System Factors at LEX
Here's a short list of "system factors" that seem to have been at work, not "causal", but any one of which might have changed the outcome it it had been different:
* the airport has a rise (hill) in the middle of it.
* Runway 26 was 150 feet wide, but shown on the airport diagram as 75 feet wide.
* The lights were out at the takeoff end of runway 22 for something like 30 minutes, the samewindow of time as when the First Officer arrived friday night and noted the situation.
* The airport diagram did not correspond to reality, lacking the extra runway. The airport diagrams that are current are still not updated. The small versions of the airport diagrams on the instrument procedure plates make it look like there is a closed runway that comes all the way down to runway 26, marked by an "X", even though the larger diagram shows there is a gap (from the one marked with several "x" flags.)
* There is at least one possible confusion of route to the takeoff point that the diagram discrepancy allows, in which a sharp left turn onto a 150-foot wide runway at the end of the taxiing made perfect and unambiguous sense.
* Only the pilot in the left hand seat could steer the nosewheel steering, which separated the pilot in command (the first officer) from the activity that was done incorrectly by the senior Captain in the left-hand seat.
* Unquestioned cultural convention demands that the higher ranking officer sit on the left side, even though it would make more sense in this aircraft to have the pilot in command sit on that side.
* The tower was understaffed, and the lone occupant was (correctly) busy with other traffic at the crucial few seconds when he otherwise might have idly watched flight 5191 taxi into position and noted the error. It wasn't the tower responsibility to do that, but it could have occured and caught the problem.
* The only person who noticed the error, apparently, a ramp worker, had no way to communicate by radio to the aircraft and his attempt to run to the runway and wave down the plane did not succeed.
* The aircraft was not equipped with the $18,000 piece of equipment that would have automatically detected the runway error and alerted the crew, possibly because the airline was in bankruptcy proceedings.
* The crew seemed to behave as if operating in violation of FAA regulations was something they were routinely expected to just do and shut up about - judging from the fact that they continued to attempt a takeoff from an unlit runway, even though the first officer sighed when he commented that the lights were out all over the place.
These are intended to be a list of factors beyond individual performance that are potential intervention points to prevent similar events in the future.
Do I have those right?