- the instructor who let the helicopter pilot keep flying through dangerous airspace despite her being clearly disoriented, and who ALSO failed to appropriately consider or respond to ATC’s request for visual separation
- the FAA employee who refused the helicopter chart updates to make dangerous areas clearer
- the ATC who failed to respond appropriately to the alarm by giving the helicopter a specific instruction - the supervisor who failed to separate the local and helicopter duties when the level of traffic was high
And that’s just specific individuals, to say nothing of the military bureaucracy that kept aging fleets with poor equipment operating in close proximity to heavy commercial traffic, or the idiocy of the FAA reclassifying reagan as an airport where controllers get paid less despite a heavy workload and thus increasing the incentive for controllers to leave as soon as they could, preventing any building of institutional knowledge.
Assigning all the blame to one individual, no matter how critical their role in the accident, robs us of opportunities to make the system safer. That is always the point of Admiral Cloudberg’s articles, but especially this one.