On Jan. 29, 2025, a tragic mid-air collision occurred over the Potomac River near Ronald Reagan Washington National Airport involving an American Airlines regional jet and a U.S. Army Black Hawk helicopter flying a training mission. All 67 individuals aboard both aircraft perished, making it the deadliest U.S. air disaster since 2001.
Preliminary findings indicate the Black Hawk helicopter was operating at an altitude higher than it should have been and its Automatic Dependent Surveillance-Broadcast (ADS-B) system — a critical safety feature providing real-time aircraft position data — was turned off. A single air traffic controller was reportedly managing both aircraft, a situation described as “not normal” for that time of day at such a busy airport. This staffing decision is under scrutiny as a potential contributing factor to the crash, as well as the aging and outdated traffic control systems.
Completely unrelated to this incident is the tragic death of Robert Brooks at New York’s Marcy Correctional Facility in December 2024. Brooks, a 43-year-old inmate, was fatally beaten by correctional officers while handcuffed in a medical examination room. The incident was captured on body-worn camera footage that the officers did not know was recording, revealing multiple officers assaulting Brooks as others stood by without intervening. The video is difficult to watch, and even without knowing the full story of what started the incident, the force used was clearly excessive and abusive.
An autopsy determined Brooks died from asphyxia due to compression of the neck and multiple blunt force injuries, ruling his death a homicide. In response, 13 correctional officers and two nurses were suspended without pay, and one officer resigned. Governor Kathy Hochul called for the termination and criminal prosecution of those involved, emphasizing the need for accountability.
Okay, one is a horrific plane crash — an accident — and the other is a clearly unjustified assault leading to a man’s death. What do they have to do with each other and what can we learn from them?
How Proper Risk Management Should Work
Risk management (RM) is the systematic process of identifying, assessing and mitigating potential risks to minimize negative impacts on an organization, project or operation. It involves evaluating uncertainties, implementing preventive measures and developing response strategies to enhance safety, efficiency and resilience. For law enforcement, the focus is mitigating and monitoring risks to ensure the safety of officers, the public and the organization.
This can and should involve proactive strategies as it is not a passive process. In other words, management by lack of negative consequences is the antithesis to proper risk management. True RM is also not about reducing civil liability. Instead, it is a systems process with the goal of accomplishing organizational tasks safely and effectively. If that process results in reduced liability, then great — that is yet an added benefit. But prioritizing the reduction of liability may taint the systems analysis process, rendering it less effective and misguided.
Implementing comprehensive root cause analysis in the aftermath of tragedy is essential. This process involves a thorough examination of the factors contributing to the failure, including individual actions, supervisory oversight, training adequacy and organizational culture. Identifying these root causes allows institutions to develop targeted corrective actions aimed at preventing recurrence. We need to know what the actual cause or causes are, not the proximate cause, which just tells us what happened. Critical to true RM, however, is that organizations must be perpetually uneasy, trying to identify and prevent problems before they occur. How do we do this? One way is to look at incidents that occur elsewhere and ask, “Could this happen here?”
Now let’s go back to the two situations we started with. What is the difference between the two in the world of RM? The plane crash will receive a thorough investigation, based upon proper RM and root cause principles, by the National Transportation Safety Board (NTSB) and the Federal Aviation Administration (FAA). These organizations have a long history of digging deep into tragedies such as the one in Washington and identifying definitive causes and corrective recommendations. The FAA, and the NTSB in more serious cases, also monitors and analyzes near-miss data to improve safety.
Law enforcement and corrections do not have an NTSB or FAA or anything close to it. Instead, we have a piecemeal system of civil suits, criminal prosecutions and, if a death occurs, possibly an investigation by a state attorney general’s office. Nor do we have any type of cohesive or collaborative way to review “near-misses,” or incidents that do not rise to the level of a death. Instead, those are typically dealt with by varying degrees of agency-led internal affairs investigations and civil suits. As for the latter, qualified immunity can impair a proper RM approach because it can defeat a civil suit, creating the impression that nothing was done incorrectly and there is nothing to learn from the underlying incident and response.
Because it resulted in a death, the Marcy incident will be under tremendous scrutiny. Citing a conflict of interest, the New York attorney general appointed an independent county prosecutor to investigate the incident. While important, this investigation is not a true RM approach since the purpose of the investigation will be to prosecute the individuals involved. In other words, it is the proximate cause of Robert Brooks’ death and not the root cause that is important in a criminal prosecution.
