Washington mid-air collision was ‘100% preventable’, NTSB says

“These underlying deficiencies, often referred to as latent conditions, or systemic vulnerabilities, are what aligned to allow for the worst U.S. aviation disaster – in terms of fatalities – since November 12, 2001, when American Airlines flight 587 crashed into a residential area of Belle Harbor, New York, killing all 260 people aboard the airplane and five on the ground,” she said.

According to the NTSB, a confluence of different factors resulted in the disaster, including failures by the US Federal Aviation Administration (FAA) to act on concerns about helicopter separation in congested DC airspace; heavy reliance on “visual separation” in the area; instrument failures on board the Black Hawk; and only one air traffic controller handling both local air and helicopter traffic on the night of the crash.

In particular, Homendy was scathing of FAA regulators who had not acted on reports of 80 close calls between helicopters and passenger planes in the years leading up to the accident, calling it “one failure after another”.

“The data was there. The data was in their own systems,” she told reporters.

“We should be angry, because for years, no one listened. This was preventable. This was 100 per cent preventable.

Frankly, having a helicopter route crossing Runway 33 with only 75 feet of vertical separation – what that means is 75 feet, at best, separating a helicopter and civilian aircraft. Nowhere in the airspace is that OK, nowhere.”

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While human error played a part in the disaster, Homendy also cautioned in her opening remarks against blaming individuals, noting that “human error is a symptom of a system that needs to be redesigned” in a quote from aviation expert Professor Nancy Leveson.

“There is a tendency in the immediate aftermath of any accident we investigate to question human error – on the actions or inactions of individuals,” she said.

“​However, human error in complex systems, like our modern aviation system and the National Airspace System, isn’t a cause; it’s a consequence. Many things need to go wrong for an accident to occur.

“In any investigation, the NTSB could choose to focus on a simple moment – on what happened immediately prior to the accident – on the individuals involved. But that’s not the whole picture.

“To quote research from the National Highway Traffic Safety Administration, what we refer to as human error is, in reality, ‘the last event in the causal chain immediately preceding [a] crash’.”

The US government in December admitted partial fault for the disaster in a response to a lawsuit from victims’ families.