On Jan. 29, 2025, about 2048 eastern standard time (EST), a Sikorsky UH-60L, operated by the US Army under the callsign PAT25, and an MHI (Mitsubishi Heavy Industries) RJ Aviation (formerly Bombardier) CL-600-2C10 (CRJ700), N709PS, operated by PSA Airlines as flight 5342, collided in flight approximately 0.5 miles southeast of Ronald Reagan Washington National Airport (DCA), Arlington, Virginia, and impacted the Potomac River in southwest Washington, District of Columbia. The 2 pilots, 2 flight attendants, and 60 passengers aboard the airplane and all 3 crew members aboard the helicopter were fatally injured. Both aircraft were destroyed as a result of the accident.
The NTSB held a board meeting on this investigation on Tuesday Jan. 27, 2026.
Jan. 27, 2026 Board Meeting Presentations:
Investigator-in-Charge Presentation
Air Traffic Control (ATC) Presentation
ATC Human Performance Presentation
ATC Postaccident Drug and Alcohol Testing Presentation
Collision Avoidance Presentation
Helicopter Operations Presentation
Human Performance Operations Presentation
Safety Data and Safety Management Systems Presentation
July 30 - Aug.1, 2025 Investigative Hearing
The NTSB held a 3 day invesigative hearing on July 30-Aug.1, 2025
Watch:
NTSB YouTube Playlist includes all hearings and media briefings
Images are available on
NTSB's Flickr
Findings
- The pilots of flight 5342 were certificated and qualified in accordance with federal regulations.
- The pilots of flight 5342 were medically qualified for duty, and available evidence does not indicate that they were impaired by effects of medical conditions or substances at the time of the accident.
- Review of the flight 5342 pilots’ time since waking and sleep opportunities in the days before the accident indicated that the pilots were unlikely to have been experiencing fatigue.
- The pilot, instructor pilot, and crew chief onboard PAT25 were qualified and current in their positions as designated by the unit commander in accordance with Army regulations.
- The pilot, instructor pilot, and crew chief of PAT25 were medically qualified for duty, and available evidence does not indicate that they were impaired by effects of medical conditions or substances at the time of the accident.
- Review of the three PAT25 crewmembers’ time since waking and sleep opportunities in the days before the accident indicated that the crew were unlikely to have been experiencing fatigue.
- The airplane was properly certificated, equipped, and maintained in accordance with 14 CFR Part 121. The airplane was operated within its weight and balance limitations throughout the flight. Examination of the airplane revealed damage consistent with an in-flight collision and subsequent impact with water, and there was no evidence of any structural, system, or powerplant failures or anomalies. Review of surveillance videos indicated that the airplane’s wing navigation, landing/taxi, and anti-collision strobe lights were operating at the time of the collision.
- The helicopter was properly certificated, equipped, and maintained in accordance with US Army regulations. Review of helicopter maintenance records did not reveal any open discrepancies or anomalous trends that contributed to the accident. The helicopter was operated within its weight and balance limitations throughout the flight. Examination of the helicopter revealed damage consistent with an in-flight collision and subsequent impact with water, and there was no evidence of any structural, main or tail rotor system, flight control system, or powerplant failures or anomalies. Review of surveillance videos indicated that the helicopter’s right and tail position lights, the landing light, as well as both upper and lower anti-collision lights, were operating at the time of the collision.
- The operations supervisor and four controllers who were working in the Ronald Reagan Washington National Airport air traffic control tower cab at the time of the accident were properly certified, qualified in accordance with federal regulations and facility directives, and current.
- Although the Ronald Reagan Washington National Airport air traffic control tower facility was not staffed to its target level at the time of the accident, the number of staff in the tower at the time of the accident was adequate and in accordance with Federal Aviation Administration directives.
- The decision to combine the helicopter control and local control positions was not the result of insufficient staffing, and personnel were available to staff the helicopter control and local control positions separately had the operations supervisor chosen to do so.
- The local control controller, assistant local controller, and operations supervisor were medically qualified for duty, and available evidence does not indicate they were impaired by effects of medical conditions at the time of the accident.
