Tim Lilley: Fixing What Caused the DCA Midair Collision

In a candid and heartfelt session at the Air Charter Safety Foundation Summit on March 9, Flexjet captain Tim Lilley and his wife Sheri introduced the audience to their son Sam, one of the pilots at the controls of the PSA Airlines (American Airlines Flight 5342) Bombardier CRJ that crashed after colliding with a U.S. Army Black Hawk helicopter while on final approach to Runway 33 at Ronald Reagan Washington National Airport on January 29.

During the session, “Learning from Tragedy—Enhancing Safety through Accountability and Modernization,” Tim shared how he and Sheri learned that Sam was flying as first officer on the CRJ and perished along with the 64 passengers, the captain, and the flight attendant. The three crew members on the helicopter were also killed.

Coincidentally, Lilley himself retired from the Army as a Black Hawk pilot, and he shared some insights and critiques of helicopter operations in the busy airspace around Washington, D.C. Lilley spent 20 years in the Army, followed by 15 years flying an EMS helicopter, and now he is an Embraer Praetor captain at Flexjet.

“We appreciate the chance to come up here, and it’s kind of therapeutic for us to tell this story,” he began. “I don't know how many people in here have lost a child, but when you lose a child and it happens to be in your line of work, it really hits home.

“I spent 20 years flying Black Hawks in the Army, and four of those years flying in and out of the Pentagon, so I’ve flown these routes that we’re going to talk about, literally hundreds of times, probably two or three times a week, for four years straight.”

Sam’s Journey

Although he had planned to become a pilot, Sam ended up in marketing after graduating from college. “He called me up one day and he said, ‘Dad, marketing is not for me. I want to be a pilot like you,’” Lilley said. “And I was so proud and I was so happy. Once he decided he wanted to be a pilot, he pursued it aggressively, and in just a few years, he was flying for a regional airline.

“He had a great life going ahead of him. He had just proposed, and they were going to get married in the fall, and we just really loved Lydia. We would have really been interested to see where that family went.”

Lilley shared his and Sheri’s experience learning about the accident. “I was in Teterboro on a trip, and I had a five o’clock show in the morning. I come out of the shower, and I’m watching the news. I see, oh, man, there’s been an aircraft accident. Well, aircraft accidents interest me. It doesn’t take me long to figure out it’s PSA, who my son flies for. Automatically, I want to talk to Sam about this accident. That’s what we do. When aviation stuff happens, we talk about it. So I start texting him, ‘Hey, you know what happened?’ No answer. He only doesn’t answer my text usually if he’s asleep or he’s flying. He turns his phone off when he’s flying; that’s what we’re supposed to do. Maybe he’s out flying. I called my wife and I said, ‘Hey, I knew he’s out on a trip.’ I didn’t know what his actual legs were. ‘Do you know where Sam’s at? What happened?’”

Sheri picked up the story. “When [Tim] called me that night and said, ‘Where is Sam?’ I said I know he’s on a trip because I had looked at a wedding venue earlier that day for him and Lydia. She was in Charlotte, where they live together, and so I texted her, and I said, ‘Where is Sam?’ And she said, ‘I told you he’s on a trip. [...] He’ll be home tomorrow.’ She was thinking I was pressuring her about putting the deposit down on the venue I had looked at for them that day.

"Tim had actually called me at that point. We were on the phone, and I then texted her. I was like, I’m just gonna have to ask her if he’s flying into [Washington] D.C. We knew the flight number. I knew that flight started in Wichita. It was one nonstop a day from Wichita. So I said to Lydia, ‘Is Sam in D.C.?’ Immediately my phone rang with her calling. As soon as she joined the call, she was terrified. She knew something was up, and she said, ‘Why are you asking me that?’ I said, ‘Honey, a plane has come down in D.C.’ And she said, ‘I just talked to him this afternoon. He was in Wichita.’ And we knew.”

A Caring Team

Although post-accident care for families has improved, in the immediate aftermath of the accident, the Lilleys received no communication. “Unfortunately, a lot of the emergency response did not work out,” Sheri recalled. “We were not notified by PSA or American for several days. We’re still not certain why that happened.”

