AA5342 Down DCA

[Lead Balloon]

Originally Posted by island_airphoto

For us lowly civilians a Velcro ADS-B receiver isn't getting you within 30 miles of KDCA, you need it to transmit too. The helicopter having even receive ADS-B would have helped hugely if they looked at it, the fact they weren't looking at the plane they thought they were would have been pretty apparent.

Who said “receiver” alone? I think you’ll find that those units transmit as well. I have a similar unit clipped to a suction cup on the windscreen of my aircraft.

What they could have seen and heard in the PAT helo depends on a lot on the matters to which I referred, among others, in my earlier post.

[island_airphoto]

Originally Posted by Lead Balloon

Who said “receiver” alone? I think you’ll find that those units transmit as well. I have a similar unit clipped to a suction cup on the windscreen of my aircraft.

What they could have seen and heard in the PAT helo depends on a lot on the matters to which I referred, among others, in my earlier post.

Those things do not transmit, see https://stratusbyappareo.com/product...s-b-receivers/.

[RatherBeFlying]

Excerpt from Feb 14 NTSB Briefing Points on Mid-Air Collision near DCA

• At 8:47:52, or 7 seconds before impact, the CRJ rolled out on final for runway 33. The CRJ was at a radio altitude of 344 ft, 143 kts.
• At 8:47:58, or 1 second before impact, the CRJ began to increase its pitch, reaching about 9 degrees nose up at the time of collision. FDR data showed the CRJ elevators were deflected near their maximum nose up travel.
• The last radio altitude recorded for the CRJ was 313 ft and was recorded two seconds prior to the collision. The CRJ pitch at this time was, again, 9 degrees nose up, and roll was 11 degrees left wing down. The CRJ was descending at 448 feet per minute.
• The radio altitude of the Blackhawk at the time of the collision was 278 feet and had been steady for the previous 5 seconds. The Blackhawk pitch at the time of the collision was about a half degree nose up with a left roll of 1.6 degrees. Examination of wreckage will assist in determination of the exact angle of the collision.

So nothing yet reported on the CRJ CVR when maximum elevator was applied.
I was once stopped at a red light, began rolling when the light turned green - and suddenly found myself on the brakes before I was conscious of the car running the red light. Possibly a CRJ pilot similarly caught the helo in peripheral vision and reacted subconsciously.
​​​​​

[HaroldC]

Originally Posted by ATC Watcher

Hi Bill , understood, I was a bit too harsh maybe, but I get upset to continuously read what the controller should have done. Remember he was trained like this , to follow procedures that were basically unsafe in order to move the traffic . I can say unsafe because they were removed immediately after the accident , not waiting for the NTSB to recommend it . No everyone is stupid in the FAA , they knew this route was in conflict with 33 Visual arrivals. And did not pass any safety case, but the procedure was kept , most probably due political or military pressures , relying on controllers and pilots to mitigate the risks.

Now on the Conflict alert on the BRITE display . I have no first hand info on the SOPs in DCA on how a TWR controller uses the BRITE and if STCA are even displayed . `, but if they are, seen the charts and the routes , I guess STCA alerts are very common .especially when you delegate separation and you then play with a couple of hundred feet, vertical separation Too many unnecessary alerts equals normalization of deviance, . Look at the Haneda preliminary report , same ..

Finally since you mention TCAS RAs , there is a major difference with STCA , it is not the same as a TCAS RA . With an RA , as a pilot you have to react and follow , it is mandatory , for a controller a STCA is just an alert , just like a TCAS TA , if in your judgement it will pass you will not do anything , and if you have already issued a correcting instruction ( heading, level , etc,,) or here delegate visual separation , the STCA just becomes a nuisance. .

I sincerely hope the DC Controller will not be made the scapegoat of this accident . Not so sure it will not.

I agree that the DC controllers should not be scapegoated. At the same time, the concept of professionalism must be addressed. The concept that professionals in a field must alone (without management, without lawyers, without the public) maintain the best practices of the given professional discipline.

In the US, physicians who work for "Health Maintenance Organizations" are asked to practice medicine, at times, in a "basically unsafe" manner...to keep patients moving. On occasion, such practices will bite a patient (and sometimes the physician). As a whole, HMO physicians do not enjoy the best reputation.

