AA5342 Down DCA

[Bratchewurst]

Originally Posted by Denflnt

The CRJ was diverted to 33 because of traffic. No other reason. The pattern was congested, so ATC diverted them to relieve those issues for them at the time. The CRJ could have declined the ATC's request, but they would have had to circle for another approach to R1.

You’re assuming facts not in evidence. It’s possible the LC wanted to create more separation between the CRJ and traffic departing on 01, but I was responding to another explanation, apparently one given by someone who regularly flies RJs into DCA.

That’s the kind of information that the NTSB will discover from interviews.

[Lead Balloon]

Originally Posted by photonclock

Well, that's interesting. You seem to be saying that "the system" worked as designed? FDR notes immediately before your reply:



Did ATC do all of that? Having listened to the ATC comms (including the UHF) a few times, I believe they did, for the most part? They mentioned CRJ (of what use is mentioning the type at night, I have no idea, but they did), they mentioned where it was and where it was headed, and they received two acknowledgments...

So that means this collision occurred entirely within all established protocls?

These aircraft crashed, as per the system specifications.

So the system is, to put it plainly...FUBAR?

That's not good.

I agree. I expressed my inexpert opinion earlier:

The procedures effectively abdicate separation responsibility to a single point of failure, where failure is not unlikely and, as a consequence of the airspace design, failure results in high probabilities of collision.

The difficulties of identifying a specific aircraft, at night, in a background of stationary and moving lights, when moving objects on a collision course will always appear stationary to each other, are well known, as are the probabilities of mis-identification. The airspace design 'squeezes' inbound aircraft and transiting helicopters to practicality the same altitude, when instrument and other tolerances are taken into consideration.

[The Blu Riband]

Originally Posted by gretzky99

It's a symptom of a system operating beyond its capacity.

The fact that this sort of procedure is so normalised that many crew don’t even see this as a threat is quite telling about the safety culture within the US aviation sector. Someone above mentioned that night circling approaches are not approved in many company Ops Manuals, so ATC issue late visual approaches instead, as a means to work around this limitation. This should be ringing alarm bells to all.

This sort of thing wouldn’t even be attempted in most parts of the world, let alone allowed to become normal sop.

Exactly.
Plus the often aggressive and intimidating tone from US ATC, and their habit of simply talking faster and saying everything multiple times (eg say again), has persuaded pilots and controllers that they are "making it work"
Whereas it's a classic example of Normalisation of Deviance

[cbradio]

Originally Posted by Denflnt

Miniimum vertical separation is 500'. The helo would have had to be a submarine to maintain separation. The helo should have been told to hold short, and wait for crossing traffic. That is what ATC is supposed to do, maintain separation from controlled aircraft.

ATC did do what he is "supposed" to do. The Blackhawk was told to "pass behind". Nothing to do with vertical separation. It's a form of separation. That's how it works. Thousands of times every day, all over the place.

As a system ' - at night - I think it's crazy. But that's the system.

[BuzzBox]

Originally Posted by Lead Balloon

The procedures effectively abdicate separation responsibility to a single point of failure, where failure is not unlikely and, as a consequence of the airspace design, failure results in high probabilities of collision.

The difficulties of identifying a specific aircraft, at night, in a background of stationary and moving lights, when moving objects on a collision course will always appear stationary to each other, are well known, as are the probabilities of mis-identification. The airspace design 'squeezes' inbound aircraft and transiting helicopters to practicality the same altitude, when instrument and other tolerances are taken into consideration.

Absolutely, and it will be very interesting to see what the NTSB has to say about the "rules" and if the FAA does anything to change those rules. Pilot-applied visual separation is common at airports all over the US, day and night. Frankly, it was only a matter of time before a tragedy occurred, for the reasons you mentioned.

[Max Tow]

Originally Posted by gretzky99

I dare say that this attitude may be part of the problem…..

I have no doubt that you're right about the generally high level individual skills of U.S. pilots and ATC staff, rather than deficiencies, actually being part of the problem. A slight extension of the Frank Borman adage about superior pilots using their superior skills to get out of dangers that they never should have encountered in the first place, but in so doing, inadvertently masking the erosion of safety margins they confront daily as a result of flawed ATC procedures and political pressure. I know it has become the norm, but where's the union push-back? Perhaps a few days of "down-tools" would restore public and political attention?

