On a bright, clear morning in July 2018, three military helicopters traveling south along the Potomac River came seconds away from smashing into a plane that was arriving at Ronald Reagan National Airport. The air traffic controller had failed to warn the aircraft of the potential collision, and the helicopters had to maneuver abruptly to avoid a crash.
The Federal Aviation Administration documented the incident in safety reports and used it as a case study in a nationwide training course for air traffic controllers on how to issue precise warnings to pilots when they are in danger.
But problems with air traffic around Reagan National persisted. Controllers, pilots and military officials were so worried about busy helicopter routes near the airport that they formed safety groups in attempts to prevent a crash, four people familiar with the discussions said.
And after a series of incidents, an internal report in 2019 explicitly warned that recurring controller error increased “the risk of a collision and loss of life,” according to a copy reviewed by The New York Times.
Despite these efforts, an Army Black Hawk helicopter slammed into American Airlines Flight 5342 two weeks ago at almost exactly the same location as the 2018 incident, killing all 67 people aboard both aircraft.
The crash was the culmination of mounting warning signs at Reagan National, according to interviews with more than a dozen current and former air traffic controllers, pilots and aviation safety experts, as well as federal safety reports and F.A.A. records reviewed by The Times.
Federal investigators are still trying to piece together what caused the crash. The helicopter appears to have been flying higher than authorized and its pilots seem to have been dealing with other complex conditions. But even before an official determination is made, a growing body of clues suggest the midair collision was the result of a cascading series of breakdowns long in the making, including by air traffic control, whose mandate is to guide aircraft safely on the ground and through the skies.
Repeated attempts to draw attention to safety lapses and potentially dangerous operating conditions at the control tower at Reagan National at times went unheeded, according to four people familiar with the matter and F.A.A. safety records reviewed by The Times.
An F.A.A. spokesman declined to comment, citing the active investigation.
Because of its proximity to Washington, the airport is one of the most high-profile in the country. Lawmakers and government officials routinely travel in and out of the airport. It is also one of the busiest, requiring intense focus and special training by pilots. Helicopters crowd the air, often using a route that could cross directly under a common flight path.
The air traffic control tower has also been chronically understaffed, putting extra strain on employees. Controllers were frequently faulted for failing to follow F.A.A. rules for communicating with pilots and keeping safe distances between planes, according to three people with knowledge of the tower and federal aviation safety reports.
Last month, the tower was nearly 20 percent below its target staffing level, with 23 fully certified controllers instead of 28, according to data from the union representing controllers that was obtained by The Times.
That was not unusual: More than 90 percent of the country’s 313 air traffic control facilities operate below recommended staffing levels, a Times analysis showed. The shortage has prompted fears from controllers that the resulting overtime and fatigue could lead to mistakes.
Before the fatal crash, there were other alarming episodes at Reagan National. In March last year, three incidents involving planes getting too close to each other happened on the same runway in a span of about three hours, according to federal aviation safety reports. In April, two passenger planes came seconds from hitting each other. The next month, there was another close call involving a commercial plane and a private jet.
In many ways, the issues at Reagan National’s control tower are emblematic of the fraying safety net that protects air travel throughout the United States. A Times investigation in 2023 found that close calls involving passenger planes happened, on average, multiple times each week across the country. The near misses were often the result of human error by pilots or air traffic controllers.
At Reagan National, the busy helicopter corridor around the airport became such a concern that safety groups identified conflict points, where the possibility for a collision was highest, according to three people familiar with the meetings.
One was over the Potomac when a plane was coming in to land — on Runway 33, the location where the American Airlines jet had been attempting to land when the Army Black Hawk hit.
The safety groups made a number of proposals, including moving the helicopter routes farther east, according to two of the people. The helicopter routes did not change.
As the safety groups convened, controllers in the tower were frequently under scrutiny for allowing planes to get too close together and failing to give proper directions to pilots.
In an effort to reduce the number of close calls because of controller errors, the F.A.A. identified numerous areas for improvement. Those included following more precisely the agency’s rules for communicating with pilots, keeping safe distances between aircraft and issuing pilots more specific warnings that another aircraft was close to their flight path or on a potential collision course.
Controllers were required to undergo extra training to address these issues, yet some feared that the exercises did little to address the underlying safety concerns as near misses continued, the two people said.
After the close call last May, the National Transportation Safety Board determined in its preliminary report on the incident that there had been “safety concerns” at the airport’s air traffic control tower related to “human performance” that required additional investigation.
“Doing so much, with so little,” Timothy Harman, the control tower’s former top manager, wrote in a LinkedIn post about six months ago, “is a testament to your dedication and perseverance.”
Before 9 p.m. on the night of Jan. 29, many of these longstanding issues at Reagan National pushed to the fore. As it circled to land on Runway 33, the passenger plane was heading for one of the known conflict points. The helicopter was flying higher than it should have been, investigators have said, so the vertical distance needed to keep the aircraft adequately separated had collapsed.
Staffing in the control tower was “not normal for the time of day and volume of traffic,” according to an internal F.A.A. safety report. There were five fully trained controllers, one controller-in-training, one supervisor and one supervisor-in-training on duty, the report said.
Five of the people were actively working during the incident, including one controller who was directing both the helicopter and the plane, according to the report. The task of instructing helicopters is typically a stand-alone job at that hour.
Recurring communication problems also came into play, according to current and former controllers who reviewed the incident. The issues included the controller’s failure to use proper phraseology, which refers to the prescribed language that a controller is supposed to use when communicating with pilots.
The helicopter asked the controller for permission to use visual separation, a method intended to allow pilots to navigate an airspace while keeping a constant line of sight to another plane nearby. The request was granted, which is common, and put the responsibility on the helicopter pilots to avoid the American jet.
But current and former controllers said the tower had left too much room for confusion. The controller, for instance, told the pilots of the helicopter about the “CRJ” — the American Airlines plane — but did not alert the American pilots to the helicopter. Pilots in both aircraft should have received warnings that they were on a collision course, the current and former controllers said.
The helicopter’s pilots said they had an aircraft in sight, but the controller did not tell them the location of the American Airlines plane in reference to the helicopter’s position; as a result, the helicopter’s pilots may have mistakenly thought they had the American plane in sight when they were looking at another plane or other lights in the night sky.
As the two aircraft continued converging, the controller should have given specific instructions to the pilots on both the jet and the helicopter to prevent them from getting any closer to each other, some controllers said. The controller in the last moments instructed the helicopter to “pass behind the CRJ.”
The controller may have been focused on trying to get a plane to depart on another runway before the American flight landed. That added a level of complication because the runway of the departing plane and the one where the American flight was supposed to land intersected, so it required a calculated choreography.
Investigators with the N.T.S.B. have since interviewed five people working in the control tower that night.
Their colleagues have returned to work directing planes. For days, as planes and other aircraft whipped in and out of view during takeoffs and landings, they had one constant sight from their vantage point high up in the tower: a giant red crane fishing wreckage from the Potomac.
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