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Situational Blindness, Fatal Consequences

February 1, 2025 By Nagesh Belludi Leave a Comment

How Situational Blindness Caused the American Airlines-Black Hawk Fatal Collision Near Reagan National Airport Earlier this week, I mentioned how accidents rarely result from a single cause, but rather from a series of factors that align to trigger disaster. On their own, these ‘contributing factors’ may seem minor, but together, they can lead to significant incidents, as was the case on Wednesday night.

An American Airlines flight (5342), operated by American Eagle/PSA, collided with an Army Black Hawk helicopter near Reagan National Airport (DCA) in Washington D.C., sending both aircraft into the Potomac River. Tragically, all 60 passengers and 4 crew members aboard the flight, along with the 3 soldiers in the helicopter, lost their lives. Investigations are underway, but while it’s too early for deductions, it appears that a combination of factors contributed to this devastating event.

The Black Hawk was flying under Visual Flight Rules (VFR,) relying heavily on visual references to navigate. This required the pilots to maintain visual separation from other aircraft and use landmarks for guidance. Although typically crewed by four, this Black Hawk had only three personnel aboard. It is unclear whether a single pilot was at the controls, but the absence of a second pilot may have removed a crucial safety layer. In a high-traffic airspace like this, having two pilots flying allows for cross-checking decisions, reducing the risk of errors. Disorientation is a real danger, especially at night with lights reflecting off the river. A second pilot would have provided an additional perspective for decision-making, an extra set of eyes for maintaining visual separation, and crucial support for monitoring instruments and communicating with air traffic control, all of which enhance situational awareness.

The Black Hawk pilot can be heard on the radio confirming visual contact with the incoming aircraft, stating, “PAT 25 [call sign of the Black Hawk] has the traffic in sight, request visual separation.” This indicated that the pilot had assumed responsibility for maintaining a safe distance. The air traffic controller approved the request, effectively transferring collision avoidance duties to the helicopter crew. However, the Black Hawk was supposed to be flying at 200 feet but was instead at an altitude of 350 to 400 feet when the collision occurred—just as Flight 5342 was descending. This altitude discrepancy was a critical error and a key factor in the crash. Notably, just over 24 hours before this fatal incident, another American Eagle jet had to abort its landing after coming dangerously close to a helicopter in the same congested airspace.

There may also have been confusion about which aircraft the Black Hawk needed to avoid. The pilot may have mistakenly identified a different aircraft—either one following Flight 5342 in the landing sequence or another departing from the airport. Although air traffic control communications followed standard procedures, clearer identification of aircraft could have helped prevent the tragedy.

Ultimately, the crash suggests that a series of mistakes—misidentification, altitude discrepancies, and the challenges of navigating busy airspace—may have contributed to the collision. While the Black Hawk was highly maneuverable and could have potentially adjusted its course, these errors seem to have compounded, making avoidance increasingly difficult.

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Filed Under: Effective Communication, Mental Models, Sharpening Your Skills Tagged With: Aviation, Biases, Confidence, Critical Thinking, Decision-Making, Mindfulness, Problem Solving, Thinking Tools, Thought Process

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About: Nagesh Belludi [hire] is a St. Petersburg, Florida-based freethinker, investor, and leadership coach. He specializes in helping executives and companies ensure that the overall quality of their decision-making benefits isn’t compromised by a lack of a big-picture understanding.

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