (2) helicopter pilots who failed to see and avoid, no matter the situation or circumstances. Yes, this is tragic, but it is also factual.

Mark Denari
CAPT USN (ret)

2

I disagree. This accident was just one more tragic reminder that “see and avoid” doesn’t work. Yes, the helicopter pilots have a responsibility to avoid the collision. ATC has a responsibility also. The Tower controller got a collision warning from her system yet watched the helicopter fly straight into the face of incoming traffic. Rather than rattle off “visual separation approved” by rote memory, she could have given the helicopter a turn or stop instruction.
Just as only one aircraft is allowed on the runway at a time, only one should be allowed on short final at a time. The helo route could have been redesigned or procedures changed to make sure that two aircraft don’t conflict.
In aviation, we don’t rely on a single system. We have redundancies. We take multiple steps to ensure that things don’t go wrong. Relying on “see and avoid” is relying on a single point of failure. 67 people shouldn’t have died because of that. Thank God it was only a CRJ and not a 737. And that the helicopter wasn’t full of soldiers.

3

Questions.

How poorly designed can a chunk of airspace be before that factor jumps to the top of the list of contributing factors, or even above the top item you suggest? Would you grant that it is possible to design procedures and airspace that elevate the risk to a level that no aircrew can safely manage to a sufficient degree of certainty. What more would it take to raise that factor to the top of the list?