The first notification was from the medical examiner, letting them know that Sam’s body had been recovered. “We were in NTSB briefings in D.C., and they were still trying to track us down to notify us,” she said.

Flexjet stepped in and had Fireside Partners work with the Lilleys. “[That was] a great gesture that Flexjet made, bringing them in to take care of us,” Sheri said. “Fireside brought a lot of the understanding of the process and walked us through that process and helped us understand everything that was going to happen. They were great at handling people who were in shock.”

Flexjet also sent people to help, as did PSA. “Their director of flight ops was right there with us every day. That personal touch meant a lot to us as a family, having the president of PSA call us on the telephone. All sorts of American [Airlines] executives were calling us and reaching out to us, and that was really critical.”

Sheri had some advice for aircraft operators and emergency response planning. “When you look at putting together your emergency response, you’ve got to think about who those family members are going to want to hear from, who do they have relationships with?”

Tim Lilley immediately called Flexjet and said he couldn’t take the trip he had been scheduled to fly. Flexjet’s chief pilot quickly offered any help needed, and the company arranged for a car to drive Lilley to Washington, D.C., and sent a Challenger to pick up the family in Savannah, Georgia. A Flexjet care team met everyone when they arrived in D.C.

“That care team is so invaluable,” Lilley said. “We’re all in shock. We have no idea who to talk to, what to do. We don’t even believe it’s true. It takes a while to get that information to really sink in, that this really happened. It happened to somebody that we really, really love, and so that care team is so important. If you’re in a smaller organization, and you don’t have the resources to put together a care team, it’s well worth your while to add somebody like Fireside or band together with other operators to put a care team together.”

The Accident

The PSA/American Airlines Flight 5342 CRJ used the callsign “Bluestreak.” Sam, with 2,500 hours of flight time, was flying as first officer and was on the list for the next series of captain upgrades. The captain had about 4,000 hours, including 3,000 in the CRJ, according to Lilley. “So far, we haven’t found any evidence that the Bluestreak was anywhere but the place they were supposed to be flying, exactly the way they were supposed to fly.”

PAT (Priority Air Transport) 25 was a Lima-model Army Black Hawk. “They were doing a checkride, so an annual eight-part evaluation,” he said. “They’re going to put the NVGs [night-vision goggles] on and do maneuvers and emergency procedures training, then fly the route back to their base and do some traffic patterns.

“The most experienced person in that aircraft was the crew chief. He had about 1,200 hours riding around in the back of the aircraft. The Army’s been saying that [it was] a highly experienced crew. I have a problem with that statement, and I think it’s a leadership failure. If that’s the highly experienced crew that the Army has, what the Army has is a retention problem, because over the last decade, the average experience of an Army aviator has dropped 300 hours, and even the instructor pilot had less than 1,000 hours. The person taking a checkride, who was qualified as a PIC [pilot-in-command], had about 450 hours. They were both good, honorable people serving their country and doing what they had signed up to do. But there were a lot of reasons they got set up for failure, and a lot of that had to do with the culture of the unit they were in.”

On the screens behind the stage, Lilley pulled up an image showing a portion of the Baltimore-Washington helicopter route chart showing Route 1 and 4, which PAT 25 was supposed to follow. He pointed out that iPad users might not as easily “pick up” all the information that is provided on the paper version. This is because the iPad user has to take more steps to make sure it displays the legend information, which shows the description of the route with altitudes that must be flown.

“One of the things that it says about Route 4 is [it’s] along the east bank of the Potomac River. The NTSB pointed out that there’s nowhere on this map that says how wide that route actually is. Are you on the route if you’re on the east bank or if you’re in the middle of the river? I don't know, but the way I learned it, you fly it with one wheel over land and one wheel over water. Apparently, that’s not the standard that they maintain anymore. 

“There are a lot of things that are still unknown and not for certain. I’m going to try to talk about the things we know for certain, and then I’m going to tell you some of the things that are kind of more opinionated that are coming from me, from my experience of flying those routes and flying in the Army.

