Comair CRJ crash in Kentucky [Archive]

Flight Safety

27th Aug 2006, 13:32

The aircraft took off around 6:07am, while it was still dark. The weather information is somewhat confusing at this point. Some information says the conditions were mostly clear with some clounds. Others indicate that there were light showers (with fog and haze) in the vicinity with small thunderstorms developing southwest of Lexington. One archived weather radar image from a local TV station showed a small thunderstorm southwest of the airport, in the general direction of the extended runway centerline for 22, however the storm looked several miles out from the airport. The crash occurred about mile from the runway. I undestand the takeoff was to the west, but I don't know if they used 22 or 26, however 26 is only 3500 feet long, so my guess would be they used 22, which is 7000 feet long.

One survivor is being reported, a male in critical condition.

Airbubba

27th Aug 2006, 13:36

Just seen footage of emergency vehicles on SKy - at intersection of Rice and Versailles.

Yep, that would be the field right off the end of runway 26.

MSNBC is reporting that the survivor may be one of the pilots or the jumpseat rider.

Flight Safety

27th Aug 2006, 13:43

Boy you guys are fast. Yes, Rice and Versailles is off the end of 26. A crash off the end of 22 would has put them near Parkers Mill Rd and Dedman Rd. Can this aircraft takeoff of 26? It was fully loaded with 47 passengers and 3 crew.

Two's in

27th Aug 2006, 13:47

Someone will know the exact distance required for a CRJ 200, but Comair are under FAR Part 121, and the good book says Runway 26 was probably not a conscious option:

Sec. 121.189 - Airplanes: Turbine engine powered: Takeoff limitations.

(a) No person operating a turbine engine powered airplane may take off that airplane at a weight greater than that listed in the Airplane Flight Manual for the elevation of the airport and for the ambient temperature existing at takeoff.

(b) No person operating a turbine engine powered airplane certificated after August 26, 1957, but before August 30, 1959 (SR422, 422A), may take off that airplane at a weight greater than that listed in the Airplane Flight Manual for the minimum distances required for takeoff. In the case of an airplane certificated after September 30, 1958 (SR422A, 422B), the takeoff distance may include a clearway distance but the clearway distance included may not be greater than 1/2 of the takeoff run.

(c) No person operating a turbine engine powered airplane certificated after August 29, 1959 (SR422B), may take off that airplane at a weight greater than that listed in the Airplane Flight Manual at which compliance with the following may be shown:

(1) The accelerate-stop distance must not exceed the length of the runway plus the length of any stopway.

(2) The takeoff distance must not exceed the length of the runway plus the length of any clearway except that the length of any clearway included must not be greater than one-half the length of the runway.

(3) The takeoff run must not be greater than the length of the runway.

(d) No person operating a turbine engine powered airplane may take off that airplane at a weight greater than that listed in the Airplane Flight Manual --

(1) In the case of an airplane certificated after August 26, 1957, but before October 1, 1958 (SR422), that allows a takeoff path that clears all obstacles either by at least (35+0.01D) feet vertically (D is the distance along the intended flight path from the end of the runway in feet), or by at least 200 feet horizontally within the airport boundaries and by at least 300 feet horizontally after passing the boundaries; or

(2) In the case of an airplane certificated after September 30, 1958 (SR 422A, 422B), that allows a net takeoff flight path that clears all obstacles either by a height of at least 35 feet vertically, or by at least 200 feet horizontally within the airport boundaries and by at least 300 feet horizontally after passing the boundaries.

(e) In determining maximum weights, minimum distances, and flight paths under paragraphs (a) through (d) of this section, correction must be made for the runway to be used, the elevation of the airport, the effective runway gradient, the ambient temperature and wind component at the time of takeoff, and, if operating limitations exist for the minimum distances required for takeoff from wet runways, the runway surface condition (dry or wet). Wet runway distances associated with grooved or porous friction course runways, if provided in the Airplane Flight Manual, may be used only for runways that are grooved or treated with a porous friction course (PFC) overlay, and that the operator determines are designed, constructed, and maintained in a manner acceptable to the Administrator.

(f) For the purposes of this section, it is assumed that the airplane is not banked before reaching a height of 50 feet, as shown by the takeoff path or net takeoff flight path data (as appropriate) in the Airplane Flight Manual, and thereafter that the maximum bank is not more than 15 degrees.

(g) For the purposes of this section the terms, takeoff distance, takeoff run, net takeoff flight path and takeoff path have the same meanings as set forth in the rules under which the airplane was certificated.

[Doc. No. 6258, 29 FR 19198, Dec. 31, 1964, as amended by Amdt. 121-268, 63 FR 8321, Feb. 18, 1998]

Flight Safety

27th Aug 2006, 13:53

Assume the aircraft is a CRJ-200. According to Bombarier, the CRJ-200ER in SL ISA conditions, requires 5800 feet at MTOW. This aircraft had to be near MTOW with 47 passengers and 3 crew on board.

