By Alexandra Skores, Aaron Cooper, CNN

Washington, DC (CNN) — In more than 32 hours of testimony across three days the National Transportation Safety Board probed virtually every detail of what led up to the January 29 midair collision between a US Army Black Hawk helicopter and an American Airlines regional jet, operated by PSA airlines.

The focus Friday evening was the many organizational structures that may have impacted the deadly collision, which killed 67 people over the Potomac River, near Ronald Reagan Washington National Airport.

“I don’t think the accident occurred that night. I think it happened years before,” Clark Allen, Air Traffic Control Specialist at the Federal Aviation Administration said. “It was a combination of many years that built up to that evening.”

Management replaced

After the collision, the FAA replaced many of the air traffic control managers with responsibility for the Reagan National Airport area “in what appears to be blame and even punishment or retribution, in their eyes,” NTSB investigator Brian Soper noted Friday. “It’s always struck me how many times that as soon as we announce a launch (of an investigation)… the air traffic manager and or key management personnel are often relieved, moved, changed out sometimes, right while we’re on site.”

The general manager and assistant general managers from the Washington district as well as the air traffic manager and operations manager from the airport control tower were removed, he said, “effectively removing all of the institutional knowledge at the management level.”

“So we didn’t remove anybody as a result of an accident,” Nick Fuller, FAA Deputy Chief Operating Officer of Operations, noted.

“You didn’t?” Jennifer Homendy, NTSB chair asked skeptically. “I think many would disagree, since it was done pretty immediately. Also, the NTSB had to weigh in several times to get people help in the tower.”

“Because what we’re hearing is and seeing, and what they’re seeing is the response is people get transferred or fired, or the safety culture team got removed,” she said. “So we’re trying to figure out, OK, that’s the message they’re hearing, which isn’t good.”

The new management team in charge of the Washington controllers had “great resumes,” but “don’t have the skill set or the experience,” Soper said. “Can you please help me understand how this will provide an orderly and safe transition to the new and still evolving operational procedures, a decrease in risk of reoccurrence and an increase in safety?”

“The individuals that were put into that place, as you said, their resumes were not just impeccable, but they’ve actually shown as proven leaders that can actually effectuate change in a positive manner and ensure that safety is not compromised,” Frank McIntosh, FAA Chief Operating Officer said.

A communication breakdown

The NTSB noted an apparent communication breakdown between what controllers were saying and what witnesses in this week’s hearing were saying.

“We’re sitting here getting testimony ‘we have done these great things, we’ve done these wonderful things.’ The documents and the information and the facts that we have are not seeing that,” Inman said. “There’s a significant frustration between what’s actually occurring being what’s being said for public consumption.”

“I 100% agree with you. There definitely seems to be some barrier in communication where the people that impacts the most are not hearing the things that the FAA is moving forward on, and that needs to be addressed,” McIntosh responded.

The questioning included probing organizational systems in place to manage risk, and NTSB board member Michael Graham noted the breakdowns were a failing of these essential programs.

“You don’t have a safety management system if that person out on the leading edge, or in the control tower doesn’t feel like they can report, they can be heard be responded to,” he said. “For our system to be as safe as can be you have got to engage every employee.”

Highlighting the frustrations, the NTSB noted their team was in the control tower facility in March when there was a fight between a traffic management coordinator and a controller. One employee was arrested at the time.

‘I think you are interfering with the investigation’

NTSB chair Homendy was also highly critical of FAA not providing all of the data the board requested, citing back and forth requests for information the agency collected about close calls at airports.

“I think you are interfering with the investigation,” Homendy said. “I want to hear ‘great, let’s work together.’ I don’t want to hear ‘no’ every time we ask for information.”

She additionally noted the FAA provided different data to Congress than it gave to the NTSB.

“I’m not going to play the data game with you guys anymore,” she said. “It’s actually a well known thing that every time we come out with data you are going to come out with other data.”

“It just is not helpful. It just looks like you are trying to hide things, which I don’t think you are,” she said.

The FAA vowed to work together to get the information needed.

“The last thing we want is for there to be a feeling that we are not good partners when it comes to raising our safety standards,” McIntosh said.

A challenging airport requiring special training

The airport, often called by its code DCA, is considered by the Federal Aviation Administration to be a “special qualification airport” and anyone who flies there must undergo specific training due to the complex and challenging characteristics of the airspace.

