The National Transportation Safety Board (NTSB) has blamed “deep, underlying systemic failures” for last year’s fatal mid-air collision over Washington, DC.
Speaking about the investigation into the Jan. 29, 2025, disaster that killed all 67 people aboard an American Airlines CRJ700 and a U.S. Army Sikorsky UH-60 Black Hawk, Jennifer Homendy, chairwoman of the NTSB, said “system defects” were responsible for the crash.
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“These underlying deficiencies, often called latent conditions or systemic vulnerabilities, are what enabled the worst U.S. aviation disaster – in terms of fatalities – since November 12, 2001, when American Airlines Flight 587 crashed in a residential area of Belle Harbor, New York, killing all 260 people on board the plane and five on the ground,” he said.
According to the NTSB, a confluence of different factors caused the disaster, including the failure of the US Federal Aviation Administration (FAA) to act on concerns about helicopter separation in congested DC airspace; heavy reliance on “visual separation” in area; instrument failures aboard the Black Hawk; and only one air traffic controller was handling both local and helicopter air traffic on the night of the accident.
In particular, Homendy was scathing of FAA regulators who had failed to act on reports of 80 close calls between helicopters and airliners in the years leading up to the crash, calling it “one failure after another.”
“The data was there. The data was in their own systems,” he said. told reporters.
“We should be angry, because for years no one listened. This was preventable. It was 100 percent preventable.
Frankly, having a helicopter route crossing runway 33 with only 75 feet of vertical separation, what that means is, at best, 75 feet separating a helicopter and a civilian aircraft. Nowhere in the airspace is that okay, nowhere.”
While human error played a role in the disaster, Homendy also warned in his 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, immediately after any accident that we investigate, to question human error, in the actions or inactions of individuals,” he said.
“However, human error in complex systems, such as our modern aviation system and the National Airspace System, is not a cause; it is a consequence. Many things have to go wrong for an accident to occur.
“In any investigation, the NTSB might choose to focus on a single moment in time – what happened immediately before the accident – on the people involved. But that’s not the whole picture.
“To quote research from the National Highway Traffic Safety Administration, what we call human error is actually ‘the last event in the causal chain immediately preceding the error.’ [a] crash’.”
In December, the U.S. government admitted partial blame for the disaster in response to a lawsuit from victims’ families.
