There is news in every direction these days, but I still follow the press conferences by the National Traffic Safety Board (NTSB) concerning the midair collision over the Potomac River one week ago.
As I shared with my first post on this topic, I try to avoid speculation about aircraft accidents until all the facts are known. Having flown for 50 years, I know there are always a number of factors that go into any accident.
Yesterday, the NTSB shared important information, and I do think they are narrowing the focus in a search to determine what happened.
It seems clear that the commercial regional jet accepted a change in their approach to land on runway 33 at Reagan National and was carrying out that maneuver when the collision occurred. It is also clear that since the collision occurred at about 300 feet, the Black Hawk military helicopter was above an altitude restriction of 200 feet. Flight tracking also suggests the helicopter diverted from the standard flight path.
The question remains: why?
Here are the areas of inquiry that most interest me.
The tower controller:
- he can be heard on at least two occasions, telling the pilot of the Black Hawk helicopter that they have traffic and both times the helicopter pilot stated they had the traffic in sight….we should find out what the tower controller saw on his screen with regard to the helicopter’s altitude. It should not have been above 200 feet.
- because the controller was told the traffic was in sight by the helicopter, the controller did not provide any reference information about where the traffic was in relationship to the helicopter nor did he provide a heading that would have kept the helicopter away from the aircraft…not so much an error as a very unfortunate omission.
- the helicopter pilot requested a “visual separation clearance,” and the controller responded, “vis sep approved.” What did the controller mean exactly (more below)?
The Black Hawk Pilot:
- traffic was pointed out twice to the helicopter and twice the pilot reported “traffic in sight.” It is highly doubtful in my view that the helicopter actually saw the traffic the controller cautioned about….pilots just don’t hit things they see.
- the helicopter pilot, upon receiving the second caution for traffic, said they had it in sight and requested a “visual separation clearance.” What did he actually mean by that (more below)?
- and, most importantly, why would the helicopter have been high and slightly off the designated course for the route they were flying, even making a slight turn to the right apparently before the crash which was away from their flight path?
The Helicopter’s Altimeter
- these devices are very accurate provided the correct barometric pressure is set manually into the altimeter. NTSB will closely examine this and all instruments aboard the helicopter, but even a small error in a setting could cause a 100 foot deviation where the indicated altitude was different than the actual altitude. Had the altimeter setting been updated on a very cold (20 degree) night is something we should know. In listening to the voice recording, the tower controller was informing landing aircraft of the proper altimeter setting and it was changing.
About “pilot/controller speak:”
One of the important aspects of our air traffic management system is the language used by controllers and pilots is carefully constructed and common across the entire system.
In over 5,000 hours of flying, I have many times been instructed by a controller to “maintain visual separation” from another aircraft. This instruction is issued when a pilot sees the other aircraft and it specifically requires the pilot to “maneuver” in a manner to avoid the other aircraft.
Now, I did not fly helicopters, but in all of my flying I never requested a “visual separation clearance.” Interestingly, the tower controller “granted” the request, instructing the helicopter to pass behind the traffic.
At that moment, the collision was seconds away.
Hopefully the cockpit voice recorders will reveal exactly what the helicopter pilots elected to do with their “clearance.” The flight records suggest they turned slightly right and climbed above 200 feet. The question remains, why? Did they believe the 200 foot restriction was lifted? Did the altimeter show an altitude of 200 feet when it was actually 300 feet? Did they turn to stay behind an aircraft other than the one that the controller cautioned them about?
While the focused has narrowed, the questions remain. However, it seems we are getting closer to learning why.
Craig Fuller served four years in the White House as assistant to President Reagan for Cabinet Affairs, followed by four years as chief of staff to Vice President George H.W. Bush. Having been engaged in five presidential campaigns and running public affairs firms and associations in Washington, D.C., he now resides on the Eastern Shore and publishes DECADE SEVEN on Substack.
Reed Fawell 3 says
Trump had it about right. This was obvious by last Sunday based on graphics of the two machines’ flight paths shown in the Sunday morning Post newspaper. The towers change in the jetliners approach fron its straightforward landing approach over directly ahead upriver over water all the way in onto the airports longest runway to the shorter crosswise 33 runway, forced the jetliner to veer northward inland off the river and over the Maryland Shore over land before it then had to swing back, headed across the river directly in front of the Chopper unless below 200 feet off the water.