Do we have enough information on the Marcy incident to draw some likely root causes? I think many signs point to deficient organizational culture.
The first indicator of this is in the video itself. This incident highlights a profound failure in the duty to intervene — a fundamental responsibility requiring officers to prevent or stop misconduct by their peers. The presence of multiple officers, including sergeants, who either participated in or passively observed the assault without taking action underscores systemic issues within the facility’s culture and oversight mechanisms. Clearly, the duty to intervene does not exist in their culture.
Another strong indicator of a seriously flawed culture is the number of complaints of excessive force and civil suits in the years leading up to this incident. Numerous former incarcerated persons consistently provided the same information: They were told by corrections officers this was a “hands on facility” and if they did not do what they were told there would be physical repercussions. Despite all this publicly known information, the behavior obviously continued.
For purposes of this article, let’s assume the NTSB will cite the outdated air traffic control system as at least a partially contributing factor in the Black Hawk crash. One recommendation will be what everyone in the industry already knew before the incident, that the system needs to be replaced. Looking back at the Marcy incident, it is clear the culture of the organization needs to be changed dramatically and the duty to intervene indoctrinated in all its members.
However, identifying root causes is only the first step. Effective RM necessitates the implementation of corrective measures and continuous monitoring to ensure their efficacy. Otherwise, the root cause analysis would be for nothing. To do this, it is sometimes necessary to look in the past to see what problems may arise when trying to implement needed changes.
“Leaders cannot be afraid of confrontation and instituting disciplinary actions. The people who deserve to be there will appreciate it, and I can verify that from my own experience as a supervisor and a chief.”
Risk Management and the Lessons of Positive Train Control
A case study that illustrates both the importance of root cause analysis and the challenge of follow-through is the nationwide implementation of Positive Train Control (PTC) in the U.S. rail system.
PTC is a safety technology designed to prevent train collisions, overspeed derailments and other human error-related accidents. While its benefits were widely recognized, the system was not fully implemented until 2020 — over a decade after a deadly accident highlighted the need for it. The long road to full deployment reveals key lessons about risk management that are highly relevant to law enforcement leaders.
The urgency for PTC implementation became evident after the 2008 Metrolink train collision in Chatsworth, California. The accident, which killed 25 people and injured over 135, was caused by an engineer who ran a red signal while distracted by text messaging. A post-accident investigation revealed that PTC could have prevented the tragedy by automatically stopping the train before it entered a conflicting track.
This was a textbook example of risk management in action: A catastrophic failure led to a root cause analysis, which in turn identified a solution. However, what followed was a struggle to implement that solution effectively.
Despite a congressional mandate in 2008 requiring PTC implementation by 2015, railroads encountered numerous challenges, leading to extending the deadline first to 2018 and then to 2020. The delays stemmed from multiple factors, including the complexity of integrating new technology with existing rail systems, interoperability challenges among different railroads, high costs (over $14 billion industry-wide), supply chain shortages and regulatory hurdles. Although progress was steady, ensuring the necessary corrective action was fully implemented took years of sustained effort and oversight. In the meantime, more lives were lost and hundreds of injuries occurred in train crashes that probably could have been prevented if the PTC system had been fully implemented on time.
If the NTSB report into the Black Hawk crash includes a recommendation to replace the outdated air traffic control system, it is entirely possible that results similar to the PTC rollout could occur. Purchasing and installing the necessary equipment, training an already short staff of air traffic controllers, and maintaining safe and uninterrupted passage for the tens of thousands of flights that occur daily would be a difficult task.
The Difficulties Lying Ahead
Drawing parallels to the previously discussed aviation and rail disasters, the death of Robert Brooks illustrates the catastrophic consequences that can arise from the absence of effective RM and accountability systems. Just as the failure to implement safety technologies like PTC in the rail industry led to preventable tragedies, the lack of a proactive duty to intervene policy and enforcement within correctional facilities and police agencies can result in loss of life and erosion of public trust.
For law enforcement leaders, the lessons from the PTC rollout are clear: RM requires more than just identifying problems; it demands persistent follow-through to ensure corrective actions are implemented effectively. In policing, failures — whether related to use of force incidents, officer safety or community trust — often have identifiable root causes. However, the difference between a proactive agency and a reactive one is in its ability to move beyond analysis and execute meaningful, lasting solutions.
