The Role of Management Systems in the Tragic Collision Over the Potomac

by Dr. IJ Arora


A significant tragedy occurred in Washington D.C. on January 29, 2025, with the deadly collision between a U.S. military Black Hawk helicopter and a regional jet flying for American Airlines. The resulting crash caused the loss of 67 precious lives and pointed to a multilayered failure of safety mechanisms.

In a short article like this it is not my intent to explore the reasons for this event, and I have neither the expertise nor the authority to investigate, anyway. The U.S. National Transportation Safety Board (NTSB) and other relevant agencies will do that in a most professional manner. However, I do have a degree of experience relating to the systems approach for managing processes at large and complex organizations. I feel called to share my perspective on this disaster with a systems approach in mind.

Proactive appreciation for risk

Hindsight, it has been said, is 20/20. I am aware that I’m writing this after the tragedy has already occurred. However, management systems should be proactive, where data drives the understanding and mitigation of risk. As a practitioner and advocate of process-based management systems, I believe that well-implemented procedures give an organization the best chance to produce conforming products and services.

A systems approach, based on ISO 9001’s subclause 4.4., which relates to quality management system processes, could have played a role in preventing an incident of this type. Subclause 4.4.1 states, in part, “The organization shall establish, implement, maintain and continually improve a quality management system, including the processes needed and their interactions….”

Following this requirement is no guarantee of safe and successful outcomes, but it is surely the best bet. I had similar thoughts on the tragedy of the implosion of the Titan submersible and the Baltimore Bridge collapse. The core principles of ISO 9001, especially risk-based thinking, continual improvement, and process interaction, align well with safety imperatives, particularly safety management for the aviation industry. The systems approach is a fundamental that organizations often neglect at their (and their customers’) peril.

ISO 9001—and for that matter, the aerospace standard AS9100—is built on risk-based thinking. A structured process aligned with the risk management standard ISO 31000 and aviation safety management systems are required by ISO 9001 subclause 6.1, regarding actions for addressing risks and opportunities, and subclause 8.1 concerning operation planning and controls. Conformance with these requirements can help identify and mitigate collision risks between civil and military aircraft.

Process interaction and communication are vital in such situations.  A failure in communication between air traffic control, military operations, and civilian aviation may have contributed to the crash. Of course, we will wait for the full report from the NTSB investigation. However, it is never too late (or for that matter, too early) to be proactive and implement a process approach to ensure that all stakeholders follow well-defined communication and coordination protocols.

PDCA, SWOT, and FMEA

Being proactive requires an appreciation of risk at the Plan stage of the Plan-Do-Check-Act (PDCA) cycle. Note that preventive actions and continual improvement are integral to the system approach.

The media have reported on the details of numerous previous aviation incidents. Analyzing near-miss incidents and integrating lessons learned into improved procedures could enhance safety protocols. Human factors and process redundancy must be considered in a systematic manner. Human errors (e.g., miscommunication, misinterpretation of airspace usage, etc.) can be minimized with automated systems and via decision-making redundancy checks.

In principle, the process approach found in ISO 9001 emphasizes addressing process issues as opposed to blaming individuals. However, in the aviation field, the human factor is important; clause 10.2.1 b2 of AS9100 expresses the importance of this concept. The industry-specific interpretation of requirements as seen in this standard provides a robust framework (via a clause structure) to design an efficient management system. This, together with auditing and compliance requirements, gives leadership confidence that their system can and will produce conforming products and services.

Further to this point, regular audits of flight coordination between civilian and military aviation could highlight gaps before they lead to accidents. As such, integrating ISO 9001 with AS9100 and AS9110 (the aerospace quality standard specifically designed for maintenance, repair, and operations) as well as ISO 45001 covering the management of operational health and safety will provide a solution to proactively address risks in the context of the aviation industry. This would cover all interested parties, as per clauses 4.1 and 4.2 of ISO 9001. Although aviation already has strict regulatory frameworks (e.g., FAA, ICAO, etc.), the structured process management systems required by ISO 9001 and AS9100 can complement these frameworks by embedding the statutory and legal requirements into the management system.

If the organizations involved focus on how specific elements of ISO 9001 can be applied to aviation safety, particularly in preventing collisions, I would first recommend that they look at risk-based thinking as seen in clause 6.1, addressing actions related to risks and opportunities. This can partially be accomplished by undergoing a strengths, weaknesses, opportunities, and threats (SWOT) analysis. ISO 9001 emphasizes risk assessment and mitigation throughout processes.