Ranger One

27th Aug 2006, 13:58

Well apparently FDR and CVR recovered. Images I'm seeing on TV show a sparsely-wooded area some distance off the end of the runway, with some trees between the runway and the crash site with their *tops* lopped-off. So they evidently got into the air.

R1

Doors to Automatic

27th Aug 2006, 14:08

04 departure would be unlikely as winds were from the SW at the time at about 10 kts.

A CRJ at this sort of weight would require 4000-5000ft (less if it was a -700 but I don't think it was).

Airbubba

27th Aug 2006, 14:12

Just for local background, there was another fatal jet crash on Versailles Road four years ago:

http://www.enquirer.com/editions/2002/08/31/loc_jet_crashes_at_end.html

sikeano

27th Aug 2006, 16:49

the sole surviour is the first officer he is in critical condition the next press conference is at 5pm est so let us be patient here and stop slagging any one off

jondc9

27th Aug 2006, 16:52

Flight Safety

27th Aug 2006, 16:57

The local NBC television station in Lexington (and several other news sources) are reporting that the aircraft definitely took off from runway 26. The crash site is located less than a mile from the end of runway 26, south of Versailles Rd. The lcation of the crash site indicates that the takeoff could not have been from either 4 or 22, without large turns back to the airport being made prior to the crash.

Other information:

There was a local rain storm right over Fort Spring at 6:08am, just west of the airport on Versailles Rd (also named HWY 60). There is speculation of a microburst from this storm.

Other reports indicate the aircraft was cleared for takeoff on runway 22, not 26. A takeoff from 22 would have avoided the storm (going well south of it), but not a takeoff from 26. Again, runway 26 is only 3500 feet long.

From the Naval Observatory for Lexington KY on Aug 27th: civil twilight - 6:36am, sunrise - 7:03am. There have been some reports of fog in the area at the time of the accident, which was at 6:08am.

PlatinumFlyer

27th Aug 2006, 17:13

CNN now reporting from 2 independent sources that "the wrong runway was used."

ORAC

27th Aug 2006, 17:16

LEXINGTON, Ky...........Three police officers, two at the airport and one from the city police, were “instrumental” in saving the life of the copilot, the only survivor, Scott Lanter, chief of airport security. He said the three officers observed movement in the front of the aircraft and extricated the first officer from the nose. The three officers did not have to enter the plane, he said.

Lexington Herald Leader - Farm owner: Plane “used wrong runway”

The owner of the farm where Comair Flight 5191 crashed said.... the plane hit an 8-foot fence between his property and the airport, and clipped several trees......

He said the crash location is a “straight line” from the start of the smaller runway to where the airplane landed on his farm.

HowlingWind

27th Aug 2006, 17:22

According to CBS News, crew acknowledged clearance for 22. Orr (referred to below) is a CBS Correspondent.

A little after 6 a.m., flight controllers gave the pilots clearance to take off from runway 22 and the pilots acknowledged the controllers with a "roger," Orr reports. However, it appears the pilots took off from runway 26, which is only half the size of the 7,000 foot runway 22.

Sources tell Orr the radar tape and debris from the crash site suggest the plane never got airborne, that instead it went off the end of the runway and through a retaining area before settling into the crash site where it seems a significant post-crash fire erupted.

Orr adds that two flights took off from the correct runway (22) just prior to the Comair flight's departure.

Link to full story (http://www.cbsnews.com/stories/2006/08/27/national/main1936906.shtml)

filejw

27th Aug 2006, 17:26

For those of you yapping about low time FO's, the guy was hired in 2002. So he should have had lots of time in the A/C. What they should really be looking for is distractions caused by management that is threating these guys carreers.

hughesyd

27th Aug 2006, 17:32

no one is trying to place blame...
if a takeoff was made on the short runway, questions about pilot fatigue, procedures (checking compass on runway lineup) airport markings, signage and so forth come to mind.
no one wanted this crash, but we must prevent another with speaking out about things like fatigue/crew rest/ stand up over nights etc
jon

must be all of a couple of hours since the accident and already everybody racing to speculate the cause and where/who the possible blame lies with, how sad.

At least have some respect and wait for the FACTS to emerge!!. And as for feeding CNN or any other news channel with speculation, im sure the media are well capable of creating whatever glorified story they feel fit with the limited information they have!!.

Thoughts go out to the families of the passengers and crew, and fingers crossed for the recovery of the remaining survivor.

