A7700 .. cheers!
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Bug … agree again with your recent contributions
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jon .. equally in the FAA Doc it further clarifies those roles and responsibilities, they are lengthy and complex … I come back to the reasonableness of the tower controller ‘expecting’ or even ‘suspecting’ that in this case an un-notified, unlit, unsuitable runway was to be used (by a two crew RPT) at night! ….. I further ask this ….
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… if there were no other notified vehicles or aircraft moving (at night) … what exactly is the ATC ‘reasonably’ looking for apart from lights (aircraft, taxiways and runways)?? .. as any ‘unlit’ obstacles (horses, cows dogs, etc) that might have wandered onto the runway are not visible in any case??
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….. it follows then that if ATC could not know of or predict unlit obstacles …. do we then mandate runway inspections with a vehicle prior to each movement at night??? …… by the same logic …do we now mandate ‘continuous’ ATC watch (no other duties) over ‘single’ aircraft to ensure they do not enter ‘unlit’ taxiways and runways at night??
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….. before deciding that 2 ATC’s will fix …… perhaps we might ask …. are there other examples of RPT aircraft attempting/using unlit runways at night??? …. is this particular set of fault tree components properly extinguished by simplistically suggesting an increase in ATC’s?? … is it cost effective when applied across the like type towers … or do you only up the anti after a completely unforeseeable accident at each individual airport?
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If you are going to invest in extra ATC eyes .. you might also ask …. does this solve the issues in all situations that may precipitate the unapproved use of 26 vice 22 at Kentucky??
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.. one of the questions in that risk/ hazard reduction assessment might be:-
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… is it more/as likely this type of error might occur in daylight in fog?? ….
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…. does the extra set of eyes help when ATC cannot see the aircraft attempting to use an incorrect runway …. hmmm ….
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The questions go to the effective mitigations that might be employed to provide better fault resistance at a reasonable cost in all weather and light conditions…. ?
….. SMR, Flight deck taxiing displays (as discussed), and as important as these IMHO is visual stimulus for the pilots (markings, systems etc) …..lets face it …. where are you (pilots) looking whilst taxiing?! ....... out the front of course!
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Back to the Issues:-
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- Runways both had a ‘2’ in the identifier
- Taxi turns might have felt similar
- Taxi turns might have looked similar
- Could the pilots have caught a glimpse of a '2' out the right hand side (in the landing lights) as they turned left onto centreline?
- Notam/ATIS re: 22 centreline lights U/S may have influenced what they expected to see
- Was the pilots (Capt taxied to the Line-up .. FO took over for the roll) field of visual concentration ‘straight ahead’
- Could a strongly lit runway surface/centreline from landing/taxiing lights on the aircraft preclude (at a glance) noticing the edge lights not operative??
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I am very interested in this particular subject as I am aware of at least two other ‘uneventful’ departures (B737) on our side of the pond where the runway lights ‘might’ not have been on and not noticed by the crew (outside tower hours and no crossing runway to confuse mind!)
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- Does the runway edge lighting 26 (when turned off) provide enough reflection back to the pilots (inadvertently lined up on 26) that they might think the lights were on (set to a low stage)
- Would the absence of edge and end lights only become apparent to the crews once they were fast and committed?
- From the 26 threshold.. could they (the pilots) see the runway edge lighting on 22 (no one has answered whether 22 has ‘omni’ or ‘all around’ visible runway edge lights)
- Is the MAG signage at the taxiway/runway 26 intersection clear and unambiguous
- Could the resurfacing provide confusion based on familiarity and therefore expected pavement colour (black/grey)
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.. this accident is no piece of cake from an investigation point of view!!
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.. regarding the ATC and visual monitoring..
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.. let’s assume for arguments sake, the controller had scanned 22 when they cleared the aircraft for takeoff ..... before the taxiing aircraft had taxied/reached the threshold of 26 (which they were expected to taxi across)
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.. if the controller was very experienced at Blue Grass, he/she would have automatic timing triggers in the melon! ….. i.e.
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- CRJ taxiing to 22 for takeoff …. might be 4-5 mins until you might expect to hear (if the tower is close enough to the thresholds for the sound to be audible in the tower cab) the Kero being applied for takeoff …. If not audible;
- He/she would almost certainly subconsciously have an ‘expected’ timer going in their head to know when to have a squiz out the window (if it is visual) to watch the takeoff was proceeding … so;
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… what is the time lapse difference between:-
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.. taxing to 22, line-up and go (lets say for argument that normally would take around 4-5mins)
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… and the time elapsed of taxing to 26, line-up and go (taking account of the reduced taxiing distance)
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…… where would/could the accident aircraft have been (in equivalent time elapsed) at around the time the ATC might have expected to look for acceleration/departure/positive rate of climb off 22?
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…… in the trees off the end of 26!!! (the ATC heard the impact!)
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…. the ATC could not in their wildest dreams, have imagined they might need to watch for this type of error at night with an unlit runway!! …. and IMHO they were being completely reasonable in assuming they could perform other tasks in the interim!
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… is it a good idea to have ADC’s doing other stuff …. probably not …is it plausible in all cases to have ATC’s able to look out the window every second of every day … probably not ……. was it relevant or casual in this case ….. I guess the NTSB will determine that, but for what it is worth ….
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…… ATC’s problem solve in 8 (or less) second chunks/windows …. when tasks are outstanding (no matter what they are) .. we will check … satisfy ourselves the ‘ducks are in a row’ … and then look to other tasks (otherwise you can get busy and way behind which might further impact primary duties) …. then, as the head timer tells us .. time! .. we re-evaluate …. No different in this case IMHO
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… tower controllers (no matter how many there are) cannot physically look out the window all of the time … practical fact!
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… the real mitigations for avoiding a repeat of a bazaar accident such as this one are IMHO to be found elsewhere!