- Review of the local control and assistant local control controllers’ and operations supervisor’s (OS) time since waking and sleep opportunities in the days before the accident indicated that the controllers, including the OS, were unlikely to have been experiencing fatigue.
- Visual meteorological conditions prevailed in the area at the time of the accident. A review of observations recorded throughout the night of the accident revealed no evidence of any local atmospheric pressure anomalies that would have impacted barometric altimeter readings.
- The Metropolitan Washington Airports Authority Airport Rescue and Firefighting and airport operations staff responded immediately and in accordance with applicable emergency plans and regulatory requirements, deploying land- and water-based resources, and coordinating mutual aid under complex nighttime and on-water conditions.
- Keeping the helicopter control and local control positions continuously combined on the night of the accident increased the local control controller’s workload and negatively impacted his performance and situation awareness.
- The local control and helicopter control positions should have been separated at the time of the accident given present traffic volume and complexity.
- In the two minutes before the accident when traffic volume was increasing, the assistant local controller should have prioritized surveillance of aircraft in the air in order to assist the local controller, rather than diverting her attention to the lower priority task of documenting helicopter information, which could have been completed when traffic volume and complexity had subsided.
- Had the helicopter and local control positions been staffed separately, PAT25 might have received a more timely and effective traffic advisory.
- Due to extended time on position at the time of the collision and his complacency, the operations supervisor was likely experiencing reduced alertness and vigilance, which decreased his awareness of the operational environment and reduced his ability to proactively assess the risks posed by the traffic and environmental conditions at the time of the accident.
- The lack of mandatory relief periods for supervisory air traffic control personnel is contrary to human factors research that shows clear performance deterioration in situations of prolonged time on task.
- Although the local control controller provided an initial traffic advisory to the crew of PAT25 in accordance with Federal Aviation Administration Order Job Order 7110.65, he did not provide a corresponding advisory to the crew of flight 5342 regarding PAT25’s location and intention, which could have increased situation awareness for the crew of flight 5342.
- If the local control controller had issued a standard safety alert to the flight crews of either aircraft as prescribed in FAA Order Job Order 7110.65, providing the conflicting aircraft’s position and positive control instructions, the crew of either aircraft could have taken immediate action to avert the impending collision.
- Initial and recurrent scenario-based training in threat and error management would help controllers identify and mitigate risks and strengthen situation awareness.
- A risk assessment or decision making tool would likely have benefited the accident OS in identifying and mitigating the operational risk factors that were present on the night of the accident.
- Due to degraded radio reception, the crew of PAT25 did not receive salient information regarding flight 5342’s circling approach to runway 33.
- The PAT25 instructor pilot did not positively identify flight 5342 at the time of the initial traffic advisory despite his statement that he had the traffic in sight and his request for visual separation.
- With several other targets located directly in front of the helicopter represented by points of light with no other features by which to identify aircraft type, and without additional position information from the controller, the instructor pilot likely identified the wrong target.
- Interference that obscured the controller’s “circling to” call, the microphone keying that blocked the PAT25 crew from receiving the instruction to “pass behind,” ambiguous visual cues, and the lack of an integrated traffic awareness and alerting system likely reinforced the PAT25 crew’s expectation bias that the airplane was among the traffic approaching runway 1 and did not pose a conflict.
- The absence of documented training on Ronald Reagan Washington National Airport’s fixed-wing procedures and the mixed-traffic operating environment represented a safety vulnerability for Army flight crews operating in the Ronald Reagan Washington National Airport Class B airspace.
- Due to additive allowable tolerances of the helicopter’s pitot-static/altimeter system, it is likely that the crew of PAT25 observed a barometric altimeter altitude about 100 ft lower than the helicopter’s true altitude, resulting in the crew erroneously believing that they were under the published maximum altitude for Route 4.
- A recurrent task to verify the continued accuracy of recorded flight data for US Army aircraft would help ensure the data integrity needed to support quality assurance and safety programs and accident investigations.
- The Federal Aviation Administration and the Army failed to identify the incompatibility between the helicopter routes’ low maximum altitudes and the error tolerances of barometric altimeters, which contributed to helicopters regularly flying higher than published maximum altitudes and potentially crossing into the runway 33 glidepath.