“The CRJ, when they were doing their approach, [was] cleared to do the Mount Vernon visual. Probably 90% of you guys have done the Mount Vernon visual to Runway 1. About the time they get to Wilson Bridge, they’re asked if they can circle to land, Runway 33. My son was the pilot monitoring, because he answers the radio and says, ‘We can do 33.’ As they’re coming, they’re circling, doing 33. They’re very close to on the proper glide path, and they’re configuring, as best I can tell. They were doing everything right.

“I don’t have a complete transcript, just excerpts of what the NTSB told us that they said. For instance, I’m not for sure if they made their 500-foot stabilized call. They did hear an audio ‘500 feet’ [from the avionics], and they were configured and ready to [land]. They did get a ‘traffic, traffic,’ I believe it was like 17 seconds before impact. And I don’t know what the conversation in the cockpit was for that, but one second before impact, there’s an expletive, which I believe is my son saying, ‘Oh, fudge, the helicopter,’ and the controls go to a full-scale deflection. Near full-scale is what the NTSB said. I don’t know if Jonathan [the captain] pulled the yoke back or if Sam did, because just the time amount that they had to try to survive that thing. But it was too little, too late. It didn’t help.”

PAT 25 had been following Route 1, then 4, starting at 1,300 feet at Cabin John and stepping down until the helicopter should have been at 200 feet at the Memorial Bridge. 

“When they get to Key Bridge, you’re supposed to be at 300 feet or below. Then there’s a conversation in the cockpit where the instructor pilot says, ‘We're at 400 feet,’ and the pilot flying says, ‘We’re at 300 feet.’ So there’s some kind of disagreement, and we still don’t know exactly why, whether they had a different perception, or whether their altimeters were reading differently. In the Army, the altimeter error allowed is 70 feet. And so you could technically have a legal altimeter, and you could be reading 100 feet different. We don’t know if that’s the issue. The NTSB has said that the pressure altitude readings that were in the data are corrupted and not usable. They’re trying to get to the bottom of that. We do know that the radar altimeter was working and working quite well.

“So they get here, they have this conversation, but then they don’t resolve it. And as they get to Memorial Bridge, the instructor says, ‘We’re at 300, we need to be at 200,’ and the other pilot says, ‘I’m getting down to 200.’ About this time, they call Memorial Bridge, and the air traffic control tower gives them the traffic. They say, ‘Your traffic is a CRJ, just south of Wilson Bridge, 1,200 feet, circling to land, 33.’

“The transmission where they said circling to land is not on the cockpit voice recorder of the Black Hawk. It is on the CRJ. It is on the tower tapes. So either the Black Hawk stepped on it, or for some reason, they didn’t get the circle to land [transmission]. They did get the 33. [It was] very unfortunate they didn’t call back and go, ‘What again?’ They didn’t ask for clarification.”

A Strange Request

Lilley then raised an issue that has been the subject of much discussion in the safety community, which was PAT 25’s request for visual separation.

“So [PAT 25] said, ‘Traffic in sight, request visual separation.’ I’ve been flying for 40 years, professionally. I have never once asked for visual separation. Has anybody in here ever, as a pilot, requested visual separation? I don't know any other place it’s ever done. When I flew these routes, we didn’t ask for it. But talking to all the guys that fly these routes now, that’s their standard. As soon as they get told there's traffic, they ask for visual separation. Why did they learn to take that shortcut? It had become a cultural norm to take that shortcut, because if they didn’t, they'd have to do what we used to do when we got to Hains Point. If somebody was on approach to 33, we either had to turn and go down Route 6, or we had to hold at Hains Point. They didn‘t want to do that because they wanted to go where they wanted to go.

“As they pass Hains Point, the air traffic control tower is starting to get a traffic warning. You can hear it in the air traffic control tapes, that they call out to the Black Hawk, ‘Confirm you have the CRJ in sight, pass behind the CRJ.’ Again, the instructor pilot steps on that transmission [blocks the transmission by transmitting at the same time as another transmitter] and he doesn’t hear all of that transmission. He doesn’t hear, ‘Pass behind the CRJ.’ He stepped on it. He doesn’t ask for clarification. He says to the pilot who’s taking the evaluation, ‘They want us further to the east.’