In aviation, a structured risk-based approach would identify potential hazards (e.g., conflicting flight paths, miscommunication, system failures, etc.). The system would also assess risk severity and likelihood of occurrence and probability of detection, using tools like a failure modes and effects analysis (FMEA). Controls could be implemented (e.g., enhanced air traffic control coordination, better radar tracking, AI-driven airspace monitoring, etc.). For example, aviation safety bodies could require all civilian and military flights to undergo a real-time risk assessment check before takeoff, considering airspace congestion, weather, and military training exercises.

Potential solutions

Process interaction and communication (as seen in ISO 9001’s clause 4.4.1 b regarding understanding process interactions) would systematically improve the system. Aviation operations involve multiple stakeholders, such as airlines, air traffic controllers, military operations, ground crews, etc. A process approach would ensure defined standard operating procedures for communication between civilian and military aviation. These could include real-time data sharing using standardized digital platforms and/or automated conflict-resolution systems that detect and alert pilots and controllers regarding possible mid-air conflicts. An integrated civil-military coordination dashboard could be established, where both parties have real-time visibility on flight plans, airspace restrictions, and emergency deviations.

Risk appreciation and continual improvement (as seen in ISO 9001’s clause 10.2 regarding nonconformity and corrective action, clause 10.3 on continual improvement, and clause 5.1.2 regarding customer focus) require organizations to analyze failures, investigate causes, and take corrective actions. In aviation safety, this could mean automated reporting and analysis of near-miss incidents and regular safety audits to evaluate procedural weaknesses and machine learning-based predictive analytics to foresee and prevent future crashes.

When a near-miss incident occurs, such a system could automatically trigger a root cause analysis and recommend safety adjustments for all stakeholders. Human factors and redundancy (as seen in clause 7.1.6 regarding organizational knowledge) promote knowledge management and human reliability strategies. In aviation, this could mean mandatory cross-training for military and commercial pilots on shared airspace procedures. AI-assisted decision-making tools that provide secondary verification for pilots and controllers could be a positive outcome of data analysis.

Data drives risk and trends. A digital co-pilot system could use AI to continuously monitor air traffic conflicts and intervene if human errors are detected. Auditing and compliance (as seen in clause 9.2 regarding internal auditing) would provide objective and independent inputs by regular safety audits of flight coordination. Air traffic control systems could ensure compliance with standardized airspace usage protocols, identification of gaps in inter-agency communication, and implementation of best practices from previous incident investigations. A shared civil-military aviation audit framework could ensure uniform compliance with risk management policies, reducing the chance of airspace conflicts.

I am not a technical subject matter expert in the aviation industry. My expertise is in looking at systems. My 30 years of experience suggests the importance of strengthening the Plan stage of the PDCA cycle. Things go wrong at the Do stage (i.e., implementation), however, if the plan itself is deficient and not coordinated, the implementation can and perhaps will go wrong.

By integrating ISO 9001 principles into aviation safety proactively and appreciating the risks, management can prevent mid-air conflicts. Process-driven coordination ensures better civil-military collaboration. Automated monitoring and auditing could improve response times to emerging threats.

Sadly, this tragedy once again bears out the wisdom of W. Edwards Deming when he said that a bad system will beat a good person every time.

Note – The above article was recently featured in Exemplar Global’s publication ‘The Auditor”. Click here to read it.

Controlling Sub-Sea Infrastructure


The recent implosion of the Titan, a sub-sea submersible used for taking elite, high-paying tourists to see the wreck of the Titanic, brought the safety protocols of both vessels into focus. There were no statutory requirements for regulating the Titan and neither were there any when the Titanic sank in 1912! As a reactive measure, the maritime community came up with the Safety of Life at Sea (SOLAS) Convention soon after the sinking of the Titanic. Ironically, after the Titan submersible imploded, we have come to realize there are no requirements covering this vessel. Perhaps with time, the involved counties will react.

The question is, why was nothing done proactively? Tourists go up in hot air balloons all the time. Is there any statutory requirement that these tourist companies must meet? Is there even a requirement to have a management system in place so that these companies work systematically, appreciate the risks in the context of the organization, and plan their operations keeping risks in mind? It is true that entrepreneurs do not like regulations and consider requirements a hindrance in a free business environment. And yet the Titanic, which was declared to be “unsinkable,” did, in fact, sink! In the United States, the domestic towing vessel industry functioned without statutory requirements until recently. The industry avoided regulation, but tragedies occurred, and now the industry is regulated under the U.S. regulatory framework. A process-based management system is the best systematic structure to produce conforming products and services, ensure continual improvement, and implement the statutory requirements if available.

