AMERICAN AIRLINES FLIGHT 5342 MID-AIR COLLISION MILITARY HELICOPTER - APPROACH RADAR SCREEN NOT SO PRECISE FOR TARGETS PRESENTATION

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Above image: APPROVED FLIGHT PLAN

ATC: PAT25...PASS BEHIND...CRJ7"

PAT25 CVR: NOT RECORDED THE 'PASS BEHIND' PHRASE

Updated FEB 15, 2025 

NTSB Cleared up the ATC instruction to helicopter PA25

Ipsis Litteris

NTSB Feb. 14, 2025, NTSB Briefing Points on Mid-air Collision near DCA

Preliminary investigative information which is derived from a variety of electronic and other sources as of 1:00pm today.

• About 8:15 pm EST, the CRJ left 37,000 feet pressure altitude for an initial descent.

• About 8:30, the Blackhawk began travelling generally southbound after maneuvering near Laytonsville, Maryland. CVR audio from the Blackhawk indicated the instructor pilot was the pilot monitoring and transmitting on the radio and the pilot was the pilot flying. (ATC Radar & Blackhawk CVR)

• At 8:33:41, the Blackhawk crew requested Helicopter Route 1 to 4 to Davison Army Air Field, which the tower controller approved.

• 8:38:39, the Blackhawk reached the intersection of the DC Beltway and the Potomac River near Carderock, Maryland. After briefly turning westbound, the Blackhawk turned back to the east and began descending as it picked up helicopter route 1 over the Potomac River southeast toward downtown Washington, DC.

• At 8:39:10, Potomac Approach cleared the crew of the CRJ for the Mount Vernon Visual Runway 1 approach.

• At 8:40:46, the CRJ rolled out of a left turn established on the ILS Localizer for

Runway 1, at approximately 4,000 feet pressure altitude, 170 knots, with

landing gear up and flaps extended to 20 degrees.

• At 8:43:06, the CRJ crew made initial contact with DCA Tower. The tower

controller then asked if the crew could switch to runway 33. The CRJ crew

agreed to switch to runway 33.

• At 8:43:48, the Blackhawk was about 1.1 nautical miles (NM) west of the Key

Bridge. The pilot flying indicated they were at 300 feet. The instructor pilot

indicated they were at 400 feet. Neither pilot made a comment discussing an

altitude discrepancy. At this time, we do not know why there is a discrepancy

between the two; the investigative team is exploring this.

• At 8:44:27, as the Blackhawk approached the Key Bridge, the instructor pilot

indicated the Blackhawk was at 300 feet descending to 200 feet.

• Between 8:44:41 and 8:44:45 the CRJ crew selected 30 degrees of flaps and

then 45 degrees of flaps.

• At 8:44:49, the CRJ landing gear were down and locked. The aircraft was fully

configured for landing, approximately 6.2 NM south of the airport.

• At 8:45:27, the autopilot was disconnected and the CRJ began a shallow right

turn off of the Runway 1 localizer at a radio altitude of approximately 1,700 ft

and an airspeed of 134 kts. This occurred approximately 5.0 NM south of the

airport.

• At 8:45:30, the Blackhawk passed over the Memorial Bridge. The instructor

pilot told the pilot flying that they were at 300 feet and needed to descend.

The pilot flying said they would descend to 200 feet.

• At 8:45:58, the Blackhawk then crossed over the Washington Tidal Basin and

followed the Washington Channel consistent with Helicopter Route 1.

• It is now approximately two minutes before the collision.

• At 8:46:01, a radio transmission from the tower was audible on the CRJ CVR

informing the Blackhawk that traffic just south of the Wilson Bridge was a CRJ

at 1200 feet circling to runway 33.

3Feb. 14, 2025, NTSB Briefing Points on Mid-air Collision near DCA

• CVR data from the Blackhawk indicated that the portion of the transmission

stating the CRJ was “circling” may not have been received by the Blackhawk

crew. We hear the word “circling” in ATC communications, but we do not hear

the word “circling on the CVR of the Blackhawk. The Recorders Group is

evaluating this.