“We talked about this route. It’s supposed to be along the edge of the river. They were more like in the middle. This is the ADS-B information from the CRJ plotted as it actually was, and this is where they ended up, so that the impact happened somewhere in here. I ask you, is this the edge of the river? It doesn’t look like the edge of the river to me.

“The radar altimeter on the Black Hawk at impact: 278 feet. We don’t know for sure what the barometric altimeter said. We know the radar altimeter said 278 feet. Fourteen feet is the altitude of the airport, so we’re talking pretty close. MSL [mean sea level] and radar altimeter are going to be pretty darn close to each other.

“The last five seconds, the Black Hawk is flying. They don’t flinch. The instructor pilot says we need to be further to the east. They don’t turn east. They just continue straight ahead.”

Discussing the likelihood that the pilots of PAT 25 were using night-vision goggles (NVG), Lilley explained how he was trained to fly with the device. “One of the NVG 101 [training protocols] is to have your head out of the cockpit, constantly, scanning. That could not have possibly been happening. Nobody was looking out that window. When we talk about getting back to the basics, that is what we’re talking about. You’ve got to look out the window when you’re in a high-traffic area. Whatever they were looking at, I don't know. When we get the real transcripts of all of that, what was going on in that cockpit, we might get a better idea. But for now, we don’t know. I’m hoping the NTSB gives us that information.”

The Black Hawk was 6.5 miles from the CRJ that was called out as traffic when PAT 25 asked for visual separation. With NVG, Lilley explained, “All you’re going to see of another aircraft—because they’re at 200 feet in an area of lots and lots of man-made light—from six and a half miles away, is a light, and you’re going to assume, is that my aircraft? You can’t tell how far away it is, because an NVG limitation is your depth perception is gone. So you’re seeing all these lights, you see one light, and are you going to make an assumption that’s the one you’re looking for? It’s kind of a crazy idea, but again, it became the cultural norm.

“You also have a 40-degree field of view, so you need to be scanning. And there are all these bright lights, and you’re at 200 feet. There’s a doggone Ferris wheel out here. When they’re told again, ‘Confirm you have the aircraft in sight,’ what do they do? They come back and say, ‘Affirmative, request visual separation.’ It was the way they had been programmed. They had been taught that by the guys that taught them how to fly those routes. It was a shortcut that they took because that’s what they knew. 

“They didn’t have the aircraft in sight. Obviously, they said they did, and they requested visual separation. Once again, when you’re looking from here, all you’re probably going to see is bright lights. There was an aircraft that had just taken off. They may have thought that’s what they were looking for. There was another one on approach to [Runway] 1 that was pretty far out. Now, when you look down the river and you see a big light, you may think that’s the guy that you’re looking for.

“Let me go back one. It’s important to note, and I think I said it before: the Black Hawk crew made no evasive maneuver, so they could not have been looking out the window.”

Intolerable Risk

“The NTSB took a three-year look back, and they called it intolerable risk. We had at least one TCAS RA [resolution advisory] per month during that three-year look back, and in those TCAS RAs, two-thirds of them were at night, and most of them were between airplanes and helicopters. The helicopters were above the route, at least half of them. But the data is a little inconclusive: 15,000 times that an airplane and a helicopter were within one mile and 400-foot vertical separation.

(Editor’s note: An audience member later pointed out that some of these 15,000 reports could have been from different parties for the same event, so the total might not reflect the actual number of events.)

“To put that in perspective, for the number of operations that happened at that airport during those three years, one in 62 commercial aircraft were within one mile and 400 feet. Okay, 85 times in those three years, there was a lateral separation of less than 1,500 feet and less than 200 feet vertical. All this data was in ASIAS [the FAA’s Aviation Safety Information Analysis and Sharing database]. This was all here. They talk about aviation regulations being written in blood. Let’s write aviation regulations in data, in analytics. Let’s write it in a way where we can keep the accident from happening before it happens.”

