S.Hrg.119-455

1[Senate Hearing 119-455]2[From the U.S. Government Publishing Office]34                                                        S. Hrg. 119-45556                         THE NTSB FINAL REPORT7                      ON THE DCA MIDAIR COLLISION89=======================================================================1011                                HEARING1213                               before the1415                         COMMITTEE ON COMMERCE,16                      SCIENCE, AND TRANSPORTATION17                          UNITED STATES SENATE1819                    ONE HUNDRED NINETEENTH CONGRESS2021                             SECOND SESSION2223                               __________2425                           FEBRUARY 12, 20262627                               __________2829    Printed for the use of the Committee on Commerce, Science, and Transportation3031                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]3233                Available online: http://www.govinfo.gov3435                               ______3637                 U.S. GOVERNMENT PUBLISHING OFFICE383964-071 PDF                WASHINGTON : 20264041       SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION4243                    ONE HUNDRED NINETEENTH CONGRESS4445                             SECOND SESSION4647                       TED CRUZ, Texas, Chairman4849JOHN THUNE, South Dakota             MARIA CANTWELL, Washington,50ROGER WICKER, Mississippi                Ranking51DEB FISCHER, Nebraska                AMY KLOBUCHAR, Minnesota52JERRY MORAN, Kansas                  BRIAN SCHATZ, Hawaii53DAN SULLIVAN, Alaska                 EDWARD MARKEY, Massachusetts54MARSHA BLACKBURN, Tennessee          GARY PETERS, Michigan55TODD YOUNG, Indiana                  TAMMY BALDWIN, Wisconsin56TED BUDD, North Carolina             TAMMY DUCKWORTH, Illinois57ERIC SCHMITT, Missouri               JACKY ROSEN, Nevada58JOHN CURTIS, Utah                    BEN RAY LUJAN, New Mexico59BERNIE MORENO, Ohio                  JOHN HICKENLOOPER, Colorado60TIM SHEEHY, Montana                  JOHN FETTERMAN, Pennsylvania61SHELLEY MOORE CAPITO, West Virginia  ANDY KIM, New Jersey62CYNTHIA LUMMIS, Wyoming              LISA BLUNT ROCHESTER, Delaware6364                 Brad Grantz, Republican Staff Director65           Nicole Christus, Republican Deputy Staff Director66                   Lila Harper Helms, Staff Director67                 Melissa Porter, Deputy Staff Director6869                            C O N T E N T S7071                              ----------72                                                                   Page73Hearing held on February 12, 2026................................     174Statement of Senator Cruz........................................     175Statement of Senator Cantwell....................................     376Statement of Senator Moran.......................................     577Statement of Senator Duckworth...................................     678Statement of Senator Wicker......................................    6679Statement of Senator Klobuchar...................................    7280Statement of Senator Sullivan....................................    7481Statement of Senator Lujan.......................................    7682Statement of Senator Budd........................................    7883Statement of Senator Markey......................................    798485                               Witnesses8687Hon. Jennifer Homendy, Chairwoman, National Transportation Safety88  Board..........................................................     889    Prepared statement...........................................    119091                                Appendix9293Response to written questions submitted to Hon. Jennifer Homendy94  by:95    Hon. Jerry Moran.............................................    8396    Hon. Maria Cantwell..........................................    8897    Hon. Tammy Duckworth.........................................    9398    Hon. John Hickenlooper.......................................   10199    Hon. Andy Kim................................................   105100101                         THE NTSB FINAL REPORT102                      ON THE DCA MIDAIR COLLISION103104                              ----------105106                      THURSDAY, FEBRUARY 12, 2026107108                                       U.S. Senate,109        Committee on Commerce, Science, and Transportation,110                                                    Washington, DC.111    The Committee met, pursuant to notice, at 10:17 a.m., in112room SR-253, Russell Senate Office Building, Hon. Ted Cruz,113Chairman of the Committee, presiding.114    Present: Senators Cruz [presiding], Wicker, Fischer, Moran,115Sullivan, Blackburn, Budd, Sheehy, Lummis, Cantwell, Klobuchar,116Markey, Duckworth, Lujan, and Fetterman.117118              OPENING STATEMENT OF HON. TED CRUZ,119                    U.S. SENATOR FROM TEXAS120121    The Chairman. Good morning. The Senate Committee on122Commerce, Science, and Transportation will come to order.123    Before I begin my opening statement, today marks the 17th124anniversary of the Colgan Air Flight 3407 accident in New York.125We remember the 50 lives lost as we somberly meet to discuss126another deadly aviation accident.127    Aviation safety relies on the Swiss cheese model to128mitigate and manage risk. Layers upon layers of human129intervention and technology are meant to close any130vulnerabilities or figurative holes left by the previous layer.131Unfortunately, just over 1 year ago, that safety system failed132just 3 miles from here at Ronald Reagan Washington National133Airport. For more than 15 years, pilots, controllers, and reams134of aviation data detected at least one near mid-air collision135each and every month at National Airport.136    In 2013, after a helicopter and plane on approach to DCA137nearly crashed into each other, controllers and helicopter138operators formed a working group to improve coordination in the139local airspace. That group met often, and at some point, even140elevated recommendations to revise and improve mapped flight141routes to show known hotspots, but their suggestions were142ignored. That's one of the many failures uncovered by the NTSB143that, had people responded differently, tragedy would have been144avoided last year.145    I want to commend NTSB Chairwoman Jennifer Homendy and all146of the NTSB staff for their efforts. They did yeoman's work to147complete the DCA crash investigation in just 12 months. In148addition to examining the causes of the DCA accident, the NTSB149made 50 recommendations to improve aviation safety. One of150those recommendations, arguably the most impactful one, should151be familiar. For the 18th time, let me repeat that, for the15218th time, the NTSB is urging aircraft in busy airspace to have153ADS-B on board.154    Had the Black Hawk and Bombardier CRJ been equipped to155receive ADS-B location signals on January 29, 2025, the pilots156would have been warned of each other's exact position nearly157one minute before impact, and 67 people would still be alive158today. Instead, the CRJ's pilots didn't see the helicopter159until a split second before impact, while the helicopter crew,160it appears, never saw the CRJ.161    The NTSB review revealed another major safety loophole.162Military aircraft were routinely ignoring rules that required163aircraft flying in busy airspace to transmit ADS-B signals.164Although planes don't share locations with each other via ADS-165B, they must broadcast such information to air traffic control,166but the Army uses a special carve-out so that it didn't have to167consistently comply with the broadcast mandate. Moreover, the168NTSB discovered that this particular helicopter's ADS-B Out169wasn't even configured correctly. After the January crash, the170FAA eliminated the military's blanket exemption, but just a few171weeks ago, a brand-new loophole was tucked into the annual172Defense Authorization Bill, making it easier for the military173to continue flying without ADS-B around DCA.174    If we learned anything from the DCA crash, it's that you175can't have a safe airspace when operators are following176different sets of rules. That's why our committee authored and177passed the bipartisan ROTOR Act. The ROTOR Act, which passed178the Senate unanimously in December, rescinds that new Defense179bill loophole and enacts the central NTSB recommendation of180this investigation.181    The ROTOR Act requires all aircraft in congested airspace182to broadcast their location to each other via ADS-B. The ROTOR183Act ensures a commercial airliner landing in a major airport184has visibility, in daytime or darkness, to any nearby aircraft,185whether it's a military helicopter or a general aviation pilot,186and vice versa. No more flying blind. The ROTOR Act will begin187to protect the flying public now, which is why the House should188pass it, and put it on the President's desk for his signature.189    Now, I've heard some faint grumbling from stakeholders and190others who want to put the same kind of loopholes into the191ROTOR Act that caused the DCA crash. Some want exemptions for192private jets, while a few airlines quietly carp about the cost193of safety-enhancing technology. These criticisms aren't valid,194and they are, frankly, disturbing. Flying can only be safe when195everybody follows the same standards. Why would we want to196exempt regional airlines from ADS-B given that Flight 5342 was197a regional airline?198    I hope my House colleagues don't wait for another accident199or for the NTSB to have to come back and recommend ADS-B for200the 19th time before acting. And the notion that somehow201private jets should receive a blanket exception makes no sense202whatsoever. I don't know how anyone can look in the eyes of the203victims' families and justify that argument. I also hope the204House doesn't try to resolve the dozens of other safety205recommendations from the NTSB, because we know this particular206one on ADS-B can start now and save lives.207    Today, there are planes taking off from Ronald Reagan208National Airport. Today, there are planes landing at Ronald209Reagan National Airport. There are planes that may have your210loved ones on them or my loved ones on them, and every single211day we delay we are putting our families in danger for no212reason whatsoever.213    In the room with us today, are loved ones of the 67 men,214women, and children who were killed in last January's crash.215I'm encouraged and inspired by your tireless advocacy for safer216skies. It pains all of us to know that your lives have been217irreparably changed. There's nothing we can do to bring back218your spouses, your children, your parents, your cousins, or219your friends, but I hope that we can turn your grief into220action. Thank you for working so hard to make sure that no221other family has to suffer the kind of tragedy that you're222feeling, the pain of each and every day.223    I now turn to Ranking Member Cantwell.224225               STATEMENT OF HON. MARIA CANTWELL,226                  U.S. SENATOR FROM WASHINGTON227228    Senator Cantwell. Thank you, Mr. Chairman, and this is a229very important hearing this morning. I feel like it's almost a230culmination of years to finally get a report so crisp and clear231about the failures of the FAA, and what it needs to do to232change its culture.233    I, too, want to remind and remember the individuals here234about the Colgan Air crash. Our heart still goes out to the235families affected by that incident, including people from236Seattle. I also want to say that the Colgan families have been237a constant presence in this room, and while that is not the way238the political system is supposed to work, where the victims239have to come and be the biggest advocates for safety, that is240certainly what the Colgan Air families have done. So, we241certainly remember them today.242    And I want to also just say, Mr. Chairman, that yesterday's243incident at El Paso reminds me of why this interagency244coordination is so important. If we can get into this kind of245conflict where the FAA is saying that we're going to shut down246airspace for 10 days, and then another agency is saying247something different, and there's concern about what is248happening in the airspace, it just seems to me that we have a249real problem of coordination between DOD and FAA, so we need to250resolve that. I hope that your calls for an interagency251briefing will be heeded, and that we will get to the bottom of252this. Not one more day needs to go by without that kind of253information and oversight for the public.254    But we are here today to thank Chair Homendy and the NTSB,255and to thank them for their recommendations and findings after256a thorough, long investigation into the tragic crash in DCA257last year. The loss of 67 souls when an Army helicopter258collided with American Airlines 5342 has weighed heavily on259many of us, but certainly the families who are most affected.260Our hearts go out to you.261    Many of the family members are here today, and I know they262will be following today's discussion very closely. You have263stood with us to make our aviation system safer, including your264support for the ROTOR Act, which was critical in trying to push265this legislation through the U.S. Senate, and, hopefully, to266get it to the President's desk.267    I want to thank Chair Homendy again for her work with her268team tirelessly delivering answers to these families. I know269that you deliver a lot of answers and information to us. I270think no one knows how hard that is in delivering the271information to the families. I know from our own air accidents272with the seaplane in Seattle, how trying to find the victims of273that crash, there's just so much work that goes into274communicating with the families, and so we thank you for that275as well. These answers demonstrate that this tragedy was a276result of many systematic failures and that that failed277everyone on Flight 5342, and the Army helicopters, and the air278traffic controllers. And so, this is part of a larger trend279where we have to be the ones that put a stop to this finally.280    We have witnessed multiple near misses between commercial281airline flights and military flights, including a helicopter282flying too close to DCA traffic last May, exposing283communication failures between the Pentagon air traffic control284tower and the DC tower, and a near mid-air collision between an285Air Force tanker and JetBlue flying from Curacao back to the286United States.287    These incidents are just unacceptable. So, we look forward288to the 14 recommendations that you are making today, especially289the issue of NTSB and the larger FAA reforms. I am concerned290that the NTSB found that the FAA and Army are dangerously over-291reliant on pilots to see-and-avoid. How can a congested292airspace rely on see-and-avoid other traffic around the293National Capital Region?294    The NTSB found these practices created an unacceptable295risk, especially without the help of a key safety technology296that we've already implemented in so many other aspects of our297airspace: ADS-B In and ADS-B Out. NTSB has also emphasized298having TCAS is not enough. Not enough. The CRJ pilots did not299get air traffic alerts at lower altitudes below 900 feet, and300pilot alerts are more limited if ADS-B In data is not feeding301into the system.302    Last week, the NTSB issued their 18th recommendation in 20303years on this type of technology: ADS-B In and Out. That304basically is the alert system that we expected in the digital305age to be implemented 20 years ago. So, recommending that all306aircraft are required to fly in a controlled airspace with this307to ensure pilots have real-time awareness and traffic alerts308both in the air and on the ground is just the last piece of an309aviation safety system safeguard that has been recommended for310years, and the question is why hasn't someone been doing it?311    Money cannot be the answer because the cost of lives has312been too great. The bipartisan ROTOR Act also is key in the313NTSB recommendations and it will help to save and strengthen314the oversight. NTSB reinforced that the FAA and Army had access315to safety data in years leading up to the crash that warned of316heightened risk of mid-air collisions in D.C., but the FAA317failed to act on that, as did the Army.318    So, NTSB's investigation of the DCA collision and the Air319Alaska door plug accident showed that the FAA's Safety320Management System has been superficial at best. While the FAA321has mandated SMS, a Safety Management System, which means when322you have a safety problem, you have to stop and fix it, that's323all that safety management system means. It means you have to324stop and fix it. It means don't keep going on production, don't325keep going on your system until you fix the safety risk. But if326you don't have a real SMS, then it really doesn't stop to fix327the safety concerns.328    That is why the legislation we passed this morning is a329start. We will hear from experts about why the FAA needs to do330this, similar to the expert witnesses that provided us so much331information about the MAX crashes. With the Committee's vote on332this today, I think we are one step closer, and we certainly333know that controllers who voiced safety concerns about334helicopter routes and stressful controller workloads were also335ignored by FAA managers. So, we have to fix this as well.336    Mr. Chairman, I stand ready to work with you on getting the337ROTOR Act onto the President's desk. This is critical338legislation that will help now, and we also have more work to339do because this sequence of events and the events at El Paso340show us that we have real communication issues, and we must do341our oversight role. So, thank you, Mr. Chairman, and I look342forward to Chair Homendy's important testimony this morning.343    The Chairman. Thank you. I now recognize Chairman Moran for344an opening statement.345346                STATEMENT OF HON. JERRY MORAN,347                    U.S. SENATOR FROM KANSAS348349    Senator Moran. Mr. Chairman, thank you, and I join in350supporting and commending your opening statement, you, and the351Ranking Member. I appreciate the demands and sentiments that352you both expressed. I appreciate the way that you both have353carried out this--conducting the hearings of allowing our354subcommittee to take a significant role in pursuing safety355measures, and really directing the leadership, providing the356leadership to this committee to take concrete actions to357prevent other accidents from occurring in the future.358    We continue to mourn the losses of the victims. We express359our condolences on behalf of citizens of my state. We express360our condolences to the members of the family who are present361here today and those who are not. We remember the heroism that362was displayed on the night of January 29 at DCA at Reagan363National Airport as the heroic efforts were made to find and364save lives.365    And I commend NTSB Chair Homendy and her team for their366significant and diligent work, the calls for action that have367been made by the Chairman and the Ranking Member. It seems to368me that I can't remember the circumstance in which we had the369factual basis to be more unified in a response than what we370have with the presence of what Chair Homendy and her team have371provided us.372    In so many instances in Congress, we get this point of373view, and this point of view, and then we try to hash out who's374telling us the truth and what matters in the conversation. And375Chairman Homendy, I can't find a circumstance in which NTSB376didn't do its job in a way that none of us should have doubts377about the conclusions you reached and the recommendations you378have provided. There is no excuse for us not to achieve the379goal of those recommendations by passing legislation, and380perhaps as important, maybe even more importantly, to insist381that once we pass legislation, that legislative effort is382rewarded by action by the FAA and others so that it is383implemented fully in a way that makes a difference.384    I've been in Congress enough to see the circumstances in385which we often pass legislation. We issue the press release and386say we've done something, but we haven't done anything until387we've done something. And that means the administration, the388execution of those laws have to be fully fulfilled. It's our389responsibility, our responsibility in this committee and as390members of the U.S. Senate, to turn the conclusions of the NTSB391report into action. Congress must determine what steps we need392to take following those recommendations, and we need to make393sure that the FAA, the Army, and all others are following those394recommended and enacted safety measures.395    Following a yearlong investigation, NTSB has affirmed again396that passing and implementing the ROTOR Act could have, and I397would say, would have, saved lives on January 29, 2025. The398passage and implementation of the ROTOR Act is critical to399achieving the safety of our skies. I urge the House not to400delay in its passage.401    The Chairman made the point that every day that goes by402creates a greater risk for others. If there's something that403needs to be addressed in the ROTOR Act, don't delay. Let's have404the conversation and fix something. If there's something405missing or wrong, that doesn't mean watering it down. It means406fully implementing the ROTOR Act as passed just as soon as we407make certain we've got it right.408    Additionally, Congress must continue to provide the funding409that is necessary to further modernize our aviation system,410advance new technologies. At the FAA, the FAA Administrator was411in front of us with a roundtable discussion yesterday about412implementation of advanced technologies in the system, and we413must continue to recruit, train, and support air traffic414controllers. No steps back. Moving forward. Act on the415recommendations and make sure that January 29 never occurs416again. Mr. Chairman, I thank you. I appreciate the opportunity417I've had to work with you, Senator Cantwell, and Senator418Duckworth in this regard.419    The Chairman. Thank you. Ranking Member Duckworth.420421              STATEMENT OF HON. TAMMY DUCKWORTH,422                   U.S. SENATOR FROM ILLINOIS423424    Senator Duckworth. Thank you, Mr. Chairman. Thank you also425to Ranking Member Cantwell, and to my Chairman of the426Subcommittee, Senator Moran, who has been a joy to work with as427a partner on this issue.428    Chair Homendy, I want to thank you and the entire team at429the NTSB for carrying out your mission without fear or favor to430independently investigate the DCA mid-air collision. You431provided FAA, DOD, Congress, and most importantly, the families432of the victims of Flight 5342, clear answers explaining how433this deadly crash happened, and you've given us a framework to434ensure such utterly preventable tragedies never happen again.435    Many of the NTSB's findings from the DCA mid-air collision436point to issues that have persisted for years: the urgent need437to address the air traffic controller shortage, the need for438advanced safety technology, and the unacceptable lack of439coordinated communications between the FAA and the DOD. I've440repeatedly sounded the alarm on these issues and I haven't been441the only one. The NTSB found that in prior years, rank-and-file442controllers working in the DCA tower sought spacing of at least4434 miles in trail, while Potomac TRACON controllers asked for a444decrease in DCA's dangerous airport arrival rate. Yet, FAA445management failed to act on the warnings being raised by an446understaffed and overworked controller workforce that was447clearly struggling to manage the busiest, most congested runway448in the United States.449    FAA's failure in the face of blaring alarm bells screaming450out that it was a matter of when, not if, one of the near451misses at DCA would become a deadly tragedy is, unfortunately,452emblematic of a chronic crisis that's plagued FAA for years453under multiple administrations. An unacceptable culture of454complacency.455    Chair Homendy, 826 days ago, you sat in that very chair in456this very room to testify alongside FAA at a hearing I convened457on addressing close calls to improve aviation safety. That day,458your message could not have been clearer as you warned459everyone, and I'm quoting you, ``The concerning uptick in such460incidents is a clear warning sign that the U.S. aviation system461is sharply strained. We cannot wait until a fatal accident462forces action. We must act before there is a tragedy.'' And463your message was embraced by many in this chamber in a464bipartisan way.465    As I recall, I opened that hearing by stating that our466Nation is experiencing an aviation safety crisis. Near misses467are happening way too frequently, and I refuse to be complacent468in waiting to act until the next runway incursion becomes a469fatal collision. Eight hundred and twenty-six days ago, we had470that exchange.471    That recognition is why I fought so hard to protect the4721,500-hour rule, and to stop Congress from adding more flights473to DCA. Unfortunately, on that latter fight, I and the members474of Virginia and Maryland delegations were soundly defeated. And475as the NTSB report found, the intense traffic demand in the476region forced Potomac TRACON to routinely reduce the trail477spacing between aircraft, which increased the workload on DCA478air traffic controllers.479    Tragically, the one audience that refused to hear these480messages was the one entity with the authority to act: the FAA.481And it seems as if the FAA's complacency has only hardened over482time, regardless of which political party controls the White483House. Again, this is a bipartisan failure.484    The NTSB report showed that the FAA failed to conduct485annual reviews of helicopter routes in the DCA airspace leading486up to the DCA mid-air collision, reviews that would have shown487the helicopter route was too close to an approach runway. A488review of helicopter routes would have also potentially489prevented some of the 15,000 close calls between airplanes and490helicopters in the DCA airspace that took place between October4912021 and December 2024.492    We have long known about the mounting strain on air traffic493controllers. That is why I will continue to reiterate that any494investment in our ATC system must be informed by and prioritize495the most important asset of the ATC system: its people.496    The FAA needs to improve how it reviews relevant safety497data on hotspots, how critical feedback from frontline498controllers is funneled to decisionmakers, and most499importantly, how to ensure enough rested, well-trained500employees are at work every day with all the tools that they501need.502    The House must also act to pass the ROTOR Act so we can503codify many of the NTSB's recommendations. But even if that504happens, there is more work to do because the bottom line is505that any system that repeatedly forces pilots to take emergency506evasive actions to save lives is a broken system. We need to507prevent the conditions that will lead to even a near miss.508    So, I thank you again, Chairwoman Homendy. You have been a509wonderful resource to this committee. I also thank the510leadership of the Committee, the Chairman, the Ranking Member,511and again my partner on the Subcommittee, Chairman Moran.512    Thank you, I yield back, Mr. Chairman.513    The Chairman. Thank you. I now want to introduce our514witness, Ms. Jennifer Homendy, the Chairwoman of the National515Transportation Safety Board. The NTSB investigates all civilian516aviation accidents and other major roadway, pipeline, rail, and517marine accidents. We thank Chairwoman Homendy and the NTSB518staff for their work to complete the investigation of the D.C.519mid-air collision in one year.520    Chairwoman Homendy, you're recognized for five minutes.521522   STATEMENT OF HON. JENNIFER HOMENDY, CHAIRWOMAN, NATIONAL523                  TRANSPORTATION SAFETY BOARD524525    Ms. Homendy. Chairman Cruz, Ranking Member Cantwell,526Chairman Moran, Ranking Member Duckworth, and members of the527Committee, thank you for the opportunity to be here today to528discuss our investigation of the mid-air collision that529occurred just over a year ago near Ronald Reagan Washington530National Airport.531    As we discuss NTSB's thorough fact-finding, extensive532analysis, and comprehensive safety recommendations, I want to533make one thing abundantly clear. We should not be here today.534In this room, sitting with us or watching online, are family535members of the 67 people who died on January 29. We are so536sorry for your loss. You should not have to be here, because as537I've said many times, this was 100 percent preventable. It was538preventable.539    In fact, now that our investigation has concluded, I can540say without a shadow of a doubt that we've seen this before.541We've investigated similar mid-air collisions going back542decades, and we've issued safety recommendations like ADS-B In543over, and over, and over again aimed at preventing just these544kinds of collisions, recommendations that have been rejected,545sidelined, or just plain ignored.546    As Chairman Cruz and Congressman Onder recently wrote,547``Last year's crash was not an isolated incident. It was the548fatal result of years of unheeded warnings.'' Years.549    Fifty-seven years ago, in 1969, we investigated a mid-air550collision between Allegheny Airlines Flight 853 and a small551Piper Cherokee outside Shelbyville, Indiana. Eighty-three552people died. Soon after, the Board held a hearing and issued 14553recommendations aimed at preventing future mid-air collisions,554including our first ever recommendation for FAA to555expeditiously develop and implement a collision avoidance556system in all civil aircraft.557    For perspective, that same year we put a man on the moon,558and yet, it took another two decades and a congressional559mandate for FAA to finally implement TCAS. TCAS didn't prevent560this accident, but there are technologies that are readily561available that could have. If I could pull up my slide--while562that's coming up, with ADS-B In and what I'm--maybe I'll give563it a second. With ADS-B In--hopefully it'll come up: technical564difficulties. I'll continue on and when it comes up, I'll565explain.566    With ADS-B In----567    Senator Cruz. I don't do the AV.568    Ms. Homendy. Yes, me, too. There we go. So, on the left569side is the PAT25, and on the right side is Flight 5342. We did570a laser scan of exemplar aircraft, and so the gray around is571the structure, and then, of course, you see the night vision572goggles on the left side.573    With ADS-B In, the helicopter pilots would have gotten an574audible alert, if it was in their headset, at 48 seconds prior575to collision when they were over Hains Point, allowing them to576take action. They never got a single alert. They had no idea577that it was--that 5342 was coming from the left, and we can578talk about that in the hearing, if you'd like.579    On the right side, outside--looking out of 5342, the CRJ580would have gotten their first alert with ADS-B In at 59 seconds581prior to collision. Instead, they got a TCAS alert that just582said, ``Traffic, traffic,'' and what they need to do is look583out, and figure out where that traffic is, and take action,584which is very difficult to see in many circumstances. And we585can talk about why that is, too.586    But, ``Traffic, traffic,'' 19.5 seconds prior to collision.587They didn't actually recognize that the helicopter was there588until 1 second, 1 second prior to collision. Had they gotten589ADS-B In, they would have gotten something more along the lines590of, ``Traffic 12 o'clock, 2 nautical miles, 500 feet below,''591then they could have taken action. What we're talking about592here is lifesaving information for pilots. It's information.593    In 2008, we again called on the FAA to implement ADS-B In.594We stated, ``The Safety Board believes that the benefits of595ADS-B technology warrant rapid adoption,'' and that, ``the596equipage of aircraft with ADS-B In capability will provide an597immediate and substantial contribution to safety underline,598especially in and around airports.'' We said that in 2008. What599if the FAA had acted?600    I want to be clear though: What happened at DCA could601happen anywhere in our airspace. The NTSB has for years, long602before this tragedy at DCA, been sounding the alarm about the603safety risks of see-and-avoid. Yet we continue to rely on see-604and-avoid to separate traffic throughout the national airspace605when technology is available to provide pilots with the606situation awareness they need and deserve to ensure safety.607    See and avoid is exactly what it sounds like. A pilot has608to visually acquire an approaching aircraft, recognize a609collision course, decide on action, execute the control610movement, and allow the aircraft to respond in a matter of611seconds.612    Since 2008, we've investigated 211 aviation accidents and613incidents resulting from a mid-air collision or loss of614separation, which killed 281 people and injured 12 others. In615almost half, we raised concerns with see-and-avoid. These616include many in your home states. And I know not all the617Senators are here, but I'm going to pretend they are because we618have--we investigated since 2008 where we stated our concerns.619    Sixteen in Texas, one in Kansas, 15 in Alaska, including620the 2019 tragedy in Ketchikan where six people died and 10 were621injured, and I was the Board Member on scene. And we discussed622at length in that report, ``the lack of ADS-B In requirements623for Part 135.'' Two in North Carolina, one in Missouri, two in624Utah, one in Ohio, one in Wyoming, one in Michigan, two in625Wisconsin, one in Illinois, 12 in Nevada, seven in Colorado,626two in Pennsylvania, four in New Jersey, and now, one in D.C.627    The fact is, our aviation system is the safest in the world628for a reason. Thanks to the work of you all, the work of the629entire Congress, our work at NTSB, the work of our partners at630FAA, redundancy has been built into the system to prevent631catastrophe, but that doesn't mean system flaws don't exist.632    Our aviation system is complex. The National Airspace633System is complex, but it is generally safe, which means many,634many things have to go wrong for a tragedy like this to occur,635and we have an obligation to fix those vulnerabilities.636    The question before us is: How many more people need to die637before we act? How many more people need to die before we act?638I've heard others say it can't be done. It's too expensive. The639technology isn't available. The risk is only at DCA. None of640that is true. Absolutely none of it. The technology is641available with an iPhone, or an iPad, a headset--this is mine--642and a cable, and a few hundred dollars for a receiver. That's643what this is: ADS-B In receiver. Even the oldest general644aviation planes can be outfitted with ADS-B In.645    The gentleman behind me who is the Director of our Office646of Aviation Safety has no electricity in his plane. This is647what he has. He has ADS-B In with an iPad. In commercial648aviation, American Airlines has equipped its entire fleet of649more than 300 Airbus A321 aircraft with ADS-B In. I was in the650cockpit to look at it. Flew to Phoenix from here. Do you know651how much it cost them? I asked the COO: less than $50,000 per652plane to retrofit.653    Boeing offers it on new planes. Airbus offers it on new654planes. Gulfstream includes it. It is possible the technology655is available so we can solve this problem and save lives. We656should not have to be here, and we wouldn't be if the NTSB's657warnings had been heeded.658    Exactly 17 years ago, Colgan Air Flight 3407 crashed in New659York. 50 people died. In response to that accident, we issued66025 new safety recommendations to the FAA. Ten were closed,661unacceptable action, because they weren't going to do anything662about it. In the letters they told us don't ask anymore. One is663open, unacceptable.664    We cannot allow this to happen again. Every single one of665the 50 safety recommendations we issued in response to the DCA666catastrophe must be acted on immediately. The FAA has had667multiple, multiple opportunities to implement NTSB668recommendations. Time after time, they've declined. Now, we669need action. Whether that's through the FAA--and they can670implement a lot of the recommendations we just issued, some of671them are simple, and we can talk about that--Army, Department672of War, or an Act of Congress.673    We cannot accept having to be here years from now lamenting674yet more inaction. Not only must we do this for the 67 people675who died on January 29, we must do this for all those who lost676their lives in accidents that the NTSB has investigated. We677must do this for their families. We must do this for future678generations, lives we can still save.679    Chairman Cruz, Ranking Member Cantwell, Chairman Moran,680Ranking Member Duckworth, I am immensely grateful to you and681the members of this committee for your robust advocacy via the682bipartisan ROTOR Act. Not only do I want to thank you for your683incredible leadership, but I mean this from the bottom of my684heart: thank you for your willingness to stand up and do what's685right for safety.686    I look forward to working with you to create a future where687no family ever has to endure such tremendous loss. Thank you.688    [The prepared statement of Ms. Homendy follows:]689690          Prepared Statement of Jennifer Homendy, Chairwoman,691                  National Transportation Safety Board692    Good morning. My name is Jennifer Homendy, and I'm honored to serve693as Chairwoman of the National Transportation Safety Board (NTSB).694    As you know, the NTSB is an independent Federal agency charged by695Congress with investigating and establishing the facts, circumstances,696and cause or probable cause of all civil aviation accidents and serious697incidents in the United States and defined accidents in all other modes698of transportation, including roadway accidents, grade crossing699incidents, railroad accidents, pipeline accidents, major marine700casualties occurring on or under the navigable waters, internal waters,701or the territorial sea of the United States, and other accidents702related to the transportation of individuals or property when the Board703decides the accident is catastrophic, the accident involves problems of704a recurring character, or the investigation of the accident would carry705out our statutory requirements. In addition, the NTSB carries out706special studies concerning transportation safety and coordinates the707resources of the Federal government and other organizations to aid708victims and their family members impacted by major transportation709disasters.710    Thank you for the opportunity to appear before you today to discuss711our investigation of the midair collision between a Sikorsky UH-60L712helicopter, operated by the U.S. Army under the callsign PAT25, and an713MHI (Mitsubishi Heavy Industries) RJ Aviation (formerly Bombardier) CL-714600-2C10 (CRJ700), N709PS, operated by PSA Airlines as American715Airlines flight 5342. These aircraft collided in flight about 0.5 miles716southeast of Ronald Reagan Washington National Airport (DCA),717Arlington, Virginia, about 8:48 pm eastern standard time on January 29,7182025.719    The 2 pilots, 2 flight attendants, and 60 passengers on board the720airplane and all 3 crewmembers on board the helicopter died. Flight7215342 was operating under the provisions of Title 14 Code of Federal722Regulations Part 121 as a scheduled domestic passenger flight from723Wichita Dwight D. Eisenhower National Airport, Wichita, Kansas, to DCA.724PAT25 originated from Davison Army Airfield (DAA), Fort Belvoir,725Virginia, for the purpose of the pilot's annual standardization726evaluation flight with the use of night vision goggles (NVGs). Night727visual meteorological conditions prevailed in the area of DCA at the728time of the accident.729    PAT25 departed DAA and landed at sites in Virginia and Maryland730before the crew turned south toward Washington, DC, and was cleared by731the DCA tower controller (who was working combined local control and732helicopter control positions) to transition the DCA airspace via733helicopter Routes 1 and 4 before proceeding back to DAA. The helicopter734joined Route 1 near Cabin John, Maryland, and followed the Potomac735River southbound at low altitude, passing the Key Bridge, Memorial736Bridge, Tidal Basin, and Hains Point before continuing onto Route 4.737    At the same time, flight 5342 was approaching DCA on an instrument738flight rules flight that had been uneventful during departure, cruise,739and initial descent. The airplane was inbound from the south on a740visual approach to runway 1 when the DCA tower controller asked the741flight crew if they could accept runway 33 instead.742    Our final investigation report is being formatted for an743anticipated public release date of February 17, 2026. To enable the744Committee to adequately prepare for the hearing, we are providing the745analysis section of the report in full here:746Analysis747Introduction748    The accident occurred when PAT25, which was transiting southbound749on Helicopter Route 4, impacted flight 5342, which had just turned onto750final approach for runway 33 at DCA. At the time of the accident, the751DCA local control (LC) controller was working both the LC and752helicopter control (HC) positions. About 5 minutes before the753collision, the first officer (FO) of flight 5342 contacted the tower754while inbound on approach for landing on runway 1. The LC controller755asked if they could switch to runway 33. After deliberation, the crew756determined that they could accept the runway change and the FO informed757the controller, who then instructed the flight crew to circle to runway75833 and issued a landing clearance.759    About 2 minutes before the collision, when the aircraft were about7606.5 nautical miles (nm) apart, the LC controller issued a traffic761advisory to PAT25, informing them of a ``C-R-J just south of the Wilson762Bridge circling to runway three three''; however, the helicopter's763cockpit voice recorder (CVR) captured this transmission as, ``PAT two764five traffic just south of Wilson Bridge is a C-R-J at one thousand two765hundred feet for runway three three,'' indicating that the PAT25 crew766did not receive the word ``circling'' as part of the advisory due to767degraded radio reception. At this time, PAT25 was crossing the Tidal768Basin, and flight 5342 was one of five airplanes approaching DCA in769darkness from the south. The PAT25 instructor pilot (IP) stated to the770controller that they had the traffic in sight and requested visual771separation, which the controller approved.772    The LC controller contacted the helicopter crew again about 20773seconds before the collision and asked the crew if they had the CRJ in774sight, followed by instructions to ``pass behind that C-R-J''; however,775the helicopter CVR indicated that the ``pass behind that'' portion of776the transmission was blocked by a 0.8-second mic key from within the777helicopter. The IP indicated that they had the airplane in sight and778requested visual separation, which the controller again approved. About7796 seconds before the collision, the IP stated to the pilot, ``alright780kinda come left for me ma'am, I think that's why he's asking . . .781we're kinda . . . out towards the middle.'' The pilot acknowledged and782the helicopter subsequently started to move left. The aircraft collided783at an altitude about 278 feet mean sea level (msl) about 2,500 feet784from the runway 33 threshold.785    The analysis discusses the accident sequence and evaluates the786following safety issues:787788   the extensive use of pilot-applied visual separation and the789        inherent limitations of the see-and-avoid collision avoidance790        concept;791792   controller workload, position combining, and communications793        practices;794795   the design of the Washington, DC, area helicopter routes and796        operators' awareness and interpretations of route structure and797        limitations;798799   the limitations of the traffic awareness and alerting800        systems on both aircraft;801802   shortcomings in Federal Aviation Administration (FAA) and803        U.S. Army safety assurance and risk management processes;804        including lack of proactive data sharing and analysis to805        identify and mitigate midair collision risk; and806807   deficiencies in FAA safety culture and postaccident drug and808        alcohol testing procedures.809810    The NTSB investigation's comprehensive review of the accident811circumstances determined that the following factors did not contribute812to the cause of the accident:813814    Flight 5342 crew qualifications. The pilots of flight 5342 were815certificated and qualified in accordance with Federal regulations.816[FINDING 1]817    Flight 5342 crew medical factors. The pilots of flight 5342 were818medically qualified for duty, and available evidence does not indicate819that they were impaired by effects of medical conditions or substances820at the time of the accident. [FINDING 2]821    Flight 5342 crew fatigue.\1\ Review of the flight 5342 pilots' time822since waking and sleep opportunities in the days before the accident823indicated that the pilots were unlikely to have been experiencing824fatigue. [FINDING 3]825---------------------------------------------------------------------------826    \1\ In this report, ``fatigue'' is used consistent with human827performance science to describe performance impairment associated with828insufficient sleep, circadian disruption, and/or extended time awake.829Operational factors such as high workload, sustained attention demands,830stress, and task saturation can also degrade vigilance and situational831awareness, but these effects are analytically distinct from fatigue and832are addressed separately in the report.833---------------------------------------------------------------------------834    PAT25 crew qualifications. The pilot, IP, and crew chief onboard835PAT25 were qualified and current in their positions as designated by836the unit commander in accordance with Army regulations. [FINDING 4]837    PAT25 crew medical factors. The pilot, IP, and crew chief of PAT25838were medically qualified for duty, and available evidence does not839indicate that they were impaired by effects of medical conditions or840substances at the time of the accident. [FINDING 5]841    PAT25 crew fatigue. Review of the PAT25 three crewmembers' time842since waking and sleep opportunities in the days before the accident843indicated that the crew were unlikely to have been experiencing844fatigue. [FINDING 6]845    Airplane mechanical factors. The airplane was properly846certificated, equipped, and maintained in accordance with 14 Code of847Federal Regulations (CFR) Part 121. The airplane was operated within848its weight and balance limitations throughout the flight. Examination849of the airplane revealed damage consistent with an in-flight collision850and subsequent impact with water, and there was no evidence of any851structural, system, or powerplant failures or anomalies. Review of852surveillance videos indicated that the airplane's wing navigation,853landing/taxi, and anti-collision strobe lights were operating at the854time of the collision. [FINDING 7]855    Helicopter flight controls, rotor system, and powerplants. The856helicopter was properly certificated, equipped, and maintained in857accordance with U.S. Army regulations. Review of helicopter maintenance858records did not reveal any open discrepancies or anomalous trends that859contributed to the accident. The helicopter was operated within its860weight and balance limitations throughout the flight. Examination of861the helicopter revealed damage consistent with an in-flight collision862and subsequent impact with water, and there was no evidence of any863structural, main or tail rotor system, flight control system, or864powerplant failures or anomalies. Review of surveillance videos865indicated that the helicopter's right and tail position lights, the866landing light, as well as both upper and lower anti-collision lights,867were operating at the time of the collision. [FINDING 8]868    Air traffic controller qualifications and tower staffing. The869operations supervisor (OS) and four controllers who were working in the870DCA airport traffic control tower (ATCT) cab at the time of the871accident were properly certified, qualified in accordance with Federal872regulations and facility directives, and current. [FINDING 9] Although873the DCA ATCT facility was not staffed to its target level at the time874of the accident, the number of staff in the tower at the time of the875accident was adequate and in accordance with FAA directives. [FINDING87610] Therefore, the NTSB concludes that the decision to combine the HC877and LC positions was not the result of insufficient staffing, and878personnel were available to staff the HC and LC positions separately879had the OS chosen to do so. [FINDING 11]880    Controller medical factors. The LC controller, assistant local881control (ALC) controller, and OS were medically qualified for duty, and882available evidence does not indicate they were impaired by effects of883medical conditions at the time of the accident. [FINDING 12]884    Controller fatigue. Review of the LC and ALC controllers' and OS's885time since waking and sleep opportunities in the days before the886accident indicated that the controllers, including the OS, were887unlikely to have been experiencing fatigue. [FINDING 13]888    Weather conditions. Visual meteorological conditions prevailed in889the area at the time of the accident. A review of observations recorded890throughout the night of the accident revealed no evidence of any local891atmospheric pressure anomalies that would have impacted barometric892altimeter readings. [FINDING 14]893    Airport response. Metropolitan Washington Airports Authority (MWAA)894aircraft rescue and firefighting (ARFF) and airport operations staff895responded immediately and in accordance with applicable emergency plans896and regulatory requirements, deploying land-and water-based resources,897and coordinating mutual aid under complex nighttime and on water898conditions. [FINDING 15]899Accident Sequence900Controller Performance901Workload and Resource Management902    Because the LC and HC positions were combined on the night of the903accident, the LC was not only responsible for providing services to the904arriving and departing fixed-wing aircraft, but had the added905responsibility of providing services to numerous helicopters that were906transitioning the airspace. In the 20 minutes before the accident, the907total number of aircraft that the LC controller was handling fluctuated908between 7 and 12 aircraft. In a postaccident interview, the LC stated909that he felt ``a little overwhelmed'' about 10 to 15 minutes before the910accident, and that he felt the volume was manageable when ``one or two911helicopters'' left the airspace. This statement was consistent with a912peak in observed traffic volume of 10 aircraft around this time (5913helicopters and 5 airplanes); 1 helicopter subsequently departed the914airspace at 2040:28, or 7:31 before the collision. The LC controller915reported that he would have asked to have the HC and LC positions916staffed separately if he received two more helicopters.917    In the 2 minutes before the accident, there were a total of 29918transmissions between the LC controller and airplanes/helicopters on919his frequency, and about 90 seconds before the collision, the number of920aircraft on the LC controller's frequency increased to 12. During that921time, the controller spoke to or received communications from six of922those aircraft: three inflight helicopters, one inflight airplane, and923two airplanes on the ground. The other six aircraft, with which the924controller did not directly communicate during the 2 minutes before the925accident, but which he was still responsible for maintaining awareness926of, included two inflight helicopters, two inflight airplanes, and two927airplanes on the ground.928    Human factors research has consistently shown that in air traffic929control (ATC) operations, voice communications reliably capture and930direct controller attention toward the aircraft involved. Several931studies have shown that auditory communication events--including932issuing clearances and receiving pilot readbacks--function as933attentional anchors that trigger cognitive focus and updates to the934controller's mental representation of that aircraft's trajectory and935status (Endsley and Rogers 1997; McGee, Mavor, and Wickens 1997).936Therefore, the LC controller's moment-to-moment subject attention937allocation can be reasonably inferred from the aircraft with which he938was communicating at any given point in time.939    The complexity of the airspace and limited airfield surface area at940DCA require controllers to carefully coordinate the flight paths and941timing of aircraft taking off, landing, and transitioning through the942airspace and to issue instructions and clearances as necessary to943efficiently facilitate these various flight operations. The LC944controller's communications in the 2 minutes before the accident are945consistent with his continuous shifting of priorities between airborne,946ground, and transitioning aircraft.947    After initially approving PAT25's request to maintain visual948separation from flight 5342, he turned his attention to an airplane949waiting to depart, informing them about traffic three miles out950circling to runway 33 (flight 5342) and additional traffic on a six-951mile final approach for runway 1, and instructing them to line up and952wait on the runway. At 2046:29.1 (about 1:30 before the collision), an953Air Force helicopter checked in on the frequency, along with a954simultaneous transmission from an inbound American Airlines airplane.955The LC controller instructed the Air Force helicopter to standby, then956instructed a landing airplane to continue their landing roll to957``taxiway November.'' A medical transport helicopter then contacted the958tower. The LC controller cleared the airplane waiting to depart runway9591 for an ``immediate takeoff,'' as the airplane needed to be clear of960the intersection of runways 1 and 33 before flight 5342 crossed the961runway 33 threshold for landing. About 2046:58, the LC controller962replied to the Air Force helicopter, which was west-southwest of the963airport, and approved their requested route of flight. About 45 seconds964before the collision, the American Airlines airplane that had attempted965to contact the tower at the same time as the Air Force helicopter966transmitted their location on the runway 1 approach; however, that967transmission was stepped on by the medical transport helicopter's968second transmission to tower. The LC controller then approved the969medical transport helicopter's request to transition through the Class970B airspace. A conflict alert was audible during two brief mic keys from971the controller at 2047:37.8, and would have been visible on the972controller's control tower radar display (CTRD). Less than 2 seconds973later, about 20 seconds before the collision, the LC controller asked974PAT25 if they had the CRJ in sight. Three seconds later, the LC975instructed PAT25 to pass behind the CRJ. PAT25 said it had the aircraft976in sight and requested visual separation; the LC controller stated,977``vis separation.'' The American Airlines airplane inbound on the978runway 1 approach then contacted the tower a third time, and the LC979controller was communicating with that airplane when the collision980occurred.981    Given the LC controller's statement that he felt ``a little982overwhelmed'' with a traffic volume of ten aircraft, it is likely he983began to feel overwhelmed again in the 2 minutes before the accident984when traffic volume increased. A review of the DCA ATCT standard985operating procedures (SOPs) and training documents did not indicate any986guidance specifically related to controller workload and how and when987controllers should ask for relief.988    Where a controller's attention is focused can influence the amount989of time it takes to recognize and respond to an unexpected event. A990study that evaluated scanning patterns and detection times of expert991tower controllers to abnormal events found that the controllers'992average detection times, beginning from the onset of the abnormal993event, ranged from 14 seconds to 204 seconds (Crutchfield et al.,9942021), which could lead to adverse outcomes for time-critical safety995events. The conflict alert system acts as a safety net to assist996controllers responding to traffic conflicts in a timely manner. During997the 2 minutes before the accident, the LC controller was communicating998with aircraft located primarily south and west-southwest of the999airport; therefore, his attention would have been focused in that1000direction. Just before the conflict alert activated, the LC controller1001was communicating with a medical transport helicopter located about 161002miles west of the airport. The LC controller likely would have looked1003at the CTRD to confirm that helicopter's location. The LC controller1004recalled that he noticed the conflict between PAT25 and flight 53421005during his scan and queried PAT25 to ensure that they still had the1006airplane in sight, which PAT25 confirmed.1007    Situation awareness forms a basis for decision-making and is1008defined as the ``perception of the elements in the environment within a1009volume of time and space [Level 1], the comprehension of their meaning1010[Level 2], and the projection of their status in the near future [Level10113]'' (Endsley, 1988).\2\ Figure 1 presents an illustration of the1012situation awareness concept. Situation awareness is not only what the1013controller is perceiving in the current air traffic situation (level 1)1014but how they interpret that information (level 2) and use it to project1015the future state of air traffic (level 3) moving in their airspace.1016Levels 2 and 3 are especially critical in the air traffic environment1017because it is dynamic and constantly changing.1018---------------------------------------------------------------------------1019    \2\ These three levels of situation awareness, which are1020sequential, are followed by decisions and performance of actions.10211022[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]10231024    Recognizing an impending collision requires information to be1025perceived from the environment, stored in working memory, and1026interpreted against knowledge stored in long term memory, allowing1027controllers to identify familiar situations, predict future events, and1028determine an appropriate response (Wickens, Mavor, and McGee, 1997).1029Controllers must routinely monitor the current state of an aircraft and1030predict its future location in relation to other aircraft (Endsley,10311995). Conflicts that develop slowly, particularly at night, are1032inherently difficult for people to recognize due to reduced visual cues1033and the fact that gradual change can reduce situation awareness and1034delay recognition.1035    Controllers must maintain awareness of each aircraft they are1036managing (to include, for example, location, altitude, and airspeed)1037and anticipate where that aircraft will be in the seconds and minutes1038to follow. A controller's ability to maintain situation awareness is1039impacted by their workload and divided attention. As remaining1040cognitive resources are reduced with increasing workload (such as1041increasing traffic complexity, traffic volume, and/or radio1042communications), a controller's ability to maintain situation awareness1043is reduced. Because the LC was working the combined LC and HC1044positions, he was required to manage and maintain awareness of fixed-1045wing aircraft arrivals and departures as well as the movements of1046helicopters in the airspace, which required dividing his attention1047between airborne, ground, and transiting traffic. The NTSB concludes1048that keeping the HC and LC positions continuously combined on the night1049of the accident increased the LC controller's workload and negatively1050impacted his performance and situation awareness. [FINDING 16]1051    It is also likely that the controller was using expectation-driven1052processing, which directs a person's attentional focus. When events1053occur as expected or are routine, such as a pilot correctly reading1054back a clearance or adhering to a published flight path, information1055processing occurs rapidly with minimal effort. This expectation can1056lead to errors if a pilot or aircraft does not behave as expected. In1057this case, the controller expected that PAT25 would remain clear of1058flight 5342 because the PAT25 IP stated that they had the airplane in1059sight and would maintain visual separation. The frequent use of pilot-1060applied visual separation reinforces the expectation that the pilot of1061one aircraft will maintain separation from another aircraft, and1062because it has repeatedly worked as expected, it can be more difficult1063for a controller to notice deviations, especially when workload is1064high. It is likely that the controller did not expect the conflict1065between PAT25 and flight 5342 to occur, and felt comfortable dividing1066his attention between the accident aircraft and the numerous other1067aircraft under his control at the time of the accident.1068    The primary duties of the ALC control position were to alert the LC1069controller of any unusual situations or traffic conflicts, maintain1070surveillance of the local traffic pattern and landing area, and assist1071the LC controller with monitoring of aircraft on final via the CTRD.1072These duties would be accomplished by scanning the airspace as well as1073the tower displays. When the HC and LC positions were combined, the ALC1074position had the additional duty of monitoring the helicopter and1075airplane frequencies. In a postaccident interview, the ALC controller1076recalled that she was ``writing down what the different helicopters1077were doing'' when she heard the conflict alert and the LC controller1078asking PAT25 if they had the CRJ in sight, then instructing PAT25 to1079pass behind the CRJ.