- Pilots need all available information on the potential total error, allowed by design, that could occur in flight on an airworthy barometric altimeter.
- The Army’s post-installation functional check of the transponder on the accident helicopter was insufficient to detect that it was not broadcasting Automatic Dependent Surveillance–Broadcast Out.
- The Army’s lack of a recurrent transponder inspection procedure resulted in the incorrect aircraft address being transmitted by the accident helicopter’s transponder, and the incorrect automatic dependent surveillance–broadcast settings on several other helicopters being undetected.
- Because the APX-123A transponder is designed for use on multiple aircraft platforms, it is possible that incorrect settings may be present on other aircraft used throughout the Department of War armed services.
- The crew of flight 5342 did not see the helicopter until it was too late to avoid a collision because of the high workload imposed during the final phase of their approach, and due to the helicopter’s low conspicuity and lack of apparent motion.
- Times of compacted demand as a result of air carrier scheduling practices increased operational complexity and required mitigations by controllers to maintain spacing and surface movement.
- Ronald Reagan Washington National Airport air traffic control tower routinely received less than the requested miles in trail spacing from Potomac Consolidated Terminal Radar Approach Control, which increased controller workload by requiring them to generate additional spacing to prevent delays or gridlock.
- The practice of “offloading” arrival traffic on approach to runway 1 by asking pilots if they could accept a circling approach to runway 33 was a routine mitigation strategy for Ronald Reagan Washington National Airport controllers to generate spacing that was not provided by Potomac Consolidated Terminal Radar Approach Control.
- Time-based flow management, or metering, would provide Potomac Consolidated Terminal Radar Approach Control and Ronald Reagan Washington National Airport air traffic control tower with a consistent flow of traffic with more accurate spacing and greater predictability, thereby reducing controller workload.
- Ronald Reagan Washington National Airport air traffic control tower has significant airspace, airfield, mixed fleet, and operations complexities that appear to be inconsistent with its current facility level classification.
- The Federal Aviation Administration Air Traffic Organization failed to recognize external compliance verification results as indicators of systemic traffic management, volume, and flow issues at Ronald Reagan Washington National Airport for which controllers were required to compensate.
- The longstanding practice of relying on pilot-applied visual separation (see-and-avoid) as the principal means of separating helicopter and fixed wing traffic in the Washington, DC, area by Ronald Reagan Washington National Airport air traffic control tower, the Army, and other helicopter operators led to a drift in operating practices among controllers and helicopter crews that increased the likelihood of a midair collision.
- Reliance on pilot-applied visual separation (see-and-avoid) as a primary means of separating mixed traffic introduced unacceptable risk to the Ronald Reagan Washington National Airport Class B airspace.
- Ronald Reagan Washington National Airport air traffic control tower’s procedure of maintaining a discrete helicopter frequency when the local and helicopter control positions were combined decreased overall situation awareness for pilots operating in the area.
- Providing controllers with additional salient cues regarding the perceived severity of a potential conflict would reduce controller cognitive load and would likely improve reaction time to the most critical conflict alerts.
- There was no evidence that the local control controller, assistant local control controller, or operations supervisor were under the influence of alcohol or prohibited drugs at the time of the accident; however, evidence was substantially limited by the lack of postaccident alcohol testing, and evidence was of somewhat lower quality than it would have been if drug testing had been conducted sooner following the accident.
- The Federal Aviation Administration Air Traffic Organization’s (ATO) drug and alcohol testing determination did not meet Department of Transportation (DOT) timeliness requirements; furthermore, the ATO’s decision to not conduct drug testing as soon as possible after the testing determination, and to not conduct alcohol testing at all, violated DOT requirements.
- The delayed and inappropriate drug and alcohol testing determination was due in part to the Air Traffic Organization’s (ATO) determination process being inadequately designed to routinely meet Department of Transportation requirements for timely testing, and in part to ATO staff’s incomplete understanding of those requirements.
- Annual reviews of helicopter route charts as required by Federal Aviation Administration Order 7210.3DD would have provided an opportunity to identify the risk posed by the proximity of Route 4 to the runway 33 approach path, but there is no evidence to support that these reviews were being performed at Ronald Reagan Washington National Airport.
