San Francisco Chronicle: A Key Lesson From A 2013 San Francisco Crash Could Have Prevented the Tragedy in Washington

The D.C. area crash may look different than the July 6, 2013, San Francisco crash of Asiana Flight 214, but similar underlying factors led to both.

By Shem Malmquist and Roger Rapoport

San Francisco Chronicle

 January 31, 2025

On Wednesday night, a PSA Airlines regional codeshare flight for American Airlines collided with a military helicopter near Washington, D.C. Tragically, all 67 people aboard both aircraft perished after the plane crashed into the Potomac River. Our hearts go out to those lost, their friends and loved ones. It’s now incumbent on air safety experts to figure out what happened and to apply lessons learned to prevent similar accidents.

Investigators will no doubt focus on decisions made by the flight crews as well as air traffic control. But human error alone won’t teach us all we need to know about this crash. More and more, flight accidents are beginning to share common underlying factors even when they appear unrelated.

Although the Washington crash may look different than the July 6, 2013, crash of Asiana Flight 214 at San Francisco International Airport — which killed three people — similar underlying factors led to both. These tragedies shared the unrelenting demand for our understaffed air traffic system to move more and more aircraft.

This is particularly true for our nation’s capital, where political officials commuting nonstop into Reagan National Airport create additional pressure on the Federal Aviation Administration. There is a big push on controllers to reduce delays, especially at the airport named after the president who fired 11,359 of them on Aug. 5, 1981. This indirectly contributes to daily challenges across our nation’s vulnerable air traffic control system. 

One way air traffic controllers deal with the volume of planes they are expected to manage is that they will, when possible, clear aircraft for “visual approaches.” This means that during the critical landing phase of a flight, pilots are entirely responsible for their own vertical and arrival paths. Air traffic controllers ask if pilots have other nearby planes in sight and then expect them to maintain separation visually, without additional guidance.

This FAA policy is nationwide and uniquely shifts flight path and traffic separation responsibility from controllers to pilots. While it gives controllers the ability to handle far more flights and reduces delays, it also reduces safety margins.

Outside the U.S., airline flights are rarely given a visual approach. Air traffic controllers give them a defined route, built by procedure design specialists or within defined guidelines. Further, airline pilots operating abroad are virtually never asked to maintain visual separation from other aircraft. Other governments have decided the risk is too great.
Exhibit A is the 2013 Asiana Boeing 777 flight, which was given a visual approach to SFO. Because this aircraft was fairly high, the pilots needed to manage their flight path aggressively. 

Was it possible?  Absolutely. But for a tired trans-Pacific training flight crew unaccustomed to such a clearance it proved to be too much. If controllers at SFO had provided these pilots with the type of routine proscriptive guidance occurring in Asia, Europe or the Middle East, the accident would almost certainly never have occurred.

The key operational benefit of using this procedure is that it reduces the burden on our nation’s air traffic controllers, enabling fewer people to manage more traffic. When this approach contributes to a crash, it is convenient for grandstanding politicians to quickly blame controllers while ignoring more critical factors.
Wednesday’s crash occurred after controllers handed off responsibility for traffic separation to the military helicopter crew. 

It was their job to avoid the regional jet as it approached a secondary runway at one of our nation’s most overcrowded airports. Effective automation designed to prevent this crash did not prevent it.

By design, an installed traffic collision avoidance system automatically inhibited warnings at the low altitude where this crash happened. This setting prevents distracting false warnings, especially from aircraft on the ground.

It also may be one reason why the PSA flight crew was unable to avoid colliding with an Army Blackhawk helicopter at 400 feet. Of course, if both aircraft had been under direct air traffic controller supervision — as occurs in most other countries — it would have prevented the collision.

Stopping future accidents requires understanding fundamental system pressures and constraints contributing to these crashes. The solution — maintaining positive control of all aircraft by adding more controls — potentially means hiring thousands of new controllers. The alternative is reducing flight schedules and increasing flight separation, an air traffic controller’s customary response during bad weather.

It is no surprise that this accident waiting to happen took place in the Washington airspace saturated with a high density of military, corporate and civilian traffic. Special procedures mandated by a wide swath of prohibited airspace and noise reduction requirements add risk. It is the strategy to hand off control that keeps heavy traffic flowing.

These factors are central to today’s air traffic control system that took shape after aircraft collided over the Grand Canyon in 1956. Following years of debate, the federal government created a system designed to rule out the kind of collision that happened Tuesday.

Yet that system is insufficient to handle today’s overcrowded airspace. Finding a way to add thousands of controllers is a critical job for our high-flying political leaders. Evasive political action and blamesmanship are no solutions.

Veteran aviation accident investigator and  Boeing 777 Capt. Shem Malmquist and investigative reporter Roger Rapoport are authors of the air safety books “Angle of Attack” and “Grounded.”