\3\ Monitoring traffic is a workload-intensive1080task, and, like the LC, the ALC was also subject to high workload in1081the minutes before the accident. If the LC and HC positions had been1082staffed separately, the LC and ALC would have only been working fixed-1083wing traffic, and another controller would have been working helicopter1084traffic. This would have reduced the number of aircraft the LC and ALC1085were controlling and monitoring--for example, about 90 seconds before1086the accident, the LC/ALC would have been handling 7 airplanes while a1087separate helicopter controller handled the 5 helicopters on frequency1088at the time. This would have reduced cognitive loading and enabled the1089HC controller to more easily keep track of the movement of the1090helicopters and their potential conflicts with arriving airplanes. It1091is possible that if the positions had been staffed separately, a1092standalone HC controller could have detected the potential conflict1093between PAT25 and flight 5342 earlier, enabling an earlier and more1094effective traffic advisory to PAT25. The NTSB concludes that had the HC1095and LC positions been staffed separately, PAT25 might have received a1096more timely and effective traffic advisory. [FINDING 17] The NTSB1097further concludes that the LC and HC positions should have been1098separated at the time of the accident given traffic volume and1099complexity. [FINDING 18]1100---------------------------------------------------------------------------1101    \3\ Note taking and recording aircraft information are routine1102components of local and assistant local controller duties, along with1103radio communications, coordination, and traffic sequencing. Such tasks1104require temporary shifts of attention between displays, communications,1105and the out-the-window visual scan.1106---------------------------------------------------------------------------1107    The NTSB also concludes that in the 2 minutes before the accident1108when traffic volume was increasing, the ALC should have prioritized1109surveillance of aircraft in the air in order to assist the local1110controller, rather than diverting her attention to the lower priority1111task of documenting helicopter information, which could have been1112completed when traffic volume and complexity had subsided. [FINDING 19]1113    The primary duties and responsibilities of the OS included1114providing operational supervision, directing the tower operation to1115ensure efficiency, and determining when the HC and LC positions should1116be combined or separately staffed. The DCA ATCT SOP stated that the OS,1117as the watch supervisor, must maintain situation awareness of traffic1118activity and operational conditions in order to provide timely1119assistance to controllers and ensure that available resources are1120deployed for optimal efficiency. To do this, the OS must not only1121maintain a general awareness of traffic volume and complexity within1122the airspace, but also continuously assess the risk of the operation to1123determine when a controller needs assistance and when the HC/LC1124positions should be separately staffed. The OS should also scan the1125airspace and CTRD to identify any potential conflicts.1126    The HC and LC positions were combined when the OS came on duty1127earlier on the day of the accident. Why the positions were combined1128earlier that day was not determined, as facility SOP had been revised1129in June 2024 to remove the requirement for documentation of the reason1130for combining. Some controllers interviewed felt that combining the HC1131and LC positions resulted in better situation awareness and reduced1132workload, because they did not have to coordinate with another1133controller the way they did when the positions were separately staffed.1134Controllers stated that the benefits to staffing the positions1135separately were having another set of eyes scanning traffic, less1136frequency congestion, and a controller dedicated to helicopters only.1137In other words, duties and responsibilities would be divided between1138two controllers, allowing for more focused attention to aircraft on1139their respective frequencies to recognize the development of a1140potential conflict. Although the DCA ATCT SOP specified hours during1141which the HC position ``should normally be de-combined,'' the SOP1142allowed the OS to combine or separately staff the position at their1143discretion after considering factors such as staffing, weather1144conditions, and traffic volume. The LC controller stated he was feeling1145a little overwhelmed about 10 to 15 minutes before the accident and had1146thought about asking for the HC/LC positions to be staffed separately,1147but did not because a helicopter left the airspace. Helicopter and1148airplane traffic volume subsequently increased again in the 2 minutes1149before the accident; however, the OS stated in a postaccident interview1150that there was no need to staff the positions separately in the hour1151before the accident, as they only had one helicopter at a time.1152    The OS had been working multiple control positions for over 4 hours1153and had been working the OS position for over 2 hours at the time of1154the accident. From the OS position in the tower, he was listening to1155the LC controller's transmissions, which were broadcast on a speaker in1156the tower cab, and ``look[ing] out the window.'' He could not recall1157the specifics of the traffic situation at the time of the accident, and1158did not recall the conflict alert activating, but witnessed the1159collision.1160    To provide timely assistance to controllers and ensure that1161available resources are deployed for optimal efficiency, the OS should1162continuously assess the risk of ongoing factors in the operation,1163including traffic volume and complexity, controller experience, time on1164position, nighttime conditions, and any other factors deemed relevant.1165However, given his extended time on position, it is likely that the OS1166was experiencing reduced alertness at the time of the accident, which1167decreased his ability to effectively assess operational risks. Research1168in a simulated air traffic control room showed that extended time on1169task (over 90 minutes) increased detection latency for complex events1170such as two aircraft at the same altitude on the same flight path1171(Thackray and Touchstone, 1989).1172    The OS's reduced alertness and attentiveness would be consistent1173with his extended time on position at the time of the accident and his1174not recognizing the increases in traffic volume that occurred 10 to 151175minutes before the accident and again in the 2 minutes before the1176accident. In addition, he did not recognize the developing traffic1177conflict as PAT25 continued toward flight 5342. The NTSB concludes that1178due to extended time on position at the time of the collision and his1179complacency, the OS was likely experiencing reduced alertness and1180vigilance, which decreased his awareness of the operational environment1181and reduced his ability to proactively assess the risks posed by the1182traffic and environmental conditions at the time of the accident.1183[FINDING 20]1184    FAA Order 7210.3DD, ``Facility Operations and Administration''; the1185collective bargaining agreement (CBA) between the National Air Traffic1186Controllers Association (NATCA) and the FAA; and DCA ATCT SOPs outline1187the duties and responsibilities of supervisors, including the1188requirement to ensure that adequate relief opportunities are provided1189to all operational staff. However, none of these documents detail how a1190supervisor is expected to manage the supervisor's own relief periods1191throughout the duty day or shift. The CBA states that employees should1192not be required to spend more than 2 consecutive hours performing1193operational duties without a break from operational areas.\4\ While1194breaks for controllers in accordance with the collective bargaining1195agreement (CBA) are closely monitored and strictly enforced, the CBA1196does not cover supervisory personnel such as operations supervisors and1197controllers-in-charge; therefore, individuals performing these duties1198are not subject to the same break requirements.1199---------------------------------------------------------------------------1200    \4\ A break is defined in the CBA as, ``a period of time during1201which no duties are assigned and offer employees opportunities to1202attend to personal needs or rejuvenate their mental acuity.''1203---------------------------------------------------------------------------1204    A supervisor's duties are extensive, and providing oversight in an1205operational environment can be as mentally taxing as working a control1206position. Under current rules, supervisors are often conducting1207supervisory duties for hours, and in some cases, entire shifts, but are1208not provided the same relief periods as operational personnel. The NTSB1209concludes that the lack of mandatory relief periods for supervisory air1210traffic control personnel is contrary to human factors research that1211shows clear performance deterioration in situations of prolonged time1212on task. [FINDING 21] Therefore, the NTSB recommends that the FAA1213develop and implement time-on-position limitations for supervisory air1214traffic control personnel, including guidance for district and facility1215level management to adapt these limitations to account for their own1216staffing and local standard operating procedures. [RECOMMENDATION 1]1217Traffic Advisories1218    The LC controller's first advisory to PAT25 regarding flight 53421219occurred about 2 minutes before the collision. This advisory was1220consistent with air traffic policy. In response to the controller's1221traffic advisory, the PAT25 IP stated that they had the traffic in1222sight and requested visual separation. The controller did not issue a1223corresponding traffic advisory to the crew of flight 5342.1224    The controller later stated that he had other priority duties at1225the time he issued the initial advisory to PAT25 and that he intended1226to go back and issue an advisory to flight 5342. However, because he1227was attending to other priority tasks, he did not return to the1228airplane before the conflict alert activated about 1 1/2 minutes later.1229Although the crew of flight 5342 had other contextual clues about the1230presence of PAT25 (see discussion in section 0), they never received an1231advisory from the controller about the helicopter, which would have1232increased their situation awareness. The NTSB concludes that, although1233the LC controller provided an initial traffic advisory to the crew of1234PAT25 in accordance with FAA Order JO 7110.65, he did not provide a1235corresponding advisory to the crew of flight 5342 regarding PAT25's1236location and intention, which could have increased situation awareness1237for the crew of flight 5342. [FINDING 22]1238    FAA Order JO 3120.4, ``Air Traffic Technical Training,'' conveys1239instructions, standards, and guidance for the administration of air1240traffic technical training (FAA, 2024c). The order lists ``positive1241control'' as a job subtask, which it defined, in part, as taking1242command of control situations and not acting in a hesitant or unsure1243manner. The LC controller reported that, after the conflict alert1244activated, he noted that the helicopter was ``way closer'' to the1245airplane than it was supposed to be. In response, the controller1246contacted the crew of PAT25 and stated, ``PAT two five do you have that1247C-R-J in sight?'' The controller then instructed PAT25 to ``pass behind1248that C-R-J.'' The PAT25 IP replied that they had ``a-aircraft'' in1249sight and again requested visual separation, which the controller1250approved.1251    FAA Order JO 7110.65AA, ``Air Traffic Control,'' paragraph 5-1-4,1252Merging Target Procedures, stated that controllers must provide traffic1253information to any turbojet aircraft whose target appears likely to1254merge with another aircraft, unless those aircraft are separated by1255more than the appropriate vertical separation minima. Safety alert1256procedures and phraseology requirements, contained in paragraph 2-1-6,1257stated that controllers should immediately issue a safety alert to an1258aircraft that is in unsafe proximity to another aircraft, and to offer1259the pilot an alternative course of action if feasible, ending the1260transmission with the word ``immediately.''1261    When the LC controller recognized that the two aircraft were in1262unsafe proximity, the most appropriate action would have been to issue1263safety alerts to both aircraft regarding the other aircraft's position1264and distance, and to issue positive control instructions to the pilots1265that would have prevented their courses from converging, such as climb,1266descend, or turn, as appropriate. However, the controller's traffic1267call to PAT25 at this time provided no information that could have1268assisted the crew in visually locating and positively identifying the1269airplane, nor did it contain positive control instructions that the1270crew could have taken to resolve the conflict. Additionally, the1271controller did not issue a safety alert to flight 5342, contrary to1272merging target procedures. Timely issuance of positive control1273instructions by the controller and subsequent compliance with those1274instructions by the flight crew(s) could have averted the impending1275collision. The NTSB concludes that if the LC controller had issued a1276standard safety alert to the flight crews of either aircraft as1277prescribed in FAA Order JO 7110.65, providing the conflicting1278aircraft's position and positive control instructions, the crew of1279either aircraft could have taken immediate action to avert the1280impending collision. [FINDING 23]1281Threat and Error Management1282    The primary purposes of the ATC system are to prevent a collision1283between aircraft operating in the system and to provide a safe,1284orderly, and expeditious flow of traffic. FAA Order 7110.65, Air1285Traffic Control, paragraph 2-1-2, ``Duty Priority,'' states, that1286controllers should ``give first priority to separating aircraft and1287issuing safety alerts as required in this order. Good judgment must be1288used in prioritizing all other provisions of this order based on the1289requirements of the situation at hand.''1290    Because there are many variables involved, it is virtually1291impossible to develop a standard list of duty priorities that would1292apply uniformly to every conceivable situation. Controllers must1293evaluate each on its own merit, and when more than one action is1294required, exercise their best judgment based on the facts and1295circumstances known to them. According to FAA Order JO 7110.65AA,1296``That action which is most critical from a safety standpoint is1297performed first.'' One way that controllers may do this is to use1298recognition primed decision making, which allows for quick and1299effective decision making in complex situations. Recognition primed1300decision making relies on pattern matching of the current situation1301with past experiences to identify a course (or courses) of action, and1302mental simulation of how the course(s) of action will play out (Klein,13031998).1304    In this accident, when the LC controller recognized that PAT25 and1305flight 5342 were converging after the conflict alert activated, he1306should have issued a safety alert to both aircraft; however, the LC1307controller asked PAT25 if they had the airplane in sight. Under high1308workload and time pressure, controllers have reduced cognitive capacity1309for responding to unusual situations (Damos, 1988). The LC controller1310knew he had to resolve the conflict, but had limited time and capacity1311to do so. Asking if PAT25 still had the CRJ in sight, then instructing1312PAT25 to pass behind the CRJ, required less processing load than1313issuing a safety alert, which should include a clock position or1314location of the traffic, distance, and an action for the pilot to take.1315    In November 2016, the NTSB issued Safety Recommendation A-16-51,1316asking the FAA to provide initial and recurrent training for air1317traffic controllers on controller judgment, vigilance, and/or safety1318awareness with specific reference to two midair collisions that1319occurred in 2015 to be used as case studies.\5\ The FAA responded that,1320in July 2017, it delivered instruction to controllers on threat and1321error management (or TEM, which the FAA described as the practice of1322applying controller judgment, vigilance, and safety awareness) as part1323of instructor-led recurrent training and stated that the training would1324also be required training for future controllers. The FAA also stated1325that they delivered a web-based ``Emergencies'' training in July 20171326to highlight accidents similar to the two midair collisions cited in1327the recommendation. After reviewing this training, the NTSB determined1328that the materials did not highlight the safety issues identified in1329the 2015 midair accidents, nor did the training provided discuss those1330or similar accidents as recommended. When the FAA indicated that it did1331not plan to take further action, Safety Recommendation A-16-51 was1332classified Closed--Unacceptable Action in 2023.1333---------------------------------------------------------------------------1334    \5\ Additional information about the two accidents and the findings1335that led to our recommendations may be found, respectively, in the1336reports of the investigations (ERA15MA259A/B and WPR15MA243A/B) and the1337safety recommendation report (ASR-16-6).1338---------------------------------------------------------------------------1339    A vast majority of the time, controllers perform very effectively1340and reliably; however, human vulnerabilities such as fatigue, increased1341workload, time pressure, and biases can increase errors. A controller's1342ability to anticipate, detect, and mitigate risks is essential. TEM1343provides a strategy to combat these vulnerabilities. TEM is a process1344for identifying safety risks--threats, errors, and undesired states--in1345the environment and mitigating those risks. In the context of air1346traffic control, threats include many of the complexities faced by1347controllers, such as airspace congestion, pilot errors, terrain or1348obstacles near the airport, and adverse weather conditions. Some1349threats can be anticipated, while others occur unexpectedly. Errors are1350actions or inactions by the controller that result in a deviation from1351the controller's intention or expectation, such as instructing an1352aircraft to taxi across an occupied runway, not detecting a pilot1353readback error, or providing an incorrect clearance, heading, or1354altitude. Undesired states are operational conditions where the margin1355of safety is reduced. An undesired state often results from mismanaged1356or missed threats and errors and is often considered the ``last stage''1357before an accident or incident. To restore the margin of safety, a1358controller must act to mitigate the risk by addressing the undesired1359state rather than the error (ICAO 2005).1360    In an observational study performed by the FAA at two air traffic1361control centers, they found that communication was the most frequent1362threat identified, resulting primarily from frequency congestion,1363simultaneous transmissions, incorrect pilot readback, or failure of a1364pilot to respond. On average, 15 percent of threats lead to an error1365and 13 percent of errors lead to an undesirable state (Eurocontrol,13662011). A review of United Kingdom incident data identified controller1367scanning patterns of radar and flight strips to be a primary1368contributor.1369    None of the controllers involved in this accident were familiar1370with the term ``threat and error management'' during postaccident1371interviews, nor were they familiar with the concepts that would be1372included in such training, suggesting that they did not receive1373training on this method of safety management. The NTSB requested and1374received controller training materials related to identifying and1375mitigating risk. Review of this material did not reveal any formal TEM1376training other than the 2017 workshop, and there was no evidence to1377indicate that the workshop or the subject matter it contained had been1378offered in any training since 2017.1379    Adequate training on the use of TEM can strengthen situation1380awareness by teaching controllers to continuously monitor their1381environment to more quickly identify threats; promote team1382communication to ensure that communications are clear, timely, and1383assertive; emphasize effective scanning habits; recognize patterns in1384the development of adverse events; and enhance decision making under1385stress by developing habits that balance procedural compliance with1386problem solving to mitigate the risks of threats and errors. TEM would1387have likely improved the situation awareness of all controllers in this1388event, which may have allowed for earlier conflict recognition or1389encouraged the OS to conduct a risk assessment of the steady helicopter1390traffic and its resulting workload on the LC and ALC controllers.1391    The NTSB continues to believe that including case studies in1392initial and annual air traffic controller training and highlighting1393situations in which controller judgment, vigilance, and safety1394awareness could be improved would enhance controllers' ability to1395identify and manage threats and errors. FAA guidance on the use of good1396judgment is vague, and case studies provide the opportunity to examine1397a real chain of events that had resulted in an accident, imparting1398valuable lessons without exposing participants to the potential risk of1399adverse outcomes inherent to on-the-job training, which the FAA often1400relies upon for controller training. The NTSB also believes that1401providing controllers the opportunity to discuss and practice applying1402TEM using scenario-based training is critical, as repetition of skills1403through training leads to automaticity of behaviors (Wickens et al.,14042004), thus freeing up working memory.\6\ Automaticity has been1405demonstrated to improve speed and accuracy (Wickens et al., 2004),1406situation awareness (Endsley, 2010), and decision making (Haith and1407Krakauer, 2018). Therefore, the NTSB concludes that initial and1408recurrent scenario-based training in threat and error management would1409help controllers identify and mitigate risks and strengthen situation1410awareness. [FINDING 24] Therefore, the NTSB recommends that the FAA1411develop instructor-led, scenario-based training on threat and error1412management that trains controllers to continuously monitor their1413environment to more quickly and accurately identify threats; promote1414team communication to ensure that communications are clear, timely, and1415assertive; emphasize effective scanning habits; recognize patterns in1416the development of adverse events; and enhance decision-making under1417stress by developing habits that balance procedural compliance with1418problem solving to mitigate the risks of threats and errors, and1419provide this training to all air traffic controllers annually.1420[RECOMMENDATION 2]1421---------------------------------------------------------------------------1422    \6\ ``Automaticity'' refers to highly learned skill performance1423driven by schemas that does not require much controlled attention.1424---------------------------------------------------------------------------1425    TEM training would also benefit controllers performing supervisory1426duties, who are responsible for overseeing facility operations and1427making operational decisions, such as when to combine or de-combine1428control positions, provide additional monitoring of a position or1429frequency, or rotate controller positions to allow for adequate break1430opportunities. When making these decisions, OSs must balance safety and1431risk management with the operational demands of the facility, which are1432continually changing based on factors such as traffic flow and weather1433conditions. Other than the list of factors that the accident OS was to1434consider when combining the HC and LC positions, there was no guidance1435or tool available in the DCA ATCT SOP to support supervisors in1436identifying risk, analyzing the potential impact of that risk on1437individual controllers or the overall operation, prioritizing risks1438based on likelihood and impact, or developing strategies to reduce or1439eliminate the identified risks. Additionally, no such tool or guidance1440was available in the Air Traffic Organization (ATO) ATO SMS Manual or1441in FAA Order 7110.65, which prescribes air traffic control procedures.1442There were several factors that increased risk to DCA ATCT operations1443on the night of the accident, including nighttime conditions, the1444steady volume of helicopter traffic, and the lack of requested miles-1445in-trail spacing from Potomac TRACON that resulted in offloading1446airplanes to runway 33. The NTSB concludes that a risk assessment or1447decision making tool would likely have benefited the accident OS in1448identifying and mitigating the operational risk factors that were1449present on the night of the accident. [FINDING 25] A risk assessment1450tool that could be tailored to the operational needs of each facility1451would benefit supervisory air traffic control personnel throughout the1452National Airspace System (NAS). Therefore, the NTSB recommends that the1453FAA ATO develop and implement a risk assessment tool for supervisors1454that incorporates the principles of threat and error management to1455assist in risk identification, mitigation, and operational decision1456making. [RECOMMENDATION 3]1457PAT25 Operations1458Helicopter Radio Quality1459    Review of recorded ATC communications on the night of the accident1460revealed that the transmissions made by PAT25 were accompanied by1461static interference, which likely made intelligibility of their1462transmissions difficult for both ATC and other aircraft. The1463helicopter's CVR also captured a conversation between the pilots1464earlier in the flight regarding the poor quality of the transmissions1465received from the controller, many of which were incomplete or broken.1466Most critically, the portion of the controller's initial traffic1467advisory regarding flight 5342, in which he stated that the airplane1468would be ``circling runway 33,'' was not received in its entirety by1469the PAT25 crew; radio interference characteristic of that experienced1470by the helicopter crew throughout the flight caused the transmission to1471sound like, ``for runway 33'' inside the helicopter, omitting the word1472``circling.'' \7\1473---------------------------------------------------------------------------1474    \7\ This instance of interference was different from the subsequent14750.8 second mic key that resulted in the PAT25 flight crew not hearing1476``two five pass behind that.''1477---------------------------------------------------------------------------1478    If the PAT25 crew had heard the word, ``circling,'' it possibly1479would have served as a salient cue alerting the crew to the airplane's1480intended flight path and allowed the IP to better anticipate its1481subsequent movement. Without hearing the word ``circling,'' the IP had1482to infer the circling pattern from the airplane's stated destination of1483runway 33. Interviews with other The Army Aviation Brigade (TAAB)1484pilots indicated that they were not very familiar with fixed-wing1485approaches to runway 33. Although the IP likely knew that airplanes1486landing on runway 33 approached from the southeast due to the runway's1487orientation, and although this implied that traffic landing on runway148833 had to cross over Route 4, anticipating this would have required the1489IP's deliberate thought and attention. The NTSB concludes that, due to1490degraded radio reception, the crew of PAT25 did not receive salient1491information regarding flight 5342's circling approach to runway 33.1492[FINDING 26]1493    Clear and effective communication is essential for safe air traffic1494control operations and pilot situation awareness. When radio quality is1495degraded, pilots and controllers can miss important information, and1496having to repeat control instructions can result in time lost for other1497safety-critical tasks. Given the importance of clear radio1498communications and the evidence presented in this accident, in which1499poor radio reception quality may have affected the PAT25 crew's1500awareness of flight 5342's position and intentions, the NTSB recommends1501that the Department of War Policy Board on Federal Aviation conduct a1502study to evaluate the quality of radio transmissions and reception for1503those aircraft operated within the National Airspace System (NAS) to1504identify factors that degrade communications equipment performance and1505adversely affect the safety of civilian and military flight operations.1506[RECOMMENDATION 42] The NTSB further recommends the Department of War1507implement appropriate enhancements, based on the findings of the study1508recommended in Safety Recommendation [42],to remediate identified1509deficiencies in air-ground radio communications performance.1510[RECOMMENDATION 43]1511Flight Crew Performance1512    Visual meteorological conditions prevailed in the DCA area on the1513night of the accident, and the recorded wind about the time of the1514accident was from 300+ at 14 kts with gusts to 23 kts, with the wind1515direction varying between 270+ and 330+. These wind conditions would1516constitute a right quartering tailwind for the accident helicopter,1517which was traveling on a southerly course at the time of the collision.1518The helicopter's CVR captured several comments between the pilots1519throughout the accident flight regarding the wind and turbulence. The1520comments suggested that maintaining helicopter trim, altitude, and1521heading required the flying pilot's close attention.1522    During a postaccident simulator observation, investigators asked a1523current and qualified Army pilot with over 600 hours of flight1524experience in the UH-60L to retrace the accident helicopter's flight1525path in conditions programmed to simulate those present on the night of1526the accident. When asked to rate the workload, he reported that he had1527insufficient capacity for ``easy attention'' to additional tasks due to1528the conditions.1529    It is likely that the accident pilot, as the pilot flying, was1530experiencing similar workload during the accident flight and was1531relying on the IP, as the pilot monitoring, to respond to the1532controller and look for traffic. The IP's prompt reply to the1533controller that he had the aircraft in sight likely further reassured1534the pilot that he had visually acquired the airplane, although there1535was no discussion between the crew to confirm this.1536    At the time of the controller's initial traffic advisory to PAT25,1537four other airplanes were approaching runway 1 for landing, and flight15385342 would have appeared among them when viewed from the helicopter.1539None of these airplanes would have been discernable from PAT25's1540position at the time of the initial traffic advisory as anything other1541than a point of light in the distance. These airplanes were about 3,15427.5 (flight 5342), 11, 15, and 20 statute miles from PAT25. In the1543investigative hearing, an Army standardization instructor pilot stated1544that, when he was flying over Cabin John, Maryland, at night when1545wearing NVGs, he was able to see airplanes ``lined up'' at the Wilson1546Bridge, a distance of about 14 miles. He also stated that it was1547difficult to discern any individual aircraft's sequence in a group of1548airplanes, because the brightest landing or position light did not1549necessarily correspond to the closest aircraft. NTSB observations of1550airplane traffic at DCA from the roof of a building on the southwest1551Washington, DC, waterfront (near the location where PAT25 received the1552first traffic advisory) confirmed that investigators were able to see1553airplanes over 16 miles away when using NVGs. It is likely that the1554accident IP was able to see at least four, and possibly five, airborne1555targets on the horizon in the direction of the Wilson Bridge when the1556controller issued the initial traffic advisory. The NTSB visibility1557study determined that these targets would have appeared as lights in a1558tight cluster near the horizon south of the airport.1559    During the NTSB NVG observation, investigators found it difficult1560to determine which of several tightly spaced approaching airplanes was1561closest to the Wilson Bridge; thus, the IP's task of identifying the1562``CRJ just south of the Wilson Bridge,'' would have been challenging.1563However, despite the ambiguous visual scene at the time, the IP1564responded almost immediately that he had the traffic in sight and1565requested visual separation. The speed of the accident IP's reply1566suggests a rote response that occurred without positively identifying1567flight 5342. This also seems likely because the IP never pointed out or1568discussed the traffic with the pilot, despite extensive discussions of1569other nearby targets earlier in the flight. This issue will be1570discussed further in section 0. The NTSB concludes that the PAT25 IP1571did not positively identify flight 5342 at the time of the initial1572traffic advisory despite his statement that he had the traffic in sight1573and his request for visual separation. [FINDING 27] The NTSB further1574concludes that, with several other targets located directly in front of1575the helicopter represented by points of light with no other features by1576which to identify aircraft type, and without additional position1577information from the controller, the IP likely identified the wrong1578target. [FINDING 28]1579    Several other reasons support the plausibility that the IP's1580response to the initial traffic advisory was automatic and that he1581likely did not fully realize the implications of the controller's1582message. First, the IP was busy. In the 47 seconds before the1583controller's transmission, the IP made a position report to the1584controller, instructed the pilot to apply additional right pedal,1585advised the pilot to begin a turn, corrected the pilot's altitude, and1586called out a nearby obstacle (a crane). Second, at the time of the1587initial traffic advisory, the IP knew that the airplane was at the1588Wilson Bridge, a distance that did not pose an immediate conflict.1589Finally, the IP understood that accepting visual separation was the1590most efficient means of transitioning the DCA Class B airspace. This1591factor will be discussed in additional detail in section 0.1592    The NTSB visibility study indicated that, from the IP's point of1593view, the airplane would have been visible in the right windshield for1594most of the 2 minutes before the collision, except for brief periods1595when it was obscured by aircraft structure, and would have appeared as1596a small dot of light low on the horizon among an area of bright1597cultural lighting. As the helicopter neared the approach path of runway159833, the lights of flight 5342 would have appeared in the helicopter's1599center windshield, outside the IP's NVG field of view when looking1600straight ahead. Spotting the airplane in the 30 seconds before the1601collision would have required the IP to turn his head to the left and1602perform a focused visual search of the sky in the approach area for1603runway 33. That he did not see the airplane at that time suggests that1604he did not scan the area in the center windshield, which in turn1605indicates that it did not occur to him that the airplane might be to1606his left. In the absence of a focused search in the proper area, it is1607unlikely that the PAT25 pilots would have spontaneously noticed the1608airplane because it was outside the NVG field of view in an area of1609very low visual acuity and would have appeared against a complex1610background of ground lighting. Further, because the airplane was on a1611collision course with the helicopter, it would have exhibited little1612relative motion.1613    The IP's visual search for traffic was likely hindered by the1614informational content of the LC controller's second traffic callout. If1615the controller had provided information about the location of the1616airplane in relation to the helicopter (for example, ``ten o'clock''),1617the IP would have known where to look; however, the controller merely1618asked if the PAT25 crew had the ``C-R-J in sight.''1619    Review of the helicopter's CVR indicated that the IP did not1620verbally discuss with the pilot the location of flight 5342 after the1621controller's initial advisory about 2 minutes before the collision nor1622after the second call from the controller about 20 seconds before the1623collision. The helicopter CVR recording suggests that his attention was1624subsequently focused on coaching the pilot on the use of the rudder1625pedals to compensate for a quartering tailwind and on monitoring radio1626conversations between the local controller and two other helicopters.1627His instruction to the pilot to ``kinda come left'' following his final1628interaction with the controller just before the collision occurred1629reinforces the idea that he believed the ``CRJ'' referenced by the1630controller was among the airplanes approaching runway 1; however, he1631was likely unsure which of those airplanes was the airplane in1632question. Thus, the IP did not positively identify the location of the1633airplane and he did not communicate his uncertainty about its location1634to the pilot.1635    Information provided by the Army indicated that the accident IP and1636pilot received aircrew coordination training during Army Helicopter1637Flight School in 2019 and 2021, respectively. The crew also received1638annual aircrew coordination training. A TAAB standardization pilot1639stated that the 2024 aircrew coordination training involved the1640discussion of several class A mishaps (as defined by the Army,1641occurrences that are fatal or cause permanent disability or more than1642$2.5 million in damage) and what each accident crew could have done to1643improve the situation. Additionally, the accident IP was an aircrew1644coordination instructor and, according to the B Company safety officer,1645had provided aircrew coordination training 5 days before the accident.1646    The Army's H-60 Series Aircrew Training Manual, chapter 7, Aircrew1647Coordination Training, stated that crews ``must use clear, concise1648terms that can be easily understood and complied with in an environment1649full of distractions,'' and further defined preferred terms for1650communicating about traffic. Terms included, ``visual'' to indicate1651that a target, traffic or obstacle was seen or identified; ``traffic,''1652indicating an aircraft that presented a collision hazard, followed by1653clock position, distance, and reference to altitude; and ``no joy,''1654indicating that a target, traffic or obstacle was not positively seen1655or identified. As an aircrew coordination training instructor, the1656accident IP would have been familiar with these terms.1657    Additional guidance was available in chapter 4, H-60 Crewmember1658Tasks, which stated that aircrews should ``immediately inform other1659crewmembers of all air traffic or obstacles that pose a threat to the1660aircraft'' using the ``clock, altitude, and distance method.'' Although1661the IP could have used other methods to point out the airplane to the1662pilot, he most likely did not do so because he was uncertain about the1663airplane's position and assumed that it was one of the airplanes in1664front of the helicopter on approach to runway 1, as evidenced by his1665lack of a verbal affirmation to the pilot that he had located the1666airplane.1667    Another factor that contributed to the PAT25 crew not positively1668identifying flight 5342 was the lack of an integrated traffic awareness1669and alerting system in the helicopter that could have provided aural1670alerts to the crew's headsets and depicted traffic information on an1671instrument panel display in the pilots' primary field of view as part1672of their normal instrument scan. Although the crew had the capability1673to display ADS-B In traffic information on a moving map display on1674portable tablets using the ForeFlight application, The Army Aviation1675Brigade (TAAB) pilots told investigators that they did not typically1676monitor their tablets during low-level operations on the DC helicopter1677routes because the flying task was too demanding. They also stated that1678any aural alerts from the device could not be heard because of the high1679level of ambient noise in the helicopter and because their helmets were1680not equipped to receive audio from the tablets.1681    In the absence of an accurate mental model of the airplane's1682expected flight path to runway 33, the lack of instruction from the1683controller to direct his visual scan, and without an integrated traffic1684awareness system, the IP's baseline expectations about traffic flow in1685the DCA area likely drove his visual search. Aggregated flight tracking1686data from the FAA showed that, in the year before the accident, only 5-16877 percent of northbound arrivals at DCA had landed on runway 33.1688Anecdotal statements from other TAAB pilots indicated that some had1689never encountered an airplane landing on runway 33 while traveling on1690Route 4.1691    Thus, the more common flight path for airplanes during a north1692operation at DCA was, by far, a straight-in approach to runway 1, and1693the IP's baseline expectation would have been for conflicting traffic1694to approach from the south for runway 1 (to the right of the1695helicopter) rather than from the southeast (to the left of the1696helicopter) for runway 33. The numerous airplanes on approach for1697runway 1 likely reinforced this expectation, making it likely that the1698IP considered one of them as the conflicting traffic. This scenario1699would be consistent with his statement to the pilot just before the1700collision, ``alright kinda come left for me. . .I think that's why he's1701asking,'' because moving left would have increased the helicopter's1702separation from traffic approaching runway 1.1703    Expectations drive attention, and people sometimes have difficulty1704noticing a variance between what they usually see and the actual state1705of things. When expectations are strong, people tend to seek out and1706attend to confirmatory visual information while overlooking indications1707that the current situation is different. This phenomenon, known as1708expectation bias, not only influences perception in the present, it1709also influences perception of past events by promoting recollections1710that conform more closely to typical patterns. Expectation bias is a1711well-known vulnerability in human performance. In this case,1712expectation bias likely played a role in the IP's ineffective scan1713following the controller's traffic callouts. The NTSB concludes that1714interference that obscured the controller's ``circling to'' call, the1715microphone keying that blocked the PAT25 crew from receiving the1716instruction to ``pass behind,'' ambiguous visual cues, and the lack of1717an integrated traffic awareness and alerting system likely reinforced1718the PAT25 crew's expectation bias that the airplane was among the1719traffic approaching runway 1 and did not pose a conflict. [FINDING 29]1720    It could not be determined whether the PAT25 pilots received1721specific training addressing DCA runway use and traffic patterns,1722including fixed-wing approach and departure procedures. However, given1723the proximity and routine interaction of published helicopter routes1724with DCA fixed-wing traffic flows, additional airspace-specific1725training on DCA arrival and departure corridors and runway1726configurations would likely have improved the PAT25 crew's1727understanding of the risks inherent in the Army's routine mission-1728related operations in this environment. Therefore, the NTSB concludes1729that the absence of documented training on DCA fixed-wing procedures1730and the mixed-traffic operating environment represented a safety1731vulnerability for Army flight crews operating in the DCA Class B1732airspace. [FINDING 30] As a result, the NTSB recommends that the U.S.1733Army revise training procedures for flight crews assigned to operate in1734the Washington, DC, area to ensure that they receive initial and1735recurrent training on fixed-wing operations at DCA, including approach1736and departure paths, runway configurations, and the interaction of1737those traffic flows with published helicopter routes. [RECOMMENDATION173834]1739Helicopter Altimetry1740    Aircraft pitot-static systems and barometric altimeters have1741defined performance specifications. These include allowable instrument1742errors, which are tolerances for allowable errors after manufacture and1743during operation. They also include tolerances for position errors,1744which are errors caused by external aerodynamic effects from the1745airflow over the aircraft and (on helicopters) the main rotor downwash.1746Although cockpit instruments are designed to be accurate, in general it1747is not feasible to design barometric altimeters to be perfectly1748accurate in all flight conditions or throughout their entire service1749life. Older design mechanical barometric altimeters, such as those on1750the accident helicopter, have multiple types of allowable errors that1751can accumulate while still remaining within design and performance1752criteria. Additionally, changes to the aerodynamic shape of the1753aircraft, such as adding external stores support system (ESSS) tanks,1754change the pressure effects on the pitot-static system and can increase1755the position error. Altimeter testing showed that the 100-ft pressure1756altitude discrepancy seen in the flight data recorder data for the1757accident flight was observed on three other UH-60L helicopters operated1758by the 12th Aviation Battalion. These altimeter testing results also1759showed that the pressure altitude data recorded by the helicopters'1760FDRs, when corrected for local conditions, was representative of what1761was indicated on the right side altimeter. Therefore, the FDR pressure1762altitude data for the accident helicopter, when corrected for local1763conditions, was likely representative of what was indicated on the IP's1764barometric altimeter during the accident flight.1765    The allowable tolerances are additive, with the total error having1766the potential of exceeding 100 ft. These tolerances are not unique to1767military aircraft; they apply to civil aircraft as well. While a1768difference of 100 ft would have little consequence at higher altitudes,1769given the low altitudes prescribed along portions of the DC helicopter1770routes and Army procedures that stated that flight should be conducted1771no lower than 100 ft agl, such a discrepancy resulted in the increased1772likelihood of altitude exceedances along these routes.1773    Although the instrument error specific to the accident helicopter1774could not be determined, disassembly and examination of the internal1775components did not reveal any anomalous wear that would have prevented1776normal operation. Additionally, the CVR recording did not capture any1777conversations between the flight crew regarding any malfunction of the1778barometric altimeters during the accident flight. It is likely that the1779behavior of the accident helicopter's static system position error and1780barometric altimeter instrument error were similar to that observed on1781other 12th Aviation Battalion UH-60L helicopters. The NTSB concludes1782that, due to additive allowable tolerances of the helicopter's pitot-1783static/altimeter system, it is likely that the crew of PAT25 observed a1784barometric altimeter altitude about 100 ft lower than the helicopter's1785true altitude, resulting in the crew erroneously believing that they1786were under the published maximum altitude for Route 4. [FINDING 31]1787    The accident helicopter's FDR should have contained a radio keying1788parameter; however, these data were not present on the accident1789helicopter's recorder. The radio keying parameter is needed to1790synchronize timing between the FDR and CVR, and accurate parametric1791data from the FDR is crucial for accident investigation purposes as1792well as for flight operations quality assurance (FOQA) programs used to1793support a safety management system (SMS). The investigation found that1794after the initial installation of the helicopter's FDR, there was no1795scheduled recurrent task to verify the continued accuracy of the1796recorded data. FAA Advisory Circular (AC) 20-141B recommends that1797operators of aircraft equipped with a digital FDR perform a1798``reasonableness check'' at an interval not to exceed 18 months (FAA,17992010). The NTSB concludes that a recurrent task to verify the continued1800accuracy of recorded flight data for U.S. Army aircraft would help1801ensure the data integrity needed to support quality assurance and1802safety programs and accident investigations. [FINDING 32] Therefore,1803the NTSB recommends that the U.S. Army develop and implement a1804recurring procedure, at an interval not to exceed 18 months, to verify1805the continued accuracy of recorded flight data. [RECOMMENDATION 35]1806    The Washington, DC, helicopter route altitudes, particularly the1807low altitudes specified for Routes 1 and 4 in the vicinity of DCA, did1808not account for the errors inherent to barometric altimeters, nor did1809they account for human error tolerances--both Army standards and FAA1810commercial pilot standards require pilots to maintain altitude within1811100 ft while in flight. Review of aggregated aircraft1812flight track information for helicopters on the DC helicopter routes1813from January 1, 2024, through January 30, 2025, indicated that1814helicopters regularly exceeded published maximum route altitudes. For1815the northern segment of Route 4, which included the area of the1816collision, of the 523 flights analyzed, 260 flights (49 percent) were1817identified as exceeding route altitude limitations at some point during1818the flight. Had the error tolerances of barometric altimeters been1819considered during design of the helicopter route maximum altitudes, the1820incompatibility of a 200-ft ceiling and barometric altimeter errors may1821have been identified. Although the data did not attribute an exact1822number or rate of altitude exceedances specifically to Army1823helicopters, the data indicated that military users comprised about 791824percent of the helicopter flight track data; therefore, it is1825reasonable to assume that at least some Army helicopters were exceeding1826maximum route altitudes. The NTSB concludes that the FAA and the Army1827failed to identify the incompatibility between the helicopter routes'1828low maximum altitudes and the error tolerances of barometric1829altimeters, which contributed to helicopters regularly flying higher1830than published maximum altitudes and potentially crossing into the1831runway 33 glidepath. [FINDING 33]1832    Despite helicopter manufacturer flight testing that showed1833increased barometric altimeter position errors with the ESSS installed,1834the Army's UH-60L operator's manual did not contain an altimeter1835correction chart for the ESSS configuration. The lack of this1836information in the operator's manual would result in UH-60L pilots1837being unaware that the ESSS could result in a greater-than-anticipated1838position error in flight. Neither maintenance checks nor the pilot's1839preflight check against local field elevation would detect this error,1840as these checks are not performed with the helicopter's main rotor1841turning.1842    The U.S. Army issued Standardization Communication message 25-02 to1843inform pilots of the potential for increased position error in UH-601844helicopters equipped with ESSS.\8\ This message included instructions1845to maintain a minus 50-ft margin when flying with a clearance with a1846maximum altitude to ensure the maximum altitude is not exceeded.1847However, at the time of this report, the U.S. Army has not incorporated1848information into the UH-60 series operator's manuals to inform pilots1849of the increased position error with the ESSS configuration. The NTSB1850concludes that pilots need all available information on the potential1851total error, allowed by design, that could occur in flight on an1852airworthy barometric altimeter. [FINDING 34] Therefore, the NTSB1853recommends that the U.S. Army incorporate information within the1854appropriate operator's manual for all applicable aircraft on the1855potential total error allowed by design that could occur in flight on1856an otherwise airworthy barometric altimeter, including the increased1857position error associated with the ESSS configuration. [RECOMMENDATION185836]1859---------------------------------------------------------------------------1860    \8\ The message was signed by the Director of the U.S. Army1861Aviation Center of Excellence's Evaluation and Standardization1862Directorate on August 5, 2025.1863---------------------------------------------------------------------------1864Helicopter Transponder1865    Postaccident examination of the helicopter's transponder revealed1866that it was transmitting the incorrect aircraft address during the1867accident flight due to a broken solder connection, which was the result1868of an incomplete bond at the time of the unit's manufacture. This1869incorrect address was not a factor in the accident flight, because no1870other aircraft in the geographic area was transmitting an identical1871address, but it could pose a safety risk if two aircraft in the same1872vicinity were to broadcast the same address.