Much like the railroad industry’s struggle with PTC implementation, law enforcement agencies may encounter resistance to change, logistical challenges and financial constraints when attempting to mitigate risks. Yet, failure to follow through can lead to preventable tragedies, reputational damage and legal liability.
As you get to this point, you may be saying, “Wait a minute, just hold on here! This all sounds great and may make sense in a college classroom or in a textbook, but how do we do this?”
The first thing law enforcement leaders need to do is adopt proper perspective and priorities. For whatever reason, there can be a tendency for leaders to have willful blindness — the conscious decision to ignore warning signs, risks or systemic failures despite evidence that action is needed — or even feel it necessary to protect problem employees. That must change. Supervisors at all levels must understand their priority is to make the organization a better place for the people who deserve to be there.
I need to point out something very important about the Marcy incident. I have to believe there are many good corrections officers at the Marcy facility who would thrive in a proper organizational culture. Ultimately, the culture of any agency starts at the top through clearly stated or latent values. If these values are not clear or are flawed, the result is a cultural cancer. For those corrections officers and employees who deserve to be there, their organization failed them as well as Robert Brooks. Officers are not going to speak up or act if they know their organizations will not support them. Instead, they (as well as their charges) may just suffer in silence for fear of retribution.
Leaders cannot be afraid of confrontation and instituting disciplinary actions. The people who deserve to be there will appreciate it, and I can verify that from my own experience as a supervisor and a chief. The duty to intervene should not be presented as the need to “rat out” someone. Could it be as simple as that? Sure, but it needs to be looked at more expansively. It must be viewed as a means of serving as “redundant systems” for each other and stepping in to prevent issues before they can happen. We are all human beings and can have a bad day or make a bad decision. Knowing that you will be watching over each other is a means of instilling respect in your culture while doing the right thing to protect the public, your members and the organization. (For more information on this, please watch the recent Lexipol webinar on the duty to intervene.)
In a multigenerational workplace, leaders need to show they genuinely care about their members. To that end, the well-being of members is important. Having some type of wellness solution beyond access to an Employee Assistance Program (EAP) can be critical to a proper organizational culture that embraces a holistic approach to the duty to intervene. Stepping in when you see a co-worker is struggling personally or professionally can possibly save a career.
The phrase “compassion fatigue” refers to the physical, emotional and psychological exhaustion individuals may experience as a result of prolonged exposure to the suffering of others, particularly in caregiving or helping roles. Officers see many bad things others do not, and this type of fatigue can be a problem. They may need help keeping things in perspective. Plus, officers can be negatively impacted by fatigue and exhaustion caused by excessive shifts or stress-induced lack of sleep. This can also have a negative impact on an officer’s job performance and lead to an act of frustration or anger. For those of you who have members working excessive overtime due to staffing shortages, you have your first proactive RM assignment before something bad happens: Find out how it is impacting them. Do you need to provide some type of wellness solution?
First Steps
The death of Robert Brooks serves as a poignant example of the dire consequences that can result from systemic failures in risk management and accountability. It underscores the imperative for law enforcement leaders to not only conduct thorough root cause analyses following incidents of misconduct but also to diligently implement and enforce corrective actions. By doing so, agencies can work toward preventing such tragedies in the future and maintaining public trust in the justice system.
Many leaders will view the severity of the Marcy incident as an outlier and dismiss it. I hope it is an outlier. This should not, however, prevent an honest, introspective examination of your own agency. Ask these questions of your staff: Do our members feel empowered to step in and act when they think it is necessary? Does our culture adequately convey the need for members to act as redundant systems for each other? If not, take action. Your members and your organization will be better for it.
Author’s Note: Significant events occurred in New York State after this article was published. Thousands of union corrections officers went on strike, leading to more than 2,000 being fired by the time the strike ended. Another incarcerated person died at the hands of corrections officers who had shut off their body cameras, which led to yet another criminal prosecution. And significant attention was brought on a prior law that restricted the use of solitary confinement as a means of controlling violent inmates. All this just reinforces the need for the union, management and legislature to work together to determine root causes and work together to solve them. Otherwise, this situation will follow the path of the Positive Train Control system.
