The Swiss Cheese Model

As an avid viewer of Air Disasters reruns on the Smithsonian Channel, I've been trying to soak up every detail about the Washington regional jet-Army helicopter collision. But one comment by a Fox News guest sums up the whole situation:

"It's our system that is bad and that's what has to be looked at. To be honest with you… we need to take a bulldozer to the front of the FAA. This is bad management, and it's putting us at risk," Boyd Group International President Mike Boyd said Thursday in reaction on "Mornings with Maria."

"We had two flying machines run into each other over the Potomac. That is the FAA's job to avoid those things," he argued. "We have all kinds of human issues here. But the fact is, we've had near-miss after near-miss for the past 20 years. Now we've had a collision. The collision is the responsibility of the FAA and the air traffic control system. Somebody failed."

Until late yesterday afternoon, the focus was on the Army helicopter and why it was 200 feet above its assigned altitude -- then another crash seems to have derailed the whole discussion. But Mr Boyd has correctly refocused the question: there are human issues in place, humans make mistakes. But it's the FAA's job to design and implement a system that eliminates human mistakes.

The problem with the Washington collision wasn't that the air traffic controllers were overworked, or were hired via DEI, or that an incompetent pilot was flying the helicopter, or that there should have been four people on the crew instead of three, or that the lane for helicopter flights down the Potomac crossed the approach pattern for Reagan National Airport; the problem was all these factors working in combination. According to Wikipedia,

The Swiss cheese model of accident causation is a model used in risk analysis and risk management. It likens human systems to multiple slices of Swiss cheese, which has randomly placed and sized holes in each slice, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers and types of defenses which are "layered" behind each other. Therefore, in theory, lapses and weaknesses in one defense do not allow a risk to materialize (e.g. a hole in each slice in the stack aligning with holes in all other slices), since other defenses also exist (e.g. other slices of cheese), to prevent a single point of failure.

Thus yesterday afternoon, the FAA very belatedly took the step of closing the path for helicopters to fly down the Potomac in conflict with the Reagan National approach pattern:

NEW: With the support of @POTUS and in consultation with the @SecDef, effective today, the @FAANews will restrict helicopter traffic around Ronald Reagan Washington National Airport airport.

Today’s decision will immediately help secure the airspace near Reagan Airport, ensuring… pic.twitter.com/Oo6B9H8z8S

— Secretary Sean Duffy (@SecDuffy) January 31, 2025

This simply elminates one of the holes in the series of slices that allowed the collision to happen. But that doesn't mean there aren't other holes that need to be closed as well. Via CBS News,

The permitted flight ceiling on the Potomac River near Reagan National Airport is 200 feet – a crucial ceiling for keeping the heavy flow of military helicopters safely clear of the steady commercial aircraft traffic into and out of the nation's capital.

Data from FlightRadar24, which tracks and records aircraft data for most flights across the U.S., showed the helicopter's last estimated altitude was about 400 feet when it crashed. The jet's altitude was about 375 to 400 feet, according to data from FlightAware and FlightRadar24.

"They're military pilots; they're familiar with the routes," [former NTSB investigator Doug] Feith said. "Why is it on this day, on that flight, they were [as much as] 150 to 200 feet higher than they knew they should be?"

That's just another hole in the Swiss cheese. If the helicopter lane crossed the airport flight path, but the helicopter crew had stayed at the prescribed altitude, the collision wouldn't have happened, either. This focuses attention on the crew.

The United States Army released the information of two of the three soldiers/pilots onboard the Black Hawk that flew into a regional airplane, crashing into the Potomac River. Reuters said two of the names were released, but the Army refused to provide the third.

Now people want to know what's going on and they're demanding transparency.

A Reuters report quoted at the link said it was done at the request of the soldier's family, but this raises inevitable questions about whether the third soldier had something to do with the helicopter being at the wrong altitude. If the family hoped to avoid oppobrium at their son or daughter, or at the family name or background, if such a blunder was involved, this will prove only a temporary fix. Beyond that, according to an experienced Blackhawk pilot and crew chief,

The single-greatest error in this accident was the decision to fly without a second Crew Chief on the left-hand side of the Blackhawk, who could have provided an extra set of eyes to “look out-and-up” to see the approaching American Airlines Passenger plane.

. . . Flight Unit Leadership failed to recognize the need for a second Crew Chief in the Mission Planning and Risk Assessment Process. This is where either incompetence, or DEI (or both), may have come into play. This was certainly poor leadership.

. . . The Flight Unit Commanders must share the blame, and they’re still alive! There is a 12th Aviation Battalion commander of that B Company, and I don’t know who that is, but this individual was the first leader in the chain of events for the Mission Plan and Risk Assessment to get signed off and approved. This B Company commander should be asked why they did not enforce a second Crew Chief to be on that flight.

So there were at least three slices of Swiss cheese whose holes lined up to cause the accident. The helicopter lane down the Potomac crossed the landing flight pattern for Reagan National, and near-misses were common. It was only a matter of time until a helicopter would fly high enough to hit a civilian airliner. The helicopter in this case apparently had a pilot wih shaky experience who in fact did fly too high. But on top of that, the helicopter unit commander failed to recognize that the crew needed additional supervision.

The factors contributing to this appear to have included extreme complacency at the FAA, which neglected to address the conflicting flight patterns near the airport for decades, as well as the apparent distraction within both Army and FAA management as they were forced to focus on DEI in hiring and performance appraisal. At the Department of Transportation, there was the additional problem at the cabinet level that the secretaries in previous administrations of both parties were patronage hacks, Elaine Chao, who is Mitch McConnell's wife, and Pete Buttigieg, who was appointed to appease the gay wing of the Democrats.

Given the Trump administration's track record so far, I would expect heads to roll, and quickly.