Im sure we can all agree on that one.

av8boy

27th Aug 2006, 17:39

http://www.atcmuseum.org/picture_library/Lexington.jpg

Willie Everlearn

27th Aug 2006, 18:31

The aircraft described in the Press Conference this morning by the President of Comair was reported to have been delivered in 2001. That means it is a 200 series aircraft as Bombardier did not manufacture the 100 series at that time.
The 100 was discontinued in the mid 90s.

Nothing seems to be outstanding in this accident at least up to the point where it was reported that the aircraft departed on the shorter runway.
If true, I can't imagine anyone with the CRJ operational experience this crew is reported to have had, operating into and out of Lexington on a regular basis would have ever entertained the idea of departing off the shorter runway at or near gross weight. The performance margin just isn't there. This aircraft, which does NOT have high lift leading edge slats, uses an incredible amount of runway to achieve V1 at high gross weights.
Using manufacture’s data, the ASD req’d for both 51,000 and 53,000 lbs is 5,900 feet.
:confused:

The declared distance for Rwy 26 is 3500 feet of runway.
V1 at Flap 8 is approximately 148 KIAS and with F20 it is 137 KIAS. (I believe Comair has the 4 flap settings option, which means F20 is the first flap setting and the setting Comair are most likely to use for takeoff) It should also be mentioned that at 25 Celcius and 947' ASL the aircraft weight is limited to approximately 49,800 pounds on a 6,000 ft runway. What would the weight limit and V1 speed be for a 3500 ft runway?

It should also be pointed out that all AFM data is based on a 6000 ft runway. That's the kind of takeoff run this regional jet uses.

Willie

ORAC

27th Aug 2006, 18:40

MONTREAL, Aug 27 (Reuters) - Canadian plane and train maker Bombardier Inc. said the 50-seat CRJ-100 regional jet in Sunday's deadly crash in Lexington, Kentucky, was delivered new to Comair in 2001. Bombardier, the world's third-largest civil aircraft maker and No. 1 manufacturer of trains, said the jet was delivered Jan. 30 of that year.

Loose rivets

27th Aug 2006, 18:47

Golsen

27th Aug 2006, 18:51

The airport diagram posted earlier shows runway 26 to be only 75 ft wide versus 150 for runway 22. Wouldnt you think the crew would have noticed this?

Flight Safety

27th Aug 2006, 18:54

This is the accident aircraft, a CRJ-200ER. N431CA, S/N 7472. The registration number and S/N came from the President of Comair.

http://www.airliners.net/open.file/0889583/M/

http://www.airliners.net/open.file/0803068/M/

These are the basic specs for this aircraft, including the takeoff field length for the CRJ-200ER.

http://www.crj.bombardier.com/CRJ/en/specifications.jsp?langId=en&crjId=200

falco85

27th Aug 2006, 18:55

From CNN.com (http://edition.cnn.com/2006/US/08/27/plane.crash/index.html) :

The Bombardier Canadian Regional Jet (CRJ)-200 was cleared to take off from runway 22, which is more than 7,000 feet long, the sources said.
Instead, it took off from runway 26, which is 3,500 feet long, the sources said.

That length is "pretty short for that type of aircraft," former National Transportation Safety Board Vice Chairman Bob Francis told CNN.
Lanter confirmed that the crash site was at the end of runway 26 but would not speculate from which runway the flight took off.

"Part of the investigation will establish what runway they were using," Lanter said. "Based on the information we received for the incident, we don't know what runway they were using."

Asked about the possibility that the wrong runway was used, Bornhorst told reporters, "I think that is a rumor and speculation that would be not good for any of us to go down right now."

NTSB investigators could take up to a year before formally ruling on the cause of the crash.

CaptainProp

27th Aug 2006, 18:59

must be all of a couple of hours since the accident and already everybody racing to speculate the cause and where/who the possible blame lies with, how sad.
At least have some respect and wait for the FACTS to emerge!!. And as for feeding CNN or any other news channel with speculation, im sure the media are well capable of creating whatever glorified story they feel fit with the limited information they have!!.
Thoughts go out to the families of the passengers and crew, and fingers crossed for the recovery of the remaining survivor.
Im sure we can all agree on that one.

Correct!! This is what I was trying to say earlier!! To hear someone who claims to be ex airline employee chasing a "story" is really, really sad....

Dream Land

27th Aug 2006, 18:59

Not sure of the accuracy, but the local news guy was saying that the taxiway going to the end of RW22 is closed, access to RW22 is now via the taxiway that cuts across the approach end of RW26 due to a new displaced threshold for RW22.

antilla

27th Aug 2006, 19:05

Just a thought...and that's it is...would the crew normally accept a T/O from the intersection? My thinking is this.
Looking at the layout of the taxiways, they would have made a far greater miscalculation, if they had muddled the runways while taxiing to the end. If they had gone for the intersection, it would have been far easier to make this error.

