AA5342 Down DCA

[Hot 'n' High]

Originally Posted by layman54

..........." I don't think a bias against assigning any responsibility for accidents to the pilots involved is helpful in using accidents to become better pilots. Sometimes many other parts of the system will fail but the pilot will still have a final opportunity to save the day. Or not. ........

Hi layman54, I think it's much more subtle than that. As you say, other bits of the system may put the pilots into danger but you then need to fully understand why the Pilot(s) didn't save the day. You sort of start off with the premise that the crew of PAT25 took off that evening and certainly didn't want to fly into the CRJ - so, why did they?

To say so-and-so got it wrong is often obvious ........ but why did they get it wrong? That's often very complex and can involve a lot more people and a raft of other factors and that's where the really valuable lessons are to be found. That's the real reason behind any "bias" - it's so we don't simply stop at that first person (or persons) who got something wrong, but look at what led to them doing what they did and what other factors contributed to the end result. That is the real way Safety is improved. You can then look at appropriate mitigation to try and prevent that same scenario from setting up another crew to fail in the same way at a later date.

Originally Posted by layman54

...........According to post 1346 the accident helicopter was higher and to the west of the position of the typical helicopter flying that route. Was this a slight error that in this case was fatal?

As others have said, height and track is a red herring TBH as the deal with ATC was for PAT25 to "see and avoid" so they could have quite safely passed behind the CRJ at the same altitude or even above it - but not too close due to things like wake effects. If you can't manage "see and avoid" safely, you need to build in much, much bigger safety margins - such as holding PAT until the CRJ had landed. Many, including me, have asked how on earth the PAT25 crew (or, indeed, anyone) could reliably be expected to pick out the CRJ in that scenario especially at that range. For vertical/horizontal separation, relying on a few 10's of feet up/down or left/right is simply worthless given errors with altimeters and piloting accuracy in such a high-workload situation where it's "eye's out" navigating and looking for traffic all at a couple of hundred feet above land/water which is quite unforgiving if you get too low (I know ex helo crew who are no longer here because they inadvertently hit the sea) - not to mention any issues with NVGs (no idea, never used them!). What the NTSB implied was that, by suggesting that such a set-up as Route 4 passing under the approach to 33 was intrinsically safe through vertical/lateral separation, was madness. The route was pulled almost immediately pretty much on that basis.

So, for example, based on the difficulty in picking out the correct aircraft from the inbound stream, one of the many questions I've been asking myself is "Why were the PAT25 crew so willing to say they had the CRJ in sight (twice they said that) in that environment?". Had that become "normalised" on the Sqdn, or were the risks of miss-IDing a/c not being adequately highlighted in Local Orders, particularly given the geometry of that specific set-up? There may be several reasons - that's for the NTSB to dig out. I used to do a lot of visual separation stuff Commercially and I was nervous as hell - and that was in wayyyyyyyy simpler scenarios in way better conditions usually involving just one other aircraft. ATC were the same - they were very pointed in making sure I'd really seen the a/c in question. Any doubts in my mind or the ATCs mind and it was either an orbit till traffic was well clear or, if busier, it was "Contact Approach ....... lets chat again when they hand you back to me on the ILS.". OK, the ILS bit is not applicable to PAT25 but you get my drift!

There is no one reason why this accident happened - there will be quite a list with each one contributing to the final outcome. Any one of those things, had they been different decisions by those involved on the night, or, for example, by those who designed and approved Route 4 way back when, would have saved the day. So correct not just the 1st issue you find, find out and correct ALL the issues! That's what we really need to do to stop similar things happening again, not just at DCA, but anywhere.

Anyway, hope the above helps with the context of the word "bias". It was not that long ago it was "Hang the crew! Erm, oh no! Someone else has done it now! Hang them too!" Rinse & repeat! Thankfully, we are much better at digging out all the issues these days. But we have to constantly remind ourselves to "Look for everything, not just the 1st thing you find!". Cheers, H 'n' H

[sunnySA]

Originally Posted by layman54

According to post 1346 the accident helicopter was higher and to the west of the position of the typical helicopter flying that route. Was this a slight error that in this case was fatal?

Although the data in post 1346 does distinguish between day time and night time, it doesn't (nor probably can't) highlight which flights were adjusted by ATC, e.g. track this, sight that, pass behind, track direct, etc. If the use of Route 4 was simply pilots doing their own thing ie a single direction route without any ATC inputs then the tracking difference might be interesting. In this case, it could highlight an issue, perhaps not.