From my perspective, there is practically no difference between the plight of an American air traffic controller and an American HMO physician. Both are expected to "squeeze one more in." Both fields are staffed by above-average capable individuals who thrive on challenges. Both are managed in such a manner that they cannot say "no" and also keep their job. In this regard, at least physicians have job portability.

But the take home point is that one cannot admit to knowing a practice is fundamentally unsafe, yet do it anyway. The public, rightfully, should not accept this. I have no solution except more staff and/or more airports (and not some next-gen whizzbang computer system).

[Lead Balloon]

Originally Posted by island_airphoto

Those things do not transmit, see https://stratusbyappareo.com/product...s-b-receivers/.

I stand corrected.

The one I use looks similar but is a different brand and is a portable ADS-B In/Out transceiver. Looks like it's not compatible with whatever systems are in use in the USA.

But I reiterate that what they could have seen and heard in the PAT helo, had it been fitted with an ADS-B "receiver" depends a lot on the matters to which I referred, among others, in my earlier post.

[airplanecrazy]

Originally Posted by RatherBeFlying

Excerpt from Feb 14 NTSB Briefing Points on Mid-Air Collision near DCASo nothing yet reported on the CRJ CVR when maximum elevator was applied.
I was once stopped at a red light, began rolling when the light turned green - and suddenly found myself on the brakes before I was conscious of the car running the red light. Possibly a CRJ pilot similarly caught the helo in peripheral vision and reacted subconsciously.
​​​​​

In a prior briefing the NTSB said that the crew of the CRJ “had a verbal reaction” to something, and flight data showed the plane beginning to increase its pitch. A second later there was a sound of the collision.

[Easy Street]

Originally Posted by HaroldC

But the take home point is that one cannot admit to knowing a practice is fundamentally unsafe, yet do it anyway.

It's an interesting comparison, but I am not sure it's fair to say that a controller would know that visual separation at night is unsafe or appreciate the counterintuitive point that NVG make it less safe. Of course, they *should* know, but since they don't need to have night flying (or any flying) experience of their own, they are reliant on being educated on that point. That would be a matter for the regulator (specifically, pilots and human factors specialists within the regulator) to ensure. The same goes for the more robust option of prohibiting night visual separation entirely.

Spoiler

 

 

I'm less charitable on the separate matter of ATC-directed runway incursions, where the potential outcomes of simultaneously clearing multiple aircraft onto one runway are readily foreseeable even from a lay perspective.

Returning to your doctor analogy: if front line medics prescribed a drug which years later turned out to be harmful to patients, despite following all professional best practice and having no reason at the time to suspect that the drug had been wrongly certified, it would be grossly unfair to hold the medics responsible. Instead we would turn to the drug regulator and those who carried out the trials.

Spoiler

 

 

I was going to liken "visual separation at night" to thalidomide, but Google tells me that the USA was one of the few countries in which the drug was not certified, largely down to the efforts of one woman at the FDA, fortunately backed by her bosses in the face of corporate lobbying.

[MPN11]

Sad to see the NTSB reporting PAT25 was between 278" and 313' in the seconds before the collision instead of 'at or below' 200' OK, PAT25 seems to attract much of the blame for the impact, but that doesn't detract from the unsuitability of Route 4 in the broader sense.

[Lascaille]

Originally Posted by MPN11

Sad to see the NTSB reporting PAT25 was between 278" and 313' in the seconds before the collision instead of 'at or below' 200' OK, PAT25 seems to attract much of the blame for the impact, but that doesn't detract from the unsuitability of Route 4 in the broader sense.

The route doesn't provide safe clearance, is the answer. Even if they didn't collide, I can't imagine the ride being particularly gentle after something that size passes ~50ft overhead. Even the near miss might have resulted in a critical loss of control.

[blind pew]

Apologies on not using accurate terminology wrt being stepped up solutions but;
the technology is available to stop dual transmissions, even a warning light in the cockpit (ATC station).when simultaneous transmissions are being made would help safety.

On the collision avoidance technology the CAA gave a grant of Ł250 towards the cost of approved FLARM devices one of which I have - XC TRACER MAXX - which also has FANET.

The swiss invented FLARM nearly 30 years ago and marketed it at cost; it has been obligatory in France for glider operations for the last decade. According to the CAA website it is better than the ADS-B out.

