When Everyone Is Doing Their Job and it Still Goes Wrong. Lessons from the Potomac midair collision

Image of the BlackHawk wreckage courtesy of NTSB

On the evening of 29 January 2025, a regional jet on approach to Washington Ronald Reagan airport and a US Army Black Hawk helicopter collided over the Potomac River.

Sixty-seven people lost their lives.

Both aircraft were operating legally with crews who were trained and experienced. Air traffic control was in place and functioning. On paper, this is most definitely what a safe system is supposed to look like. However, it still failed.

As is the norm with accidents like this, the investigation does not point to a single catastrophic error or an obvious breakdown. It reveals something far more uncomfortable: a system that had gradually evolved to the point where success depended on everything going right and failure only required one thing to go wrong.

1. When “See and Avoid” Quietly Becomes the Strategy

One of the most striking findings in the report is the extent to which the system relied on visual separation to manage risk, even in conditions where that reliance was inherently fragile. Pilots were expected to acquire and maintain visual contact with other aircraft at night, against a dense background of city lighting, while managing demanding flight profiles and operating in close proximity to complex airspace.

Over time, this approach had shifted from being a backup to something far more central. It had become the plan.

Despite popular opinion, visual separation is not a robust control, especially at night. It can help build confidence, but is not reliable enough to protect a system operating under pressure. The report makes clear that this reliance was not a one-off decision and had become a normalised way of working that prioritised flow and efficiency over resilience.

Corporate environments are full of equivalent assumptions. Teams rely on individuals to “spot the issue,” to raise concerns at the right moment, or to intervene when something begins to drift. These expectations are rarely written down, but they are embedded in how work is actually done.

A system that relies on people noticing problems in real time, under pressure, with incomplete information, is not a system designed to manage risk. It is a system hoping to get away with it.

2. When Workload Doesn’t Break the System. It Redefines It

The report highlights the impact of workload on controller performance, particularly with combined positions and increasing traffic complexity. As demand increased, the controller’s ability to maintain a clear and accurate picture of the situation began to degrade.

Communication became more fragmented, prioritisation more difficult, and critical information less reliable. This was far more a gradual shift rather than a sudden failure.

Workload didn’t specifically break the system. It quietly redefined what “normal” looked like.

This is where many organisations get caught out. Teams operate under sustained pressure, absorbing additional tasks, juggling competing priorities, and continuing to deliver. From the outside, this looks like resilience.

In reality, it is often adaptation. Adaptation has a cost. As workload increases, the system’s ability to detect weak signals reduces, margins narrow, and decision-making becomes more reactive. None of this is immediately visible, which makes it easy to ignore. Until the system is asked to do something it can no longer support.

High-performing people will continue to deliver long after the system has started to degrade.

Which means leaders often only notice the problem when it is already too late.

3. When Threat and Error Management Isn’t How You Think

One of the more actionable findings in the report is the lack of consistent Threat and Error Management training, particularly for controllers. This matters, because TEM is not about preventing errors, it is about expecting them, anticipating them, and managing them before they escalate.

In this case, the threats were well known. The proximity of helicopter routes to approach paths, the complexity of mixed traffic, and the limitations of visual separation were not new information. Signals existed in the form of prior events, operational data, and concerns raised within the system.

What was missing was the structured application of that knowledge in real time and this highlights a more uncomfortable point: If your system relies on people recognising and managing threats, but you don’t explicitly train them to do that, then you are not really managing risk. You might satisfy a compliance box-ticking exercise but really, you're hoping for the best.

In corporate settings, this shows up in a different way. Organisations train people how to follow process, how to meet standards, and how to operate when conditions are stable. Very few train people how to think when conditions are unstable, when assumptions are wrong, or when the situation no longer fits the plan.

This means that when things start to drift, teams improvise. Sometimes they recover. Sometimes they don’t.

A resilient system does not assume that people will just figure it out under pressure. It gives them the tools to recognise when they need to.

4. When the System Knows But Still Doesn’t Change

Perhaps the most confronting aspect of the report is not what happened on the night, but what was already known beforehand. The system had access to data showing repeated close proximity events. Concerns had been raised. Patterns were visible that indicated increasing complexity and reduced margins.

The report highlights fragmented data, limited sharing between organisations, and safety management systems that were either incomplete or not fully embedded. Individually, each part of the system had pieces of the picture. Collectively, no one acted on it.

And it is one of the most common organisational weaknesses. Most organisations do not lack information about risk. They lack the mechanisms – and often the willingness – to act on it. Risks are discussed, documented, and understood locally, but rarely integrated in a way that drives meaningful change.

Over time, this can create a dangerous narrative: “If it was that serious, something would have been done.” In reality, the opposite is often true. The longer a risk exists without consequence, the more normal it becomes.

Final thought

This accident was not the result of a single mistake, nor was it caused by individuals failing to do their jobs. It was the product of a system that had come to rely on human judgement as a primary defence, that allowed workload to quietly erode situational awareness, that had not embedded how to think about threat and error, and that failed to act on risks it already understood.

None of this is unusual and that is the problem. People were not failing the system. The system was designed in a way that made failure increasingly likely—and then waited.

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If you’re a leader…

The most useful questions are not about who made the mistake. They are about how your system behaves under pressure.

Where are you relying on people instead of design?

Where has workload become “normal” rather than manageable?

How do your teams recognise and respond to emerging risk?

What does your organisation already know but hasn’t acted on?

By the time failure becomes visible, the conditions that made it possible have been in place for a long time.

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Mike Mason and Sam Gladman are the co-founders of On Target, a leadership and team development company that brings elite fighter pilot expertise into the corporate world. With decades of combined experience in high-performance aviation, they specialise in translating critical skills such as communication, decision-making, and teamwork into practical tools for business. Through immersive training and cutting-edge simulation, Mike and Sam help teams build trust, improve performance, and thrive under pressure—just like the best flight crews in the world.

If you'd like to learn more about how On Target can help your team, contact Mike and Sam at info@ontargetteaming.com.