Surely this is unlikely, since no taxiway leads directly to the intersection, allowing a choice of runway.

Isn't it more likely that the pilot turned three-quarters left at the earlier junction with the shorter runway, instead of pressing on to the next junction at end of the longer one, when precisely the same three-quarters left turn would have been needed.

Flight Safety

27th Aug 2006, 19:06

Dream Land, right, the taxiway to 22 now crosses right over the end of 26.

Various news agencies are now reporting airport parameter fence damage and treetop damage just past the end of 26.

er340790

27th Aug 2006, 19:12

(3) The takeoff run must not be greater than the length of the runway.

A salutory FAR reminder that the bleeding obvious may not always be obvious.

Can anyone confirm if this was the longest period in US jet transport history without a passenger fatality - some 4.5+ years?
R.I.P.

Airbubba

27th Aug 2006, 19:19

Another issue that comes to mind is the jumpseat rider. Assuming it was a pilot, it should have given another set of eyes to catch any mistakes.

Was it possibly an offline rider who needed assistance with his or her shoulder harness just as the plane took the runway for takeoff? I needed help figuring out the jumpseat last time I rode in an RJ cockpit. Not even sure if Comair allows offline cockpit riders under the post 9/11 CASS system.

A cockpit jumpseat rider can be a help, but the rider can also be a distraction. An online rider coming off of days off can be very chatty trying to catch up on managment's latest move to cut costs and reign in the unions.

I remember Avianca had a 727 crash in South America years ago where the captain was chatting with the jumpseat rider as the FO flew the aircraft into rising terrain. When the GPWS alert sounded, the captain famously announced 'Shutup Gringo!' and the CVR recording ended a few seconds later.

http://aviation-safety.net/database/record.php?id=19880317-0&lang=en

nooluv

27th Aug 2006, 19:31

Why didn't anybody notice that the heading was wrong?
Not 262! but 223 .ILS 110.5 ?

DanAir1-11

27th Aug 2006, 19:40

Why didn't anybody notice that the heading was wrong?
Not 262! but 223 .ILS 110.5 ?

'Assuming' that speculation that 22 was used and not 26 is correct, then yes why indeed, however I am not at all convinced that there are not more contributing factors, only time will tell, and until then, endless and possibly unfounded speculation may just be a rather unpleasant blight against the crew. Our thoughts must go to the deceased.

Regards

DA1-11

DingerX

27th Aug 2006, 19:41

SIA 006 also had a jumpseat rider.
First Left or Second Left?
early in the morning, little sleep, easy mistake to make.

Mad (Flt) Scientist

27th Aug 2006, 19:42

Aren't US airports supposed to have (or be getting?) surface movement radars or some such thing? Did Kentucky have one?

320DRIVER

27th Aug 2006, 19:43

With that runway layout, and at night, with 20/20 hindsight it is quite easy to visualize howthese poor guys lined up with 26 rather than 22. With the recorders recovered, we should soon get some hard facts from the Agencies.

But for the Grace of God...

Oilhead

27th Aug 2006, 20:06

SaturnV

27th Aug 2006, 20:09

From a meteorologist in Lexington KY posted on another board:
No fog.. no thunderstorms (weak shower .01)... weather was not a factor.

The problem is changes were just made this week at the arport as a major repaving operation wrapped up Monday. Changes to the taxi lanes will likely play a huge factor.

Again... weather does not look to have played a role.

Bolding mine.

PaperTiger

27th Aug 2006, 20:09

'Assuming' that speculation that 22 was used and not 26 is correct, then yes why indeed, however I am not at all convinced that there are not more contributing factors, only time will tell, and until then, endless and possibly unfounded speculation may just be a rather unpleasant blight against the crew.Posted on flyertalk.com:In 1993, the pilot of an air carrier filed a report with the NASA ASRS (aviation safety reporting system) after nearly departing from runway 26 when instructed to depart from runway 22 at Lexington. The report reads: "Aircraft was cleared for immediate takeoff (traffic was inside the marker) on runway 22 at KLEX. We taxied onto the runway and told tower we needed a moment to check our departure routing with our weather radar (storms were in the area, raining at the airport). We realized our heading was not correct for our assigned runway and at that moment, tower called us to cancel the takeoff clearance because we were lined up on runway 26. We taxied clear and then held short of runway 22 for landing traffic. We took off on runway 22 and proceedd without incident. Possible contributing factors were poor visibbility and weather (rain. Confusing runway intersection and tower's request for an immediate takeoff. Suggest possible warning page (similar to Houston Hobby) to clarify multiple runway ends."Emphasis mine. How many of us always check before rolling I wonder ?

