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.