On Tuesday, January 27, the National Transportation Safety Board (NTSB) convened a hearing regarding the January 2025 mid-air collision over Washington Reagan National Airport (DCA) between a passenger airliner and a military helicopter that resulted in 67 deaths. NTSB Board Members received presentations from NTSB staff and presented 74 findings from the investigation. The Board Members also presented the probable cause of the accident and 50 recommendations to the Federal Aviation Administration (FAA), U.S. Army, U.S. Department of War, and USDOT. The hearing took place one year following the tragic collision and served as both a moment for somber reflection and a forum to hold the organizations responsible for safe aviation operations accountable.

The extensive discussion of the findings and recommendations underscored the NTSB’s thorough approach, reflecting a deliberate effort to examine every aspect of the accident and present its conclusions in detail. Consistent with that breadth, the Board’s determination of probable cause was lengthy, attributing the accident to multiple causes identified during the investigation.

The NTSB determined the probable cause to include the FAA’s placement of the helicopter route near the DCA runway and the agency’s failure to evaluate the risk of the route placement and mitigate risk of midair collisions at DCA, the DCA tower staff’s loss of situational awareness due to workload and capacity issues, the lack of safety risk assessments at DCA, and the Army’s failure to make pilots aware of altitude instrument errors.

The Board also pointed to several contributing factors to the probable cause, including limitations of collision avoidance technology and the FAA’s failure to implement previous collision avoidance recommendations, traffic capacity concerns at DCA, and the Army’s lack of a robust safety management system.

Helicopter Route Placement

The FAA is in charge of establishing helicopter routes within the National Airspace System (NAS) and publishes helicopter route charts to help pilots navigate complex, high-traffic airspace. In the January 2025 accident, the helicopter was operating on Route 4, one of the helicopter routes used in the congested, mixed-traffic airspace over DCA. The Board found that the FAA’s placement of Route 4 was a probable cause of the crash, which points to a structural error embedded in the airspace design. Placing a helicopter route too close to active runway operations reduces the separation between aircraft and increases the likelihood of conflicts.

This risk of collision around DCA is not new. One reported incident involved an airplane coming within 200 feet of a helicopter, forcing the plane to abort its landing to avoid a collision. That near-miss led to the creation of the DCA ATC Helicopter Working Group. The working group recommended the relocation or removal of Route 4, which the FAA did not implement.

Following the January 2025 crash, the NTSB issued urgent recommendations to restrict air traffic around runways 15 and 33 at DCA and to close Route 4 between Hains Point and Woodrow Wilson Bridge. The FAA responded to the NTSB’s 2025 recommendations and closed Route 4 between the set locations and published an Interim Final Rule in January 2026 that restricts use of runways 15 and 33 when helicopters are operating in the area.

Capacity Constraints

During the night of accident, the NTSB reported that the air traffic controllers felt “overwhelmed” with the volume of traffic, and the Board found that the increased workload led to reduced situational awareness. This finding is significant because it ties the reduced situational awareness of controllers to system performance constraints at DCA and does not target deficiencies in any individual controller.

DCA’s runway 01/19 is considered the nation’s busiest runway, seeing over 800 daily takeoffs and landings. The airport manages this demand through airport arrival rates, slot controls, and miles-in-trail, which defines the minimum distance required between aircraft. The NTSB highlighted two compounding factors that can intensify workloads. First, air carriers cluster scheduled arrivals at the beginning and end of two-hour slot blocks, creating periods of concentrated flight arrivals. Second, the DCA tower received “less than requested” miles-in-trail. Collectively, these factors compress arrival spacing and leave controllers less time to identify and resolve conflicts. These conditions force controllers to make rapid and frequent interventions to preserve separation of aircraft.

One such intervention that has been used at the DCA tower is to offload traffic to runway 33. While offloading traffic relieves pressure on the primary runway, it creates an environment for aircraft crossing paths with each other, increasing the risk of collisions.

Operators have attempted to address capacity constraints in the past. In May 2023, operators at the Potomac Consolidated Terminal Radar Approach Control (TRACON) submitted a proposal to the FAA to reduce the aircraft arrival rate. According to operators at a previous NTSB hearing, this proposal did not reach the proper management at FAA for consideration, signaling a safety-management gap, where signals from the field are not reaching decision-makers.