• At 8:46:08, the Blackhawk crew responded they had the traffic in sight and

requested visual separation which was approved by DCA Tower.

• At 8:46:29, the CRJ crew received a 1000-foot automated callout.

• At 8:46:47, DCA tower cleared other jet traffic on Runway 1 for immediate

departure with no delay.

• At 8:47:27, or 32 seconds before impact, the Blackhawk passed the southern

tip of Hains Point.

• A second later, the CRJ began a left roll to turn to final on Runway 33. The CRJ

was at a radio altitude of 516 ft and 133 kts.

• At 8:47:29, the CRJ crew received a 500-foot automated callout.

• At 8:47:39, or 20 seconds before impact, a radio transmission from the tower

was audible on both CVRs asking the Blackhawk crew if the CRJ was in sight.

Audible in the ATC radio transmission was a Conflict Alert in the background.

• At 8:47:40, the CRJ crew received an automated traffic advisory from the TCAS

system stating “Traffic, Traffic.” TCAS is the Traffic Alert and Collision Avoidance

System on the CRJ.

• At 8:47:42, or 17 seconds before impact, a radio transmission from the tower

was audible on both CVRs directing the Blackhawk to pass behind the CRJ.

CVR data from the Blackhawk indicated that the portion of the transmission

that stated “pass behind the” may not have been received by the Blackhawk

crew. Transmission was stepped on by a 0.8 second mic key from the

Blackhawk. The Blackhawk was keying the mic to communicate with ATC.

• In response, at 8:47:44, the Blackhawk crew indicated that traffic was in sight

and requested visual separation which was approved by DCA Tower. The

instructor pilot then told the pilot flying they believed ATC was asking for the

helicopter to move left toward the east bank of the Potomac.

4Feb. 14, 2025, NTSB Briefing Points on Mid-air Collision near DCA

• At 8:47:52, or 7 seconds before impact, the CRJ rolled out on final for runway 33. The CRJ was at a radio altitude of 344 ft, 143 kts.

• At 8:47:58, or 1 second before impact, the CRJ began to increase its pitch, reaching about 9 degrees nose up at the time of collision. FDR data showed the CRJ elevators were deflected near their maximum nose up travel.

• The last radio altitude recorded for the CRJ was 313 ft and was recorded two seconds prior to the collision. The CRJ pitch at this time was, again, 9 degrees nose up, and roll was 11 degrees left wing down. The CRJ was descending at 448 feet per minute.

• The radio altitude of the Blackhawk at the time of the collision was 278 feet and had been steady for the previous 5 seconds. The Blackhawk pitch at the time of the collision was about a half degree nose up with a left roll of 1.6 degrees. Examination of wreckage will assist in determination of the exact angle of the collision.

• We are confident that the radio altitude of the Black Hawk at the time of the collision was 278 feet. I want to caution this does not mean this is what the Black Hawk crew was seeing on the barometric altimeters in the cockpit.

• We are seeing conflicting information in the data, which is why we aren’t releasing altitude for the Blackhawk’s route.

INSIDE ALL AIR TRAFFIC CONTROL TOWER THERE IS AT LEAST A RECORDER

• The CRJ’s cockpit voice recorder has now been downloaded and read out. All times listed in Eastern Standard Time —
• 20:45:27: CRJ Autopilot off
• 20:46:01: ATC makes PAT25 aware of CRJ south of the Wilson Bridge
• 20:46:29: 1000’ call out on CRJ
• 20:47:29: 500’ call out on CRJ
• 20:47:39: ATC asks if PAT25 has the CRJ in sight
• 20:47:40: TRAFFIC TRAFFIC aural alert sounds
• 20:47:42: DCA Tower directs PAT25 to pass behind the CRJ
• 20:47:58: CRJ crew has verbal reaction and airplane begins to increase its pitch
• 20:47:59: Sounds of impact
• There were 5 air traffic controllers in the DCA tower at the time of the accident
• 1 Local controller working fixed wing and helicopter traffic
• 1 Ground controller
• 1 local assistant controller
• 1 Supervisor
• 1 Supervisor in training