\9\ The examination also1873revealed that the transponder Automatic Dependent Surveillance--1874Broadcast (ADS-B) squitter was off and the time source was incorrectly1875set, which prevented the transponder from broadcasting ADS-B Out. Given1876that there was no historical ADS-B data for the accident helicopter1877following the installation of the transponder in April 2023, it is1878likely that either the squitter or time source setting, or both, were1879incorrectly set at the time of installation. A functional check of the1880transponder that was required after its installation should have1881detected that ADS-B Out was not broadcasting. Therefore, the NTSB1882concludes that the Army's post-installation functional check of the1883transponder on the accident helicopter was insufficient to detect that1884it was not broadcasting ADS-B Out. [FINDING 35] Inspection of other1885helicopters from the 12th Aviation Battalion found incorrect time1886source settings on several aircraft equipped with APX-123A1887transponders, resulting in the Army directing a one-time inspection of1888transponders to verify ADS-B Out functionality. It could not be1889determined how or why the time source setting was changed following1890installation of the transponders. At the time of the accident, the Army1891had no established recurrent procedure for verifying transponder ADS-B1892functionality or confirming that it was transmitting the correct1893address. The NTSB concludes that the Army's lack of a recurrent1894transponder inspection procedure resulted in the incorrect aircraft1895address being transmitted by the accident helicopter's transponder, and1896the incorrect ADS-B settings on several other helicopters being1897undetected. [FINDING 36] As of the date of this report, the Army has1898not yet developed a recurring procedure for this task, and it is1899possible that future ADS-B Out or aircraft address issues could go1900undetected. Therefore, the NTSB recommends that the U.S. Army develop1901and implement a transponder inspection procedure on all aircraft with1902transponders capable of transmitting Mode S and ADS-B and operated in1903the NAS, at least annually and upon each aircraft's entry into service1904in the NAS, that ensures1905---------------------------------------------------------------------------1906    \9\ Although there is a very low probability that two aircraft in1907the same geographical vicinity and covered by the same radar may1908broadcast the same aircraft address, the scenario is not impossible.19091910---------------------------------------------------------------------------1911  1)  the transponder ADS-B settings are correct,19121913  2)  the transponder is transmitting ADS-B, and19141915  3)  the transponder is transmitting the correctly assigned address.1916[RECOMMENDATION 37]19171918    Additionally, the NTSB concludes that, because the APX-123A1919transponder is designed for use on multiple aircraft platforms, it is1920possible that incorrect settings may be present on other aircraft used1921throughout the Department of War armed services. [FINDING 37]1922Therefore, the NTSB recommends that the Department of War Policy Board1923on Federal Aviation require the Department of War to verify on all1924aircraft with transponders capable of transmitting Mode S and ADS-B and1925operated in the NAS, at least annually and upon each aircraft's entry1926into service in the NAS, that19271928  1)  the transponder ADS-B settings are correct,19291930  2)  the transponder is transmitting ADS-B, and19311932  3)  the transponder is transmitting the correctly assigned address.1933[RECOMMENDATION 44]1934Flight 5342 Operations1935    FDR and CVR information from the airplane indicated that the1936airplane's control columns rapidly moved aft and the crew indicated1937surprise and alarm about 1 second before the impact; these actions are1938consistent with the crew of flight 5342 not detecting the helicopter1939until it was too late to avoid a collision. The limitations of see-and-1940avoid, discussed in section 0, likely explain the crew's late1941detection. Factors particularly relevant in this case include a complex1942background of dense cultural lighting behind the helicopter until about194310 seconds before impact, which would have made the helicopter's1944external lighting inconspicuous, and the helicopter's minimal relative1945motion in the flight 5342 crew's field of view, which also would have1946made it difficult to spot. The crew's moderate to high workload during1947the final stage of the circling approach, as shown in simulator studies1948conducted as part of this investigation, likely also reduced the odds1949of the flight crew detecting the helicopter.1950    The CVR recording indicated that the crew did not verbally1951communicate about the traffic alert and collision avoidance system1952(TCAS) traffic advisory (TA) they received 19.2 seconds before the1953collision. Guidance provided by PSA Airlines did not specify standard1954callouts pilots were required to make in response to a TA. PSA's Flight1955Operations Manual (FOM) stated that, upon receiving a TA, a crew should1956``attempt to see the reported traffic'' and ``should not maneuver based1957on a TA alone.'' The FOM referred to FAA AC 120-55, which contained1958guidance indicating that crews should ``respond to TAs by attempting to1959establish visual contact with the intruder aircraft and other aircraft1960which may be in the vicinity.'' The AC also included the statement,1961``coordinate to the degree possible with other crewmembers to assist in1962searching for traffic. Do not deviate from an assigned clearance based1963only on TA information.'' Thus, crew members were advised to search for1964the conflicting traffic and coordinate with each other as workload1965allowed, but were not permitted to maneuver in response to a TA without1966seeing a target that posed a collision risk.1967    The TA aural alert activated when the airplane was 1.05 nm from the1968helicopter and as the captain was turning the airplane left to align it1969with the runway 33 final approach path about 450 ft radio altitude.1970Simulator observations with current and qualified PSA CRJ pilots1971indicated that this was a visually demanding task that required the1972captain to control the airplane's lateral path, thrust, airspeed, and1973glidepath (as indicated by the precision approach path indicator or1974PAPI). It is unlikely that he had spare capacity to perform an1975extensive visual search for traffic at this time. The FO was also1976performing visually demanding tasks, such as monitoring the airplane's1977lateral alignment, glidepath, and energy state to ensure that the1978approach remained stable, and monitoring the position of an airplane1979that had been cleared for takeoff on runway 1 to ensure that it would1980not pose a conflict. That airplane was still on or near the surface of1981the runway at the time the TA occurred, and it did not cross the1982centerline of runway 33 (thus no longer posing a conflict) until 41983seconds after the TA. The FO also would have been required to adjust1984the airspeed indicator bug for the airplane's final approach speed as1985soon as the captain had aligned the airplane with the runway. Thus,1986both pilots were busy and had limited opportunity to search for traffic1987in response to the TA.1988    If, despite this workload, the FO had promptly reacted to the TA,1989it is likely that he would have glanced at the multifunction display1990(which was set to show traffic within a 5 nm radius) to determine the1991traffic's location. This would have revealed a traffic icon 1 nm mile1992in front of the airplane at a relative altitude of -200 feet. He would1993then have looked directly in front of the airplane. For 9 seconds after1994the TA occurred, the helicopter was surrounded by, and likely1995indistinguishable from, a dense array of both steady and flashing1996lights that stretched along the horizon to the right of the airport.1997Given the complexity of this background and the helicopter's lack of1998apparent motion when viewed from the airplane, it is likely that the FO1999would have been unable to spot it during a brief search. Even if the2000crew was unsuccessful in visually locating the helicopter, they were2001trained not to maneuver unless they received an resolution advisory2002(RA). Many of the PSA pilots interviewed were unaware of the altitude2003below which RAs were inhibited.2004    It is also possible that the radio transmissions audible to the2005flight crew reduced the extent of their visual search for the2006helicopter. Although the crew could not hear PAT25's transmissions to2007the controller, they could hear the controller's transmissions to the2008helicopter. These transmissions would have been reassuring if the crew2009heard them and recognized their airplane as the ``CRJ'' being2010referenced. One second before they received the TA aural alert, they2011would have heard the LC controller transmit, ``PAT two five you got the2012C-R-J in sight?'' followed by, ``PAT two five pass behind the C-R-J.''2013A few seconds later, they would have heard the LC controller transmit2014``vis sep.'' The crew of flight 5342 undoubtedly understood the2015terminology associated with approving visual separation. Thus, these2016transmissions (if listened to) would have indicated to the crew that2017the helicopter had their airplane in sight and intended to avoid them.2018The fact that the controller did not issue them any advisories or2019instructions would also have been reassuring, because it would have2020indicated that the responsibility for deconfliction had been assigned2021to the helicopter. If heard and attended to, the radio communications2022audible to the flight 5342 crew could have reassured them that the2023helicopter was not a significant threat and that they could focus their2024attention on completing their approach and landing. However, because2025the CVR did not contain any discussions between the crew about these2026transmissions or the potential of a conflict with the helicopter, their2027level of awareness of the transmissions and their involvement in the2028traffic conflict could not be determined.2029    The NTSB concludes that the crew of flight 5342 did not see the2030helicopter until it was too late to avoid a collision because of the2031high workload imposed during the final phase of their approach, and due2032to the helicopter's low conspicuity and lack of apparent motion.2033[FINDING 38]2034DCA Air Traffic Control Tower Facility2035Traffic Management, Volume, and Flow2036    Postaccident interviews and investigative hearing testimony2037provided by DCA ATCT and Potomac terminal radar approach control2038(TRACON) personnel, as well as FAA Air Traffic Organization (ATO)2039leadership, indicated that managing the flow of traffic at DCA had been2040a longstanding challenge that could be attributed to several factors,2041one of which was DCA's airport arrival rate (AAR).2042    Potomac TRACON and DCA ATCT personnel stated in interviews and2043investigative hearing testimony that managing the rate of arrivals into2044DCA while providing adequate MIT spacing between arriving aircraft was2045a continual issue. Potomac TRACON and DCA ATCT had agreed that aircraft2046would arrive at the runway threshold at DCA with a spacing of 4 miles2047in trail (MIT); however, the FAA found through a systematic review2048conducted after the accident that DCA ATCT controllers were provided2049with less than 4 MIT about 40 percent of the time. This spacing was2050critical because it allowed adequate time for departures to take place2051between arriving aircraft, thereby reducing backups on DCA's limited2052taxiway surface area.2053    In 2023, Potomac TRACON requested a decrease to the existing AARs2054due to changes to the mix of aircraft types serving DCA over the2055previous decade, flight schedule increases that did not allow for use2056of reduced separation of aircraft on final approach, airspace and2057weather constraints, and an inability to regulate traffic flow based on2058time, also referred to as ``metering.'' The Potomac TRACON air traffic2059manager (ATM) stated in postaccident interviews that the request to2060reduce DCA's AARs was not forwarded to higher levels because it was2061``too political.'' The FAA's denial of the documented request to change2062the AAR at DCA without feedback to the requester effectively eliminated2063what could have been an important operational safety improvement and2064violated their established review process.2065    Another factor that DCA ATCT controllers cited as contributing to2066traffic complexity was that airlines often grouped their allotted2067departures or arrivals for a given 2-hour period into the last 302068minutes of the first hour and the first 30 minutes of the second hour2069rather than spreading them evenly throughout the hour, which resulted2070in times of ``compacted demand'' on controllers to accommodate traffic2071surges. The NTSB concludes that times of compacted demand as a result2072of air carrier scheduling practices increased operational complexity2073and required mitigations by controllers to maintain spacing and surface2074movement. [FINDING 39] Other airports, including New York's LaGuardia2075Airport, have mitigations in place to prevent this practice through2076Federal regulations contained in 14 CFR 93 Subpart K, which prescribes2077air traffic rules for aircraft operating to and from high density2078traffic airports. The regulation specifies the number of operations2079that can occur during any 30-minute period or any two consecutive 30-2080minute periods. In order to alleviate the effects of compacted demand2081at DCA, the NTSB recommends that the FAA initiate rulemaking in 14 CFR2082Part 93 Subpart K, High Density Traffic Airports, that prescribes air2083carrier operation limitations at DCA in 30-minute periods, similar to2084those imposed at LaGuardia Airport, to ensure that the airport does not2085exceed capacity and to mitigate inconsistent air carrier scheduling2086practices. [RECOMMENDATION 4]2087    A time-based flow management (TBFM), or metering, system had been2088in place at Potomac TRACON for at least 10 years before the accident2089and controllers had been trained in its use; however, the system was2090never activated. The core function of TBFM is the ability to schedule2091aircraft to reach a defined point at a specified time, creating a time-2092ordered sequence of traffic.2093    According to testimony provided in the investigative hearing by the2094FAA's Washington District traffic management officer, TBFM would allow2095for better management of the compacted demand at DCA. A representative2096of American Airlines testified that TBFM was in use at several of the2097airline's other hub airports and that it ``smooths out the volume'' of2098traffic while providing more accurate MIT. Information provided by the2099FAA indicated that, as of February 2025, the TBFM project at Potomac2100TRACON was on hold until further notice due to budget constraints. A2101manager at Potomac TRACON testified that they had ``not seen it yet,2102and it is supposed to come in March of [20]26.''2103    In interviews with DCA ATCT personnel, as well as review of ATC2104audio and personal observation by investigators, ``offloading''2105arrivals to another runway was common practice at DCA to build spacing2106between aircraft, particularly during times of heavier traffic flow and2107when the airport was in a north configuration (airplanes landing on2108runway 1).2109    The DCA ATCT operations manager at the time of the accident stated2110that controllers routinely offloaded traffic on approach to runway 1 by2111having them circle to runway 33. Although other methods were available2112to DCA controllers to build additional spacing between aircraft, the2113operations manager stated that offloading traffic to runway 33 was a2114preferred mitigation at DCA ATCT because it continued the flow of2115arrivals and departures during compacted demand times.\10\ In contrast,2116having an airplane decrease airspeed on final approach to increase2117separation would cause traffic buildup behind that aircraft that would2118also affect Potomac TRACON.2119---------------------------------------------------------------------------2120    \10\ During the NTSB's investigative hearing, the ATO's acting2121deputy COO testified that other methods included slowing aircraft after2122check-in on final approach, instructing aircraft to perform S-turns on2123final approach, and ``demand[]'' that Potomac TRACON provide a certain2124MIT interval between aircraft, if needed.2125---------------------------------------------------------------------------2126    Many of the factors that contributed to DCA's uniquely complex2127traffic situation were present on the night of the accident and2128contributed to high controller workload. The LC controller stated in a2129postaccident interview that a traffic ``push,'' or compacted demand,2130had begun about 2000 that night, but he believed that traffic was2131decreasing around the time of the accident. He also stated that the2132tower ``wasn't getting spacing on final'' at the time of the accident,2133referring to the 4 MIT agreement with Potomac TRACON. Further, he had2134traffic on the ground waiting to depart. As a result, he was asking2135pilots of aircraft inbound for landing whether they could switch to2136runway 33 as a means of increasing space between arrivals to allow for2137departures. The NTSB concludes that DCA ATCT routinely received less2138than the requested miles in trail spacing from Potomac TRACON, which2139increased controller workload by requiring them to generate additional2140spacing to prevent delays or gridlock. [FINDING 40] The NTSB also2141concludes that the practice of ``offloading'' arrival traffic on2142approach to runway 1 by asking pilots if they could accept a circling2143approach to runway 33 was a routine mitigation strategy for DCA2144controllers to generate spacing that was not provided by Potomac2145TRACON. [FINDING 41] The NTSB further concludes that TBFM, or metering,2146would provide Potomac TRACON and DCA ATCT with a consistent flow of2147traffic with more accurate spacing and greater predictability, thereby2148reducing controller workload. [FINDING42]2149    The NTSB recognizes that, according to the FAA, Potomac TRACON2150began limited operational use of TBFM in October 2025; however, TBFM2151had not yet been implemented at the Potomac TRACON or the DCA ATCT at2152the time of the accident, and full implementation and operational use2153of TBFM in both facilities is expected by March 2026. Therefore, the2154NTSB recommends that the FAA fully implement operational use of the2155TBFM system at Potomac TRACON and its associated air traffic control2156towers. [RECOMMENDATION 5] The NTSB also recognizes that FAA also made2157a temporary adjustment to the AAR following this accident, which2158remains in effect as of the date of this report. In order to fully2159address the traffic management, volume, and flow issues in the DCA2160airspace, the NTSB recommends that the FAA reassess the DCA AAR with2161special consideration to its airspace complexity, airfield limitations,2162mixed-fleet operations, and traffic volume. [RECOMMENDATION 6]2163    The NTSB is concerned also that the spacing issue observed in this2164accident may exist elsewhere in the NAS. Therefore, the NTSB also2165recommends the FAA require each Class B or Class C ATCT facility to2166evaluate its existing MIT procedures or agreements to ensure that the2167spacing provided is appropriate for operational safety, and make the2168results publicly available. [RECOMMENDATION 7]2169    During the course of the investigation, the NTSB learned that the2170DCA ATCT had been downgraded from a level 10 facility to a level 92171facility in 2018. Facility level is a factor that determines controller2172compensation, and controllers stated that the downgrade at DCA ATCT2173impacted employee morale and resulted in the loss of experienced2174controllers, who left for higher paying facilities. Despite several2175requests from the NTSB during this investigation, the FAA did not2176provide documentation of the criteria or formula it used in its2177determination to downgrade DCA ATCT's facility level.2178    The NTSB is concerned about the impacts of the downgrade on the DCA2179ATCT's long-term facility health and by the FAA's lack of transparency2180regarding the metrics used to define facility levels throughout the2181NAS. Although the DCA ATCT's facility level downgrade could not be2182directly correlated to the circumstances of this accident, the NTSB2183concludes that DCA ATCT has significant airspace, airfield, mixed2184fleet, and operations complexities that appear to be inconsistent with2185its current facility level classification. [FINDING 43] Therefore, the2186NTSB recommends that the FAA define objective criteria for the2187determination of air traffic facility levels considering traffic and2188airspace volume, operational factors unique to each facility, and cost2189of living. [RECOMMENDATION 8] Using this criteria, determine whether2190the classification of the DCA ATCT as a level 9 facility appropriately2191reflects the complexity of its operations. [RECOMMENDATION 9]2192Visual Separation2193    The FAA's Pilot-Controller Glossary states that visual separation2194is a means employed by ATC to separate aircraft in terminal areas and2195enroute airspace in the NAS. In the terminal, or airport, area, visual2196separation can be either tower-applied, in which the tower controller2197sees the aircraft involved and issues instructions to effect2198separation; or pilot-applied, in which a pilot sees the other aircraft2199involved and provides their own separation by maneuvering as necessary2200to avoid it. Visual separation does not require a certain minimum2201separation distance between aircraft; therefore, pilots are permitted2202to determine their own spacing. In the absence of visual separation at2203DCA, Class B radar separation minimums would apply, which require 1 1/22204mile lateral or 500 ft vertical distance between IFR (airplane) and VFR2205(helicopter) traffic.2206    Postaccident interviews with controllers and testimony provided in2207the NTSB investigative hearing revealed that visual separation was the2208primary means of separating helicopter and fixed-wing traffic in the2209DCA area when weather conditions permitted. One controller testified2210that the use of visual separation was ``paramount'' to efficient2211operations at DCA given the volume of traffic and the complexity of the2212airspace. Due to the proximity of the helicopter routes and zones to2213the approach and departure corridors for fixed-wing traffic, applying2214standard Class B separation minimums at all times would likely require2215controllers to frequently issue holds to helicopter traffic and,2216depending on traffic priority, could also result in controllers2217frequently issuing go-around instructions to fixed-wing traffic, all of2218which would increase controller workload and contribute to additional2219airspace congestion and traffic complexity. To avoid these2220difficulties, controllers were motivated to provide a traffic advisory2221and authorize visual separation for helicopters transiting DC airspace2222as early as possible, and interviews with controllers indicated that2223this practice had become the norm.2224    Previous external compliance verifications (ECVs) at the DCA ATCT2225identified issues such as shortcutting standard phraseology, instances2226in which the HC position was combined or de-combined without required2227documentation in the facility logs, and occurrences in which2228helicopters flew in close proximity to arriving fixed-wing aircraft and2229traffic information was not issued to either aircraft. The team also2230observed occasions where fixedwing traffic was not advised regarding2231helicopters operating in close proximity to the final approach course.-2232wing traffic was not advised regarding helicopters operating in close2233proximity to the final approach course.2234    During a November 2024 ECV, the ECV team noted ``a few2235occurrences'' in which the LC controller advised aircraft on final2236approach that helicopters operating near the final approach course had2237them in sight and were maintaining visual separation. However, at the2238time these transmissions were made, the helicopter had not reported the2239traffic in sight and had not been advised to maintain visual2240separation. The LC controller appeared to be anticipating that the2241helicopters would visually acquire the arrival traffic, report traffic2242in sight, and then be instructed to maintain visual separation.2243    A retired FAA air traffic specialist who was subsequently employed2244as a contractor to perform ECVs at DCA ATCT stated that, during his 92245months at the facility, he had concerns about potential conflicts with2246the helicopter routes, which he raised to the ATM at the time.2247    In the NTSB's investigative hearing, the DCA ATCT operations2248manager (OM) at the time of the accident stated that the controllers at2249DCA would ``just make it work'' by utilizing all available tools to2250compensate for the traffic volume.2251    Because DCA was a high volume, complex airport with ``not a lot of2252real estate,'' controllers had to ``keep things moving'' in order to2253provide safe and efficient service. He stated that this ``make it2254work'' mentality had become normalized at DCA ATCT before the accident2255and that, ``it can be taxing on a person. . .constantly having to give,2256give, or push, push, push in order to efficiently move traffic.'' He2257further stated that, ``Whenever the controllers at DCA just make it2258work, they are going above and beyond to approach the limit of the2259rules and regulations. They're pushing the limits of what can be done2260to safely and efficiently move the aircraft and/or helicopters at DCA.2261. .you're pushing the line.''2262    The issues identified by previous ECVs at DCA should have served as2263symptoms of a controller workforce under constant pressure to ``make it2264work.'' Controllers relied on the use of pilot-applied visual2265separation in order to accommodate helicopters operating on the routes2266and zones while moving a high volume of aircraft through complex2267airspace into and out of an airport with limited surface area. The NTSB2268concludes that the FAA ATO failed to recognize ECV results as2269indicators of systemic traffic management, volume, and flow issues at2270DCA for which controllers were required to compensate. [FINDING 44]2271    Interviews and testimony from helicopter operators in the DCA area2272indicated widespread understanding that visual separation allowed more2273efficient traffic flow and that requesting and receiving approval for2274visual separation was normal practice. Helicopter operators reported2275receiving traffic advisories at distances that made it difficult to2276identify specific targets. Nevertheless, they were generally2277comfortable using pilot-applied visual separation, particularly on2278clear nights and when using NVGs, which allowed aircraft lights to be2279seen from long distances.2280    The expectation that helicopter crews would maximize use of visual2281separation to facilitate traffic flow likely promoted a pattern of2282automatic responses when flight crews received traffic advisories. An2283Army standardization instructor pilot stated in a postaccident2284interview that he sometimes responded to traffic advisories before2285visually acquiring the traffic if he knew that it was far away and was2286not an imminent threat. The accident IP's significant experience flying2287on the DC helicopter routes and the speed of his reply to the2288controller's traffic advisory support the likelihood that he had also2289developed this habit. This practice was contrary to FAA requirements2290that a crew should visually identify aircraft before requesting visual2291separation.2292    The acceptance of a gap between typical operating practices and2293formal operating requirements has been described as normalization of2294deviance. Coined after the Space Shuttle Challenger disaster in 1986,2295``normalization of deviance'' refers to the gradual shift away from2296standards or acceptable practices (Vaughan 1996). Such deviations2297originate from frontline personnel trying to manage conflicting goals,2298such as maximizing production, protection, and minimizing workload2299(Rasmussen, 1999). When such gaps develop, they can become2300incrementally larger if they persist without negative consequences, and2301this can lead to systemic safety vulnerabilities.2302    In this case, controller expectations that a helicopter crew would2303have a specific aircraft in sight before requesting and receiving2304approval for visual separation were not necessarily valid. As a result,2305there was potential for controllers to overestimate the level of2306traffic awareness a helicopter crew had, following a traffic advisory,2307and to underestimate the level of information and assistance they might2308subsequently require to ensure collision avoidance.2309    The NTSB concludes that the longstanding practice of relying on2310pilot-applied visual separation (see-and-avoid) as the principal means2311of separating helicopter and fixed-wing traffic in the Washington, DC,2312area by DCA tower, the Army, and other helicopter operators led to a2313drift in operating practices among controllers and helicopter crews2314that increased the likelihood of a midair collision. [FINDING 45]2315    There are inherent limitations to seeing and avoiding other2316airborne traffic. These include the limited field of view from the2317cockpit, including the obscuring effects of aircraft structures or, in2318this accident, the limited field of view provided by NVGs. Even the2319positioning of aircraft in a pilot's field of view near the cockpit2320structure reduces the odds of detection due to the effect of nearby2321objects on visual accommodation (Chong and Triggs 1989).2322    In this accident, both aircraft were located adjacent to or within2323a field of background lights when viewed from the other's perspective.2324Aircraft superimposed on or adjacent to complex backgrounds are more2325difficult to detect (Steedman and Baker 1960). Although aircraft2326lighting may improve the conspicuity of aircraft flying at night, the2327effect of a complex background of ground lighting may offset the2328advantages of such lighting. An Army standardization instructor pilot2329testified during the investigative hearing that, although it was easy2330to identify airplanes on approach to runway 1, it would be much more2331difficult to maintain visual contact with an airplane circling for2332runway 33, particularly as the helicopter descended to 200 ft. He also2333testified to the challenges inherent to NVG use, including the limited2334field of view and the difficulty in identifying aircraft operating near2335or below the horizon against dense cultural lighting.2336    Attentional limitations also play a role. Research indicates that2337fixed-wing pilots spend, on average, 30 percent to 35 percent of their2338time scanning outside, and even less time when engaged in tasks that2339demand their attention inside the cockpit (Wickens et al., 2001). When2340pilots do scan outside for traffic, they are biased toward the area2341directly in front of them, or toward outside features most pertinent to2342their current task (Colvin et al., 2005). Aircraft on a collision2343course lack relative motion in a pilot's field of view, which makes2344them less likely to attract visual attention because peripheral vision2345is more sensitive to motion than fine detail (Gibb et al., 2010).2346    These and other factors contribute to delays in detection that can2347lead to a midair collision when crews are visually self-separating.2348Research involving actual test flights indicates that most unalerted2349visual acquisitions of conflicting aircraft occur after two aircraft2350have closed to within 1 to 2 nm of each other. Mathematical modeling of2351the probability of visual acquisition based on these studies has2352indicated that, for a closure rate of 120 kts, the probability of2353detecting an intruder aircraft in the daytime does not reach 85 percent2354until 12 seconds before a collision (Andrews 1991). In this accident,2355CVR and FDR data indicate that the crew of flight 5342 detected the2356helicopter about 1 second before the collision, and that the crew of2357PAT25 had no awareness of the impending collision.2358    The NTSB has highlighted the limitations of see-and-avoid in2359previous investigations and argued that these limitations cannot be2360overcome by recommending greater pilot diligence and scanning for2361traffic. Traffic awareness and alerting technologies with aural alerts,2362however, can significantly improve detection and reaction times2363(Andrews 1991). This underscores the importance of such technology in2364airspace with a high concentration of commercial air traffic.2365    This accident, in which neither the crew of PAT25 nor the crew of2366flight 5342 detected each other in time to avoid a collision, amplifies2367the serious inherent limitations of the see-and-avoid concept, a2368primary means of separation between helicopters and commercial2369airplanes at DCA. The NTSB concludes that reliance on pilot-applied2370visual separation (see-and-avoid) as a primary means of separating2371mixed traffic introduced unacceptable risk to the DCA Class B airspace.2372[FINDING 46]2373    Although this accident occurred in the uniquely complex DCA Class B2374airspace, the underlying limitations of pilot-applied visual separation2375are inherent to human performance and are present wherever see-and-2376avoid is used as a means of aircraft separation in the NAS. Because2377controllers nationwide routinely apply visual separation in mixed-2378traffic environments, mitigating this risk requires consistent,2379systemwide training that emphasizes the limitations of see-and-avoid2380and the conditions under which its use may introduce unacceptable risk.2381Therefore, the NTSB recommends the FAA develop a new and comprehensive2382instructor-led, scenario-based training on the proper use of visual2383separation, both tower-and pilot-applied. This training should include2384information on the inherent limitations of see and avoid,2385responsibilities when applying visual separation, and guidance for2386controllers on factors, such as current traffic volume, workload,2387weather or environmental factors, experience, and staffing, that should2388be considered when applying visual separation. Require this training2389for all controllers and include on a recurrent basis thereafter in2390annual simulator refresher training. [RECOMMENDATION 10]2391Radio Frequency Management2392    The DCA air traffic control tower utilized a discrete frequency for2393communicating with helicopters to avoid interference and frequency2394congestion. When the HC and LC positions were combined, it was normal2395practice to keep helicopters on their own frequency rather than2396directing all traffic to use the same frequency. This also made the2397process of de-combining the helicopter and local control positions2398easier. When the HC and LC positions were combined, all pilots could2399hear all transmissions made by the controller; however, the use of2400separate frequencies meant that transmissions made from helicopters2401were not audible to airplanes and transmissions made from airplanes2402were not audible to helicopters. Pilots indicated that there were2403advantages and disadvantages to this practice. The advantages included2404reducing non-pertinent transmissions that could impede communication2405between crewmembers and alleviating frequency congestion; however,2406pilots reported that being able to hear transmissions from all other2407aircraft would be an asset to flight crew situation awareness. Had the2408accident crews been able to hear each other's transmissions to the2409controller, PAT25 would have heard flight 5342's acceptance of the2410runway 33 circling approach and their subsequent readback of the2411landing clearance. Flight 5342 would have heard PAT25's position report2412at the Memorial Bridge. These transmissions contained additional2413salient information regarding each aircraft's position and intentions,2414which may have increased the crews' awareness of the potential for a2415traffic conflict. The NTSB concludes that DCA tower's procedure of2416maintaining a discrete helicopter frequency when the local and2417helicopter control positions were combined decreased overall situation2418awareness for pilots operating in the area. [FINDING 47] Therefore, the2419NTSB recommends the FAA conduct a comprehensive evaluation, in2420conjunction with local operators, to determine the overall safety2421benefits and risks to requiring all aircraft to use the same frequency2422when the helicopter and local positions are combined in the DCA ATCT.2423[RECOMMENDATION 11]2424    The very high frequency (VHF) radio communications used by air2425traffic control do not allow for simultaneous transmissions. If a pilot2426or controller attempts to broadcast on the same frequency at the same2427time as another pilot, one or both transmissions may be garbled,2428incomplete, or blocked from reception entirely. This leads to missed2429control instructions, lack of clarity, loss of situation awareness, or2430readback errors; however, there is currently no system in use that2431allows controllers to know when a simultaneous broadcast has occurred.2432    Review of the helicopter's CVR indicated that the controller's2433instruction 17 seconds before the collision, which stated, ``PAT two2434five pass behind that C-R-J,'' was interrupted by a 0.8-second2435microphone key from one of the helicopter crewmembers, which resulted2436in much of the transmission being interrupted, and the crew did not2437receive the instruction to ``pass behind.''2438    In 1984, the FAA was petitioned to enact rulemaking requiring two-2439way radio communication systems employing anti-blocking and stuck2440microphone protection circuitry. In response, the FAA issued Technical2441Standard Order (TSO) C128, which provided standards for preventing2442blocked channels used in two-way radio communications due to2443unintentional transmissions, and TSO C122, which provides standards for2444equipment designed to prevent blocked channels in two-way radio2445communications caused by simultaneous transmissions. TSO-C128 and its2446subsequent revision has proven effective and popular with VHF radio2447manufacturers; however, only one manufacturer had been issued a letter2448of TSO design approval under TSO-C122 since its original issuance in24491994. In June 2012, the FAA issued a Notice of Intent to Cancel C122a,2450the current revision, citing the lack of design approvals and ``the2451eventual obsolescence of TSO-C122a equipment''; however, the FAA has2452not finalized the cancellation of the TSO. In July 2025, citing the2453circumstances of this accident, the FAA announced that it was2454withdrawing its previous intent to cancel TSO-C122a and was reopening2455the associated comment period. The FAA stated that it welcomed comments2456on whether TSO-C122a and the standard it references, RTCA/DO-209, are2457obsolete, as well as input to identify current technologies that may2458have replaced these standards.2459    The NTSB recognizes that implementing same-frequency communications2460for airplanes and helicopters in a high traffic volume area such as DCA2461increases the risk of simultaneous radio transmissions that prevent2462critical information from being transmitted or received by both pilots2463and controllers. Therefore, the NTSB recommends that the FAA implement2464anti-blocking technology that will alert controllers and/or flight2465crews to potentially blocked transmissions when simultaneous2466broadcasting occurs. [RECOMMENDATION 12]2467Conflict Alert System2468    The conflict alert system is designed to draw the controller's2469attention to a potential conflict and is presented in three ways, an2470aural alert, a flashing conflict alert ``(CA)'' on the display, and a2471conflict list on the display, which indicates in red the aircraft2472involved. The activation criteria comprises three algorithms that each2473detect conflicts independently, sensing potential linear, maneuver, and2474proximity conflicts. Some of these logics predict where the aircraft is2475going, while others consider where the aircraft is located at that2476time; however, the CA presented to the controller is the same2477regardless of which algorithm is activated. This requires the2478controller to identify and interpret the severity of the conflict and2479evaluate the action they should take based on other available2480information. Interviews with DCA ATCT personnel indicated that CAs were2481heard ``often'' and were ``pretty common'' at DCA. In the 30 minutes2482before the accident occurred, the conflict alert could be heard in the2483background during 18 controller transmissions.\11\ Controllers reported2484that they often received CAs for non-conflicts, such as when aircraft2485were on diverging paths, or that the CA would continue to activate even2486after the controller had taken action to mitigate the conflict. In this2487accident, the controller responded about 6 seconds after the alert2488activated. There was a slight delay in the LC controller's response, as2489he was completing a transmission with another helicopter when the CA2490activated, and he did not query PAT25 until after the other helicopter2491had responded.2492---------------------------------------------------------------------------2493    \11\ As previously noted in section 1.7.8.4, these instances did2494not necessarily represent 18 distinct CA activations. Review of2495available radar display replay data for the final 18 minutes before the2496accident identified five separate CA activations, several of which2497persisted long enough to be audible across multiple transmissions.2498---------------------------------------------------------------------------2499    Allendoerfer et al., (2007) analyzed 607 CAs from 5 enroute and 172500terminal ATC facilities and categorized controller responses to the2501alerts and the timing of the responses. Their research indicated that2502the majority of CAs (44 percent in the terminal area) received no2503response from controllers; many are so brief that controllers have2504resolved the situation before the alert activated, or that the2505situation resolved itself without any controller input. They noted that2506no operational errors nor deviations occurred in these instances.2507Alerts that activate and require no controller action may increase2508workload, as the alert directs the controller's attention away from2509their current tasks and toward the aircraft involved in the alerting2510event. Of the alert situations where controllers acted, they most often2511acted before the alert activated (67 percent of the time). This2512suggests that, while many alerts are valid according to the alert2513algorithms, they do not provide useful information to controllers; that2514nuisance alerts are common (81-87 percent of CAs are estimated to be2515nuisance alerts); and that high nuisance alert rates may desensitize2516controllers and lead to poor responses to critical alerts.2517    The current system displays all CAs in the same manner regardless2518of the algorithm that triggered the alert. In the absence of any2519salient information conveying the severity of the conflict, controllers2520must make their own determination regarding whether the conflict alert2521requires immediate action, thus increasing cognitive load. The FAA's2522Human-Systems Integration Branch manager stated during the NTSB's2523investigative hearing that improvements are available to the CA2524software that could provide color coding or various aural alerts2525depending on which of the three conflict alert algorithms was2526activated. The NTSB concludes that providing controllers with2527additional salient cues regarding the perceived severity of a potential2528conflict would reduce controller cognitive load and would likely2529improve reaction time to the most critical conflict alerts. [FINDING253048] Therefore, the NTSB recommends that the FAA develop and implement2531improvements to the conflict alert system to provide more salient and2532meaningful alerts to controllers based on the severity of the conflict2533triggering the alert. [RECOMMENDATION 13] Once the improvements to the2534conflict alert system discussed in Safety Recommendation [13] are2535implemented, provide training to controllers on its use.2536[RECOMMENDATION 14]2537Postaccident Drug and Alcohol Testing2538    The LC controller, ALC controller, and OS underwent U.S. Department2539of Transportation (DOT) workplace postaccident drug testing about 182540hours, 20 hours, and 18 hours after the accident, respectively. This2541testing did not detect any tested-for substances indicative of2542prohibited drug use. They did not undergo alcohol testing.2543    The 14 tested-for substances on the DOT workplace drug testing2544panel in effect at the time of the accident may be detectable in urine2545for a day or more after last drug use. As such, the testing was2546worthwhile, although it was less sensitive for identifying pre-accident2547prohibited drug use than it would have been if it was conducted sooner2548after the accident. There was no evidence to indicate that any of the2549controllers were under the influence of alcohol at the time of the2550accident; however, had timely postaccident alcohol testing been2551conducted, controller alcohol use might have been definitively excluded2552as a factor in the accident. Unfortunately, postaccident alcohol2553testing was not conducted, so there was no toxicological evidence2554available to support such a determination. The NTSB concludes that2555there was no evidence that the LC controller, ALC controller, or OS2556were under the influence of alcohol or prohibited drugs at the time of2557the accident; however, evidence was substantially limited by the lack2558of postaccident alcohol testing, and evidence was of somewhat lower2559quality than it would have been if drug testing had been conducted2560sooner following the accident. [FINDING 49]2561    DOT Order 3910.1D, ``Drug and Alcohol-Free Departmental Workplace2562Program,'' stated that air traffic controllers must undergo2563postaccident drug and alcohol testing as soon as possible after a fatal2564accident, any accident that involved a need for medical treatment away2565from the accident site, or following an accident which resulted in2566substantial damage to aircraft or other vehicles or property. The order2567also required that, whenever possible, alcohol testing must take place2568within 2 hours after the accident, and drug testing within 4 hours2569after the accident. Review of documentation provided by the FAA2570indicated that the drug and alcohol testing determination was not made2571until almost 3 1/2 hours after this accident, when the FAA ATO2572determined that there was a requirement to test the LC controller, ALC2573controller, and OS. By that time, the controllers had left the2574facility. Although DOT Order 3910.1D permitted alcohol testing for2575another 4 1/2 hours after the determination was made and stated that2576controllers must remain readily available for testing, the ATO decided2577to test for drugs only, and the testing was scheduled for late the2578following afternoon. Thus, the NTSB concludes that the FAA ATO's drug2579and alcohol testing determination did not meet DOT timeliness2580requirements; furthermore, the ATO's decision to not conduct drug2581testing as soon as possible after the testing determination, and to not2582conduct alcohol testing at all, violated DOT requirements. [FINDING 50]2583    FAA Order JO 1030.3B, ``Initial Event Response,'' outlines ATO2584procedures following an accident, to include the postaccident/incident2585drug and alcohol testing determination being made concurrently with the2586ATO's Services Rendered Telephone Conference (SRT), which is a2587management review to assess air traffic services associated with an2588event (FAA, 2014a). However, initiating an SRT requires multiple2589initial notifications and preliminary review of the event, to include2590preparing audio and radar display recordings of the event for playback.2591These administrative and investigative actions take time. When2592possible, SRTs are convened the administrative day following the2593accident to allow time for such actions to be completed, though major2594air carrier accidents or fatal accidents involving air traffic control2595services require an SRT to be convened no later than 3 hours following2596initial notification. However, an SRT conducted 3 hours after an2597accident is already outside the 2-hour postaccident alcohol testing2598window outlined by the DOT, and an SRT conducted the next2599administrative day is likely to fall outside both the 4-hour2600postaccident drug testing window and the 8-hour maximum time for2601alcohol testing.2602    Additionally, there was evidence that ATO staff lacked a complete2603understanding of DOT postaccident drug and alcohol testing2604requirements. First, the testing determination itself violated DOT2605requirements. Also, a DOT-required memorandum as to why testing was not2606performed in a timely manner was not prepared, which an ATO2607representative attributed to staff's lack of awareness of this2608requirement.\12\2609---------------------------------------------------------------------------2610    \12\ This accident was not the only recent NTSB investigation to2611identify delayed drug testing and missed alcohol testing of an air2612traffic controller who was providing services during a serious safety2613event. The NTSB's investigation of a 2023 runway incursion involving a2614Southwest Airlines passenger airplane and a Federal Express cargo2615airplane identified that the controller who had been communicating with2616both airplanes had not undergone postincident alcohol testing, and did2617not undergo postincident drug testing until the day after the event. In2618response to NTSB queries about the drug testing determination in that2619event, the FAA provided a copy of an FAA e-mail request to ``please2620test'' the controller that had been sent more than 8 hours after the2621event, by which time the window for alcohol testing had closed.2622---------------------------------------------------------------------------2623    The NTSB concludes that the delayed and inappropriate drug and2624alcohol testing determination was due in part to the ATO's2625determination process being inadequately designed to routinely meet DOT2626requirements for timely testing, and in part to ATO staff's incomplete2627understanding of those requirements. [FINDING 51]2628    A primary intended purpose of DOT workplace drug and alcohol2629testing is to deter and identify abuse of alcohol and use of certain2630illegal drugs by individuals performing security-and safety-sensitive2631duties, with the recognition that those substances may have impairing2632effects on the performance of those duties (US Congress, 1991).2633Systemic obstacles to accomplishing timely and appropriate postaccident2634and postincident testing weaken the ability of such testing to serve2635its intended safety purpose. Accordingly, the ATO's inadequately2636designed determination process presents a public safety risk that2637extends beyond any single accident investigation.2638    The ATO representative testified at the NTSB's investigative2639hearing that the FAA had begun efforts to revise the initial event2640response procedures outlined by FAA Order JO 1030.3B. As of the date of2641this report, those initial event response procedures have not been2642revised. In this process, the FAA could consider the example of drug2643and alcohol testing requirements for FAA-regulated employers such as2644airlines, which are closely related to the requirements for FAA-2645employed air traffic control specialists.2646    The DOT requires the FAA to conduct postaccident testing of FAA-2647employed controllers whose performance is thought to have contributed2648to an accident or cannot be completely discounted as a contributing2649factor, and the FAA imposes similar requirements on its regulated2650employers. FAA regulations contain language clarifying the permissive2651intent of the requirement imposed by the FAA on regulated employers,2652stating that the employer's decision not to administer a test must be2653based on a determination, using the best information available at the2654time of the determination, that the employee's performance could not2655have contributed to the accident.\13\2656---------------------------------------------------------------------------2657    \13\ For corresponding DOT/FAA workplace testing language, see DOT2658Order 3910.1D, Chapter III, paragraph 6.i(2). For corresponding2659language pertaining to safety-sensitive employees of FAA-regulated2660employers, see 14 CFR 120.109(c) and 14 CFR 120.217(b)(1).2661---------------------------------------------------------------------------2662    There is no requirement in the DOT's workplace drug and alcohol2663testing program, or in DOT/FAA regulations for regulated employers, for2664each drug and alcohol testing determination to be based on upper2665managerial consensus after investigation. DOT's own workplace drug and2666alcohol testing guidance states, ``the decision to subject an employee2667to a postaccident test shall be made using the best information that is2668reasonably available to management at or about the time of the2669accident.'' DOT's guidance to DOT/FAA-regulated employers is more2670explicit:26712672    The supervisor at the scene of the accident/event should know the2673testing criteria and make a good-faith effort decision to test or not2674test based on the information available at the time [emphasis in2675original]. The supervisor may consult with others, but the supervisor2676is the person who has to make the decision.26772678    If the FAA were to adopt a process whereby on-site supervisors are2679empowered to make postaccident/incident testing determinations using2680available information independently from SRTs, this would not only2681remove many of the barriers to timely decision making but also would2682achieve parity with DOT's guidance on best practices for DOT/FAA-2683regulated employers. Any such process change would need to be2684effectively communicated throughout the ATO, including by revising FAA2685Order JO 1030.3B, leveraging existing training procedures, and possibly2686developing new tools, to ensure that ATO staff possess a strong2687understanding of associated requirements. This institutional2688understanding would need to be resilient to workforce turnover, and to2689the relative infrequency of events triggering postaccident and incident2690testing. Therefore, the NTSB recommends that the FAA revise the Air2691Traffic Organization's initial event response procedures so that an2692appropriate on-site supervisor makes each postaccident and postincident2693drug and alcohol testing determination, based on their assessment of2694whether the event meets testing criteria and which controllers had2695duties pertaining to the involved aircraft, without needing to wait for2696investigation or approval. [RECOMMENDATION 15]2697    The NTSB additionally recommends that the FAA at least annually,2698provide training on the revised postaccident and postincident drug and2699alcohol testing determination procedure discussed in Safety2700Recommendation [15] to all staff who have responsibilities under that2701procedure; this training should include a post-learning knowledge2702assessment. [RECOMMENDATION 16]2703    FAA ATO procedures that limit the timeliness of postaccident/2704incident testing determinations also limit opportunities to evaluate2705potential downstream barriers to timely testing. It is possible that2706successful revision of ATO procedures might expose other weaknesses--2707for example, in contractor availability to conduct timely testing once2708a timely drug and alcohol testing determination is made. The DOT,2709including the Assistant Secretary for Administration and the2710Departmental Drug Office (DDO), has the responsibility to oversee FAA2711adherence to DOT workplace drug and alcohol testing requirements and2712associated required training of supervisors. To enforce its workplace2713drug testing requirements effectively, the DOT should ensure that the2714FAA systematically identifies and addresses barriers to timely2715postaccident and postincident drug and alcohol testing at its2716facilities. Importantly, addressing these barriers likely would require2717administrative support from the DOT DDO, not just oversight.2718    Accordingly, the NTSB recommends that the DOT require the FAA to2719demonstrate at least annually that each air traffic control facility it2720operates has the routine capability to accomplish required postaccident2721and postincident drug and alcohol testing within the U.S. DOT's2722specified timeframes of 2 hours for alcohol and 4 hours for drugs, and2723implement a process to ensure that any facility without such capability2724will demonstrate timely remediation. [RECOMMENDATION 47]2725Helicopter Route Design and Information2726    Preliminary investigative findings of this accident revealed that,2727when flown at the recommended maximum altitude of 200 ft, a helicopter2728operating over the eastern shoreline of the Potomac River on Helicopter2729Route 4 would have about 75 ft of vertical separation from an airplane2730approaching runway 33. This vertical separation decreases the farther2731west of the shoreline the helicopter is flown, or if the airplane is2732operating below the 3+ visual glidepath provided by the runway 332733precision approach path indicator (PAPI).2734    In an urgent safety recommendation report published on March 11,27352025, the NTSB concluded that the separation distances between2736helicopter traffic operating on Route 4 and aircraft landing on runway273733 that existed at the time of the accident were insufficient and posed2738an intolerable risk to aviation safety by increasing the chances of a2739midair collision. The NTSB also concluded that it was critical for2740public safety helicopter operators to have an alternate route available2741for operating in and around Washington, DC, without increasing2742controller workload.2743    As a result of our findings, we issued two urgent safety2744recommendations to the FAA. Urgent Safety Recommendation A-25-1 asked2745the FAA to prohibit operations on Helicopter Route 4 between Hains2746Point and the Wilson Bridge when runways 15 and 33 were being used for2747departures and arrivals, respectively, at DCA. Urgent Safety2748Recommendation A-25-2 asked the FAA to designate an alternative2749helicopter route that could be used to facilitate travel between Hains2750Point and the Wilson Bridge when that segment of Route 4 was closed.2751    Immediately following the accident, the FAA implemented temporary2752airspace restrictions around DCA. On March 14, 2025, the FAA removed2753from helicopter route charts the section of Helicopter Route 4 between2754Hains Point and the Wilson Bridge. Additionally, the FAA prohibited use2755of runways 15/33 and 4/22 at DCA during ``specific, limited helicopter2756operations'' in the vicinity of DCA. The NTSB responded that these2757actions exceeded the intent of Safety Recommendation A-25-1 and2758classified it Closed--Exceeds Recommended Action.2759    In correspondence dated March 26, 2025, the FAA stated that it2760would collaborate with stakeholders to develop a new helicopter route2761connecting the Wilson Bridge to the Anacostia River and would provide2762updates on the alternative route designation process as it progresses.2763The NTSB stated that this planned work was responsive to Safety2764Recommendation A-25-2 and, pending its completion, the recommendation2765was classified Open--Acceptable Response.2766    FAA Order JO 7210.3DD listed criteria and procedures for the2767development and modification of helicopter route charts. One of the2768listed criteria was that, ``Care should be exercised to avoid2769recommending altitudes or flight ceilings/floors which would cause2770helicopters operating on a designated route to encounter inflight wake2771turbulence generated by large, fixed-wing traffic.'' The order stated2772that Terminal Operations Service Area Directors were responsible for2773reviewing and approving new or revised helicopter route chart proposals2774and assuring that they complied with all prescribed criteria. These2775directors were also responsible for conducting annual reviews of2776existing visual flight rules (VFR) helicopter route charts to determine2777their accuracy and continued utility; however, the FAA was unable to2778provide documentation of the required annual reviews for the Baltimore-2779Washington Helicopter Route Chart. As of the date of this report, no2780information has been provided regarding annual reviews conducted,2781including criteria used, if such reviews were conducted. The NTSB2782concludes that annual reviews of helicopter route charts as required by2783FAA Order 7210.3DD would have provided an opportunity to identify the2784risk posed by the proximity of Route 4 to the runway 33 approach path,2785but there is no evidence to support that these reviews were being2786performed at DCA. [FINDING 52] The NTSB is concerned that the lack of2787documentation of annual reviews for the Baltimore-Washington Helicopter2788Route Chart may be an indication that these annual reviews are not2789occurring at other locations throughout the NAS. Therefore, the NTSB2790recommends that the FAA ensure that annual reviews of helicopter route2791charts are being conducted throughout the NAS as required by FAA Order.2792[RECOMMENDATION 17]2793    Although the FAA took immediate action following this accident to2794remove the portion of Route 4 between Hains Point and the Wilson2795Bridge, the NTSB remains concerned about the potential for other areas2796of conflict within this airspace. Following the accident, the FAA2797published a NAS Helicopter Operations Helicopter Route Analysis, which2798summarized the ATO's safety analysis of domestic airports with charted2799helicopter routes. Using Performance Data Analysis and Reporting System2800(PDARS), TCAS events, and Near Midair Collision System (NMAC) data, the2801FAA reviewed charted routes and high-traffic-volume areas for possible2802conflicts with traffic patterns and reviewed the descriptions for2803charted and agreement-established routes. The analysis identified2804hazards in the airspace encompassing the routes and proposed actions to2805address priority concerns. This analysis, however, did not include DCA.2806    The NTSB reviewed PDARS data provided by the FAA regarding2807encounters between fixed-wing airplanes and helicopters operating on2808Routes 1 or 4 from January 2018 to February 2025. During this time,2809there were 4,067 encounters (65.6 encounters per month) in which2810separation was less than or equal to 1,000 ft and 348 encounters (5.62811encounters per month) in which separation was less than or equal to 5002812ft. A heat map depicting the frequency of these events showed several2813areas where encounters between helicopters and fixed-wing aircraft were2814concentrated, including the area of the accident site, as well as north2815of DCA, consistent with encounters with aircraft on approach to runway281619, and south of DCA, consistent with encounters with aircraft on2817approach to runway 1.2818    In unofficial correspondence dated January 16, 2026, the FAA2819reported that it had conducted an in-depth analysis of the helicopter2820operations within DCA's airspace and made additional changes to the2821Baltimore-Washington Helicopter Route Chart. As of the date of this2822report, that analysis has not been provided to the NTSB. Therefore, the2823NTSB recommends that the FAA conduct an SRM process to evaluate whether2824modifications to the remaining DCA helicopter route structure are2825necessary to safely deconflict helicopter and fixed-wing traffic and2826provide the results to the NTSB. [RECOMMENDATION 18] In addition, the2827NTSB recommends that the FAA amend their helicopter route design2828criteria and approval process to ensure that current and future route2829designs or design changes provide vertical separation from airport2830approach and departure paths. [RECOMMENDATION 19] Once the criteria and2831approval process referenced in Safety Recommendation [17] are developed2832and implemented, review all existing helicopter routes to ensure2833alignment with these updated criteria. [RECOMMENDATION 20]2834    According to testimony provided by personnel from the FAA's2835Aeronautical Information Services office during the NTSB's2836investigative hearing, the routes depicted on a helicopter chart do not2837have lateral limitations unless explicitly outlined on the chart's2838route description. The routes were described as ``recommended paths''2839that served to streamline traffic flow and facilitate easier2840communication between pilots and controllers regarding expected flight2841paths, reporting points, and area ingress and egress locations.2842According to the FAA, helicopter routes were not specifically designed2843to provide separation between helicopters and fixed-wing traffic.2844    The Baltimore-Washington Helicopter Route Chart included depictions2845of each helicopter route and associated altitudes; however, it provided2846inconsistent guidance on route altitudes, showing the depicted2847altitudes as both ``maximum'' and ``recommended'' in the chart legend,2848textual route description, and additional information sections. The2849chart did not describe any lateral boundaries associated with the2850helicopter routes nor were the visual depictions of each route on the2851chart associated with any specific measurement or scale. The2852description of Route 4 stated that pilots should fly ``via east bank of2853Potomac River'' between the Anacostia River north of DCA and the Wilson2854Bridge south of DCA. The version of the Baltimore-Washington Helicopter2855Route Chart effective October 2, 2025, removed language in the route2856descriptions that stated, ``All Route Altitudes are Maximum.''2857    Three pilots from the 12th Aviation Battalion stated in2858postaccident interviews that they assumed that the published helicopter2859route altitudes provided separation from the flow of fixed-wing2860aircraft, and, as long as they remained at or below the published2861altitude, they would be deconflicted from fixed-wing traffic. In2862testimony provided at the NTSB investigative hearing, a standardization2863instructor pilot stated that the battalion did not have written2864guidance regarding the proximity to the east bank that they were2865required to maintain, but that ``tribal knowledge'' was to ``hug the2866shoreline'' along this portion of the route unless it was necessary to2867deviate for traffic avoidance.2868    Given the low altitudes of the routes, the fact that these route2869altitudes decreased nearer to DCA, and that the battalion's letter of2870agreement with the DCA ATCT required adherence to the published route2871altitudes, it is understandable that helicopter pilots would conclude2872that the purpose of the route altitudes was to separate fixed-wing and2873helicopter traffic; and the FAA provided no warnings or advisories on2874the helicopter route chart to ensure that they understood this was not2875the case. The NTSB concludes that the information published by the FAA2876regarding Washington, DC, area helicopter routes was insufficient to2877provide helicopter and fixed-wing operators with a complete2878understanding of the helicopter route structure and its lack of2879procedural separation from fixed-wing traffic. [FINDING 53]2880    Interviews with four DCA-based PSA pilots revealed that only one of2881the pilots, who was previously a military pilot in the area, had2882specific knowledge of the helicopter routes, locations, and altitudes.2883Another pilot was aware that there were helicopter routes but was not2884aware of their associated lateral or altitude limitations. The other2885two pilots had no knowledge of the helicopter routes. FAA-published2886terminal procedures did not contain any information to inform fixed-2887wing pilots operating at DCA about the presence or location of the2888helicopter routes, and DCA-specific airport and approach information2889published by PSA also did not include information about the helicopter2890routes.2891    Without this information, fixed-wing pilots were left uninformed to2892the potential that they may come in close proximity to or conflict with2893helicopters utilizing visual separation on published helicopter routes2894underlying