PaperTiger

27th Aug 2006, 20:14

if they were cleared to taxy to RW 22 via "Alpha" they would not be told to hold short of 26, or cleared to cross runway 26 etc, which could serve as a very appropriate reminder that there is more than one runway out there.Is LEX so busy that it actually needs two runways just 40deg apart ?

Flight Safety

27th Aug 2006, 20:22

CNN is reporting that ground radar data confirms that the aircraft used runway 26 for takeoff instead of 22. They are also reporting that the pilots completed their last flight into KLEX just after midnight, which left them very little time to get to the hotel and sleep, and then get up and prepare for a 6am flight.

Fatigue could easily explain the wrong choice of runway for takeoff.

ATC Watcher

27th Aug 2006, 20:37

possible factors so far :

crew fatigue ( 4 hours rest or less ?)
bad visibilty ?
new taxiway markings ?
Confusing ( or not standard ) R/T ?
Confusing layout ?
Commercial pressure ?

Should we abandon the " who" made the error but rather look into a whole system that put a crew in this situation ?

jondc9

27th Aug 2006, 20:54

of course we should look at the system...if crew rest is an issue, time to re do the regs

standup over nights are awful!

jon

Sunfish

27th Aug 2006, 20:58

If this is any help, from the airnav.com website details of the runways.

Runway 22:

Dimensions: 7003 x 150 ft. / 2135 x 46 m
Surface: asphalt/grooved, in good condition
Weight bearing capacity:
Single wheel: 140000 lbs
Double wheel: 169000 lbs
Double tandem: 275000 lbs
Runway edge lights: high intensity

Runway 26:

Dimensions: 3500 x 75 ft. / 1067 x 23 m
Surface: asphalt/concrete, in poor condition
CONC IS SEVERELY CRACKED.
Weight bearing capacity:
Single wheel: 12500 lbs
Runway edge lights: medium intensity
MIRL RY 08/26 OTS INDEFLY.

Remarks:

RY 08/26 DAYTIME VMC USE ONLY.

22 has centreline lights, 26 apparently does not.

God bless them all.

Cross-eyed

27th Aug 2006, 21:31

This aircraft took off from rwy26 folks. Early views from a newscopter camera pointed straight down rwy26 showed tree limb damage at approx. 25ft. high at the end of 26. Also seen was impact point to final resting place ground skid about 150 yds. along rwy26 heading. The big question is why. Precip. cell over airport between 6:07 and 6:10 and still dark. Renovation to rwy22 added displaced threshold and change to taxiway. Taxi from Charlie brings you right over numbers 26 to left turn to A5 to 22, slightly more left and you're lined up with 26. The hold short line at the departure end of 26 is not easily visible from the tower.

gofer

27th Aug 2006, 21:42

Comair News Site (http://www.comair.com/news/index.html?id=317)

Flight Safety - you could be right or wrong on that - but its a conclusion - and its much too early for speculation. Let the FAA draw the conclusions, and lets try and avoid feeding the panic and rumour mills.

Huck

27th Aug 2006, 21:44

Local news photos of site here:

http://www.heraldleaderphoto.com/featuredgalleries/featuredgalleriesindex.html

Photo #4 clearly shows tire marks in the grass off 26....

RobertS975

27th Aug 2006, 21:44

If this crew mistakenly tried to take off from a 3500 foot runway instead of the 7000 foot runway, then we need to understand why a competent and qualified crew made such an error. Short night of sleep, pre-dawn darkness, short taxi while blasting through the checklist... all possible factors. I heard (not confirmed!) that there was an AirTran pilot in the jumpseat... another potential distraction.

At some point during the t/o roll, options disappeared. Far too fast to abort the attempt without a high speed exit off the end of the runway, it would appear that a minimum airspeed rotation might have occurred. Unfortunately, as most of us can recall, they call that part of the power curve the "coffin corner"... raise the nose and you'll stall, lower the nose to gain airspeed and you'll settle into the terrain.

This accident, IF in fact caused by attempted t/o on a 3500 general aviation runway, will raise the issues of pilot fatigue and CRM to the forefront.

John47

27th Aug 2006, 22:13

There is a map of the crash site at
http://www.kentucky.com/multimedia/kentucky/0828-Comair-crash.gif

Astra driver

27th Aug 2006, 22:16

emp18

27th Aug 2006, 22:33

No doubt we'll soon know the actual causes of this tragedy and, hopefully, the human factors which contributed to it. Then, as others have said, we can all learn from them.

In the meantime, I was astonished to read on another website that "this is the worst US airline accident for nearly five years." Given the high-pressure operating environment in the USA, with high-density traffic and countless external pressures, I am amazed that there are so few major accidents. So, after you professionals have finished thinking "there but for the Grace of God go I", you should all give yourselves a pat on the back for contributing this excellent record of air safety in recent years.

