At a public meeting on Tuesday, the National Transport Safety Board laid out a list of recommended changes in response to the crash, criticizing the FAA for allowing helicopters to operate dangerously close to passenger planes and for allowing professional standards to slip at the control tower.
What has gone unexamined in the public discussion of the crash, however, is why these particular pilots were on this mission in the first place, whether they were competent to do what they were trying to do, what adverse conditions they were facing, and who was in charge at the moment of impact. Ultimately, while systemic issues may have created conditions that were ripe for a fatal accident, it was human decision-making in the cockpit that was the immediate cause of this particular crash.
This account is based on documents from the National Transportation Board (NTSB) accident inquiry and interviews with aviation experts. It shows that, when we focus on the specific details and facts of a case, the cause can seem quite different from what a big-picture overview might indicate. And this, in turn, suggests different logical steps that should be taken to prevent such a tragedy from happening again.
6:42 p.m.: Fort Belvoir, Virginia
The whine of the Blackhawk’s engine increased in pitch, and the whump-whump of its four rotor blades grew louder, as the matte-black aircraft lifted into the darkened sky above the single mile-long runway at Davison Army Airfield in Fairfax County, Virginia, about 25 miles southwest of Washington, D.C.
The UH-60, as it’s formally designated, is an 18,000-pound aircraft that entered service in 1979 as a tactical transport aircraft, used primarily for moving troops and equipment. This one belonged to Company B of the 12th Aviation Battalion, whose primary mission is to transport government VIPs, including Defense Department officials, members of Congress, and visiting dignitaries. Tonight’s flight would operate as PAT 25, for “Priority Air Transit.”
Black Hawks are typically flown by two pilots. The pilot in command, or PIC, sits in the right-hand seat. Tonight, that role was filled by 39-year-old chief warrant officer Andrew Eaves. Warrant officers rank between enlisted personnel and commissioned officers; it’s the warrant officers who carry out the lion’s share of a unit’s operational flying. When not flying VIPs, Eaves served as a flight instructor and a check pilot, providing periodic evaluation of the skills of other pilots. A native of Mississippi, he had 968 hours of flight experience and was considered a solid pilot by others in the unit.
Before he took off, Eaves’ commander had discussed the flight with him and admonished him to “not become too fixated on his evaluator role” and to remain “in control of the helicopter,” according to the NTSB investigation.
His mission was to give a check ride to Captain Rebecca Lobach, the pilot sitting in the left-hand seat. Lobach was a staff officer, meaning that her main role in the battalion was managerial. Nevertheless, she was expected to maintain her pilot qualifications and, to do so, had to undergo a number of annual proficiency checks. Tonight’s three-hour flight was intended to get Lobach her annual sign-off for basic flying skills and for the use of night-vision goggles, or NVGs. To accommodate that, the flight was taking off an hour and 20 minutes after sunset.
Both pilots wore AN/AVS-6(V)3 Night Vision Goggles, which look like opera glasses and clip onto the front of a pilot’s helmet. They gather ambient light, whether from the moon or stars or from man-made sources; intensify it; and display it through the lens of each element. The eyepiece doesn’t sit directly on the face but about an inch away, so the pilot can look down under it and see the instrument panel.
Night-vision goggles have a narrow field of view, just 40 degrees compared to the 200-degree range of normal vision, which makes it harder for pilots to maintain full situational awareness. They have to pay attention to obstacles and other aircraft outside the window, and they also have to keep track of what the gauges on the panel in front them are saying: how fast they’re going, for instance, and how high. There’s a lot to process, and time is of the essence when you’re zooming along at 120 mph while lower than the tops of nearby buildings. To help with situational awareness, Eaves and Lobach were accompanied by a crew chief, Staff Sergeant Ryan O’Hara, sitting in a seat just behind the cockpit, where he would be able to help keep an eye out for trouble.
The helicopter turned to the south as it climbed, then flew along the eastern shore of the Potomac until the point where the river makes a big bend to the east. Eaves banked to the right and headed west toward the commuter suburb of Vicksburg, where the lights of house porches and street lamps seemed to twinkle as they fell in and out of the cover of the bare tree branches.
What has gone unexamined in the public discussion of the crash, however, is why these particular pilots were on this mission in the first place, whether they were competent to do what they were trying to do, what adverse conditions they were facing, and who was in charge at the moment of impact. Ultimately, while systemic issues may have created conditions that were ripe for a fatal accident, it was human decision-making in the cockpit that was the immediate cause of this particular crash.
This account is based on documents from the National Transportation Board (NTSB) accident inquiry and interviews with aviation experts. It shows that, when we focus on the specific details and facts of a case, the cause can seem quite different from what a big-picture overview might indicate. And this, in turn, suggests different logical steps that should be taken to prevent such a tragedy from happening again.