the DCA approach and departure corridors. The NTSB concludes2895that current aeronautical charting does not provide information on VFR2896helicopter routes that may conflict or come in close proximity to2897approach and departure corridors, which reduces pilot situation2898awareness. [FINDING 54] Although the flight 5342 crew's awareness of2899the helicopter routes could not be determined, other PSA pilots2900interviewed displayed a varying level of knowledge about the routes.2901Including helicopter route information on approach procedure charts2902would increase pilot situation awareness of the operating environment2903and potential risk. Therefore, the NTSB recommends that the FAA2904incorporate the lateral location and published altitudes of helicopter2905routes onto all instrument and visual approach and departure procedures2906to provide necessary situation awareness to fixed-wing operators of the2907risk of helicopter traffic operating in their vicinity. [RECOMMENDATION290821]2909ADS-B and Collision Avoidance Technologies2910    The accident helicopter was equipped with a transponder that could2911transmit ADS-B Out information. This capability was tied to the Mode S2912function of the transponder such that, when Mode S was selected, the2913helicopter should have broadcasted ADS-B Out information. As of January29141, 2020, all aircraft operating above 10,000 ft msl or in Class B and C2915airspace are required to transmit ADS-B Out; however, Federal2916regulations exempt Department of War aircraft from broadcasting ADS-B2917Out when performing sensitive government missions.2918    Due to the routes and landing sites used during the accident2919flight, the Department of War considered PAT25's flight path sensitive2920and, therefore, the helicopter was not required to be broadcasting ADS-2921B Out at the time of the accident. Radar data indicated that the2922helicopter's transponder switched from Mode 3/A and C to Mode S near2923Cabin John, Maryland, before proceeding south along the Potomac River2924about 8 minutes before the accident, but the helicopter was not2925broadcasting ADS-B Out despite the crew's selection of the Mode S2926function. Although the helicopter's CVR did not capture any crew2927conversation about activating Mode S, it is likely that the crew turned2928on the transponder's Mode S function before flying south on Helicopter2929Route 1 toward the high-traffic airspace near DCA in order to provide2930ADS-B Out data to air traffic control and other aircraft; however, the2931crew's activation of Mode S during the flight was contrary to Army SOP,2932which stated that flight crews should not change transponder modes2933during flight.2934    The TAAB commander testified during the NTSB's investigative2935hearing that the reason for the prohibition on changing transponder2936modes during flight was due to the amount of ``heads down'' time2937required to change the transponder mode; however, the UH-60L operator's2938manual, as well as testimony by a former TAAB standardization pilot at2939the NTSB's investigative hearing, indicated that activating Mode S2940required just two button pushes.2941    Although the helicopter was not transmitting ADS-B Out, its2942position and speed was available to the DCA local controller because2943its transponder was responding to Mode S interrogations, and ADS-B Out2944information would not have appreciably changed the timing of the2945conflict alert the controller received before the collision. Flight29465342 was not equipped with ADS-B In, nor was its TCAS II system capable2947of receiving ADS-B In information as part of its activation algorithm.2948The NTSB concludes that the lack of ADS-B Out from the accident2949helicopter did not contribute to this accident, as the helicopter was2950still being tracked by radar, and ADS-B Out would not have provided2951improved traffic alerting for the DCA controller or the crew of flight29525342, because the airplane was not equipped with ADS-B In. [FINDING 55]2953    Although the lack of ADS-B Out information from the accident2954helicopter did not change the circumstances of this accident, collision2955avoidance technologies that leverage ADS-B In information are most2956effective if all aircraft broadcast ADS-B Out at all times. The NTSB2957concludes that the Army's standard operating procedures that prevent2958flight crews from enabling ADS-B Out while in flight, when not2959performing sensitive missions that require ADS-B to be disabled, limit2960the visibility of military aircraft on collision avoidance technologies2961that leverage ADS-B information. [FINDING 56] Therefore, the NTSB2962recommends that the Department of War Policy Board on Federal Aviation2963require armed services to amend their operational procedures to allow2964flight crews to enable ADS-B Out while in flight. [RECOMMENDATION 45]2965    The accident airplane was equipped with TCAS II, and information2966obtained from the airplane's FDR and CVR indicated that the crew2967received a TA regarding PAT25 about 20 seconds before the collision,2968which was within TCAS system alerting specifications. This TA remained2969active until the collision occurred; however, the crew had been trained2970not to maneuver based solely on a TA, and their workload at the time2971they received the TA was high, resulting in limited available capacity2972to look for and visually acquire the traffic. The TCAS system did not2973generate a subsequent RA even though the two aircraft continued to2974converge, because TCAS II inhibit logic was designed to suppress RAs2975below 900 ft above ground level during descent. A known limitation of2976TCAS II is that it often issues RAs during some normal and routine2977operations, including when visual separation is being applied. The TCAS2978II RA inhibit altitude threshold was established based on the2979technological limitations available at the time it was developed to2980maximize effective alerting while minimizing these types of nuisance2981alerts.2982    PSA crews were trained to respond promptly to RAs and maneuver as2983indicated by the advisory, even if such a maneuver conflicted with ATC2984instructions. Therefore, it is probable that the crew of flight 53422985would have maneuvered in accordance with the instructions provided by2986the RA had they received one, which may have prevented the collision.2987The NTSB concludes that although the airplane's TCAS operated as2988designed, it was ineffective in preventing the collision because of2989current activation criteria and resolution advisory inhibit altitudes.2990[FINDING 57]2991    The NTSB has previously advocated for the FAA to require ADS-B In2992technology on the basis that equipping aircraft with ADS-B In2993capability would provide an immediate and substantial contribution to2994safety, especially near airports. Simulations using the circumstances2995of this accident reaffirm this conclusion and demonstrate the value of2996ADS-B In-derived traffic information in improving pilots' situation2997awareness and supporting earlier identification of potential traffic2998conflicts.2999    ADS-B traffic advisory system (ATAS) is an ADS-B application3000intended to reduce the number of midair collisions and near midair3001collisions involving general aviation aircraft. ATAS utilizes ADS-B3002information to generate verbal alerts indicating the clock position,3003relative altitude, range, and vertical tendency of proximate traffic.3004    In this accident, the TA that the flight 5342 crew received3005consisted simply of the annunciation, ``Traffic, traffic.'' No3006information about the location of the traffic threat relative to the3007airplane was annunciated, and the crew would have had to refer to the3008TCAS display to determine the relative position of the threat before3009directing their visual scan in the appropriate area. Given the crew's3010high workload at the time they received the TA, it is unlikely that3011they performed a focused visual search for the helicopter at this time.3012    The NTSB performed a simulation to determine how an ADS-B based3013system capable of providing ATAS-style alerts would have performed in3014the accident scenario. The simulation indicated that the crew of flight30155342 would have received two alerts concerning PAT25 had it been3016equipped with such a system. The first aural and visual alert would3017have occurred 59 seconds before the collision, annunciating ``Traffic,301812 o'clock, low, three miles, descending.'' A second aural alert would3019have occurred 35 seconds before the collision, annunciating ``Traffic,302012 o'clock, low, two miles.'' These two alerts would have occurred 403021and 16 seconds, respectively, before the TCAS TA that the crew received3022before the collision, providing the crew with additional awareness of3023the helicopter.3024    While TCAS TAs provide a verbal annunciation that a potential3025traffic conflict exists, the annunciations do not include the position3026and range of the target, requiring the pilot to first refer to the TCAS3027display inside the cockpit to determine the direction in which they3028need to direct their visual search. An ATAS-style TA indicating the3029clock position, relative altitude, range, and vertical tendency of3030nearby traffic would allow pilots to immediately direct their visual3031search in the proper direction outside the aircraft. The NTSB concludes3032that TA aural alerts that include additional information about the3033location of traffic could reduce the time pilots need to visually3034acquire target aircraft. [FINDING 58] The NTSB recommends that the FAA3035modify airborne collision avoidance system (ACAS) TA aural alerts to3036include clock position, relative altitude, range, and vertical3037tendency. [RECOMMENDATION 22]3038    The crew of flight 5342 could have intervened in the accident3039sequence if they had more knowledge about the level of the threat posed3040by the traffic that triggered the TCAS TA. While a TCAS display does3041depict traffic targets, a pilot must monitor the display over time to3042determine in what direction the target is moving. By leveraging ADS-B3043In traffic information, an ACAS display can depict the ground track of3044traffic targets, increasing pilots' awareness of the movements of3045nearby traffic and providing more timely information to help a pilot3046determine whether that target may become a collision threat. The NTSB3047concludes that had the airplane been equipped with an airborne3048collision avoidance system that used ADS-B In information to show3049directional traffic symbols, the crew of flight 5342 would have3050received enhanced information about the risk posed by the helicopter,3051which could have enabled them to take earlier action to avert the3052collision. [FINDING 59] Therefore, the NTSB recommends that the FAA3053require existing and new TCAS I, TCAS II, and ACAS X installations to3054integrate directional traffic symbols. [RECOMMENDATION 23]3055    The helicopter was not equipped with an integrated cockpit display3056of traffic information (CDTI), nor was it required to be under current3057regulations. As previously discussed, the pilot and IP onboard PAT253058had tablets that were capable of displaying ADS-B traffic information3059from other aircraft and providing visual and aural alerts.\14\ A3060simulation of the ForeFlight CDTI display available on the tablets3061indicated that the application would have generated a visual and aural3062alert concerning the airplane at 2047:11, or 48 seconds before the3063collision. The tablets, which would likely have been strapped to the3064pilots' thighs, were normally referenced in flight by the pilot3065monitoring (in this accident, the IP); however, statements from Army3066helicopter pilots indicated that it was unlikely that the accident crew3067were referring to the tablets for traffic information at the time of3068the accident given the demands of visual, low-level flight at night3069under NVGs. Simulator testing indicated that, when using a tablet3070secured to a thigh, a pilot would be required to divert their attention3071below a normal scan of the cockpit instruments in order to view the3072tablet screen. Additionally, the aural alerting that could have been3073provided by the tablets was not integrated into the crew's helmets and3074would not have been heard by the crew over the ambient noise inside the3075helicopter, even if the application had been configured to provide3076aural traffic alerts. At the time of the accident--and still as of the3077date of this report--the DOW had no requirement for military aircraft3078to receive ADS-B In, or to be equipped with any integrated cockpit3079display of traffic information derived from ADS-B In data. The NTSB3080concludes that, although the pilot and IP onboard PAT25 were equipped3081with tablets that had the ability to display traffic transmitting ADS-B3082Out, it is unlikely that the pilots were using the tablets to monitor3083or identify traffic at the time of the accident due to the workload3084associated with low-altitude flight. [FINDING 60]3085---------------------------------------------------------------------------3086    \14\ Although tablets and other portable traffic-display devices3087can provide helpful supplementary awareness, they are not a functional3088substitute for an integrated CDTI within the normal instrument scan or3089for timely ATC traffic advisories and safety alerts--particularly in3090complex Class B environments.3091---------------------------------------------------------------------------3092    The NTSB has investigated numerous midair collision accidents that3093occurred within controlled airspace or in which air traffic control was3094in contact with at least one of the involved aircraft. In many of these3095investigations, the NTSB noted that a CDTI with ADS-B In information3096would enhance pilots' situation awareness by providing information3097regarding traffic conflicts that may otherwise go undetected due to the3098numerous documented limitations of see-and-avoid.\15\3099---------------------------------------------------------------------------3100    \15\ Examples include ERA09MA447, CEN19MA141AB, ANC20LA074,3101ERA22FA318, CEN22FA081, and ERA23FA142.3102---------------------------------------------------------------------------3103    Following the investigation into a midair collision between two air3104tour airplanes in Ketchikan, Alaska, in 2019, the NTSB issued several3105safety recommendations to the FAA, asking them to identify areas with a3106high concentration of air tour traffic and to require that CFR Parts 913107and 135 air tour operators which operate within those areas be equipped3108with an ADS-B Out-and In-supported traffic advisory system that3109includes visual and aural alerts (NTSB, 2021). We also recommended that3110the FAA require all aircraft operating within those high density3111traffic areas, not just those conducting air tours, be equipped with3112ADS-B Out.3113    In an October 24, 2023, follow-up letter regarding Safety3114Recommendation A-21-17, the NTSB emphasized that the absence of an ADS-3115B In requirement for Part 135 passenger-carrying operations fails to3116take advantage of the demonstrated safety benefit of ADS-B In traffic3117awareness and alerting and is inconsistent with the ``appropriate level3118of public safety'' the FAA itself expects for operations in which3119passengers bear no responsibility for the aircraft's operation (NTSB,31202023). In a response dated November 2024, the FAA stated that they had3121determined that, ``current ADS-B requirements continue to adequately3122address the needs of aviation safety,'' and that they would ``not3123pursue additional ADS-B operator requirements at this time'' (FAA,31242024e).3125    During the NTSB's investigative hearing for this accident, the FAA3126ATO's acting deputy chief operating officer (COO) stated that the3127agency supported requiring that newly manufactured aircraft in the3128United States be equipped with ADS-B In. He also stated that the agency3129supported requiring that aircraft operating in airspace where they are3130required to transmit ADSB Out, also be required to install and operate3131ADS-B In.-B Out, also be required to install and operate ADS-B In.3132    The circumstances of this accident illustrate that the additional3133information provided by an ACAS system supplemented with ADS-B In3134information, including ATAS alerts and directional traffic displays,3135further enhance the safety benefit provided by ACAS. For all pilots,3136ADS-B In information provided on a CDTI with alerting that is audible3137to the pilot would provide critical situation awareness to help3138mitigate the risk of midair collisions, even if their aircraft are not3139equipped with an ACAS. In order to take full advantage of the safety3140benefits provided by ADS-B, the NTSB recommends that the FAA require3141all aircraft operating in airspace where ADS-B Out is required to also3142be equipped with ADS-B In with a cockpit display of traffic information3143that is configured to provide alerting audible to the pilot and/or3144flight crew. [RECOMMENDATION 24] In order to provide the same situation3145awareness advantages to military flight crews, the NTSB recommends that3146the Department of War require all military aircraft operating in the3147NAS be equipped with ADS-B In with a cockpit display of traffic3148information that is configured to provide alerting audible to the pilot3149and/or flight crew, and that such requirement apply wherever in NAS the3150FAA requires any aircraft to operate with ADS-B Out. [RECOMMENDATION315146]3152    Advances since the development of TCAS II standards allow ACAS X,3153the next generation of airborne collision avoidance systems, to provide3154improved alerting. Among other enhancements, ACAS X systems utilize3155ADS-B In information in addition to transponder interrogations, and3156include improved algorithms to more accurately reflect actual collision3157risk.3158    A series of simulations conducted using the circumstances of this3159accident showed that the crew of flight 5342 would have received a TA3160about 8 seconds earlier if the airplane had been equipped with ACAS Xa,3161an ACAS X variant for airplanes, even though ADS-B information from the3162helicopter was unavailable. However, although ACAS Xa can deliver3163earlier and more accurate alerts than TCAS II, the current RA inhibit3164altitudes under ACAS Xa are the same as those of TCAS II, and would3165also have prevented ACAS Xa from issuing a RA under the accident3166circumstances. The results of the simulation indicated that the risk of3167a NMAC was reduced by more than 90 percent when the ACAS Xa logic was3168modified to allow RAs down to 300 ft, because it is possible that the3169crew would have taken the action prescribed by the RA to avoid the3170collision. The NTSB concludes that technological advances since the3171development of TCAS II operating standards may allow ACAS Xa with3172reduced inhibit altitudes to have an expanded alerting envelope while3173reducing nuisance alerts. [FINDING 61] Furthermore, the NTSB believes3174that ACAS X, as the standard is currently defined, would improve the3175safety of aircraft that are currently required to be equipped with3176TCAS. Therefore, the NTSB recommends that the FAA require the use of3177the appropriate variant of ACAS X on new production aircraft that are3178subject to TCAS equipage regulations [RECOMMENDATION 25] and that the3179FAA require existing aircraft that are subject to TCAS equipage3180regulations be retrofitted with the appropriate variant of ACAS X.3181[RECOMMENDATION 26] Given the results of the TCAS and ACAS X simulation3182study, which showed a significant reduction in the risk of a NMAC when3183the RA inhibit altitude was lowered, the NTSB also recommends that the3184FAA evaluate the feasibility of decreasing the TA and RA inhibit3185altitudes in ACAS Xa to enable improved alerting throughout more of the3186flight envelope. [RECOMMENDATION 27] If the FAA's evaluation resulting3187from Safety Recommendation [27] finds that inhibit altitudes can be3188safely decreased, the NTSB further recommends that the FAA require3189retrofitting of the applicable ACAS X variant incorporating the reduced3190TA and RA inhibit altitudes on all aircraft that are subject to TCAS3191equipage regulations. [RECOMMENDATION 28]3192    The ACAS simulations using the circumstances of this accident also3193showed that, had the helicopter been equipped with ACAS Xr, a version3194of ACAS X that is still under development and intended specifically for3195rotorcraft, the risk of a NMAC was reduced by more than 50 percent,3196with no changes to the TCAS or ACAS Xa inhibit altitudes. This3197information would have been provided to the crew via a cockpit display3198that would have been part of their normal instrument scan and also3199would have provided aural alerting integrated with the helicopter's3200internal communications system. Therefore, the NTSB concludes that,3201although not yet commercially available, had the helicopter been3202equipped with ACAS Xr with integrated aural alerting, the crew could3203have received an alert regarding flight 5342 and could have taken3204action to avert the collision. [FINDING 62]3205    Given the significant reduction in the risk of a NMAC as shown in3206the simulations when the helicopter was equipped with ACAS Xr, the NTSB3207recommends that the RTCA Program Management Committee finalize and3208publish the minimum operational performance standards for ACAS Xr for3209rotorcraft. [RECOMMENDATION 50] The NTSB also recommends that the FAA3210require that all rotorcraft operating in Class B airspace be equipped3211with ACAS Xr technology once the ACAS Xr standard has been published.3212[RECOMMENDATION 29]3213Safety Management Systems and Safety Data3214Indicators of Midair Collision Risk3215    Multiple safety occurrence reporting systems contained reports from3216pilots and controllers about close calls between airplanes and3217helicopters in the vicinity of DCA in the years before the accident,3218some of which included airplanes on approach to runway 33.\16\ Several3219of those reports described issues similar to those found in this3220investigation, including airspace complexity, problems with ATC3221communications, challenges associated with combining helicopter and3222local control positions, and helicopters flying above recommended3223altitudes. An Aviation Safety Information Analysis and Sharing (ASIAS)3224review of Aviation Safety Action Program (ASAP) reports filed by pilots3225from February 2020 through October 2024 found 85 reports, or about 183226reports per year, that contained information on close calls between3227helicopters and airplanes near DCA.\17\ Reports of close calls near DCA3228were also found in other safety occurrence reporting systems, including3229Air Traffic Safety Action Program (ATSAP), Aviation Safety Reporting3230System (ASRS), NMACS and mandatory occurrence reports (MORs). Although3231it is possible that some of the reports in these systems described the3232same events, it is reasonable to conclude that there were more than 183233close calls per year, or more than 1 close call per month on average,3234reported in the 4 years before the accident.3235---------------------------------------------------------------------------3236    \16\ These included a NMAC (1070511144 in the NMAC database) for3237the May 2013 near-miss between an airplane and a military helicopter3238that was the catalyst for the formation of the HWG at DCA ATCT; an ASRS3239report from July 2015 that involved a near miss between an airplane on3240a circling approach to runway 33 and a helicopter (ACN 1283693); and an3241ASRS report from June 2013 in which an airplane on the River Visual3242approach to runway 19 received a TCAS RA due to a helicopter passing3243below (ACN 1095485).3244    \17\ The term ``close calls'' commonly refers to events in which3245the proximity between two aircraft was perceived as potentially unsafe.3246See, for example, Ending Serious Close Calls (FAA). Other terms, such3247as near misses, close proximity events, and airborne encounters have3248been used by different groups to describe similar types of events.3249---------------------------------------------------------------------------3250    Safety occurrence reporting systems rely on subjective self-reports3251with varying submission criteria and are therefore unlikely to capture3252all safety events (Dy and Mott, 2024).\18\ By comparison, objective3253aircraft position data, such as TCAS RA data captured by ground-based3254receivers, indicated that there were about 15 TCAS RAs per month, on3255average, within 10 nm of DCA between April 2023 and March 2025.3256Aviation Risk Identification and Assessment (ARIA) data showed that3257airplanes and helicopters came within 1 nm laterally and 400 feet3258vertically 390 times per month, on average, between October 2021 and3259December 2024. PDARS data identified an average of 5.6 instances per3260month between 2018 and 2025 in which helicopters flying on Routes 1 or32614 came within 500 ft of airplanes arriving or departing DCA.3262---------------------------------------------------------------------------3263    \18\ Additionally, pilots may not be aware of close proximity3264events or may have been successfully applying visual separation, which3265would not result in safety reporting in instances when objective3266measures indicated close proximities.3267---------------------------------------------------------------------------3268    Some objective measures of aircraft proximity that were examined3269after the accident were not used for safety assurance before the3270accident occurred. For example, postaccident review of PDARS radar-3271based data identified close encounters between aircraft in the vicinity3272of airports and revealed instances of helicopters flying above maximum3273route altitudes; however, the FAA had not previously used those data to3274track such metrics. Additionally, ARIA proximity data and TCAS RA data3275from ground-based receivers were available to ASIAS, but those data3276were also not actively monitored by ASIAS or widely available before3277the accident.\19\3278---------------------------------------------------------------------------3279    \19\ TCAS TA and RA data were available through an operator's FOQA3280and could have provided useful information, but those data are3281proprietary and only represented information from, and were only3282available to, operators who participated in ASIAS.3283---------------------------------------------------------------------------3284    The Army and PSA had varied knowledge of and limited access to3285safety data systems. The Army did not participate in ASIAS, did not3286request FAA data, and did not routinely use information that the FAA3287made publicly available. The Army did not have a robust safety3288occurrence reporting system, nor did it collect and aggregate safety3289data from their helicopters. PSA had an SMS, as required by 14 CFR Part32905, and participated in the ASIAS program. Although PSA reported3291reviewing safety occurrence reports from its pilots and FOQA-based TCAS3292data provided by the ASIAS program, PSA did not have access to3293objective proximity data from PDARS or ARIA. As a result, their safety3294assurance and safety risk management processes did not identify a3295heightened risk of midair collision at DCA.3296    The FAA ATO had access to many sources of data, including ASIAS,3297PDARS, ARIA, ATSAP, MORs, ASRS, and NMACs, as well as limited access to3298ASAP and TCAS RA information. Although the ATO reported that they3299reviewed a large number of data sources as part of their safety3300assurance process, they also did not identify the risk of a midair3301collision between helicopters and fixed-wing traffic at DCA. In the3302investigative hearing, FAA officials acknowledged that the ATO had3303missed these indicators of risk.3304    The ARIA system was designed specifically to use objective criteria3305to automatically identify air traffic operations that represented3306potential safety risks and generate reports known as preliminary ARIA3307reports, or PARs. However, ATO's subsequent reviews of PARs were3308subjective and largely focused on regulatory compliance rather than3309potential risk. For example, ARIA generated 874 PARs for the area3310surrounding DCA between June 2022 and May 2025, but ATO classified none3311of them as NMACs, even though pilots and controllers made multiple3312reports of close calls during that period. Additionally, the safety3313group manager for the FAA's Eastern Service Area noted that their3314Quality Assurance Office reviewers did not normally search for3315voluntary reports and acknowledged that, ``from one validator to3316another, or from somebody that's looking at that report, their3317perception of what is the possibility of collision may be different.''3318As a result of these subjective reviews, potentially valuable objective3319risk-based safety data were not tracked. The NTSB concludes that3320multiple data sources provided evidence of midair collision risk3321between fixed-wing aircraft and helicopters at DCA, including on3322approach to runway 33, before this accident; however, the limited3323access to and use of available objective and subjective proximity data3324hindered industry and government stakeholders' ability to identify3325hazards and mitigate risk. [FINDING 63]3326    In its Safety Risk Management Policy, the FAA recognized the value3327of objective data, stating, ``While any data is better than no data,3328when available, analytical data is preferred, followed by empirical,3329and finally, judgmental. This is due to the margin of error associated3330with each type of data. Analytical data typically has the lowest margin3331of error; the margin of error of empirical data can be controlled by3332sample size; and judgmental data has the largest margin of error due to3333human biases and subjective experience'' (FAA, 2023d).3334    Since the accident, the FAA ATO has used objective proximity data3335to identify areas of potential conflict between airplanes and3336helicopters in the NAS. It conducted a helicopter route analysis using3337multiple data systems to count ``close proximity'' events with3338objective measures based on parameters such as vertical/horizontal3339proximity, slant range, or time to contact. In addition to identifying3340near midair collisions, analyses of objective proximity data can3341identify areas of high traffic density and potential routing conflicts,3342and depict areas with a high concentration of encounters involving3343distances less than those provided by standard IFR separation, which3344could have shown evidence of the dependence on visual separation to3345manage traffic in the DCA airspace before the accident.\20\3346---------------------------------------------------------------------------3347    \20\ During the investigative hearing, the FAA ATO acting deputy3348COO cited the dependence on visual separation between helicopters and3349IFR traffic at DCA as an example of risk that was missed prior to the3350accident.3351---------------------------------------------------------------------------3352    Although there is value in using multiple data sources to3353understand a problem, the lack of standard proximity metrics or indexes3354to signify when aircraft are ``too close'' results in difficulty3355comparing the risk levels of different locations or tracking the3356incidence of events over time. The NTSB concludes that improving3357stakeholder access to standardized and objective information about3358aircraft close proximity encounters for use in safety assurance3359processes would increase the likelihood of detecting and mitigating3360hazards before accidents occur. [FINDING 64] Therefore, the NTSB3361recommends that the FAA create an objective definition of close3362proximity encounter and a public database of those encounters and their3363locations that can be used to monitor their prevalence and identify3364areas of potential traffic conflict for safety assurance and safety3365risk management. [RECOMMENDATION 30]3366Safety Information Sharing3367    Most of the stakeholder groups involved in the investigation3368described internal processes for evaluating and addressing safety3369occurrence reports. That the midair collision between PAT25 and flight33705342 occurred despite these reported activities raises the question of3371why they did not lead to more meaningful risk mitigations at DCA. Some3372evidence suggests that safety occurrence reports were used at DCA tower3373to identify hotspots, including a hotspot in the same location as the3374midair collision, and propose changes to helicopter route charting3375through the safety risk management panel (SRMP) process; however, these3376efforts met with resistance from ATO, yielding little success.3377    The investigation also revealed that, although helicopters3378routinely triggered TCAS RAs for airplanes on approach to DCA and were3379the subject of many voluntary pilot reports, helicopter operators were3380largely unaware of their involvement in these events. Upon learning of3381its involvement in TCAS RA events involving airplanes on approach to3382DCA, one helicopter operator made changes to its standard operating3383procedures to help mitigate such events. Additionally, an Army3384representative stated in the investigative hearing that learning of3385Army helicopter involvement in TCAS RAs would be valuable for risk3386mitigation.3387    FAA regulations (see 14 CFR Part 5.57) state that, if a hazard is3388identified through an operator's SMS, that operator must provide notice3389to anyone involved that could address the hazard or mitigate the risk.3390Additional guidance in FAA Order JO 1000.37C states that safety3391promotion activities include actively sharing safety-related3392information with other external parties, such as industry stakeholders,3393air navigation service providers, and other Federal agencies.3394    Despite this guidance, this investigation revealed that reviews of3395close proximity events around DCA appeared to have occurred in3396isolation rather than involving all relevant parties. For example,3397preliminary ARIA reports were only reviewed by FAA ATO Quality3398Assurance Office staff and did not incorporate the operators involved3399in the events. PSA Airlines reported reviewing TCAS RAs involving its3400aircraft, but noted that there was often a delay of several months3401between the occurrence and the review. Additionally, PSA relied on the3402Confidential Information Share Program (CISP) or the FAA to identify3403other aircraft that triggered TCAS RA activations on PSA aircraft.3404    When two TCAS-equipped aircraft come into conflict, both aircraft3405receive RAs that alert the pilots and are captured on flight data3406recorders. However, when a TCAS RA is triggered by an aircraft without3407TCAS, the pilot of the unequipped aircraft may never become aware of3408the event. If timely steps are taken to identify the threat aircraft,3409the pilots or operators can be notified of their involvement in the3410event. However, as this investigation showed, it may be difficult to3411identify aircraft that triggered TCAS RAs if not attempted until months3412or years after the event, particularly if they are not broadcasting3413ADS-B Out. The NTSB concludes that the FAA's lack of an established3414process to inform parties about their involvement in events such as3415NMACs or TCAS RAs reduces the likelihood of fully understanding and3416mitigating future midair collision risk. [FINDING 65] Therefore, the3417NTSB recommends that the FAA develop and implement a process that will,3418in a timely manner, notify involved parties after events such as NMACs3419or TCAS RA activations, such that notification occurs while relevant3420data remain available and before meaningful safety analysis, reporting,3421or corrective action is no longer practicable. [RECOMMENDATION 31]3422FAA Air Traffic Organization Safety Management System3423Safety Risk Management and Safety Assurance3424    At the time of the accident, the FAA had an established SMS for3425several of its organizations, including the ATO and ATO facilities3426(such as DCA ATCT). FAA policy required that each organization3427establish and maintain each of the four components of SMS--safety3428policy, safety risk management, safety assurance, and safety promotion.3429However, despite the ATO's established and well documented safety3430policy, this investigation indicated significant gaps in its safety3431risk management, safety assurance, and safety promotion processes and3432procedures.3433    FAA guidance for SMS implementation clearly establishes3434responsibility and requirements for operators and external service3435providers to coordinate safety risk management and safety assurance3436activities with external parties to collect and share safety hazard3437information and monitor safety risk controls. For example, the FAA3438stated that airport operators, tenants, and users should coordinate SMS3439efforts to the fullest extent possible, and that a method of data3440sharing and reporting among the separate SMSs be included in the safety3441risk management process. The FAA also required that air traffic3442managers coordinate with local airport operators to increase awareness3443and understanding of local operations and safety challenges, including3444convening conferences to discuss and clarify operations.3445    By contrast, the FAA ATO Order on identification and mitigation of3446hazards at the local level does not require external stakeholder3447involvement. Participation is limited to bargaining unit3448representatives and management at FAA air traffic facilities (FAA,34492020b). Although the 2021 GAO report called on the FAA to develop a3450mechanism to exchange information with operators in the DC area, there3451was no formal process in place at DCA for operators and the FAA to3452share information about helicopter route traffic, TCAS RAs, or3453potential traffic conflicts. In the absence of a formal process,3454formation of helicopter working groups in the Washington, DC, area3455demonstrated recognition by local controllers and operators of safety3456risks and attempted coordination of the diverse helicopter operations3457in the DCA Class B airspace. However, these groups were described as3458informal, did not include a mission statement or statement of work, and3459their attempts to recommend changes were met with resistance from, and3460little action by, the ATO.3461    As an example of informal collaboration, the DCA ATCT helicopter3462working group (HWG) identified areas of increased collision risk3463between airplanes and helicopters, and proposed changes to the charted3464helicopter route and zone altitudes to mitigate those risks. One of the3465proposed changes included relocating or eliminating the section of3466Route 4 adjacent to DCA due to the risk posed by the proximity of that3467route to fixed-wing approach and departure paths. A near midair3468collision between a military helicopter and a regional jet in 20133469(which occurred in the same vicinity as this accident) was the catalyst3470for this initial proposal, and the DCA ATCT HWG made additional3471recommendations to move Route 4 in the years after; however, members of3472the group recalled a lack of feedback from management at higher levels3473within the ATO regarding why their suggestions to move or eliminate3474Route 4 were not adopted.3475    The group also proposed the addition of ``hotspots'' to the3476Baltimore-Washington Helicopter Route Chart to highlight areas that3477posed an increased risk of potential conflicts between airplanes and3478helicopters to increase pilot and controller vigilance in those areas.3479However, the FAA also rejected the proposal to chart these hotspots3480because, ``hotspots are associated with ground or surface movement and3481are not within the VFR aeronautical chart specification.'' The HWG3482comprised DCA ATCT controllers--the individuals most familiar with the3483flow and separation of helicopter and fixed-wing traffic around DCA and3484with the greatest insight into its vulnerabilities and areas of highest3485risk; however, the FAA repeatedly failed to act on proposals provided3486by the group and rejected changes that would have raised pilot3487awareness of areas of increased midair collision risk and increased3488separation between Helicopter Route 4 and fixed-wing approach and3489departure paths.3490    In addition, the investigation did not identify evidence showing3491that the ATO conducted annual, documented reviews of helicopter route3492charts in the Washington, DC, area as required by FAA Order JO34937210.3DD. Further, review of FAA data programs did not indicate that3494the ATO routinely used available data to evaluate separation risk3495between fixed-wing traffic and helicopter operations at congested3496airports, including DCA.3497    The NTSB concludes that, given their access to a wide range of data3498sources and information, the FAA ATO was made aware of, and had3499multiple opportunities to identify the risk of a midair collision3500between airplanes and helicopters at DCA; however, their data analysis,3501safety assurance, and risk assessment processes failed to recognize and3502mitigate that risk. [FINDING 66] The NTSB further concludes that the3503FAA ATO's application of its safety management system did not3504effectively coordinate safety assurance and safety risk management3505activities with external stakeholders in the DCA Class B airspace.3506[FINDING 67]3507    The FAA established the Air Traffic Safety Oversight Service (AOV)3508in 2004 as the safety oversight authority to ensure effective and3509independent safety oversight of ATO and to enforce safety regulations3510related to air navigation services, including ATO SMS functions (FAA,35112024a). However, in December 2025, the FAA Administrator announced that3512the FAA was implementing a single, agencywide SMS, stating in testimony3513before the House Committee on Transportation and Infrastructure's3514Subcommittee on Aviation that, ``This unified approach will help the3515FAA detect, analyze, and mitigate risk more consistently and ensure3516that lessons from accidents, incidents, and near misses are acted upon3517quickly across the agency'' (FAA, 2025f). Additionally, in a document3518titled, ``FAA Flight Plan 2026'' the agency stated its intent, as part3519of creating one FAA SMS, to establish a Safety Integration Office and3520implement an FAA-wide safety risk management process (FAA, 2026).3521    Therefore, the NTSB recommends that the U.S. Department of3522Transportation Office of Inspector General complete an audit of the FAA3523ATO SMS functions and data sharing activities at all air traffic3524control facilities and determine whether these activities are conducted3525in collaboration with all relevant external stakeholders, ensuring that3526the audit's results are documented, reported to the Secretary of3527Transportation and the FAA Administrator, and made available to the3528public. [RECOMMENDATION 49] Additionally, the NTSB recommends that the3529FAA, based on results of the audit, ensure that all SMS functions and3530data sharing activities at all air traffic control facilities are3531conducted in collaboration with all relevant external stakeholders.3532[RECOMMENDATION 32]3533    At the NTSB's investigative hearing, the DCA ATCT OM at the time of3534the accident testified that controllers would routinely compensate for3535the conditions provided by reduced MIT spacing and compacted demand3536times by ``making it work,'' and using ``all available tools.'' The3537``make it work'' mindset had become normalized and ``routine'' at DCA3538ATCT.3539    Although processes were in place to conduct risk assessments of3540hazards at the facility level, existing procedures did not provide3541robust guidance to assist controller and supervisor risk assessment and3542decision making in real-time, day-to-day operations. For example, the3543DCA ATCT SOP contained a list of seven factors that an OS should3544consider when deciding to combine or de-combine the HC position, but3545did not provide additional information on how to effectively evaluate3546the impact of those factors on the control position(s). Changes to the3547DCA ATCT SOP in 2023 removed the requirement for the OS to document the3548time and reason for combining or de-combining the HC position in the3549facility log. Requiring this information to be recorded made it more3550likely that the OS would consider and evaluate the risks associated3551with combining or de-combining the position under the existing3552operational and environmental conditions, and it is likely that the3553removal of this requirement normalized combining the positions without3554a thorough evaluation of the associated risk factors. Maintaining this3555record could also provide background information for safety assurance3556processes to determine whether the positions were being combined and3557de-combined appropriately. The NTSB concludes that changes to DCA ATCT3558SOPs prior to the accident removing the requirement for the OS to3559document the time and reason for combining or de-combining the HC3560position in the facility log made it less likely that the OS would3561consider and evaluate the risks associated with combining or de-3562combining the position. [FINDING 68] Because operational position-3563combining decisions are made routinely at towers throughout the NAS3564under time pressure and with similarly limited documentation3565requirements, establishing a standardized, nationwide requirement to3566record the time and rationale for combining or de-combining positions3567would strengthen real-time risk-based decision making and provide3568consistent safety assurance inputs across facilities. Therefore, the3569NTSB recommends that the FAA establish a requirement across all ATCT3570SOPs that the OS or controller in charge (CIC) document in the daily3571facility log when any control position is combined with the LC3572position, or when the OS/CIC position is combined with a control3573position, along with a rationale for doing so. [RECOMMENDATION 33]3574    A number of hazards existed within the DCA ATCT at the time of the3575accident. Nighttime operations reduced visibility and made3576identification of aircraft more difficult; traffic volume was3577increasing with reduced MIT, which increased controller workload and3578required the use of runway 33 to build additional spacing; helicopter3579traffic was present; and the HC and LC positions were combined, which3580increased workload for the LC and ALC controllers. The DCA ATCT SOP3581stated that the OS was responsible for maintaining situation awareness3582of the operation, providing assistance to controllers, and deploying3583available resources for optimal efficiency; however, there was no3584guidance provided by the ATO or the ATCT SOP that would have assisted3585the OS in assessing, anticipating, or alleviating controller workload.3586Because concerns about potential conflicts between airplanes and3587helicopters had been identified in previous ECVs at the tower facility,3588the night conditions, helicopter traffic on Route 4, and use of runway358933 at the time of the accident should have raised an additional level3590of awareness and vigilance, particularly on the part of the OS, as all3591of those factors increased the likelihood that an airplane and3592helicopter may come in close proximity. However, the guidance available3593to the OS was insufficient to help him evaluate these factors and apply3594operational risk management in a manner that could have more3595effectively mitigated these hazards.3596    It is apparent that controllers in the DCA area were under pressure3597to accommodate more traffic volume, and in response, developed their3598own methods of traffic management in order to maintain operational3599efficiency. A functional SMS should have identified and addressed these3600locally accepted operational practices, the ``make it work'' mentality3601described by controllers, and the lack of a robust process for day-to-3602day risk assessment and mitigation. The NTSB concludes that safety risk3603management practices were not fully integrated into DCA ATCT operations3604and did not identify or mitigate the operational challenges faced by3605controllers or the lack of guidance regarding operational risk3606assessments for controllers and supervisors. [FINDING 69]3607Safety Promotion and Positive Safety Culture3608    According to ICAO, safety promotion is how an organization builds3609and sustains a positive safety culture and the foundation for an3610effective SMS. It does this by actively communicating safety3611information, policies, priorities, and lessons learned. The goal is to3612ensure that everyone understands their shared responsibility for3613safety, feels supported by leadership, and has the awareness, tools,3614and motivation to manage safety risks effectively. During the3615investigative hearing, the ATO acting deputy COO stated that there was3616no formal SMS training for controllers, though he believed that3617facility management would be familiar with the ATO SMS Manual. Ensuring3618that every employee is familiar with their organization's SMS through3619training and consistent, transparent communication is essential for3620building trust and collaboration. FAA AC 120-92D stated that3621organizations are required to provide initial safety training for3622employees so that they can perform their SMS-related duties, and that3623recurrent training may be necessary to maintain employee competencies.3624The FAA's previously discussed failure to deliver recurrent TEM3625training highlights a missed opportunity to reinforce controllers'3626abilities to recognize and mitigate hazards, which are critical skills3627that they can apply not only in their day-to-day duties of managing air3628traffic, but also in providing feedback through established safety3629reporting systems to foster continuous improvement of the SMS.3630    At the facility level, ATO utilized and encouraged use of formal3631safety reporting systems, such as ATSAP, to collect safety concerns3632from tower personnel without fear of punishment. However, the practice3633of a just culture was not consistently followed by ATO management.3634Interviews with some ATO staff indicated that there was a fear of3635retaliation for raising safety issues, and some individuals would only3636speak to investigators because they were close to retirement or had3637retired. An air traffic safety specialist, who would not speak to3638investigators until after her retirement was finalized, discussed3639multiple occasions where mandatory reporting events went unreported as3640well as harassment for pushing back on unsafe practices. Following this3641accident, DCA ATCT management personnel were reassigned, an action that3642appeared inconsistent with the characteristics of a positive safety3643culture defined by the ATO acting deputy COO. During the NTSB's3644investigative hearing, ATO management witnesses had to be separated3645from subordinate witnesses due to concern that answers were being3646influenced due to their close proximity. Organizations involved in the3647investigative hearing were asked to confirm that there would not be any3648retaliation against the witnesses participating in the hearing, and all3649affirmed this commitment. Additionally, interviews with current and3650former DCA ATCT personnel indicated that morale had been low for years3651before the accident due to the 2018 facility level downgrade and the3652FAA's lack of transparency regarding the metrics used to support that3653decision.3654    DCA ATCT controllers were familiar with the ATSAP program for3655reporting safety concerns. As previously discussed, between January36562011 and August 2023, a total of 520 ATSAP reports (approximately 403657reports per year) were filed related to DCA, supporting controller3658statements that they felt comfortable reporting safety concerns through3659the system. If a safety concern did not warrant filing an ATSAP report,3660controllers stated they also felt comfortable expressing their concerns3661to facility management.3662    Although there were multiple indicators of the risk of a midair3663collision in the DCA airspace from numerous objective and subjective3664data sources, such as ATSAP, ASRS, MORs, ARIA and NMACs, these risks3665were not identified by ATO safety assurance processes. The FAA also3666lacked an established process for informing parties about their3667involvement in NMACs and TCAS RAs. Without adequate awareness that such3668risks exist, ATO and parties were unable to take adequate mitigations3669and the DCA airspace remained vulnerable to the risk of a midair3670collision.3671    Although traffic flow volume and management issues had been3672longstanding challenges at DCA, ATO management did not adequately3673respond to concerns expressed by frontline personnel. For example,3674suggestions from personnel who were involved in efforts to reduce DCA's3675AAR were often met with resistance and a lack of communication from ATO3676management. Instead, controllers were required to adopt a ``make it3677work'' mindset and compensated for these conditions by relying on3678mitigations such as extensive use of pilot-applied visual separation3679and offloading arrivals to runway 33. Potomac TRACON personnel stated3680that they also employed workarounds for dealing with the high volume of3681traffic in the DCA airspace. Proposals from the DCA ATCT HWG to move3682Route 4 and add ``hotspots'' to the helicopter route chart were3683rejected despite their identification of risks in these areas.3684    Finally, on numerous occasions during the course of this3685investigation, the FAA failed to provide the NTSB with requested3686investigative information, even after agreeing to do so, or provided3687incomplete responses to information requests.3688    The lack of flexibility in adapting procedures to changes in air3689traffic, the dismissal of safety improvements suggested by frontline3690personnel, the fear of retaliation expressed by some former employees,3691and the ATO's actions following this accident all suggest an3692organization that does not embrace the principles of open3693communication, just culture, and continuous improvement inherent to a3694positive safety culture. The NTSB concludes that FAA ATO management did3695not follow the tenets of SMS to support its workforce, encourage open3696communication, identify and mitigate risks, or foster a just culture,3697which eroded the overall safety culture within ATO. [FINDING 70] The3698NTSB recognizes that the FAA's postaccident initiative to introduce a3699single, agencywide SMS presents an opportunity to identify and correct3700inconsistencies between ATO SMS guidance and its other SMS policies and3701guidance. Therefore, the NTSB recommends that the Secretary of3702Transportation work with the FAA Administrator to convene an3703independent panel to conduct a comprehensive review of the safety3704culture within the FAA's ATO, and use the findings to enhance the ATO's3705existing SMS and integrate it into all levels of the organization.3706[RECOMMENDATION 48]3707US Army Safety Assurance3708    Although helicopters and airplanes had routinely experienced close3709encounters in the DCA area, the organizations involved appeared to lack3710awareness of how common such encounters were, or the safety-related3711implications. Aside from the DCA ATCT controllers who recommended the3712relocation of Helicopter Route 4 away from the runway 33 approach path,3713neither FAA or Army was effectively monitoring the risk of a midair3714collision between military helicopters and civilian fixed-wing aircraft3715in the area.3716    The NTSB's review of the Army's safety management processes3717revealed deficiencies in safety assurance that were not in compliance3718with DOW requirements and that left the Army unaware of the potential3719for a midair collision in the DCA area (DOD, 2019b). For example, the3720Army lacked a flight data monitoring program that could have detected3721deviations above the published altitudes on Route 4. Flight data3722monitoring programs have been used by commercial operators,3723manufacturers, and the FAA to identify, evaluate, and monitor the risks3724of specific categories of accidents and design and implement safety3725enhancements to mitigate such risks; however, these programs depend on3726the collection of relevant operational data, which the Army was not3727collecting.3728    Flight data monitoring programs analyze data from a variety of3729sources, such as flight recorders, dedicated quick access recorders,3730and ADS-B. If Army safety professionals had been analyzing operational3731data from its helicopters, it is likely they would have identified3732altitude exceedances on the helicopter routes adjacent to DCA and would3733have taken steps to understand why the exceedances were occurring at3734such a high rate. This may have also raised their awareness about3735cumulative errors in the UH-60s barometric altimetry system, and the3736lack of compatibility between the narrow acceptable range of operating3737altitudes on Route 4 and the acceptable range of error in the3738barometric altimeters. The NTSB concludes that the Army did not have a3739flight safety data monitoring program for helicopters, and as a result,3740was unaware of routine altitude exceedances and related risks in the3741DCA terminal area. [FINDING 71] Given the density of civil air traffic3742in close proximity to the helicopter routes, this was an unacceptable3743oversight. Class B airspace surrounds the busiest airports in the3744country used by passenger-carrying airlines. The Army must take3745extraordinary care that it does not routinely introduce unacceptable3746risk to civil aircraft operations in such areas. A 2020 report from the3747National Commission on Military Aviation Safety found that, if all3748military services fully employed FOQA, Line Operations Safety Audit3749(LOSA), and ASAP programs, ``the Department of Defense and services3750would have an invaluable collection of data that would support the3751development of predictive analysis safety programs'' (National3752Commission on Military Aviation Safety, 2020). Therefore, the NTSB3753recommends that the Secretary of the Army establish a flight data3754monitoring program for rotary-wing aircraft the U.S. Army operates in3755the NAS. [RECOMMENDATION 38]3756    Another limitation in the Army's safety assurance capability was3757the absence of a mature, front-line incident reporting program capable3758of capturing first-hand accounts of close encounters between aircraft.3759The Army's framework for hazard identification, reporting, and analysis3760consisted of operational hazard reports (OHRs) and the Army Safety3761Management Information System (ASMIS) ``mishap and near miss3762reporting'' module; however, participation in these programs was3763limited, and they had not yet matured into full operational use.3764    The TAAB safety manager stated that ASMIS 2.0 was being used to3765record monthly inspection results, mishaps, and near-misses, but3766described these as company-level safety inputs rather than individual3767pilot submissions. TAAB pilots similarly described company safety3768officers as responsible for most safety paperwork and data entry. Pilot3769interviews gave no indication of flight crew-initiated OHRs, and no3770interviewee described pilots directly logging events in ASMIS.3771    According to the brigade safety manager, no ASMIS near-miss reports3772or OHRs related to near mid-air collisions between aircraft had been3773filed, and no OHRs had been filed about near midair collisions in the3774DCA area. The brigade safety manager stated that no OHRs had been3775submitted by brigade pilots for any reason in the year preceding the3776accident. This low utilization could explain, in part, the Army's lack3777of awareness about the prevalence of close proximity events in the DCA3778area. The NTSB concludes that the Army's safety reporting systems for3779pilots were not well utilized and did not provide the organization with3780information about close encounters between Army helicopters and other3781aircraft that were later found to have occurred frequently. [FINDING378272]3783    Given the number of close encounters between helicopters and fixed-3784wing aircraft in the DCA area revealed by postaccident analysis of3785safety data, the NTSB believes that it is important for the Army to3786improve its capability in this area. Interviewed pilots did not offer3787reasons for their lack of utilization of the safety reporting systems.3788Research literature suggests that common reasons for underreporting3789cited by pilots include the effort required to file a safety report,3790concern over negative consequences, and disbelief that safety reporting3791will lead to safety improvements (Haslbeck, Schmidt-Moll, and Schubert,37922015, 596-601). Such barriers might be addressed by reducing the effort3793required to file a report, cultivating a supportive (``just'') culture,3794or providing feedback to pilots about changes resulting from safety3795reports. The first step in addressing this issue would be for the Army3796to identify the specific reasons for the low utilization of safety3797reporting systems among its pilots. Therefore, the NTSB recommends that3798the Secretary of the Army survey U.S. Army helicopter pilots to3799identify barriers to the utilization of flight safety reporting3800systems, develop a plan to address the identified barriers, and3801implement that plan across Army aviation units. [RECOMMENDATION 39]3802    The deficiencies noted above likely existed because the Army had3803yet to fully implement best practices for safety management. Based on3804testimony from the TAAB commander during the investigative hearing,3805TAAB was in the beginning stages of implementing the Army's version of3806SMS (Army Safety and Occupational Health Management System, or ASOHMS)3807and had not yet reached the point where it was focused on the3808development of effective safety assurance capabilities.3809    The Army's slow progress in implementing ASOHMS could stem from3810several causes. First, responsibility for different aspects of safety3811management was widely distributed across various Army organizations.3812Second, the program was designed to address the full range of safety3813issues that a commander might seek to manage, both on-and off-duty, not3814only safety of flight operations. Third, the Army encountered resource3815issues, as evidenced by comments made at the NTSB's investigative3816hearing by the director of the Data Analysis and Prevention Directorate3817that the military flight operations quality assurance (MFOQA) mandate3818was unfunded. Fourth, TAAB safety personnel indicated that staffing was3819an issue. Until shortly before this accident, TAAB had only one full-3820time safety manager, who was responsible for five battalions and a3821variety of different functions. Due to his broad range of3822responsibilities, only half of his time was available for working on3823flight safety issues, and only a portion of that time was spent3824specifically on helicopter safety. The 12th Aviation Battalion safety3825officer, who was also a pilot, spent about 75 percent of his time on3826ground safety and occupational health matters and 25 percent on3827aviation safety. B Company's safety officer, also a pilot, estimated3828that 80 percent of his time was spent on occupational health and safety3829matters. By comparison, a Part 121 airline typically employs several3830individuals working full-time on flight safety management-related3831functions.3832    A 2023 GAO study of Army National Guard helicopter units found that3833workload and staffing imbalances hindered the scope of safety officer3834efforts in the Guard's aviation units. Safety officers interviewed by3835the GAO described struggling to address the broad scope of their ground3836and flight safety responsibilities and their roles as pilots. This3837impeded their ability to do such things as ``coordinating with other3838safety organizations; using data systems to perform hazard analysis;3839communicating with unit personnel for aircraft-specific insights; and3840overseeing the quality of hazard and accident reporting processes.''3841Evidence from this investigation suggests that TAAB and the 12th3842Aviation Battalion faced similar challenges with safety-related3843staffing and workload allocations.3844    At the NTSB's investigative hearing, the director of safety and3845occupational health for the U.S. Army Secretariat acknowledged the3846existence of these challenges and said that the Army was updating its3847``manpower evaluation'' model to address the issue. Although updating3848the manpower evaluation model was an annual requirement, past updates3849did not result in adequate safety staffing. The NTSB concludes that the3850Army's process for allocating resources to aviation safety management3851did not ensure the development of a robust SMS for helicopter3852operations in the Washington, DC, area. [FINDING 73] This accident3853demonstrates the importance of having the capability for, at a minimum,3854implementing safety assurance processes to monitor the safety of Army3855aviation operations in densely utilized airspace with a high3856concentration of commercial air traffic. Therefore, the NTSB recommends3857that the Secretary of the Army revise the method for allocating3858resources to ensure the development of a robust SMS that will, at a3859minimum, identify and monitor the potential for midair collisions3860between Army aircraft and civil air traffic operating in the NAS.3861[RECOMMENDATION 40]3862US Army Safety Culture3863    Our investigation identified several characteristics of the Army's3864safety culture relevant to this accident.3865    Just culture: At the operational unit level (brigade and3866battalion), investigators found evidence of a generally non-punitive3867and non-repressive safety climate. Frontline personnel reported feeling3868comfortable expressing safety-related concerns to safety officers and3869to their chain of command. The absence of a repressive climate did not3870appear to be a limiting factor in safety information flow.3871    Reporting culture: Although formal safety reporting systems3872existed, including OHRs and ASMIS near-miss reports, their utilization3873by flight crews was low. As a result, the organization had limited3874visibility into emerging operational risks, including the frequent3875close proximity of helicopters to jet aircraft arriving at DCA. This3876gap reflects a reporting culture that was formally established but not3877functionally embedded in routine operations.3878    Informed culture: The Army's ability to maintain an informed3879understanding of operational risk was constrained by organizational3880structure and priorities. Safety professionals who might otherwise3881analyze safety reports and operational data were largely consumed by3882ground safety and occupational health responsibilities mandated at the3883Army level. In combination with the low volume of flight safety reports3884and the absence of flight data monitoring capability, these constraints3885limited the organization's capacity to synthesize available information3886and maintain awareness of hazards, such as routine altitude exceedances3887on Washington, DC, helicopter routes.3888    Flexible culture: The Army's safety system lacked the structural3889flexibility and analytical capability necessary to adapt its safety3890focus in response to changes in the operational environment.3891Consequently, safety oversight did not adjust to the increasing density3892of aircraft arrivals at DCA, the reliance on visual separation to3893maintain traffic flow, or the infrequent use of runway 33, which made3894encounters between helicopters on Route 4 and low-flying airplanes3895approaching from the southeast atypical and less anticipated.3896    Learning culture: Organizational learning within the Army was3897primarily reactive, occurring in response to mishaps rather than3898through anticipatory identification of weak signals and emerging3899trends. The Secretary of the Army had mandated adoption of the ASOHMS3900in 2024, and the Army Combat Readiness Center had developed tools to3901support hazard tracking and analysis; however, these capabilities were3902not effectively utilized due to the structural and cultural limitations3903described above.3904    Although Army leadership had recently initiated policy changes3905intended to shift aviation safety management in a more proactive3906direction, these efforts were constrained by limitations in3907organizational capacity and safety culture. Specifically, Army aviation3908exhibited an underdeveloped reporting culture, limited informed3909awareness of operational hazards, insufficient flexibility to adapt3910safety oversight to changing risk, and a learning culture oriented3911toward reactive rather than anticipatory risk management.3912    The NTSB concludes that the Army's aviation safety system failed to3913consistently detect, interpret, and act on signals of latent hazards,3914resulting in degraded safety assurance, organizational learning, and3915safety culture. [FINDING 74]3916    The NTSB believes that addressing the identified safety culture3917limitations described above would require the Army to take several3918interrelated, system-level steps. First, the Army would need to ensure3919that flight safety management functions are adequately staffed and3920resourced, including the assignment of competent safety professionals3921with the expertise and time necessary to cultivate a robust reporting3922culture and to identify weak signals of risk through effective3923analysis.3924    Second, the Army would need to structurally protect these personnel3925from collateral duties unrelated to aviation safety that dilute their3926capacity to perform proactive safety oversight.3927    Third, the Army would need to provide flight safety personnel with3928objective data collection and analysis tools, such as a funded and3929institutionalized MFOQA capability, to support the detection of3930emerging risk trends during normal operations.3931    Finally, the Army would need to ensure that flight safety personnel3932are empowered, through organizational authority and access to3933leadership, to effectively advocate for safety-related changes based on3934the risks they identify.3935    As a result, the NTSB recommends that the U.S. Army develop and3936maintain a flight safety management capability that is independently3937resourced and functionally separate from its occupational and3938environmental health management system, and ensure that this capability3939is both culturally and functionally integrated with units conducting3940sustained flight operations in the NAS. [RECOMMENDATION 41]3941                              Attachment:3942        NTSB Findings, Probable Cause, and Recommendations List3943Findings3944   1.  