Lilley summarized his experience flying these routes and how that has changed. “I do not to this day understand why they changed the standard. When I flew those routes, we always held at Hains Point if somebody was on approach to [Runway] 33, or we went a different way.

“Asking for visual separation. I don’t know how it became [standard]. The air traffic controllers became used to that and started letting them take that route. We know in 2018, there was a near miss there under almost the exact circumstances, except it was during the day. This became a training event for the air traffic controllers, but apparently nobody learned that maybe we should not put aircraft on Route 4 when somebody’s on approach to 33. If the Black Hawk was exactly where it was supposed to be—and we already said it was not exactly where it’s supposed to be—it would be flying down Route 4. If the CRJ was exactly on glidepath to 33, there would be 75 feet between the 200-foot maximum [altitude for that route] and the glidepath. The tail rotor of the Black Hawk sticks up about 17 feet when you’re in straight and level flight. That leaves us 58 feet of clearance.”

To demonstrate how small that distance is, Lilley had two audience members hold a 58-foot-long tape in front of the stage. “What do we have here? Fifty-eight feet of clearance. That’s how much clearance [is] between a Black Hawk tail rotor and a CRJ flying on that route. That’s insane. The wake turbulence alone would cause a hazard. That’s just unacceptable. Not to mention, if anybody is just a hair off, this is what happens.”

The risks of this kind of operation weren’t mitigated properly, he explained. “This is a leadership failure on the part of the Army. They spent the last decade, I believe—even though I love Army aviation, and I spent 20 years of my life there—letting things go.

“I haven’t been able to see the actual risk analysis. I’ve been told by several pilots and I’ve seen a whole bunch of experts on podcasts and TV saying, ‘This was a low risk because of something we did every day.’ Well, guess what? Just because something you do every day doesn’t make it a low risk, because those same guys who tell you how low that risk was, [they] tell you how challenging it is to fly that route under NVGs, under those conditions. You can’t have it be super challenging and difficult and low risk at the same time. There was a bunch of risk mitigation that could have taken place that wasn’t taking place.

“I knew back in the ‘80s when I watched two Black Hawks run together, and the outcome of that safety investigation said, ‘We need to have four crew members on a Black Hawk every time it flies NVGs.’ But only three were on that aircraft. Now they tell me, NVG visual acuity has increased dramatically since then. That’s true, but they’re still 40 degrees [field of view]. We knew we could mitigate risk by putting an extra guy. We didn’t do it.”

Another factor in this accident may be that the Black Hawk’s ADS-B Out was switched off. “Come to find out they weren’t using ADS-B Out at all in Class B airspace,” he said. “The NTSB, I recently found out during the congressional hearings, went out and checked some of the aircraft. Some of them didn’t even work. The ADS-B Out didn’t even work on that particular aircraft that was flying that day; [it] hadn't transmitted in 700 days.

“When the FAA gave the Department of Defense the waiver to fly in Class B without the ADS-B Out operating, the waiver said this would not be used as an everyday waiver. This is going to be an exception, not the rule, but the Department of Defense decided that wasn’t good enough, and they, 100% of the time, almost never used ADS-B.

“I talked to a lot of Black Hawk pilots in the last two months who are actively flying. About half of them couldn’t even tell me how to turn ADS-B on. They didn’t even know how to use it.

“They weren’t wearing the HUD [head-up display] they had available. What would the HUD have helped them do? It’ll help them maintain their altitude and their airspeed while still looking out the aircraft. They don’t have to scan inside as much. They had the HUD available and didn’t wear it.”

The mission could have been flown at a time when traffic flow at DCA was much lower, he pointed out. “If they went late enough, there would have been no traffic at all.”

L model Black Hawks, like the one involved in the accident, don’t have the altitude-hold autopilot and glass instruments that are in the Mike model, but there aren’t enough Mike models for everyone to fly them all the time, he explained. “That’s something I’d like to see them change. The L model is steam gauges, hand flying. They could have been more likely on altitude had they been flying a Mike model. They didn't take any of those risk mitigations, because this was a low-risk [operation].

