Do you know what’s going on around you?
SA requires good perception, comprehension, and projection of your environment.
By Shannon Forrest
Contributing Writer
In January 2025, a midair collision occurred between a CRJ 700 operated by PSA airlines and a Sikorsky UH-60L helicopter operated by the US Army. The CRJ was operating as a scheduled Part 121 flight from ICT (Dwight D Eisenhower, Wichita KS) to DCA (National, Washington DC). The military helicopter was being flown as a training flight with the goal of conducting a night vision goggle (NVG) standardization evaluation.
The CRJ captain was the pilot flying (PF), and he held an ATP certificate with 3950 hrs TT and 3024 in make and model. The first officer was the pilot monitoring (PM), and had accumulated 2469 hrs TT, including 966 in make and model. The UH-60 pilot receiving the NVG standardization evaluation held the military rank of captain and had flown a total of 450 hrs, 326 of which were in the make and model of the accident aircraft.
The instructor pilot (IP) in the UH-60 was a chief warrant officer 2 with 968 hrs TT and 300 in make and model. A crew chief (staff sergeant) with 1149 hrs in the UH-60 was also aboard the helicopter. Both crews perished, along with 2 flight attendants and 60 passengers on the CRJ. Although the National Transportation Safety Board (NTSB) has not published a final report, the preliminary report (DCA25MA108) provides some relevant facts and details associated with the event.
The elements of situational awareness
Situational awareness (SA) is a term that’s ubiquitous in aviation. Dr Mica Endsley is a recognized world leader in human SA. Her pioneering work in the field dates to 1995. According to Endsley, SA can be defined as “perception of environmental elements with respect to time or space, the comprehension of their meaning, and the projection of their future behavior.” However, if you ask a pilot to define SA, the most likely response is something to the effect of “knowing what’s going on around you.”
While that statement may be true, that’s only part of it. Endsley’s widely accepted SA paradigm contains 3 elements – perception, comprehension, and projection. Perception means gathering sensory information from the environment. Human senses are notoriously flawed when airborne. For example, consider the runway illusions a pilot learns at the beginning of flight training. A runway that’s narrower than usual may trick a pilot into thinking he’s higher than he is. Conversely, a wider runway has the opposite effect in driving the perception of being lower.
Night and instrument flying in instrument meteorological conditions (IMC) induces a myriad of other perceptual errors. Comprehension means a pilot understands the situation if perception is accurate. Failure to understand is common among students and novice pilots, and is also a phase of the fundamentals of learning all instructors are taught. As a reminder, these are rote, understanding, application, and correlation.
Projection aligns nicely with application and correlation. If perception and comprehension are correct, accurate SA necessitates projection. In other words, a pilot must look out or forecast what may happen next.
A common question posed to student pilots by flight instructors is, “What are the 2 most important things in flying?” At first glance it’s a philosophical open-ended question – and one that could generate numerous correct answers. However, it’s a loaded question. The answer the instructor is looking for is “the next 2 things.” And this is true in the context of SA.
Of the 3 facets of SA, projection is the most difficult to do. Years ago, the initial CRM course at FlightSafety International (FSI) provided an everyday example. You’re driving 80 mph on a freeway. Traffic is heavy. Suddenly, traffic in front of you comes to a screeching dead stop. After hitting the brakes and stopping, what’s the next thing you do? If you thought of looking in the rear-view mirror, you made it through the projection phase of SA correctly. This is because you determined accurately what has happened and what’s currently happening, and now it’s important to consider what may happen, which in this case is getting rear-ended when the driver behind you fails to stop.
Loss of situational awareness
Accident reports often identify failure to maintain SA as a causal or contributing factor. Looking at it as an outcome without attending to the precursors is akin to treating the symptoms instead of addressing the cause. One of the CRM training tools provided to participants in the FSI course was a handout that identified clues to a potential loss of SA. As specified, these are failure to meet targets, undocumented procedures, departure from standard operating procedures (SOPs), violating minimums or limitations, failure to monitor, communications, ambiguity, unresolved discrepancies, preoccupation or distraction, confusion, perceived need to hurry, last-minute changes, and fatigue.
