chas
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I know a number of you are pilots, and I am not. But I have always been highly interested in aviation, and have read and studied for decades on numerous aviation topics. Regarding the collision of American Eagle JIA342 and Army Blackhawk PAT25, I lay the blame squarely on the shoulders of both the FAA and the United States Army Aviation Branch. If the NTSB in any way blame the pilots in the incident, they are not doing their job. Let’s look at all of the holes in this swiss cheese:
1. In an effort to maximize commercial air traffic in and out of DCA, the FAA has created the “deviate to RWY 33 procedure” for air traffic in-bound to RWY 01. This requires a right-hand turn from the RWY 01 approach followed by an immediate hard left-hand turn to line up on RWY 33. FAA criteria for a stabilized approach states that you have to be stable at 500 feet AGL on final in VMC or perform an immediate go-around. But on this particular approach, you will be at or below 400 feet AGL as you come out of the left turn to final. So the FAA has granted an exception to the “stabilized requirements” at DCA to allow for this maneuver. This allows ATC to shorten the distance between arriving and departing aircraft that are utilizing conflicting RWYs. The FAA in essence violates its own safety standards on stabilized approaches for the sake of expediency.
2. The FAA creates the Route 1/4 helicopter route through the DCA airspace as a VFR route with constantly changing altitude requirements. The lowest limit is at 200 ft MSL through the area east of DCA. Any pilot will tell you that flying that low over water at night is a best a tense experience. Try not to break that limit flying at night while also trying to communicate with ATC and simultaneously searching for possible conflicting aircraft.
3. The United States Army Aviation Branch deems it acceptable to allow training missions for Army Reserve pilots with limited flying experience to fly these helicopter routes through this complex and extremely active airspace. Compounding this, training flights at night using night-vision goggles are deemed “safe” in spite of the fact that using said goggles severely limits peripheral vision and makes it difficult if not impossible to perceive any color other than green and white. Picking out particular lights against the background of urban lighting is challenging, as is depth perception. Scanning key cockpit instruments is also made more difficult, making it challenging to accurately maintain altitude. Add to that workload the need to be in constant communication with ATC as well as monitoring all other comms traffic not directed to you but necessary in order to maintain good situational awareness. Given the density of commercial air traffic on this route, common sense would dictate that this route be flown by only the most experienced pilots and only when absolutely necessary. Reasonable logic would understand that conducting training missions should not be using final approach areas with heavy commercial traffic.
4. The Army crew on PAT25 are flying a mission they have been ordered to fly, at night and using night vision goggles. Although they may feel it is difficult and may be anxious about it, their command structure has determined that it is an appropriate training procedure and as such must meet minimum safety requirements. They do not have the authority to question the mission or the orders to fly it.
5. JIA342 is on approach for RWY 01, but is asked at the last minute by ATC to deviate to RWY 33, requiring the “circle to land” maneuver. Therefore, they are now on approach different from what they briefed for.
6. Any aircraft following the “circle to land” approach to RWY 33 will most likely have both pilots focused on RWY 33 as they come out of the left turn to final, especially if it was a last-minute request by ATC. In this case they will be looking to make sure that AA1630, which has just been given clearance to depart from RWY 01, is clear of the intersection with RWY 33 as they complete their final approach, and be ready for a go-around if it is not. In addition, this left bank makes it extremely difficult for the first officer to see any conflicting traffic coming towards them from the 1 to 2 o’clock position, as that traffic will probably be below the right window level. For the pilot, who is on the left side of the cockpit, visibility of such conflicting traffic will be nearly impossible.
7. For whatever reason, ATC is working with “split frequencies while controlling this airspace, so that although the controller hears both the aircraft on approach and the helo traffic south-bound on “Route 1”, the pilots of those respective aircraft only hear information directed at them. Thus they are not aware of all that is going on around them, and as such their situational awareness is limited by factors outside of their control.
8. ATC informs PAT25 of the conflicting aircraft on approach for RWY 33 at 1200 feet MSL, but at the time, PAT25 is heading almost due east towards the Jefferson Memorial on Helo Route 4 while JIA342 (the CRJ) is executing its right turn departing from the RWY 01 approach and is now heading in a northeast direction as it prepares to make a hard left onto the RWY 33 short final approach. From their respective positions, PAT25 in all likelihood sees the landing lights of AA3130 which is trailing JIA342 and whose landing lights are pointed almost directly in his direction, and mistakenly identifies it as the aircraft approaching RWY 33. At no time does it appear that ATC notifies JIA342 of the conflicting helo traffic. They are most likely focused on their approach to RWY 33, which was just handed to them.
9. As JIA342 rolls out of its left hand turn to final on RWY 33, completing the deviation they were just handed and had not briefed for, it is now approaching the 9-11 o’clock position of PAT25. Since the pilot of PAT25 is on the right-hand side of the Blackhawk, visibility of the CRJ may be limited. Both pilots of PAT25 are now most likely visibly fixated on passing to the rear of AA3130, which is in their 1-3 O’clock position, and which is the conflicting aircraft they perceive as the one ATC initially warned them about.
10. ATC, now receiving a conflicting aircraft warning, asks PAT25 if they have JIA342 in sight. In the absence of any obvious difference from the first mid-identification of the conflicting traffic, confirmation bias raises its ugly head. The voice response from the training pilot is calm and confident in stating that they do have it in sight and claim visual separation, probably proving once again that he mistakenly has AA3130 in sight slightly to his right directly in front of him and more than a mile away. Both pilots are totally unaware of JIA342 which is now arriving in front of them from their left.
11. The collision occurs.
Left out of this rant is the staffing issues at DCA. Listening to the ATC recordings, I really don't see a DEI issue as being a causality here. But the number of people on shift (or lack thereof) does play a role in creating an overtasked and fatigued workforce.
In my humble opinion, the crews of both aircraft involved were set up by both the FAA and the Army Department of Aviation through a series of poorly based decisions which focused on expediency and departed from any appropriate utilization of a rational use of risk assessment. Consider the following:
1. Approval of the circling to RWY 33 maneuver which violates normal stabilized approach standards.
2. The establishment of a series of complex VFR helicopter tracks through complex and heavily restricted air space, as well as through final approach paths.
3. A 200 foot maximum altitude requirement over water and required even at night, which may result in a less than 200 foot vertical separation between aircraft on approach to RWY 33 and those traveling on Helo Route 1/4. (again, try maintaining level flight under 200 MSL over water at night, and then concentrate on everything else!)
4. The decision to conduct military training missions in this complex and busy airspace with an abundance of commercial passenger traffic either arriving to or departing from DCA.
5. The use of split frequencies by the FAA which negatively impacts the situational awareness of all of the pilots in the airspace.
6. The use of night vision goggles to place even more limitations on the pilots.
Granted, all pilots involved may not have had the thousands of hours senior commercial and military pilot possess. But even the most senior individuals when placed in the task saturated environments these two crews faced would have at the very least felt their “pucker factor” increase through this. And there is probably an equal chance that the lack of common sense and appropriate safety design exhibited by the controlling entities would have resulted in a similar outcome. The odds were significantly stacked against these two flight crews, and unfortunately, against the passengers and flight attendants as well. If ever there were an example of an accident waiting to happen, this is it.
Respectfully, Chas
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