[fdr]

Originally Posted by photonclock

Well, that's interesting. You seem to be saying that "the system" worked as designed? FDR notes immediately before your reply:



Did ATC do all of that? Having listened to the ATC comms (including the UHF) a few times, I believe they did, for the most part? They mentioned CRJ (of what use is mentioning the type at night, I have no idea, but they did), they mentioned where it was and where it was headed, and they received two acknowledgments...

So that means this collision occurred entirely within all established protocls?

These aircraft crashed, as per the system specifications.

So the system is, to put it plainly...FUBAR?

That's not good.

YES/NO

Musings:

"The system" includes all of us that are involved in aviation at all levels, everyday. Thee are a lot of flights that go into DCA every day, each crew observing the same conditions, and conducting briefings of the arrivals, approaches and departures. Same out of LAX etc. How many of us, as stakeholders in the system have raised our concerns to the system by the means available, the ASRS, company safety reporting systems, the squadron SMS systems. How many safety managers have bothered to go and do an operational route survey/audit? Without our active participation, then we are relying on some person long retired who designed a procedure that survives to this point in time, and due to our collective indifference to the common users safety we remain broadly mute, until something falls off the perch. At this point we feign surprise, shock and some horror, yet, search inside, how many of us are surprised by this event, or Jeju Air in Muan, or the Russians shooting down yet another civil aircraft, Instead, we pontificate, (myself possibly more than most) and point the bone at all others in the system,

SMS systems only work if they have data that is meaningful. Each airline may seem to be swamped in data, that however is not the case for dealing with extremely low incidence, but high consequence events. There is not enough data generally to do a damned thing with, for just UAL, DAL, AAL etc or other operators. To be able to understand fully a system behavior there has to be adequate data, At present the only aggregated data of any note is that with NASA under the ASRS, and with ICAO at the reportable event level. Each ICAO state safety plan is supposed to provide data to the extent it can to its own community and to ICAO, and that is generally the last that is seen of the data. The airlines and operators dont get feedback, ICAO may or may not apply that data towards rule making, but that is years hence, and does not meet the needs of the user or the public today. Without the data being available to all, it is diminished in its utility. SMS systems have limited effectiveness that is IMHO glossed over universally, as actually getting data that is useful takes effort, and then evaluating that data takes critical analysis. By squandering the opportunity to have the data to evaluate, it should be no surprise that occasionally, we have SA-1, SA-2 and SA-3 type situational awareness failures of biblical proportions.

Aerospace suffers from frequent events that are normal in most respects. Functional resonance is a reasonable paradigm to assess how the system is really working, to give the system the understanding of how large the slip between assumptions and real system behavior is. The means of doing that is available from the flight data, and from operational audit aimed at understanding how expectations of process match with the real world.

Alternatively, we can sit back and blame the victims of the most recent mishaps, chasing those that should take responsibility for this, which to an extent falls on all of us that use the system and don't bother to raise concerns to the system.

Complacency works well though, until it doesn't.

[DaveReidUK]

Originally Posted by cbradio

ATC did do what he is "supposed" to do. The Blackhawk was told to "pass behind". Nothing to do with vertical separation. It's a form of separation. That's how it works. Thousands of times every day, all over the place.

As a system ' - at night - I think it's crazy. But that's the system.

To be fair to posters, the preceding 650-odd posts have contained a disturbing number harping on about "vertical separation" - and the media haven't helped, either.

[remi]

Originally Posted by photonclock

These aircraft crashed, as per the system specifications.

So the system is, to put it plainly...FUBAR?

That's not good.

See and avoid will always eventually produce midair collisions because physics, geometry, and humans don't permit see and avoid to work flawlessly.

This incident follows the same script as decades of others where ATC verifies that a pilot has the (incorrect) traffic in sight and shortly afterward there is a midair.