In nearly all situations that involved a loss of SA, at least 3 of these markers were evident. It’s important to note that these variables do not equate directly to a loss of SA. The intent is to make pilots aware that as these markers appear, and as the number of markers increases, so does the potential for a loss of SA. Although not included in the original material, complacency is another significant marker of SA.
One of the least discussed concepts as it pertains to SA is collective SA, or the aggregate level of SA of all participants in the operation. Collective SA is a variable in every operation, and the combinations of participants are endless. It can apply between 2 pilots within the same aircraft, pilots in different aircraft, pilots and air traffic control, pilots and cabin crew, and pilots and maintenance. In some cases, an individual’s SA can be high but collective overall SA may be low.
It’s collective SA that ultimately equates to risk, and it’s driven down by the person whose SA is lowest. It’s also possible that the individual (or crew) does “all the right things” and yet the environment, system, or other actors makes the situation untenable and increases the possibility of harm. Some may describe this scenario as being in the wrong place at the wrong time. Others may call it pure dumb luck.
So what caused the accident?
The preliminary report on the DCA midair collision identifies several markers that are congruent with the potential for degrading SA. Approximately 10 miles from touchdown, the crew of the CRJ – which had previously been assigned a charted visual approach to Rwy 1 – was asked to switch to Rwy 33. This was a last-minute change.
This effectively made it a circling approach at night. As indicated in the Airport Facility Directory, Rwy 1 has a landing distance available of 6869 ft, whereas Rwy 33 is 5204 ft long. The reduced landing distance means that not all aircraft can accept the shorter runway.
The operational advantage of using Rwy 33 is that it relieves pressure on the main north/south-oriented runway. However, Rwy 33 intersects both Rwy 1/19 and Rwy 4/22 (another shorter runway). As a result, timing of arrivals and departures is critical. Although there’s an RNAV approach to Rwy 33, at 1.4 miles from the runway there’s a visual guidance fix (VGF) that specifies a requirement to fly visual to the airport on a track of 334 degrees.
The airspace, which is adjacent to prohibited areas that protect the US Capitol building, Washington Monument, and the White House, makes the operation complex and induces high workload for both the pilots and air traffic controllers. As one flies a fixed-wing aircraft into DCA, it’s common to see helicopters in proximity. Many pilots describe operating out of DCA as putting 10 lb of groceries into a 5-lb bag, meaning the operational pace is intense.
As the crew of the helicopter (callsign PAT25) passed northwest of the airport on a southerly track, the cockpit voice recorder (CVR) captured an exchange between the pilot and the instructor regarding the altitude. The pilot stated they were showing 300 ft. The instructor said 400 ft. No communication ensued about the disparity in altitude.
This was an unresolved discrepancy. Approximately 2 minutes later, the instructor in PAT25 told the pilot they were at 300 ft and needed to descend. This was considered failure to meet target. As the helicopter crossed over the Washington Tidal Basin and joined charted Helicopter Route 1, ATC advised the crew that the traffic south of the Wilson Bridge (a charted landmark on the visual approach to Rwy 1) was a CRJ circling to Rwy 33. Oddly, the word “circling” is heard on both ATC tapes and the CVR in the CRJ, but not on the CVR in the helicopter.
According to the preliminary report, it’s possible that the word circling was not heard by the PAT25 crew. This is an obvious failure in communication. Nonetheless, PAT25 reported the CRJ in sight and requested to maintain visual separation. The request was approved by ATC, and at this point the 2 aircraft were 6.5 miles apart.