The pilots of flight 5342 were certificated and qualified in3945        accordance with Federal regulations.39463947   2.  The pilots of flight 5342 were medically qualified for duty, and3948        available evidence does not indicate that they were impaired by3949        effects of medical conditions or substances at the time of the3950        accident.39513952   3.  Review of the flight 5342 pilots' time since waking and sleep3953        opportunities in the days before the accident indicated that3954        the pilots were unlikely to have been experiencing fatigue.39553956   4.  The pilot, instructor pilot, and crew chief onboard PAT25 were3957        qualified and current in their positions as designated by the3958        unit commander in accordance with Army regulations.39593960   5.  The pilot, instructor pilot, and crew chief of PAT25 were3961        medically qualified for duty, and available evidence does not3962        indicate that they were impaired by effects of medical3963        conditions or substances at the time of the accident.39643965   6.  Review of the three PAT25 crewmembers' time since waking and3966        sleep opportunities in the days before the accident indicated3967        that the crew were unlikely to have been experiencing fatigue.39683969   7.  The airplane was properly certificated, equipped, and maintained3970        in accordance with 14 CFR Part 121. The airplane was operated3971        within its weight and balance limitations throughout the3972        flight. Examination of the airplane revealed damage consistent3973        with an in-flight collision and subsequent impact with water,3974        and there was no evidence of any structural, system, or3975        powerplant failures or anomalies. Review of surveillance videos3976        indicated that the airplane's wing navigation, landing/taxi,3977        and anti-collision strobe lights were operating at the time of3978        the collision.39793980   8.  The helicopter was properly certificated, equipped, and3981        maintained in accordance with U.S. Army regulations. Review of3982        helicopter maintenance records did not reveal any open3983        discrepancies or anomalous trends that contributed to the3984        accident. The helicopter was operated within its weight and3985        balance limitations throughout the flight. Examination of the3986        helicopter revealed damage consistent with an in-flight3987        collision and subsequent impact with water, and there was no3988        evidence of any structural, main or tail rotor system, flight3989        control system, or powerplant failures or anomalies. Review of3990        surveillance videos indicated that the helicopter's right and3991        tail position lights, the landing light, as well as both upper3992        and lower anti-collision lights, were operating at the time of3993        the collision.39943995   9.  The operations supervisor and four controllers who were working3996        in the Ronald Reagan Washington National Airport air traffic3997        control tower cab at the time of the accident were properly3998        certified, qualified in accordance with Federal regulations and3999        facility directives, and current.40004001  10.  Although the Ronald Reagan Washington National Airport air4002        traffic control tower facility was not staffed to its target4003        level at the time of the accident, the number of staff in the4004        tower at the time of the accident was adequate and in4005        accordance with Federal Aviation Administration directives.40064007  11.  The decision to combine the helicopter control and local control4008        positions was not the result of insufficient staffing, and4009        personnel were available to staff the helicopter control and4010        local control positions separately had the operations4011        supervisor chosen to do so.40124013  12.  The local control controller, assistant local controller, and4014        operations supervisor were medically qualified for duty, and4015        available evidence does not indicate they were impaired by4016        effects of medical conditions at the time of the accident.40174018  13.  Review of the local control and assistant local control4019        controllers' and operations supervisor's (OS) time since waking4020        and sleep opportunities in the days before the accident4021        indicated that the controllers, including the OS, were unlikely4022        to have been experiencing fatigue.40234024  14.  Visual meteorological conditions prevailed in the area at the4025        time of the accident. A review of observations recorded4026        throughout the night of the accident revealed no evidence of4027        any local atmospheric pressure anomalies that would have4028        impacted barometric altimeter readings.40294030  15.  The Metropolitan Washington Airports Authority Airport Rescue4031        and Firefighting and airport operations staff responded4032        immediately and in accordance with applicable emergency plans4033        and regulatory requirements, deploying land-and water-based4034        resources, and coordinating mutual aid under complex nighttime4035        and on-water conditions.40364037  16.  Keeping the helicopter control and local control positions4038        continuously combined on the night of the accident increased4039        the local control controller's workload and negatively impacted4040        his performance and situation awareness.40414042  17.  The local control and helicopter control positions should have4043        been separated at the time of the accident given present4044        traffic volume and complexity.40454046  18.  In the two minutes before the accident when traffic volume was4047        increasing, the assistant local controller should have4048        prioritized surveillance of aircraft in the air in order to4049        assist the local controller, rather than diverting her4050        attention to the lower priority task of documenting helicopter4051        information, which could have been completed when traffic4052        volume and complexity had subsided.40534054  19.  Had the helicopter and local control positions been staffed4055        separately, PAT25 might have received a more timely and4056        effective traffic advisory.40574058  20.  Due to extended time on position at the time of the collision4059        and his complacency, the operations supervisor was likely4060        experiencing reduced alertness and vigilance, which decreased4061        his awareness of the operational environment and reduced his4062        ability to proactively assess the risks posed by the traffic4063        and environmental conditions at the time of the accident.40644065  21.  The lack of mandatory relief periods for supervisory air traffic4066        control personnel is contrary to human factors research that4067        shows clear performance deterioration in situations of4068        prolonged time on task.40694070  22.  Although the local control controller provided an initial4071        traffic advisory to the crew of PAT25 in accordance with4072        Federal Aviation Administration Order Job Order 7110.65, he did4073        not provide a corresponding advisory to the crew of flight 53424074        regarding PAT25's location and intention, which could have4075        increased situation awareness for the crew of flight 5342.40764077  23.  If the local control controller had issued a standard safety4078        alert to the flight crews of either aircraft as prescribed in4079        FAA Order Job Order 7110.65, providing the conflicting4080        aircraft's position and positive control instructions, the crew4081        of either aircraft could have taken immediate action to avert4082        the impending collision.40834084  24.  Initial and recurrent scenario-based training in threat and4085        error management would help controllers identify and mitigate4086        risks and strengthen situation awareness.40874088  25.  A risk assessment or decision making tool would likely have4089        benefited the accident OS in identifying and mitigating the4090        operational risk factors that were present on the night of the4091        accident.40924093  26.  Due to degraded radio reception, the crew of PAT25 did not4094        receive salient information regarding flight 5342's circling4095        approach to runway 33.40964097  27.  The PAT25 instructor pilot did not positively identify flight4098        5342 at the time of the initial traffic advisory despite his4099        statement that he had the traffic in sight and his request for4100        visual separation.41014102  28.  With several other targets located directly in front of the4103        helicopter represented by points of light with no other4104        features by which to identify aircraft type, and without4105        additional position information from the controller, the4106        instructor pilot likely identified the wrong target.41074108  29.  Interference that obscured the controller's ``circling to''4109        call, the microphone keying that blocked the PAT25 crew from4110        receiving the instruction to ``pass behind,'' ambiguous visual4111        cues, and the lack of an integrated traffic awareness and4112        alerting system likely reinforced the PAT25 crew's expectation4113        bias that the airplane was among the traffic approaching runway4114        1 and did not pose a conflict.41154116  30.  The absence of documented training on Ronald Reagan Washington4117        National Airport's fixed-wing procedures and the mixed-traffic4118        operating environment represented a safety vulnerability for4119        Army flight crews operating in the Ronald Reagan Washington4120        National Airport Class B airspace.41214122  31.  Due to additive allowable tolerances of the helicopter's pitot-4123        static/altimeter system, it is likely that the crew of PAT254124        observed a barometric altimeter altitude about 100 ft lower4125        than the helicopter's true altitude, resulting in the crew4126        erroneously believing that they were under the published4127        maximum altitude for Route 4.41284129  32.  A recurrent task to verify the continued accuracy of recorded4130        flight data for U.S. Army aircraft would help ensure the data4131        integrity needed to support quality assurance and safety4132        programs and accident investigations.41334134  33.  The Federal Aviation Administration and the Army failed to4135        identify the incompatibility between the helicopter routes' low4136        maximum altitudes and the error tolerances of barometric4137        altimeters, which contributed to helicopters regularly flying4138        higher than published maximum altitudes and potentially4139        crossing into the runway 33 glidepath.41404141  34.  Pilots need all available information on the potential total4142        error, allowed by design, that could occur in flight on an4143        airworthy barometric altimeter.41444145  35.  The Army's post-installation functional check of the transponder4146        on the accident helicopter was insufficient to detect that it4147        was not broadcasting Automatic Dependent Surveillance-Broadcast4148        Out.41494150  36.  The Army's lack of a recurrent transponder inspection procedure4151        resulted in the incorrect aircraft address being transmitted by4152        the accident helicopter's transponder, and the incorrect4153        automatic dependent surveillance-broadcast settings on several4154        other helicopters being undetected.41554156  37.  Because the APX-123A transponder is designed for use on multiple4157        aircraft platforms, it is possible that incorrect settings may4158        be present on other aircraft used throughout the Department of4159        War armed services.41604161  38.  The crew of flight 5342 did not see the helicopter until it was4162        too late to avoid a collision because of the high workload4163        imposed during the final phase of their approach, and due to4164        the helicopter's low conspicuity and lack of apparent motion.41654166  39.  Times of compacted demand as a result of air carrier scheduling4167        practices increased operational complexity and required4168        mitigations by controllers to maintain spacing and surface4169        movement.41704171  40.  Ronald Reagan Washington National Airport air traffic control4172        tower routinely received less than the requested miles in trail4173        spacing from Potomac Consolidated Terminal Radar Approach4174        Control, which increased controller workload by requiring them4175        to generate additional spacing to prevent delays or gridlock.41764177  41.  The practice of ``offloading'' arrival traffic on approach to4178        runway 1 by asking pilots if they could accept a circling4179        approach to runway 33 was a routine mitigation strategy for4180        Ronald Reagan Washington National Airport controllers to4181        generate spacing that was not provided by Potomac Consolidated4182        Terminal Radar Approach Control.41834184  42.  Time-based flow management, or metering, would provide Potomac4185        Consolidated Terminal Radar Approach Control and Ronald Reagan4186        Washington National Airport air traffic control tower with a4187        consistent flow of traffic with more accurate spacing and4188        greater predictability, thereby reducing controller workload.41894190  43.  Ronald Reagan Washington National Airport air traffic control4191        tower has significant airspace, airfield, mixed fleet, and4192        operations complexities that appear to be inconsistent with its4193        current facility level classification.41944195  44.  The Federal Aviation Administration Air Traffic Organization4196        failed to recognize external compliance verification results as4197        indicators of systemic traffic management, volume, and flow4198        issues at Ronald Reagan Washington National Airport for which4199        controllers were required to compensate.42004201  45.  The longstanding practice of relying on pilot-applied visual4202        separation (see-and-avoid) as the principal means of separating4203        helicopter and fixed wing traffic in the Washington, DC, area4204        by Ronald Reagan Washington National Airport air traffic4205        control tower, the Army, and other helicopter operators led to4206        a drift in operating practices among controllers and helicopter4207        crews that increased the likelihood of a midair collision.42084209  46.  Reliance on pilot-applied visual separation (see-and-avoid) as a4210        primary means of separating mixed traffic introduced4211        unacceptable risk to the Ronald Reagan Washington National4212        Airport Class B airspace.42134214  47.  Ronald Reagan Washington National Airport air traffic control4215        tower's procedure of maintaining a discrete helicopter4216        frequency when the local and helicopter control positions were4217        combined decreased overall situation awareness for pilots4218        operating in the area.42194220  48.  Providing controllers with additional salient cues regarding the4221        perceived severity of a potential conflict would reduce4222        controller cognitive load and would likely improve reaction4223        time to the most critical conflict alerts.42244225  49.  There was no evidence that the local control controller,4226        assistant local control controller, or operations supervisor4227        were under the influence of alcohol or prohibited drugs at the4228        time of the accident; however, evidence was substantially4229        limited by the lack of postaccident alcohol testing, and4230        evidence was of somewhat lower quality than it would have been4231        if drug testing had been conducted sooner following the4232        accident.42334234  50.  The Federal Aviation Administration Air Traffic Organization's4235        (ATO) drug and alcohol testing determination did not meet4236        Department of Transportation (DOT) timeliness requirements;4237        furthermore, the ATO's decision to not conduct drug testing as4238        soon as possible after the testing determination, and to not4239        conduct alcohol testing at all, violated DOT requirements.42404241  51.  The delayed and inappropriate drug and alcohol testing4242        determination was due in part to the Air Traffic Organization's4243        (ATO) determination process being inadequately designed to4244        routinely meet Department of Transportation requirements for4245        timely testing, and in part to ATO staff's incomplete4246        understanding of those requirements.42474248  52.  Annual reviews of helicopter route charts as required by Federal4249        Aviation Administration Order 7210.3DD would have provided an4250        opportunity to identify the risk posed by the proximity of4251        Route 4 to the runway 33 approach path, but there is no4252        evidence to support that these reviews were being performed at4253        Ronald Reagan Washington National Airport.42544255  53.  The information published by the Federal Aviation Administration4256        regarding Washington, DC, area helicopter routes was4257        insufficient to provide helicopter and fixed-wing operators4258        with a complete understanding of the helicopter route structure4259        and its lack of procedural separation from fixed-wing traffic.42604261  54.  Current aeronautical charting does not provide information on4262        visual flight rules helicopter routes that may conflict or come4263        in close proximity to approach and departure corridors, which4264        reduces pilot situation awareness.42654266  55.  The lack of Automatic Dependent Surveillance-Broadcast (ADS-B)4267        Out from the accident helicopter did not contribute to this4268        accident, as the helicopter was still being tracked by radar,4269        and ADS-B Out would not have provided improved traffic alerting4270        for the Ronald Reagan Washington National Airport controller or4271        the crew of flight 5342, because the airplane was not equipped4272        with ADS-B In.42734274  56.  The Army's standard operating procedures that prevent flight4275        crews from enabling Automatic Dependent Surveillance-Broadcast4276        (ADS-B) Out while in flight, when not performing sensitive4277        missions that require ADS-B to be disabled, limit the4278        visibility of military aircraft on collision avoidance4279        technologies that leverage ADS-B information.42804281  57.  Although the airplane's traffic alert and collision avoidance4282        system operated as designed, it was ineffective in preventing4283        the collision because of current activation criteria and4284        resolution advisory inhibit altitudes.42854286  58.  Traffic advisory aural alerts that include additional4287        information about the location of traffic could reduce the time4288        pilots need to visually acquire target aircraft.42894290  59.  Had the airplane been equipped with an airborne collision4291        avoidance system that used Automatic Dependent Surveillance-4292        Broadcast In information to show directional traffic symbols,4293        the crew of flight 5342 would have received enhanced4294        information about the risk posed by the helicopter, which could4295        have enabled them to take earlier action to avert the4296        collision.42974298  60.  Although the pilot and instructor pilot onboard PAT25 were4299        equipped with tablets that had the ability to display traffic4300        transmitting Automatic Dependent Surveillance-Broadcast Out, it4301        is unlikely that the pilots were using the tablets to monitor4302        or identify traffic at the time of the accident due to the4303        workload associated with low-altitude flight.43044305  61.  Technological advances since the development of traffic alert4306        and collision avoidance system II operating standards may allow4307        airborne collision avoidance system Xa with reduced inhibit4308        altitudes to have an expanded alerting envelope while reducing4309        nuisance alerts.43104311  62.  Although not yet commercially available, had the helicopter been4312        equipped with airborne collision avoidance system Xr with4313        integrated aural alerting, the crew could have received an4314        alert regarding flight 5342 and could have taken action to4315        avert the collision.43164317  63.  Multiple data sources provided evidence of midair collision risk4318        between fixed-wing aircraft and helicopters at Ronald Reagan4319        Washington National Airport, including on approach to runway4320        33, before this accident; however, the limited access to and4321        use of available objective and subjective proximity data4322        hindered industry and government stakeholders' ability to4323        identify hazards and mitigate risk.43244325  64.  Improving stakeholder access to standardized and objective4326        information about aircraft close proximity encounters for use4327        in safety assurance processes would increase the likelihood of4328        detecting and mitigating hazards before accidents occur.43294330  65.  The Federal Aviation Administration's lack of an established4331        process to inform parties about their involvement in events4332        such as near midair collisions or traffic alert and collision4333        avoidance system resolution advisories reduces the likelihood4334        of fully understanding and mitigating future midair collision4335        risk.43364337  66.  The Federal Aviation Administration Air Traffic Organization was4338        made aware of, and had multiple opportunities to identify the4339        risk of a midair collision between airplanes and helicopters at4340        Ronald Reagan Washington National Airport; however, their data4341        analysis, safety assurance, and risk assessment processes4342        failed to recognize and mitigate that risk.43434344  67.  The Federal Aviation Administration Air Traffic Organization's4345        application of its safety management system did not effectively4346        coordinate safety assurance and safety risk management4347        activities with external stakeholders in the Ronald Reagan4348        Washington National Airport Class B airspace.43494350  68.  Changes to Ronald Reagan Washington National Airport air traffic4351        control tower's standard operating procedures to the accident4352        removing the requirement for the operations supervisor (OS) to4353        document the time and reason for combining or de-combining the4354        helicopter control position in the facility log made it less4355        likely that the OS would consider and evaluate the risks4356        associated with combining or de-combining the position.43574358  69.  Safety risk management practices were not fully integrated into4359        Ronald Reagan Washington National Airport air traffic control4360        tower operations and did not identify or mitigate the4361        operational challenges faced by controllers or the lack of4362        guidance regarding operational risk assessments for controllers4363        and supervisors.43644365  70.  Federal Aviation Administration Air Traffic Organization (ATO)4366        management did not follow the tenets of safety management4367        systems to support its workforce, encourage open communication,4368        identify and mitigate risks, or foster a just culture, which4369        eroded the overall safety culture within ATO.43704371  71.  The Army did not have a flight safety data monitoring program4372        for helicopters, and as a result, was unaware of routine4373        altitude exceedances and related risks in the Ronald Reagan4374        Washington National Airport terminal area.43754376  72.  The Army's safety reporting systems for pilots were not well4377        utilized and did not provide the organization with information4378        about close encounters between Army helicopters and other4379        aircraft that were later found to have occurred frequently.43804381  73.  The Army's process for allocating resources to aviation safety4382        management did not ensure the development of a robust safety4383        management system for helicopter operations in the Washington,4384        DC, area.43854386  74.  The Army's safety system failed to consistently detect,4387        interpret, and act on signals of latent hazards, resulting in4388        degraded safety assurance, organizational learning, and safety4389        culture.4390Probable Cause4391    We determined that the probable cause of this accident was the4392FAA's placement of a helicopter route in close proximity to a runway4393approach path; their failure to regularly review and evaluate4394helicopter routes and available data, and their failure to act on4395recommendations to mitigate the risk of a midair collision near Ronald4396Reagan Washington National Airport; as well as the air traffic system's4397overreliance on visual separation in order to promote efficient traffic4398flow without consideration for the limitations of the see-and-avoid4399concept.4400    Also causal was the lack of effective pilot-applied visual4401separation by the helicopter crew, which resulted in a midair4402collision. Additional causal factors were the tower team's loss of4403situation awareness and degraded performance due to the high workload4404of the combined helicopter and local control positions and the absence4405of a risk assessment process to identify and mitigate real-time4406operational risk factors, which resulted in misprioritization of4407duties, inadequate traffic advisories, and the lack of safety alerts to4408both flight crews. Also causal was the Army's failure to ensure pilots4409were aware of the effects of error tolerances on barometric altimeters4410in their helicopters, which resulted in the crew flying above the4411maximum published helicopter route altitude.4412    Contributing factors include:44134414   The limitations of the traffic awareness and collision4415        alerting systems on both aircraft, which precluded effective4416        alerting of the impending collision to the flight crews;44174418   An unsustainable airport arrival rate, increasing traffic4419        volume with a changing fleet mix, and airline scheduling4420        practices at DCA, which regularly strained the DCA ATCT4421        workforce and degraded safety over time;44224423   The Army's lack of a fully implemented safety management4424        system, which should have identified and addressed hazards4425        associated with altitude exceedances on the Washington, DC,4426        helicopter routes;44274428   The FAA's failure across multiple organizations to implement4429        previous NTSB recommendations, including ADS-B In, and to4430        follow and fully integrate its established safety management4431        system, which should have led to several organizational and4432        operational changes based on previously identified risks that4433        were known to management; and44344435   The absence of effective data sharing and analysis among the4436        FAA, aircraft operators, and other relevant organizations.4437What We Recommended4438    On Mar. 7, 2025 we issued an urgent recommendation report (AIR-25-443901) with two urgent recommendations on mitigating the risk of midair4440collisions at DCA.4441    To the Federal Aviation Administration:44424443   Prohibit operations on Helicopter Route 4 between Hains4444        Point and the Wilson Bridge when runways 15 and 33 are being4445        used for departures and arrivals, respectively, at Ronald4446        Reagan Washington National Airport (DCA). (Urgent)44474448   Designate an alternative helicopter route that can be used4449        to facilitate travel between Hains Point and the Wilson Bridge4450        when that segment of Route 4 is closed. (Urgent)44514452    As a result of this investigation, we made the following new safety4453recommendations.4454    To the Federal Aviation Administration:44554456   1.  Develop and implement time-on-position limitations for4457        supervisory air traffic control personnel, including guidance4458        for district and facility level management to adapt these4459        limitations to account for their own staffing and local4460        standard operating procedures.44614462   2.  Develop instructor-led, scenario-based training on threat and4463        error management that trains controllers to continuously4464        monitor their environment to more quickly and accurately4465        identify threats; promote team communication to ensure that4466        communications are clear, timely, and assertive; emphasize4467        effective scanning habits; recognize patterns in the4468        development of adverse events; and enhance decision-making4469        under stress by developing habits that balance procedural4470        compliance with problem solving to mitigate the risks of4471        threats and errors, and provide this training to all air4472        traffic controllers annually.44734474   3.  Develop and implement a risk assessment tool for supervisors4475        that incorporates the principles of threat and error management4476        to assist in risk identification, mitigation, and operational4477        decision making.44784479   4.  Initiate rulemaking in 14 Code of Federal Regulations Part 934480        Subpart K, High Density Traffic Airports, that prescribes air4481        carrier operation limitations at DCA in 30-minute periods,4482        similar to those imposed at LaGuardia Airport, to ensure that4483        the airport does not exceed capacity and to mitigate4484        inconsistent air carrier scheduling practices.44854486   5.  Fully implement operational use of the time-based flow4487        management system at Potomac Consolidated Terminal Radar4488        Approach Control and its associated air traffic control towers.44894490   6.  Reassess the Ronald Reagan Washington National Airport's airport4491        arrival rate with special consideration to its airspace4492        complexity, airfield limitations, mixed-fleet operations, and4493        traffic volume.44944495   7.  Define objective criteria for the determination of air traffic4496        facility levels considering traffic and airspace volume,4497        operational factors unique to each facility, and cost of4498        living.44994500   8.  Using the criteria established by Safety Recommendation [7],4501        determine whether the classification of the Ronald Reagan4502        Washington National Airport's air traffic control tower as a4503        level 9 facility appropriately reflects the complexity of its4504        operations.45054506   9.  Conduct a comprehensive evaluation, in conjunction with local4507        operators, to determine the overall safety benefits and risks4508        to requiring all aircraft to use the same frequency when the4509        helicopter and local positions are combined in the Ronald4510        Reagan Washington National Airport air traffic control tower.45114512  10.  Implement anti-blocking technology that will alert controllers4513        and/or flight crews to potentially blocked transmissions when4514        simultaneous broadcasting occurs.45154516  11.  Develop and implement improvements to the conflict alert system4517        to provide more salient and meaningful alerts to controllers4518        based on the severity of the conflict triggering the alert.45194520  12.  Once the improvements to the conflict alert system discussed in4521        Safety Recommendation [11] are implemented, provide training to4522        controllers on its use.45234524  13.  Revise the Air Traffic Organization's initial event response4525        procedures so that an appropriate on-site supervisor makes each4526        postaccident and postincident drug and alcohol testing4527        determination, based on their assessment of whether the event4528        meets testing criteria and which controllers had duties4529        pertaining to the involved aircraft, without needing to wait4530        for investigation or approval.45314532  14.  At least annually, provide training on the revised postaccident4533        and postincident drug and alcohol testing determination4534        procedure discussed in Safety Recommendation [13] to all staff4535        who have responsibilities under that procedure; this training4536        should include a post-learning knowledge assessment.45374538  15.  Ensure that annual reviews of helicopter route charts are being4539        conducted throughout the National Airspace System as required4540        by Federal Aviation Administration Order.45414542  16.  Conduct a safety risk management process to evaluate whether4543        modifications to the remaining helicopter route structure in4544        the vicinity of Ronald Reagan Washington National Airport are4545        necessary to safely deconflict helicopter and fixed-wing4546        traffic and provide the results to the National Transportation4547        Safety Board.45484549  17.  Amend your helicopter route design criteria and approval process4550        to ensure that current and future route designs or design4551        changes provide vertical separation from airport approach and4552        departure paths.45534554  18.  Based on the criteria and approval process established by Safety4555        Recommendation [17], review all existing helicopter routes to4556        ensure alignment with these updated criteria.45574558  19.  Incorporate the lateral location and published altitudes of4559        helicopter routes onto all instrument and visual approach and4560        departure procedures to provide necessary situation awareness4561        to fixed-wing operators of the risk of helicopter traffic4562        operating in their vicinity.45634564  20.  Modify airborne collision avoidance system traffic advisory4565        aural alerts to include clock position, relative altitude,4566        range, and vertical tendency.45674568  21.  Require existing and new traffic alerting and collision4569        avoidance system (TCAS) I, TCAS II, and airborne collision4570        avoidance system X installations to integrate directional4571        traffic symbols.45724573  22.  Require all aircraft operating in airspace where Automatic4574        Dependent Surveillance-Broadcast (ADS-B) Out is required to4575        also be equipped with ADS B In with a cockpit display of4576        traffic information that is configured to provide alerting4577        audible to the pilot and/or flight crew.45784579  23.  Require the use of the appropriate variant of airborne collision4580        avoidance system X on new production aircraft that are subject4581        to traffic alert and collision avoidance system equipage4582        regulations.45834584  24.  Require existing aircraft that are subject to traffic alert and4585        collision avoidance system equipage regulations be retrofitted4586        with the appropriate variant of airborne collision avoidance4587        system X.45884589  25.  Evaluate the feasibility of decreasing the traffic advisory and4590        resolution advisory inhibit altitudes in airborne collision4591        avoidance system Xa to enable improved alerting throughout more4592        of the flight envelope.45934594  26.  If the evaluation resulting from Safety Recommendation [25]4595        finds that the inhibit altitudes can be safely decreased,4596        require retrofitting of the applicable airborne collision4597        avoidance system X variant incorporating the reduced traffic4598        advisory and resolution advisory inhibit altitudes on all4599        aircraft that are subject to traffic alert and collision4600        avoidance system and equipage regulations.46014602  27.  Require that all rotorcraft operating in Class B airspace be4603        equipped with airborne collision avoidance system (ACAS) Xr4604        technology once the ACAS Xr standard has been published.46054606  28.  Create an objective definition of close proximity encounter and4607        a public database of those encounters and their locations that4608        can be used to monitor their prevalence and identify areas of4609        potential traffic conflict for safety assurance and safety risk4610        management.46114612  29.  Develop and implement a process that will, in a timely manner,4613        notify involved parties after events such as near midair4614        collisions or traffic alert and collision avoidance system4615        resolution advisory activations, such that notification occurs4616        while relevant data remain available and before meaningful4617        safety analysis, reporting, or corrective action is no longer4618        practicable.46194620  30.  Based on the results of the audit completed in accordance with4621        Safety Recommendation [49], ensure that all safety management4622        system functions and data sharing activities at all air traffic4623        control facilities are conducted in collaboration with all4624        relevant external stakeholders.46254626  31.  Establish a requirement across all air traffic control tower4627        standard operating procedures that the operations supervisor4628        (OS) or controller-in-charge (CIC) document in the daily4629        facility log when any control position is combined with the4630        local control position, or when the OS/CIC position is combined4631        with a control position, along with a rationale for doing so.46324633  32.  Develop a new and comprehensive instructor-led, scenario-based4634        training on the proper use of visual separation, both tower-and4635        pilot-applied. This training should include information on the4636        inherent limitations of see and avoid, responsibilities when4637        applying visual separation, and guidance for controllers on4638        factors, such as current traffic volume, workload, weather or4639        environmental factors, experience, and staffing, that should be4640        considered when applying visual separation. Require this4641        training for all controllers and include on a recurrent basis4642        thereafter in annual simulator refresher training.46434644  33.  Require each Class B or Class C air traffic control tower4645        facility to evaluate its existing miles-in-trail procedures or4646        agreements to ensure that the spacing provided is appropriate4647        for operational safety, and make the results publicly4648        available.46494650    To the U.S. Army:46514652  34.  Revise training procedures for flight crews assigned to operate4653        in the Washington, DC, area to ensure that they receive initial4654        and recurrent training on fixed-wing operations at Ronald4655        Reagan Washington National Airport, including approach and4656        departure paths, runway configurations, and the interaction of4657        those traffic flows with published helicopter routes.46584659  35.  Develop and implement a recurring procedure, at an interval not4660        to exceed 18 months, to verify the continued accuracy of4661        recorded flight data.46624663  36.  Incorporate information within the appropriate operator's manual4664        for all applicable aircraft on the potential total error4665        allowed by design that could occur in flight on an otherwise4666        airworthy barometric altimeter, including the increased4667        position error associated with the external stores support4668        system configuration.46694670  37.  Develop and implement a transponder inspection procedure on all4671        aircraft with transponders capable of transmitting Mode S and4672        automatic dependent surveillance--broadcast (ADS-B) and4673        operated in the National Airspace System (NAS), at least4674        annually and upon each aircraft's entry into service in the4675        NAS, that ensures 1) the transponder ADS-B settings are4676        correct, 2) the transponder is transmitting ADS-B, and 3) the4677        transponder is transmitting the correctly assigned address.46784679  38.  Establish a flight data monitoring program for rotary-wing4680        aircraft the U.S. Army operates in the National Airspace4681        System.46824683  39.  Survey U.S. Army helicopter pilots to identify barriers to the4684        utilization of flight safety reporting systems, develop a plan4685        to address the identified barriers, and implement that plan4686        across Army aviation units.46874688  40.  Revise the method for allocating resources to ensure the4689        development of a robust safety management system that will, at4690        a minimum, identify and monitor the potential for midair4691        collisions between Army aircraft and civil air traffic4692        operating in the National Airspace System.46934694  41.  Develop and maintain a flight safety management capability that4695        is independently resourced and functionally separate from its4696        occupational and environmental health management system, and4697        ensure that this capability is both culturally and functionally4698        integrated with units conducting sustained flight operations in4699        the National Airspace System.47004701    To the Department of War Policy Board on Federal Aviation:47024703  42.  Conduct a study to evaluate the quality of radio transmissions4704        and reception for those aircraft operated within the National4705        Airspace System to identify factors that degrade communications4706        equipment performance and adversely affect the safety of4707        civilian and military flight operations.47084709  43.  Implement appropriate enhancements, based on the findings of the4710        study recommended in Safety Recommendation [41], to remediate4711        identified deficiencies in air-ground radio communications4712        performance.47134714  44.  Require the Department of War to verify on all aircraft with4715        transponders capable of transmitting Mode S and automatic4716        dependent surveillance--broadcast (ADS-B) and operated in the4717        National Airspace System (NAS), at least annually and upon each4718        aircraft's entry into service in the NAS, that 1) the4719        transponder ADS-B settings are correct, 2) the transponder is4720        transmitting ADS-B, and 3) the transponder is transmitting the4721        correctly assigned address.47224723  45.  Require armed services to amend their operational procedures to4724        allow flight crews to enable Automatic Dependent Surveillance--4725        Broadcast Out while in flight.47264727  46.  Require all military aircraft operating in the National Airspace4728        System (NAS) be equipped with Automatic Dependent Surveillance-4729        Broadcast (ADS-B) In with a cockpit display of traffic4730        information that is configured to provide alerting audible to4731        the pilot and/or flight crew, and that such requirement apply4732        wherever in the NAS the Federal Aviation Administration4733        requires any aircraft to operate with ADS-B Out.47344735    To the Department of Transportation:47364737  47.  Require the Federal Aviation Administration to demonstrate at4738        least annually that each air traffic control facility it4739        operates has the routine capability to accomplish required4740        postaccident and postincident drug and alcohol testing within4741        the U.S. Department of Transportation's specified timeframes of4742        2 hours for alcohol and 4 hours for drugs, and implement a4743        process to ensure that any facility without such capability4744        will demonstrate timely remediation.47454746  48.  Work with the Federal Aviation Administration (FAA)4747        Administrator to convene an independent panel to conduct a4748        comprehensive review of the safety culture within the FAA's Air4749        Traffic Organization (ATO), and use the findings to enhance the4750        ATO's existing safety management system and integrate it into4751        all levels of the organization.47524753    To the Department of Transportation Office of Inspector General:47544755  49.  Complete an audit of the Federal Aviation Administration (FAA)4756        Air Traffic Organization safety management system functions and4757        data sharing activities at all air traffic control facilities4758        and determine whether these activities are conducted in4759        collaboration with all relevant external stakeholders, ensuring4760        that the audit's results are documented, reported to the4761        Secretary of Transportation and the FAA Administrator, and made4762        available to the public.47634764    To the RTCA Program Management Committee:47654766  50.  Finalize and publish the minimum operational performance4767        standards for airborne collision avoidance system Xr for4768        rotorcraft.47694770    The Chairman. Thank you, Madam Chair. In just a moment,4771Chairwoman Homendy is going to play a short video simulation4772that the NTSB produced that includes the transcript of the4773cockpit voice recordings along with air traffic control4774transmission. And I will say right before this hearing began,4775the Chairwoman played for the members of this committee, in the4776back conference room, the video along with the audio of the4777cockpit voice transmissions.4778    Under Federal law, we're not allowed to play the actual4779voice transmissions publicly. But I will tell you, watching and4780listening, and for any members that did not see that, I'm4781certain that Chairwoman would be happy to give you the4782opportunity to see it and listen to it. It is positively4783horrifying. And watching it and listening to the voices of the4784pilots makes you sick to your stomach.4785    After watching, it is indisputable that ADS-B In and Out4786could have prevented, and likely would have prevented, this4787accident, and we have an obligation to prevent the next4788accident. I do want to give a moment if any of the family4789members wish to step out and not watch the video. We certainly4790understand that, and so, I want to give you an opportunity if4791you would prefer not to watch it.4792    And, Madam Chair, you can play the video now.4793    [Video shown.]4794    Ms. Homendy. So, it I think it stopped here because that--4795it says 47 seconds, but at 48 seconds, the helicopter crew4796had--they did have ADS-B In on an iPad that was strapped to4797their thigh, but they also had NVGs on, and it was a high night4798vision goggles on, and it was a high workload environment.4799    And so, they didn't look down. You don't look down4800constantly in this airspace with NVGs on to--it would be very4801difficult. Had--the problem is that they would have received an4802oral alert from their iPad at 48 seconds had that been4803connected into their headsets, but their headsets aren't able4804to receive those oral alerts.4805    And so, an oral alert, had that been connected and4806integrated into their headset, which was one of our4807recommendations to do that so that they can get those alerts,4808it would have been 40--they would have been at 280 feet. The4809aircraft would have been at 640 feet. They would have been4810miles apart and could have taken evasive action because, at4811this point, they're at Hains Point, in plenty of time to take4812action. But that was the first time they would have received an4813alert, but didn't because they couldn't hear. It doesn't come4814across their headset.4815    [Video shown.]4816    Ms. Homendy. At 59 seconds, this is where Flight 5342, had4817they had ADS-B In, would have gotten their first alert. That4818would have been their first alert had there been ADS-B In, and4819I know there has been statements made, but the helicopter4820wasn't transmitting ADS-B Out. Even if this aircraft had ADS-B4821In, it wouldn't have mattered because at DCA you have something4822called TIS-B, it's Traffic Information Service-Broadcast. They4823have ground radar stations that take information from4824transponders and other aircraft in the air that have ADS-B, and4825relay it back up to aircraft that have ADS-B In.4826    So, they would have gotten their first alert and it would4827have sounded something like, ``Traffic 12 o'clock, 2 nautical4828miles, 500 feet below,'' or, ``low altitude.'' What you're4829going to hear in a minute--in just a few seconds, at 19 and a4830half seconds, is what they actually did here, and that's--we'll4831go ahead and play.4832    [Video shown.]4833    Ms. Homendy. Yes, sorry, you didn't hear, ``Traffic,4834traffic,'' at 19 and a half seconds because the CVR audio isn't4835on there, but that would have been 19 and a half seconds. And4836then at that point at, ``Traffic, traffic,'' you're looking4837out, trying to figure out where the traffic is. Helicopters4838down in the lights. Pilots are told when it's a traffic4839advisory, you're not to take any sort of evasive action because4840you need to be looking at and acquiring that traffic.4841    Resolution advisories, which is part of TCAS that you can4842get, resolution advisories would have provided them with a4843climb/descend. Except, below 900 feet, across our entire4844airspace, resolution advisories are inhibited, meaning they are4845quiet, all you get is, ``Traffic, traffic.'' What we're talking4846about is timely information for pilots.4847    The Chairman. Thank you, Madam Chair. The NTSB conducted a4848thorough investigation into this accident. What did the NTSB4849investigation show about what would have happened if both4850aircraft had been equipped with ADS-B In?4851    Ms. Homendy. The accident wouldn't have happened. At 484852seconds, the helicopter crew would have gotten an oral alert,4853they could have taken evasive action, and the flight crew of48545342, at 59 seconds, could have had an alert that allowed them4855to take evasive action. So, we have recommended ADS-B In4856everywhere there is ADS-B Out for all aircraft.4857    The Chairman. As you know, the bipartisan ROTOR Act, which4858passed out of this committee and which is passed to the Senate4859unanimously, every Republican, every Democrat has voted for it,4860mandates ADS-B In and Out on aircraft flying into congested4861airspace. In your professional judgment, if the ROTOR Act had4862been the law at the time of this accident, would the accident4863have occurred?4864    Ms. Homendy. No, it wouldn't have occurred. Though, this4865helicopter route shouldn't have existed, but that's another4866story. No, I don't believe it would have occurred.4867    The Chairman. Well, and as you know, that's another4868component of the ROTOR Act is mandating a reassessment of4869helicopter----4870    Ms. Homendy. Absolutely.4871    The Chairman.