[safetypee]

The role of management

A poor system will ultimately defeat even the best humans.
Eighty-five percent of the reasons for failure are deficiencies in the systems and process rather than the employee.
The role of management is to change the process rather than badgering individuals to do better.
W. Edwards Deming

[TheAerosCo]

Originally Posted by Lead Balloon

The difficulties of identifying a specific aircraft, at night, in a background of stationary and moving lights, when moving objects on a collision course will always appear stationary to each other, are well known.

Whilst maybe not a factor here, that is only true when neither object is accelerating (for example in a turn). This has often been quoted in the thread and it's worth remembering that even if the other object shows relative movement it might still hit you (or vice versa).

[remi]

Originally Posted by fdr

SMS systems only work if they have data that is meaningful. Each airline may seem to be swamped in data, that however is not the case for dealing with extremely low incidence, but high consequence events.

But I don't think this is a scenario that suffers from a lack of data. Near misses and incursions are frequent enough that they are well characterized. Nor is it that difficult to project risk from repetitive danger. The risk, in this case, and in many other cases, is known and has been accepted.

[procede]

Originally Posted by galaxy flyer

I’m not in job of defending the US system, but there needs to be some perspective. The US airspace operates about 40%-50% of all global aviation. Only half of daily flights are air carrier. For lot of reasons outside this discussion, air carriers are the default transport, trains and buses are a tiny fraction of long distance transport. Apply EASA aviation standards and the US network would grind to halt or create huge gaps in service. We’ve gone 16 years without a fatal US carrier major accident, which isn’t different than the rest of the world, especially when the US has a 50% share. Our economy would suffer greatly and passengers revolt at what would required.

Either proper safety evaluations have been done and an accident like this every few years is considered acceptable and/or everyone just closed their eyes and hoped it would not happen to them (but to someone else first).

Alternatively, you impose (IATA) slot constraints to your congested airports, just like the rest of the world does.

[photonclock]

Originally Posted by fdr

Helicopters avoid stopping unless landing or undertaking a task that requires a fixed position such as rappelling (sometimes...) winching (almost always). Power requirement goes way up, control is more interesting, and the H-V curve come into play, particularly if a SE helicopter. To do a quick stop at night, over water, low level, is an interesting maneuver, the chance of ending up with a splash is above zero. rapid deceleration and sharp turns add to the pleasures of low flying at night with an indistinct horizon, varied lighting, NVG or not. If that is the plan to avoid a disaster, then they really need to rethink the plan.

Here's a Blackhawk pilot saying, and I quote, "they could have totally pulled that thing into a hover and stopped". Can't post a link. Tack on

watch?v=X3PtOdR_VCc&t=1675s

to youtube dot com.

He is not a Blackhawk pilot, and has given quite inaccurate advice

Senior Pilot

[remi]

Originally Posted by procede

Either proper safety evaluations have been done and an accident like this every few years is considered acceptable and/or everyone just closed their eyes and hoped it would not happen to them (but to someone else first).

Alternatively, you impose (IATA) slot constraints to your congested airports, just like the rest of the world does.

I think that anyone who spends a few hours reading the rather large collection of runway incursion and near miss events that have accumulated in the past couple of decades of US aviation will be left with the feeling that we have been not just lucky but incredibly lucky.

[Junkflyer]

See and avoid works well most of the time. It's the rest of the time that needs to be addressed. Normally one tower for fixed wing and another for helo traffic during busy hours at this field. One was apparently released early so the remaining on took on a high workload. That may have been the first hole in the cheese. Stepping back the whole scenario seems to be an accident waiting to happen. The Feds, local authorities or whomever should have dictated a minimum of two tower controllers during these high workload time frames.

[Deep Throat]

Originally Posted by TheAerosCo

Originally Posted by Lead Balloon
The difficulties of identifying a specific aircraft, at night, in a background of stationary and moving lights, when moving objects on a collision course will always appear stationary to each other, are well known.

Whilst maybe not a factor here, that is only true when neither object is accelerating (for example in a turn). This has often been quoted in the thread and it's worth remembering that even if the other object shows relative movement it might still hit you (or vice versa).

On a wider aviation note:

I have decided to stay out of this thread (from early on) but what I just read is wrong. If you have ever experienced an aircraft descending 'into' you in a constant curving descent into the cct on a constant aspect you would not make that statement. It has happened to me.

