Creating risks, the DC plane crash: risk analysis and investigation
The tragic crash resulting in 67 deaths seems preordained ("Boats return to the Potomac River for D.C plane crash recovery and investigation," Philadelphia Inquirer).
For years, it's been written that because of restrictions on airspace use around the White House, planes fly to and from National Airport through extremely narrow corridors and tight elevations ("Pilots have long worried about DC’s complex airspace contributing to a catastrophe," AP, note: it requires going into a good library articles database to get older links).
But I don't recall these articles discussing airplanes also having to negotiate airspace with military helicopters on training missions from various bases along the Potomac River, like Fort Belvoir, the duty station for the helicopter involved in the crash.
A Reddit thread shared an interesting article, "Why You’ve Never Been In A Plane Crash" (Asterisk Magazine) about airplane crash investigation not being focused on "blame" as much as the process/system that likely generated the crash, with a focus on structural change.
It discusses a case in Los Angeles, and how a series of near misses similar to the final crash bred complacency. The New York Times article, "Washington Crash Renews Concerns About Air Safety Lapses" sounds like it could have been pulled from the files on the LA crash, detailing ongoing process issues at National Airport, which, scarily, appear to be more common across the country. From the article:
Clues emerging from the moments before the deadly collision Wednesday night between an Army helicopter and an American Airlines passenger jet suggest that multiple layers of the country’s aviation safety apparatus failed, according to flight recordings, a preliminary internal report from the Federal Aviation Administration, interviews with current and former air traffic controllers and others briefed on the matter.
The helicopter flew outside its approved flight path. The American Airlines pilots most likely did not see the helicopter close by as they made a turn toward the runway. And the air traffic controller, who was juggling two jobs at the same time, was unable to keep the helicopter and the plane separated.
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The same kind of complacency at the airport ("Near-misses at Washington airport worried pilots well before fatal crash," Reuters) seems comparable to WMATA's Metrorail which experienced a number of signals failures induced near misses before the 2009 crash that killed 9 ("WMATA circuit failure," 2009).
Plus things could have been even more discombobulated because of the Trump Administration's call for air traffic controllers to leave government service ("Air traffic controllers were initially offered buyouts and told to consider leaving government," AP). OTOH, Trump blamed DEI and the Biden Administration ("Trump was challenged after blaming DEI for the DC plane crash. Here’s what he said," AP).
Labels: business process redesign, disaster planning, incompetence and failure, risk analysis, risk management and redundancy
posted by Richard Layman @ 4:30 AM&Permanent Link
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Pilots got 100 collision warnings for helicopters near National in past decade
https://www.washingtonpost.com/business/2025/02/13/dca-airport-crash-warnings-helicopters-airliner/
The 104 incidents contained in government data involved an alert from airliners’ anti-collision technology, known as a Traffic Alert and Collision Avoidance System, or TCAS. It is designed to prevent midair collisions and is mandatory for passenger planes in the United States. The system automatically communicates with all aircraft equipped with a transponder within about 12 miles, relaying their position and altitude and calculating the trajectories to warn of a possible collision.
If two aircraft are on a collision course, a plane’s TCAS would give pilots a voice warning: “traffic, traffic,” while showing the nearby aircraft on a cockpit display. The system escalates a warning into a “resolution advisory,” instructing the pilot how to avoid a collision, when it projects the aircraft are 15 to 30 seconds from impact.
Nearly a quarter of the warnings identified by The Post involved military helicopters, almost half were medical flights, and the rest involved police departments and private operators.
In at least 24 incidents in the past three years, airplane pilots aborted their landings at National, a maneuver that involves abruptly pulling up and circling around before returning to the airport, flight-tracking data shows. In other incidents, the jets were able to continue on safely to National without changing course, the data shows.
The most recent incident in the data of a TCAS alert logged by controllers occurred the day before last month’s crash, when a Republic Airways flight arriving from Connecticut aborted a landing after receiving a collision warning.
The TCAS system has some limitations, experts say. It works by forecasting the paths of nearby aircraft and does not know what other pilots intend or what air traffic controllers are doing to manage airspace by telling aircraft to watch out for one another.
The system is also not designed to provide course corrections below 1,000 feet, so it provides fewer safeguards in the final minutes before a plane lands. The jet that crashed was at about 325 feet, and investigators have said pilots received only an audio advisory stating “traffic, traffic.”