 

• The CRJ’s cockpit voice recorder has now been downloaded and read out. All times listed in Eastern Standard Time —
• 20:45:27: CRJ Autopilot off [Piloto Automático do avião foi desligado]
• 20:46:01: ATC makes PAT25 aware of CRJ south of the Wilson Bridge [Controlador de Tráfego Aéreo alerta o piloto do helicóptero acerca do avião ao sul da ponte Wilson]
• 20:46:29: 1000’ call out on CRJ [o Sistema de automático de alerta de altitude do avião anuncia que a aeronave está 1000 pés acima da superfície da água]
• 20:47:29: 500’ call out on CRJ [o EGPWS alerta que o avião está 500 pés acima da superfície da água]
• 20:47:39: ATC asks if PAT25 has the CRJ in sight [o Controlador de Tráfego Aéreo pergunta ao piloto do helicóptero se ele tem na visão dele o avião]
• 20:47:40: TRAFFIC TRAFFIC aural alert sounds [o Sistema de Alerta de Colisão entre Aeronaves dispara o anúncio TRÁFEGO, TRÁFEGO]
• 20:47:42: DCA Tower directs PAT25 to pass behind the CRJ [o Controlador de Tráfego Aéreo instrui o helicóptero para passar por trás do avião]
• 20:47:58: CRJ crew has verbal reaction and airplane begins to increase its pitch [o piloto do avião reage verbalmente e inicia o aumento de inclinação do nariz do avião para cima]
• 20:47:59: Sounds of impact [ouve-se o ruido da colisão das duas aeronaves]
•  
• There were 5 air traffic controllers in the DCA tower at the time of the accident
• Havia 5 Controladores de Tráfego Aéreo na hora do acidente:

 

• 1 Local controller working fixed wing and helicopter traffic

[Um Controlador local trabalhando no tráfego de aeronave com asa fixa(avião) e helicóptero].

• 1 Ground controller

[Um Controlador de tráfego no solo]

• 1 local assistant controller

[Um Assistente de Controlador]

• 1 Supervisor

[Um Supervisor]

• 1 Supervisor in training

[Um Supervisor em treinamento]

According to an Army report, the service began issuing night-vision devices to its aviators in 1985 and has continually acquired goggles that allow pilots and aircrew to see more clearly and with better depth perception at night ever since.

Pete Hegseth, secretary of defense, said the Army crew members involved in Wednesday’s crash were performing a required annual night training and that they “did have night-vision goggles.”

Recent Army-wide standardization inspections and accident investigations have revealed deficiencies in maintenance and use of night vision goggles (NVGs) and the Aviator’s Night Vision Imaging System (ANVIS). The purpose of this article is to clarify requirements for modification, inspection, and use of AN/PVS-5 series NVGs and the ANVIS-6.

 

AN/PVS-5 series NVGs Modification.  Only two modifications are authorized for ANI PVS-5 series NVGs used in aviation operations. One is the modified faceplate

(MFP) described in the U.S. Army Aviation Center booklet: AN/PVS-5, 5A Night Vision Goggle Aviator Modifications, dated 10 Jun 83.

The other modification authorized for AN/PVS-5 NVGs in aviation use is the GX-5 flip-up described in an April 1987 booklet published by the Aviation Life Support Equipment Project Manager’s Office, Aviation Systems Command (AVSCOM).

Runway 33 and Runway 04 CLOSED

Above image: OFFICIAL HELICOPTER CORRIDORS in hard blue; APPROVED Flight Plan in magenta; MAXIMUM ALTITUDE in red circle.