- The information published by the Federal Aviation Administration regarding Washington, DC, area helicopter routes was insufficient to provide helicopter and fixed-wing operators with a complete understanding of the helicopter route structure and its lack of procedural separation from fixed-wing traffic.
- Current aeronautical charting does not provide information on visual flight rules helicopter routes that may conflict or come in close proximity to approach and departure corridors, which reduces pilot situation awareness.
- The lack of Automatic Dependent Surveillance–Broadcast (ADS-B) Out from the accident helicopter did not contribute to this accident, as the helicopter was still being tracked by radar, and ADS-B Out would not have provided improved traffic alerting for the Ronald Reagan Washington National Airport controller or the crew of flight 5342, because the airplane was not equipped with ADS-B In.
- The Army’s standard operating procedures that prevent flight crews from enabling Automatic Dependent Surveillance–Broadcast (ADS-B) Out while in flight, when not performing sensitive missions that require ADS-B to be disabled, limit the visibility of military aircraft on collision avoidance technologies that leverage ADS-B information.
- Although the airplane’s traffic alert and collision avoidance system operated as designed, it was ineffective in preventing the collision because of current activation criteria and resolution advisory inhibit altitudes.
- Traffic advisory aural alerts that include additional information about the location of traffic could reduce the time pilots need to visually acquire target aircraft.
- Had the airplane been equipped with an airborne collision avoidance system that used Automatic Dependent Surveillance–Broadcast In information to show directional traffic symbols, the crew of flight 5342 would have received enhanced information about the risk posed by the helicopter, which could have enabled them to take earlier action to avert the collision.
- Although the pilot and instructor pilot onboard PAT25 were equipped with tablets that had the ability to display traffic transmitting Automatic Dependent Surveillance–Broadcast Out, it is unlikely that the pilots were using the tablets to monitor or identify traffic at the time of the accident due to the workload associated with low-altitude flight.
- Technological advances since the development of traffic alert and collision avoidance system II operating standards may allow airborne collision avoidance system Xa with reduced inhibit altitudes to have an expanded alerting envelope while reducing nuisance alerts.
- Although not yet commercially available, had the helicopter been equipped with airborne collision avoidance system Xr with integrated aural alerting, the crew could have received an alert regarding flight 5342 and could have taken action to avert the collision.
- Multiple data sources provided evidence of midair collision risk between fixed-wing aircraft and helicopters at Ronald Reagan Washington National Airport, including on approach to runway 33, before this accident; however, the limited access to and use of available objective and subjective proximity data hindered industry and government stakeholders’ ability to identify hazards and mitigate risk.
- Improving stakeholder access to standardized and objective information about aircraft close proximity encounters for use in safety assurance processes would increase the likelihood of detecting and mitigating hazards before accidents occur.
- The Federal Aviation Administration’s lack of an established process to inform parties about their involvement in events such as near midair collisions or traffic alert and collision avoidance system resolution advisories reduces the likelihood of fully understanding and mitigating future midair collision risk.
- The Federal Aviation Administration Air Traffic Organization was made aware of, and had multiple opportunities to identify the risk of a midair collision between airplanes and helicopters at Ronald Reagan Washington National Airport; however, their data analysis, safety assurance, and risk assessment processes failed to recognize and mitigate that risk.
- The Federal Aviation Administration Air Traffic Organization’s application of its safety management system did not effectively coordinate safety assurance and safety risk management activities with external stakeholders in the Ronald Reagan Washington National Airport Class B airspace.
- Changes to Ronald Reagan Washington National Airport air traffic control tower’s standard operating procedures to the accident removing the requirement for the operations supervisor (OS) to document the time and reason for combining or de-combining the helicopter control position in the facility log made it less likely that the OS would consider and evaluate the risks associated with combining or de-combining the position.
- Safety risk management practices were not fully integrated into Ronald Reagan Washington National Airport air traffic control tower operations and did not identify or mitigate the operational challenges faced by controllers or the lack of guidance regarding operational risk assessments for controllers and supervisors.
