I Assign Blame to FAA
Below is a copy of the ICAO risk mitigation chart. Everyone can see that these operations into DCA would be in the red zone mandating a fix. They've always been in the red zone because we should never have had military operations conducting training and flying below passenger aircraft.
The FAA did not mitigate risk in this high risk environment, despite every message saying they should, and thus this accident happened. The question was never "if" it would happen, it was always "when" it would happen. The FAA rolled the dice on the profitability of airline operations over passenger safety. The passengers, crew, and all their families lost.
Our safety system is supposed to identify and reduce risk so accidents don't happen. In the past, we had a system that fixed the problem after we killed people, so it wouldn't occur again. Today we have systems in place to mitigate risk, to avoid the crash before we kill people, but the FAA does not enforce any of them.
History taught us that poor crew communications impacted safety, thus in 1990 CRM began. AQP became a methodology for training with a CRM focus. The 5th generation of CRM brought us Threat and Error Management. These regulations and programs identified our industry was working towards a positive safety culture. Without a positive safety culture, we do not have a safe environment. Then in 2015 came Safety Management Systems (SMS). But wait! Did you know that the International Civil Aviation Organization (ICAO) introduced SMS to its annexes in 1980? It took the FAA 35 years to enact SMS in the United States. This federal regulation was not enacted until 2015, but airlines were not required to have one in place until 2018.
SMS is a federal regulation that mandates risk mitigation. Everyone in the organization is tasked to identify and report high-risk operations to those empowered to create change and reduce risk and avoid accidents. Unfortunately employees are retaliated against when they report safety concerns and their lives are subsequently destroyed. Even when the FAA knows of the violations, the employees still face adverse actions. While it's not the FAA's responsibility to defend pilots, it is their responsibility to protect the airspace! The FAA received ASAP reports and knew of the multiple near misses and yet they did nothing.
We know that that the Blackhawk helicopter hit the American Eagle Jet. We know that this was a checking event. We even know they were off altitude and course. The answers as to why the course and altitude irregularities, will (should) be disclosed after the accident investigation. I speculate that human error was involved. Human error is inevitable, and the reason we have implemented safety measures over the years, to help trap and capture those errors. While it appears the industry has been working to improve safety, unfortunately todays safety measures are nothing but smoke and mirrors.
Because the FAA has an incestuous relationship with airline management. Many of those in FAA oversight also do not have a clue as to the new regulations or constraints of flying today. One FAA oversight inspector on Delta's certificate said, when I mentioned SMS and AQP, "I don't know what those are because I retired before they came into effect." That is scary. Regardless, the options as how to mitigate risk in this DCA environment were many, but they would have impacted the bottom line of airline operations. Therefore, status quo until death.
Until we prohibit the revolving door between airline management, the FAA, and the board of directors position, and find an FAA administrator who believes in life over money and doing the right thing, we will continue to play Russian Roulette with passengers lives.
My heartfelt prayers go out to the families of those lost in this accident. I will not allow your loved ones deaths to be in vain. I'm actually angry at what transpired because it could have been avoided if the FAA did its job. This is the very reason I spoke out in 2015, to fight for safety so accidents would not happen and I fought a legal battle for seven years to create change. (Petitt vs Delta, Seattle Times) Nobody was held accountable. No change was made. And the FAA looked the other way and even sanitized records of violations. There are a lot of good people working in the FAA, but they too are fearful for their jobs if they speak out. Something must be done. I took early retirement in 2023 so I could be a voice for safety, and I while we cannot bring your loved ones back, I will fight to make change happen.
I hope that every person will file a wrongful death lawsuit against the FAA. I have evidence of what I write here today and will provide as requested. We cannot bring your loved ones back, but we can create change together and ensure the pain you feel will never be experienced by anyone else.
A350, B777, A330, B747-400, B747-200, B767, B757, B737, B727
Karlene,
ReplyDeleteThe moment they confirmed it was a CRJ-700 (an aircraft I flew at my previous airline) I started sobbing. I felt so much sadness thinking of the passengers onboard...and thinking about what the crew would have been doing in the seconds before.
Then came anger as I thought, "We've been telling the powers in charge for years that this was going to happen...why the hell do they always wait for people to die!?"
I'm heartbroken and angry, but I know all of us involved in the industry have to use that emotion to pressure them into actually making changes that keep people safe. Yesterday, I flew again for the first time since it happened. I looked at my passengers as they were waiting in the gate area...and silently said to myself, "All of us have work to do...for them."