PSA pilots are all qualified to operate there and receive FAA-approved training, PSA’s Assistant Director Flight Operations, Technical, Grant Clow testified.

“Think of it like a consolidated playbook of DCA-related guidance that we extract from all the different manuals and resources that we have as like an orientation guide for both new pilots and pilots that maybe have recently upgraded or have been away for a while to kind of re-familiarize themselves with information specific to DCA,” he said.

However, neither this document nor any of the airline manuals provided to PSA pilots had information specifically describing helicopter operations or routes around at the airport at the time of the accident, according to Clow.

Flying with the tracking turned off

The Army’s reluctance to use an anti-collision technology known as Automatic Dependent Surveillance–Broadcast, or ADS-B, and why the FAA allowed military helicopter pilots to fly without it was a key topic of questioning Friday.

“ADS-B out” transmits radio signals with GPS location, altitude, ground speed and other data once per second, independent of air traffic control. However, on January 29, the Black Hawk was flying following an FAA memorandum which allowed it to be turned off.

There are currently no rules stating the military must use the collision avoidance system nationwide, an FAA official testified, as ADS-B requirements are determined by location.

Lt. Col. Paul Flanigen of the US Army said the Department of Defense has “concerns” with the technology.

“I pretty sure most people are aware of the fact that it’s inherently open source,” Flanigen testified. “It has some spoofing vulnerabilities which make it non-conducive for those sensitive missions, which not just the Army, but all of DOD has to operate on.”

Earlier this week, a bill was introduced that would require aircraft operators to install ADS-B technology on all flights and require the Army to keep it turned on in almost every case.

FAA supports increased tracking

The NTSB has also called for aircraft to be equipped with “ADS-B in,” the ability to receive data from surrounding aircraft and display it on a cockpit screen for pilots. The NTSB can make recommendations, but it is up to the FAA to mandate something.

On Friday, the FAA agreed it should be required, but stopped short of saying it will act on the issue.

“Does the FAA, right now, support requiring that any newly manufactured aircraft registered in the US be equipped with ADS-B in?” Homendy, the NTSB chair asked.

“Yes, ma’am,” McIntosh, the FAA chief operating officer replied.

“Do you also support or oppose requiring that any aircraft required to be equipped with ADS-B out today… also be required to install and operate ADS-B in?” Homendy followed up.

“Yes, ma’am,” McIntosh replied again.

“Your position has shifted, and I appreciate that,” Homendy said.

Days of hearings

The first two days of testimony highlighted critical moments leading up to the collision as investigators probed witnesses about standard safety practices that should have occurred, altimeters that displayed incorrect altitude, and the helicopter route that came perilously close to the path planes use landing at the airport.

There were over ten hours of testimony on each of the first two days of the hearing.

The NTSB asks questions, but parties to the investigation including the Army, PSA Airlines, air traffic controller’s union and FAA can also examine witnesses.

On Thursday, an FAA witness acknowledged the air traffic control tower failed to warn the pilots flying the American Airlines regional jet, operated by PSA Airlines.

“No safety alerts,” were given, Fuller, the FAA Deputy Chief Operating Officer of Operations, testified.

“Should the local controller have let the PSA crew know that there was a helicopter there?” Homendy asked.

“Yes,” Fuller acknowledged.

The tower did warn the pilots of the Black Hawk helicopter about the approaching regional jet and they said they would avoid it, transcripts of the cockpit voice recorders and air traffic control audio released revealed.

Yet, moments later, the aircraft collided.

Multiple air traffic controllers and pilots at Reagan National Airport told the NTSB they struggled with the constant stream of planes, leading to a “make it work” attitude among them.

“This is ‘we just make it work,’ because we don’t have another choice,” NTSB investigator Brian Soper said they told him in on-site interviews. “There are airplanes coming in and everything was related to the capacity, the demand or the amount of traffic.”

Another witness, Rich Dressler of Metro Aviation, which operates medical helicopters in Washington said the way the Army flies helicopters around the city makes him uneasy.

“Is there any unit that when you hear it makes you feel uncomfortable?” Soper asked.

“Sadly, yes,” Dressler responded. “I don’t like saying that 12th aviation battalion gives us all pause in the community. And I’m speaking from my group there; we are all very uncomfortable when those two units are operating.”

An NTSB determination of the collision’s probable cause is expected in January.

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