Hudson River Recap

September 15, 2010 by Bruce Landsberg

The NTSB had a public hearing yesterday to report on one of last year’s most horrific accidents, the collision between a Piper Saratoga transiting the Hudson river corridor and a sight seeing helicopter. Summarized are the findings:

“The National Transportation Safety Board determines that the probable cause of this accident was (1) the inherent limitations of the see-and-avoid concept, which made it difficult for the airplane pilot to see the helicopter until the final seconds before the collision, and (2) the Teterboro Airport local controller’s nonpertinent telephone conversation, which distracted him from his air traffic control duties, including correcting the airplane pilot’s read back of the Newark Liberty International Airport (EWR) tower frequency and the timely transfer of communications for the accident airplane to the EWR tower. Contributing to this accident were (1) both pilots’ ineffective use of available information from their aircraft’s electronic traffic advisory system to maintain awareness of nearby aircraft, (2) inadequate Federal Aviation Administration (FAA) procedures for transfer of communication among air traffic control facilities near the Hudson River class B exclusion area; and (3) FAA regulations that did not provide adequate vertical separation for aircraft operating in the Hudson River class B exclusion area.”

The FAA, AOPA, Air Safety Foundation, the NY helicopter community and a number of other players wasted no time in convening a special working group immediately after the accident to assess and address highlighted shortcomings in the crash. This was complete only months after the crash which serves as a model of responsiveness!

They came up with some reasonable procedures which included tightening up ATC’s responsibility, creating ground rules for operations in an SFRA for anyone who would operate in this high density airspace and improving the charting.

It was both a privilege and pleasure to conduct a live seminar and one of our first webinars in Newark, NJ and White Plains, NY after the working group had come up with their recommendations. The Jersey meeting was entertaining and educational! Living up to its reputation for attitude, the participants waxed “energetic” and challenged some of the working group’s assertions.  I love Jersey!

I have to question the NTSB’s first finding on probable cause. There are limitations to see and avoid but the primary cause here was procedural involving ATC performance and practice (largely addressed now) by putting a “non-participating” aircraft into the high density of  the corridor – as it existed at that time. The other questionable finding is the contributing factor regarding the pilots’ ” Ineffective use of available information from the electronic traffic advisory systems” that both aircraft had aboard.

The systems were NOT intended nor designed to function effectively in that level of traffic density and anyone who has flown them should understand their limitations in this regard.  The wonderful TCAS system on board airliners disables  itself below 1000 agl to eliminate nuisance alerts. This technology is evolving but the board’s insistence on this point, overruling NTSB staff recommendation,  is unfortunate.

The new recommendations are generally reasonable. However, the idea that ALL revenue helicopter operations need collision avoidance gear is not appropriate. There are low density locations where the cost-benefit just won’t compute well.

I’m certain there will be some discussion. Two big things I take away from this accident -

1) Multi-tasking degrades our ability to really focus on critical priorities and as a mindset, it’s now more prevalent than ever! This applies to both controllers and pilots.

2) On a more global sense just because we haven’t had an accident in a certain area or activity doesn’t necessarily mean we’re doing it right – it just means we’ve been lucky. There were no accidents in the corridor for nearly 40 years and yet, after looking at the details, the new procedures make a lot of sense. The devilish difficulty is that the safety-at-all-costs crowd  can legislate any activity out of business in no time. It is often the case that excellent safety procedures have been in place but there was a lapse. The mere fact that an accident occurred doesn’t always mean the system failed. Finding the balance point is exceedingly difficult.

NTSB’s New Recommendations

The National Transportation Safety Board recommends the following to the Federal Aviation Administration:

  1. Redefine the boundaries of the East River common traffic advisory frequency (CTAF) so that the Downtown Manhattan Heliport will be located in the area that uses the Hudson River CTAF.
  2. Revise 14 Code of Federal Regulations 93.352 to specify altitudes of use for aircraft conducting local operations in the Hudson River special flight rules area so that the regulation includes required operating altitudes for both local and transiting aircraft, and incorporate the altitude information for local operations onto published visual flight rules aeronautical charts for the area.
  3. Update Advisory Circular 90-48C to reflect current-day operations, including (1) a description of the current National Airspace System and airspace classifications, (2) references to air tour operational areas as high-volume traffic environments, and (3) guidance on the use of electronic traffic advisory systems for pilots operating under the see-and-avoid concept.
  4. Develop standards for helicopter cockpit electronic traffic advisory systems that (1) address, among other flight characteristics, the capability of helicopters to hover and to fly near other aircraft at lower altitudes, slower airspeeds, and different attitudes than fixed-wing airplanes; (2) reduce nuisance alerts when nearby aircraft enter the systems’ alerting envelope; and (3) consider the different types of operations conducted by helicopters, including those in congested airspace. (Supersedes Safety Recommendation A-09-04 and is classified “Open—Unacceptable Response”)
  5. Once standards for helicopter electronic traffic advisory systems are developed, as requested in Safety Recommendation [4], require electronic news gathering operators, air tour operators, and other operators of helicopters used for passenger revenue flight to install this equipment on their aircraft. (Supersedes Safety Recommendation A‑09‑05)

What do you think?

Bruce Landsberg
Senior Safety Advisor, Air Safety Institute

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8 Responses to “Hudson River Recap”

  1. Bob H. Says:

    Alternate ending: The NTSB finds that mediocrity and complacency on the part of ATC were deadly factors in the crash.

    The pilot in command of the aircraft requested 3500 and NO ONE has provided a sufficiently reasonable justification for why that request was ignored. Organizational intransigence is not a a sufficient justification, but ymmv.

    “Do it right or not at all,” needs to come right after ” …safe, orderly and expeditious….”

  2. Chris P. Says:

    I concur with Bob H. to an extent. I watched the entire Board Meeting via web cast.

    Tom Haueter, an aviation safety expert and staff member employed by the NTSB for over 26 years, vigorously argued to the Board to place the Teterboro tower controller’s non-pertinent “dead cat” telephone call at the top of the probable cause list. Although he was unsuccessful, it was clear to anyone watching the logic of his case was incontrovertible.

    Why the Board placed the limitations of “see and avoid” at the top is anyone’s guess. Chairman Hersman’s Vice Chairman, Christopher Hart, was absent. It seemed as though the Board was frustrated and tired. They had difficultly getting the exact language of the probable cause adopted. The FAA has termination proceedings against the controller in question and his supervisor.

    As Mr. Haueter argued, the limitations of “see and avoid” has been known since the deadly mid air over the Grand Canyon in 1956. That accident was the catalyst for sweeping changes in regulating air traffic.

    Only time will tell if the lessons of this tragedy are learned.

  3. John Wyker Says:

    They missed the entire point of it. The controller was talking on his phone while he was supposed to be controlling traffic. The railroad industry had a wake-up call in this area last year when an engineer was texting instead of paying attention to operating his train. He ran by a “Stop” signal and had a head-on collision with another train. Personal phones should be banned in the cockpit and in the control tower, approach or center.

  4. MJSchwartz Says:

    I believe the NTSB got it right. Both aircraft were VFR. The foundation for Visual Flight Rules is to see and avoid terrain, other aircraft, etc. Anyone who has been flying for a while, and is honest with themselves, completely understands that there are serious limitations to seeing and avoiding other small aircraft in the daytime. It’s a lot easier at night (with strobes, beacons and position lights). I’ve been flying with a TCAD system for the past 5 years and I am amazed at how many aircraft I miss with my normal visual scan (and that’s in relatively uncongested airspace).

  5. C. Craig Morris Says:

    Bruce, you’re off the mark in this article, and you’re doing a disservice to general aviation, pilots, and their passengers. See and avoid is the root problem of all midair collisions, not just this one with its interesting, but hardly germane, peculiarities. For an exact analysis of limitations of the see and avoid concept, see: http://www.ingentaconnect.com/content/asma/asem/2005/00000076/00000004/art00007.

  6. Bruce Landsberg Says:

    Craig….

    Thank you for the reference – we will review it in detail.

  7. Mike Hayden Says:

    Had the pilot used something as simple and easy as Flight Following he would have some warning from ATC of the deteriorating weather on his route. I recall a VFR flight I made from Boston using Flight Following when I was told by ATC of a long line of severe thunderstorms over the Columbus, Ohio area that the controller said I could neither go over nor conveniently go around. I landed at a nearby airport and spent several hours safely on the ground waiting for it to pass.

  8. Mike Hayden Says:

    The comment I submitted 9/25/10 at 5;46 am was meant for the “Bad Day at Huntington” accident review and not “Hudson River Recap”..

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