6:42 p.m.: Fort Belvoir, Virginia
The whine of the Blackhawk’s engine increased in pitch, and the whump-whump of its four rotor blades grew louder, as the matte-black aircraft lifted into the darkened sky above the single mile-long runway at Davison Army Airfield in Fairfax County, Virginia, about 25 miles southwest of Washington, D.C.
The UH-60, as it’s formally designated, is an 18,000-pound aircraft that entered service in 1979 as a tactical transport aircraft, used primarily for moving troops and equipment. This one belonged to Company B of the 12th Aviation Battalion, whose primary mission is to transport government VIPs, including Defense Department officials, members of Congress, and visiting dignitaries. Tonight’s flight would operate as PAT 25, for “Priority Air Transit.”
Black Hawks are typically flown by two pilots. The pilot in command, or PIC, sits in the right-hand seat. Tonight, that role was filled by 39-year-old chief warrant officer Andrew Eaves. Warrant officers rank between enlisted personnel and commissioned officers; it’s the warrant officers who carry out the lion’s share of a unit’s operational flying. When not flying VIPs, Eaves served as a flight instructor and a check pilot, providing periodic evaluation of the skills of other pilots. A native of Mississippi, he had 968 hours of flight experience and was considered a solid pilot by others in the unit.
Before he took off, Eaves’ commander had discussed the flight with him and admonished him to “not become too fixated on his evaluator role” and to remain “in control of the helicopter,” according to the NTSB investigation.
His mission was to give a check ride to Captain Rebecca Lobach, the pilot sitting in the left-hand seat. Lobach was a staff officer, meaning that her main role in the battalion was managerial. Nevertheless, she was expected to maintain her pilot qualifications and, to do so, had to undergo a number of annual proficiency checks. Tonight’s three-hour flight was intended to get Lobach her annual sign-off for basic flying skills and for the use of night-vision goggles, or NVGs. To accommodate that, the flight was taking off an hour and 20 minutes after sunset.
Both pilots wore AN/AVS-6(V)3 Night Vision Goggles, which look like opera glasses and clip onto the front of a pilot’s helmet. They gather ambient light, whether from the moon or stars or from man-made sources; intensify it; and display it through the lens of each element. The eyepiece doesn’t sit directly on the face but about an inch away, so the pilot can look down under it and see the instrument panel.
Night-vision goggles have a narrow field of view, just 40 degrees compared to the 200-degree range of normal vision, which makes it harder for pilots to maintain full situational awareness. They have to pay attention to obstacles and other aircraft outside the window, and they also have to keep track of what the gauges on the panel in front them are saying: how fast they’re going, for instance, and how high. There’s a lot to process, and time is of the essence when you’re zooming along at 120 mph while lower than the tops of nearby buildings. To help with situational awareness, Eaves and Lobach were accompanied by a crew chief, Staff Sergeant Ryan O’Hara, sitting in a seat just behind the cockpit, where he would be able to help keep an eye out for trouble.
The helicopter turned to the south as it climbed, then flew along the eastern shore of the Potomac until the point where the river makes a big bend to the east. Eaves banked to the right and headed west toward the commuter suburb of Vicksburg, where the lights of house porches and street lamps seemed to twinkle as they fell in and out of the cover of the bare tree branches.
7:11 p.m.: Approaching Greenhouse Airport, Stevensburg, Virginia
PAT 25 followed the serpentine course of the Rapidan River through the hills and farm fields of the Piedmont. At this point, Eaves was not only the pilot in command, but also the pilot flying, meaning that he had his hands on the controls that guide the aircraft’s speed and direction and his feet on the rudder pedals that keep the helicopter “in trim” — that is, lined up with its direction of flight. Lobach played a supporting role, working the radio, keeping an eye out for obstacles and other traffic, and figuring out their location by referencing visible landmarks.
Lobach, 28, had been a pilot for four years. She’d been an ROTC cadet at the University of North Carolina at Chapel Hill, which she graduated from in 2019. Both her parents were doctors; she’d dreamed of a medical career but eventually realized that she couldn’t pursue one in the Army. According to her roommate, “She did not have a huge, massive passion” for aviation but chose it because it was the closest she could get to practicing medicine, under the circumstances. “She badly wanted to be a Black Hawk pilot because she wanted to be a medevac unit,” he told NTSB investigators. After she completed flight training at Fort Rucker, she was stationed at Fort Belvoir, where she joined the 12th Aviation Battalion and was put in charge of the oil-and-lubricants unit. One fellow pilot in the unit described her to the NTSB as “incredibly professional, very diligent and very thorough.”
