Blame Culture and Just Culture in Aviation Safety

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Safety is the number one priority in the aviation industry. With so many moving parts , from people and technology to the environment ,making sure everything runs safely is no small task. That’s why having a strong safety culture is so important. A safety culture means that everyone in an organization shares the same values and attitudes about putting safety first. The way a company handles safety issues, especially when mistakes happen, plays a big role in how safe things actually are. In this article, we’ll look at two different ways companies can respond to mistakes: blame culture and just culture . We’ll explain what they mean, how they affect safety in aviation, and explore how building a just culture can help make the skies even safer.  Blame Culture in Aviation: A blame culture in aviation safety can be defined as an organizational environment where the primary response to incidents, errors, or near misses is to identify and punish the individuals perceived to be direc...

NTSB Released Preliminary Report on Mid-Air Collision Between American Airlines Jet and US Military Helicopter

 The National Transportation Safety Board (NTSB) has released its preliminary report regarding the tragic midair collision that occurred between US Army Helicopter and American Airline Jet (Bombardier - CRJ700) . 

On January 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. Flight 5342 was operating under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121 as a scheduled domestic passenger flight from Wichita Dwight D. Eisenhower National Airport (ICT), Wichita, Kansas, to DCA. PAT25 originated from Davison Army Airfield (DAA), Fort Belvoir, Virginia, for the purpose of the pilot’s annual standardization evaluation with the use of night vision goggles (NVGs). Night visual meteorological conditions prevailed in the area of DCA at the time of the accident. Below shows preliminary radar flight track information for PAT25 and preliminary automatic dependent surveillancebroadcast (ADS-B) information for flight 5342. 


Crew Experience

The flight crew of the CRJ700 operated by PSA Airlines consisted of a captain and a first officer, both holding FAA first-class medical certificates and current on type. The captain had accumulated approximately 3,950 total flight hours, including 3,024 hours specifically on the CRJ series. The first officer had logged around 2,469 total flight hours, of which 966 hours were on the CRJ series. The UH-60L Black Hawk helicopter crew from the US Army included an instructor pilot with about 968 total flight hours, including 300 hours on the UH-60. The pilot had approximately 450 total flight hours, with 326 of those on the UH-60 platform. The crew chief, who also served aboard the helicopter, had over 1,100 hours of flight experience, all accumulated on the UH-60. All members of both flight crews were fully qualified and current for the flights they were operating.

History of Flight

Flight 5342 departed ICT at 1839 EST on an instrument flight rules flight plan. The helicopter flight crew filed a visual flight rules flight plan with DAA base operations and departed at 1845 with the IP in the right seat and the pilot in the left seat. About 2015, flight 5342 started its initial descent. About 2030, PAT25 began travelling generally southbound after maneuvering near Laytonsville, Maryland. CVR audio from the helicopter indicated the IP was the pilot flying and the pilot was the pilot monitoring and transmitting on the radio at this time.

 PAT25 first checked in with the DCA tower controller at 2032. The controller issued the altimeter setting of 29.89 inches of mercury, and the PAT25 crew acknowledged by correctly reading back the altimeter setting. Following this initial contact with DCA tower, the crew conducted a change of control; the pilot became the pilot flying and the IP became the pilot monitoring and transmitting on the radio for the remainder of the flight.

At 2033:41, the PAT25 crew requested Helicopter Route 1 to Route 4 to DAA, which the tower controller approved. At 2038:39, the helicopter reached the intersection of the DC Beltway and the Potomac River near Carderock, Maryland. After briefly turning westbound, PAT25 turned back to the east and began descending as it picked up Helicopter Route 1 over the Potomac River southeast toward downtown Washington, DC.

At 2039:10, Potomac Approach cleared the crew of flight 5342, which was inbound to DCA from the south, for the Mount Vernon Visual Runway 1 approach. At 2040:46, the airplane rolled out of a left turn established on the instrument landing system localizer for runway 1, at approximately 4,000 ft pressure altitude, 170 knots (kts), with the landing gear up and flaps extended to 20º.

