A National Transportation Safety Board review of the mid-air collision between an Army Black Hawk helicopter and an American Airlines regional jet in January 2025 found that the Federal Aviation Administration was plagued by systemic safety issues in the lead-up to the accident that killed 67 people.

“The Federal Aviation Administration Air Traffic Organization had multiple opportunities to identify the risk of a mid-air collision between airplanes and helicopters at Ronald Reagan Washington National Airport. However, their data analysis, safety assurance, and risk assessment processes failed to recognize and mitigate that risk,” the board shared in findings.

The investigation suggests that the helicopter route was dangerously close to the path taken by civilian aircraft. NTSB Chair Jennifer Homendy said that the FAA was supposed to conduct annual safety reviews of helicopter routes, but the board was unable to find evidence of such reviews taking place.

The NTSB also notified the FAA of 15,214 close-proximity events, 85 of which were serious. The investigators said at a hearing on Tuesday that reviews of such near-collisions were done on a case-by-case basis.

“The data was in their own systems,” Homendy told reporters. “This was 100% preventable.”

There wasn’t a positive safety culture at the FAA’s operational arm, Air Traffic Organization, NTSB investigators said, with some employees reporting facing retaliation for raising safety concerns.

Although safety concerns were raised over mid-air collisions in the D.C. airspace, investigators said, the Air Traffic Organization failed to respond to these concerns. Tower personnel also put together their own helicopter working group to “repeatedly” raise concerns and submit recommendations, Homendy said.

At the hearing, Homendy also said that there were “some concerns with an overreliance on AI by the FAA,” but stopped short of making any connection between the incident and AI use.

“They’ve got to be careful on the use of AI to pick up trends, to make sure it doesn’t discount some reports,” Homendy said. According to NTSB’s chief data scientist Loren Groff, the FAA has been using AI to sort through large volumes of pilot reports.

“There really does need to be a human understanding of what all of these things mean together,” Groff said.

The chair also signaled that the FAA has yet to learn from its mistakes.

“Commercial airlines have called me to say the next mid-air is going to be in Burbank, and nobody at the FAA is paying attention to us,” Homendy said.

The investigators said that the FAA still does not have a standardized definition of what constitutes a close-proximity event.

On top of inadequate safety measures by the FAA, the Army’s aviation safety system was also riddled with failures, the report found. The army failed to allocate adequate resources to aviation safety management for D.C. area helicopter operations and also lacked a positive safety culture, according to investigators.

The close call issue in aviation is something that the NTSB has been ringing alarm bells over for years. Back in 2023, Homendy told a U.S. Senate panel that there was an increase in serious near-miss aviation incidents, and it was a symptom of a strained aviation system.

“We cannot wait until a fatal accident forces action,” Homendy said at the time.

What happened on Jan. 29?

On January 29th, 2025, over the Potomac River in Washington D.C., an Army Black Hawk helicopter crashed into an American Airlines regional flight from Wichita, Kansas, as it was about to land in Washington D.C.’s Ronald Reagan National Airport. The incident has been deemed the deadliest plane crash in the country since 2001.

The tower at Ronald Reagan National Airport was managing both helicopter and flight traffic simultaneously. The tower was understaffed at the time, but the Board found that there were still enough personnel to separate the control positions. The decision was up to the operations supervisor, who had been working a really long shift and investigators believe that the “lack of mandatory relief periods for supervisory air traffic control personnel” could have led to poor performance.

“Keeping the helicopter control and local control positions continuously combined on the night of the accident increased the local control controller’s workload and negatively impacted his performance and situation awareness,” the report found

The controllers notified the helicopter of the passenger plane approaching, but failed to warn the flight crew of the helicopter. The pilots could not see the helicopter coming, and the airplane lacked airborne collision avoidance systems that could have alerted the pilots to the risk posed by the helicopter.

When warned, the helicopter crew said they had eyes on the incoming flight, but had likely confused the aircraft with another, because the controller had not specified direction or distance.

The helicopter was also flying roughly 100 feet above its maximum altitude, and it’s possible that the crew saw a wrong altitude reading. According to the NTSB’s findings, the FAA and the Army failed to identify “incompatibility” between the error tolerances of barometric altimeters in the helicopters and the helicopter route, which meant that helicopters were “regularly” flying higher than they should and even potentially crossing into airplane paths.

“It is possible that incorrect settings may be present on other aircraft used throughout the Department of War armed services,” the board concluded.