[layman54]

"I will be neither surprised nor shocked if the lawsuits also name American Airlines, which has no protection obviously under the FTCA. It didn't do anything wrong ..."

Well presumably any lawsuit naming American Airlines will have to allege they did something to incur liability. The only such theory I can come up with is that the jet pilot should have refused the rerouting to runway 33 because he should have known that would increase the jet's exposure to reckless helicopters. Which is sort of blaming the pilots squared. Is that what you want to go with or do you have an alternative way of dragging American Airlines into this? Of course American Airlines is already involved in that they have a FTCA claim against the government for at least the value of their plane.

[layman54]

Originally Posted by Hot 'n' High

....
So, for example, based on the difficulty in picking out the correct aircraft from the inbound stream, one of the many questions I've been asking myself is "Why were the PAT25 crew so willing to say they had the CRJ in sight (twice they said that) in that environment?". Had that become "normalised" on the Sqdn, or were the risks of miss-IDing a/c not being adequately highlighted in Local Orders, particularly given the geometry of that specific set-up? ...
...

This raises the question of what fraction of helicopter crews in that situation asked for visual separation. And how often did ATC grant it? According to posts above sometimes helicopters were held at Hains Point so apparently visual separation wasn't universal.

[Hot 'n' High]

Originally Posted by layman54

This raises the question of what fraction of helicopter crews in that situation asked for visual separation. And how often did ATC grant it? According to posts above sometimes helicopters were held at Hains Point so apparently visual separation wasn't universal.

Yep, that question .......... and loads more.

Originally Posted by layman54

........ The only such theory I can come up with is that the jet pilot should have refused the rerouting to runway 33 because he should have known that would increase the jet's exposure to reckless helicopters. Which is sort of blaming the pilots squared. Is that what you want to go with or do you have an alternative way of dragging American Airlines into this? Of course American Airlines is already involved in that they have a FTCA claim against the government for at least the value of their plane.

One thing I mentioned earlier is that airlines also have a responsibility for conducting safe operations; safe for their crews, their pax and by-standers. For eg, airlines often have additional rules for certain airfields (eg some require specialist training before crews can operate in there due to say, terrain issues on the approach). As has anecdotally been reported on here, if there have been an above "average" (and someone will need to figure out exactly what that means) number of issues with this particular approach in terms of TA's, irrespective of the outcomes, then the airline has a Duty of Care to have a system which identifies such issues, assesses them and then, if necessary, to put additional mitigation in place - such as, say, banning the use of 33. AA may have looked at this and, if so, their Safety Case should explain why they concluded it was safe. Sadly, even that doesn't guarantee the right decision was reached ...... but at least they'll have formally assessed it. Trouble is, landing on 33 seems to have cut taxi time = fuel = $'s.......

Anyway, just some thoughts! You know, I can be a right cynic at times but, having a background in Safety Engineering in a previous life, that's par for the course!!! Cheers, H 'n' H

[FullWings]

...then the airline has a Duty of Care to have a system which identifies such issues, assesses them and then, if necessary, to put additional mitigation in place - such as, say, banning the use of 33. AA may have looked at this and, if so, their Safety Case should explain why they concluded it was safe.

I refer to the case of Lufthansa identifying night visual separation as a safety issue and deciding not to allow it, then one of their aircraft having to divert from SFO because of this decision. AA banning DCA 33 might have had the same kind of result.

Anyway, after 72 pages it seems fairly clear that separating IFR from VFR at night by visual means inside the circuit pattern of a major airport is not a great plan. This could happen anywhere in the US and it would be an interesting exercise for the NTSB/FAA to see how many separation losses there were at other airports, as they have the software to do that. It is easy to fixate on this accident and the immediate environment when similar setups exist all over the place. It’s not just about helicopters and the military - civil and fixed wing on that kind of clearance could be just as risk-bearing.

[WillowRun 6-3]

Originally Posted by layman54

"I will be neither surprised nor shocked if the lawsuits also name American Airlines, which has no protection obviously under the FTCA. It didn't do anything wrong ..."

Well presumably any lawsuit naming American Airlines will have to allege they did something to incur liability. The only such theory I can come up with is that the jet pilot should have refused the rerouting to runway 33 because he should have known that would increase the jet's exposure to reckless helicopters. Which is sort of blaming the pilots squared. Is that what you want to go with or do you have an alternative way of dragging American Airlines into this? Of course American Airlines is already involved in that they have a FTCA claim against the government for at least the value of their plane.

