Pilot Debrief

BOMBARDIER INC CL-600-2C10 near Washington, DC — 2025-01-30

Final reportDCA25MA108
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Date
2025-01-30
Location
Washington, DC, USA
Aircraft
BOMBARDIER INC CL-600-2C10
Registration
N709PS
Category
Airplane
Highest injury
Fatal
Fatalities
67

Probable cause

The Federal Aviation Administration’s (FAA) placement of a helicopter route in close proximity to a runway approach path; their failure to regularly review and evaluate helicopter routes and available data, and their failure to act on recommendations to mitigate the risk of a midair collision near Ronald Reagan Washington National Airport (DCA); as well as the air traffic system’s overreliance on visual separation in order to promote efficient traffic flow without consideration for the limitations of the see-and-avoid concept. Also causal was the lack of effective pilot-applied visual separation by the helicopter crew, which resulted in a midair collision. Additional causal factors were the tower team’s loss of situation awareness and degraded performance due to the high workload of the combined helicopter and local control positions and the absence of a risk assessment process to identify and mitigate real-time operational risk factors, which resulted in misprioritization of duties, inadequate traffic advisories, and the lack of safety alerts to both flight crews. Also causal was the Army’s failure to ensure pilots were aware of the effects of error tolerances on barometric altimeters in their helicopters, which resulted in the crew flying above the maximum published helicopter route altitude. Contributing factors include: · the limitations of the traffic awareness and collision alerting systems on both aircraft, which precluded effective alerting of the impending collision to the flight crews; · an unsustainable airport arrival rate, increasing traffic volume with a changing fleet mix, and airline scheduling practices at DCA, which regularly strained the DCA air traffic control tower workforce and degraded safety over time; · the Army’s lack of a fully implemented safety management system, which should have identified and addressed hazards associated with altitude exceedances on the Washington, DC, helicopter routes; · the FAA’s failure across multiple organizations to implement previous NTSB recommendations, including Automatic Dependent Surveillance–Broadcast In, and to follow and fully integrate its established safety management system, which should have led to several organizational and operational changes based on previously identified risks that were known to management; and · the absence of effective data sharing and analysis among the FAA, aircraft operators, and other relevant organizations.

NTSB narrative

On January 29, 2025, about 2048 eastern standard time, a Sikorsky UH 60L, operated by the US Army under the callsign PAT25 (Priority Air Transport Flight 25), and an MHI (Mitsubishi Heavy Industries) RJ Aviation (formerly Bombardier) CL-600-2C10 (CRJ700), N709PS, operated by PSA Airlines as American Airlines flight 5342, collided in flight about 0.5 miles southeast of Ronald Reagan Washington National Airport (DCA), Arlington, Virginia, and impacted the Potomac River in southwest Washington, DC. The 2 pilots, 2 flight attendants, and 60 passengers on board the airplane and all 3 crewmembers on board the helicopter died. Both aircraft were destroyed as a result of the accident. Flight 5342 was operating under the provisions of Title 14 Code of Federal Regulations Part 121 as a scheduled domestic passenger flight from Wichita Dwight D. Eisenhower National Airport, Wichita, Kansas, to DCA. PAT25 originated from Davison Army Airfield, Fort Belvoir, Virginia, for the purpose of the pilot’s annual standardization evaluation flight with the use of night vision goggles. Night visual meteorological conditions prevailed in the area of DCA at the time of the accident.

NTSB coding

Evidence available

  • CVR
  • ATC audio
  • Video
  • FDR / data
  • ADS-B / radar
  • 208 docket documents
View NTSB final reportView NTSB docket

Docket documentsshowing 50 of 208

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