None of this is meant to encourage complacency, of course, as all transport professionals recognise that the next major incident may happen as soon as their next trip or duty.

Good luck!

RoyHudd

27th Aug 2006, 22:35

IF those crazy hours of rest (less than 4) are true, then one over-riding cause is staring everyone in the face.

No FTL's in the USA?

captjns

27th Aug 2006, 22:42

In this modern age of the glass cockpits, which this CRJ, I just have to ask how one could take off on the wrong runway if the extended center line is not even remotely close to the runway actually used, let alone the heading bug set to the the same runway, that is of course this were the case?

tiggerific_69

27th Aug 2006, 22:59

does anyone know if the crew operated any sectors before the inbound flight to Lexington and whether they were due to operate any after their departure from Lexington?Given their arrival time and departure time to/from Lexington and the amount of rest the crew had,id say it was probably a split duty they were operating and so it would have been legal?
my thoughts go to the families of those involved,and also to the man still in hospital.

Nov71

27th Aug 2006, 23:06

Local Kentucky TV reporting 2 bodies found outside a/c and Coroner states from position of some bodies some pax prob realised what was happening.
Crash site looks very compact
My pure speculation:
Wheels off (no tire tracks other than 150yds did someone say?)
Insuff speed
touchdown & roll into trees or clipped tree
pause
fire/explosion

Be interesting to see if any emergency exits had been opened from inside If yes & fire main CoD then possible factor - remember Manchester UK 1985?
Engine fire on runway during t/o, door facing fire opened, fire spread through cabin causing all fatalities. Bigger plane and many survived.

Right Way Up

27th Aug 2006, 23:09

If rwy 26 is "day/vmc only" as an earlier poster has indicated, I would hope that at night its edge lighting would be switched off so as not to confuse crews taxing out in darkness.
God rest their souls!

HowlingWind

27th Aug 2006, 23:10

Nov71, I believe the local coroner was quoted as saying that most of the deaths were "due to fire, and not smoke inhalation."

con-pilot

27th Aug 2006, 23:17

Am sure that the crew rest period will be examined very seriously and to great detail.

Sad really, very sad.

(By the way, I have a very good friend who is in ATC at Lexington, I learned from him 4 hours ago that the aircraft departed on 26. No, he was not the controller on duty, but one of his best friends was the one on duty. I refrained from making any comments on runway 26 until the NTSB confirmed that the aircraft did in fact takeoff, or rather attempted to take off, on runway 26. I will make no other comment about the controller except the fact he is taking this horrible accident very hard.)

God bless all involved and pray for the First Officer.

Lost in Saigon

27th Aug 2006, 23:23

Can you ask your friend if the tower is even open at 6am? Is it a 24hr tower?

barit1

27th Aug 2006, 23:27

Not the first time this has happened; very similar accident. (http://www.ntsb.gov/ntsb/brief.asp?ev_id=20001214X41329&key=1)

Two's in

27th Aug 2006, 23:33

Does either rwy have distance marker boards?

Nov71

27th Aug 2006, 23:33

Howling Wind
I suggest too early for autopsies, Coroners still recovering bodies 35 so far
If no smoke or heat damage to lungs/trachea shown at PM then all dead before fire ie on impact. Obvioulsy all bodies will be badly burned from the fire.
I take your point that lung damage does not indicate a door was opened deliberately or that the 2 bodies got out of their own free will.
I think Coroner said "...from the position of the bodies, some appear to have known what had happened (crash)" I assume this to mean not strapped in and trying to get out.
I apologise for speculating, but all this talk of fatique... The pilots seem to have done a pretty good job subsequently even if the t/o was on the wrong r/w. I shall wait for the FAA prelim

viking737

27th Aug 2006, 23:41

Nov 71 :I apologise for speculating, but all this talk of fatique... The pilots seem to have done a pretty good job subsequently even if the t/o was on the wrong r/w. I shall wait for the FAA prelim
What do you mean by pretty good job?

Alloy

27th Aug 2006, 23:44

Lost in Saigon, from what I remember years ago the tower was in operation 24Hrs a day and I would be suprised if it has changed.

con-pilot

27th Aug 2006, 23:45

Can you ask your friend if the tower is even open at 6am? Is it a 24hr tower?

It is a 24 hour manned control tower.

Does either rwy have distance marker boards?

As far as I know runway 26 does not, as I was mostly flying 727s into LEX I never used runway 26. I did taxi on it, but I don't remember any distance markers. As a general rule in the United States only runways that would have a lot of military operations have distance markers. I don't believe that there are any hard rules on distance markers. However, in this case I don't know if distance markers would have made any difference. All the other rules on being on the correct runway were ignored.

Why is what we need to find out.