The telecommunication industry has come a long way from the necessity of climbing into the electrical bay and re racking or thumping a radio module but basic cockpit radio procedures haven’t.

What appears to be also relevant is the language and associated phraseology; there was a narrow airmiss in Dublin between an executive jet on take off and a private helicopter pilot caused by ambiguous crossing clearance issued - cross behind the rolling aircraft IIRC which the helicopter pilot took to mean the aircraft rolling down the runway after landing whereas the controller meant the executive jet about to roll; the copilot stuffed the stick forward after take off and passed underneath helicopter.

In this accident I presume that all were Americans; flying around a southern French airfield the controller standard can be diabolical.

[bill fly]

Simplex RT works fine. We are all trained how to listen before using the PTT, how to formulate a transmission and how to allow space for an answer - most of the time.

ATC works very well. All efforts are made to avoid any confliction from the flight plan stage to the tactical stage - most of the time.

Pilots develop an awareness of other aircraft around them by listening to the RT, watching TCAS / Wx radar and looking out. This is most useful in understanding complicated situations - most of the time.

Even when the odd situation occurs where time and ideas run out and things are tight, people get away with it - most of the time.

But - not all the time. The Tenerife crash for instance involved a double transmission. One aircraft in extremis stuck on the foggy runway, trying desperately to stop the other rolling, while a tower communication took place and the RT was jammed. The question is, do we want to plan for these rare last second occurrences? I would guess yes - same philosophy as with GPWS and TCAS. We should have a means of communicating where an priority transmission overrides other radio traffic. There will be many who can explain why this can't be done, impossible, too expensive or unworkable. I am not here to explain in this modern and digital World how it should be done but you young bloods should suss out fairly quickly how it could be done. (spoiler - don't forget the open guard box)

[hanche]

Originally Posted by Easy Street

There are no prizes for playing it safe and being dead.

Thanks for your answer. I should make it clear that I did not intend any criticism against the crew for their reaction. It seems reasonable enough under the circumstances. But it makes it even more clear that obsessing over the consequences of a few feet higher or lower is not useful. (I'll revert to lurking mode now.)

[Not_apilots_starfish]

Just Washington DC Air space. No biggie

Not quite sure why you all are being relaxed about the air space.

It’s the capital of the US & tightly controlled.

200 feet is the maximum and they had to get permission for this route. They’re flying past a busy airport. On one hand you’re all saying this accident was bound to happen, on the other hand this in and of itself indicates pilots don’t fly through these zones without concerns & vigilance. It makes no sense they would play roulette with the height - most pilots would be adhering to rules & a little on edge knowing a VIP or any number of emergency protocols could happen in the capital of America.

It just doesn’t add up - the complacency over elevation. Between two pilots it should have been rectified. May they rest in peace & this isn’t a slur against their name but in support of it not being their fault and something amiss.

[Easy Street]

Originally Posted by Not_apilots_starfish

Not quite sure why you all are being relaxed about the air space.

200 feet is the maximum and they had to get permission for this route. They’re flying past a busy airport. On one hand you’re all saying this accident was bound to happen, on the other hand this in and of itself indicates pilots don’t fly through these zones without concerns & vigilance. It makes no sense they would play roulette with the height - most pilots would be adhering to rules & a little on edge knowing a VIP or any number of emergency protocols could happen in the capital of America.

It just doesn’t add up - the complacency over elevation. Between two pilots it should have been rectified. May they rest in peace & this isn’t a slur against their name but in support of it not being their fault and something amiss.

The point is that PAT25 could have been tightly hugging the eastern bank at precisely 200 feet, and yet everyone would still have died if the CRJ had been slightly below its proper approach path (as it might easily have been). Yes, you can say that *this* accident wouldn't have happened if the helo had been at 200 feet, but that gets us precisely nowhere in preventing recurrence.

Systems that rely on human perfection are 100% guaranteed to fail. The only question is how often. The system in place at DCA required helo pilots to assume responsibility for visual (*not vertical*) avoidance of collisions in order to fulfil their ordered missions. Given what we know about human visual performance at night, that would eventually end badly, and sure enough it did. There is a strong element of the pilots having been set up to fail, which is why no-one here is going hard on them.

