NTSB Finds Systemic Failures Behind Deadly Washington D.C. Midair Collision
I return to aviation and I recall my work regarding the Shoreham Air Disaster.
It is nearly one year after a fatal midair collision over the Potomac River, Washington DC – the U.S. National Transportation Safety Board, (NTSB), has concluded that the crash on January 29 2025 between an American Airlines regional jet and a U.S. Army Black Hawk helicopter was the result of systemic regulatory and operational failures, not isolated human error.
The collision, which occurred near Ronald Reagan Washington National Airport (DCA), killed all 67 people aboard both aircraft, making it the deadliest U.S. commercial aviation accident in more than two decades.
The Probable Cause
In its final public board meeting, the NTSB sharply criticised the Federal Aviation Administration, (FAA), for placing helicopter routes in dangerous proximity to active runway approach paths without adequate procedural safeguards. The Board formally adopted a probable cause finding that faulted the FAA for multiple issues:
- designing helicopter routes with minimal vertical separation from landing aircraft,
- failing to regularly review and evaluate helicopter traffic data,
- ignoring years of near collision data and
- internal warnings and failing to act on prior safety recommendations aimed at mitigating midair collision risk at DCA.
According to NTSB Chair Jennifer Homendy, the FAA possessed data showing more than 15,000 close proximity events, including 85 serious incidents over a number of years, yet failed to meaningfully analyse or act upon it. Investigators identified an average of 18 close calls per year between helicopters and airplanes operating near the airport.
The Visual Separation
The Board also identified an over reliance on pilot applied ‘visual separation’, which was particularly problematic in congested, night time airspace such as DCA. Investigators concluded that this reliance introduced risk because of cockpit blind spots, background city lighting and the limitations of human perception.
Recreated flight simulations showed how the commercial jet blended into Washington’s night lights from the helicopter cockpit, while cockpit structure and aircraft geometry significantly limited what the airline pilots could see. The NTSB found it would have been extremely difficult for the jet’s crew to visually detect or avoid the helicopter in time.
The Air Traffic Control
Although the NTSB determined that staffing levels alone did not cause the crash, it is not surprising that investigators highlighted controller workload and combined control positions as contributing factors. At the time of the collision, a single controller was communicating with six airplanes and five helicopters.
Crucially, the FAA acknowledged that the control tower failed to warn the airline pilots of nearby helicopter traffic. While the helicopter crew was instructed to pass behind the jet, a partially blocked radio transmission meant they did not hear the full instruction. Believing they had the correct aircraft in sight, a phenomenon attributed to expectation bias, the helicopter crew requested visual seperation.
The Technology Gaps
The investigation also focused heavily on the absence of effective collision avoidance technology, including the Automatic Dependant Surveillance- Broadcast, (ADS-B), a system that transmits an aircraft’s GPS based position, altitude and speed to controllers and nearby aircraft, enabling real time collision alerts.
At the time, the Army Black Hawk was allowed to fly with ADS-B turned off and the regional jet lacked ADS-B In, which would have received alerts. Investigators concluded that, if fully equipped, both crews could have received warnings up to a minute before the collision, potentially preventing the crash.
The findings underscore calls for broader ADS-B equipage, now central to the bipartisan ROTOR Act, which would mandate the system for civil and military aircraft operating near congested airspace.
The Altitude Discrepancies
Investigators also identified discrepancies in the helicopter’s altitude readings. Although the published route capped helicopter altitude at 200 feet, the collision occurred at nearly 300 feet. Allowable equipment tolerances and Army altitude holding standards meant aircraft could unintentionally fly closer to commercial traffic than intended. The NTSB cited shortcomings in the Army’s safety culture, including failures to ensure pilots fully understood altimeter tolerances and route limitations.
The Legal Implications
In December 2025, the U.S. Department of Justice formally admitted federal liability, citing the actions of both the Army helicopter crew and the FAA air traffic controller. During the NTSB hearing, board members emphasised that individual errors were set up for failure, to some extent, by the systems around them.
The Safety Recommendations
The NTSB approved 50 new safety recommendations; the majority quite rightly directed at the FAA. These include redesigning helicopter routes near DCA, integrating helicopter route data into approach procedures, enhancing controller training and conflict alert systems, improving staffing practices and expanding and improving airborne collision avoidance systems.
The Board also warned that similar risk hotspots may exist elsewhere, citing concerns raised by airlines about airports such as Hollywood Burbank in California. We should look for this here in the UK as well.
The Next Steps
An executive summary of the findings is expected shortly, with the full final report, approximately 500 pages, to be released in the coming weeks. While the FAA has implemented some post-crash measures, including reduced arrival rates and increased staffing at DCA, the NTSB stressed that lasting safety reform will depend on sustained regulatory action.
© Lawrence Power 2026
Sources
https://avweb.com/flight-safety/accidents-ntsb/ntsb-dca-midair-collision-was-preventable
https://edition.cnn.com/2026/01/27/us/ntsb-plane-crash-dc-potomac?utm_medium=email&ut m_source=rasa_io&utm_campaign=newsletter