Thank you for your continued work towards making the industry better!
-JC
JC, I cried too. Not only for the pilots, but the passengers looking out the window at the lovely river and the beautiful lights on approach, and saw the helicopter heading their way. Helpless. We all have been telling the powers in charge this would happen, and yet they did nothing. Now we don't need to analyze all the events that created this perfect storm... because all weather reports said it was coming and lives would be lost if we did not do something to avoid it. The FAA gambled and lives were lost for airline profitability. Thanks for your comment and fly safe.
DeleteIt's so sad, and it was so preventable. Why was night training done under civilian traffic? Why were they 200 feet too high? Add in the runway change, a short-staffed tower, maybe misidentified traffic or a multitude of other mistakes, and they put the lid on the coffin. :(
ReplyDeleteExcellent questions. The only reason it was done, because the government asserts it needs to be done, and it would cost airlines, and the airport, and all the services, too much money to stop flights during training. The only reason it occurred is because the FAA did not prohibit that training with ongoing airline operations. The runway change was to get another plane out off the other runway. Otherwise they would have had to wait for the first plane to land and clear. Now they could land and take off at the same time. Trying to be efficient. The altitude error... human error, training, maybe the student was under a hood, doing instrument work, distraction, confusion, a number or reasons ... we don't know. Hopefully the NTSB will figure that part out. But, whatever they find out, we can't change human mistakes. We have a way of making new ones all the time. We train airline pilots in a simulator so we can allow pilots to make mistakes without harming people. But, we do train on the line, and then the check airman is the expert to ensure the operation is safe.
DeleteThere is simply airspace that should be prohibited to fly if unsafe operations are ongoing. This is one of those spaces. But authorities knew that.
On April 8, 2024- A Southwest Boeing 737 and a JetBlue Airways Embraer E190 narrowly avoided a a runway collision at DCA. JetBlue was cleared for takeoff. Southwest was cleared to cross the same runway. On May 29, 2024- An American Airlines A319 had to brake to avoid a private King Air flight as it was cleared to land on an intersecting runway at the same time. I used to live in Fairfax Virginia. I drove by DCA and witnessed violations of the minimum separation distance among aircraft on final (especially for runway 1).
ReplyDeleteAnd Dennis if you saw this... many others did too. We all know you can only get lucky so many times. And accident prevention should not be based upon luck. Thank you for sharing this long and ongoing problem in that airport.
DeleteThe FAA bows to the Airlines and the Aircraft Manufacturers. The FAA was provided irrefutable evidence that UPS submitted false statements obtained from pilots with duis and refusal to submit to chemical tests to FAA HIMS AMEs. These false statements were used to target and terminate a 22 year USAF vet/ 20 year UPS pilot.
ReplyDeleteEmployees who address safety and security issues will be retaliated against and fired. When the FAA is provide proof; the FAA does NOTHING! DARK MONEY, LOBBIESTS, & THE OLIGARCHY RULES.
The reason that this is allowed to continue is because nobody is held accountable. Those who believe they have power to do what they want, play God with pilot's lives in the HIMS program. One AME said he was FAA certified so he could do what he wanted and had no personal responsibility, he was protected. Yes, this is part of a culture problem in the FAA. that must be fixed.
DeleteIt reminds us of a cruel and inescapable truth: we are here today, and perhaps not tomorrow.
ReplyDeleteSixty-four people boarded a plane together after spending tedious hours waiting in the departure lounge barely noticing each other, their eyes glued—as so often happens—to their phones.
Sixty different lives, sixty stories from the day before that flight. A pilot and his young first officer, experienced yet still at the start of his career, likely facing their last flight of the day—just another one to add to their weekly routine.
Two young flight attendants meet their two unfamiliar pilots, glance over the passenger list among the boarding papers, and think about their layover in Washington that night. They’ll land at nine, be in their hotel rooms by eleven—unless, as they might already be planning, they go for a drink together after the flight.
They board. Someone shivers, annoyed by the cold draft creeping through the jet bridge.
Sixty-four lives take off together, all bound for the same fate, one that will announce itself with a deafening crash—just three or four seconds of horror before the dark, icy waters claim them all in a shared grave.
Yesterday, they were all here. Today, they are not. And they never even introduced themselves.
In the air, just seconds from their destination, 300 feet above the Potomac after soaring at 30,000 feet among the clouds, they are suddenly thrust into a past no one expected—and certainly not in such a tragic way.
Beautifully written. It reminds me that life can flash away in a moment. Here then not.
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