Remarks as prepared for delivery.
Good morning and welcome to the National Transportation Safety Board.
I’m Jennifer Homendy and I’m honored to serve as Chairwoman of the NTSB. I’m joined by my fellow Board Members: Member Michael Graham and Member Todd Inman.
Today’s meeting is open to the public, in accordance with the Government in the Sunshine Act; it’s the first time Board Members and staff have come together to discuss the draft report and to consider the proposed findings, probable cause, and safety recommendations.
The NTSB meets today to finalize our investigation of the midair collision between a Blackhawk operated by the U.S. Army under the callsign PAT25 and a CRJ700 operated by PSA Airlines as American Airlines flight 5342. The collision occurred on January 29, 2025, at about 8:48 pm eastern standard time about a half a mile southeast of Ronald Reagan Washington National Airport.
Tragically, there were no survivors. The two pilots, two flight attendants, and 60 passengers aboard the airplane and three crewmembers aboard the helicopter were fatally injured.
I want to take a moment to address the families and friends of the 67 people who died that day. I imagine every day since January 29th is incredibly difficult for each of you — today, even more so, as we release our findings and Thursday, especially, as we mark one year since this tragedy occurred.
As a mom, I can only imagine all that you’ve been through. You are in our prayers and, on behalf of everyone at the NTSB, please accept our heartfelt condolences and our deepest sympathies.
You are also an inspiration to so many of us. You have, in the wake of absolute devastation, shown remarkable selflessness, courageously advocating for important reforms to improve aviation safety.
I have no doubt the information uncovered by our investigation will support your efforts to make aviation safer…to save lives…to work towards a future where no family endures such tremendous loss.
Our family assistance team and the American Red Cross are here today to provide support for anyone who may need it.
I also want to recognize NTSB staff for your incredible work on this investigation, which is undoubtedly one of the most complex in NTSB’s history.
If anyone would like a glimpse of what these dedicated safety experts have done over the past year, look no further than the public docket for this investigation; it spans more than 19,000 pages and includes testimony from our investigative hearing last July.
And yet, we can never quantify the time you dedicated to this investigation over the past year, from your work on scene to the countless hours spent analyzing and distilling the information into a comprehensive report to ensure every lesson is learned from this devastating tragedy.
That you did so in less than 12 months’ time…while meeting the high bar for quality and impartiality that our agency is known for…at one point working through the longest government shutdown in history with a myriad of other accident investigations underway…is a true testament to your dedication and professionalism. Thank you for all you do.
There is a tendency in the immediate aftermath of any accident we investigate to question human error — on the actions or inactions of individuals.
However, human error in complex systems, like our modern aviation system and the National Airspace System, isn’t a cause; it’s a consequence. Many things need to go wrong for an accident to occur.
In any investigation, the NTSB could choose to focus on a simple moment — on what happened immediately prior to the accident — on the individuals involved. But that’s not the whole picture.
To quote research from the National Highway Traffic Safety Administration, what we refer to as human error is, in reality, “the last event in the causal chain immediately preceding [a] crash.”
Indeed, in Board meetings over the years, in our findings and analyses, across all modes of transportation, we’ve often referred to the work of leading scholars like Dr. James Reason, Captain Dan Maurino, and Professor Nancy Leveson to demonstrate that human error is a symptom of deeper, underlying systemic failures. A consequence, not a cause.
These underlying deficiencies, often referred to as latent conditions, or systemic vulnerabilities, are what aligned to allow for the worst U.S. aviation disaster — in terms of fatalities — since November 12, 2001, when American Airlines flight 587 crashed into a residential area of Belle Harbor, New York, killing all 260 people aboard the airplane and five on the ground.
And certainly, we remember the 50 people who died on February 12, 2009, when Colgan Air flight 3407 crashed into a residence in Clarence Center, New York.
A year before the midair collision at DCA, Alaska Airlines flight 1282 experienced an in-flight separation of the left mid-exit door plug and rapid depressurization during climb after takeoff from Portland International Airport.
We were fortunate no one lost their life or was seriously injured. But within weeks, there was a lot of focus on human error — on the actions of a team of Boeing manufacturing employees in Renton.
In the final investigation report, we cited Dr. James Reason:
[W]ithin a robust system, the introduction of a single error is almost never the only cause of an accident. Rather, several barriers of defense must fail for the error to lead to an accident.
In other words: there was a long chain of events that led to the door plug departing from the aircraft — just as there is for every accident we investigate.
In preparing for this Board meeting, I reviewed a myriad of midair collisions we’ve investigated since 1968, when North Central Airlines Flight 261, a Convair 580, collided with a Cessna 150 near General Mitchell Airport in Milwaukee, Wisconsin. That was just one of 38 midair collisions we investigated in 1968.
