Transportation Safety Board overrules staff to put VFR flight as cause of mid-air over Hudson River

After a five hour public meeting to discuss the mid-air collision between a Piper and a helicopter over the Hudson River, the National Transportation Safety Board overruled the recommendations of its staff and cited “inherent limitations of the see-and-avoid concept” and inattention of an air traffic controller as the probable cause of the accident, which killed nine people.

This is the first time VFR flight was cited as a cause and one in which the staff that studied and worked on the investigation did not agree. Board members overruled the staff members, bringing into question whether or not the make-up of the present board is unbiased or knowledgeable enough about issues to ignore experienced staffers.

The staff report centered on procedure failures in transferring communication to the Newark Airport tower and errors in frequency readback/hearback and regulations that do not provide for adequate vertical separation in the congested area. The controller’s distractions from duties, the staff reported, was because he was making a personal phone call. Board members rejected this and instead chose to put primary blame on see-and-avoid — VFR — flight. In the past, see-and-avoid has been cited as a contributing factor but never listed as a cause.

The Aircraft Owners and Pilots Association immediately went on the offensive putting on its website a detailed account of the accident and the questionable decision of the board members to ignore staff issues.

More division between staff and Board members can be expected in relation to this issue as well as strong efforts by AOPA and possibly other groups to defend the assault on see-and-avoid brought on by political appointees overruling technically trained staffers.


  1. Alan says

    Well written Doc. I’m an “almost retired” Air Traffic Controller with 34+ years of ATC experience. I’ve spent a couple decades scratching my head over NTSB decisions too. Additionally, it’s been disheartening to see the way the FAA has continued to lower the standards required to certify as an ATC Spectialist over the last 15 years or so. Yes, I’m somewhat of a “dinosaur” as controllers go! That being said (proudly!), many (not all) of new hires from the last decade and a half seem to have little or no respect for the profession itself or appreciation of the damage their indifference can cause. They then pass on that indifference to the next generation when they begin to train others. It’s a matter of wanting to learn the “tricks of the trade” instead of the “trade” itself. It’s not an isolated problem. I’ve always embraced new technology that makes my job easier and safer but I’ve also had every piece of technology fail on me at some point. It’s knowing what to do THEN that seems to be lacking the most in our training. I’m sure many other professions suffer these same problems. I believe we STILL have the safest ATC system in the world but unless I need to cross an ocean or go a thousand miles or more in a short time, I fly my Cessna VFR or drive.

  2. The Doc says

    Subject: Transportation Safety Board overrules staff to put VFR flight as cause of mid-air over Hudson River

    Having just read of the action by the NTSB above, where the “professional opinion” of staff members was “overturned” in favor of “an interpretation”, as to the cause of the “Hudson River Crash/Mid-Air”, by the board, I am compelled to comment!

    In the past few years my opinion of the NTSB has declined to one of “no confidence”. The board has now been reduced (because of politics, that should have never been allowed) to nothing more than a “government rubber stamp” in judging “Probable Cause” in matters of aviation crashes/incidents.

    It should be easily discernable by anyone, with any ” degree of professional experience ” in aviation operations, the actual “causative factors” and reasons for this fatal collision, were not primarily the result of VFR operations.

    As a Commercial Pilot, Educator, Flight Instructor (civil and military) and Aviation Accident Investigator for over 44 years, I have seen more than my share of crashes, incidents and screw-ups.

    This “accident” (and I use that term loosely, because it was a “caused occurrence”) didn’t just happen! The discipline in FAA facilities over the past 15 years, has declined to the point of one of near criminal neglect! The incident at JFK, of a controller allowing a child to transmit a clearance on the frequency, the complete lack of “attention to duty” at LEX in 2006 and this crash, highlights this fact! Therefore the outcome should come as a surprise to no one! Excepting the current Administrator (who has a huge mess to “clean up”), the previous Administrators since the inauguration of Bill Clinton, have been “woefully unqualified” to perform the duties of their office.

