A federal fact-finding probe into a deadly midair crash near Washington earlier this year that concluded on Friday shows a disaster decades in the making.
Over three days of hearings before the independent National Transportation Safety Board, witnesses described an aviation system that seemed bound to eventually fail and a sclerotic government response to the catastrophe that virtually everyone saw coming.
The contours of the problem in the skies near Ronald Reagan Washington National Airport echo those seen across the country: subpar equipment, a congested and complicated airspace and overworked air traffic controllers. Those issues are as well-documented as they are tough to fix, especially in an era where Congress regularly flirts with shutdowns and policy priorities change with each administration.
Indeed, one of the most common threads during the long inquiry was that nobody seemed shocked that a PSA Airlines passenger jet and an Army Black Hawk helicopter collided in January, killing all 67 on board both aircraft.
“I was chairman of the board for almost eight years. I’ve followed aviation for several decades. Nothing in this surprises me,” said Jim Hall, who served as NTSB chair under then-President Bill Clinton and watched part of this week’s NTSB proceedings. It “only demonstrates that the past is prologue.”
Asked for comment, the FAA pointed to a statement from Thursday saying it will work with NTSB “to uncover the truth to ensure this never happens again.”
Here are four things we learned from the NTSB’s three-day hearing into the crash:
Changes that could have increased safety have been proposed but never implemented.
The NTSB’s final report on what went wrong is still about a year away. But for days witnesses have outlined a host of solutions proposed well before the crash that were never implemented. That includes moving a helicopter route at the center of the investigation, reducing flights at Reagan National, which has one of the single-busiest runways in the country, or making better use of collision-warning or alerting technologies. None of those were implemented.
The FAA has for years tried to upgrade its equipment and shore up its air traffic controller workforce. But funding is subject to politics, and the washout rate for controllers is high.
“Could you hurry it up?” NTSB board member Todd Inman said repeatedly to various FAA and Army officials as they explained what they’ve been doing to try to fix their problems.
Jeff Guzzetti, an aviation safety consultant who was a longtime official at both the FAA and NTSB, called the hearing “the FAA’s day of reckoning” and predicted that the hearings could put pressure on the FAA to finally curtail flights at Reagan National and take further action to bolster air traffic controller staffing. And it could push the Army to reduce its helicopter operations in the area.
The Washington airspace is busy and used by dozens of federal entities with competing priorities.
In testimony, Army officials and federal investigators described a hectic and congested airspace around Reagan National where military helicopters often operate alongside commercial airplanes — sometimes even flying behind or underneath passenger planes as they land. In the case of the deadly flight, the Army helicopter had been on a training mission. Investigators believe the crew may have been wearing night vision goggles, which can be difficult to use in bright urban environments such as Washington.
The routes are no stranger to scrutiny; for at least a decade pilots have complained about risks posed by growing helicopter congestion — a majority of which is military traffic — near the airport.
Lawmakers have questioned why the military needs to fly so close, especially for flights used to ferry VIP officials to and from the Pentagon. Over the years, the routes have been changed, but mostly to alleviate noise concerns. (Documents released as part of the crash investigation show those noise-related changes may have made the routes even riskier.)
A working group including air traffic controllers at Reagan National had previously pushed to remove the route the helicopter used on the night of the crash. But an air traffic controller testified that management canned it because the change was “too political.”
The FAA closed the route for good to non-essential traffic in March this year — a month-and-a-half after the crash.
Fatigued controllers just have to “make it work.”
Air traffic controllers, in interviews with NTSB investigators and in testimony, described an environment at Reagan National where they felt forced to just figure out how to “make it work” despite fears about the safety risks posed by the feverish pace of flights.
That refrain — “make it work” — arose repeatedly during the hearing, though FAA officials maintained the facility was adequately staffed the night of the crash.
Clark Allen, the operations manager at Reagan National the night of the crash, in an interview transcript said “everyone’s just trying to constantly make it work, make it work, make it work.”
Prior to the crash, air traffic controllers had asked their superiors to reduce the pace of flights at Reagan National. But that recommendation never went anywhere. On Thursday, some FAA officials involved with air traffic management said some of the problem isn’t the sheer number of flights, but that some airlines schedule them stacked up around certain times of the day. They recommended a flight limit cut into 30-minute chunks, rather than the current one hour, similar to procedures in place at LaGuardia International Airport in New York.
On Friday some senators called for action.
Sen. Jerry Moran (R-Kansas), who chairs the Senate Commerce panel on aviation, said he wants to hold a hearing on why the FAA has such an arduous process when it comes to acting on safety recommendations from employees. His counterpart, Sen. Tammy Duckworth (D-Ill.), agreed, and said she wants to examine the FAA’s process for “frontline folks to raise concerns.”
“We need a more aggressive FAA,” Maria Cantwell (D-Wash.), ranking member of the Senate Commerce Committee, said on CNN Thursday. “That’s their job to protect the flying public, to make these decisions, and if air traffic controllers are telling them, ‘Look, this is too much,’ then they need to listen.”
Unfixed problems significantly impair safety buffers, leaving little margin for error.
The night of the crash, amid a typical busy night, air traffic control did not give the passenger jet a key warning — and the helicopter pilot may not have heard a key directive.
On cockpit recordings, air traffic control can be heard telling the helicopter pilots to pass behind the jet, which was attempting to land. But a mic on the helicopter was keyed at a crucial moment, making the words “pass behind” indecipherable.
ompounding the problem, air traffic control did not alert the plane that a helicopter was going to pass close. Interviews with controllers that night suggest that they could not detect that the helicopter and plane were about to cross paths. FAA officials who testified were unable to explain why the controller did not see what was about to happen.
A location-transmitting technology that would have helped controllers see the helicopter’s position was not working during its flight. In fact, investigators found that the device had been inactive for about two years prior to that night. Nobody had checked to make sure the device was working that night, Army Col. Andy DeForest testified.
Additionally, the helicopter had been using an altimeter, which determines height above the surface, that could have made pilots think they were flying lower than they actually were. Army spokesperson Matt Ahearn said in a statement that the Army is looking into the NTSB’s finding on the altimeter’s limitations and trying to figure out if “it represents a significant error across the fleet.”
John Cox, an aviation safety consultant who was previously executive air safety chair of the Air Line Pilots Association, said the altimetry issues with the Army’s Black Hawk helicopters appears to reflect a more systemic problem.
“They need a fleet campaign to get their altimeters fixed,” he said.