NTSB · Safety Recommendation
Safety Recommendation A-26-055
Recommendation
TO THE UNITED STATES DEPARTMENT OF TRANSPORTATION: Work with the Federal Aviation Administration (FAA) Administrator to convene an independent panel to conduct a comprehensive review of the safety culture within the FAA’s Air Traffic Organization (ATO), and use the findings to enhance the ATO’s existing safety management system and integrate it into all levels of the organization.
Safety Issue and Context
This report discusses the January 29, 2025, midair collision involving a Sikorsky UH-60L helicopter, operated by the US Army under the callsign PAT25, and a Mitsubishi Heavy Industries RJ Aviation (formerly Bombardier) CL-600-2C10 (CRJ700) airplane, N709PS, operated by PSA Airlines as flight 5342, over the Potomac River in southwest Washington, DC, about 0.5 miles southeast of Ronald Reagan Washington National Airport (DCA), Arlington, Virginia. The 2 pilots, 2 flight attendants, and 60 passengers on board the airplane and all 3 crewmembers on board the helicopter died. Both aircraft were destroyed as a result of the accident. Safety issues discussed in this report include:
• helicopter route design surrounding DCA;
• the extensive use of pilot-applied visual separation and the inherent limitations of see-and-avoid, including when using night vision goggles;
• unclear and inconsistent Federal Aviation Administration (FAA) guidance on helicopter route altitudes and boundaries and operators’ misinterpretation of those altitudes;
• limitations and gaps in the traffic awareness, alerting, and collision-avoidance technologies available to both aircraft;
• risks associated with separate helicopter and airplane radio frequencies and blocked transmissions;
• controller workload, position-combining, and communication practices;
• deficiencies in FAA safety culture, facility-level oversight, and postaccident drug- and alcohol-testing procedures; and
• shortcomings in FAA and US Army safety assurance and risk management processes, including lack of proactive data sharing and safety analysis to identify and mitigate midair collision risk in complex terminal environments.
As a result of this investigation, the National Transportation Safety Board makes 33 recommendations to the FAA, 8 recommendations to the US Army, 5 recommendations to the Department of War Policy Board on Federal Aviation, 2 recommendations to the Department of Transportation (DOT), 1 recommendation to the DOT Office of the Inspector General, and 1 recommendation to the RTCA.
Response History
July 9, 2026 · NTSB Correspondence · DOT
We note that you are requesting that the DOT Office of Inspector General (OIG) complete the review recommended in Safety Recommendation A-26-55. We believe the OIG is sufficiently independent to conduct an unbiased review of the safety culture within the FAA’s ATO. We also believe this work will complement the OIG’s ongoing efforts related to Safety Recommendation A-26-56, which asks the OIG to audit the FAA ATO safety management system functions and data-sharing activities at all air traffic control facilities.
Pending future updates and completion of the recommended actions, the Board has voted to classify Safety Recommendation A-26-55 OPEN-- ACCEPTABLE RESPONSE.
July 6, 2026 · NTSB Correspondence · DOT
Please update us when the audit is complete.
July 1, 2026 · Recipient Response · DOT
The DOT OIG is launching its new audit engagement in response to Secretary Duffy's request to address this recommendation. Please see the DOT OIG announcement letter released yesterday. https://www.oig.dot.gov/library-item/47306
-From Marshall E. Jackson, Assistant Inspector General for Aviation Audits to Director, Audit and Evaluation: Subject: INFORMATION: Audit Announcement FAA Air Traffic Organization’s Safety Management System and Organizational Culture Project No. 26A3005A000 Federal Aviation Administration
On January 29, 2025, a U.S. Army Black Hawk helicopter collided with American Airlines flight 5342, operated by PSA Airlines, while the airliner was on approach to land at Ronald Reagan Washington National Airport (DCA). Tragically, all 67 individuals aboard both aircraft lost their lives. The National Transportation Safety Board (NTSB) investigated the collision and identified gaps in the Federal Aviation Administration (FAA) Air Traffic Organization’s (ATO) application of its Safety Management System (SMS).