    The very fact that the lone controller on duty, who “permitted” this crash to occur, because he was on the telephone, speaks volumes. That used to be an absolute no…no! Now, I fully expect the controller hasn’t as yet been fired from his position, for his “absolute indifference, total disregard for safety and complete negligence”, as it regards the “safe and efficient flow of air traffic”, mandated by the Controllers Operating Handbook, FAA 7110.65.

    Lenience and blaming others (usually the pilot(s)) has become a “Hallmark” of the agency and the NTSB, since a B737 landed on top of a Sky West Embreair E110 at LAX in 1990. The controller in that incident was “psychologically unfit and therefore not qualified” to the be the “Local Controller” in that deadly incident. Many people died (unnecessarily) and the controller was “just reassigned”.

    I watched with absolute astonishment, the hearings into the investigation of Colgan Air 3407 at Buffalo, February 13, 2009. I watched as the NTSB basically “whitewashed” the entire crash investigation, so far as the “true and material facts” were concerned. It was an abomination! I watched as members of the board asked questions and accepted as fact, answers that were completely implausible, regarding this crash. To make matters worse, it was abundantly clear they didn’t even know the “right questions to ask” the witnesses/experts in this investigation.

    That is completely indicative of individuals who are not “competent technically” to sit on such a board. So, I conducted background investigations of these individuals and determined that in fact, some of them weren’t qualified!

    This then caused me to go back and review past accidents/incidents, I was familiar with, that, had been investigated by the NTSB. I was appalled! After reviewing the crash of N873G, a Canadair Challenger 600, at Montrose, Colorado on November 28, 2004, it became abundantly clear to me that the judgement of the NTSB could no longer be trusted! They blamed the crash on wing frost/icing when none existed. I knew it for a fact, because I was there at the time and the “real factors”, were never even discussed or “brought to light.

    I then reviewed the crash of the ComAir 5191 Regional Jet at LEX on August 27, 2006. The “Ruling of Probable Cause” in this crash was an abomination! It was exactly as happened in the Hudson River crash, where the controller “was not doing his job”! This crash was completely avoidable, had the lone controller on duty done his job as specified in FAA regulations and directives!

    Yes, the flight crew made some mistakes. However, it is the function of the controller to “act as the safety net” in all incidents involving ATC, in these types of situations. Had the controller “insured” that the crew carried out his instructions as given, they would have been stopped by the controller, before any crash could have occurred! That did not happen, because the controller purposely distracted himself with duties that were “irrelevant” at that moment in time.

    The 7110.65 expressly states: “The controller shall have no other duties” as it relates to the “safe, efficient and expeditious flow” of air traffic”! That wasn’t carried out, just as it wasn’t in the case of the Hudson River mid-air!

    It then does not come as a surprise to me to read that VFR is now blamed for the crash over the Hudson, instead of the “true factor”, of a controller who was clearly not doing his job, by allowing himself to be “distracted” by a personal telephone call, which is absolutely forbidden by FAA regulations and directives!

    The very fact that the board reversed the ruling of its own “professional investigators” in “deference” to “some one else’s agenda”, speaks volumes about “internal politics”, in this organization, thus minimizing it’s effectiveness. This cannot be tolerated! Every reader and aviator who has ever flown VFR as PIC knows that VFR has it’s limitations, risks and vagaries, as does even IFR. We do not live in a “perfect world”.

    Now it seems that neither does the NTSB and an agency who is “trusted” to determine the “true causative factors” of aviation crashes/incidents, to thus mitigate their occurrence in the future, is now “suspect” in the performance of their duties.

    The “once trusted” and “vaunted beyond question” authority to “determine the facts” appears “tarnished and not trustworthy” for whatever reason.

  3. says

    Well it seems the pilot and the ATC were all at fault here. However, there are limitations to the see-and-avoid concept since one cannot see in all directions when flying. It seems to me that for such a busy area, flight following should be mandatory.

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