Flight-tracking data shows many of the incidents identified by The Post happened to the north of National, where airliners are still high enough to receive the advisories. That probably means there could be close calls at lower altitudes not reflected in the data, experts said. An incident a week before the collision, previously reported by The Post, in which a jet suddenly abandoned a landing at low altitude because of a nearby helicopter, does not appear in the records.
Consequences from not following up on risk management.
Clifford Law Files $250 Million Pre-Case Claims Against Federal Government in Aviation Crash Over the Potomac; Simultaneously Notices Sent to Corporate Aviation Entities to Preserve All Evidence in Anticipation of Lawsuits
Clifford Law Offices, a leading aviation firm based in Chicago, filed today (Tuesday, Feb. 18, 2025) pre-case claims against the Federal Aviation Administration (FAA) and the U.S. Army involving a passenger killed in the Jan. 29 midair crash of an American Airlines regional jet with a military helicopter, killing all 67 on board. The claims were filed on behalf of the widow and children of Casey Crafton of Connecticut. He died as a result of the collision, leaving behind his wife and three young sons.
Clifford Law Offices filed a government-issued “Form 95” that is required to present claims against the United States under the Federal Tort Claims Act (FTCA) for property damage, personal injury or wrongful death allegedly caused by a federal employee's negligence or wrongful act occurring within the scope of the employee's federal employment. The $250 million claims are directed against multiple governmental agencies that may be responsible. The National Transportation Safety Board (NTSB) has reported that staffing in the tower of air traffic controllers (ATC) was “not normal” at the time of the nighttime collision and that there were communication lapses between the ATC and the aircraft. The helicopter in the collision was operated by the Army and was manufactured by Sikorsky Aircraft. It is being reported that the Trump Administration began notifying hundreds of probationary FAA workers late Friday that they are fired and will be barred from entering their offices effective today.
The government now has six months to act upon the claims, and, if rejected or not acted upon within that time, plaintiffs have the right in the next two years to file lawsuits in federal district court that would be heard by a judge. Jury trials are not allowed in civil wrongful death actions against the government. The notice of a claim against the FAA was sent to the FAA Tuesday. A pre-case Form 95 claim also was filed Tuesday against the U.S. Army at its Fort Meade, Maryland, offices.
Robert A. Clifford, founder and senior partner of Clifford Law Offices and Lead Counsel in the pending litigation in federal District Court in Chicago in the crash of a Boeing 737 MAX8 jet in Ethiopia six years ago, further sent via certified overnight mail preservation letters to American Airlines and its regional carrier, PSA, as well as Sikorsky Aircraft and Collins Aerospace, to preserve all evidence in the midair crash of the two aircraft Jan. 29. Clifford said that for now he is taking a cautionary approach to the filing of lawsuits against others such as American Airlines and Sikorsky awaiting the release of information to be disclosed in the NTSB preliminary report that it promised within 30 days of the crash. Clifford Law Offices also has initiated an investigation into potential claims of willful neglect by the airlines for the many years of congestion of commercial aircraft and helicopters that went ignored in the air space near Reagan National Airport.
The NTSB is responsible for finding the probable cause of aviation crashes. NTSB Chair Jennifer Homendy updated the public Friday afternoon (Feb. 14) on the latest information available regarding this tragedy. https://www.ntsb.gov/news/press-releases/Pages/MA20250213.aspx
Crafton, 40, who lived in Salem, Connecticut, left his wife of 16 years, Rachel, and three young sons. He was killed when American Airlines Flight 5342 from Wichita, Kansas, collided midair with a U.S. Army Black Hawk helicopter that then exploded into a fireball before plunging into the Potomac River.
“Casey was an incredible human being. He was a giver. He was a loving husband and father. He enjoyed coaching his boys on their youth soccer and little league baseball teams. They will be grieving him for the rest of their lives that will never be the same,” Clifford said. “This crash involves complex matters, and the family deserves answers as to what happened to their loved one.” Crafton studied aviation management in college at Bob Jones University where he met his wife, Rachel. He was returning from Wichita, Kansas, on a business trip working as a technical support manager at Guardian Jet, an aviation consulting firm.
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