The whole airframe was invisible and appeared as a black void - the only thing alerting me to the fact, was the absence of the background night sky as it grew bigger and bigger in the field of view

I manoeuvred below and behind - it was only then that I could see nav and anti col lights - and even then they were so close they meant nothing

We were about 3 seconds from impact but I had watched that bit of sky for a lot longer - not knowing what I was seeing

The other pilot had absolutely no idea I was there [I was low (under) in his 2 o'clock] - or behind him when he leveled off and rolled wings level to continue down wind

That night I saved our lives - but it was only by luck and good fortune

And yes - I had been passed Traffic Information - which is why I was looking where I was at the time

It is a big sky - but not that big

Over the last few days this mental video has played over and over to me when I think about it

This little story may stick in the memory and save someone else one day

To add: What the controller would have seen - if he had seen anything - was two aircraft deconflicting beautifully, as one joined and the other positioned behind

[ATC Watcher]

Originally Posted by galaxy flyer

. Apply EASA aviation standards and the US network would grind to halt or create huge gaps in service......... Our economy would suffer greatly and passengers revolt at what would required.
.

and from island air photo :

And yes, trying to do EU IFR for everything all the time would create some epic traffic jams

Spot on, but there is no EU or EASA IFR there are IFR rules and agreed global aviation standards ,Period What is ( or should I say was ) done in DC , or in SFO or with LAHSO, etc are all deviations to allow more traffic outside of the rules. Expedition taking over our good old "safety first" mantra .

Now , is delegating visual separation to an Helicopter ,at night ,( with pilots wearing NGV ) on an aircraft cleared off the ILS doing a circle visual NPA at 500 ft with 4 eyes most probably locked on the PAPI something safe ? with a 150- Ft margin of error designed on the chart ? But it is how the system was built and local controllers trained on doing this , since years. Normalization of Deviance.

I wish good luck to the NTSB and the FAA is trying to reverse this .

[DP.]

Originally Posted by galaxy flyer

I’m not in job of defending the US system, but there needs to be some perspective. The US airspace operates about 40%-50% of all global aviation. Only half of daily flights are air carrier. For lot of reasons outside this discussion, air carriers are the default transport, trains and buses are a tiny fraction of long distance transport. Apply EASA aviation standards and the US network would grind to halt or create huge gaps in service. We’ve gone 16 years without a fatal US carrier major accident, which isn’t different than the rest of the world, especially when the US has a 50% share. Our economy would suffer greatly and passengers revolt at what would required.

Mere SLF here - I work in risk management (in a different industry) and so have an interest here, along with a lifelong interest in aviation - fully ready to be modded if I'm talking out of turn!

I accept the point regarding the likely economic impact. However I think its worth making the point that in the context of that '16 years without a fatality' record. there have been a number of potentially serious near-misses on the ground (JBU at BOS, AAL/DAL at JFK, SWA/FDX at AUS, etc etc) that are indicative of a system operating beyond its capacity and implementing procedures that are deemed to be of an acceptable risk profile in order to stretch that capacity. It was fortunate that those previous incidents were narrowly avoided. Wednesday night was where that luck, sadly, ran out.

[Easy Street]

Originally Posted by galaxy flyer

Apply EASA aviation standards and the US network would grind to halt or create huge gaps in service ... Our economy would suffer greatly and passengers revolt at what would required.

... The politics of DCA are going to drive a band-aid fix is my prediction. Visual separation won’t go away. FAA will get crucified over manning. DCA may lose some significant service, if we closed 33 permanently.

I think your predictions are good ones. Underlying them is the idea that while the extra airspace capacity afforded by visual separation at night may come at the price of occasional accidents such as this, that price is worth paying for passenger, government and economic benefit. Those kind of ideas don't tend to be well received or understoood by the public, or by extension by elected representatives, so a prediction of my own: every single agency and authority involved will go out of its way to avoid acknowledging that idea, and instead will pretend that visual separation at night is a fundamentally sound practice let down by poor procedure design and/or ATC at DCA.

[I think of the Austin investigation, which did not even mention, let alone question the practice of issuing runway clearances to multiple aircraft at the same time, which IMHO is the root cause of most of the recent near misses.]