- Federal Aviation Administration Air Traffic Organization (ATO) management did not follow the tenets of safety management systems to support its workforce, encourage open communication, identify and mitigate risks, or foster a just culture, which eroded the overall safety culture within ATO.
- The Army did not have a flight safety data monitoring program for helicopters, and as a result, was unaware of routine altitude exceedances and related risks in the Ronald Reagan Washington National Airport terminal area.
- The Army’s safety reporting systems for pilots were not well utilized and did not provide the organization with information about close encounters between Army helicopters and other aircraft that were later found to have occurred frequently.
- The Army’s process for allocating resources to aviation safety management did not ensure the development of a robust safety management system for helicopter operations in the Washington, DC, area.
- The Army’s safety system failed to consistently detect, interpret, and act on signals of latent hazards, resulting in degraded safety assurance, organizational learning, and safety culture.
Probable Cause
We determined that the probable cause of this accident was the FAA’s 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; 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 ATCT 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 ADS-B 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.
On Mar. 7, 2025 we issued an urgent recommendation report (AIR-25-01) with two urgent recommendations on mitigating the risk of midair collisions at DCA.
To the Federal Aviation Administration:
- Prohibit operations on Helicopter Route 4 between Hains Point and the Wilson Bridge when runways 15 and 33 are being used for departures and arrivals, respectively, at Ronald Reagan Washington National Airport (DCA). (Urgent)
- Designate an alternative helicopter route that can be used to facilitate travel between Hains Point and the Wilson Bridge when that segment of Route 4 is closed. (Urgent)
As a result of this investigation, we made the following new safety recommendations.
To the Federal Aviation Administration:
- Develop and implement time-on-position limitations for supervisory air traffic control personnel, including guidance for district and facility level management to adapt these limitations to account for their own staffing and local standard operating procedures.
- Develop instructor-led, scenario-based training on threat and error management that trains controllers to continuously monitor their environment to more quickly and accurately identify threats; promote team communication to ensure that communications are clear, timely, and assertive; emphasize effective scanning habits; recognize patterns in the development of adverse events; and enhance decision-making under stress by developing habits that balance procedural compliance with problem solving to mitigate the risks of threats and errors, and provide this training to all air traffic controllers annually.
- Develop and implement a risk assessment tool for supervisors that incorporates the principles of threat and error management to assist in risk identification, mitigation, and operational decision making.
- Initiate rulemaking in 14 Code of Federal Regulations Part 93 Subpart K, High Density Traffic Airports, that prescribes air carrier operation limitations at DCA in 30-minute periods, similar to those imposed at LaGuardia Airport, to ensure that the airport does not exceed capacity and to mitigate inconsistent air carrier scheduling practices.
- Fully implement operational use of the time-based flow management system at Potomac Consolidated Terminal Radar Approach Control and its associated air traffic control towers.
- Reassess the Ronald Reagan Washington National Airport’s airport arrival rate with special consideration to its airspace complexity, airfield limitations, mixed‑fleet operations, and traffic volume.
- Define objective criteria for the determination of air traffic facility levels considering traffic and airspace volume, operational factors unique to each facility, and cost of living.
- Using the criteria established by Safety Recommendation [7], determine whether the classification of the Ronald Reagan Washington National Airport’s air traffic control tower as a level 9 facility appropriately reflects the complexity of its operations.
- Conduct a comprehensive evaluation, in conjunction with local operators, to determine the overall safety benefits and risks to requiring all aircraft to use the same frequency when the helicopter and local positions are combined in the Ronald Reagan Washington National Airport air traffic control tower.
- Implement anti-blocking technology that will alert controllers and/or flight crews to potentially blocked transmissions when simultaneous broadcasting occurs.
- Develop and implement improvements to the conflict alert system to provide more salient and meaningful alerts to controllers based on the severity of the conflict triggering the alert.
- Once the improvements to the conflict alert system discussed in Safety Recommendation [11] are implemented, provide training to controllers on its use.
- Revise the Air Traffic Organization’s initial event response procedures so that an appropriate on-site supervisor makes each postaccident and postincident drug and alcohol testing determination, based on their assessment of whether the event meets testing criteria and which controllers had duties pertaining to the involved aircraft, without needing to wait for investigation or approval.