Altimetry and height keeping would be important matters for investigators if the collision had occurred due to a breakdown in vertical separation, which as a minimum would involve 500 feet (and more often 1000 feet) of planned spacing to account for instrument and height keeping errors. FAA instrument rating standards require pilots to be able to maintain altitude plus or minus 100 feet. This helicopter was being flown VFR at very low height, which means that looking outside takes primacy over monitoring instruments. I'm sure helo pilots could fly along at 175ft plus or minus 25ft if they really tried, but you can be certain they wouldn't be looking out for traffic (as is required when holding responsibility for visual separation).

However, as there was no vertical separation built into this procedure, all of this is at best a distraction. The more important questions are why procedural barriers were not in place to stop the route being used during landings on runway 33, and whether visual separation at night is an adequate barrier to collision when airliners and their human cargo are involved.

[island_airphoto]

Originally Posted by Easy Street

The point is that PAT25 could have been tightly hugging the eastern bank at precisely 200 feet, and yet everyone would still have died if the CRJ had been slightly below its proper approach path (as it might easily have been). Yes, you can say that *this* accident wouldn't have happened if the helo had been at 200 feet, but that gets us precisely nowhere in preventing recurrence. Systems that rely on human perfection are 100% guaranteed to fail. The only question is how often.

Altimetry and height keeping would be important matters for investigators if the collision had occurred due to a breakdown in vertical separation, which as a minimum would involve 500 feet (and more often 1000 feet) of planned spacing to account for instrument and height keeping errors. FAA instrument rating standards require pilots to be able to maintain altitude plus or minus 100 feet. This helicopter was being flown VFR at very low height, which means that looking outside takes primacy over monitoring instruments. I'm sure helo pilots could fly along at 175ft plus or minus 25ft if they really tried, but you can be certain they wouldn't be looking out for traffic (as required when taking visual separation).

However, as there was no vertical separation built into this procedure, all of this is at best a distraction. The more important questions are why procedural barriers were not in place to stop the route being used during landings on runway 33, and whether visual separation at night is an adequate barrier to collision when airliners and their human cargo are involved.

N123, join the downwind, your traffic is a 737 on final 2 miles out, turn base behind him, you are #2. I can do that at night unless there are other 737s lined up and then I have to figure out which one.
N123, do you see the closest plane lined up, pass right below and behind him and never mind all the other planes right behind. Ah......NO.
There is night visual and there is night nutty visual. The first example leaves a lot of room for error and time for ATC to see if it is going wrong.

[Wide Mouth Frog]

I think I can probably guess the word.

[deltafox44]

Originally Posted by Wide Mouth Frog

I was very surprised also to hear Jennifer tell us that the heliroutes have no lateral boundaries, which is a bit bizarre given that the Route 4 in the notes on the chart is described as following the East bank of the Potomac which is about on the left end of the diagram. Doesn't matter though, same problem there. Routes shouldn't be designed so that aircraft can infringe on landing (or any other kind) of passenger jet traffic.

She said there were no defined boundaries, though there were marked in blue on the maps. As already noted here, the width of the routes (as marked on the maps) is different from one map to another, especially when not at the same scale. There is a good reason for not having precise boundaries, they are VFR routes and there is no means to determine the position from the center of the route with a good accuracy, it is just visual navigation. And at night.

[Sven Sixtoo]

Unlikely to be of much help, and have you (or the poster suggesting this) worked on the process to get a new electronic device cleared for use on a military aircraft?

[Wide Mouth Frog]

Originally Posted by deltafox44

She said there were no defined boundaries, though there were marked in blue on the maps. As already noted here, the width of the routes (as marked on the maps) is different from one map to another, especially when not at the same scale. There is a good reason for not having precise boundaries, they are VFR routes and there is no means to determine the position from the center of the route with a good accuracy, it is just visual navigation. And at night.

Errr. No means to identify the East bank of a major river in the middle of a well lit city at night ? Not sure about that. They are what they are though and I'm sure Jennifer would have checked her facts. Just by way of comparison, I can assure you if you were 1000ft away from the London Heliroutes over Heathrow you'd have the undivided attention of the controller.

[ATC Watcher]

Width of routes on the map is irrelevant as in VFR you fly from point to point. or it is following a landmark, a river, road, or here a river bank. It is a track and it has no width .