--routes as well. ADS-B Out and In is not new4872technology. Today, the FAA only requires ADS-B Out, which sends4873signals directly to air traffic control. In 2010, the Agency4874chose not to require ADS-B In, which would have given pilots4875those same signals. Nonetheless, some aviators voluntarily use4876ADS-B In, receiving weather, traffic, and other information in4877the cockpit. American Airlines, for example, has equipped4878nearly 30 percent of its fleet with ADS-B In. More than 804879percent of private pilots use some form of ADS-B In. It is4880clearly a popular technology.4881    I've heard a handful of special interest groups, however,4882want carve outs from the ADS-B In requirement. I don't think a4883private jet or a charter flight flying into DCA, or Dulles, or4884DFW, should be able to adhere to a lower safety standard than a4885passenger airline. Special treatment for them would put4886everyone else's lives at a risk. Others have said that all of4887general aviation should be exempt, even though pilots in rural4888areas are already exempted, and the ROTOR Act protects general4889aviation's ability to use portable transponders. In your4890judgment, should different aircraft be flying into congested4891area using different ADS-B safety rules?4892    Ms. Homendy. No, absolutely not. It's a shared airspace.4893    The Chairman. Those same skeptics like to claim that ADS-B4894In is too costly. Major airlines like American Airlines have4895figured out how to install ADS-B In. Every new Gulf Stream has4896ADS-B In, and, of course, the ROTOR Act only requires ADS-B In4897for planes flying into busy airspace. A crop duster flying in4898Arkansas isn't going to need it and won't be affected, but if4899that crop duster decides to land at DCA Reagan, then it should4900have the technology and not be endangering the lives of4901passengers flying into and out of Reagan every day. In your4902judgment, is it too expensive for planes to install ADS-B In?4903    Ms. Homendy. Four hundred dollars. Everybody's got a phone.4904Everybody's got a headset. Four hundred dollars. Maybe you get4905an iPad, it's a little more expensive, but that isn't costly.4906American Airlines, less than $50,000 a plane to retrofit. The4907plane was out of service. They told me one or two days when4908they retrofitted it--each plane.4909    The Chairman. So, I want you to repeat that because one of4910the concerns people are raising is this is some onerous4911government mandate. A private pilot can get the equipment4912necessary, A, to keep himself or herself safer, B, to keep4913everyone else flying into that congested airspace safer. They4914can get that equipment for $400.4915    Ms. Homendy. You already have a headset. Everybody has a4916phone. Some people have iPads. Four hundred dollars. This is4917the receiver.4918    The Chairman. Another objection that has been raised is the4919claim that somehow the military should be exempt, that the4920military should be able to fly in congested airspace and not be4921subject to the rules everyone else is. Does that make any4922sense?4923    Ms. Homendy. No, it does not.4924    The Chairman. Well, 100 members of the U.S. Senate agree4925with you. The Secretary of War agrees with you. The Secretary4926of Transportation agrees with you, and I am hopeful that within4927the next two weeks, the House of Representatives will put the4928ROTOR Act on the floor, will pass it, and will put it on4929President Trump's desk for signature. We owe it to the families4930of those who lost their lives, the 67 souls who should be with4931us today if only Congress had listened to the first 16 times4932the NTSB recommended ADS-B In. Thank you.4933    Ms. Homendy. I know you don't have any more time, but can4934I----4935    The Chairman. Sure.4936    Senator Cantwell. He's the Chair.4937    Ms. Homendy. I know you--yes. Can I have one thing to point4938out?4939    The Chairman. You could have two.4940    Ms. Homendy. OK. Thank you. In 2001, the FAA had a4941rulemaking on fractual ownership, and they stated in there that4942passengers who are transported under Parts 121 and Part 135,4943``Exercise no control over and bear no responsibility for the4944airworthiness or operation of the aircraft aboard which they4945are flown.''4946    I would also say that applies to Part 91, Revenue4947Generating Passenger Operations. The FAA concluded that, ``The4948appropriate level of public safety is provided by very4949stringent regulations and oversight under Part 121 and Part4950135.'' In Ketchikan in 2019, we stated that, ``Aircraft without4951ADS-B do not demonstrate the appropriate level of safety for4952passenger-carrying operations conducted under Part 1354953Regulations,'' and we also stated that there's shared airspace4954between 121, 135, and GA.4955    We've conducted numerous investigations between Part 1214956airlines and GA aircraft, or GA aircraft carrying passengers4957who paid for a service with other GA aircraft, or between 135s4958and 121s, or 135 and GA. The fact is everyone should be under4959the same rules, one level of safety, because it doesn't matter4960if you're in a private plane, a commercial jet is also4961operating in your airspace.4962    The Chairman. Thank you. Ranking Member Cantwell.4963    Senator Cantwell. Thank you, Mr. Chairman. Chair Homendy,4964you, in my opinion, have become a sentry for aviation safety.4965And that means that you're standing guard over our system,4966which, I believe, should be standing guard over by the FAA, and4967you should play a role on the details that then, jointly, this4968works together.4969    But somehow, the industry has too much influence over this4970process, and I don't know if the FAA just thinks that it can't4971keep up technologically. I don't know, but these4972recommendations have been on the table for a long time, and4973they've never been implemented. And so, I want to ask several4974questions about your 14 key recommendations.4975    But, first, on this issue of ADS-B In, you just talked4976about the issue of what it would take to implement. But isn't4977there a cost? General aviation is saying this is too expensive4978and you just refuted that, but isn't there a cost for not doing4979it? NTSB data showed that between 2006 and 2025, they4980investigated 153 mid-air collisions involving general aviation4981operators compared to one mid-air collision and four near mid-4982air collisions involving commercial jets. So, these general4983aviation accidents have cost 198 lives. So, there is a huge4984cost to general aviation for not doing this. Isn't that4985correct?4986    Ms. Homendy. That's correct. Unfortunately, when you do4987rulemaking, the DOT puts the price of a life at $11.6 million.4988The NTSB considers all life priceless. You can't put a price4989tag on a life.4990    Senator Cantwell. How many times did you or your4991individuals listen to the audio tapes here?4992    Ms. Homendy. Quite a number of times.4993    Senator Cantwell. Hundreds?4994    Ms. Homendy. If I combined everyone. Yes.4995    Senator Cantwell. So, I think that's the difference. You're4996listening to this, analyzing this, and you are steadfast in4997your recommendations, and somehow, these guys are listening to4998other voices and saying we don't have to do it because there's4999a cost. And I got news for the FAA: in the digital age that's5000not going to stand because we all can see this information, and5001we need an FAA that basically is on top of this, and will push5002through the regulations to implement.5003    So, on this issue, a safety management system, which is5004basically part of the requirements, you're basically saying5005that they didn't integrate a system. Would a safety management5006system with the number of near misses that you said were alarm5007bells going off in the cockpit, demanded that this run--this5008route no longer exist?5009    Ms. Homendy. A safety management system--a properly5010implemented safety management system should have identified the5011risk. But it is pretty clear from our investigation----5012    Senator Cantwell. Well, would have----5013    Ms. Homendy.--that did not occur.5014    Senator Cantwell.--not only identified it, but would have5015required, once identified, to fix it.5016    Ms. Homendy. Yes, once you identify, then you look at your5017mitigations, and then you implement those mitigations, and5018monitor those mitigations, and reevaluate for change. But in5019this case, there were numerous warning signs from people within5020the FAA saying we have a problem here. Then, there was their5021own data that they weren't even looking at: 15,214 close5022proximity events.5023    I can tell you this much, the FAA requires a lot of data.5024They've got 10 different systems just for mid-air collisions,5025but they don't actually have a definition for what they5026consider is a mid-air collision, a near miss, not one single5027definition. So, then, you have people who aren't looking at the5028data. Then, you have the tower who is trying to raise concerns5029over and over again, year after year, and not being heard, told5030to go away. And I have to tell you, this same scenario that5031occurred on January 29, also occurred in 2013 between a5032military aircraft and a private commercial jet. It was averted.5033Same thing happened.5034    Senator Cantwell. So, we need an aggressive FAA in this air5035traffic control office and safety office on aviation safety to5036actually collect data, report on data. And my guess is we're5037going to have to get some of this data, and review it, and5038require hearings because, otherwise, this job isn't getting5039done. It appears to be.5040    Ms. Homendy. Yes.5041    Senator Cantwell. So, if you would just comment on San5042Antonio--I mean El Paso, for us about this newest event.5043    Ms. Homendy. I don't know a lot. I don't know anything5044about El Paso other than what I read. It's not something that5045we handle. However, you know, from the--what little I know, I5046will say there has been miscommunication or no communication5047between--at least, the Army and FAA for years. Now, the Army5048participated--the 12th Battalion participated in the Helicopter5049Working Group, but in general, they weren't having5050conversations.5051    Senator Cantwell. Which this--is in this accident, the key5052issue as well. The conversation should have been happening, and5053we, obviously, had a rule that somehow got changed that allowed5054this to happen, and it wasn't an accurate assessment even after5055the rule was changed, so.5056    Ms. Homendy. Yes. And if you don't mind me mentioning,5057the--listen, the reason why the NTSB has the party system, when5058we do an investigation, we invite entities who are technical5059experts into our investigation, like FAA, like the Army, like,5060you know, a number of others, PSA, you name it, in order for us5061to get the evidence we need to conduct our investigation.5062They're not part of the analysis, right? But during that time--5063it has been a year--during that time, parties get that5064information in real time and can make change immediately. They5065don't need to wait for our final investigation to come out with506650 recommendations.5067    You know what the best result of an investigative report5068is? It's the best thing that has happened in years at the NTSB,5069in Missouri, actually. I wish Mr. Schmitt was here to hear it.5070We had at the end of a terrible train derailment, I was on5071scene, went to meet with a farmer in his barn who said he had5072been talking about, you know, this terrible accident that could5073occur for years on Facebook, doing videos. I met with him in5074his barn and said, ``What's going on,'' for, like, 2 hours, and5075he said to me--I said, ``I'm going to fix this before we5076leave,'' and he's like, ``Sure you are.'' I don't blame him.5077You know, he had been facing a government bureaucracy for5078years. So, I got everybody together before we left. I said, you5079name it, and I said, ``We are fixing this crossing.'' And you5080know what happened? A year later, we issued our final report on5081a deadly train collision at this terribly designed grade5082crossing. And Governor Parson not only fixed that crossing, he5083fixed 49 others, and we issued no recommendations.5084    The failure in this report is that we had to issue5085recommendations. Now, I'm going to get a briefing from FAA on5086the reorganization, but we can't be just shifting around the5087deck chairs. ATC didn't contribute to this. We need reform.5088    Senator Cantwell. Well, other people here need to listen.5089Thank you, Mr. Chairman.5090    The Chairman. Thank you. Senator Wicker.50915092                STATEMENT OF HON. ROGER WICKER,5093                 U.S. SENATOR FROM MISSISSIPPI50945095    Senator Wicker. Thank you, Mr. Chairman. And also, thank5096you, Ranking Member Cantwell, and former Chairman Cantwell, for5097asking that question about El Paso.5098    Senator Cantwell and I were leading this committee during5099the time when we were investigating the 737 MAX 8 tragedies,5100and this is the most heartrending and gut-wrenching issue that5101we could possibly ever investigate. And I just don't have the5102words to tell the families how awful this is, and how terrible5103I realize they must feel. Thank you, Chairwoman Homendy, for5104your leadership in this.5105    Since the accident in January of last year, what has5106changed at Reagan National Airport between the FAA, the towers,5107and the National Guard, in the interim, before our Act can be5108passed by the House?5109    Ms. Homendy. Well, one thing that did change is that5110within--we issued two urgent safety recommendations for5111immediate action in March of this past year, just a couple of5112months after the accident occurred, calling on the Secretary of5113Transportation to take action about the helicopter route5114itself, Route 4.5115    And within two hours--it's the fastest we have ever had an5116entity implement our recommendation. Within two hours, he did5117so. He prohibited mixed traffic between Hains Point and Wilson5118Bridge, which is now in an interim final rule before him. But5119he's continued that prohibition on mixed traffic, and has5120required ADS-B Out in the airspace. He has authorized5121additional personnel in the tower. However, the tower is facing5122some challenges. The numbers are lower because a lot of people5123are going through training, but a number of other measures need5124to be--need to take place.5125    Senator Wicker. Sure----5126    Ms. Homendy. But he's done a great job.5127    Senator Wicker. I understand that, but things have been5128done within weeks of this accident based on your5129recommendations.5130    Ms. Homendy. Yes. And I have to say, this was his first day5131on the job.5132    Senator Wicker. Right. Yes.5133    Ms. Homendy. It was his first day on the job. He did--this5134will forever stay with him, which is why he is so committed to5135aviation safety, and he has been an excellent partner on this5136with us.5137    Senator Wicker. When you speak to skeptical members of the5138other body, is it the cost to general aviation that they5139mention as the only reason they're skeptical about the bill?5140What other reasons do they give for not readily passing what5141has been passed unanimously over here?5142    Ms. Homendy. I've heard a number of things. I've heard5143cost. I've heard aircraft----5144    Senator Wicker. That would be the cost to the general5145aviation owners?5146    Ms. Homendy. I've heard for everybody. Cost for general5147aviation, 135, 121 regional airlines, major airlines. I've5148heard difficulty in retrofitting, planes being out of service.5149I've heard privacy concerns. I've heard--and I'm sure Senator5150Budd is going to raise this, I've heard concerns about tracking5151aircraft with ADS-B Out where some airports and third-party5152entities are tracking aircraft, especially GA aircraft, to5153charge them landing and ramp fees, which is something you-all5154can address. Those are the main issues I've heard about.5155    Senator Wicker. Let me ask you--let me ask you this. On the5156headsets, it just strikes me as so inconceivable that this5157helicopter had the ADS-B, but the two pilots could not hear it5158on their headsets. Why was that, and how readily could that be5159fixed?5160    Ms. Homendy. So it can be fixed. We have issued a5161recommendation for them to have an integrated headset so that5162they can hear any sort of alerting, but we've also recommended5163better technology on the helicopters so they're not relying on5164iPads on their legs while they're in a night vision goggle,5165high workload environment.5166    I will say the Army has been very responsive. They have5167completely replaced their helicopters at the 12th Battalion,5168from the old Lima models to the new MIC models, and they have5169stated they're going to implement that technology. They're5170still working on the headset issue and haven't quite committed5171to that, but implement better technology for ADS-B In and Out5172by the third quarter of 2027, though, they're asking for $5005173million. So, since you're in charge of that, I will ask for5174$500 million.5175    Senator Wicker. And if the Chair will indulge me, should5176the House pass this bill that has now passed unanimously in the5177Senate, should they pass it next week, how soon could it be5178implemented?5179    Ms. Homendy. I think certain measures can be implemented5180immediately. Some measures will take a little bit of time. I5181don't know how much time, but it would take a little bit of5182time, and FAA would have to sort some of it out through a5183rulemaking in that amount of time, like ADS-B In. But in that5184amount of time, the risk still is in our airspace. So, every5185day that goes by, we face the potential for another catastrophe5186to occur.5187    Senator Wicker. Well, thank you for your stewardship of5188this issue.5189    Ms. Homendy. Thank you.5190    The Chairman. Senator Duckworth.5191    Senator Duckworth. Thank you, Mr. Chairman. As our5192committee conducted oversight and aftermath of the tragic DCA5193crash, I've noticed that the stories from FAA and the Army have5194gradually evolved over time. Specifically, my sense is that the5195information provided have come to resemble more of a telling of5196what should have happened rather than what actually happened,5197and I fear this pattern is yet another symptom of a complacent5198culture.5199    For example, NTSB is now officially recommending that FAA5200and the Army engage in proactive data sharing. The lack of5201coordination between the FAA and the Army was on full display5202in May of last year when it was reported that the dedicated5203direct access line connecting the Pentagon tower with the DCA5204tower had not worked since 2022, meaning that for more than52051,000 days--1,000 days--not a single soul ever used the hotline5206directly connecting the DCA tower and the Pentagon's Army5207heliport. Now, in the aftermath of this scandal, which itself5208occurred only months after the preventable deadly DCA crash,5209FAA issued statements downplaying the impact, implying that the5210inoperable hotline was really no big deal because, look,5211controllers could just ``call each other on the telephone.''5212    But FAA cannot hand-wave away the scandal because FAA's5213Deputy Chief Operating Officer publicly admitted that FAA had5214no idea that the dedicated hotline was not working for 3 years.5215FAA had no idea until another Army helicopter incident less5216than 4 months after the DCA crash forced two commercial flights5217to abort landings at DCA. Meaning, that after the tragedy of5218Flight 5342 civil military collision, not one FAA employee5219thought, ``Hmm, maybe we should test our direct communications5220line to the Army heliport from the DCA Tower?''5221    Chair Homendy, does the fact that the FAA's dedicated5222direct access line to the Pentagon was literally inoperable for5223years without anyone noticing, serve as an apt metaphor for the5224sheer amount of work that must be done to improve5225communications between DOD and FAA?5226    Ms. Homendy. That one's still under investigation by NTSB,5227but, yes, I would agree with that.5228    Senator Duckworth. Just yesterday, the FAA announced a 10-5229day temporary flight restriction in El Paso, then abruptly5230reversed it hours later. The conflicting reports that emerged5231do not inspire confidence that the FAA and DOD have improved5232their communications either with each other or within their own5233organizations. In fact, the FAA Administrator yesterday in5234response to the Chairman Cruz's question about what happened in5235El Paso said that Secretary Duffy's tweet about drug cartel5236drones was absolutely correct, that they knew about the5237impending--the request for closure of the airspace, but he did5238not know why FAA actually closed the airspace for 10 days.5239    Chair Homendy, the DCA collision, and now we're hearing5240it's a party balloon that they shot down. So, I'm still waiting5241to hear what's happening. But Chair Homendy, the DCA collision,5242the May Pentagon go rounds, the B52 incident in South Dakota,5243and now, El Paso, showcases a severe lack of coordination.5244    What must change at the FAA, DOD to prevent future5245coordination failures? What is at risk if there is no5246improvement, and has NTSB been included in some of these5247meetings with--and coordination between FAA and DOD because5248they were keeping you out for a while there?5249    Ms. Homendy. No, we are not part of that, but we would not5250necessarily be part of that. But FAA, we can talk about5251separately because I do have some concerns there. Army actually5252worked really well with us. What we investigated was between5253the Army and the FAA, and there was no communication. I mean,5254the Army participated, the 12th Battalion participated in a5255helicopter working group that was formed by the tower because5256the tower was saying, hey, we've got a serious safety issue5257here and nobody's doing anything about it. Let's try to5258coordinate. But Army wasn't asking for data. They had their own5259safety management system problems and there was lack of5260coordination.5261    Look, I'm going to tell you, I worked 15 years on Capitol5262Hill, and we talk about this all the time. When you go to an5263agency, the lack of communication, even within a large agency5264and between agencies is terrible. I don't understand it. People5265can't talk. It's astounding to me, but it's not surprising from5266what we've seen from the investigation.5267    Senator Duckworth. Would it be safe to presume that you5268would support Congress elevating the NTSB recommendations5269following the DCA mid-air collision into a statutory5270requirement?5271    Ms. Homendy. Yes. And you can do that simply by requiring5272the entities to adopt the recommendations, and reference our5273report without actually having to do language everywhere. What5274I will say, though, is we shouldn't wait to move the provisions5275in the ROTOR Act. This isn't a wait on ROTOR move, this5276legislation. This is a yes, and. Congress can move many pieces5277of legislation every day, so it's a yes/and.5278    Senator Duckworth. Thank you.5279    The Chairman. Thank you. Senator Moran.5280    Senator Moran. Senator Cruz, thank you. I intended in my5281line of questioning to reemphasize the importance of ROTOR Act,5282but perhaps that has been accomplished in this hearing,5283although one would have thought that 17 other times it may have5284been accomplished. So, maybe it can't be said enough, but I5285reaffirm my commitment to seeing the passage of the ROTOR Act a5286bit along the lines of Senator Duckworth about--and you talked5287about communication.5288    One of the things, and I don't have any of the details in5289front of me, so you'll have to refresh my memory. But the5290number of near misses you mentioned in your opening statement5291that were reported at DCA in regard to potential collisions,5292but you also, in an earlier testimony or in our conversations,5293talked about the number of times that somebody at DCA reported5294a problem that they thought needed to be fixed, but it never5295worked its way up the chain of command. And I think, as I5296recall, like nothing ever made it to the folks who actually5297could implement changes recommended by air traffic controllers5298or others involved in air traffic safety. Am I saying enough to5299refresh your memory about what I'm talking about?5300    Ms. Homendy. Yes. First of all, the data which we actually5301obtained from the FAA, in coordination with them, showed 15,2145302close proximity events over about 10 years, 85 of which were5303near misses, and----5304    Senator Moran. But you also indicated today something I5305didn't realize. There's no real definition because those have5306been dismissed as unimportant, but to me or to Kansans and5307Americans, you hear a near miss, that means something. But5308apparently there's no definition that would awake somebody5309within the FAA.5310    Ms. Homendy. Yes. They need a common definition because you5311all--you brought together FAA, NTSB, and the Army at one point5312behind closed doors, and I talked about the near miss numbers5313that we had received from FAA. And all of a sudden FAA spoke up5314and said, no, it's five. And I looked over, where'd you get5315five? You somehow whittled down 15,214 to five because there's5316no common definition. Ten different data sources, and it's5317whatever you choose it to be that day, a definition. And, you5318know--so, you know, from my standpoint, that is just one of5319many areas that they could have fixed before we even got to a5320recommendation.5321    Senator Moran. You fill in spaces on my other aspect of my5322question----5323    Ms. Homendy. Yes.5324    Senator Moran.--about that, where things were reported time5325and time again, but never did anyone in the hierarchy ever hear5326of the complaints because there was timidity in complaining.5327    Ms. Homendy. Well, one, I would probably--I would say the5328hierarchy at the air traffic organization did understand----5329    Senator Moran. Yes.5330    Ms. Homendy.--what was going on, which was a problem. I5331mean it was push it down, make it go away, not an issue. Too5332political. Too political was from one of the interviews, not my5333phrasing. The leadership of the FAA probably were totally5334unaware. So, you have the tower--that's the ultimate5335bureaucracy, by the way. I think at one point, we counted the5336steps from the tower to get something all the way up to5337leadership. It was like 10 or 12 steps. It's ridiculous.5338    Senator Moran. Almost nothing made it the 10 or 12 steps--5339--5340    Ms. Homendy. No.5341    Senator Moran.--if you recall what you----5342    Ms. Homendy. No. It made it to the district level and made5343it nowhere else. So, what happened was the air traffic control5344tower said, you know what, we're going to have to take things5345into our own hands. So, we're going to create this Helicopter5346Working Group. So, they did, not just with the military, but5347all the private operators, police, you name it, law5348enforcement, and they pulled together the working group. They5349did some work. They proposed to their hierarchy, hey, you know,5350we should move helicopter Route 4. Another time they said, we5351think we should put some hotspots, you know, on the helicopter5352charts, including at the end of Runway 33, which we've seen is5353an area where we have a great concern for risk if there's a5354mid-air collision. And FAA's response----5355    And then, they had numerous reports just coming from the5356tower, written reports. They also had a report saying, we're5357getting too many requests from Potomac TRACON to reduce spacing5358between aircraft landing. There were so many reports, and each5359time it was nope, or no--and this is the ultimate in5360bureaucracy when the response to the hotspot was, yes, we don't5361put hotspots on maps. Oh, the only hotspots we do on maps is5362for ground movement. Come on.5363    At our hearing, we raised this issue. Why didn't you do5364anything? The person who showed up from FAA said, well, they5365could have raised it at a symposium. Really? They were raising5366it so many times in writing, verbally. If that happens at DCA,5367you know it's happening everywhere else in our airspace.5368    Senator Moran. Thank you for refreshing my memory and5369putting that on the record today. Let me ask you, if there's5370any indication or what are the indications that the FAA, the5371Department of Transportation are taking aggressive action to5372implement recommendations, past and present? Has anything5373changed since January 29 of last year? I think you made a5374really important point that you don't--I think there's a5375tendency, I can see myself thinking the same thing: we'll wait5376for the recommendations, and then we'll know what to do when we5377know there are things to be done today.5378    Ms. Homendy. And that's perfectly reasonable for you-all,5379but for those that were parties to our investigation, the5380reason why you are parties is because you're privy to factual5381information so you can take early action. None of that5382occurred. In fact, the entire time--we work for FAA, and I'm5383going to be honest with you, I met with the DOT IG at one point5384to talk about whether we should write a letter about5385obstruction to our investigation, because we weren't--we were5386repeatedly denied data we requested. What we kept hearing from5387FAA was, well, you're not asking for it properly. We did. I5388audited it, but here's what I'll say on the changes. I don't5389know of any other than what the Secretary did, and that isn't5390right.5391    Senator Moran. Message received. I wrote on my notes today5392that our subcommittee, this committee, we ought to rely--I5393guess, request GAO Inspector General, constant oversight on the5394Department of Transportation, and the FAA in particular.5395    Ms. Homendy. Yes.5396    Senator Moran. Thank you, again.5397    Ms. Homendy. And on DOT IG, one thing I will say, sometimes5398they don't get access to their data systems. That's something5399you should chat with them about, because they aren't getting5400the data. They're relying on people giving them the data.5401    Senator Moran. Thank you.5402    The Chairman. Thank you. Senator Klobuchar.54035404               STATEMENT OF HON. AMY KLOBUCHAR,5405                  U.S. SENATOR FROM MINNESOTA54065407    Senator Klobuchar. Thank you very much, Senator Cruz. And,5408thank you, Chairwoman. Not only do you bring this incredible5409expertise--you know I've always been a supporter of yours, but5410you also bring the passion and the anger that I know so many of5411the families and the loved ones in this room are feeling over5412what happened. I want to thank your dedicated NTSB staff for5413all of their hard work. And I want to acknowledge the 67 people5414who lost their lives, including Wendy Jo Schaffer, a mom of two5415from Mahtomedi, Minnesota.5416    So, this committee, as you noted, has worked in a5417bipartisan fashion to advance the ROTOR Act, and I thank the5418Chairman and the Ranking Member for their work on this, as well5419as Senator Moran and Senator Duckworth. So, my questions are,5420first of all, on air traffic control staffing, we have a5421shortage of air traffic controllers. Former Senator Braun and I5422pushed to address staffing shortages by requiring the FAA to5423conduct maximum hiring of air traffic controllers.5424    While the number of the staff at the time in the tower, as5425you've noted in the report, was adequate, and in accordance5426with FAA directives, the facility was staffed below its target5427level. How can lower staffing levels impact controller5428performance and awareness? Has the FAA increased staffing at5429DCA to mitigate some of the issues raised today?5430    Ms. Homendy. So, it impacts staff--we didn't find a concern5431with staffing on that day, as you noted, but it does impact5432safety because it impacts their workload. In this case, you can5433see two people should have been on position, one on helicopter5434control, one on local control. And what happened was the local5435controller was doing two jobs. People were at the--in the tower5436and on staff, and available, but he was forced to do two jobs5437and taking--and handling between seven and 12 aircraft.5438    What I will say, as far as staffing today, there are5439staffing challenges, and that is an significant impact on5440safety. They are authorized at DCA to have pretty high numbers,5441but they're not at those numbers. On January 6, right before5442our board meeting, I checked--we checked the numbers at DCA.5443There's authorized numbers, but then you have to ask any day,5444what's operational, who's out, who's on medical leave, who's on5445military leave? It was lower than it was on January 29.5446    Senator Klobuchar. OK. Thank you. The NTSB report showed5447that the flight path for helicopter Route 4 comes within 755448feet of the approach to Runway 33, and that video was chilling5449to watch. Are there any circumstances in which 75 feet of5450vertical separation is safe?5451    Ms. Homendy. Absolutely not. Not safe, anywhere in our5452airspace.5453    Senator Klobuchar. The FAA is required to annually review5454these helicopter flight routes. Who was tasked with reviewing5455helicopter routes, and why hadn't this risk been identified5456previously?5457    Ms. Homendy. I'm only laughing a little bit because it's so5458sad, because DCA has existed since 1940s. Runway 33, 1940s,5459traffic certainly has changed, but helicopter Route 4 has been5460there since 1986. FAA is required to do an annual review of5461those routes. Not a single annual review was done. Not a single5462one. In fact, they couldn't--at first, when we asked who was5463responsible for doing those annual reviews----5464    Senator Klobuchar. I think we asked NTSB or FAA. Have they5465been able to identify who has that role?5466    Ms. Homendy. They finally--they did finally tell us who it5467was. It was like a terminal operations director, but nobody5468knows who specifically that is.5469    Senator Klobuchar. And do you know if they've changed this5470now?5471    Ms. Homendy. No, I do not.5472    Senator Klobuchar. OK. Well, that's a good question for us5473to ask. Could you talk about how you did this report and got5474this thorough analysis, through all the grief? And as I was5475watching the video, I was thinking about the hard work of your5476staff, and I was thinking about the grief of the families. And5477I was thinking about how every single day they had to come to5478work, your staff, feeling that weight of what had happened to5479these families and then still do their jobs. How many staff5480contributed to this investigation? How many hours? And what is5481the funding status for NTSB? And you can put it in writing5482later if you don't have it. Exactly.5483    Ms. Homendy. It's probably about 50 or 60 staff. I mean,5484we're only about 415 right now. It's significant. How were we5485able to do this? The people behind me. I can only advocate like5486I do, and know the facts that I do, and do a good job because5487of them. We are a team, and they put together--they gathered548819,000 pages of evidence. It's my duty to read every single5489word of that evidence because that's their hard work. I mean,5490it's a lot--a lot of work, while they also have about 15 to 205491other cases. Mr. Chin here, who's behind me, did all the5492helicopter work: helicopter systems, barometric altimeters,5493you'll name it, on this investigation. He's also leading the5494UPS crash as the investigator in charge.5495    Senator Klobuchar. Thank you, Mr. Chin.5496    Ms. Homendy. So, the personnel, it has been difficult. I5497mean, it's a difficult year for them, and the shutdown was5498difficult. It's a strain on all of them, but I have never been5499more proud of the team than I was on January 27, and every day5500since I came to the NTSB. Thank you.5501    Senator Klobuchar. Thank you. I just think this--the5502findings and the fact that on a bipartisan basis, the Chairman5503and Ranking Member have worked on this, as you noted, focused5504on this, along with Senator Moran, Senator Duckworth. I just5505don't detect partisanship here when it comes to this, and it is5506such an example of why we're never going to be able to make5507things better if we don't get to the bottom of what went wrong.5508And as I understand already, some changes have been made that5509you've recommended, and must continue to be made, every single5510one of them. Thank you.5511    Ms. Homendy. Thank you. And I'll also add for the Chairman,5512this is the same team behind me that helped us--helped me5513evaluate NDAA before we even did anything. We got to--we get5514together as a group and make decisions as a team.5515    Senator Klobuchar. Thanks.5516    The Chairman. Senator Sullivan.55175518                STATEMENT OF HON. DAN SULLIVAN,5519                    U.S. SENATOR FROM ALASKA55205521    Senator Sullivan. Thank you, Mr. Chairman, and, Madam5522Chair, it's good to see you again, and I want to thank you as5523well. You're doing an exceptional job, and you're--your whole5524team. I want to begin by, of course, expressing my deepest5525condolences to the families and loved ones of those we lost in5526the American Airlines Flight 5342 tragedy at DCA.5527    As you know, Madam Chair, also around the same time, we had5528another airplane crash in Alaska, the Bering Air crash over5529Norton Sound. One year later, these losses remain deeply felt5530throughout our country with witnesses here, in my state in5531Alaska, where, as you know, aviation is not a luxury, it's a5532lifeline. And I want to thank the NTSB for its thorough work,5533and I appreciate the work you've done on the latest Bering Air5534crash--or not, or that latest crash in Alaska. We are grateful5535for your commitment. We're grateful for you going up to Alaska5536so soon after that crash, and aviation safety is particularly5537important in my state, where communities depend on reliable air5538service, for healthcare, for commerce. We have over 2305539communities in my state that are not connected by roads, and5540so, it really, really matters.5541    So, I want to broaden the aperture here. It has been 65542years since the February 2020 NTSB report that found over a 10-5543year period, Alaska's aviation crash rate was almost two and a5544half times higher than the national average, and the fatality5545rate was 1.3, almost 1.4 times higher. That led me and the FAA5546Administrator at the time, Steve Dixon, and you, to push for5547what we now refer to as the Alaska Aviation Safety Initiative,5548the FAASI Initiative.5549    I was able to get that initiative codified in the FAA5550Reauthorization Act of 2024, ensuring that it would be in law5551with the goal that we would reduce fatal aviation accidents in5552Alaska by 90 percent by 2033, require the FAA to improve5553maintenance and reliability of weather equipment, and to5554reauthorize $25 million, at a minimum, annually, through 2028,5555to carry out this work.5556    We've made significant progress on that. As you know, the5557Working Families Tax Cuts Act had a huge investment in aviation5558safety, ATC reform. A lot of that, about $180 million so far,5559is going to Alaska. So, given the substantial work and funding5560we've had since 2020 in the NTSB report, would you agree with5561me that it's time to take a more comprehensive look at where we5562are with the state of aviation safety in Alaska? And can I get5563your commitment to work with me on this?5564    Ms. Homendy. Yes. In fact, I will offer, if you'd like,5565we'll come back to Alaska, and would certainly welcome having a5566robust conversation with you and others about aviation safety5567and your needs, which are very unique.5568    Senator Sullivan. Good. Well, I appreciate that. Mr. Chair,5569one of the things I'm going to be working on, and hopefully5570with the Chair's--you know, and the Committee's help, is5571possibly a field hearing with the Chairman of the NTSB, who5572again, I think is doing a great job with the FAA on the state5573of where we are in the FAASI Initiative. Because what we're5574trying to do----5575    The Chairman. Can the field hearing coincide with salmon5576fishing season?5577    Senator Sullivan. If you come, it can. But what we're5578trying to do is preempt, you know, what Senator Duckworth5579actually said, which is see our challenges. You know, I did5580notice, Madam Chair, in your opening statement, you mentioned5581Alaska with regard to 15 potential near collisions. We did have5582a collision in 2019 in Ketchikan. Six people died, you know, in5583that collision.5584    So, yes, I'd like to get to have you up and have my5585constituents see, because I think there's progress, but there5586are still gaps. And would you agree with that? And you know,5587the President, Secretary Duffy, did announce a huge investment5588in AWA systems in Alaska. I think the President actually5589announced 170 for my state, which would be fantastic, but we5590need to work on all elements of that. Can I get your commitment5591again on that? And are there any things that, from the5592preliminary look at the Bering Air investigation, or your other5593areas of expertise that relate to Alaska, that you could kind5594of lay out right now here?5595    Ms. Homendy. Well, we're still collecting--well, first of5596all, yes, you have my commitment on that.5597    Senator Sullivan. Great. Thank you.5598    Ms. Homendy. I was the Board Member on scene for Ketchikan.5599It was really devastating.5600    Senator Sullivan. Yes.5601    Ms. Homendy. And Brice Banning was also on that5602investigation. He's our investigator in charge for DCA. Yes, so5603we're still conducting the investigation on Nome. We hope--I5604need to check in with the team on what the--when that will be5605completed.5606    But you have a lot of needs in Alaska, infrastructure for5607one of them, resources. I mean, just to see how different5608aviation is, that you're relying on aviation from everything5609from mail, to prescriptions, lifesaving medicine, to food.5610    Senator Sullivan. Yes.5611    Ms. Homendy. And you need to have that infrastructure there5612so you can get all of that in, whether it's weather, whether5613it's runway lights, or anything else.5614    Senator Sullivan. Good. Well, I look forward to that. And5615Mr. Chairman, I look forward to maybe getting you up there and5616your team, but that'll be an important hearing. And again,5617thank you for your work. Thank you for your work on the FAASI5618Initiative. I want to thank the Committee on that. We made some5619really good progress on the Alaska Safety Initiative here in5620the last FAA reauthorization, and the Working Families Tax Cuts5621Act, which we passed in July. And your work on this, I know5622it's difficult. And again, to the families who have lost loved5623ones, we are very focused on making sure this doesn't happen5624again, either in D.C. or in Alaska. Thank you.5625    The Chairman. Thank you. Senator Lujan.56265627               STATEMENT OF HON. BEN RAY LUJAN,5628                  U.S. SENATOR FROM NEW MEXICO56295630    Senator Lujan. Thank you. Mr. Chairman. To all the families5631that are here, thank you for being here. Not just lifting the5632memories and names of those that you lost personally, but of5633all 64 that we lost, for reminding us that behind policy,5634behind these decisions, that there are people. And I want to5635thank you all for being here.5636    Chair Homendy, one of the many findings and recommendations5637in this report, one that stood out to me, is how the lack of5638communication and coordination between the FAA and the Army5639contributed to this crash. What's even more concerning is that5640this lack of coordination apparently has not been resolved.5641    Just yesterday, we saw how the lack of coordination between5642the FAA and the Department of Defense can lead to widespread5643confusion. Flights were delayed, canceled for many of my5644constituents, Senator Cruz's constituents, and others5645throughout the United States. But it's more than those fights5646being canceled. It's the worry and the uncertainty that also5647came from this.5648    There has still been no answer from the President, from the5649U.S. Government, from the Department of Transportation, from5650the Department of Defense. And now, we're learning the5651Department of Homeland Security, they've all been quiet and5652they stand behind what Secretary Duffy said, that it was about5653a drone incursion. Well, what's being reported now is that it5654was a laser that was on loan from the Department of Defense to5655the Department of Homeland Security, Border Patrol, and that5656they were--that they shot a party balloon.5657    I thought that was a technical term for some craft. A party5658balloon is a balloon any one of you would buy for someone's5659birthday party, and they shut down--they said they were going5660to shut down air traffic for 10 days without calling the White5661House, without calling the Department of Defense. Do you all5662know how long the airspace was shut down over Venezuela when5663the full force of the United States military went down there?5664Twenty-four hours.5665    Further, what's being reported is that the FAA and DOD have5666said that this technology was safe for air travel. It also says5667that there are accounts that there were DOD personnel on the5668ground there with Border Patrol. I appreciate Senator Cruz and5669Senator Cornyn making it abundantly clear that there needs to5670be a briefing in a SCIF. I don't know why there needs to be a5671briefing in a SCIF shooting a party balloon.5672    But it's not just the Department of Defense that needs to5673be there. The Department of Transportation, the FAA, as part of5674the Department of Transportation, the Department of Homeland5675Security, and the Border Patrol, and the people that were on5676the ground that did this, and I want to know why they're not5677communicating.5678    So, my question to you is, are you going to investigate5679this?5680    Ms. Homendy. Our mandate is to investigate after a tragedy5681occurs.5682    Senator Lujan. I appreciate that. Let me ask you a5683different question. Yes or no, is a lack of Federal5684coordination harmful to the safety of our airspace?5685    Ms. Homendy. Yes.5686    Senator Lujan. Will the--well, I just asked that as well.5687My other questions around this, Ms. Homendy, is with--what5688Congress needs to do to make sure that the crash that you are5689here to share information about does not happen again. The5690question that Senator Moran asked about how many communications5691have there been throughout the years, whether it's under a5692Republican or a Democratic President, it doesn't matter, from5693air traffic controllers or from anyone else, have been5694silenced?5695    I certainly hope that we're able to demand that that5696information be shared to this committee to oversight, and that5697we have a real conversation about what it takes to implement5698those changes, because no administration has been willing to do5699this by rule. Clearly, from the point that Senator Duckworth5700made, that even a phone that should be used to communicate is5701not even being utilized.5702    A few years ago, I was in New Mexico at a site for aircraft5703that was used to put out forest fires at one of the command5704centers that is under, I believe, the jurisdiction of the5705United States Department of Agriculture. When I was in there5706looking at this particular tower, they told me the Internet5707didn't work inside the tower, and they were hesitant to tell5708me.5709    Well, I started calling everyone that I could, and we got a5710bunch of folks on board. Chairman, I think your office might5711have even helped with this one. Well, now that tower has access5712to the Internet, and the people in that air traffic tower are a5713little more safe than they were before it was out. If it's5714little things like that that are getting in the way of this5715because someone's being told you have to stay quiet, shame on5716all of us.5717    And so, as I close here, I know I didn't ask many questions5718in this area. I just certainly hope that we can get to the5719bottom of this, and that, Chairman, we truly can make things5720safer, and that we don't forget the names of those that have5721been lost. Not just on this horrific crash, but on the others5722as well, and that we do something significant in this space,5723and I look forward to working with you and doing my part. You5724let me know how we can make this better.5725    But in the case of what's happened in El Paso, Southern New5726Mexico, it's not just a briefing in a SCIF. I don't want to5727hear the spin. I don't want to hear the cover up. I want to5728hear the facts. I want to hear the truth. I certainly hope that5729that briefing doesn't have to take place in a SCIF. There5730should be information that's shared with the American people as5731to what happened there, because that can't happen anywhere5732else. We need people coordinating. I'm not suggesting we don't5733go after bad people or bad things. It's not what I'm saying,5734but we need to make sure that we're keeping people safe as5735we're also going after bad things throughout the United States5736that are endangering all of our constituents as well. Thank you5737for the time, Mr. Chairman.5738    The Chairman. Thank you.5739    Ms. Homendy. May I have 10 seconds?5740    The Chairman. Sure.5741    Ms. Homendy. Just--and I don't know, we're not involved in5742El Paso, but what I will say is we did note the poor safety5743culture within the Air Traffic Organization, and throughout our5744investigation, we found numerous people were afraid to talk to5745us. They didn't want to be formally interviewed. Some people5746actually came directly to me and that would not be appropriate5747for me to talk to them in an investigation.5748    So, I--over time, with--our investigators were able to gain5749trust, their trust, to then interview them, but some people5750wouldn't provide their names. They were scared. I can't tell5751you the number of people who were just scared to speak up5752because they were worried about retaliation. At our own5753hearing, I had to get everyone to commit to not to retaliate.5754Still, that occurred, but it's not a good culture right now.5755    Senator Lujan. I appreciate that. Thank you, Chairman.5756    The Chairman. Senator Budd.57575758                  STATEMENT OF HON. TED BUDD,5759                U.S. SENATOR FROM NORTH CAROLINA57605761    Senator Budd. Thank you, Chairman. You know, Flight 53425762was a Charlotte-based flight crew. A North Carolina pilot was5763in the Blackhawk. But wherever folks were from, even outside5764North Carolina, we never want this to happen again. Thanks for5765your work on this and that of your team behind you. Chair5766Homendy, I think you had this in your written testimony, but5767would you agree that ADS-B In information is most effective5768when all aircraft are broadcasting ADS-B Out?5769    Ms. Homendy. Yes, sir.5770    Senator Budd. Should policymakers address incentive5771structures that discourage the installation and use of ADS-B5772Out?5773    Ms. Homendy. We don't have a formal position on that, but I5774will say yes.5775    Senator Budd. You know, as you mentioned a few moments ago,5776a couple questioners ago, some airports are now contracting5777with third-party companies to use ADS-B Out data to assess5778landing fees on operators. Would you say that this aligns with5779the intent of ADS-B?5780    Ms. Homendy. Absolutely not. ADS-B is a safety tool, and it5781should be used for safety, not to--not as a revenue generator5782to charge, certainly, general aviation pilots and others, ramp5783fees, or landing fees. That's not how it should be used. It's a5784safety technology.5785    Senator Budd. Do you think using it in a manner that you5786just described, like to generate fees, would encourage pilots,5787aircraft owners to have them turned off?5788    Ms. Homendy. Yes. They turn them off, or just not install5789it at all, or use it. That would be--that would discourage5790their use. So, I would--and I believe you have legislation on5791this. I hope it moves because I think it should be prohibited.5792    Senator Budd. Well, to address the issue, I introduced the5793Pilot and Aircraft Privacy Act, which would prevent airports5794from using ADS-B to assess fees on aircraft operators for that5795very reason that you just mentioned. I think it harms safety.5796    You know, you noticed--as you noted in your testimony, if5797both the helicopter Flight PAT25 and Flight 5342 had been using5798ADS-B, a collision avoidance system, the crew of 5342 would5799have had nearly a minute more, advanced warning than they5800received from the TCAS. Now, it may not have prevented the5801tragedy, but it would have been another layer in this so-called5802Swiss cheese model.5803    Chair Homendy, I do appreciate the time today, time you5804gave today. I appreciate your team, and I look forward to5805working with you and with this committee to ensure as many5806aircraft as possible use the ADS-B system and other critical5807safety technologies. Thank you so much.5808    Ms. Homendy. Thank you.5809    The Chairman. Thank you. Senator Markey.58105811               STATEMENT OF HON. EDWARD MARKEY,5812                U.S. SENATOR FROM MASSACHUSETTS58135814    Senator Markey. Thank you, Mr. Chairman. First of all,5815Madam Chair, I just want to say that you are one of America's5816great public servants. You're fearless, and you're very smart,5817and very needed at this time. So, I just wanted to tell you5818that publicly.5819    Ms. Homendy. I'm only as good--I'm only that good because5820of them behind me.5821    Senator Markey. But we need people like you to make them5822good, because there are other people who have positions in our5823government who, as you're saying, they put even their own5824personnel in a code of omerta where they're afraid to speak the5825truth, afraid to say the right thing, and you create the right5826culture to protect the American people. I just want to tell you5827how grateful I am, and I think our Nation is whenever they hear5828you speak because they know you're speaking the truth.5829    And I want to begin just by taking a moment to honor the 675830individuals who lost their lives when American Eagle Flight58315342 crashed into the Potomac River. In Massachusetts, this5832tragic crash hit us especially hard. Six individuals associated5833with the Skating Club of Boston, as well as Massachusetts5834native, Chris Collins, were on board Flight 5342. Chris's5835brother, Matt Collins, is in the audience at today's hearing.5836To Matt and all of the families here, and watching, we are5837committed to honoring your loved ones with more than just5838words, with actions that we are going to take.5839    And it is because of you, the families, who have turned5840unimaginable grief into determined advocacy, that the Senate5841unanimously passed the bipartisan ROTOR Act in December. Change5842does not happen without your bravery, without your5843perseverance, without the families standing up and demanding5844that something be done.5845    And even as we speak, Maxim Naumov, the son of two of the5846members of the Skating Club of Boston, and a Norwood,5847Massachusetts resident, is honoring his parents' memory right5848now on the world stage at the Winter Olympics, skating with5849extraordinary strength, extraordinary grace, which is what all5850the families are showing right now. So, it's time for Congress5851that it takes inspiration from Max's courageous performance and5852enacts the ROTOR Act into law in our Nation. This legislation5853is the action needed to honor the crash victims and prevent5854future tragedies so hearings like this are not necessary in the5855future.5856    Now, I'd like to talk about airline accountability. The5857NTSB's final report concludes that it is vital that all5858commercial aircraft are equipped with crash avoidance5859technology called ADS-B In. Despite the importance of this5860technology, the airline industry has repeatedly said that it5861would be too costly to implement. So, Chair Homendy, is it true5862that this technology is too costly to implement?5863    Ms. Homendy. Not by the evidence. American Airlines5864outfitted--retrofitted over 300 Airbus A321s for less than5865$50,000 an airplane, and only had them out of service for 1 or58662 days.5867    Senator Markey. Yes. It reminds me when the auto industry5868used to say it's too expensive to have airbags, it's too5869expensive to have seat belts, we just can't afford it makes the5870car too unaffordable. You know what the American public said?5871Build in the safety. And it turns out, the more you do it, is5872the lower the cost is. We have to get it done for our airline5873industry as well.5874    Ms. Homendy. And that's the cost.5875    Senator Markey. Without question. It's just an unacceptable5876price that we have to pay because the industry wants to cheap5877out in terms of building in the protections that the families5878of our country deserve. So, I believe that an industry that5879rakes in billions in profits every year, can afford lifesaving5880technology for a very small cost.5881    And I want to turn to one final issue: FAA staffing. Soon5882after the crash, the NTSB examined flight data and identified5883over 15,000 close proximity events between airplanes and5884helicopters here at the Washington airport. If an FAA employee5885had been analyzing this data, they may have identified the risk5886in this DCA airspace before the tragic crash.5887    Rather than bolstering FAA staffing capacity, the Trump5888administration responded by cutting the very FAA staff needed5889to conduct this life-saving analysis, and that's why last July,5890I sent a letter to the FAA demanding answers about its staffing5891levels and capacity to identify similar risk at other airports5892in our country. And it's also why I fought for and won an5893amendment in the ROTOR Act to ensure the FAA Administrator5894maintains the necessary staffing levels to analyze safety5895trends before a disaster happens.5896    Unfortunately, over a year later, according to NTSB's5897report, the FAA is still not analyzing these trends to catch5898close calls before they occur. It's a year later. This is5899unacceptable. Chair Homendy, do you agree that the FAA is still5900not proactively acting to identify these risks at U.S.5901airports?5902    Ms. Homendy. They are not doing what we have recommended,5903and we have been urging them to do the entire time, which is to5904not only evaluate their data, which they're starting to do now,5905but to develop a simple definition of what a close call is.5906They have 10 different types of data sources coming in for a5907near miss and not one single definition that everyone can get5908around on what is a near miss. And then, even the information5909and data they collect, isn't shared with the airlines until5910about 3 to 6 months later.5911    Senator Markey. Yes. You recommend that there be the5912creation of an office to collect the data and then to5913disseminate the information. And that still has not happened.5914    Ms. Homendy. We had recommended that they develop a5915standard definition for what a close proximity event is, and to5916improve their data analysis, and to share that data with5917external stakeholders, including Federal agencies and the5918airlines in a very timely manner.5919    Senator Markey. You recommended the creation of an office5920in order to track and publicly report this data, and that has5921not happened.5922    Ms. Homendy. I don't think we recommended an office, but--5923--5924    Senator Markey. That was in the NTSB report, so I'll5925double-check on that, but that's how I read the report.5926    Ms. Homendy. We did mention an office about doing a safety5927management system review of Air Traffic Organization. That is5928one area that we did mention that we needed some work done.5929    Senator Markey. Thank you, Mr. Chairman, and we must pass5930this legislation. It's absolutely critical.5931    Ms. Homendy. Thank you.5932    The Chairman. Thank you, Chairwoman Homendy, for your5933testimony here today, and thank you for the hard work of your5934team who does a consistently excellent job.5935    Senators will have until the close of business on February593619 to submit questions for the record. The witnesses will have5937until close of business on March 5, to respond to those5938questions.5939    That concludes today's hearing. The Committee stands5940adjourned.5941    [Whereupon, at 12:19 p.m., the Committee was adjourned.]59425943                            A P P E N D I X59445945    Response to Written Questions Submitted by Hon. Jerry Moran to5946                         Hon. Jennifer Homendy5947    Question 1. As part of its investigation, the NTSB simulated the5948flight paths of American Airlines Flight 5342 and Priority Air5949Transport 25 with and without the most advanced position broadcast and5950traffic collision avoidance technologies, including ADS-B In-enabled5951Cockpit Display of Traffic Information--or ``CDTI''--and Airborne5952Collision Avoidance System X--or ``ACAS-X''--respectively. The5953investigation concluded that installation and use of ADS-B In--and the5954suite of more advanced cockpit alerting technologies it enables--would5955have provided the commercial jet with its first indication of the5956potential hazard posed by the helicopter nearly one minute before the5957collision, rather than just 19 seconds before the collision using older5958traffic collision avoidance technology. Similarly, the investigation5959concluded that the installation and use of ADS-B In and ADS-B In-5960enabled technologies would have provided the helicopter with its first5961indication of the hazard posed by the commercial jet 48 seconds before5962the collision. The NTSB's investigation attested to the difference that5963ADS-B In and ADS-B In-enabled technologies could have made in this5964circumstance. Would you elaborate on how installation and use of ADS-B5965and comparable technologies would impact air safety?5966    Answer. The NTSB has previously advocated for the FAA to require5967ADS-B In technology on the basis that equipping aircraft with ADS-B In5968capability would provide an immediate and substantial contribution to5969safety by enhancing pilot and flight crew situation awareness of5970surrounding traffic, especially near airports. Simulations using the5971circumstances of this accident reaffirm this conclusion and demonstrate5972the value of ADS-B In-derived traffic information in improving pilots'5973situation awareness and supporting earlier identification of potential5974traffic conflicts.5975    In this accident, the traffic alert (TA) that the flight 5342 crew5976received with the installed traffic alert and collision avoidance5977system (TCAS) consisted of the aural annunciation, ``Traffic,5978traffic,'' with the TCAS display simply depicting a yellow circle in5979front of the airplane. Information about the specific location of the5980traffic threat relative to the airplane was not announced, and the crew5981would have had to watch the TCAS display to determine the threat's5982relative position and direction of motion before visually scanning the5983appropriate area. Given the crew's high workload