Collision Avoidance Technology Concerns

The NTSB pointed to limitations in collision avoidance technology and the FAA’s failure to implement previous recommendations as contributing factors in the accident. One of the technologies in question is Automatic Dependent Surveillance- Broadcast (ADS-B) Out and In. ADS-B Out is the ability for an aircraft to transmit altitude, position, and velocity to ground facilities or other aircraft. ADS-B Out improves controllers’ awareness of aircraft. ADS-B In enables aircraft to receive information from other aircraft and the ground. ADS-B In is a feature that gives the pilot position and altitude data directly from other aircraft, assisting the pilot to keep adequate separation and improve their field of view. The FAA requires the use of ADS-B Out but does not require the use of ADS-B In. Additionally, the FAA provides the Army with an exemption on using ADS-B Out during military operations.

During the night of the accident, the helicopter was not transmitting using ADS-B Out. However, NTSB staff highlighted that the helicopter was transmitting information using a different transponder. The issue was that the passenger airliner was not equipped with ADS-B In, so the pilot did not have the ability to directly receive information from other aircraft, and had to rely on visual separation, “see-and-avoid” techniques and the information from the control tower. The use of ADS-B In would have improved the airline pilot’s awareness of the airspace conditions and an opportunity to avoid the helicopter.

One of the NTSB’s 2026 recommendations was for the FAA to require that all aircraft operating in airspace where ADS-B Out is required to also be equipped with ADS-B In. This is not the first time the NTSB has made such a recommendation. In 2021, the NTSB recommended the FAA to require the installation of ADS-B Out and In in aircraft, following a mid-air collision in Ketchikan, Alaska in 2019. During Tuesday’s hearing, NTSB Chair Jennifer Homendy noted that the NTSB has recommended the requirement of ADS-B In 17 times since 2006.

Implementing the ADS-B In requirement raises practical and cost considerations because not all aircraft are currently equipped with ADS-B In. Aircraft owners and operators would need to install the necessary ADS-B receiver and display, which costs around $1500-$3000. While aircraft owners and operators will see an increase in cost because of an ADS-B In requirement, there is research to support the safety benefits. One study examined accident and operational data from 2013 to 2017 and found that accident rates decreased by 53 percent for aircraft equipped with ADS-B In and fatal accident rates decreased by 89 percent for aircraft equipped with ADS-B In.

Safety Management Systems

A Safety Management System (SMS) is a formal and structured approach to manage safety risk through set procedures and policies. In theory, the SMS is designed to identify risks to safety before they become accidents. However, the NTSB found that that SMS for the Air Traffic Organization (ATO) was not functioning as a robust risk-control mechanism: the ATO’s SMS did not call for collecting and sharing safety hazard information with external stakeholders and the ATO did not use the SMS to mitigate the risk of collisions at DCA.

The NTSB identified parallel shortcomings with the U.S. Army SMS. The Board found that the Army’s SMS did not have a flight data monitoring program and that the lack of this program resulted in the pilot’s unawareness of altitude exceedances. Without routine performance monitoring, safety programs can miss patterns of error, like errors in altitude instruments readings, that would trigger targeted training or procedural changes.

The NTSB also concluded that the ATO did not foster a positive safety culture, noting that operators felt pressure of retaliation for raising safety concerns. Even when SMS exists, fear of retaliation weakens the flow of information the SMS depends on. This reflects an organizational problem at the FAA that prevents risks from being surfaced and resolved.

These findings come following an announcement from USDOT and the FAA on a major re-organization effort. Part of this re-organization effort includes the creation of a new Aviation Safety Management Organization, that would centralize all safety management activities previously distributed across “siloed” offices. The creation of a centralized SMS office at the FAA was not included in the NTSB’s recommendations, and it remains unclear how this new office would implement the NTSB’s recommendations on risk mitigation. The key question is whether reorganization changes outcomes or simply changes boxes on an organizational chart.

Next Steps

The NTSB will release its final report on the investigation in the coming weeks. The Board’s recommendations now go to the FAA, U.S. Army, USDOT, and Department of Defense. Those agencies will be tasked with deciding which recommendations to adopt and how to implement them. While the NTSB’s recommendations are not binding, they provide the respective agencies with direction on closing safety gaps identified in the investigation.

Congress, too, has a role in what comes next: ensuring agency accountability through oversight and advancing aviation safety legislation that turns the lessons from the accident into lasting improvements across the aviation system. It is possible that the Senate will take action as soon as later today: Senator Ted Cruz (R-TX) has proposed adding the text of his ROTOR Act, expanding ADS-B mandates and forcing changes in DCA airspace, to the pending year-end appropriations package as amendment 4242. A “yes” vote could have the ROTOR Act, as part of the larger bill, on the President’s desk by early next week.