If my post is open to misinterpretation, then that's on me. In other words it's not a matter of affirmatively wanting to "drag" the airline into a lawsuit in which it would not be a legitimate party. Rather, in the exercise of forecasting the inevitable lawsuits (or at least applying some analytic foresight), and trying to think like counsel for the victims' families, a non-frivolous claim against the airline could open the case in total to claims for punitive damages. As you note, although in the role of claimant, for its hull loss the airline would likely be involved anyway. And so would its insurers.

Beyond that, and because my referring to making the airline a party is not meant to be trivial, the underlying idea is that establishment of a fund and claims process would be one of two main components of an approach to resolving the matter. The other component would have to be some - and I realize this is perhaps too much magical thinking - hard-truth reform and rework of airspace configuration and usage rules, nationwide. I don't wish to preach or pontificate, but this catastrophic accident happened after the Safety Call to Action, after the National Airspace Safety Team report, after the intense public, political, and international attention to and focus upon FAA in the aftermath of Lion Air and Ethiopian. So the underlying and motivating objective is to follow and apply former U.S. Amb. to Japan Rahm Emanuel's aphorism, "a crisis is a terrible thing to waste."

And yes, though it's hopefully non-frivolous, and despite it being a placeholder claim rather than an entirely direct claim, telling ATC "Unable" in re: Rwy 3-3 given the known airspace complications would appear the most viable option.

[Hot 'n' High]

Originally Posted by FullWings

I refer to the case of Lufthansa identifying night visual separation as a safety issue and deciding not to allow it, then one of their aircraft having to divert from SFO because of this decision. AA banning DCA 33 might have had the same kind of result.

Who knows, you may be right. I think AA rocking up at DCA and stating that, as "policy", they'd never ever use the sidestep to 33 due to their own safety assessment flagging it up, esp if based on TCAS evidence, would have led to interesting discussions at senior levels. As you say, how that would have ended is anyone's guess. Bit academic anyway as there was no AA ban and the AA flight accepted it when offered it and the next AA asked for it on initial contact ..... not realising what had just happened! That's why I had a $ sign in my earlier post! The cynic that I am........

[WillowRun 6-3]

Originally Posted by Hot 'n' High

Who knows, you may be right. I think AA rocking up at DCA and stating that, as "policy", they'd never ever use the sidestep to 33 due to their own safety assessment flagging it up, esp if based on TCAS evidence, would have led to interesting discussions at senior levels. As you say, how that would have ended is anyone's guess. Bit academic anyway as there was no AA ban and the AA flight accepted it when offered it and the next AA asked for it on initial contact ..... not realising what had just happened! That's why I had a $ sign in my earlier post! The cynic that I am........

About those discussions at senior levels . . . If your reference to such discussions was meant to include not only within a given airline, but also some or all of the cadres of senior officials in the industry, U.S. government, international colleagues, and think tanks - those are the same discussions which are supposed to be going on now, in light of the NTSB's pro-active responses to the accident. Although it is a limited sample, in the accidents in which Board processes have been involved in the time I have been trying to keep up via PPRuNe and other information sources, I can't recall a similar "urgent recommendation" addressed to FAA as NTSB issued in this matter. Safety Alerts to Operators (SAFO's) yes, such as after Air Canada "There's no one on 2-8-Right but you" 759 in San Francisco in 2017. But not the same as what has issued from NTSB now. Perhaps I missed some salient details but the review which FAA became instructed and/or motivated to conduct would have a total NAS scope.

Or maybe such a review will, regrettably, require an Act of Congress (it should not require this, but, you know, K Street, campaign donors, the seniority system, and the generally stellar academic and career experience required prior to election to the Congress . . . . too bad elected represenatives are not required to build hours first).

[Hot 'n' High]

Originally Posted by WillowRun 6-3

About those discussions at senior levels . . . If your reference to such discussions was meant to include not only within a given airline, but also some or all of the cadres of senior officials in the industry, U.S. government, international colleagues, and think tanks - those are the same discussions ......

Hiya WR 3-6, no nothing grandiose, just a big user of DCA services talking to DCA managers at a working level about concerns they (AA) may have had re operating into the field. Normal business practice really. Of course, that may not be the way it works in the USA........ or elsewhere tbh. Corporations (Govt or Commercial) are skilled in the art of avoiding unpleasant issues as I have seen countless times!

But I doubt AA even did the analysis in the first place to flag up the issue to start with ......................................................... Nuff said in my eyes at least!

[LowObservable]

Originally Posted by A0283

Another interesting point is that mixed heli and fixed wing is forbidden in the yellow zone (permanently), and ADSB mandatory in the red zone. With routes 4 and 6 cut.