At 2043:06, the flight 5342 crew made initial contact with DCA tower. At this time, the airplane was about 10.5 nautical miles (nm) from DCA. The tower controller asked if the crew could switch to runway 33. The crew agreed, and the controller subsequently cleared flight 5342 for landing on runway 33. The crew acknowledged and read back the clearance.

At 2043:48, PAT25 was about 1.1 nm west of the Key Bridge. According to the helicopter’s CVR, the pilot indicated that they were at 300 ft. The IP indicated they were at 400 ft. Neither pilot made a comment discussing an altitude discrepancy. At 2044:27, as the helicopter approached Key Bridge, the IP indicated that the helicopter was at 300 ft descending to 200 ft.

The flight 5342 FDR indicated that, between 2044:41 and 2044:45, the crew selected 30º of flaps and then 45º of flaps. At 2044:49, the airplane’s landing gear were down and locked. The airplane was fully configured for landing about 6.2 nm south of the airport. At 2045:27, the autopilot was disconnected and flight 5342 began a shallow right turn off of the runway 1 localizer at a radio altitude of approximately 1,700 ft and an airspeed of 134 kts. This occurred approximately 5 nm south of the airport.

At 2045:14, the crew of PAT25 advised the controller of their position over the Memorial Bridge. At 2045:30, PAT25 passed over the Memorial Bridge. CVR data revealed that the IP told the pilot that they were at 300 ft and needed to descend. The pilot said that they would descend to 200 ft. At 2045:58, the helicopter crossed over the Washington Tidal Basin and followed the Washington Channel consistent with Helicopter Route 1.

At 2046:02, a radio transmission from the tower was audible on flight 5342’s CVR informing PAT25 that traffic just south of the Wilson Bridge was a CRJ (flight 5342) at 1,200 ft circling to runway 33. CVR data from the helicopter indicated that the portion of the transmission stating the CRJ was “circling” may not have been received by the crew of PAT25. The word “circling” is heard in ATC communications as well as the airplane’s CVR, but not on the helicopter’s CVR. At 2046:08, the PAT25 crew reported that they had the traffic in sight and requested to maintain visual separation. The controller approved the request. At this time, the distance between the two aircraft was about 6.5 nm. Figure 2 shows each aircraft’s approximate position at 2046:02, when the controller first advised the crew of PAT25 of flight 5342.

At 2046:29, the flight 5342 CVR data indicated that the crew received a 1,000-ft automated callout. At 2046:48, DCA tower cleared other jet traffic on runway 1 for immediate departure with no delay. At 2047:27, or 32 seconds before impact, PAT25 passed the southern tip of Hains Point. About one second later, flight 5342 began a left roll to turn to final on runway 33. The airplane was at a radio altitude of 516 ft and 133 kts. At 2047:29, the crew of flight 5342 received a 500-ft automated callout. At 2047:39, or 20 seconds before impact, a radio transmission from the tower was audible on both CVRs asking the PAT25 crew if the CRJ was in sight. A conflict alert was audible in the background of the ATC radio transmission. At 2047:40, the crew of flight 5342 received an automated traffic advisory from the airplane’s traffic alert and collision avoidance system (TCAS) system stating, “Traffic, Traffic.” At this time, the aircraft were about 0.95 nm apart, as shown in Figure 3.


At 2047:42, or 17 seconds before impact, a radio transmission from the tower was audible on both CVRs directing PAT25 to pass behind the CRJ. CVR data from the helicopter indicated that the portion of the transmission that stated “pass behind the” may not have been received by the PAT25 crew, as the transmission was stepped on by a 0.8-second mic key from PAT25. In response, at 2047:44, the crew of PAT25 indicated that traffic was in sight and requested visual separation, which was approved by DCA tower. CVR data indicated that, following this transmission, the IP told the pilot they believed ATC was asking for the helicopter to move left toward the east bank of the Potomac.

At 2047:52, or 7 seconds before impact, flight 5342 rolled out on final approach for runway 33. The airplane was at a radio altitude of 344 ft and 143 kts.