- At least annually, provide training on the revised postaccident and postincident drug and alcohol testing determination procedure discussed in Safety Recommendation [13] to all staff who have responsibilities under that procedure; this training should include a post-learning knowledge assessment.
- Ensure that annual reviews of helicopter route charts are being conducted throughout the National Airspace System as required by Federal Aviation Administration Order.
- Conduct a safety risk management process to evaluate whether modifications to the remaining helicopter route structure in the vicinity of Ronald Reagan Washington National Airport are necessary to safely deconflict helicopter and fixed-wing traffic and provide the results to the National Transportation Safety Board.
- Amend your helicopter route design criteria and approval process to ensure that current and future route designs or design changes provide vertical separation from airport approach and departure paths.
- Based on the criteria and approval process established by Safety Recommendation [17], review all existing helicopter routes to ensure alignment with these updated criteria.
- Incorporate the lateral location and published altitudes of helicopter routes onto all instrument and visual approach and departure procedures to provide necessary situation awareness to fixed-wing operators of the risk of helicopter traffic operating in their vicinity.
- Modify airborne collision avoidance system traffic advisory aural alerts to include clock position, relative altitude, range, and vertical tendency.
- Require existing and new traffic alerting and collision avoidance system (TCAS) I, TCAS II, and airborne collision avoidance system X installations to integrate directional traffic symbols.
- Require all aircraft operating in airspace where Automatic Dependent Surveillance–Broadcast (ADS-B) Out is required to also be equipped with ADS B In with a cockpit display of traffic information that is configured to provide alerting audible to the pilot and/or flight crew.
- Require the use of the appropriate variant of airborne collision avoidance system X on new production aircraft that are subject to traffic alert and collision avoidance system equipage regulations.
- Require existing aircraft that are subject to traffic alert and collision avoidance system equipage regulations be retrofitted with the appropriate variant of airborne collision avoidance system X.
- Evaluate the feasibility of decreasing the traffic advisory and resolution advisory inhibit altitudes in airborne collision avoidance system Xa to enable improved alerting throughout more of the flight envelope.
- If the evaluation resulting from Safety Recommendation [25] finds that the inhibit altitudes can be safely decreased, require retrofitting of the applicable airborne collision avoidance system X variant incorporating the reduced traffic advisory and resolution advisory inhibit altitudes on all aircraft that are subject to traffic alert and collision avoidance system and equipage regulations.
- Require that all rotorcraft operating in Class B airspace be equipped with airborne collision avoidance system (ACAS) Xr technology once the ACAS Xr standard has been published.
- Create an objective definition of close proximity encounter and a public database of those encounters and their locations that can be used to monitor their prevalence and identify areas of potential traffic conflict for safety assurance and safety risk management.
- Develop and implement a process that will, in a timely manner, notify involved parties after events such as near midair collisions or traffic alert and collision avoidance system resolution advisory activations, such that notification occurs while relevant data remain available and before meaningful safety analysis, reporting, or corrective action is no longer practicable.
- Based on the results of the audit completed in accordance with Safety Recommendation [48], ensure that all safety management system functions and data sharing activities at all air traffic control facilities are conducted in collaboration with all relevant external stakeholders.
- Establish a requirement across all air traffic control tower standard operating procedures that the operations supervisor (OS) or controller-in-charge (CIC) document in the daily facility log when any control position is combined with the local control position, or when the OS/CIC position is combined with a control position, along with a rationale for doing so.
- Develop a new and comprehensive instructor-led, scenario-based training on the proper use of visual separation, both tower- and pilot-applied. This training should include information on the inherent limitations of see and avoid, responsibilities when applying visual separation, and guidance for controllers on factors, such as current traffic volume, workload, weather or environmental factors, experience, and staffing, that should be considered when applying visual separation. Require this training for all controllers and include on a recurrent basis thereafter in annual simulator refresher training.
- Require each Class B or Class C air traffic control tower facility to evaluate its existing miles-in-trail procedures or agreements to ensure that the spacing provided is appropriate for operational safety, and make the results publicly available.