The CRJ began a left turn to align with Rwy 33 about 31 seconds prior to impact, at a radio altitude of 516 ft. Twenty seconds prior to impact, a conflict alert sounded in the tower (unresolved discrepancy) and the controller asked PAT25 if the CRJ was in sight. One second later, with the aircraft less than a mile apart, the TCAS on the CRJ stated “Traffic, traffic.” The controller then issued an instruction to PAT25 to pass behind the CRJ. Unfortunately, a 0.8-second microphone key from PAT25 may have clipped the transmission, making it inaudible as the instruction cannot be heard on the CVR of the helicopter (again, failure in communication).
PAT25 responded to ATC by saying they had the traffic in sight. After this transmission, the instructor in PAT25 told the pilot he believed ATC was asking for the helicopter to make a left turn and track the east bank of the Potomac (confusion).
Aids have limitations
Whenever there’s an accident like this, pilots tend to divide into 2 camps – the “could have, should have, would have” and the “how do I prevent this from happening to me” crowd. The former doesn’t offer any benefits to safety. The best the latter can hope for is to identify the links in the chain that, if broken, might have averted the event. One post-crash question that pilots have asked is why the TCAS – which is designed to prevent midair collisions – didn’t rectify the situation.
TCAS II version 7.1 provides traffic advisories (TAs) and resolution advisories (RAs) – awareness and corrective action, respectively – in the vertical dimension. But the system will not provide resolution RAs during descent below 900 ft AGL. And below 400 ft AGL on arrival, the aural TA alert (“Traffic, traffic”) is inhibited. The collision occurred at 313 ft AGL.
How many pilots know the TCAS limitation or would have even considered it, given the high workload of circling at night at low altitude in the most tightly regulated airspace in the world? The very system designed to enhance SA was rendered moot as a function of altitude at the point of impact. Over-reliance on automation has become a trend over the past decade, and has the potential to impair SA.
One can certainly argue that this event was a one-off, a low-probability event. Yet the data shows that the number of incursions and near misses is not decreasing markedly. In October 2023, the pilots of a Hawker 850XP at HOU (Hobby, Houston TX) erroneously believed they heard a takeoff clearance and began the takeoff sequence.
As a result, the aircraft’s wing clipped the vertical stabilizer of a Cessna Citation Mustang landing on an intersecting runway. Instead of a takeoff clearance, the Hawker crew had been given a “line up and wait” instruction. In post-accident interviews, the Hawker crew stated that, during the beginning of the takeoff, their attention was diverted by a rudder bias and pitch trim alert, which they tried to resolve while rolling (preoccupation or distraction).
Crew resource management
The latest iteration of CRM is centered around threat and error management (TEM). The theory goes that a pilot or crew should identify a threat and then discuss a mitigation strategy to minimize the risk associated with the threat. There are some caveats regarding use of this methodology. A threat must be specific and not all encompassing. For instance, the threat should not be stated as “Teterboro.” After all, what specifically about TEB (Teterboro NJ) constitutes a threat? In the corporate world, there’s a host of tools and software solutions that do this before flight, with the output being a risk assessment.
The challenge is that SA and corresponding threats are dynamic in nature. Observations on the line and in simulator sessions have noted that pilots are good at identifying threats but often fail to complete the follow-up of annunciating how they are going to deal with the threat. What’s the strategy for mitigation? For example, if the threat is a short runway, the strategy might be a go-around if the aircraft is not down by a definitive point of demarcation.
The practice of setting targets and having the discipline to respect those targets enhances SA. The fundamental problem when looking at incident and accident analysis is that you never know how many events were averted by doing the right thing. Non-accidents don’t get any publicity. One of the biggest enemies of SA is continuation bias. It’s the tendency to continue a course of action even though signs are present that suggest such action is not prudent.
As the markers indicating a potential degradation of SA start to increase, it may be a good time to slow down, confirm that the present course of action is suitable, and, if not, switch to plan B. Ironically, the hardest word for a pilot to say – and yet the one that wields the most power – is “unable.”
Shannon Forrest is a current line pilot, CRM facilitator, and aviation safety consultant. He has more than 15,000 hrs TT and holds a degree in behavioral psychology.