NTSB Issues 33 Safety Recommendations in DCA Report

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The National Transportation Safety Board has released its final report on the January 29, 2025 midair collision near Ronald Reagan Washington National Airport, concluding that flawed airspace design and systemic safety management failures contributed to the accident that killed 67 people.

In its nearly 400-page report, the NTSB determined that the Federal Aviation Administration positioned Helicopter Route 4 too close to the Runway 33 approach path without sufficient safeguards to mitigate collision risk. Investigators found that the FAA failed to act on data and repeated warnings indicating a growing risk of midair conflicts in the complex DCA terminal area.

The accident involved a regional jet and a U.S. Army Black Hawk helicopter. The Board cited heavy reliance on pilot-applied visual separation in one of the nation’s busiest and most complex airspace environments. On the night of the collision, the DCA control tower had combined helicopter and local control positions during a high-traffic period, increasing controller workload and reducing situational awareness.

A blocked radio transmission prevented the helicopter crew from hearing part of an instruction to pass behind the arriving CRJ. Investigators said the Army crew, operating with night vision goggles, believed they had the traffic in sight but were flying above the published route altitude.

The report also identified limitations in both aircrafts’ collision-avoidance systems. While the regional jet’s Traffic Collision Avoidance System functioned as designed, it did not generate a higher-level resolution advisory due to altitude constraints. The helicopter was not equipped with an integrated traffic alerting system. The NTSB noted that next-generation systems such as ACAS Xa and ACAS Xr could significantly reduce future collision risks.

The Board issued 33 safety recommendations focused on airspace redesign, expanded use of advanced collision-avoidance technologies and stronger safety management oversight. In its probable cause finding, the NTSB cited FAA airspace design decisions, failure to mitigate known hazards, overreliance on visual separation, high controller workload and inadequate Army oversight of altimetry procedures.

Investigators said the accident resulted from a chain of systemic vulnerabilities that had been evident in safety data prior to the fatal collision.

NTSB DCA final report: https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR2602.pdf 

Sources: AirGuide Business airguide.info, bing.com, avweb.com, NTSB