Nov71

27th Aug 2006, 23:50

Until I read the similar incident link which was posted while I was typing I meant the a/c appears to have crash landed in line with the runway without veering off or dropping a wing so I assumed the pilots were doing their best, however futile.

HotDog

27th Aug 2006, 23:56

No FTL's in the USA?

Split duty? Used to hate them with a passion during my flying life. One definitely does not feel at all rested with a four hour nap but perfectly legal.

Melax

28th Aug 2006, 00:01

I think it's time for the FAA to comme up with some sort of Sign or panel color coded (easy to understand ) giving pilots a quick overview of the runway. i.e red-->c150 yellow -->Dash8 green -->B767 etc..
simple but could be effective.

Melax

28th Aug 2006, 00:21

1stflyin, you're right fatigue must be adressed I read somewhere that the crew got in after 12am to take-off again @ 6am !! , if true it is down right scary...
but back to the sign idea, it is just another reminder for the crew and I think can make a difference (if it works once, that makes it worthwhile imo).

brain fade

28th Aug 2006, 00:26

In the dark, all lit runways look similar. Especially from the low height of a CRJ cockpit. This was an easy mistake to make. Made even easier by the unfamiliar taxiiway changes in force at the time.

Personally, I always bug the expected drift hdg on the PFD during the turnaround checks.

Mind you, if i was as tired as these guys probably were............

Loose rivets

28th Aug 2006, 01:03

Apropos, my suggestion earlier, the tower would surely have given permission for the a/craft to take off from the intersection. So, this will be answered in good time.

I can't see from the aerial photo if this is really feasible, but it looks a reasonable taxi maneuver, and with recent WIP, there may have been other advantages...and indeed misleading signs.

Ignition Override

28th Aug 2006, 01:06

Captjns: I don't know about when other pilots double check their heading bugs, other than during a busy check of their HSI and VOT test etc, or whether this is clarified on a checklist, if at all. My company's checklists have never included questions or responses about heading bugs-they are assumed from the proper preflight or taxi checklist: "Instruments? [i.e.] 178*, Normal". This assumes that the correct VOR and outbound radial(s) are set, ADI looks good and gyros (HSI/RMI) match, no flags. In our old c0ckpits, I use the course knob to indicate the initial turn with the hdg bug to runway heading, in case of an engine failure etc. But at very special airports such as Wash. National etc you must quickly turn to 328* or whichever, even WITH an engine failure.

For the benefit of the laymen Ppruners who are not pilots, the First Officer is quite busy :\ (much more than the Captain) on the ground in a two-person c0ckpit, often more than in the air. And, as so often happens, a crew (going to a hub airport) begins to taxi and tower suddenly says "..eh.. FrozenDuck 292, can you make a wheels up time in five minutes"?. You are often already waiting for the ACARS screen to display your weight & balance data, which is required (unless transmitted via company radio for back-up) to begin your "Taxi", "All Engines" and "Before Takeoff" checklists, provided that there is not a problem with a passenger or objects in the cabin, or questions about the wind, visibility or braking action.

Extra abnormal procedures for deferred maint. items (MELs) are no help.This does not even begin to describe the cumulative effects of fatigue on a 4- or 5-day trip or an all-night (known as "illegal" or "stand up") duty period which sometimes allows you to have about 4 hours of sleep. The FO on an old, 2-pilot plane has the busiest job of all pilot jobs at the company, not just in a long duty period with 5-7 legs to fly and no time provided to eat. And this workload comparison includes the A-330 and 747.

The most serious danger to all of us on the ground, at many airports, is a mistaken 'runway incursion'/crossing. The accidental takeoff or landing on the wrong runway, which can easily look identical in the dark, especially if close to and parallel with the planned runway, now has the publics' attention (only for the duration of their 3-minute attention span :cool: ). Tower controllers often leave all runway and approach lights illuminated-even when your plane is the only aircraft with engines (and beacons) running within 20 miles :hmm: . They must be too busy with other things such as coordinating with Indy/Atl. Center etc.

Airbubba

28th Aug 2006, 01:12

Apropos, my suggestion earlier, the tower would surely have given permission for the a/craft to take off from the intersection.

Hmmm, you may be on to something. Intersection takeoffs have been badly botched in the past. Remember Dynasty at ANC "cleared for takeoff on Runway 32 at Kilo"? They took off on taxiway Kilo instead, left tire marks on the snowbank at the upwind end (but continued on to TPE). I also remember a Lear years ago, perhaps at CVG, that took the reciprocal heading in an intersection takeoff and took out some approach lights but got airborne.

It has been argued that 3500 feet (or 3400 feet according to some charts) on runway 26 would be enough to get a loaded RJ airborne as long as both engines were at takeoff thrust. The overhead shots from today show that both the entire long runway and part of the short runway have fresh blacktop applied. Is it possible the takeoff was inadvertently commenced from the intersection on the short runway? Both runways have the new surface near the intersection...

