So the NTSB has conducted its hearings and giant document release on the tragic DC collision in January. You can take a gander at the primary sources here, there’s a lot of them (yep, NTSB is very, very thorough). Because I developed an interest in studying systemic breakdown of air disasters some time before the collision, I’ve been following it (knowing them actually makes me more comfortable flying because of all the massive safety efforts.) Being I can read these things better than a lot of people, I’m going to give my takes. Warning: These are from an amateur non-aviator and I’ve been mostly looking at the helicopter ones.

Who Was At Fault?

Immediately, the helicopter for not seeing the incoming plane. The controller for letting a crew with literal tunnel vision try to see and steer itself instead of just having it stop (I call it, trying to save the helicopter from itself). That said, it’s not helpful to say someone immediately should have zigged instead of zagged. Or to try to exactly apportion blame since it doesn’t work out like that.

Because the overloaded DCA airspace was such a nightmare that something like this-I’m honestly surprised it didn’t happen sooner. The close calls were huge and massive. Like, yeah. Totally massive.

I’ll admit from pretty early on I was reminded of Charkhi Dadri, a somewhat similar but far worse disaster in 1996 with a 747 and Il-76 that remains as of this post the worst midair collision ever. Same overloaded capitol airspace with a bizarre civil/military boundary and the use of small vertical separation that was bound to fail miserably. There the immediate “fault” was entirely on the Il-76 for slipping a thousand feet while the controller gave perfect direction and the 747 stayed where it was supposed to, but that was not nearly as important as the systemic issues.

Was This a DEIsaster?

Short answer is no. Longer answer is that yes, Lobach was indeed not the greatest pilot and was wobbly and insufficient on the disaster flight (which should have been called off and failed) but did not fit the “stupid DEI bimbo” caricature many on the internet claimed. (Not that it’s really relevant but a massive interview with her boyfriend seemed to debunk the claim she was a lesbian). (The PAT unit from the readings actually had a much higher than normal amount of women in it from one of the documents).

What she was was a commissioned pilot with a fairly small and highly uneven amount of flight hours, and that her issues were not uncommon among junior commissioned crews, crews who probably should not be allowed into the most dangerous airspace ever. (Training flights in that area for all but specialized careful missions like route knowledge for a true emergency should not have been happening).

In any event the male instructor made the most crucial catastrophic decisions.

So, What Was the Swiss Cheese Failure

(Try my best to summarize, which I’m not the best at): DC had been incredibly overcrowded with both helicopter and commercial traffic for political reasons. Little-used runway 33 was seeing more use, including on the fatal collision. The helicopter crew was granted permission to see and avoid, a foolhardy one given the night vision goggles and light pollution. They looked at an airplane operating on the main runway and assumed that was the “traffic in sight”. It wasn’t.

To me I think the most revealing thing was how -sincerely – overconfident the army was. Everyone from safety officers (who treated birds as the most dangerous collision threat) to the accident crews themselves were disturbingly blase about working around commercial traffic. In later informal podcasts/interviews, veteran pilots who in some cases flew the exact route seemed honestly surprised at how bad it was from the aircraft’s end. They did not come across as making excuses.

Lessons

I’ll say I don’t know what the changes besides the obvious ones could or even should be. DCA is very dangerous by nature (as demonstrated before when, despite the fundamental differences, many similar things from a less-than-ideal aircrew to dubious controller decisions contributed to an earlier famous disaster), and important people should probably bite the bullet and drive to Dulles.