“I talked a lot already about requesting visual separation and that they were not really on the prescribed route,” Lilley went on, “and they were above the route altitude. They didn’t scan. They had communication failures that they didn’t come back and ask for clarification on. The [instructor pilot], he knew that they weren’t on altitude because he said so. He knew that they weren’t on the route where they should have been because he said so. But he didn’t intervene because he didn’t think it was that important.

“We had been lucky so many times flying those routes, and that nobody had died doing it already. It had become the norm. We had accepted risk and normalized. It said dangerous acts are okay, because it hasn’t failed us yet.”

Regarding the air traffic controller communications, Lilley raised the issues of stepped-on transmissions and that the lone controller in the DCA tower was monitoring two frequencies. “Everybody here knows that that is not unusual,” he said. “It would be great to go to one frequency, because the CRJ never hears the Black Hawk’s transmissions. They hear the tower talking to the Black Hawk, but not the Black Hawk talking to the tower. 

“The air traffic controller never tells the CRJ about the Black Hawk, and they only learn it by hearing the ‘traffic, traffic’ [callout] and then seeing it [at] the last second.

“Now they could hear half of the transmission, so they had an idea there was somebody out there somewhere, but they didn’t have any idea where. Of course, the air traffic controller could have de-conflicted that traffic when they were getting the traffic alert, and all they said was, ‘Confirm you have the CRJ in sight.’ That’s kind of crazy.

“The air traffic controller may not, as far as I know, even have been trained to understand that when you’re looking through NVGs and you’re trying to look for traffic, you’re not going to know if it’s a CRJ or if it’s a King Air or whatever it is, because all you see is a light moving around in the sky, and it’s very difficult to tell how far away it is. [The Black Hawk pilots] obviously didn’t see the CRJ at all. They were looking at something else.”

Change the Army?

While Lilley said he is “not happy with the Army,” he is also not sure how to initiate change in that branch. “How are we going to fix this stuff? I can’t just let my son’s death be an oopsie, right? His legacy has to be that we’re going to try to change some things.”

To that end, Lilley has met with Secretary of Transportation Sean Duffy. “I do disagree with him when he said, ‘Oh, we should fire pilots.’ He’s a good man, and he’s trying hard to help us. To be fair, a lot of the ideas that we told him we were looking for, he was already working on, but the very next day, he got on TV and laid out his plan to modernize [ATC] and to increase ATC staffing. We talked a lot about daily data analysis, and the FAA is now working on a program where AI is going to find these hot spots before they become death spots. We’re going to figure out where that next accident is going to happen and avoid it from happening.

“And then they did the route updates. Route 4 is all but closed now; it can only be flown by air ambulance with actual patients on board, and it can be flown by law enforcement when they’re actively doing law enforcement, but they’re going to shut down landing [on Runway] 33 and departures from [Runway] 15 during that time. They are working on an alternate route. It hasn’t been decided exactly where that’s going to be.”

As for the FAA, he added, “The FAA’s position has been, ‘We know we screwed up. We know we can do better, and this is how we’re going to do better.’ One of the things the families asked for was a review of the tower at DCA. I mean, there’s been fist fights there. There’s been a T-38 that was screaming through there, and they still let a Delta flight take off. There’s a lot of issues at DCA tower. The staffing levels have been difficult. You know, their own SOP says they weren’t supposed to combine that frequency until nine o’clock [p.m.]. It got combined very early in the day [the accident took place at 8:47 p.m.]. I think it was like 3:30, somewhere around there. So there’s a lot of issues with DCA, but the FAA is working hard to actually fix them.”

This includes reviewing why airlines are allowed to schedule arrivals bunched in the last 30 minutes of the hour and departures in the first 30 minutes. “Can we figure out a way to stagger that so that the workload is more even?

“The Army, on the other hand, not so much. The Army’s idea has been delay, defer, deny. They’re hiding behind the NTSB. They haven’t made any commitment to change anything they’ve done wrong. They won’t admit they did anything wrong. The only thing I’ve got them to commit to is some training.”