A year later, we investigated the midair collision of Allegheny Airlines Flight 853 and a small Piper Cherokee outside Shelbyville, Indiana, killing 83 people. Within months, the Board held a hearing on midair collisions in general and issued 14 recommendations aimed at preventing them from reoccurring, including our first recommendation to “expeditiously develop and implement a collision avoidance system in all civil aircraft.”
Fast forward 50 years to 2019. I was the Board Member on scene for a midair collision between a de Havilland DHC-2 (Beaver) airplane and a de Havilland DHC-3 (Otter) about 8 miles northeast of Ketchikan, Alaska. Six people died; 10 others were injured. Mr. Banning and Dr. Bramble were also on scene. We didn’t conclude that the cause was “pilot error,” but rather “the inherent limitations of the see-and-avoid concept.”
The similarities between the midair collisions we investigated 50 years ago in 1969, in Ketchikan in 2019, and near DCA in 2025 are chilling.
In any one of them we could have blamed flight crews, individual pilots, maintenance personnel, or controllers. But we didn’t because we have long recognized that “human error is a symptom of a system that needs to be redesigned.” That’s a quote from Professor Leveson.
When SpaceshipTwo broke up during a test flight in 2014, our probable cause didn’t cite human error, but Scaled Composites’ “failure to consider and protect against the possibility that a single human error could result in a catastrophic hazard.”
And in 2022, when an Amtrak train derailed after hitting a dump truck that was blocking a grade crossing in Mendon, Missouri, we didn’t blame the driver. We found the design of the crossing was flawed; it reduced drivers’ ability to see approaching trains and made stopping difficult for heavy trucks. That enabled Governor Parsons to address not only the safety of that grade crossing, but 49 others across Missouri, saving countless lives.
Steve Wallace, the former director of the FAA Office of Accident Investigations, was interviewed in 2023 to mark the 20th anniversary of the Space Shuttle Columbia disaster. After the Columbia disintegrated upon reentry to Earth, killing all seven astronauts on board, the NTSB was heavily involved in the investigation.
Steve was a member of the Columbia Accident Investigation Board; in the interview, he cites a lesson he learned from our investigators.
NTSB people have a saying that, when you find the human error, that’s not the end of the investigation; that’s the beginning of the investigation. What is the true root cause? The root cause is the thing that you have to change so it doesn’t happen again.
Commercial aviation embraced the same shift in root cause analysis. And the results were powerful.
Flying became safer.
Before this tragedy occurred on January 29, 2025, the U.S. aviation system was experiencing a record level of safety.
That is the power of taking a systems approach, which is based not on speculation but on decades of research, evidence, and our own investigations — where the lessons learned turned into lives saved.
As aviation safety evolves, so do the systems and so do the risks. I’ll repeat: “[W]ithin a robust system, the introduction of a single error is almost never the only cause of an accident. Rather, several barriers of defense must fail for the error to lead to an accident.”
We are here to discuss these failures. Today, you will hear how deep, underlying systemic failures — system flaws — aligned to create the conditions that led to the devastating tragedy on January 29, 2025:
- From design of our airspace around Ronald Reagan Washington National Airport;
- To the limitations of see-and-avoid, which we’ve been warning about for over five decades;
- To failures of entire organizations to evaluate and act on readily available data, heed repeated recommendations, and foster robust safety cultures; and much, much more.
Months ago, I received a letter from someone sitting in this audience today, whose fiancée was aboard flight 5342.
In that letter, he challenged us to “leave no stone unturned, ask the hard, uncomfortable questions that will ruffle feathers, and let no one […] obfuscate or delay the truth.
I assure you; we did just that. You will see today that we left no stone unturned; we asked the hard, uncomfortable questions that ruffled feathers; and we got to the truth."
Our work, however, doesn’t end today with the issuance of a final report; that is just the first step. We must relentlessly…vigorously…pursue safety change. That means we must do everything in our power…even ruffle feathers…to get our recommendations implemented.
Or this will happen again.
I’d like to thank the first responders on behalf of the Board. Dozens of organizations responded to the scene of this tragedy to support search-and-recovery efforts and assist in our investigative work.
Law enforcement, fire officials, dive teams, federal, state and local agencies…we don’t often talk about it, but they’re human, too — and what they experience can also be quite difficult. Thank you for your public service, your dedication, and your heart. You embody the best of what public service means.
Let’s now turn to today’s meeting. We’re going to do things a little differently, as there’s a lot of complex information to get through.
We’ve divided staff presentations into three sections, each of which will be followed immediately by Board Member questions. We believe this is the best way for those watching and in the room to follow along.
Once staff presentations are done, the Board will consider a set of findings, the probable cause, a number of recommendations aimed at improving safety and preventing a similar tragedy from occurring, and then the draft report.
I’ll now turn it over to our Deputy Managing Director for Investigations Brian Curtis to introduce the NTSB team. Good morning, Mr. Curtis.