In addition to her official duties, Lobach served as a volunteer social liaison at the White House, where she regularly represented the Army at Medal of Honor ceremonies and state dinners. She was both a fitness fanatic and a baker, known for providing fresh sourdough bread to her unit. She had started dabbling in real-estate investments and looked forward to moving in with her boyfriend of one year, another Army pilot with whom she talked about having “lots and lots of babies.” She was planning to leave the service in 2027 and had already applied for medical school at Mount Sinai. Helicopter flying was not something she intended to pursue.
Though talented as a manager, she wasn’t much of a pilot. Helicopter flying is an extremely demanding feat of coordination and balance, akin to juggling and riding a unicycle at the same time. For Lobach, the difficulty was compounded by the fact that she had trained on highly automated, relatively easy-to-fly helicopters at Fort Rucker and then been assigned to an older aircraft, the Black Hawk L or “Lima” model, at Fort Belvoir. Unlike newer models, which can maintain their altitude on autopilot, the Lima requires constant care and attention, and Lobach struggled to master it. One instructor described her skills as “well below average,” noting that she had “lots of difficulties in the aircraft.” Three years before, she’d failed the night-vision evaluation she was taking tonight.
Before the flight, Eaves had told his girlfriend that he was concerned about Lobach’s capability as a pilot and that, skill-wise, she was “not where she should be.”
It’s not uncommon for pilots to struggle during the early phase of their career. But Lobach’s development had been particularly slow. In her five years in the service, she had accumulated just 454 hours of flight time, and she wasn’t clocking more very quickly. The Army requires officers in her role to fly at least 60 hours a year, but in the past 12 months, she’d flown only 56.7. Her superiors had made an exception for her because in March she’d had knee surgery for a sports injury, preventing her from flying for three months. The waiver made her technically qualified to fly, but it didn’t change the fact that she was rustier than pilots were normally allowed to become.
If she’d been keen on flying, she could have used every moment of this flight to hone her skills by taking the controls herself. But she was content to let Eaves do the flying during the first part of the trip.
Drawing near to Greenhouse Airport, a small, private grass runway near a plant nursery, they navigated via an old-fashioned technique called pilotage, using landmarks and dead reckoning to find their way from point to point. Coming in for their first landing of the night, they were looking for the airstrip’s signature greenhouse complex.
Lobach: That large lit building may be part of it.
Eaves: It does look like a greenhouse, doesn’t it?
Lobach: Yeah, it does, doesn’t it? We can start slowing back.
Eaves: All right, slowing back.
As they circled around the runway, Eaves commented that the lighting of the greenhouse building was so intense that it was blinding in the NVGs, and Lobach agreed. Eaves positioned the helicopter a few hundred feet above the landing zone and asked Lobach to show him where it was. After she did so correctly, he told her to take the controls. This process followed a formalized set of acknowledgements to make sure that both parties understood who was in control of the aircraft.
Eaves: You’ve got the flight controls.
Lobach: I’ve got the controls.
As Lobach eased the helicopter toward the ground, Eaves and Crew Chief O’Hara called out times from the landing checklist.
O’Hara: Clear of obstacles on the left.
Lobach: Thank you. Coming forward.
Eaves: Clear down right.
Lobach: Nice and wide.
Eaves: 50 feet.
Lobach: 30 feet.
They touched down. One minute and 42 seconds after passing control to Lobach, Eaves took it back again. As they sat on the ground with their rotor whirring, they discussed the fuel remaining aboard the aircraft and the direction they would travel in during the next segment of their flight. Finally, after six minutes, Eaves signaled that they were ready to take off again.
Eaves: Whenever you’re ready, ma’am.
Lobach: Okay, let’s do it.
Eaves’s deference to Lobach was symptomatic of what is known among psychologists as an “inverted authority gradient.” Although he was the pilot in command, both responsible for the flight and in a position of authority over others on it, Eaves held a lesser rank than Lobach and so in a broader context was her subordinate. In moments of high stress, this ambiguity can muddy the waters as to who is supposed to be making crucial decisions.
Eaves, Lobach, and O’Hara ran through their checklists, and Eaves eased the Black Hawk up into the night sky.
PAT 25 followed the serpentine course of the Rapidan River through the hills and farm fields of the Piedmont. At this point, Eaves was not only the pilot in command, but also the pilot flying, meaning that he had his hands on the controls that guide the aircraft’s speed and direction and his feet on the rudder pedals that keep the helicopter “in trim” — that is, lined up with its direction of flight. Lobach played a supporting role, working the radio, keeping an eye out for obstacles and other traffic, and figuring out their location by referencing visible landmarks.
