The Answer is… Communication
Article by Dr. John E. Kello
January 30th, 2025, 9 AM EST
By the time this newsletter is posted, at least some answers will have come to the question, “What caused the fatal collision of AA flight 5342 and a military Blackhawk helicopter near Reagan International Airport in Washington, DC”. The crash happened on the evening of January 29th, 2025. I am starting this newsletter on the morning of January 30th, 2025, and I will update it as the investigations begin to unravel the chain of events that led to the disaster.
As of this morning, it appears that there are no survivors among the 64 passengers of the airplane and 3 crewmen on the military helicopter. The recovery operation is underway.
As of now, I have no more information than what is coming across the news feeds, but my deep background in researching aviation safety leads me to make some predictions. Those will be confirmed or disconfirmed (I am betting heavily on “confirmed”) as the situation becomes clearer.
This disaster is the first fatal airline crash of a domestic US carrier in more than 15 years. Cold comfort to the lost souls and their loved ones, but commercial aviation in the US is statistically the safest way to travel. According to the numbers, one could take a round-trip flight every day for at least 20,000 years (maybe as much as 32,000 years by some estimates) before one was involved in a fatal crash. Safety researchers that I have worked with have pointed out that the most dangerous part of a flight is the drive to and from the airport.
I have participated in several accident investigations in aviation (as well as other industries), and I have listened to a dozen or more cockpit voice recordings from airlines (mostly outside the US) which experienced a fatal crash. In the vast majority of cases, there is a common pattern. The crash is rarely caused by a major mechanical failure, the type that people who have a fear of flying worry about. It is rarely a sudden, out-of-nowhere event. It is virtually always the end point of a chain of events, and prominent in that chain are communication failures. Human error is the primary culprit.
In the late 1980s and early 1990s, the concept of the High Reliability Organization (HRO) was being developed, and while various definitions have been proposed for the concept, some common denominators include:
The work is highly technical.
Operators require high levels of training and often frequent retraining and/or recertification.
Error can lead to catastrophic consequences, so it has to be done right every time, no exceptions.
Aviation was recognized as an HRO early on. I had the opportunity to participate in research and consulting with the commercial aviation industry during the time the HRO concept was being introduced and refined. Our research led us to the conclusion that human error was a primary contributing cause of aviation accidents in upwards of 80% of cases. Further research has increased that ballpark estimate.
The human-error contribution to accidents is by no means limited to aviation or to other HROs. Much of my recent work in safety has focused on industrial environments, and while fabrication and assembly, surface mining, and flour milling aren’t identified as HROs, the data on accidents, specifically the role of human error, is the same. I conducted a 10-year review of accident reports in a food-service company, and we determined that more than 95% of their recordable accidents had human error as a primary cause. Mistakes of commission or omission occurred and were uncorrected.
Accidents are rarely if ever single-cause events. They most often represent a concatenation of events. As I write these words, I am hearing talking heads on news TV saying “one in a million… series of mistakes… no single cause… perfect storm… multiple errors…” and similar language to capture the stacking up of unlikely events which ultimately move down the chain to a tragic end result.
I note that much is now being made about the level of experience of the military helicopter crew (one with 500 hours, one with 1000 hours). The CRJ was apparently doing what it was supposed to. It appears that the helicopter crew screwed up. But, while the usual assumption is that highly experienced pilots should somehow be immune from error, the reality can be exactly the opposite. Major crashes have occurred with highly, highly experienced pilots in charge. It’s not always about knowing what to do vs. not knowing what to do. It’s not always about a lack of training.
So. I am expecting that unless the helicopter crew intentionally crashed into the AA flight (an extremely unlikely event), human error, including communication failures, is the culprit. Given my background, I expect that air traffic control (ATC) also played a critical role in the disaster. We’ll see.
January 31st, 9:45 AM EST
The story is unfolding very rapidly, much faster than in the past. Credit the 24-hour news cycle. I am not an avid cable news consumer, but I have seen the video of the moment of the crash at least 20 times so far.
As of now, the improper altitude of the helicopter is still a major mystery. There is discussion of the congestion of civilian and military aircraft around DCA. Some talking heads are saying that the problem at DCA had been widely known for a long time, that near-miss incidents were relatively common, and that such a catastrophe, a “hit”, was inevitable. Wow. There is discussion of the possibility that the helicopter crew was using night vision goggles, which could make actual vision among the city lights and airport lights especially challenging. There is a lot of discussion of the apparent short-staffing of ATC that night, with one controller having responsibility for both commercial and military traffic… off normal, but apparently not unheard of, and “acceptable”. There is some speculation that the helicopter crew might have been tracking the wrong aircraft, not the PSA flight that ATC told them to follow. Still, the helicopter was well above its approved altitude, for reasons unknown.
So far, all the data point to error, likely on the part of the helicopter pilots (again there is no indication that the CRJ crew was doing anything wrong) and the air traffic controller. I note that in two of the iconic crashes that I have researched thoroughly (Eastern 401 in December 1972 and Comair 5191 in August 2006) ATC problems (unclear communication, short-staffing) were contributing factors to the fatal crashes. In those two and several other crashes I have studied, clear communication from ATC was a last line of defense in avoiding disaster, and it failed.
So. The chain of human error continues to be the most likely culprit. Double-check, triple-check, verify all communications, maintain shared situational awareness… these are the essential error mitigation strategies that are muffed in most accidents.
February 1st, 10 AM EST
The disastrous medevac crash in Philadelphia yesterday evening has moved the DCA catastrophe down in the news queue. As the black boxes from the DCA crash are being retrieved and analyzed, there is not much new coming across the wires. As of this morning, pending further updates, it still appears that communications breakdowns were the culprit. It is common for NTSB investigations to take many months. It is not clear whether the investigation of the DCA crash can be concluded more quickly. I hope it will.
On the disaster in Philadelphia, very little is known or even speculated about at this point. There is a chance that this is one of the one-in-a-hundred sudden mechanical malfunctions. I would point out that the safety record of small private planes is nowhere near as good as for domestic commercial airplanes. Some estimates claim that fatal accidents in small private planes are as much as 25 times more likely than in a commercial carrier. Maintenance problems are more common, leading to engine failure and other mechanical breakdowns in the small private planes.
February 2nd, 11:45 AM
We know that the helicopter was on a “check”/training flight, with the 28-year-old female pilot at the controls and under evaluation. While 500 hours sounds like a lot to a civilian, some military experts who are weighing in are taking the position that 500 hours is in fact not “highly experienced”.
Attention is also still being paid to the air traffic controller on duty that night. As I said, in the cockpit voice recordings I have listened to in my research, the tower is commonly the last line of defense. Specific, accurate communication from them is critical. That issue is now front and center in the unfolding speculation about the chain of events leading to the disaster.
February 3rd, 4th, 5th, and 6th
As of now, I am aware of no new insights or informed speculations. I stand by my experience-based best guess that communication was the most critical problem. Just as communication errors can add to the causal chain, clear, accurate, and timely communication can interrupt the chain at any link and preempt an accident. The answer is… communication.