during final approach5984to land on runway 33 at the time they received the TCAS TA, they would5985have had limited capacity to look for and acquire the conflicting5986traffic. Notably, the crew of flight 5342 had not received any traffic5987information from the DCA local controller of the presence of PAT25 and5988were likely unaware of the presence and proximity of PAT25 until a few5989seconds before the collision.5990    The NTSB performed simulations using an ADS-B In application and a5991cockpit display of traffic information (CDTI) to determine how an ADS-5992B-based system would have performed in the accident scenario. The5993simulation indicated that the crew of flight 5342 would have received5994two alerts concerning PAT25 had it been equipped with such a system.5995The first aural and visual alert would have occurred 59 seconds before5996the collision, annunciating ``Traffic, 12 o'clock, low, 3 miles,5997descending.'' A second aural alert would have occurred 35 seconds5998before the collision, annunciating ``Traffic, 12 o'clock, low, 25999miles.'' These two alerts would have occurred 40 and 16 seconds,6000respectively, before the TCAS TA that the crew received before the6001collision, providing the crew with early awareness of proximate6002traffic, enhancing their situation awareness of the presence of PAT25.6003This enhanced situation awareness could have afforded an opportunity6004for the crew of flight 5342 to query the air traffic control local6005controller regarding the presence of PAT25.6006    Although TCAS TAs provide a verbal annunciation that a potential6007traffic conflict exists, the annunciations do not include the position6008and range of the target, requiring the pilot to first refer to the TCAS6009display inside the cockpit to determine the direction in which they6010need to direct their visual search. A TA indicating the clock position,6011relative altitude, range, and vertical tendency of nearby traffic would6012allow pilots to immediately direct their visual search in the proper6013direction outside the aircraft. The NTSB concludes that TA aural alerts6014that include additional information about the location of traffic could6015reduce the time pilots need to visually acquire target aircraft.6016Consequently, the NTSB recommended that the FAA modify airborne6017collision avoidance system (ACAS) aural alerts to include clock6018position, relative altitude, range, and vertical tendency (Safety6019Recommendation A-26-29 from the DCA investigation). The NTSB also6020recommended that the FAA require existing and new TCAS I, TCAS II, and6021ACAS X installations to integrate directional traffic symbols (A-26-602230).6023    We have investigated numerous midair collisions that occurred6024within controlled airspace or in which air traffic control was in6025contact with at least one of the involved aircraft. In many of these6026investigations, we noted that a CDTI--which may be part of the6027aircraft's installed avionics, such as on a dedicated navigation6028display or multifunction display, or that could be hosted on a portable6029device, such as a smartphone or tablet computer--with ADS-B In6030information would enhance pilots' situation awareness by providing6031information regarding traffic conflicts that may otherwise go6032undetected due to the numerous documented limitations of pilot-applied6033visual separation (the see-and-avoid concept). The circumstances of6034this accident illustrate that the additional information provided by an6035ACAS system supplemented with ADS-B In information, including alerts6036indicating the clock position, relative altitude, range, and vertical6037tendency of the other identified aircraft as well as directional6038traffic displays, further enhances the safety benefit provided by ACAS.6039For all pilots, ADS-B In information provided on a CDTI with alerting6040that is visible and audible to the pilot would provide critical6041situation awareness to help mitigate the risk of midair collisions. To6042take full advantage of the safety benefits provided by ADS-B, the NTSB6043recommends that the FAA require all aircraft operating in airspace6044where ADS-B Out is required to also be equipped with ADS-B In with a6045cockpit display of traffic information that is configured to provide6046alerting audible to the pilot or flight crew (Safety Recommendation A-604726-31). Additionally, to fully realize the benefit of ADS-B In, the6048NTSB recommended the following to FAA in our DCA investigation report:60496050   Require the use of the appropriate variant of airborne6051        collision avoidance system X on new production aircraft that6052        are subject to traffic alert and collision avoidance system6053        equipage regulations. (A-26-32)60546055   Require existing aircraft that are subject to traffic alert6056        and collision avoidance system equipage regulations be6057        retrofitted with the appropriate variant of airborne collision6058        avoidance system X. (A-26-33)60596060   Evaluate the feasibility of decreasing the traffic advisory6061        and resolution advisory inhibit altitudes in airborne collision6062        avoidance system Xa to enable improved alerting throughout more6063        of the flight envelope. (A-26-34)60646065   If the evaluation resulting from Safety Recommendation A-26-6066        34 finds that the inhibit altitudes can be safely decreased,6067        require retrofitting of the applicable airborne collision6068        avoidance system X variant incorporating the reduced traffic6069        advisory and resolution advisory inhibit altitudes on all6070        aircraft that are subject to traffic alert and collision6071        avoidance system and equipage regulations. (A-26-35)60726073   Require that all rotorcraft operating in Class B airspace be6074        equipped with airborne collision avoidance system (ACAS) Xr6075        technology once the ACAS Xr standard has been published. (A-26-6076        36)60776078    Question 2. Several of the NTSB's recommendations involve the6079installation and use of ADS-B In technology. Last year, the Senate6080unanimously passed the ROTOR Act, which Chairman Cruz and I and other6081members of this Committee introduced to address the precise gaps in air6082safety that the NTSB's identified. I believe that the ROTOR Act aligns6083precisely with many of the NTSB's recommendations, particularly as it6084relates to installation and use of ADS-B technology. Would you agree6085that the ROTOR Act represents a targeted and precise approach to6086improving the safety of the National Airspace System?6087    Answer. If enacted, FAA implementation of the requirements in the6088ROTOR Act would directly address 1 of 50 NTSB safety recommendations6089from the DCA midair collision investigation: Safety Recommendation A-609026-31, which recommends that the FAA require all aircraft operating in6091airspace where ADS-B Out is required to also be equipped with ADS-B In6092with a cockpit display of traffic information that is configured to6093provide alerting audible to the pilot and/or flight crew. The NTSB has6094long believed such equipage would immediately and substantially6095contribute to the safety of the National Airspace System (NAS),6096especially near airports. The ROTOR Act was introduced prior to the6097completion of our investigation, and does address long-standing NTSB-6098identified safety issues, but recipients must implement all 50 NTSB6099recommendations made in the final investigation report to address all6100the safety deficiencies identified in this investigation.61016102    Question 3. The NTSB concluded that one of the chief causes of this6103accident was a helicopter route that would have placed rotorcraft6104traversing it within 75 vertical feet, at most, of commercial traffic6105on approach to DCA's runway 33. Describe how the NTSB determined that6106this route presented such a problem to the safety of the airspace6107around DCA? Did the NTSB's investigation reveal why this route--and the6108problems it presented--was not addressed long before this collision?6109    Answer. Preliminary investigative findings of this accident6110revealed that, when flown at the recommended maximum altitude of 2006111ft, a helicopter operating over the eastern shoreline of the Potomac6112River on Helicopter Route 4 would have about 75 ft of vertical6113separation at maximum from an airplane approaching runway 33. This6114vertical separation decreases the farther west of the shoreline the6115helicopter is flown, or if the airplane is operating below the 3+6116visual glidepath provided by the runway 33 precision approach path6117indicator (PAPI).6118    In an urgent safety recommendation report published on March 11,61192025, we concluded that the separation distances between helicopter6120traffic operating on Route 4 and aircraft landing on runway 33 that6121existed at the time of the accident were insufficient and posed an6122intolerable risk to aviation safety by increasing the chances of a6123midair collision.6124    As a result of our findings, we issued an urgent safety6125recommendation to the FAA (Safety Recommendation A-25-1) asking the FAA6126to prohibit operations on Helicopter Route 4 between Hains Point and6127the Wilson Bridge when runways 15 and 33 were being used for departures6128and arrivals, respectively, at DCA. That recommendation has since been6129classified Closed--Exceeds Recommended Action.6130    Our investigation identified multiple factors resulting in the risk6131of midair collision between airplanes and helicopters at DCA remaining6132unmitigated. One factor was that the FAA Air Traffic Organization's6133data analysis, safety assurance, and risk assessment processes failed6134to recognize and mitigate the risk of collision, particularly when DCA6135air traffic controllers had previously voiced concern about near midair6136collision occurrences near DCA. We also found that multiple data6137sources provided evidence of midair collision risk between fixed-wing6138aircraft and helicopters at DCA, including on approach to runway 33,6139before this accident; however, the limited access to and use of6140available objective and subjective proximity data hindered industry and6141government stakeholders' ability to identify hazards and mitigate risk.6142Additionally, the FAA Air Traffic Organization's application of its6143safety management system (SMS) did not effectively coordinate safety6144assurance and safety risk management activities with external6145stakeholders in the airspace around DCA. As a result, we recommended6146that the Department of Transportation Office of Inspector General6147complete an audit of the FAA Air Traffic Organization's SMS functions6148and data-sharing activities at all air traffic control facilities and6149determine whether these activities are conducted in collaboration with6150all relevant external stakeholders (A-26-56). We also recommended the6151following to the FAA:61526153   Based on the results of the audit completed in accordance6154        with Safety Recommendation A-26-56, ensure that all SMS6155        functions and data-sharing activities at all air traffic6156        control facilities are conducted in collaboration with all6157        relevant external stakeholders. (A-26-39)61586159   Create an objective definition of close proximity encounter6160        and a public database of those encounters and their locations6161        that can be used to monitor their prevalence and identify areas6162        of potential traffic conflict for safety assurance and safety6163        risk management. (A-26-37)61646165   Develop and implement a process that will, in a timely6166        manner, notify involved parties after events such as near6167        midair collisions or traffic alert and collision avoidance6168        system resolution advisory activations, such that notification6169        occurs while relevant data remain available and before6170        meaningful safety analysis, reporting, or corrective action is6171        no longer practicable. (A-26-38)61726173    FAA Order JO 7210.3DD listed criteria and procedures for developing6174and modifying helicopter route charts. One of the listed criteria was6175that ``care should be exercised to avoid recommending altitudes or6176flight ceilings/floors which would cause helicopters operating on a6177designated route to encounter inflight wake turbulence generated by6178large, fixed-wing traffic.'' The order stated that Terminal Operations6179Service Area Directors were responsible for reviewing and approving new6180or revised helicopter route chart proposals and assuring that they6181complied with all prescribed criteria. These directors were also6182responsible for annually reviewing existing visual flight rule6183helicopter route charts to determine their accuracy and continued6184utility; however, the FAA was unable to provide documentation of the6185required annual reviews for the Baltimore-Washington Helicopter Route6186Chart, nor was the FAA able to identify who was responsible for6187conducting such annual reviews. As of the date of our final6188investigative report, no information has been provided regarding6189whether annual reviews have been conducted and, if so, what criteria6190were used in the review.6191    The NTSB concludes that annual reviews of helicopter route charts6192as required by FAA Order 7210.3DD would have provided an opportunity to6193identify the risk posed by the proximity of Route 4 to the runway 336194approach path, but there is no evidence to support that these reviews6195were being performed at DCA. The NTSB is concerned that the lack of6196documentation of annual reviews for the Baltimore-Washington Helicopter6197Route Chart may be an indication that these annual reviews are not6198occurring at other locations throughout the NAS. Therefore, the NTSB6199recommends that the FAA do the following:62006201   Ensure that annual reviews of helicopter route charts are6202        being conducted throughout the National Airspace System as6203        required by FAA Order. (A-26-24)62046205   Conduct a safety risk management process to evaluate whether6206        modifications to the remaining helicopter route structure in6207        the vicinity of Ronald Reagan Washington National Airport are6208        necessary to safely deconflict helicopter and fixed-wing6209        traffic and provide the results to the National Transportation6210        Safety Board. (A-26-25)62116212   Amend your helicopter route design criteria and approval6213        process to ensure that current and future route designs or6214        design changes provide vertical separation from airport6215        approach and departure paths. (A-26-26)62166217   Once the criteria and approval process referenced in Safety6218        Recommendation A-26-26, review all existing helicopter routes6219        to ensure alignment with these updated criteria. (A-26-27)62206221   Incorporate the lateral location and published altitudes of6222        helicopter routes onto all instrument and visual approach and6223        departure procedures to provide necessary situation awareness6224        to fixed-wing operators of the risk of helicopter traffic6225        operating in their vicinity. (A-26-28)62266227    Question 4. The NTSB faulted deficient data sharing practices6228across the FAA, Department of Defense, and aircraft operators, citing6229this breakdown as a contributing factor to the midair collision of6230January 29th, 2025. The ROTOR Act would require the Army Inspector6231General, as part of an audit of Army aviation, to assess the Army's6232coordination with the FAA. The bill would also establish or designate6233an office within the FAA called the Office of FAA-DOD Coordination.6234This Office would coordinate the military's airspace usage with6235relevant verticals within the FAA--including the Air Traffic6236Organization--make certain that employees are empowered to provide6237feedback--such as that raised about the dangerous airspace design near6238DCA--pursue improved aviation safety data sharing practices between6239civil and military airspace users and execute certain safety reviews.6240How would a dedicated FAA-DOD coordination apparatus like the one6241proposed in the ROTOR Act support improved aviation safety data6242sharing? Describe the significance of data sharing among all airspace6243users to aviation safety.6244    Answer. The NTSB investigation found that the FAA's lack of an6245established process to inform parties about their involvement in events6246such as near midair collisions or TCAS resolution advisories reduces6247the likelihood of fully understanding and mitigating future midair6248collision risk. While multiple data sources provided evidence of midair6249collision risk between airplanes and helicopters at DCA before this6250accident, limited access to this data hindered both industry and6251government stakeholders' ability to identify hazards and mitigate risk.6252The likelihood of detecting and mitigating these hazards and risks6253before accidents occur would be increased by improving stakeholder6254access to information about close proximity encounters for use in6255safety assurance processes. To collaborate effectively regarding these6256risks, the NTSB recommends that the FAA create an objective definition6257of close-proximity encounter and a public database of those encounters6258and their locations that can be used to monitor their prevalence and6259identify areas of potential traffic conflict for safety assurance and6260safety risk management (Safety Recommendation A-26-37). The NTSB also6261recommends that the FAA develop and implement a process that will, in a6262timely manner, notify involved parties after events such as near midair6263collisions or TCAS resolution advisories such that notification occurs6264while relevant data remain available and before meaningful safety6265analysis, reporting, or corrective action is no longer practicable6266(Safety Recommendation A-26-38). Additionally, we recommend that the6267FAA ensure that all SMS functions and data-sharing activities at all6268air traffic control facilities are conducted in collaboration with all6269relevant external stakeholders (including military NAS users; Safety6270Recommendation A-26-39).6271    The NTSB investigation found that the Army's safety reporting6272systems for pilots were not well utilized and did not provide the6273organization with information about close encounters between Army6274helicopters and other aircraft that were later found to have occurred6275frequently. As a result, the NTSB recommends that the Army survey its6276helicopter pilots to identify barriers to the utilization of flight6277safety reporting systems, to develop a plan to address the identified6278barriers, and to implement that plan across Army aviation units (Safety6279Recommendation A-26-46).62806281    Question 5. The NTSB, and this Committee, have attested to the6282importance of widespread adoption of ADS-B In technology and its6283importance to improving safety. How does the NTSB view comparable and6284complementary technologies--including, for example, ACAS-X or hybrid6285TCAS--that can also utilize ADS-B data to the benefit of aviation6286safety?6287    Answer. Many technologies contribute to aviation safety, and the6288NTSB's analysis and recommendations in response to the catastrophe at6289DCA address multiple collision avoidance technologies, including TCAS6290I, TCAS II, ACAS-X, and ADS-B In and Out. The NTSB's overarching6291concern in relation to each of these technologies is to ensure that, on6292all aircraft operating in high traffic airspace, they are equipped;6293operating properly; configured in such a way as to provide alerts6294audible to the pilot and flight crew in their operating environment;6295that such alerts to the pilot and flight crew include the clock6296position, relative altitude, range, and vertical tendency of the other6297identified aircraft; and that cockpit displays of traffic information6298integrate directional traffic symbols. In short, we believe pilots and6299flight crews should have ready access to the fullest possible dataset6300when identifying other traffic in their airspace.6301    Our recommendations from the DCA investigation to the FAA on these6302technologies include the following:63036304   Modify airborne collision avoidance system traffic advisory6305        aural alerts to include clock position, relative altitude,6306        range, and vertical tendency. (A-26-29)63076308   Require existing and new traffic alerting and collision6309        avoidance system (TCAS) I, TCAS II, and airborne collision6310        avoidance system X installations to integrate directional6311        traffic symbols. (A-26-30)63126313   Require all aircraft operating in airspace where Automatic6314        Dependent Surveillance--Broadcast (ADS-B) Out is required to6315        also be equipped with ADS B In with a cockpit display of6316        traffic information that is configured to provide alerting6317        audible to the pilot and/or flight crew. (A-26-31)63186319   Require the use of the appropriate variant of airborne6320        collision avoidance system X on new production aircraft that6321        are subject to traffic alert and collision avoidance system6322        equipage regulations. (A-26-32)63236324   Require existing aircraft that are subject to traffic alert6325        and collision avoidance system equipage regulations be6326        retrofitted with the appropriate variant of airborne collision6327        avoidance system X. (A-26-33)63286329   Evaluate the feasibility of decreasing the traffic advisory6330        and resolution advisory inhibit altitudes in airborne collision6331        avoidance system Xa to enable improved alerting throughout more6332        of the flight envelope. (A-26-34)63336334   If the evaluation resulting from Safety Recommendation A-26-6335        34 finds that the inhibit altitudes can be safely decreased,6336        require retrofitting of the applicable airborne collision6337        avoidance system X variant incorporating the reduced traffic6338        advisory and resolution advisory inhibit altitudes on all6339        aircraft that are subject to traffic alert and collision6340        avoidance system and equipage regulations. (A-26-35)63416342   Require that all rotorcraft operating in Class B airspace be6343        equipped with airborne collision avoidance system (ACAS) Xr6344        technology once the ACAS Xr standard has been published. (A-26-6345        36)63466347    NTSB recommendations to the Department of War Policy Board on6348Federal Aviation include:63496350   Require the Department of War to verify on all aircraft with6351        transponders capable of transmitting Mode S and Automatic6352        Dependent Surveillance--Broadcast (ADS-B) and operated in the6353        NAS, at least annually and upon each aircraft's entry into6354        service in the NAS, that 1) the transponder ADS-B settings are6355        correct, 2) the transponder is transmitting ADS-B, and 3) the6356        transponder is transmitting the correctly assigned address. (A-6357        26-51)63586359   Require armed services to amend their operational procedures6360        to allow flight crews to enable Automatic Dependent6361        Surveillance--Broadcast Out while in flight. (A-26-52)63626363   Require all military aircraft operating in the National6364        Airspace System (NAS) be equipped with Automatic Dependent6365        Surveillance--Broadcast (ADS-B) In with a cockpit display of6366        traffic information that is configured to provide alerting6367        audible to the pilot and/or flight crew, and that such6368        requirement apply wherever in the NAS the Federal Aviation6369        Administration requires any aircraft to operate with ADS-B Out.6370        (A-26-53)63716372    The NTSB also issued one related recommendation to the RTCA Program6373Management Committee, as follows:63746375   Finalize and publish the minimum operational performance6376        standards for airborne collision avoidance system Xr for6377        rotorcraft. (A-26-57)63786379    Question 6. Last year, I introduced the Aviation Funding Stability6380Act, which would allow the FAA to draw from the Airport and Airway6381Trust Fund to continue operating when appropriations lapse.6382Importantly, my legislation would also make certain that controllers6383get paid in the event of a shutdown. Many experts have emphasized that6384consistent and uninterrupted funding for the FAA is essential for6385maintaining and promoting a safe and efficient National Airspace6386System. Would you agree that stable funding for the FAA would enhance6387the safety and reliability of our National Airspace System?6388    Answer. Stable funding for the FAA and the NTSB would enhance the6389safety and reliability of our national airspace. The NTSB needs6390authorization to operate when appropriations lapse, and the NTSB urges6391you to consider that. When an accident occurs, it is incumbent upon the6392NTSB to take action immediately to prevent further tragedies in our6393airspace; that action can't wait for appropriations and continuing6394resolutions.6395                                 ______63966397   Response to Written Questions Submitted by Hon. Maria Cantwell to6398                         Hon. Jennifer Homendy6399    NTSB Recommendations for Air Traffic Control. It's clear Congress6400should swiftly pass the ROTOR Act so that the FAA must begin6401implementing many of the key requirements we discussed during the6402hearing. However, that does not mean our work stops there. Several of6403the NTSB's findings and recommendations related to the FAA providing6404air traffic controllers with proper training and support should be6405considered in additional legislation.64066407    Question 1. One of these recommendations says the FAA should6408develop new annual training for controllers on how to better manage6409scenario-based threats and decision-making in high stress situations.6410How would this annual training improve controllers' ability to identify6411and mitigate safety risks?6412    Answer. In November 2016, the NTSB issued Safety Recommendation A-641316-51, asking the FAA to provide initial and recurrent training for air6414traffic controllers on controller judgment, vigilance, and/or safety6415awareness with specific reference to two midair collisions that6416occurred in 2015 to be used as case studies. The FAA responded that, in6417July 2017, it instructed controllers on threat and error management (or6418TEM, which the FAA described as the practice of applying controller6419judgment, vigilance, and safety awareness) as part of instructor-led6420recurrent training and stated that the training would also be required6421for future controllers. The FAA stated that it delivered a web-based6422``Emergencies'' training in July 2017 to highlight accidents similar to6423the two midair collisions cited in the recommendation. After reviewing6424this training, the NTSB determined that the materials did not highlight6425the safety issues identified in the 2015 midair accidents, nor did the6426training discuss those or similar accidents, as recommended. When the6427FAA indicated that it did not plan to take further action, Safety6428Recommendation A-16-51 was classified Closed--Unacceptable Action in64292023.6430    A vast majority of the time, controllers perform very effectively6431and reliably; however, human vulnerabilities such as fatigue, increased6432workload, time pressure, and biases can increase errors. A controller's6433ability to anticipate, detect, and mitigate risks is essential. TEM6434provides a strategy to combat these vulnerabilities. TEM is a process6435for identifying safety risks--threats, errors, and undesired states--in6436the environment and mitigating those risks.6437    The controllers involved in this accident stated they were not6438familiar with the term ``threat and error management'' during6439postaccident interviews, nor were they familiar with the concepts that6440would be included in such training, suggesting that they did not6441receive training on this method of safety management. The NTSB6442requested, and received, controller training materials related to6443identifying and mitigating risk. This material did not reveal any6444formal TEM training other than the 2017 workshop, and there was no6445evidence to indicate that the workshop or the subject matter it6446contained had been offered in any training since 2017.6447    Adequate TEM training can strengthen situation awareness by6448teaching controllers to continuously monitor their environment to more6449quickly identify threats; promote team communication to ensure that6450communications are clear, timely, and assertive; emphasize effective6451scanning habits; recognize patterns in the development of adverse6452events; and enhance decision-making under stress by developing habits6453that balance procedural compliance with problem solving to mitigate the6454risks of threats and errors. TEM would have likely improved all6455controllers' situation awareness in this event, which may have allowed6456for earlier conflict recognition or encouraged the operations6457supervisor (OS) to conduct a risk assessment of the steady helicopter6458traffic and its resulting workload on the local control (LC) and6459assistant local control (ALC) controllers.6460    The NTSB continues to believe that including case studies in6461initial and annual air traffic controller training and highlighting6462situations in which controller judgment, vigilance, and safety6463awareness could be improved would enhance controllers' ability to6464identify and manage threats and errors. FAA guidance on the use of good6465judgment is vague, and case studies provide the opportunity to examine6466a real chain of events that had resulted in an accident, imparting6467valuable lessons without exposing participants to the potential risk of6468adverse outcomes inherent to on-the-job training, which the FAA often6469relies upon for controller training. The NTSB also believes that6470providing controllers the opportunity to discuss and practice applying6471TEM using scenario-based training is critical, as repeating skills6472through training leads to behavioral automaticity, thus freeing up6473working memory. Automaticity has been demonstrated to improve speed and6474accuracy, situation awareness, and decision-making The NTSB6475investigation found that initial and recurrent scenario-based training6476in threat and error management would help controllers identify and6477mitigate risks and strengthen situation awareness. Accordingly, the6478NTSB recommends that the FAA develop instructor-led, scenario-based6479training on threat and error management that trains controllers to6480continuously monitor their environment to more quickly and accurately6481identify threats; promote team communication to ensure that6482communications are clear, timely, and assertive; emphasize effective6483scanning habits; recognize patterns in the development of adverse6484events; and enhance decision-making under stress by developing habits6485that balance procedural compliance with problem solving to mitigate the6486risks of threats and errors, and provide this training to all air6487traffic controllers annually (Safety Recommendation A-26-9).64886489    Question 2. In the FAA Reauthorization law, we required FAA to6490deploy advanced tower simulation systems nationwide to help train6491controllers to prevent near misses. Should FAA use these systems for6492this new annual training?6493    Answer. Yes.64946495    Question 3. Other key recommendations call for FAA to implement6496more useful alerts for controllers that better flag the severity of6497issues triggering the alert, and to install technology in towers to6498alert controllers when their transmissions have been blocked. If6499implemented, how would these safety recommendations have mitigated6500risks and prevented the strained conditions at DCA Tower that6501contributed to the accident?6502    Answer. The current conflict alerts (CA) system operates in the6503same manner regardless of the algorithm that triggered the alert. In6504the absence of any salient information conveying the severity of the6505conflict, controllers must determine on their own if the conflict alert6506requires immediate action, thus increasing the controller's cognitive6507load. Available improvements to the CA software could provide color6508coding or various aural alerts, depending on which conflict alert6509algorithms were activated. Providing controllers with additional6510salient cues regarding the perceived severity of a potential conflict6511would reduce controller cognitive load and would likely improve6512reaction time to the most critical conflict alerts.6513    Regarding blocked radio transmissions, the very high frequency6514(VHF) radio communications used by air traffic control do not allow for6515simultaneous transmissions. If a pilot or controller attempts to6516broadcast on the same frequency at the same time as another pilot, one6517or both transmissions may be garbled, incomplete, or blocked from6518reception entirely. This leads to missed control instructions, lack of6519clarity, loss of situation awareness, or readback errors; however,6520there is currently no system in use that allows controllers to know6521when a simultaneous broadcast has occurred.6522    Antiblocking technology would alert controllers and/or flight crews6523to potentially blocked transmissions when simultaneous broadcasting6524occurs.65256526    Strong ADS-B In Performance Standard. It's crucial for the safety6527of the flying public that aviation operators, especially the commercial6528passenger fleet--which moves over 2 million passengers each day, are6529equipped with ADS-B In technology, and not alternatives that don't6530deliver on safety.6531    Importantly, not every type of ADS-B In performs the same way and6532delivers the same benefits. That's why our bipartisan DCA safety6533legislation requires ADS-B In that boosts situational awareness for6534pilots and delivers real-time traffic advisories and alerts to ensure a6535robust additional layer of safety on the flight deck.65366537    Question 1. What are the benefits of pilots having ADS-B In that is6538integrated with avionics on the flight deck?6539    Answer. The NTSB has previously advocated for the FAA to require6540ADS-B In technology because equipping aircraft with ADS-B In capability6541would immediately and substantially contribute to safety, especially6542near airports. Simulations using the circumstances of this accident6543reaffirm this conclusion and demonstrate the value of ADS-B In-derived6544traffic information in improving pilots' situation awareness and6545supporting earlier identification of potential traffic conflicts.6546Pilots and flight crews (not the airplane) need to receive the rich6547alerting information, including cockpit displays of traffic information6548with directional traffic symbols and audible traffic and resolution6549advisories.6550    In this accident, the TA that the flight 5342 crew received6551consisted simply of the annunciation, ``Traffic, traffic.'' No6552information about the location of the traffic threat relative to the6553airplane was annunciated, and the crew would have had to refer to the6554TCAS display to determine the relative position of the threat before6555visually scanning in the appropriate area. Given the crew's high6556workload at the time they received the TA, it is unlikely that they6557performed a focused visual search for the helicopter at this time.6558    The NTSB performed a simulation to determine how an ADS-B-based6559system capable of providing alerts would have performed in the accident6560scenario. The simulation indicated that the crew of flight 5342 would6561have received two alerts concerning PAT25 had it been equipped with6562such a system. The first aural and visual alert would have occurred 596563seconds before the collision, annunciating ``Traffic, 12 o'clock, low,65643 miles, descending.'' A second aural alert would have occurred 356565seconds before the collision, annunciating ``Traffic, 12 o'clock, low,65662 miles.'' These two alerts would have occurred 40 and 16 seconds,6567respectively, before the TCAS TA that the crew received before the6568collision, providing the crew with additional awareness of the6569helicopter.6570    Although TCAS TAs provide a verbal annunciation that a potential6571traffic conflict exists, these annunciations do not include the6572target's position and range, requiring the pilot to first refer to the6573TCAS display inside the cockpit to determine the direction in which6574they need to direct their visual search. A TA indicating the clock6575position, relative altitude, range, and vertical tendency of nearby6576traffic would allow pilots to immediately direct their visual search in6577the proper direction outside the aircraft. The NTSB concludes that TA6578aural alerts that include additional information about the location of6579traffic could reduce the time pilots need to visually acquire target6580aircraft. Consequently, the NTSB has also recommended that the FAA6581modify airborne collision avoidance system (ACAS) TA aural alerts to6582include clock position, relative altitude, range, and vertical tendency6583(Safety Recommendation A-26-29).6584    The circumstances of this accident illustrate that the additional6585information provided by an ACAS system supplemented with ADS-B In6586information, including alerts and directional traffic displays, further6587enhances the safety benefit provided by ACAS. For all pilots, ADS-B In6588information on a CDTI with alerting that is audible to the pilot would6589provide critical situation awareness to help mitigate the risk of6590midair collisions, even if an aircraft is not equipped with an ACAS. To6591take full advantage of the safety benefits provided by ADS-B, the NTSB6592recommends that the FAA require all aircraft operating in airspace6593where ADS-B Out is required to also be equipped with ADS-B In with a6594cockpit display of traffic information that is configured to provide6595alerting audible to the pilot and/or flight crew (Safety Recommendation6596A-26-31).65976598    Question 2. Do you agree that ADS-B In that is integrated with an6599aircraft's avionics on the flight deck would provide the strongest6600safety benefit for commercial passenger flights?6601    Answer. Improving pilots' situation awareness of surrounding6602traffic and potential traffic conflicts in busy airspace, such as near6603airports, is important for preventing midair collisions. Ensuring6604pilots receive effective aural and visual alerts to potential traffic6605conflicts enhances safety. Having a CDTI that uses ADS-B data to show6606surrounding traffic, and its directionality increases pilots' awareness6607of the movements of nearby traffic. The information provided to the6608pilot is equally, if not more important than the method of display.6609Therefore, the NTSB recommended that the FAA require all aircraft6610operating in airspace where ADS-B Out is required to also be equipped6611with ADS-B In with a CDTI that is configured to provide alerting6612audible to the pilot and/or flight crew.6613    For currently installed airborne collision avoidance systems on6614commercial passenger aircraft, the traffic display may only show a6615nondirectional target, requiring pilots to watch the display to infer6616the direction of movement of the traffic target relative to their own6617aircraft. Using ADS-B data to show the directionality of surrounding6618traffic provides more timely information to help pilots determine if6619certain targets may become collision threats. The NTSB recommended that6620the FAA require existing and new airborne collision avoidance system6621installations to integrate directional traffic symbols (Safety6622Recommendation A-26-30). Additionally, ensuring that aural alerts to6623potential traffic conflicts can be both heard by the pilots and contain6624additional information about the location of traffic, such as clock6625position and distance, could reduce the time pilots need to visually6626acquire these targets before they become a collision threat. Therefore,6627NTSB recommended that the FAA modify aural alerts in airborne collision6628avoidance systems (ACAS) to include clock position, relative altitude,6629range, and vertical tendency (Safety Recommendation A-26-29).6630    By adding directional traffic symbols and information-rich aural6631alerting into an installed ACAS, information would be immediately6632available to pilots in their normal visual scan of cockpit instruments6633and flight displays, pilot situation awareness of surrounding traffic6634would be enhanced, and the time for pilots to visually acquire a6635potential traffic conflict would be reduced, providing a strong safety6636benefit by preventing midair collisions.66376638    Question 3. Do you agree that ADS-B In technology and ACAS-X6639technology are two separate technologies with different capabilities?6640    Answer. ACAS-X (including ACAS-Xa and ACAS-Xr) is a family of6641technologies intended to serve as a successor to TCAS technologies.6642ACAS-X technology is intended to include, and have the capabilities to6643utilize, ADS-B data (referred to as ``ADS-B In'') as an integrated6644feature of the ACAS-X system. ACAS-X also receives information about6645nearby aircraft by interrogating their transponders. ACAS-X uses these6646data to provide both traffic advisories and resolution advisories.6647However, ADS-B In may also be utilized on aircraft without ACAS-X6648systems via other technologies. For example, a general aviation6649airplane may be equipped with a portable ADS-B receiver and a tablet6650that receives ADS-B data from the receiver to display information about6651surrounding traffic and alert the pilot of potential traffic conflicts.66526653    Question 4. If so, do you agree that ACAS-X is not an alternative6654means of compliance to NTSB's recommendations on ADS-B In issued in6655response to the Board's investigation of the January 29, 2025 mid-air6656collision near DCA?6657    Answer. ACAS-X uses ADS-B and interrogator data. If Congress is6658concerned, it should charge the FAA with mandating the use of that data6659and ACAS-X and ACAS-Xr.6660Limitations of Collision Avoidance Technologies.6661    Question 1. Do you agree that collision avoidance technologies like6662TCAS and ACAS-X depend on ADS-B In data for maximum performance and6663safety benefits?6664    Answer. Yes.6665    Older generation ACAS technologies typically do not leverage ADS-B6666data; however, newer technologies, such as ACAS-X, do use ADS-B In data6667for optimal performance.6668    In addition, although a TCAS display does depict traffic targets, a6669pilot must monitor the display over time to determine in what direction6670the target is moving. By leveraging ADS-B In traffic information, an6671ACAS display can depict the ground track of traffic targets, increasing6672pilots' awareness of the movements of nearby traffic and providing more6673timely information to help a pilot determine if a target may become a6674collision threat.66756676    Question 2. Do you agree that ADS-B In provides pilots with better6677situational awareness at lower altitudes where Traffic Alert and6678Collision Avoidance System (TCAS) does not activate?6679    Answer. Pilots using ADS-B In have improved situation awareness,6680especially when integrated with ACAS. Currently, TCAS I or II is only6681required for about 4 percent of aircraft registered in the United6682States. For the other 96 percent, there is a gap in regulations that6683ADS-B In would fill.6684    The circumstances of this accident illustrate that the additional6685information provided by an ACAS supplemented with ADS-B In information,6686including ADS-B alerts and directional traffic displays, further6687enhance the safety benefit provided by ACAS. For all pilots, ADS-B In6688information provided on a CDTI with alerting that is audible and6689visible to the pilot would provide critical situation awareness to help6690mitigate the risk of midair collisions, even if their aircraft are not6691equipped with an ACAS.6692    To take full advantage of the safety benefits provided by ADS-B,6693the NTSB recommends that the FAA require all aircraft operating in6694airspace where ADS-B Out is required to also be equipped with ADS-B In6695with a CDTI that is configured to provide alerting audible to the pilot6696and/or flight crew. To provide the same situation awareness advantages6697to military flight crews, the NTSB recommends that the Department of6698War require all military aircraft operating in the NAS be equipped with6699ADS-B In with a CDTI that is configured to provide alerting audible to6700the pilot and/or flight crew, and that such requirement apply wherever6701in the NAS the FAA requires any aircraft to operate with ADS-B Out.67026703    Question 3. In NTSB's view, why should FAA require aircraft6704operating in busy airspace to fly with both safety enhancing ADS-B In6705and ACAS-X? What is the safety benefit to pilots by having both of6706these technologies while flying in busier airspace?6707    Answer. ADS-B In is required as an input of surveillance data to6708ACAS-X systems for TSO certification; however, if ADS-B In data are6709invalid, ACAS-X systems can still alert by using the other surveillance6710input, which is transponder interrogations and replies. Per the minimum6711operational performance standards, ACAS-X uses ADS-B information for6712optimal performance.6713Clear Timeline for ADS-B In Requirement.6714    Question 1. Do you agree with how the ROTOR Act sets a clear6715compliance date for aviation operators to equip with safety enhancing6716ADS-B In? How will this help ensure aviation safety benefits can be6717delivered in a timely manner to pilots across the National Airspace6718System?6719    Answer. The Board's longstanding position is that the FAA should6720require ADS-B In as soon as possible. A clear, definitive deadline for6721compliance would provide certainty and accountability for the FAA and6722industry to move forward to implementation as soon as possible. We are6723concerned that negotiating rulemaking could water down the final rule.67246725    Question 2. How would a clear compliance date for operators to6726equip with ADS-B In help foster regulatory certainty for the aviation6727industry?6728    Answer. As noted above, a clear, definitive deadline for compliance6729would provide certainty and accountability for the FAA and industry to6730move forward to implementation as soon as possible.6731Aircraft Separation and Pilot Workload.6732    Question 1. In your estimation is ADSB-In primarily a safety6733technology to improve pilot situational awareness?6734    Answer. ADS-B is a data source that can be used by numerous6735technologies. The NTSB has previously advocated for the FAA to require6736ADS-B In technology because equipping aircraft with ADS-B In capability6737would immediately and substantially contribute to safety, especially6738near airports. The NTSB has investigated numerous midair collisions6739that occurred within controlled airspace or in which air traffic6740control was in contact with at least one of the aircraft involved. In6741many of these investigations, the NTSB noted that a cockpit display of6742traffic information with ADS-B In information would enhance pilots'6743situation awareness by providing information on surrounding traffic as6744well as alerting to traffic conflicts that augment the pilots' see-and-6745avoid task. In these accidents, the investigation found that these6746conflicts went undetected, which confirms the numerous documented6747limitations of see-and-avoid.67486749    Question 2. Would you have concerns with efforts to use ADSB-In to6750transfer primary responsibility for separation and traffic flow6751throughput from air traffic controllers to pilots?6752    Answer. This is beyond the scope of our investigation.67536754    Question 3. Would transferring primary responsibility for6755separation to pilots create higher pilot workloads and human factors6756issues for pilots in en route and terminal areas? Do you see this6757posing any issue for air traffic controllers who are exercising6758positive control of separation?6759    Answer. This is beyond the scope of our investigation.67606761    Army Safety Management System. The investigative record indicates6762the Army's aviation safety system failed to consistently detect and act6763on altimeter altitude exceedances and other operational factors6764concerning Army aviation flights in the National Capitol Region6765environment.67666767    Question 1. On top of ensuring an effective safety management6768system at the Army, what structural safety management changes should6769Congress require from the military to prevent future mismanagement of6770safety risks?6771    Answer. The NTSB issued eight safety recommendations to the U.S.6772Army as part of our DCA investigation.67736774   Revise training procedures for flight crews assigned to6775        operate in the Washington, DC, area to ensure that they receive6776        initial and recurrent training on fixed-wing operations at6777        Ronald Reagan Washington National Airport, including approach6778        and departure paths, runway configurations, and the interaction6779        of those traffic flows with published helicopter routes. (A-26-6780        41)67816782   Develop and implement a recurring procedure, at an interval6783        not to exceed 18 months, to verify the continued accuracy of6784        recorded flight data. (A-26-42)67856786   Incorporate information within the appropriate operator's6787        manual for all applicable aircraft on the potential total error6788        allowed by design that could occur in flight on an otherwise6789        airworthy barometric altimeter, including the increased6790        position error associated with the external stores support6791        system configuration. (A-26-43)67926793   Develop and implement a transponder inspection procedure on6794        all aircraft with transponders capable of transmitting Mode S6795        and Automatic Dependent Surveillance--Broadcast (ADS-B) and6796        operated in the National Airspace System (NAS), at least6797        annually and upon each aircraft's entry into service in the6798        NAS, that ensures 1) the transponder ADS-B settings are6799        correct, 2) the transponder is transmitting ADS B, and 3) the6800        transponder is transmitting the correctly assigned address. (A-6801        26-44)68026803   Establish a flight data monitoring program for rotary-wing6804        aircraft the U.S. Army operates in the National Airspace6805        System. (A-26-45)68066807   Survey U.S. Army helicopter pilots to identify barriers to6808        the utilization of flight safety reporting systems, develop a6809        plan to address the identified barriers, and implement that6810        plan across Army aviation units. (A-26-46)68116812   Revise the method for allocating resources to ensure the6813        development of a robust safety management system that will, at6814        a minimum, identify and monitor the potential for midair6815        collisions between Army aircraft and civil air traffic6816        operating in the National Airspace System. (A-26-47)68176818   Develop and maintain a flight safety management capability6819        that is independently resourced and functionally separate from6820        its occupational and environmental health management system,6821        and ensure that this capability is both culturally and6822        functionally integrated with units conducting sustained flight6823        operations in the National Airspace System. (A-26-48)6824                                 ______68256826  Response to Written Questions Submitted by Hon. Tammy Duckworth to6827                         Hon. Jennifer Homendy6828Question Topic: Improving Aviation Safety Across the National Airspace6829        System6830    Question 1. The National Transportation Safety Board (NTSB) report6831on the DCA Midair Collision issued dozens of recommendations. Which of6832the recommendations from the report would make the most significant6833impact on aviation safety if implemented across the entire National6834Airspace System?6835    Answer. Every one of the NTSB's 50 recommendations in response to6836the DCA tragedy is crucial and, if implemented, will help save lives.68376838    Question 2. The Federal Aviation Administration (FAA) is in the6839process of a $32.5 billion overhaul of the air traffic control (ATC)6840system.68416842    A. To date, the FAA has focused on upgrading equipment as a key6843pillar in the Brand New Air Traffic Control System (BNATCS). However,6844as the NTSB report showed, Terminal Radar Approach Control controllers6845repeatedly overrode DCA tower controllers, increasing the strain on the6846system. Management failed to appropriately address the issue. An6847overhaul of the ATC system does not only require new equipment, but6848significant change to the safety culture. What recommendations does the6849NTSB have to ensure the BNATCS addresses deeper cultural issues that6850contribute to strain on the system?6851    Answer. Numerous recommendations from the DCA final report call for6852ATC reforms related to operational practices, safety culture, and6853technology, including those listed below. Broadly, the FAA must ensure6854controllers are properly trained and supported by effective management6855practices, effective procedures, and the best available technology.68566857   To the FAA: Develop and implement time-on-position6858        limitations for supervisory air traffic control personnel,6859        including guidance for district and facility level management6860        to adapt these limitations to account for their own staffing6861        and local standard operating procedures. (A-26-08)68626863   To the FAA: Develop instructor-led, scenario-based training6864        on threat and error management that trains controllers to6865        continuously monitor their environment to more quickly and6866        accurately identify threats; promote team communication to6867        ensure that communications are clear, timely, and assertive;6868        emphasize effective scanning habits; recognize patterns in the6869        development of adverse events; and enhance decision-making6870        under stress by developing habits that balance procedural6871        compliance with problem solving to mitigate the risks of6872        threats and errors, and provide this training to all air6873        traffic controllers annually. (A-26-09)68746875   To the FAA: Develop and implement a risk assessment tool for6876        supervisors that incorporates the principles of threat and6877        error management to assist in risk identification, mitigation,6878        and operational decision making. (A-26-10)68796880   To the FAA: Define objective criteria for the determination6881        of air traffic facility levels considering traffic and airspace6882        volume, operational factors unique to each facility, and cost6883        of living. (A-25-15)68846885   To the FAA: Using the criteria established by Safety6886        Recommendation A-26-15, determine whether the classification of6887        the Ronald Reagan Washington National Airport's air traffic6888        control tower as a level 9 facility appropriately reflects the6889        complexity of its operations. (A-26-16)68906891   To the FAA: Develop a new and comprehensive instructor-led,6892        scenario-based training on the proper use of visual separation,6893        both tower-and pilot-applied. This training should include6894        information on the inherent limitations of see and avoid,6895        responsibilities when applying visual separation, and guidance6896        for controllers on factors, such as current traffic volume,6897        workload, weather or environmental factors, experience, and6898        staffing, that should be considered when applying visual6899        separation. Require this training for all controllers and6900        include on a recurrent basis thereafter in annual simulator6901        refresher training. (A-26-17)69026903   To the FAA: Conduct a comprehensive evaluation, in6904        conjunction with local operators, to determine the overall6905        safety benefits and risks to requiring all aircraft to use the6906        same frequency when the helicopter and local positions are6907        combined in the Ronald Reagan Washington National Airport air6908        traffic control tower. (A-26-18)69096910   To the FAA: Implement anti-blocking technology that will6911        alert controllers and/or flight crews to potentially blocked6912        transmissions when simultaneous broadcasting occurs. (A-26-19)69136914   To the FAA: Develop and implement improvements to the6915        conflict alert system to provide more salient and meaningful6916        alerts to controllers based on the severity of the conflict6917        triggering the alert. (A-26-20)69186919   To the FAA: Once the improvements to the conflict alert6920        system discussed in Safety Recommendation A-26-20 are6921        implemented, provide training to controllers on its use. (A-26-6922        21)69236924   To the FAA: Revise the Air Traffic Organization's initial6925        event response procedures so that an appropriate on-site6926        supervisor makes each postaccident and postincident drug and6927        alcohol testing determination, based on their assessment of6928        whether the event meets testing criteria and which controllers6929        had duties pertaining to the involved aircraft, without needing6930        to wait for investigation or approval. (A-26-22)69316932   To the FAA: At least annually, provide training on the6933        revised postaccident and postincident drug and alcohol testing6934        determination procedure discussed in Safety Recommendation A-6935        26-22 to all staff who have responsibilities under that6936        procedure; this training should include a post-learning6937        knowledge assessment. (A-26-23)69386939   To the FAA: Establish a requirement across all air traffic6940        control tower standard operating procedures that the operations6941        supervisor (OS) or controller-in-charge (CIC) document in the6942        daily facility log when any control position is combined with6943        the local control position, or when the OS/CIC position is6944        combined with a control position, along with a rationale for6945        doing so. (A-26-40)69466947   To the Department of Transportation (DOT): Require the6948        Federal Aviation Administration to demonstrate at least6949        annually that each air traffic control facility it operates has6950        the routine capability to accomplish required postaccident and6951        postincident drug and alcohol testing within the U.S.6952        Department of Transportation's specified timeframes of 2 hours6953        for alcohol and 4 hours for drugs, and implement a process to6954        ensure that any facility without such capability will6955        demonstrate timely remediation. (A-26-54)69566957   To the DOT: Work with the Federal Aviation Administration6958        (FAA) Administrator to convene an independent panel to conduct6959        a comprehensive review of the safety culture within the FAA's6960        Air Traffic Organization (ATO), and use the findings to enhance6961        the ATO's existing safety management system and integrate it6962        into all levels of the organization. (A-26-55)69636964   To the DOT Office of the Inspector General: Complete an6965        audit of the Federal Aviation Administration (FAA) Air Traffic6966        Organization's safety management system functions and data6967        sharing activities at all air traffic control facilities and6968        determine whether these activities are conducted in6969        collaboration with all relevant external stakeholders, ensuring6970        that the audit's results are documented, reported to the6971        Secretary of Transportation and the FAA Administrator, and made6972        available to the public. (A-26-56)69736974    B. How can the FAA more broadly implement the recommendations in6975the report to improve the ATC system through its ongoing effort to6976modernize?6977    Answer. The FAA needs to implement every recommendation resulting6978from this investigation. Safety recommendations from this investigation6979regarding the ATC system would work together with our other6980recommendations to the FAA to ensure the FAA is building safeguards at6981multiple levels of operations to prevent future tragedies.69826983    C. What would be an appropriate timeline for the implementation of6984recommendations that address ATC?6985    Answer. Many NTSB recommendations on ATC from the DCA report could6986be acted upon immediately by the FAA. The NTSB designates parties to an6987investigation so they can take early action to improve safety, and the6988FAA is mandated to be a party to all our aviation investigations. The6989agency has access to all the factual information we do, and it should6990have taken action even before we issued our final recommendations in6991this report.69926993    Question 3. If passed into law, the ROTOR Act would codify many of6994the NTSB recommendations from the NTSB's report. However, there is work6995to be done beyond the ROTOR Act.69966997    A. What key issues are not addressed by the ROTOR Act?6998    Answer. The ROTOR Act would address 1 of 50 NTSB safety6999recommendations from our DCA investigation--Safety Recommendation A-26-700031, which calls on the FAA to require all aircraft operating in7001airspace where Automatic Dependent Surveillance--Broadcast (ADS-B) Out7002is required to also be equipped with