The intent of this article is to proactively start a discussion on the need for regulating sub-sea infrastructure to reduce its affect on the marine transportation system. The phrase “sub-sea infrastructure” refers to equipment and technology placed on or anchored to the ocean floor. This infrastructure may include, but is not limited to, cables for telecommunication, cables for power transmission, pipelines for transmission of fluids, and other stationary equipment for scientific research.

The growth of sub-sea infrastructure is a global phenomenon. As an example, is in the interest of all nations, and particularly here in United States, to promote wind farms, which are a source of renewable energy. When these wind farms are placed in selected geographical locations along the continental shelf, they need sub-sea cables. But are there any laws controlling the systematic development of the industry to enable an effective marine transportation system and its protection of maritime community interests and environmental interests? Is there a central agency responsible for this coordination to allow for a balanced approach to risks? The amount of cabling piling up needs management and oversight.

Sub-sea infrastructure, the definition of the problem

Numerous industries have a stake in sub-sea infrastructure. Examples include oil and gas, telecommunications, fishing, scientific research, and perhaps military/defense applications such as sonar and other arrays and obstacles. This infrastructure is a requirement, but it also faces various challenges including those that can lead to accidents, environmental damage, and possible breaches in national security. All these bring out very significant concerns related to sub-sea infrastructure and the lack of comprehensive and globally accepted standards, requirements, obligations, and assurance mechanisms. It is not that organizations such as the United States Coast Guard, the National Oceanic and Atmospheric Administration, the Bureau of Safety and Environmental Enforcement, the U.S. Army Corps of Engineers, the Environmental Protection Agency, and other federal and state agencies do not look at these issues.

Nevertheless, it remains a concern that there is no single agency or overarching requirement to provide a framework to the industry on harmonized implementation of requirements. This lack of harmonization can mean inconsistencies in design, installation, and maintenance practices which may not address risks uniformly. This can generate consequential risks, leading to increased accidents, mechanical failures, and costs to the industry and the nation.

Recent tragedies and accidents

Recent tragedies and accidents involving sub-sea infrastructure have been limited, and yet must not lead to complacency by the agencies involved. The few that have occurred indicate the challenges and trends pointing to the need for proactive requirements. The recent tragedies include:

  • Deepwater Horizon. The potential consequences and challenges inherent in deep-water oil drilling were brought out by the Deepwater Horizon tragedy in 2010. The oil rig explosion in the Gulf of Mexico caused a massive oil spill and resulted in the loss of 11 lives. Although not technically a sub-sea incident, it highlighted a series of failures in design, maintenance, and company oversight—all factors pointing to the importance of robust safety standards and requirements, and the implementation thereof. The Deepwater Horizon incident was not directly related to sub-sea infrastructure; however, it heightened the risks associated with offshore oil and gas production and the potential for catastrophic environmental damage.
  • Nord Stream 1 and Nord Stream 2. Occurring in September 2022, the damage to these gas pipelines in the Baltic Sea highlighted concerns around sub-sea infrastructure. These pipelines transport natural gas from Russia to Europe; in this incident, they sustained multiple leaks. The exact cause of the damage is unclear, though deliberate sabotage was suspected and is still under investigation. Regardless of the ultimate findings, this incident exposed the vulnerabilities of sub-sea infrastructure to sabotage, and the potential for significant environmental and economic consequences are real. Intentional attacks to the sub-sea infrastructure have the potential for widespread disruption of energy supplies. Apart from the Nord Stream, there have been other sub-sea incidents affecting the gas and oil industry. In 2021 a fire broke out on a sub-sea production control umbilical off the coast of Brazil, causing significant damage to the underwater equipment and resulting in a major oil spill.
  • English Channel Internet Disruption. In 2021, a ship dragging its anchor on the seabed in the English Channel cut the three main internet cables to the Channel Islands. Although this only resulted in slower broadband speeds in this instance, there remains the possibility that it could have resulted in a complete outage.