 

The Air Traffic Controller's radar screen demonstrates that there is NO PRECISION for each aircraft geographical position in the target presentation on the radar screen. The targets are shown as if the helicopter had already passed behind the CRJ7 plane. In conclusion, the ATC see the target in FALSE position. There is an ERROR between the target shown on radar screen and the real aircraft position.

In the next second, the plane descends 300 feet and collides with the helicopter.

Double Collision Risks

ATC Audio-Video

Approach Collision Risks http://youtu.be/sSZq3p18d1o

UPDATED

AUG 7, 2012

FAA
MEMORANDUM

Date: AUG 07, 2012

This incident should not have happened.
Investigation reconfirmed that at no point were the aircraft on a head-to-head course and the aircraft remained at different altitudes.
Initial information indicated that the miscommunication occurred when the TRACON and Tower were turning the flow of traffic at the airport due to bad weather developing south of the airport.
As the investigation has continued, it has concluded that management's intention at the TRACON was initially only to turn the direction of a series of arrivals.
Only after the loss of separation events, was the flow of traffic at the airport turned completely.

Separately, the FAA interviewed the pilot of inbound Republic 3329  who had reported LOW FUEL to the Tower and found that the aircraft did have adequate fuel, and, in fact, upon landing had more fuel than the FAA regulations require as a reserve.
The procedure used for this series of arrival involved opposite direction operations.

These operations occur when an arrival or a departure is cleared to use a runway end that is opposite from the established flow of the airport. These procedures are used at DCA and at airports around the country in a variety of situations including noise mitigation and cargo operations.

While this procedure encompasses many of the same elements as turning the flow of an airport, there is no standard protocol in place, and FAA believe this contributed to the miscommunication.

FAA has initiated a temporary suspension on opposite direction operations at commercial airports until detailed procedures can be developed, trained and implemented. Although most air traffic facilities have detailed procedures for runway changeoperations, procedures for opposite direction arrivals and departures are not standard.

Air traffic controllers cleared two planes to take off on one runway while a third plane was on approach toward them and had been cleared to land on the same runway, according to the Federal Aviation Administration. The reason apparently was a “miscommunication” with air traffic controllers, the F.A.A. said.

Controladores de tráfego aéreo autorizaram dois aviões decolarem numa pista enquanto um terceiro avião estava em aproximação em direção a eles e tinha sido liberado para pouso na mesma pista, de acordo com a FAA. A razão aparentemente foi uma  “comunicação errônea”  com controladores de tráfego aéreo, disse o FAA.

The episode happened at about 2 p.m. Tuesday, and involved three US Airways regional jets carrying a total of 192 passengers and crew members. No one was hurt.
O episódio aconteceu por volta das 2 horas da tarde. Terça-feira, e envolveu três jatos regionais da US Airways carregando um total de 192 passageiros e membros de trupulação. Ninguém foi ferido.

The first plane taking off came within 0.82 miles of the arriving plane and the second one came within 2.7 miles, according to Michael Huerta, the F.A.A.’s acting administrator. The two departing planes and the incoming jet were 800 feet above or below one another, he said.

O primeiro avião decolando aproximou-se dentro de 1,5 Km do avião chegando e o segundo avião aproximou-se dentro de 5 Km, de acordo com Michael Huerta, o administrador da FAA. Os dois aviões partindo e o jato chegando estiveram 800 pés acima ou abaixo um dos outros, ele disse.

The episode occurred after an F.A.A. regional center changed runway flows because of bad weather developing south of the airport, which is in Arlington, Va., across the Potomac from Washington. Planes were directed to land to the north of the runway instead of to the south.

O episódio ocorreu após um Centro [de Controle de Tráfego Aéreo] regional da FAA ter mudado o fluxo de pista por causa de mau tempo em desenvolvimento ao Sul do aeroporto, o qual está em Alington, Virginia, em frente ao [rio] Potomac em Washington. Os aviões estavam direcionados para pouso na pista 01 em vez da pista 19.