At 2047:58, or 1 second before impact, flight 5342 began to increase its pitch. FDR data showed the airplane’s elevators were deflected near their maximum nose up travel. At 2047:58, the controller issued a landing clearance to another airplane. During this transmission, audible reactions could be heard from the other tower controllers as they observed the collision, which occurred about 2047:59 while flight 5342 was over the Potomac River and on final approach for runway 33.

The flight 5342 FDR indicated that the airplane’s last recorded radio altitude was 313 ft, 2 seconds before the collision. The airplane’s pitch at the time of the collision was 9º nose up and roll was 11º left wing down. The airplane was descending at 448 ft per minute.

The PAT25 FDR indicated that the radio altitude of the helicopter at the time of the collision was 278 ft and had been steady for the previous 5 seconds. The helicopter’s pitch at the time of the collision was about 0.5º nose up with a left roll of 1.6º.

The NTSB obtained video recordings from several sources that showed the collision between the aircraft and their descent to the water. A preliminary review of the videos revealed that the airplane's left- and right-wing navigation lights, left-wing, right-wing, and tail anticollision (strobe) lights, nose, right-wing, and left-wing landing lights, as well as the upper and lower beacon lights, were all illuminated before the collision. Further, the helicopter's lower fuselage and aft pylon anticollision (strobe) lights, along with the left, right, and tail pylon position lights, were also illuminated before the collision. None of the airplane’s lights used LED technology. Video showed that, immediately after the collision, the outboard left wing of the airplane separated, and the airplane rolled about 450°, impacting the water in an approximate 45° noselow attitude with a left roll about 90°.

What Might Be the Cause?

Several contributing factors may have led to this tragic accident. First, the airspace surrounding DCA is inherently complex, with helicopter routes such as Route 1 and Route 4 running directly beneath approach paths to runways 1 and 33. In this environment, helicopters operate at altitudes as low as 200 ft AGL, while fixed-wing aircraft may descend to 400 ft AGL when conducting visual approaches to runway 33, creating a narrow vertical window for separation. Secondly, there appears to have been a breakdown in communication. The UH-60L crew likely did not fully receive or understand the tower’s advisory, particularly the critical mention of the CRJ “circling” for runway 33, which may have impacted their situational awareness. Additionally, the directive for PAT25 to "pass behind" the CRJ was likely masked due to overlapping radio transmissions. Although both flight crews acknowledged visual contact, it is probable that they misjudged their relative positions and closing speeds, contributing to the collision. Another factor is the limitations inherent to the CRJ700’s TCAS system, which, while issuing a traffic advisory (TA), did not trigger a resolution advisory (RA) due to TCAS RA inhibition below 900 ft AGL—a standard setting intended to prevent nuisance alerts during landing phases. 

Other Relevant Findings

Historical data highlights a persistent safety concern in the DCA terminal area. Between 2011 and 2024, DCA recorded an average of at least one TCAS resolution advisory (RA) per month involving helicopters operating in proximity to commercial traffic. Notably, over half of these incidents involved helicopters flying slightly above or outside their designated route altitudes. Furthermore, 66% of these encounters occurred during night operations, when visual acquisition of traffic is more challenging. In response to this pattern and the recent accident, the FAA issued an immediate NOTAM on January 31, 2025, restricting helicopter operations over the Potomac River near DCA. The restriction exempts only essential missions, such as medical evacuations, law enforcement, defense, or presidential transport. Subsequently, on March 11, 2025, the NTSB issued two urgent safety recommendations to the FAA, urging enhancements to both the helicopter route structure and air traffic control (ATC) procedures in the vicinity of DCA to reduce the risk of future midair conflicts.

NOTE:this report is based on preliminary findings and the investigation is still ongoing. The information presented reflects early data from flight recorders, air traffic control communications, and initial wreckage analysis. The NTSB continues to thoroughly examine contributing factors, including human performance, airspace management, and technical systems. As additional evidence is gathered and analyzed, a final report will be issued with definitive conclusions and potential safety recommendations aimed at preventing similar accidents in the future.

For more Details Read Preliminay Report


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