Federal investigators are rejecting claims that pilot error caused the deadly midair collision Jan. 29, 2025, near Washington, D.C., instead pointing to deep, long-standing failures within government-managed aviation systems.
"There is a tendency in the immediate aftermath of any accident we investigate to question human error — on the actions or inactions of individuals," National Transportation Safety Board Chair Jennifer Homendy told a public board meeting Tuesday in her opening statement.
"However, human error in complex systems, like our modern aviation system and the National Airspace System, isn't a cause; it's a consequence.
"Many things need to go wrong for an accident to occur."
Investigators said multiple layers of safety defenses failed — including airspace design, outdated "see-and-avoid" practices, and organizational breakdowns — allowing the tragedy to occur as a U.S. Army Black Hawk helicopter collided with an American Airlines regional jet.
The crash, which occurred less than a mile from Ronald Reagan Washington National Airport, killed all 67 people aboard and marked the deadliest U.S. aviation disaster since 2001.
Homendy emphasized that modern aviation accidents rarely stem from a single mistake.
"Within a robust system, the introduction of a single error is almost never the only cause of an accident," she said. "Rather, several barriers of defense must fail for the error to lead to an accident."
A concept long recognized in aviation safety research but often overlooked in public debate is that systemic vulnerabilities coincide to be the root cause of a tragic accident, she added.
The NTSB chair also criticized agencies and organizations for failing to act on readily available safety data and decades-old recommendations aimed at preventing midair collisions, particularly in congested and complex airspace like the nation's capital.
Investigators drew parallels to past transportation disasters, including Boeing manufacturing failures and major rail accidents, in which early attention focused on individual workers before deeper systemic flaws were revealed.
The board is expected to issue multiple safety recommendations aimed at redesigning airspace procedures, improving collision-avoidance strategies, and strengthening safety oversight across civilian and military aviation operations.
Homendy warned that without meaningful reform, similar tragedies could happen again.
"Our work, however, doesn't end today with the issuance of a final report; that is just the first step," she said. "We must relentlessly, vigorously pursue safety change.
"That means we must do everything in our power, even ruffle feathers, to get our recommendations implemented, or this will happen again."
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