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The REAL Reason for the DCA Midair: NTSB Final Report
74 findings. Fifty recommendations. Five contributing factors. One probable cause.
But the number that really matters? I’ll get to that at the end.
The NTSB has released its report on the DCA midair collision, and I’m going to give you the TLDR on the findings here on Taking Off. Hi, I’m Dan Milliken.
This process has been different from most major investigations. Normally, you get an on-site press briefing in the days after the accident, then a preliminary report a few weeks later, and then you wait more than a year for the final report.
In this case, they’ve already released everything you’d typically find in a final report. And that’s what I’m going to cover now.
Let’s not lose sight of the most important number, which I’ll share at the end.
This was the worst airliner crash in the United States since the Colgan Air turboprop crash in 2009 near Buffalo that killed 50 people. That tragedy led to major changes in airline regulations. Then we went 16 years without a major airliner crash.
Until January 29, 2025.
American Airlines Flight 5342, a PSA regional jet carrying 64 people, was on short final to runway 33 at Washington Reagan National Airport when it was struck by a U.S. Army Black Hawk, call sign PAT 2-5.
The helicopter was on a check ride with a pilot, instructor, and crew member onboard. Both pilots were wearing night vision goggles.
Now let’s look at the NTSB findings.
There were 74 findings in total. The first handful state there were no issues with the crew or the plane of the regional jet. There were no fatigue or certification issues with the jet crew, the helicopter crew, or the tower crew.
Finding number 10 says that while the tower didn’t have its desired staffing levels, it was adequately staffed according to FAA standards at the time of the accident.
But then we get to findings 16 and 17. The combining of the helicopter and local control positions into one position negatively impacted the controller’s performance and situational awareness. Those positions should have been separated.
That led to finding 19: PAT 2-5 could have received a more timely alert had the positions been separated.
Finding 20 says the supervisor was complacent due to extended time on position.
Finding 22: the controller issued an alert to PAT 2-5 but did not give the required traffic alert to the PSA jet.
Finding 27 says the helicopter instructor did not positively identify Flight 5342, despite saying he had. Finding 28: he likely identified the wrong airplane.
Finding 30 states that Army training for helicopter pilots operating in that area was deficient in covering fixed-wing operations. In other words, if the Army pilots better understood fixed-wing traffic flows into Reagan National, they might have had better situational awareness.
Finding 31: the PAT 2-5 crew likely had an altimeter showing them 100 feet lower than they actually were.
Then come findings about problems with the Army’s ADS-B transponders.
Finding 40 notes that Potomac Approach often sends aircraft into DCA without enough in-trail separation, increasing tower workload. This led tower controllers to offload traffic onto runway 33 from runway 1.
Finding 43 emphasizes that DCA had far more traffic than the FAA classified the airport to handle. The FAA declined to provide detailed criteria for determining DCA’s facility level. Available information suggests traffic count alone drove the classification, with inadequate consideration of airspace and operational complexity.
Staff believed the downgrade negatively impacted staffing and retention, harming the tower’s overall health.
Finding 44 states the FAA Air Traffic Organization failed to recognize these issues, forcing the tower to compensate. The ATO is also criticized for failing to follow procedures to drug and alcohol test controllers after the accident.
Then comes finding 52 — one of the smoking guns.
Annual reviews of helicopter route charts were required by FAA order. These reviews could have identified the risk posed by the proximity of Helicopter Route 4 to the runway 33 approach path.
There is no evidence those annual reviews were ever performed at Reagan National. Not one.
Runway 33 has existed since the 1940s. Helicopter Route 4 has existed since 1986. The FAA was required to review it annually. That didn’t happen.
Other findings note that aeronautical charts were inadequate. Fixed-wing pilots were unaware of possible conflicts between helicopter routes and approach/departure corridors because charts did not provide adequate information.
Finding 55 states that the lack of ADS-B from the helicopter did not contribute to the accident. So despite the controversy, the NTSB says ADS-B would not have made a difference.
The airplane’s TCAS operated normally but was ineffective at low altitude due to system limitations designed to avoid ground clutter overload.
Finding 59 notes that TCAS does not use ADS-B data.
Later findings point to missed opportunities where newer technology could have prevented the collision.
Finding 66 says the FAA Air Traffic Organization was aware of the risks but failed to mitigate them.
Over ten years, there were 15,214 close proximity events at DCA, including 85 near misses. The FAA did not follow its own safety management system principles, eroding safety culture.
Finding 71 says the U.S. Army was not monitoring its flights and was unaware that helicopters routinely exceeded altitude limits.
The remaining findings cite shortcomings in Army safety systems and programs.
All of this leads to one probable cause.
The FAA placed a helicopter route in close proximity to a runway approach path. They failed to regularly review and evaluate helicopter routes and available data. They failed to act on recommendations to mitigate collision risks. And the air traffic system over-relied on visual separation to promote traffic efficiency without accounting for the limitations of the see-and-avoid concept.
The NTSB also states that the helicopter crew failed to effectively apply visual separation, contributing to the collision.
Additional causal factors include the tower team’s loss of situational awareness due to high workload, the absence of a real-time risk assessment process, misprioritization of duties, inadequate traffic advisories, and lack of safety alerts to both crews.
The Army also failed to ensure pilots understood altimeter error tolerances, resulting in the helicopter flying above its maximum published route altitude.
Then there are the five contributing factors: limitations of TCAS, high traffic volume at DCA, the Army’s lack of a safety management system, the FAA’s failure to implement prior NTSB recommendations, and the absence of effective data sharing among the FAA, operators, and other organizations.
The NTSB also issued 50 recommendations directed at the FAA, U.S. Army, Department of Defense, and Department of Transportation.
These recommendations address avoidance technology, safety management systems, mandatory ADS-B requirements, proper drug and alcohol testing procedures, safer spacing procedures, and implementation of existing safety programs.
But the NTSB cannot force anyone to act. It can only recommend.
Which raises the question: how many more people need to die before action is taken?
That brings us to the most important number.
Sixty-seven.
On a cold night, January 29, 2025, 67 people were gone in a flash.
Sixty-seven families devastated. Sixty-seven lives ended. Sixty-seven voices silenced.
According to the NTSB, those 67 people died because of administrative failures. Data that was known but not acted upon. Safety programs known but not implemented. Procedures known but corners cut.
Back in 2013, a nearly identical incident occurred in the same location. A helicopter almost hit an airliner. A committee was formed. It identified the risk and recommended moving or eliminating Helicopter Route 4.
An FAA administrator decided not to act.
I want to know who that was.
Sixty-seven families deserve to know who that was.
That’s my takeaway from this tragic event.
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And if you haven’t seen our previous report with the animation of what the pilot saw, check it out.
Remember: superior judgment trumps superior skill.
Take care.