The placement of the yellow line closes down the I-395/VA-110 left hook around the East side of the Pentagon that Route 5 inbound helos were using quite routinely before the accident. And whatever restrictions are or are not in place there is virtually nothing moving on Route 5, I guess the top brass has discovered Uber Black.

[BugBear]

"There's no one on 2-8-Right but you" 759 in San Francisco in 2017. But not the same as what has issued from NTSB now. Perhaps I missed some salient details but the review which FAA became instructed and/or motivated to conduct would have a total NAS scope.". (WillowRun hat tip,)

Howdy. Are you aware of any interviews the AC pilot did?
The video is damning. Besides thinking Charlie was the runway, he missed a direct hit on the tail of a holding aircraft by less than 100 feet.

Enjoy your thoughts, and objectivity....bb

[framer]

Hiya WR 3-6, no nothing grandiose, just a big user of DCA services talking to DCA managers at a working level about concerns they (AA) may have had re operating into the field. Normal business practice really.

If someone at AA had said “hey I don’t like this side-step procedure at DCA, I think it’s dangerous and we have safety reports to back it up, let’s tell the pilots not to do the side-step until further notice”……how would that have been received by their colleagues and DCA? Would DCA execs have pushed back on AA and threatened delays? If AA had implemented a policy like that ( easy for me to say with hindsight) what effect would that have had on the operating crews?
Would it have been like the Lufthansa who received no end of grief over the airways while trying to adhere to company policy?
If a CP had put their foot down and implemented policy like that would they be thought of as troublesome within their own Airline?
On that note….. did any Airline have policy refusing the side-step in certain conditions? ie at night?
I’m enjoying the conversation and appreciating the thought that people are putting into their contributions so thank you.
Framer

[BugBear]

Originally Posted by framer

If someone at AA had said “hey I don’t like this side-step procedure at DCA, I think it’s dangerous and we have safety reports to back it up, let’s tell the pilots not to do the side-step until further notice”……how would that have been received by their colleagues and DCA? Would DCA execs have pushed back on AA and threatened delays? If AA had implemented a policy like that ( easy for me to say with hindsight) what effect would that have had on the operating crews?
Would it have been like the Lufthansa who received no end of grief over the airways while trying to adhere to company policy?
If a CP had put their foot down and implemented policy like that would they be thought of as troublesome within their own Airline?
On that note….. did any Airline have policy refusing the side-step in certain conditions? ie at night?
I’m enjoying the conversation and appreciating the thought that people are putting into their contributions so thank you.
Framer

"Unable"

[WillowRun 6-3]

Originally Posted by BugBear

"There's no one on 2-8-Right but you" 759 in San Francisco in 2017. But not the same as what has issued from NTSB now. Perhaps I missed some salient details but the review which FAA became instructed and/or motivated to conduct would have a total NAS scope.". (WillowRun hat tip,)

Howdy. Are you aware of any interviews the AC pilot did?
The video is damning. Besides thinking Charlie was the runway, he missed a direct hit on the tail of a holding aircraft by less than 100 feet.

Enjoy your thoughts, and objectivity....bb

Thanks for the hat tip & etc.

Not sure of what video you've referred to about the Air Canada incident. But yes, without a doubt, it was a very close call. Only a slight difference in the height above the taxiway for the Air Canada flight, or slight delay in initiating the go-around . . . and many factors which play into those parameters (reaction time, etc.).

I don't recall any interviews of the aviators being published (but I haven't run off to go looking through sources available online). Somewhat more in the direction of drift, the thread on the incident was useful background for trying to follow and understand the Lufthansa diversion occurrence.

Edit and slight correction: NTSB Incident Report, NTSB/AIR 18/01, PB2018-101561 (Sept. 25, 2018) does include information from the incident investigation interviews of the pilots (including several quotations) but to my knowledge the transcripts of interviews were not disclosed to the public.

[ATC Watcher]

Originally Posted by BugBear

"Unable"

Yes , this is the word I teach and hammer my students who are afraid to contradict an ATC instruction with which they are uncomfortable with . Very difficult for a under 100 hors student to get this , but I know 10.000 h ATPLs who have the same problem
That said it does not always work , the Lufthansa SFO R/T exchange was an abnormality to stay politically correct . But , back to DCA , I I would be interested to know if previous instructions to circle 33 while on finals 01 was a commonly used procedure , and if it was occasionally refused by some pilots in the past and what was then the reaction of ATC .. divert to Dulles ?