This swing to the northward overland likely took Jetliner out of the chopper’s obvious view as its pilot and crew focused on that now was directly ahead, the 2nd jetliner plainly lit over the Potomac’s dark water as it came in behind where the doomed Jet liner had been before. If this is true, the towers instructions to the chopper focused its pilots on the wrong threat. The chopper ‘s lift and elevation well above 200 feet them doomed all concerned. Obviously, many other factors might will have played a roll, such as glare and optical illusion. But my questions are.
Why did the air traffic controller assume that the chopper had the right (doomed) airliner in view? Why did the traffic controller instruct the chopper to swing in behind the jetliner coming in overland from the north, and better differentiate it from the one coming straight from down river? Why did the chopper pilot not double check the doomed airliners approach crosswise over the river from Maryland? Why did the traffic controller wait so long to give the 2nd warning? And better identify the doomed jet’s approach?
Reed Fawell 3 says
President Trump just gave a remarkable talk and prayer at the national prayer breakfast in the Capital building. Among many other things, he zeroed in on the need to totally revamp the nations air traffic control system so as to bring it into the 21st century to insure that the recent National Airport disaster is not given the space to happen again. I suggest all watch it.
Below I correct dyslexia induced typo’s to the first paragraph of my comment above.
“Trump had it about right. This is obvious based the two machines’ flight paths shown in the Sunday morning Post newspaper. The control towers change in the jetliner’s approach coming direct upriver over water all the way to National’s longest runway to the shorter crosswise runway 33, forced the jetliner to veer north inland off the river over DC land before it then had to swing back across the river directly in front of the Chopper unless below 200 feet off the water.”
Rob Douglass says
Mr. Fuller,
Thank you for sharing your insights, especially as someone who has experience in aviation, and is not jumping to conclusions, and who is following where the facts lead. I will also venture you are very familiar with the excellent credibility, reputation and processes of the NTSB in their fact based investigations, assisting in lowering commercial aviation accident rates to the amazingly low numbers they are today.
My heart goes out to the families, loved ones, and the victims of this unfortunate event.
I will also share that after serving as a Commanding Officer of a nuclear submarine, was a Director of Safety and Human Performance in a large nuclear utility, and a managing consultant in healthcare safety and reliability including teaching Cause Analysis and investigating preventable harm in healthcare for the last 8 years among my other duties and responsibilities, the best leaders do not jump to conclusions and “shame and blame” before the bodies are even recovered like POTUS did last week shockingly.
He was a horrible example of poor leadership that I would at times see in those 3 careers, most often exhibited by junior, inexperienced leaders, who wanted to make quick judgements, to dish out punishment and move on, never getting to the root causes and solutions of the significant events. Quick decisions are easy and lazy, where the real hard work takes time to piece together all the facts, timelines, communications, spatial relationships, qualifications, experience, extenuating factors, human errors, deviations from generally acceptable performance standards and autopsy equipment to name just a few. Our commercial aviation and nuclear power safety records have become so good over time (remember Three Mile Island, remember the two 747’s disaster at Tenerife) because we have invested greatly, with rigorous scientific methodology to find the correct root causes and put both human performance, procedural, equipment, and sometimes cultural (the primacy of safety) corrective actions to prevent recurrence in place. Period.
Any premature insinuation that Diversity, Equity and Inclusion (DEI) hiring practices or Democratic policies caused this event are ludicrous, so no, POTUS did not get it right, he exhibited behaviors of a lazy, impatient, junior, inexperienced leader who wants to look smart and look tough but does not allow his professionals to do the hard work and invest the time to find the causes then implement corrective actions before spewing his speculations. That takes patience, humility and knowledge of processes that actually work and have shown results in high reliability organizations for decades which he lacks.
My hope is that the NTSB will be allowed to do their job as they have always done so well. I fear that if their conclusions do not match POTUS’s “shame and blame” narrative, their report will be directed to be modified or rejected as written, kind of like the sharpie extension of a hurricane track during POTUS’s first term because he couldn’t possibly be wrong while reverse engineering where the hurricane would go if he incorrectly stated what state would be hit. Remember?