Looking ahead

These incidents represent leading indicators of a tragedy in the making should proactive action not be taken. The critical importance of safety for sub-sea infrastructure underscores the need for a more comprehensive and rigorous approach to standards and assurance. Industry stakeholders together with regulatory bodies within the United States and global organizations such as the International Maritime Organization must work together to establish a harmonized set of safety standards, implement robust assurance mechanisms, and foster a culture of safety throughout the sub-sea industry.

The increasing reliance on sub-sea infrastructure for various industries (including wind farms) necessitates a proactive approach to safety and risk management. There is definitely a need to invest in research and development to enhance the resilience and monitoring capability of sub-sea infrastructure. The various companies in the sub-sea industry are holding their proprietary information close to the vest. This is understandable. However, these organizations are in competition with totalitarian governments, in which control of business practices is the exclusive dominion of the state. It is necessary to enhance transparency and information-sharing among industry stakeholders to facilitate better risk assessment and incident prevention.

Conclusion

Promoting a culture of safety that prioritizes risk identification, risk mitigation, and continual improvement is essential. There is no common ISO standard for sub-sea management systems. Of course, ISO 9001 is interpretable and can be used as the basis for now. Environmental protection is a challenge for a developing industry, and as such, even greater urgency is needed for statutory requirements encompassing all aspects of stakeholder interests, the marine industry in general, and the protection of the environment for generations to come.

Marine transportation remains the most important way for goods to be shipped across the world, as approximately 80 percent of the world’s goods are transported by ships. Vessels need a place to anchor in normal operating conditions as also in emergencies. A crowded seabed in harbors makes this a challenge for the entire maritime industry.

Without adequate and effective regulatory oversight, it may be too late to take action once cables and other sub-sea equipment have already been laid. Further, multiple agencies regulating the same aspects of the industry can potentially lead to bureaucratic delays.  There is therefore an urgent need to create a single statutory body to regulate the sub-sea infrastructure industry, which will greatly benefit all parties invested in the maritime transportation system.

Exemplar Global Publication “The Auditor”

Implementing Safety Management Systems for Passenger Vessels

PV SMS White Paper – FinalExcerpt below is from White Paper by ‘Implementing Safety Management Systems for Passenger Vessels’ by Dr. Inderjit (IJ) Arora (QMII), Julius Desilva (QMII) and Captain Lee Boone (USCG, Retired). To continue reading the paper click on link in text.

INTRODUCTION

All too often, major accidents are the catalyst for change in the maritime industry. Evidence of this is seen in the development and implementation of maritime conventions and codes in existence today. The International Safety Management (ISM) Code, the result of such a catalyst, was meant to change this reactive nature. The ISM Code intended to promote a safety culture wherein risks are properly considered, work is effectively planned, personal accountability is enhanced, and operations are continually improved.

Unfortunately, this target was missed in many cases and a pervasive by-product called compliance culture set in, wherein the system achieves the minimum and only to satisfy regulators. The maritime industry and regulators learned much from this experience. We know now that if the true value of safety management systems (SMS) is not realized, further implementation efforts become self-defeating. This leads to even more than normal resistance from many who have seen colleagues, shipmates and competitors negatively impacted. A carefully planned implementation strategy expanding the use of safety management systems (SMS) to domestic passenger vessels should therefore be executed to avoid these pitfalls. As Safety Management Systems for domestic passenger vessels are intended in the same way as those for SOLAS1 vessels, we must apply lessons that have been learned from similar regulatory efforts.

In this paper, recommendations are made for implementing SMSs for domestic passenger vessels (PV) based on the concepts of incentives, scalability, and collective use of resources. When implemented in the right way and for the right reasons, the value that SMSs offer passenger vessel owner/operators is maximized, while the cost of implementation is minimized.

BACKGROUND – RESISTANCE TO CHANGE

Looking at the data from the 1980’s to date, one would expect to see a decline in marine casualties starting in 1998 when the ISM code’s first compliance deadline came into effect. Initially the data shows a downward trend for a few years and then a spike starting in 2001. Those resisting change brought about by the ISM code would argue that the code had not delivered any improvements. However, the upward trend peaked in 2008 and has since seen a decline.

When a new management system is put in place, irrespective of industry, the first sign of success albeit non-intuitive, is a spike in accidents, incidents and hazardous occurrences. This leading indicator should be accepted as a positive as it demonstrates that the personnel within the system have started reporting non-conformities that went unreported before. This reporting enables corrective action to be taken in a systematic manner to prevent a similar non-conformity from occurring again.

To continue reading click here.