[Hot 'n' High]

Originally Posted by ATC Watcher

........... But , back to DCA , I would be interested to know if previous instructions to circle 33 while on finals 01 was a commonly used procedure , and if it was occasionally refused by some pilots in the past and what was then the reaction of ATC .. divert to Dulles ?

I've no insider knowledge but, given how the first AA accepted it and the following AA asked for it specifically, it may have been common practice within AA. Not all line pilots may fully appreciate the potential issues linked with, say, that particular sidestep.

I raised the airline responsibility bit more as "idle thoughts" to illustrate that everyone can play their part in making things safer in cases such as this - including airlines. However, it does need (a) identification of the issue, (b) then good analysis to scope it all and, finally, if there is a "real" potential issue after that analysis, (c) to work out a formal policy (here with AA and DCA) so everyone knows what's what and, importantly, appreciates any knock-on issues that such a policy may generate - such as maybe cutting down on ATC's flexibility on occasion.

So, for eg, it could have been a joint AA/DCA policy that AA would not be placed on the sidestep, or accepted on the sidestep, while something was on Route 4. Irrelevant here now as Route 4 has gone ..... but the above concept can be applied to other potential issues at other airfields.

Anyway, just some thoughts. I'll revert to lurking! Cheers, H 'n' H

[abax]

Originally Posted by Hot 'n' High

I've no insider knowledge but, given how the first AA accepted it and the following AA asked for it specifically, it may have been common practice within AA. Not all line pilots may fully appreciate the potential issues linked with, say, that particular sidestep.

I raised the airline responsibility bit more as "idle thoughts" to illustrate that everyone can play their part in making things safer in cases such as this - including airlines. However, it does need (a) identification of the issue, (b) then good analysis to scope it all and, finally, if there is a "real" potential issue after that analysis, (c) to work out a formal policy (here with AA and DCA) so everyone knows what's what and, importantly, appreciates any knock-on issues that such a policy may generate - such as maybe cutting down on ATC's flexibility on occasion.

So, for eg, it could have been a joint AA/DCA policy that AA would not be placed on the sidestep, or accepted on the sidestep, while something was on Route 4. Irrelevant here now as Route 4 has gone ..... but the above concept can be applied to other potential issues at other airfields.

Anyway, just some thoughts. I'll revert to lurking! Cheers, H 'n' H

It is buried in all these pages of this thread,,,but it seems that tragically so, 2-3 aircrafts before the fatal 5342, ATC requested rwy33 to another crew (same aircraft, same airline iirc) , and they declined ("Unable")

[BugBear]

Originally Posted by abax

It is buried in all these pages of this thread,,,but it seems that tragically so, 2-3 aircrafts before the fatal 5342, ATC requested rwy33 to another crew (same aircraft, same airline iirc) , and they declined ("Unable")

The geometry of the conflict resembles allowing Right and Left traffic to the very same runway, save two hundred feet (or less) altitude, with one LC to manage two discrete frequencies, two radar screens, neither opposing aircraft privy to the other’s comms. At night in a sea of lights? Oh, and two quite different airframes and maneuvering capabilities....something like that.....??

Not to mention one of the two is not going to turn Final... head on Base Legs? Not foolin here.

[BFSGrad]

Originally Posted by ATC Watcher

But , back to DCA , I I would be interested to know if previous instructions to circle 33 while on finals 01 was a commonly used procedure , and if it was occasionally refused by some pilots in the past and what was then the reaction of ATC .. divert to Dulles ?

The visual (circle) 33 is by far the most commonly used flight path to get aircraft into 33. The infrequently-used RNAV 33 closely tracks the visual 33 flight path. There is also the rare visual straight-in for 33 (see last year’s runway incursion with N250AA).

The NTSB preliminary report states that about 4% of DCA’s arrivals use runway 33. With 25,000 monthly flights, you can do the math. 33 used more frequently than average in the winter due to the typical strong NW winds seen in the DC area. That was the case on 1/29.

While it may be a wishful narrative that pilots get sent to ATC jail if “unable,” doubt that’s anywhere close to the truth. I think the reality is if a pilot states “unable,” ATC makes the necessary adjustments, which may involve an aircraft being resequenced in the queue. Don’t really think ATC has the authority to deny an aircraft a landing clearance out of spite if flight planned for DCA.

Originally Posted by abax

It is buried in all these pages of this thread,,,but it seems that tragically so, 2-3 aircrafts before the fatal 5342, ATC requested rwy33 to another crew (same aircraft, same airline iirc) , and they declined ("Unable")

And just as the collision was occurring, JIA5347 was checking in on the Mount Vernon Visual specifically requesting 33. Luck of the draw…