ADS-B In with a cockpit display of7003traffic information that is configured to provide alerting audible to7004the pilot and/or flight crew. The ROTOR Act does not address many other7005safety recommendations from the NTSB's DCA investigation, nor was it7006originally intended to. All 50 safety recommendations made in response7007to the DCA tragedy are key to improving safety in the NAS and must be7008implemented.70097010    B. What are the top ten NTSB recommendations beyond the ROTOR Act7011to improve aviation safety and create more redundancy in the system?7012    Answer. Every one of the NTSB's 50 safety recommendations in7013response to the DCA tragedy would improve safety and should be acted on7014immediately.7015Question Topic: FAA and Department of Defense (DoD) Coordination7016    Question 1. The NTSB recommendations include multiple areas for7017improved information sharing between the FAA and DoD. After the DCA7018Collision, there were still several close calls and loss of separation7019events between military and civilian aircraft in the National Airspace7020System.70217022    A. Please provide a list of events that the NTSB has investigated7023or is currently investigating that involve both the FAA and the DoD.7024    Answer. The following Aviation Safety Investigations in the NAS7025since 2001 have also included a branch of the U.S. Armed Services as a7026party:70277028   MIA01GA070--Marathon, FL--Coast Guard airplane collision7029        with water70307031   LAX02FA110--Marana, AZ--Midair collision between U.S. Army7032        Pilatus UV-20A and Cessna 182C70337034   CHI03IA066--Wichita, KS--Experimental airplane with in-7035        flight inverter fire70367037   CHI05FA055--Hollister, OK--Midair collision between USAF7038        military trainer (Cessna T-37B) and Air Tractor AT-502B70397040   DFW05FA244--Pleasanton, TX--Unmarked power line strike7041        during training flight70427043   DEN06LA004--Truth or Consequences, NM--Failure to maintain7044        terrain clearance70457046   DEN06GA017--Alpine, WY--Low-level flight maneuver, cable7047        strike70487049   LAX06GA254--Happy Camp, CA--Tail rotor separation during7050        fire suppression operation70517052   DEN07FA140--Dayton, WY--Loss of control during in-flight7053        weather70547055   SEA08FA023--Las Vegas, NV--In-flight collision with terrain70567057   DFW08TA225--Pueblo, CO--Wake turbulence encounter and impact7058        with terrain70597060   CEN11IA114--Colorado Springs, CO--Parts separation from7061        aircraft70627063   WPR12FA058--Coupeville, WA--Loss of engine power70647065   CEN14TA126--Fort Carson, CO--Wake encounter and loss of7066        control in flight70677068   WPR15MA243--San Diego, CA--Midair collisions between Cessna7069        172 and experimental North American Rockwell Sabreliner70707071   CEN16FA172--North Little Rock, AR--Loss of engine power70727073   CEN16FA278--Fairmont, OK--Loss of control in flight70747075   WPR17LA186--Pacific Ocean, San Diego, CA--Wake turbulence7076        and loss of control70777078   DCA19MA143--Jacksonville, FL--Runway excursion70797080   WPR21LA070--Heber City, UT--Loss of control in flight70817082   WPR23LA045--San Diego, CA--Midair collision between Sikorsky7083        UH-60A and Sikorsky MH-60R70847085   ERA23FA256--Montebello, VA--Unknown circumstances leading to7086        terrain impact70877088   DCA25MA108--Washington, DC--DCA midair collision70897090   OPS25LA034--Washington, DC--Loss of separation between Army7091        Sikorsky UH60 and Republic Airways Embraer ERJ 17070927093   MIA02LA057--River Ranch, FL--Loss of engine power and forced7094        landing70957096   LAX04GA051--Big Bear City, CA--Encounter with weather and7097        collision with terrain70987099   LAX06FA099--Buckeye, AZ--Near collision, loss of control,7100        and collision with terrain71017102   CEN14FA468--Abilene, TX--Unknown emergency and impact with7103        trees and terrain71047105   ERA15MA259--Moncks Corner, SC--Midair collision between an7106        F-16 and Cessna 150M71077108   WPR16FA166--Las Vegas, NV--Loss of engine power71097110   ERA18FA120--Daytona Beach, FL--Aircraft structural failure71117112   WPR22FA094--Glendale, AZ--Fuel exhaustion71137114   OPS25LA052--Minot, ND--Loss of separation between USAF B-52H7115        and SkyWest Airlines ERJ-170-200; subsequent loss of separation7116        between same USAF B-52H and Piper PA71177118    B. Please provide a list of any previous recommendations made by7119the NTSB involving improved coordination between the FAA and DoD and7120the status of those recommendations.7121    Answer.71227123   To the Department of Defense (DoD; Closed--Acceptable7124        Action): Coordinate with the Federal Aviation Administration to7125        ensure oversight, including periodic en route inspections, is7126        provided at all contractor bases of operation for civilian7127        contractors that provide aviation transportation to the U.S.7128        military overseas under 14 Code of Federal Regulations Part 1217129        or Part 135. (A-06-78)71307131   To the Air Force Rescue Coordination Center (Closed--7132        Acceptable Action): Work with the Federal Aviation7133        Administration to develop specific phraseology for7134        communicating about the location, time, and nature of emergency7135        locator transmitter signals and emergency beacon codes and7136        revise your procedures to reflect that phraseology. (A-10-35)71377138   To the DoD (Closed--Acceptable Alternate Action): Develop,7139        in cooperation with the FAA, a formal document that clearly7140        defines the roles & responsibilities of each agency regarding7141        the activation of the special use areas (warning areas), & that7142        provides for the timely activation of special use areas to7143        accommodate the users; prior to implementation, these agencies7144        should also ensure that air traffic control personnel in all7145        facilities are provided adequate training & formal briefing on7146        the procedures responsibilities. (A-97-114)71477148   To the DoD (Closed--Acceptable Action): Conduct, in7149        cooperation with FAA, a formal review of special use airspace7150        (warning area) procedures to ensure that they are current,7151        safe, understood, & adhered to by all those involved. Personnel7152        involved in this review should include air force, navy, FAA7153        representatives; pilots, controllers & other persons deemed7154        appropriate. Info generated by the review should be7155        disseminated to every unit involved in the scheduling, control,7156        &/or use of special use airspace. (A-97-115)71577158   To the DoD (Closed--Unacceptable Action): Require that7159        controllers solicit pilot reports of cloud & visibility7160        conditions from military flights that are operating in special7161        use areas (warning areas). During periods when the special use7162        areas have been released to the FAA, the DOD should require7163        that military controllers confer with the FAA controllers so7164        that they can maintain an awareness of flight conditions prior7165        to the start of a scheduled mission. (A-97-116)71667167   To the DoD (Closed--Acceptable Action): Vigorously pursue7168        upgrading all air traffic control equipment that directly7169        interfaces with FAA air traffic control facilities to provide7170        the same level of safety as that provided to civil aircraft by7171        the FAA & ensure compatibility with automated systems is [sic]7172        FAA facilities. (A-97-120)71737174   To the DoD (Closed--Acceptable Action): Participate in a7175        task force, to be convened by the Federal Aviation7176        Administration, to establish a permanent bird strike working7177        group to facilitate conflict resolution and improve7178        communication between aviation safety agencies and wildlife7179        conservation interests. (A-99-97)71807181    Question 2. The DCA midair collision resulted, in part, from a lack7182of coordination between the FAA and the Army. Less than a year later,7183an Air Force B-52 aircraft forced a Delta plane to take evasive action7184over Minot, South Dakota. Miscommunications between the FAA and DoD7185occur across the Department.71867187    A. Should the Senate Commerce, Science and Technology Committee7188coordinate with the Senate Armed Services Committee to ensure that the7189best practices outlined in the NTSB report are instituted across the7190Department, and importantly, that the data gained from the systems is7191proactively shared with FAA safety experts?7192    Answer. Yes.71937194    a. What specific forms of data and information would be the most7195critical for DoD and FAA to share? What is the optimal periodicity for7196each type of data or information (e.g., instantly, daily, weekly, bi-7197weekly, monthly, annually)?7198    Answer. We only looked at the Army; we would need to look more7199broadly at the DoD.72007201    B. In your investigation, what (if any) existing technical systems7202did you find currently share relevant data between DoD and FAA? What7203was your assessment of the usefulness and functioning of each system7204and what recommendations did you have for improvement?7205    Answer. We only looked at the Army; we would need to look more7206broadly at the DoD.72077208    C. Which existing Army or DoD systems could connect easily to or be7209compatible with FAA systems or data, or is the NTSB's position that DoD7210and/or FAA's systems need to be overhauled in order to speak to each7211other?7212    Answer. We only looked at the Army; we would need to look more7213broadly at the DoD.72147215    Question 3. Has the NTSB faced any resistance or obstacles to7216observing Safety Reviews conducted by the DoD or FAA? Were there any7217barriers to obtaining the information needed to complete the NTSB7218investigation of the DCA Midair Collision?7219    Answer. The FAA refused to give us investigative information in7220numerous instances; the DoD provided us with all investigative7221information requested.72227223    Question 4. Following the DCA midair collision, FAA announced it is7224using artificial intelligence and machine learning to scan incident7225reports and mine data sources to identify similar hotspots with high7226volumes of mixed helicopter and airplane traffic. Has FAA shared any of7227these analyses with NTSB and DoD?7228    Answer. We have not received this analysis; however, we would like7229to, as our Chief Data Officer has concerns about how this practice is7230being implemented and that safety concerns identified in our7231investigations may be missed.72327233    Question 5. What is the NTSB's assessment of the U.S. Army's7234aviation platforms' ability to communicate in real-time with non-7235military aircraft or air traffic controllers? Are there any gaps in7236communications systems onboard U.S. Army aircraft that prevent real-7237time communication?7238    Answer. Our investigation of the DCA midair collision found that7239several of the Army 12th Aviation Battalion's helicopters were not7240transmitting ADS-B Out. The battalion did not know this was occurring.7241The NTSB determined that the Army's lack of recurrent inspections to7242verify the transponder ADS-B settings were correct and transmitting7243ADS-B was a factor in this issue remaining undetected by the battalion.7244Accordingly, the NTSB recommended the Army and the Department of War7245Policy Board on Federal Aviation develop and implement a transponder7246inspection procedure on all aircraft with transponders capable of7247transmitting Mode S and ADS-B and operated in the National Airspace7248System (NAS), at least annually and upon each aircraft's entry into7249service in the NAS, that ensures 1) the transponder ADS-B settings are7250correct, 2) the transponder is transmitting ADS-B, and 3) the7251transponder is transmitting the correctly assigned address (Safety7252Recommendations A-26-44 and A-26-51). Verifying functionality of7253aircraft transponders will ensure these systems that interface with7254TCASs and ground radar stations work properly while flying in the NAS.7255    Our investigation also found that degraded radio reception resulted7256in the crew of PAT25 not receiving salient information regarding flight72575342's circling approach to runway 33. Clear and effective7258communication is essential for safe ATC operations and pilot situation7259awareness. When radio quality is degraded, pilots and controllers can7260miss important information, and having to repeat control instructions7261can result in time lost for other safety-critical tasks. Therefore, we7262recommended that the Department of War Policy Board on Federal Aviation7263conduct a study to evaluate the quality of radio transmissions and7264reception for those aircraft operated within the NAS to identify7265factors that degrade communications equipment performance and adversely7266affect the safety of civilian and military flight operations (Safety7267Recommendation A-26-49). We further recommended the DOW implement the7268appropriate enhancements based on the findings of this study (Safety7269Recommendation A-26-50).7270Question Topic: DoD Safety Improvements7271    Question 1. Should Congress statutorily require the development of7272a robust Safety Management System for all Military Services, including7273a flight data monitoring system for all aircraft and frontline incident7274reporting system, similar to the NTSB recommendations to the Army?7275    Answer. Yes.72767277    Question 2. What would be a reasonable deadline for the Army to7278close out the three recommendations related to development of a Safety7279Management System?72807281   Establish a flight data monitoring program for rotary-wing7282        aircraft the U.S. Army operates in the National Airspace System7283        (A-26-45)72847285   Revise the method for allocating resources to ensure the7286        development of a robust safety management system that will, at7287        a minimum, identify and monitor the potential for midair7288        collisions between Army aircraft and civil air traffic7289        operating in the National Airspace System (A-26-47)72907291   Develop and maintain a flight safety management capability7292        that is independently resourced and functionally separate from7293        its occupational and environment health management system, and7294        ensure that this capability is both culturally and functionally7295        integrated with units conducing flight operations in the7296        National Airspace System (A-26-48)72977298    Answer. As soon as possible. The team is having ongoing and7299productive discussions with the Army.73007301    Question 3. There has been an increase in military-on-military7302aircraft collisions. Would the NTSB recommend expanding its7303recommendation to identify and monitor potential for midair collisions7304between Army aircraft and civil air traffic (A-26-47) to include7305aircraft and all other traffic operating in the National Airspace7306System?7307    Answer. Our recommendations have already been made.7308Question Topic: Enhance Transparency of NTSB Proceedings7309    Question 1. Does the NTSB have ex-parte rules prohibiting7310communication between entities that would be impacted by an ongoing7311NTSB investigation while a given draft is before the board?7312    Answer. No; however, I have asked our General Counsel to draft a7313Board order prohibiting such communications. It would be helpful to7314have congressional support for this action because NTSB Board orders7315can be changed at will by the Board.73167317    Question 2. To protect NTSB independence, and to enhance public7318transparency, would you support Congress passing legislation to codify7319such a prohibition on lobbying NTSB members while considering a draft,7320and a requirement that amendments proposed by NTSB members be publicly7321disclosed?7322    Answer. Yes, I strongly support this. One of our core values is7323transparency, and that should apply to our Board. The Board will work7324the Committee on any legislation under consideration.7325Question Topic: Air Traffic Controller Training7326    While the NTSB final report does not explicitly state why the trend7327over the previous decade went from always manning the Helicopter7328Control (HC) and Local Control (LC) positions separately to both7329positions be normally combined, this period coincided with declining7330recruitment of air traffic controllers.73317332    Question 1. Does NTSB recommend that the FAA invest in additional7333pathways to increase the recruitment and training of air traffic7334controllers to minimize towers, resorting to implementing staffing7335modifications like combining the HC and LC positions?7336    Answer. This is beyond the scope of our investigation.7337Question Topic: ADS-B In/Out Recommendations7338    Question 1. Please provide a list of all previous NTSB7339recommendations issued on Automatic Dependent Surveillance--Broadcast7340(ADS-B) In and ADS-B Out, and the status of these recommendations.7341    Answer. ADS-B was first discussed in NTSB correspondence related to7342Safety Recommendation A-00-66 (Closed--Unacceptable Action), which7343resulted from our investigations of four runway incursions that7344occurred in 1999, and asked the FAA to require a ground movement safety7345system that prevents runway incursions and provides a direct warning to7346flight crews.7347    Safety Recommendation A-00-66 superseded Safety Recommendation A-734891-29, which asked the FAA to develop and implement a system to alert7349controllers to pending runway incursion.7350    ADS-B is not specified in the text of A-00-66; however, it is7351discussed in our correspondence. In a 2011 letter, we discussed the7352FAA's ADS-B rulemaking and told the FAA that ADS-B might have been a7353viable response to A-00-66, but only if ADS-B In were required.7354    In 2024, as a result of our investigation of a 2023 runway7355incursion at JFK airport, we issued Safety Recommendations A-24-47356through -6 to the FAA (all three are classified Open--Unacceptable7357Response), which collectively superseded A-00-66.73587359   Collaborate with aircraft and avionics manufacturers and7360        software designers to develop the technology for a flight deck7361        system that would provide visual and aural alerts to flight7362        crews of traffic on a runway or taxiway and traffic on approach7363        to land. (A-24-4)73647365   Require that the technology developed in response to Safety7366        Recommendation A-24-4 be installed in all newly certificated7367        transport-category airplanes. (A-24-5)73687369   Require that existing transport-category airplanes be7370        retrofitted with the technology developed in response to Safety7371        Recommendation A-24-4. (A-24-6)73727373    Between 2006 and 2007, we recommended that the FAA require7374equipment that could provide increased aircraft identification,7375location, and communication capabilities for aircraft operations in the7376Gulf of America and remote areas of Hawaii. The following7377recommendations have been classified Closed--Acceptable Action:73787379   Ensure that the infrastructure for the National ADS-B7380        Program in the Gulf of America is operational by Fiscal Year7381        2010. (A-06-21)73827383   Until the infrastructure for the National ADS-B Program in7384        the Gulf of America is fully operational, direct POIs to inform7385        operators in that region about the benefits of commercial7386        flight-tracking systems and encourage the operators to acquire7387        such systems. (A-06-22)73887389   Accelerate the implementation of ADS-B infrastructure in7390        Hawaii to include high-quality ADS-B services to low-flying7391        aircraft along heavily traveled commercial air tour routes. (A-7392        07-25)73937394   Require that Hawaii air tour operators equip tour aircraft7395        with compatible ADS-B technology within 1 year of the7396        installation of a functional National ADS-B Program7397        infrastructure in Hawaii. (A-07-26)7398FAA Rulemaking on ADS-B7399    In 2007, the FAA published a notice of advance rulemaking (NPRM)7400that only proposed requiring ADS-B Out. The FAA determined ADS-B In was7401not needed to maintain the safety and efficiency of the NAS.7402    In our 2008 NPRM comments, we pointed out that for ADS-B to provide7403maximum safety benefits, the system should support both ADS-B Out and7404ADS-B In. ADS-B Out provides basic aircraft information, such as7405location and altitude, to air traffic controllers to provide traffic7406separation. ADS-B In would permit users access to additional services,7407such as data-linked weather and traffic information, and would also7408provide a means of transmitting conflict warnings directly to pilots7409via the ADS-B In communications link.7410    In 2010, the FAA published a final rule, ``ADS-B Out Performance7411Requirements,'' which required, as of 2020, that aircraft flying in7412controlled airspace be equipped with ADS-B Out.7413    The FAA Reauthorization Act of 2018 repealed earlier legislation7414that had directed the FAA to initiate rulemaking to issue guidelines7415and regulations relating to ADS-B In technology. The repeal language7416appears as section 522 of the FAA Reauthorization Act of 2018.7417    In 2021, because of our investigation of a 2019 midair collision7418involving two Part 135 sightseeing tours near Ketchikan, Alaska, we7419issued the following safety recommendations to the FAA, which are the7420first recommendations to specify the ``Out'' and ``In'' capabilities of7421ADS-B. All are classified Open--Unacceptable Response.74227423   Identify areas with a high concentration of air tour traffic7424        and to require that CFR Parts 91 and 135 air tour operators who7425        operate within those areas be equipped with an ADS-B Out-and7426        In-supported traffic advisory system that includes visual and7427        aural alerts. (A-21-15)74287429   Require that all non-air tour aircraft operating within the7430        airspace identified as a high-traffic tour area in Safety7431        Recommendation A-21-15 be equipped with ADS-B Out. (A-21-16)74327433   Require the installation of ADS-B Out and In supported7434        airborne traffic advisory systems that include aural alerting7435        functions in all aircraft conducting operations under 14 CFR7436        Part 135. (A-21-17)74377438    In 2023 correspondence, the FAA said its current ADS-B requirements7439and guidance adequately addressed the needs of aviation safety and it7440would not pursue additional requirements. The NTSB emphasized that the7441absence of an ADS-B In requirement for Part 135 passenger-carrying7442operations fails to take advantage of the demonstrated safety benefit7443of ADS-B In traffic awareness and alerting and is inconsistent with the7444``appropriate level of public safety'' the FAA itself expects for7445operations in which passengers bear no responsibility for the7446aircraft's operation.7447    In 2022, because of our investigation of a 2019 helicopter air tour7448accident in Hawaii, the NTSB issued the following safety7449recommendations to the FAA (both are classified Open--Acceptable7450Response):74517452   Implement ADS-B infrastructure improvements in Hawaii, such7453        as additional ADS-B ground stations, that provide adequate7454        coverage to enable real-time flight tracking and traffic7455        advisory services for ADS-B Out-and In-equipped, low-flying air7456        tour aircraft throughout their entire tour routes. (A-22-12)74577458   As an interim measure until completion of A-21-15, require7459        Hawaii air tour operators to install ADS-B Out equipment in7460        their aircraft to enable real-time flight position tracking.7461        (A-22-13)74627463    Now, with the conclusion of the DCA midair collision investigation,7464we have issued additional collision avoidance and ADS-B In7465recommendations, as detailed elsewhere.74667467    Question 2. To encourage implementation of NTSB recommendations on7468the installation of ADS-B In, would the NTSB be supportive of a public7469safety rating system that ranks air carriers on their installation of7470ADS-B?7471    Answer. This is beyond the scope of our investigation.7472Question Topic: FAA Complacency7473    There is a known culture of complacency at the FAA. The NTSB has7474issued similar recommendations to those in the DCA report in previous7475investigations, but the FAA either failed to act or rejected the7476recommendations. The FAA must change its culture and not only implement7477the recommendations required by the NTSB but go beyond those7478recommendations to create a culture of safety.74797480    Question 1. Please provide a detailed timeline for each7481recommendation and explain what mechanism the NTSB will use to track7482implementation.7483    Answer. Title 49 United States Code 1135 requires an initial7484recipient response within 90 days for nonurgent recommendations (307485days for urgent) issued to the DOT and all DOT modal administrations.7486After the initial response, recipients should update the NTSB on their7487progress toward implementing the recommendation whenever a significant7488activity has been completed, or every 12 months, whichever occurs7489first. The NTSB will attempt to obtain an update from a recipient7490through formal or informal means when there has been no update for 127491or more months. If, after 18 months, no update has been received, a7492formal letter requesting an update will be sent to the recipient. An7493action recommended by the NTSB should be completed within 5 years after7494the recommendation is issued. A recommendation over 5 years old may be7495kept open if the NTSB determines that the recommendation can be7496successfully completed with additional time or that the issue has7497significant safety implications, or if the Board votes to keep it open.7498Question Topic: NTSB Staffing and Resources7499    Question 1. What resources were needed to conduct the DCA Midair7500Collision investigation?7501    Answer. Every office across the agency directly supported the7502investigation and the investigators who worked on it. Collectively,7503agency staff spent over 30,000 hours on the investigation. Fifty7504investigators supported the investigation, including four directors and7505eight chiefs, along with three dedicated writers. In addition, eight7506staff members supported family assistance, five supported media7507relations, five supported government affairs, and eighteen staff7508members directly supported the investigation and subsequent7509investigative hearing and Board meeting. This number does not include7510the staff that provided indirect support that ensured investigative7511staff had real-time human resources and travel resources, as well as7512the technology needed to work on this investigation. The total costs7513are estimated to be $3.25 million including labor and mission support7514costs.7515    This number does not reflect the work done by staff who, as part of7516their job duties, support all investigations; it is an estimate rather7517than the exact monetary cost of this investigation.75187519    Question 2. What is the appropriate level of staffing and funding7520necessary to carry out NTSB operations at full capacity?7521    Answer. Our current budget request is $145 million for Fiscal Year75222027, which will support a staffing level of 450.7523                                 ______75247525 Response to Written Questions Submitted by Hon. John Hickenlooper to7526                         Hon. Jennifer Homendy7527Culture of Safety7528    The NTSB's DCA crash investigation revealed that aviation safety7529personnel had previously raised collision risks to FAA management, yet7530these concerns were not addressed in a timely manner. We must always7531raise the bar and promote a culture of safety, transparency, and7532accountability, especially in aviation, and especially when lives are7533at risk.75347535    Question 1. Chair Homendy, could stronger legislative protections7536for voluntary safety reporting help promote a stronger culture of7537safety across the FAA?7538    Answer. Yes.7539Aircraft Instruments and Spectrum Interference7540    Aircraft instruments rely on extreme precision, making spectrum7541interference a serious safety risk. For example, recent counter-drone7542testing by the Navy and Secret Service near DCA triggered dangerous7543false alarms for pilots' Traffic Collision Avoidance Systems (TCAS). In7544Boulder, the Federal Institute for Telecommunication Science (ITS) has7545worked closely alongside the FAA, DOD, and other agencies to study and7546minimize spectrum interference to mission-critical systems.75477548    Question 2. Chair Homendy, what specific interagency research and7549testing is needed to ensure mission-critical systems aren't compromised7550by emerging wireless technologies?7551    Answer. This is beyond the scope of our investigation.75527553    Question 3. Do you believe the NTSB and FAA's safety concerns are7554being given enough weight by the NTIA or FCC before they auction off7555spectrum bands--like the ``Upper C-Band''--near sensitive aircraft7556frequencies?7557    Answer. This is beyond the scope of our investigation.7558Nationwide Mixed Airspace Review7559    Following the DCA Crash last year, the FAA confirmed to this7560Committee that it was conducting a nationwide review of airspace. The7561FAA stated it was examining airspace where commercial aviation traffic7562mixed with military airspace activities. The FAA's review is important7563to ensure any troublesome areas of mixed airspace traffic are7564identified and risks are mitigated.75657566    Question 4. Chair Homendy, how would you characterize the pace and7567scope of the FAA's ongoing review of mixed airspace nationwide? Do you7568have any further recommendations or findings regarding this airspace7569review?7570    Answer. Because the FAA's review is ongoing, this question is best7571posed to that agency.7572Runway Incursion7573    While air traffic controllers perform incredible work, many7574airports still lack the technology to prevent ground collisions. At7575most airports, safety relies entirely on human eyes and radio calls7576rather than automated tracking.75777578    Question 5. Chair Homendy, would expanding ground-based radar and7579surveillance systems, including at smaller airports, provide the7580additional required situational awareness to help pilots avoid runway7581incursions?7582    Answer. Since 1973, the NTSB has issued numerous recommendations to7583the FAA regarding the problems with runway incursions/ground collisions7584with aircraft, including the current recommendations from multiple7585recent and past incidents and accidents listed below.7586    Recommendations from a 2017 taxiway overflight at SFO (NTSB7587Incident Report AIR-18-01):75887589   Establish a requirement for airplanes landing at primary7590        airports within Class B and Class C airspace to be equipped7591        with a system that alerts pilots when an airplane is not7592        aligned with a runway surface. (A-18-25)75937594   Collaborate with aircraft and avionics manufacturers and7595        software developers to develop the technology for a cockpit7596        system that provides an alert to pilots when an airplane is not7597        aligned with the intended runway surface, and, once such7598        technology is available, establish a requirement for the7599        technology to be installed on airplanes landing at primary7600        airports within Class B and Class C airspace. (A-18-26)76017602    Recommendations from a 2023 runway incursion and rejected takeoff7603at JFK (NTSB Aviation Investigation Report AIR-24-01):76047605   Encourage Title 14 Code of Federal Regulations Part 91K,7606        135, and 121 operators to incorporate into their standard7607        operating procedures a procedural crosscheck that requires7608        flight crews to verbalize the number of a runway they are about7609        to cross, as indicated by runway signs, unless an installed7610        automated system already provides an aural advisory. (A-24-2)76117612   Collaborate with aircraft and avionics manufacturers and7613        software designers to develop the technology for a flight deck7614        system that would provide visual and aural alerts to flight7615        crews of traffic on a runway or taxiway and traffic on approach7616        to land. (A-24-4; supersedes A-00-66)76177618   Require that the technology developed in response to Safety7619        Recommendation A-24-4 be installed in all newly certificated7620        transport-category airplanes. (A-24-5; supersedes A-00-66)76217622   Require that existing transport-category airplanes be7623        retrofitted with the technology developed in response to Safety7624        Recommendation A-24-4. (A-24-6; supersedes A-00-66)76257626   Evaluate the effectiveness of the activation logic for the7627        runway status light system considering the circumstances of7628        this incident. (A-24-7)76297630   Using the findings of the evaluation conducted in response7631        to Safety Recommendation A-24-7, update the runway status light7632        system activation logic as necessary to improve system7633        effectiveness. (A-24-8)76347635    Recommendations from a 2023 runway incursion and overflight at AUS7636(NTSB Aviation Investigation Report AIR-24-02)76377638   Require air traffic controllers to advise pilots, through7639        direct communication and automatic terminal information system7640        broadcasts, when visual contact with aircraft operating on7641        taxiways and runways cannot be established or maintained and7642        instruct pilots to provide accurate position reports to aid the7643        controller in determining an aircraft's location in such7644        conditions. (A-24-11)76457646   Amend the Aeronautical Information Manual so that it7647        instructs pilots to inform controllers, before entering an7648        active runway with the intent to depart, when they need time on7649        the runway for any reason before beginning the takeoff roll.7650        (A-24-13)76517652   Require all airports with a Surface Movement Guidance and7653        Control System plan to ensure that their plans and the7654        associated letters of agreement correspond with each other and7655        the stakeholder duties and responsibilities described in7656        Advisory Circular 120-57, Surface Movement Guidance and Control7657        System. (A-24-14)76587659    Recommendations from the DCA midair collision investigation:76607661   To the FAA: Develop and implement a risk assessment tool for7662        supervisors that incorporates the principles of threat and7663        error management to assist in risk identification, mitigation,7664        and operational decision making. (A-26-10)76657666   To the FAA: Initiate rulemaking in 14 Code of Federal7667        Regulations Part 93 Subpart K, High Density Traffic Airports,7668        that prescribes air carrier operation limitations at DCA in 30-7669        minute periods, similar to those imposed at LaGuardia Airport,7670        to ensure that the airport does not exceed capacity and to7671        mitigate inconsistent air carrier scheduling practices. (A-26-7672        11)76737674   To the FAA: Fully implement operational use of the time-7675        based flow management system at Potomac Consolidated Terminal7676        Radar Approach Control and its associated air traffic control7677        towers. (A-26-12)76787679   To the FAA: Reassess the Ronald Reagan Washington National7680        Airport's airport arrival rate with special consideration to7681        its airspace complexity, airfield limitations, mixed fleet7682        operations, and traffic volume. (A-26-13)76837684   To the FAA: Require each Class B or Class C air traffic7685        control tower facility to evaluate its existing miles-in-trail7686        procedures or agreements to ensure that the spacing provided is7687        appropriate for operational safety, and make the results7688        publicly available. (A-26-14)76897690   To the FAA: Conduct a comprehensive evaluation, in7691        conjunction with local operators, to determine the overall7692        safety benefits and risks to requiring all aircraft to use the7693        same frequency when the helicopter and local positions are7694        combined in the Ronald Reagan Washington National Airport air7695        traffic control tower. (A-26-18)76967697   To the FAA: Implement anti-blocking technology that will7698        alert controllers and/or flight crews to potentially blocked7699        transmissions when simultaneous broadcasting occurs. (A-26-19)77007701   To the FAA: Develop and implement improvements to the7702        conflict alert system to provide more salient and meaningful7703        alerts to controllers based on the severity of the conflict7704        triggering the alert. (A-26-20)77057706   To the FAA: Once the improvements to the conflict alert7707        system discussed in Safety Recommendation A-26-20 are7708        implemented, provide training to controllers on its use. (A-26-7709        21)77107711   To the FAA: Require all aircraft operating in airspace where7712        Automatic Dependent Surveillance-Broadcast (ADS-B) Out is7713        required to also be equipped with ADS B In with a cockpit7714        display of traffic information that is configured to provide7715        alerting audible to the pilot and/or flight crew. (A-26-31)77167717   To the FAA: Establish a requirement across all air traffic7718        control tower standard operating procedures that the operations7719        supervisor (OS) or controller-in-charge (CIC) document in the7720        daily facility log when any control position is combined with7721        the local control position, or when the OS/CIC position is7722        combined with a control position, along with a rationale for7723        doing so. (A-26-40)77247725   To the United States Department of War, Policy Board on7726        Federal Aviation: Conduct a study to evaluate the quality of7727        radio transmissions and reception for those aircraft operated7728        within the National Airspace System to identify factors that7729        degrade communications equipment performance and adversely7730        affect the safety of civilian and military flight operations.7731        (A-26-49)77327733   To the United States Department of War, Policy Board on7734        Federal Aviation: Implement appropriate enhancements, based on7735        the findings of the study recommended in Safety Recommendation7736        A-26-49, to remediate identified deficiencies in air-ground7737        radio communications performance. (A-26-50)77387739    NTSB has issued the following additional recommendations to the7740FAA, which have been classified Closed--Acceptable Action, calling for7741research and development efforts to address the need for cost-effective7742alternatives at airports not scheduled to receive Airport Surface7743Detection Equipment (ASDE):77447745   Conduct research and development efforts to provide airports7746        that are not scheduled to receive Airport Surface Detection7747        Equipment with an alternate, cost-effective system to bring7748        controller and pilot attention to pending runway incursions in7749        time to prevent ground collisions. (A-91-30)77507751   Continue research and development efforts to provide7752        airports that are not scheduled to receive Airport Surface7753        Detection Equipment with an alternate, cost-effective system,7754        such as the ground induction loop, to bring controller7755        attention to pending runway incursions in time to prevent7756        ground collisions. (A-95-94)77577758   Convene a joint FAA/industry task force on human performance7759        initiatives to produce human performance-related surface7760        operation improvements that could be readily implemented during7761        surface operations by mitigating human error. In identifying7762        those initiatives, consider the recommendations contained in7763        the MITRE Corporation study, ``Reports by Airline Pilot Surface7764        Operations.'' (A-95-96)77657766    Finally, the NTSB has issued the following additional7767recommendations to the FAA on this issue over many years that have been7768classified Closed--Unacceptable Action:77697770   Establish and publish taxi routes for arriving and departing7771        aircraft to be used during periods of restricted visibility on7772        the order of 1/2 mile. (A-73-25)77737774   Require pilots to obtain the controllers' approval before7775        crossing alighted runway during periods of restricted7776        visibility on the order of 1/2 mile. (A-73-26)77777778   Require flight crews to read back taxi clearances when7779        operating in visibilities of less than one-half mile. (A-73-55)77807781   Establish on a trial basis, for the north and for the south7782        control operations in the Chicago O'Hare international airport7783        control tower, local control coordinator positions to monitor7784        and supervise, directly, the local control positions; staff7785        these positions whenever intersecting runways are in concurrent7786        operation. (URGENT) (A-86-45)77877788   Amend the air traffic control handbook, 711.65f, paragraph7789        3-127, to preclude the issuance of multiple landing clearances7790        to aircraft outside of the final approach fix. Also, establish7791        a numerical limit so that no more than two landing clearance7792        may be issued to successive arrivals. (A-91-28)77937794   Retain the national operational position standards as a7795        separate, independent order and: (a) direct the FAA's human7796        factors and air traffic service staffs adequacy of redundancies7797        and incorporate any resultant recommendations into the national7798        order; (b) expedite the development of chapters 5 through 10 of7799        the national order. (A-91-107)78007801   Amend FAA Order 7110.65, ``Air Traffic Control,'' paragraph7802        3-9-4, ``Takeoff Position Hold,'' to discontinue the practice7803        of allowing departing aircraft to hold on active runways at7804        nightime or at any time when ceiling and visibility conditions7805        preclude arriving aircraft from seeing traffic on the runway in7806        time to initiate a safe go-around maneuver. (A-00-69)78077808   Adopt the landing clearance procedure recommended by7809        International Civil Aviation Organization Document 4444-RAC/7810        501, ``Procedures for Air Navigation Services--Rules of the Air7811        and Air Traffic Services,'' Part V, ``Aerodrome Control7812        Service,'' Paragraph 15.2. (A-00-70)78137814   Require that all 14 Code of Federal Regulations Part 91K,7815        121, and 135 operators establish procedures requiring all7816        crewmembers on the flight deck to positively confirm and cross-7817        check the airplane's location at the assigned departure runway7818        before crossing the hold short line for takeoff. This required7819        guidance should be consistent with the guidance in Advisory7820        Circular 120-74A and Safety Alert for Operators 06013 and7821        07003. (Supersedes Safety Recommendation A-06-83) (A-07-44)78227823   Require that all 14 Code of Federal Regulations Part 91K,7824        121, and 135 operators install on their aircraft cockpit moving7825        map displays or an automatic system that alerts pilots when a7826        takeoff is attempted on a taxiway or a runway other than the7827        one intended. (Supersedes Safety Recommendation A-06-83) (A-07-7828        45)78297830   Perform a technical review of Airport Surface Detection7831        Equipment-Model X (ASDE-X) to determine if the capability7832        exists systemwide to detect improper operations such as7833        landings on taxiways. (A-11-12)78347835   At those installation sites where the technical review7836        recommended in Safety Recommendation A-11-12 determines it is7837        feasible, implement modifications to Airport Surface Detection7838        Equipment-Model X (ASDE-X) to detect improper operations, such7839        as landings on taxiways, and provide alerts to air traffic7840        controllers that these potential collision risks exist. (A-11-7841        13)7842Safety Recommendations7843    The NTSB deserves bipartisan praise for its timely investigations7844and safety recommendations that can save lives. The NTSB has long7845called for cockpit voice recorders capable of recording 25 hours of7846audio to be installed in aircraft. While the FAA has recently required7847new aircraft to include 25-hour cockpit voice recorders, existing7848aircraft do not have this equipment retrofitted.78497850    Question 6. Chair Homendy, could you underscore the importance of7851all aircraft having cockpit voice recorders in supporting NTSB's safety7852investigations? How did this data assist the NTSB in conducting the DCA7853investigation and providing its final recommendations?7854    Answer. Cockpit voice recorders (CVRs) are among the most valuable7855tools used for accident investigation. Information, such as flight crew7856verbalizations of their intentions and coordination, as well as pilots'7857awareness of the state of the aircraft and cockpit information, allows7858investigators to more comprehensively assess accident/incident factors.7859These factors include flight crews' procedural compliance, distraction,7860decision-making, workload, fatigue, and situation awareness.7861Ultimately, CVRs provide unique information with which the NTSB can7862conduct more thorough investigations to more effectively target safety7863recommendations.7864    CVRs provided critical information during the DCA midair collision7865investigation. For example, the CVR on PAT25 revealed that its crew did7866not receive salient information regarding flight 5342's circling7867approach to runway 33 due to degraded radio reception. Additionally,7868the CVR revealed that simultaneous radio transmissions blocked7869important information from the controller to PAT25, which reinforced7870the PAT25 crew's expectation bias that flight 5342 did not pose a7871conflict. Both findings led directly to NTSB safety recommendations.7872    Although the FAA's recent rulemaking did not require that existing7873aircraft be retrofitted with a 25-hour CVR, the FAA Reauthorization Act7874of 2024 requires that all aircraft operated under Part 121 and certain7875other aircraft be retrofitted with a CVR that retains the last 25 hours7876of aircraft operation by 2030.7877                                 ______78787879      Response to Written Questions Submitted by Hon. Andy Kim to7880                         Hon. Jennifer Homendy7881Helicopter Routes Recommendation/Low-Flying Helicopters7882    Question 1. One of the recommendations made during the NTSB's7883January 2026 Board Meeting was that annual reviews should be conducted7884on helicopter routes throughout the entire aviation system to ensure7885that our airspace is safe. In the New York City region, there are about788680,000 nonessential helicopter flights over this region every year,7887which is about 220 flights every day. Not only do these helicopter7888flights cause great disturbances for the residents of these densely7889populated communities, but they also pose safety risks. There are7890minimal guidelines for these helicopters to follow, even in densely7891populated residential areas. The fatal April 10, 2025 helicopter crash7892in the Hudson River increases concerns of future crashes over these7893residential areas being likely. Has the NTSB reviewed safety concerns7894of low-flying helicopters and aircraft in crowded residential areas? In7895light of the NTSB recommendations from the DCA collision investigation,7896what considerations would be most critical to better regulating7897nonessential travel to ensure the best safety outcomes?7898    Answer. All of the NTSB's open recommendations will improve7899aviation safety. In addition to the recommendations from the DCA7900investigation, the following open recommendations are directed to the7901FAA and involved investigations of accidents including helicopters.79027903   In cooperation with Hawaii commercial air tour operators,7904        aviation psychologists, and meteorologists, among others,7905        develop a cue-based training program for commercial air tour7906        pilots in Hawaii that specifically addresses hazardous aspects7907        of local weather phenomena and in-flight decision-making. (A-7908        07-18)79097910   Once a cue-based training program that specifically7911        addresses hazardous aspects of local weather phenomena and7912        weather-related, decision-making issues is developed (as7913        requested in Safety Recommendation A-07-18), require all7914        commercial air tour operators in Hawaii to provide this7915        training to newly hired pilots. (A-07-19)79167917   Require the installation of a crash-resistant flight7918        recorder system on all newly manufactured turbine-powered,7919        nonexperimental, nonrestricted-category aircraft that are not7920        equipped with a flight data recorder and a cockpit voice7921        recorder and are operating under 14 Code of Federal Regulations7922        Parts 91, 121, or 135. The crash-resistant flight recorder7923        system should record cockpit audio and images with a view of7924        the cockpit environment to include as much of the outside view7925        as possible, and parametric data per aircraft and system7926        installation, all as specified in Technical Standard Order7927        C197, ``Information Collection and Monitoring Systems.'' (A-13-7928        12)79297930   Require all existing turbine-powered, nonexperimental,7931        nonrestricted-category aircraft that are not equipped with a7932        flight data recorder or cockpit voice recorder and are7933        operating under 14 Code of Federal Regulations Parts 91, 121,7934        or 135 to be retrofitted with a crash-resistant flight recorder7935        system. The crash-resistant flight recorder system should7936        record cockpit audio and images with a view of the cockpit7937        environment to include as much of the outside view as possible,7938        and parametric data per aircraft and system installation, all7939        as specified in Technical Standard Order C197, ``Information7940        Collection and Monitoring Systems.'' (A-13-13)79417942   Initiate an aviation weather camera program in Hawaii that7943        includes the installation and maintenance of aviation weather7944        cameras at critical locations in Hawaii. Establish public7945        access to these aviation weather cameras' real-time imagery.7946        (A-13-25)79477948   Install and maintain aviation weather cameras in those7949        mountain passes in the continental United States identified in7950        its research as being high risk. Establish public access to7951        these aviation weather cameras' real-time imagery. (A-13-26)79527953   Equip flight service station specialists responsible for7954        Hawaii and the continental United States with the technical7955        capabilities and training to provide verbal preflight and en7956        route briefings using aviation weather camera imagery. (A-13-7957        27)79587959   TO THE FEDERAL AVIATION ADMINISTRATION AND THE EUROPEAN7960        AVIATION SAFETY AGENCY: After the actions requested in Safety7961        Recommendation A-17-10 are completed, require operators of7962        Airbus Helicopters dual-hydraulic AS350-series helicopters to7963        incorporate changes to the dual hydraulic system to both ensure7964        pedal control hydraulic assistance and mitigate the possibility7965        of pilot error during any check of the hydraulic system. (A-17-7966        11)79677968   Modify the supplemental passenger restraint system (SPRS)7969        approval process to (1) require letter of authorization (LOA)7970        applicants to specify a need for and the intended use of an7971        SPRS for each aircraft; (2) require the Federal Aviation7972        Administration to evaluate and review, for each specified7973        aircraft, the need for the SPRS on that aircraft for all7974        intended uses; all SPRS design, manufacture, installation, and7975        operational considerations, including, at a minimum, the7976        potential for passengers to become entangled during emergency7977        egress; the adequacy of passenger emergency egress briefings;7978        and the potential for the SPRS to interfere with aircraft7979        controls; and (3) ensure that each LOA lists the specific7980        aircraft on which the holder is authorized to use an SPRS. (A-7981        19-24)79827983   Review the activation system designs of Federal Aviation7984        Administration-approved rotorcraft emergency flotation systems7985        for deficiencies that may preclude their proper deployment,7986        such as a lack of a means to identify high pull forces on7987        manual activation handles or inadequate guidance on the7988        intended use of the activation system, and require corrective7989        actions based on the review findings. (A-19-26)79907991   Revise Miscellaneous Guidance 10 in Advisory Circular (AC)7992        27 and AC 29 to include design objectives for emergency7993        flotation systems that consider human factors design7994        objectives, such as activation handle pull-force7995        characteristics; provisions for clear, unambiguous, and7996        positive feedback to pilots to indicate that the float system7997        was successfully deployed; and inspections to ensure that an7998        installation of a manual activation system does not preclude a7999        pilot's ability to deploy the floats, as designed, after it has8000        been fielded. (A-19-27)80018002   To the FAA: After the actions requested in Safety8003        Recommendation A-19-32 are completed, require owners and8004        operators of existing AS350-series helicopters to incorporate8005        the changes. (A-19-33)80068007   Develop guidance on how to identify intoxicated or impaired8008        passengers, and distribute it to operators who carry passengers8009        for hire under Title 14 Code of Federal Regulations Part 91 and8010        Part 135. (A-19-34)80118012   Require that principal operations inspectors (POI) assigned8013        to helicopter air ambulance (HAA) operations possess helicopter8014        and either HAA experience or experience as an assistant POI8015        under a POI with HAA experience. (A-20-13)80168017   Require the National Weather Service (NWS) to add terminal8018        doppler weather radar data to the HEMS Weather Tool overlay (as8019        recommended in Safety Recommendation A-20-19 to the NWS). (A-8020        20-16)80218022   Require the National Weather Service (NWS) to provide8023        capability in the HEMS Weather Tool to graphically display8024        areas of weather radar limitations, including areas where beams8025        may lack low-altitude coverage, areas that lack radar coverage,8026        and areas of beam blockages (as recommended in Safety8027        Recommendation A-20-20 to the NWS). (A-20-17)80288029   Require the use of appropriate simulation devices during8030        initial and recurrent pilot training for Title 14 Code of8031        Federal Regulations Part 135 helicopter operations to provide8032        scenario-based training that addresses the decision-making,8033        skills, and procedures needed to recognize and respond to8034        changing weather conditions in flight, identify and apply8035        mitigation strategies for avoiding adverse weather, practice8036        the transition to the use of flight instruments to reduce the8037        risk of spatial disorientation, and maintain awareness of a8038        variety of influences that can adversely affect pilot decision-8039        making. (A-21-05)80408041   Install the necessary infrastructure in Hawaii to enable8042        continuous radio communication between the pilots of low-flying8043        tour flights and ground support personnel, such as flight8044        service station specialists and company flight support8045        personnel, along the most heavily trafficked air tour routes.8046        (A-22-11)80478048   Implement automatic dependent surveillance-broadcast (ADS-B)8049        infrastructure improvements in Hawaii, such as additional ADS-B8050        ground stations, that provide adequate coverage to enable real-8051        time flight tracking and traffic advisory services for ADS-B8052        Out-and In-equipped, low-flying air tour aircraft throughout8053        their entire tour routes. (A-22-12)80548055   As an interim measure until completion of the action to8056        satisfy Safety Recommendation A-21-15, require Hawaii air tour8057        operators to install Automatic Dependent Surveillance-Broadcast8058        Out (ADS-B) equipment in their aircraft to enable real-time8059        flight position tracking. (A-22-13)80608061   Require air tour operators to have flight support personnel8062        who are trained to exercise operational control authority,8063        participate in preflight risk analysis, provide pilots with8064        weather briefings, monitor the progress of the flights, and8065        participate in two-way communications with pilots to alert them8066        of any weather hazards. (A-22-14)80678068   Issue a safety alert for operators to encourage air tour8069        operators to establish safety assurance processes to routinely8070        review recorded onboard videos and automatic dependent8071        surveillance-broadcast (ADS-B) flight tracking data, ideally as8072        part of a safety management system with an integrated flight8073        data monitoring program, for the purpose of identifying and8074        addressing risky trends in weather-related operating practices,8075        such as encounters or near encounters with instrument8076        meteorological conditions-related hazards. (A-22-16)80778078   Improve the surveillance of air tour operations in Hawaii8079        through the use of technologies and innovative approaches,8080        including but not limited to comparing automatic dependent8081        surveillance-broadcast (ADS-B) flight position data from air8082        tour flights with weather camera imagery for the route and8083        periodically reviewing onboard video recordings, to detect and8084        correct operating practices that may lead to unacceptable8085        weather-related risky behavior. (A-22-17)80868087   Issue and periodically update a special airworthiness8088        information bulletin that lists newly manufactured helicopters8089        that are equipped with features likely to reduce accidents8090        resulting from inadvertent encounters with instrument8091        meteorological conditions, describes retrofit options for8092        helicopters that do not have such equipment, and encourages the8093        voluntary integration of these safety features. (A-22-18)80948095   Require operators of Bell 407 helicopters to conduct8096        subsequent torque checks of the tail boom attachment hardware8097        and visual inspection of the tail boom attachment fittings as8098        referenced in Safety Recommendation A-22-28 at an interval8099        significantly less than the currently required interval to8100        provide multiple opportunities for detecting any improperly8101        installed or fractured attachment hardware or fittings. Require8102        operators to report findings to the FAA. (Urgent) (A-22-29)81038104   Review all experimental exhibition airworthiness8105        certificates issued to turbine-powered rotorcraft and ensure8106        that their operating limitations meet the standards of the8107        latest iteration of Federal Aviation Administration Order8108        8130.2, Airworthiness Certification of Aircraft. (A-24-20)81098110   Establish periodic reviews for experimental exhibition8111        airworthiness certificates to ensure that those aircraft are8112        being inspected and maintained according to the latest8113        iteration of Federal Aviation Administration Order 8130.2,8114        Airworthiness Certification of Aircraft. (A-24-21)81158116   Require operators of aircraft equipped with Ozark Aeroworks8117        T53 series engines to perform recurrent inspections of the rear8118        bearing cover and the exhaust diffuser inner cone and inner8119        struts with the exhaust diffuser cover removed. (A-24-22)81208121   Remind operators of experimental exhibition aircraft about8122        the requirement to submit, to the appropriate flight standards8123        district office, program letters that list all events at which8124        the aircraft will be exhibited. (A-24-23)81258126   Develop a method for ensuring that operators of experimental8127        exhibition aircraft meet their annual obligation to submit8128        program letters; such a method could include potential8129        penalties for operators that do not meet this obligation. (A-8130        24-24)81318132   Revise Federal Aviation Administration Order 8900.1, Flight8133        Standards Information Management System, to include inspector8134        guidance requiring routine surveillance of operators of8135        aircraft with experimental exhibition airworthiness8136        certificates. (A-24-25)81378138                                  [all]