Efforts have been made to ask for help from Congress. “We’re asking for legislation, and I’m going to challenge you all, when the legislation comes up, they’re going to need a lot of money…to upgrade the air traffic control system. I think it’s super important. I don’t know if that would have kept this accident from happening, but it’s going to keep the next one, hopefully, from happening.

"We are literally working with Flintstones technology when [we need] the Jetsons age. We don’t call it bipartisan. We call it nonpartisan. Because I don’t care if you’re a Libertarian, Democrat, or Republican, aviation safety should be important to everybody. Write your congressman, ask them to vote for that.”

Lilley admitted, “I’m preaching to the choir, but what we need to do is bring others along with us and keep banging that drum.

“[Brigadier] General [Matthew] Braman testified before Congress that every commander is held responsible for the risk decisions that they make. I don’t find that to be true. Nobody’s been held accountable in the Army yet, but we’re trying to fix that. 

“In my research, trying to figure out what’s going wrong in the Army, I found a lot of stuff. This happened since I retired in 2006. Since then, the number of senior aviators has decreased dramatically. It’s like having your teenager teach your other teenager how to drive. They might figure it out, but they just don’t have that deep knowledge to be able to pass it on. What’s the right way to get this done? They’re going to just follow what the other guy did in the training.

"The Army has decreased their standards so much because they just can’t keep enough aviators that they’re willing to put people through flight school and graduate those who just can’t do the job. It’s not for everybody. If you can’t hover a Black Hawk, you can’t be a Black Hawk pilot. If you can’t fly an airplane, you can’t be an airplane pilot. It’s terrible, but it’s just one of the truths of our industry.

“I’m going to be the first one to tell you, only by the grace of God have I not caused an accident. I’ve made a lot of mistakes. When I’m talking about the mistakes these other people made, don’t get the idea that I’m pointing the finger at them. I’m just saying on this night, all those mistakes lined up, and it caused a catastrophic accident. It never had to happen. Today was the first day I heard that there was a white paper written years and years ago describing this exact scenario. Nothing was done about it.

“One of the problems that we found is that the Army’s reporting system and the Department of Defense's safety reporting system [are] not compatible with the FAA’s reporting system. So the Army will tell you that they didn’t know all of these near misses and close calls were happening, although there’s plenty of evidence that they did know. However, if that data could combine and so this is one of the things we’re pushing for, then everybody will have the same information. We’ve got to be able to communicate between the civilian and the military side. We need the military to commit to putting the lives of civilians at a higher priority.

“I just want to leave you a couple thoughts: Safety is not proprietary. Everybody in here and all of our competitors, we all need each other to step up and be safe, but we also need to pass this information to everybody else as we find hot spots. It wouldn’t be enough for Flexjet to know that a hot spot is Boca [Raton, Florida]. Everybody who flies in and out of Boca needs to know that’s a hot spot and how to prevent having a collision there. We need to share that data. We need to share lessons learned. We’ve got to push for positive change.

“And that’s where I’m going to challenge you again, when the legislation comes up, take 10 minutes to write your legislator and say ‘We support this.’

“I talked about emergency action plans before, but I’m going to push it home. No matter what size operator you are, you’ve got to plan for the very worst thing to happen. You’ve got to plan that every flight that goes out isn’t going to come back. No matter how safe we are, an accident is going to happen. Let’s hope that the next one’s at least 15, 20, 30 years away. But when it does happen, it is so important that you have a plan, that you protect the lives that can be protected. You take the lessons learned from that accident, and you push them out just as fast as you can. NTSB is going to take probably at least a year, a year and a half, before we get the final thing on this accident. However, there’s stuff that we know right now. Let’s fix what we know right now, even if there’s stuff that we're speculating about that didn’t maybe cause the accident, but we found is a hazard. Let’s fix that now.

“The NTSB came out with some recommendations when they did the preliminary [report], and they were spot on. Let’s get that stuff done now.”