To the US Army:
- Revise training procedures for flight crews assigned to operate in the Washington, DC, area to ensure that they receive initial and recurrent training on fixed-wing operations at Ronald Reagan Washington National Airport, including approach and departure paths, runway configurations, and the interaction of those traffic flows with published helicopter routes.
- Develop and implement a recurring procedure, at an interval not to exceed 18 months, to verify the continued accuracy of recorded flight data.
- Incorporate information within the appropriate operator’s manual for all applicable aircraft on the potential total error allowed by design that could occur in flight on an otherwise airworthy barometric altimeter, including the increased position error associated with the external stores support system configuration.
- Develop and implement a transponder inspection procedure on all aircraft with transponders capable of transmitting Mode S and automatic dependent surveillance—broadcast (ADS-B) and operated in the National Airspace System (NAS), at least annually and upon each aircraft’s entry into service in the NAS, that ensures 1) the transponder ADS-B settings are correct, 2) the transponder is transmitting ADS-B, and 3) the transponder is transmitting the correctly assigned address.
- Establish a flight data monitoring program for rotary-wing aircraft the US Army operates in the National Airspace System.
- Survey US Army helicopter pilots to identify barriers to the utilization of flight safety reporting systems, develop a plan to address the identified barriers, and implement that plan across Army aviation units.
- Revise the method for allocating resources to ensure the development of a robust safety management system that will, at a minimum, identify and monitor the potential for midair collisions between Army aircraft and civil air traffic operating in the National Airspace System.
- Develop and maintain a flight safety management capability that is independently resourced and functionally separate from its occupational and environmental health management system, and ensure that this capability is both culturally and functionally integrated with units conducting sustained flight operations in the National Airspace System.
To the Department of War Policy Board on Federal Aviation:
- Conduct a study to evaluate the quality of radio transmissions and reception for those aircraft operated within the National Airspace System to identify factors that degrade communications equipment performance and adversely affect the safety of civilian and military flight operations.
- Implement appropriate enhancements, based on the findings of the study recommended in Safety Recommendation [41], to remediate identified deficiencies in air–ground radio communications performance.
- Require the Department of War to verify on all aircraft with transponders capable of transmitting Mode S and automatic dependent surveillance—broadcast (ADS-B) and operated in the National Airspace System (NAS), at least annually and upon each aircraft’s entry into service in the NAS, that 1) the transponder ADS-B settings are correct, 2) the transponder is transmitting ADS-B, and 3) the transponder is transmitting the correctly assigned address.
- Require armed services to amend their operational procedures to allow flight crews to enable Automatic Dependent Surveillance—Broadcast Out while in flight.
- Require all military aircraft operating in the National Airspace System (NAS) be equipped with Automatic Dependent Surveillance-Broadcast (ADS-B) In with a cockpit display of traffic information that is configured to provide alerting audible to the pilot and/or flight crew, and that such requirement apply wherever in the NAS the Federal Aviation Administration requires any aircraft to operate with ADS-B Out.
To the Department of Transportation:
- Require the Federal Aviation Administration to demonstrate at least annually that each air traffic control facility it operates has the routine capability to accomplish required postaccident and postincident drug and alcohol testing within the US Department of Transportation’s specified timeframes of 2 hours for alcohol and 4 hours for drugs, and implement a process to ensure that any facility without such capability will demonstrate timely remediation.
- Work with the Federal Aviation Administration (FAA) Administrator to convene an independent panel to conduct a comprehensive review of the safety culture within the FAA’s Air Traffic Organization (ATO), and use the findings to enhance the ATO’s existing safety management system and integrate it into all levels of the organization.
To the Department of Transportation Office of Inspector General:
- Complete an audit of the Federal Aviation Administration (FAA) Air Traffic Organization safety management system functions and data sharing activities at all air traffic control facilities and determine whether these activities are conducted in collaboration with all relevant external stakeholders, ensuring that the audit’s results are documented, reported to the Secretary of Transportation and the FAA Administrator, and made available to the public.
To the RTCA Program Management Committee:
- Finalize and publish the minimum operational performance standards for airborne collision avoidance system Xr for rotorcraft.