The National Transportation Safety Board charged that years of inaction by the government agency assigned to ensure safe flight led directly to the fatal collision of an airliner and a U.S. Army helicopter one year ago.

“It was one hundred percent preventable,” Jennifer Homendy, the NTSB’s chief, said at the meeting on Tuesday to determine the probable causes of the crash. American Airlines Flight 5342 on a flight from Wichita to Washington, was struck from below by an ascending Army Blackhawk helicopter on a training flight. Both aircraft plunged into the icy Potomac River.

What happened was not a mystery. But the baffling takeaway from the meeting was how near collisions over one of the busiest airfields in the country went on for years without any attempt to fix the problem.

“How is it that no one, absolutely no one in the FAA did the work,” Homendy said of the agency’s failure to understand the inherent conflicts in the helicopter routes that cross the approach path to DCA’s runway 33. But her sentiment also applied more broadly.

Following the accident, which killed 67 people, investigators plowed through aviation safety reporting databases and discovered just how frequently helicopters and airplanes nearly came to grief at DCA. The answer was pretty often.

Between 2011 and 2024, cockpit collision avoidance systems known as TCAS triggered in aircraft flying in the airspace about once a month.  In just three years preceding the January 2025 collision, the NTSB found 85 events where the lateral separation between helicopters and airliners was less than 1,500 feet and vertical separation less than 200 feet.

Ronald Reagan Washington National Airport photo by Duane Lempke Photography

Given this, it is hard to understand why all of the airport’s users not only failed to fix, but made the problem worse; airlines by adding flights and manipulating arrival slots, the FAA by downgrading the pay scale for the DCA control tower so that the most experienced controllers would eschew working there. The Army by failing to equip its pilots with information and equipment to make their passage through commercial airspace as risk-free as possible. I pause from my reporting to suggest that after 9 hours of listening to the safety board staff reports and answers to board members’ questions, it’s hard not to compare the actions of safety, military, government and airline decisionmakers to Nero famously fiddling while Rome burned.

The details of the Flight 5342 disaster highlighted many safety shortcomings by the FAA. In the tower that night, one controller was handling both helicopter and airplane traffic, which were on separate communication channels that did not allow helicopter pilots and fixed-wing pilots to hear each other.

Katherine Wilson NTSB investigator

When a conflict alert sounded in the tower, it appears to have prompted the controller to wonder if the Army pilots, transiting the space using visual flight rules or see and avoid, identified the correct airliner in its path. But the controller’s instruction to “fly behind” the regional jet was vague. Issuing a safety alert would have been the appropriate action, according to the NTSB’s Brian Soper. But, ironically, the airport’s years-long history of near-collisions created a sense of complacency, according to the safety board’s human performance investigator, Katherine Wilson. “Conflict alerts are common,” she said, “and may have desensitized controllers.”

Even this might have been mitigated if the FAA had actually carried out threat and error management training for controllers, a practice endorsed by the International Civil Aviation Organization 20 years ago to help manage systems and performance within the controller environment. It is used in Europe, Canada and Australia, but the NTSB investigation could find no records that FAA controllers were ever given this training.

The Sikorsky Blackhawk helicopter with three soldiers on board ascended into the path of the PSA regional jet arriving from Wichita and flying for American Airlines as flight 5342. All three crewmembers were wearing night vision goggles, narrowing their field of vision, depth perception and creating visual halos. These limitations were known to them. However, the investigation determined that Blackhawk pilots were unaware that analog equipment on the helicopter and a modification of the fuel system skewed altimeter readings by 80 to 130 feet.

At one point, Homendy clicked through the ascent of the Blackhawk as it closed in on the airliner on approach, each time confirming with the investigators that the crew would have believed they were operating within their vertical boundary. Homendy summarized, “We have established they thought they were below 300 feet.”

In fact, they ascended through 300 feet, hitting the airliner and sending both tumbling into the river. The NTSB’s animation of the collision can be seen below.

In the 112 years since an intrepid passenger made history by becoming the first person to buy a ticket to fly on a scheduled airline, (St. Petersburg-Tampa Airboat Line,) the industry’s goal has been to improve safety and reliability so courage doesn’t have to be a prerequisite for air travelers.

The system has mostly exceeded expectations. What the safety board’s astonishingly frank testimony on Tuesday demonstrates is that sometimes entities with a vested interest in the status quo insist “safety is our number one priority,” while ignoring the inconvenient truth.