Lobach, 28, had been a pilot for four years. She’d been an ROTC cadet at the University of North Carolina at Chapel Hill, which she graduated from in 2019. Both her parents were doctors; she’d dreamed of a medical career but eventually realized that she couldn’t pursue one in the Army. According to her roommate, “She did not have a huge, massive passion” for aviation but chose it because it was the closest she could get to practicing medicine, under the circumstances. “She badly wanted to be a Black Hawk pilot because she wanted to be a medevac unit,” he told NTSB investigators. After she completed flight training at Fort Rucker, she was stationed at Fort Belvoir, where she joined the 12th Aviation Battalion and was put in charge of the oil-and-lubricants unit. One fellow pilot in the unit described her to the NTSB as “incredibly professional, very diligent and very thorough.”
In addition to her official duties, Lobach served as a volunteer social liaison at the White House, where she regularly represented the Army at Medal of Honor ceremonies and state dinners. She was both a fitness fanatic and a baker, known for providing fresh sourdough bread to her unit. She had started dabbling in real-estate investments and looked forward to moving in with her boyfriend of one year, another Army pilot with whom she talked about having “lots and lots of babies.” She was planning to leave the service in 2027 and had already applied for medical school at Mount Sinai. Helicopter flying was not something she intended to pursue.
Though talented as a manager, she wasn’t much of a pilot. Helicopter flying is an extremely demanding feat of coordination and balance, akin to juggling and riding a unicycle at the same time. For Lobach, the difficulty was compounded by the fact that she had trained on highly automated, relatively easy-to-fly helicopters at Fort Rucker and then been assigned to an older aircraft, the Black Hawk L or “Lima” model, at Fort Belvoir. Unlike newer models, which can maintain their altitude on autopilot, the Lima requires constant care and attention, and Lobach struggled to master it. One instructor described her skills as “well below average,” noting that she had “lots of difficulties in the aircraft.” Three years before, she’d failed the night-vision evaluation she was taking tonight.
Before the flight, Eaves had told his girlfriend that he was concerned about Lobach’s capability as a pilot and that, skill-wise, she was “not where she should be.”
It’s not uncommon for pilots to struggle during the early phase of their career. But Lobach’s development had been particularly slow. In her five years in the service, she had accumulated just 454 hours of flight time, and she wasn’t clocking more very quickly. The Army requires officers in her role to fly at least 60 hours a year, but in the past 12 months, she’d flown only 56.7. Her superiors had made an exception for her because in March she’d had knee surgery for a sports injury, preventing her from flying for three months. The waiver made her technically qualified to fly, but it didn’t change the fact that she was rustier than pilots were normally allowed to become.
If she’d been keen on flying, she could have used every moment of this flight to hone her skills by taking the controls herself. But she was content to let Eaves do the flying during the first part of the trip.
Drawing near to Greenhouse Airport, a small, private grass runway near a plant nursery, they navigated via an old-fashioned technique called pilotage, using landmarks and dead reckoning to find their way from point to point. Coming in for their first landing of the night, they were looking for the airstrip’s signature greenhouse complex.
Lobach: That large lit building may be part of it.
Eaves: It does look like a greenhouse, doesn’t it?
Lobach: Yeah, it does, doesn’t it? We can start slowing back.
Eaves: All right, slowing back.
As they circled around the runway, Eaves commented that the lighting of the greenhouse building was so intense that it was blinding in the NVGs, and Lobach agreed. Eaves positioned the helicopter a few hundred feet above the landing zone and asked Lobach to show him where it was. After she did so correctly, he told her to take the controls. This process followed a formalized set of acknowledgements to make sure that both parties understood who was in control of the aircraft.
Eaves: You’ve got the flight controls.
Lobach: I’ve got the controls.
As Lobach eased the helicopter toward the ground, Eaves and Crew Chief O’Hara called out times from the landing checklist.
O’Hara: Clear of obstacles on the left.
Lobach: Thank you. Coming forward.
Eaves: Clear down right.
Lobach: Nice and wide.
Eaves: 50 feet.
Lobach: 30 feet.
They touched down. One minute and 42 seconds after passing control to Lobach, Eaves took it back again. As they sat on the ground with their rotor whirring, they discussed the fuel remaining aboard the aircraft and the direction they would travel in during the next segment of their flight. Finally, after six minutes, Eaves signaled that they were ready to take off again.
Eaves: Whenever you’re ready, ma’am.
Lobach: Okay, let’s do it.
Eaves’s deference to Lobach was symptomatic of what is known among psychologists as an “inverted authority gradient.” Although he was the pilot in command, both responsible for the flight and in a position of authority over others on it, Eaves held a lesser rank than Lobach and so in a broader context was her subordinate. In moments of high stress, this ambiguity can muddy the waters as to who is supposed to be making crucial decisions.
Eaves, Lobach, and O’Hara ran through their checklists, and Eaves eased the Black Hawk up into the night sky.
by Jeff Wise, Intelligencer | Read more:
Image: Intelligencer; Photo: Matt Hecht
