NTSB finds a series of "systemic failures" led to D.C. midair crash: "This was 100% preventable"
National Transportation Safety Board members were deeply troubled Tuesday over years of ignored warnings about helicopter traffic dangers and other problems, long before last year's collision between an American Airlines jet and an Army Black Hawk, which killed 67 people.
The board listened to hours of testimony from investigators who outlined their findings in the collision and subsequent crash near Reagan National Airport nearly a year ago. Key factors emerged, including "overwhelmed" air traffic controllers, a failure to alert the jet's pilot about the other aircraft and a history of missed opportunities to reroute helicopter traffic.
"We know people were raising the concerns, people were saying this was dangerous five, 10 years ago, and nobody was really listening," NTSB member Todd Inman said of staffing.
In her opening remarks, NTSB Chair Jennifer Homendy said it was a series of "deep, underlying systemic failures" that "aligned to create the conditions that led to the crash."
Homendy also called the "similarities" between the D.C. crash and previous such disasters — including a 1969 midair collision that killed 83 people near Shelbyville, Indiana, and a 2019 midair collision that killed six people in Ketchikan, Alaska — "chilling."
"We could have blamed flight crews, individual pilots, maintenance personnel or controllers, but we didn't because we have long, long recognized that human error is a symptom of a system that needs to be redesigned," Homedy said of the three crashes.
At one point during the hearing, Inman said he had responded to 91 aviation fatality incidents in 2025.
"I did 13 family briefings, and I am tired of doing them," Inman said to the families of the victims at the hearing. "And I am sorry for you, because the pages of these reports are written in your family members' blood. So with that again, I am sorry that we have to be here."
Family members in the room listened intently during the hearing. Some were escorted out, including two in tears, as an animation of the flights began. Others entered the auditorium wearing black shirts bearing the names of crash victims.
"The negligence of not fixing things that needed to be fixed killed my brother and 66 other people. So, I'm not very happy," Kristen Miller-Zahn, who watched from the front row, said during a break.
The NTSB's job at this point is to determine the biggest factors in the crash and make recommendations. Victims' families say they hope there's meaningful change.
Everyone aboard the jet, flying from Wichita, Kansas, and the helicopter died when the two aircraft collided and plummeted into the icy Potomac River. It was the deadliest plane crash on U.S. soil since 2001, and the victims included 28 members of the figure skating community.
The Federal Aviation Administration last week made a permanent change to ensure helicopters and planes no longer share the same airspace around the airport.
Recommendations to move the helicopter routing away from the airport after a near midair collision in 2013 were rejected by the FAA.
"This was 100% preventable"
"We should be angry, because for years no one listened," Homendy told reporters prior to the hearing. "This was preventable, this was 100% preventable."
Homendy said she couldn't believe the FAA didn't realize the helicopter route in use during the crash didn't provide adequate separation from planes landing on Reagan's secondary runway. She noted that the FAA had refused to add detailed information about helicopter routes to pilots' charts so they could better understand the risks.
"We know over time concerns were raised repeatedly, went unheard, squashed — however you want to put it — stuck in red tape and bureaucracy of a very large organization," Homendy said. "Repeated recommendations over the years."
NTSB investigator Katherine Wilson said an air traffic controller felt a "little overwhelmed" when traffic volume increased to 10 aircraft about 10 to 15 minutes before the collision, but then "felt the volume was manageable when one or two helicopters left the airspace."
Yet about 90 seconds before the collision, Wilson said, "traffic volume increased to a maximum of 12 aircraft consisting of seven airplanes and five helicopters. Radio communication showed that the local controller was shifting focus between airborne, ground and transiting aircraft."
The workload "reduced his situational awareness," Wilson said.
Wilson also noted that their investigation found that the Reagan controllers working during the midair crash had not undergone a specific training workshop that may have helped them be more prepared for the situation.
NTSB investigator Brice Banning said the pilots of both aircraft were qualified, had adequate rest and no medical conditions that would have barred them from flying. He also said both aircraft had been properly equipped and maintained.
They also reiterated previous findings that the helicopter pilots were likely flying at a higher altitude than the chopper's altimeter was reading. The collision occurred at about 300 feet, while the maximum altitude for helicopters on that route near the airport is 200 feet.
NTSB investigator Dr. Jana Price said interviews with current and former Reagan tower staff found that morale at the tower "had been low for years" prior to the crash. She said that appeared to be due to a 2018 decision by the FAA to downgrade the DCA tower from a level 10 to a level 9 facility, which is a metric based on the volume of air traffic an airport receives.
NTSB investigator Brian Soper explained that downgrading the facility meant it "cannot attract the experience or get the talent" that is needed "to run a very complex air traffic control operation."
NTSB investigators also showed a video animation to demonstrate how difficult it would have been for the pilots in both aircraft to spot the other amid the lights of Washington. The animation also showed how the windshields of both aircraft and the helicopter crew's night vision goggles restricted views.
NTSB investigators believe the helicopter pilots never saw the airliner, and they said it appears the airline pilots may not have spotted the chopper until about two seconds before the collision.
The Reagan controller received a conflict alert when the two aircraft were still 1.6 miles apart, the NTSB investigators testified, and said an urgent safety alert that they were on a collision course should have been given at that point.
"The controller should have issued a safety, would have been the most appropriate thing at that time," Soper said.
Doug Lane, whose wife and son — Christine Lane and Spencer Lane — were killed in the crash, told CBS News outside the hearing that "100%, I feel like the FAA failed me and my family."
Rachel Feres, who lost her cousin Peter Livingston and his wife and two young daughters, told the Associated Press she was hoping for "clarity and urgency" from the NTSB process.
"I hope that we see a clear path through the recommendations they offer to ensure that this never happens again," Feres said. "That nobody else has to wake up to hear that an entire branch of their family tree is gone, or their wife is gone or the child is gone."
Whether that happens depends on how Congress, the Army and the Trump administration respond after the hearing. A pending bill would require all aircraft to have advanced locator systems to help avoid collisions.
Price said NTSB investigators also found the FAA is not using a standardized approach for how it defines near-miss events between aircraft.
"It's something that we think is necessary, to have more of a standard definition of what constitutes a close proximity event, so that there can be a way of comparing one airport to another, or looking at trends over time, rather than what is kind of a hodgepodge, if you will, right now, of different ways of measuring this," Price said.
Even before Tuesday, the NTSB had already spelled out many key factors that contributed to the crash. Investigators said controllers in the Reagan tower had been overly reliant on asking pilots to spot other aircraft and maintain visual separation.
The night of the crash, the controller approved the Black Hawk's request to do that twice. However, the investigation has shown that the helicopter pilots likely never spotted the American Airlines plane as the jet circled to land on the little-used secondary runway.
In a statement Tuesday, the FAA said it has reduced hourly plane arrivals at Reagan airport from 36 to 30 and increased staff. The agency said it has 22 certified controllers in the tower and eight more in training.
"We will diligently consider any additional recommendations" from the NTSB, the FAA said.
Several high-profile crashes and close calls followed the D.C. collision, alarming the flying public. But NTSB statistics show that the total number of crashes last year was the lowest since the COVID-19 pandemic hit in 2020, with 1,405 nationwide.