Just like submarines have pressure sensing depth detectors, aircraft have pressure sensing altimeters. Just like submarines have fathometers, aircraft can have radar altimeters. Was the helicopter equipped with radar altimeters, were the pilots fixated on one altitude source (an incorrect one) and were any key sensors or systems (helicopter, aircraft, tower, controllers) not being used or operated correctly or were any in a reduced or out of commission status?
No conspiracy theories here, but if we see NTSB lead investigators on this case resign or are fired (reassigned), about the same time the draft report is ready to come out, we’ll know that the chilling effect of POTUS, directing that he is always right and of course DEI and Democrats were system failure mechanisms to blame and must make it into the report, the objectivity and credibility of the NTSB will be lost and we will be putting more lives at risk due to POTUS and his ego instead of solving the real root causes. I hope I’m wrong and we see a clean, unobstructed report that helps the industry learn and improve, never forgetting those lost.
Reed Fawell 3 says
“…the best leaders do not jump to conclusions and “shame and blame” before the bodies are even recovered like POTUS did last week shockingly.
He was a horrible example of poor leadership that I would at times see in those 3 careers, most often exhibited by junior, inexperienced leaders, who wanted to make quick judgements, to dish out punishment and move on, never getting to the root causes and solutions of the significant events.”
To put it mildly, this insulting comment does not reflect the facts on the ground, including as illustrated by today’s Trump’s Prayer Breakfast speech found here:
https://www.youtube.com/watch?v=1523PWhUmJ4
“Any premature insinuation that Diversity, Equity and Inclusion (DEI) hiring practices or Democratic policies caused this event are ludicrous, so no, POTUS did not get it right, he exhibited behaviors of a lazy, impatient, junior, inexperienced leader who wants to look smart and look tough but does not allow his professionals to do the hard work and invest the time to find the causes then implement corrective actions before spewing his speculations.”
This intemperate comment does not reflect well on a former US naval officer. And to an outside observer it suggests a reason why the US Navy, after years of neglect, is in such woeful shape today in meeting America’s challenges abroad, an obvious fact written about by many informed observers. Watch the current President work very hard and effectively to fix this problem.
“Just like submarines have pressure sensing depth detectors, aircraft have pressure sensing altimeters. Just like submarines have fathometers, aircraft can have radar altimeters. Was the helicopter equipped with radar altimeters, were the pilots fixated on one altitude source (an incorrect one) and were any key sensors or systems (helicopter, aircraft, tower, controllers) not being used or operated correctly or were any in a reduced or out of commission status?”
This comment is well taken, and understood by the President, and will be fixed. See https://www.youtube.com/watch?v=1523PWhUmJ4
“No conspiracy theories here, but if we see NTSB lead investigators on this case resign or are fired (reassigned), about the same time the draft report is ready to come out, we’ll know that the chilling effect of POTUS, …”
No, this is a conspiracy theory. As suc no such threat to the NTSB has been made or suggested.
Self proclaimed experts should raise red flags for others, given their track records generally and most recently in our Nation. Best most can tell, today, it’s the experts who have let down the nation, and created the mess we are in.
Captain Damiene Pedlow Nelson says
You bring up an interesting point with the altimeter. In my 48 yrs and 17K hrs of flying, pilots can forget to set an altimeter or set it incorrectly. I’m not familiar with the Black Hawk helicopter but I’m guessing it has 3 altimeters: 2 pitot altimeters and 1 standby. The other instrument that is a necessity for low altitude work is your radar altimeter which measures the ground to the aircraft distance.
You would think in an altitude critical area, the crew would be monitoring there RAs also? And I am guessing there are two RA: one per pilot. The cross checking with the barometric altimeters would show any errors.
In all my yrs of flying and in busy airspace, I have never said I have visual on another aircraft and taken the responsibility of aircraft separation. Let the controllers keep us separated and safe. A breezy evening, the appearance of lots flashing lights, in DC, what the helicopter pilots did just didn’t make sense for how professional pilots handle aircraft separation.
A very tragic and avoidable accident.
Reed Fawell 3 says
Holman Jenkins had a very interesting take on what may well have happened here, in the
Weekend edition of the WSJ, the first time a distinct, and even obvious, possibility was put into writing.