It is quite possible that the Comair flight was cleared for takeoff and assigned a departure heading before reaching the runway. In that case, a lot of us would set the heading bug to the intial vector. Of course the lubber line or whatever it's called on a Canadair would still give a clue if the alignment for takeoff wasn't right.

In a few hours I'll take the runway for an early liftoff. I'll ponder these discussions in the hope that it will help me avoid Sunday's tragic outcome.

Check 6

28th Aug 2006, 01:25

The crew landed at LEX Friday night, had Saturday off, and went back on duty Sunday morning.

Crew rest is not likely an issue.

con-pilot

28th Aug 2006, 01:52

The crew landed at LEX Friday night, had Saturday off, and went back on duty Sunday morning.
Crew rest is not likely an issue.

I had heard that as well, but did not know it was a fact.

PPRuNeUser0199

28th Aug 2006, 01:58

I was of the impression they were doing a stand up?

Check 6

28th Aug 2006, 02:00

I had heard that as well, but did not know it was a fact.

I learned this from a Comair pilot so it seems to be accurate.

ZAGORFLY

28th Aug 2006, 02:37

Yes, this tragic mistake could be as contributor factor the marking of runway 22 at LEX.

Go to Goggle earth and zoom into the airport: if you notice the 22 marks are way at the beginning of the runway. Yuo will read the marks at yr right end sight turning the A/C left into a 22 heading (which is 4 units short than 26) if you align yourself inseatd on the 26 you must cross the markings before taking off. This does not happen on the 22.
CRM tell us to be aware that often if you believe to be somewere your eyes will confirm to yr brain.

Very sorry indeed, As happen to the Singapore Airline disaster in Taipei. However if the crew would have inserted the localizer freq.and heading into the box the Flight Director would have set warnings (with its misalignment) into the pilots regarding the wrong way out.

Hope that Localizer alignment on T/O (standard on some other airlines) will be mandatory part of the before take off check list world wide.

My sympaty to the families including those not even mentioned by the perverted US media : the pilots ones.

con-pilot

28th Aug 2006, 02:54

There was no 'intersection takeoff' granted. I will tell you all that much.

Cross-eyed

28th Aug 2006, 03:06

Be aware that Google Earth's image does not show the recent (last week) resurfacing and remarking of rwy22. The new displacement of of rwy22 may have made it more confusing. There are some current photos on some of the news links that accurately show the new markings.

Also noted on the NTSB briefing, the perimeter fence was compromised by the aircraft. The first impact above ground was a tree beyond the fence at about a height of 25ft. which would indicate the aircraft left the ground after exiting the end of the runway. EDIT - I looked at the photo again and realized it's possible that the first on scene airport fire department could have barrelled through the fence to access the crash or they may have passed through one created by the aircraft.

GreatCircle

28th Aug 2006, 03:08

411A

28th Aug 2006, 03:09

A very long time ago, when I was doing the initial B707 training at PanAmerican, they had just changed the 'before takeoff' checklist, to add the following at the end, IE, the last item, which MUST be done on the runway, prior to brakes release or, in the case of rolling takeoffs, before the throttles were advanced....

Configuration Check.

1. Flaps...set to the desired setting
2. Speed Brake...forward
3. Stab trim...set in the takeoff range
4. Compass headings...compared, and bugs set to the DESIRED RNY HEADING

Good idea then...good idea now.

Xeque

28th Aug 2006, 04:10

411 just mentioned this and I was wondering...

Is the DI in an EFIS generated by a gyro (like a regular DI)? I ask because, when I fly, one of the last items on my pre-takeoff checklist is to set the DI against the Magnetic Compass. Do you still do that with a 'glass cockpit'? A side issue of doing this, since you are lined up on the centreline, is to mentally confirm that you are on the right runway.

In the lunchtime (local) press conference the Airport Director would not comment on which runway had been used but he did say that 08/26 was 'a GA runway for daylight use only'. Are there any lights at all on that runway?

A final thought. If (as has been suggested but not confirmed) they were cleared to depart from the intersection then wouldn't a fully lit runway 22 have been visible to both pilots at their 10 o'clock?

Departure from the intersection on 22 would have given them the required 5,000 feet but less than 2,000 on 26

misd-agin

28th Aug 2006, 04:26

As jondc9 says - this is an accident no-one wanted, but one in the US regionals, sadly, that was just waiting to happen due to systemic failures all the way along the line - with crew fatigue at the top of the list....

Previous poster said they arrived Friday night and left Sunday morning. Fatigue from the schedule doesn't appear, at first glance, to be an issue.

Shore Guy

28th Aug 2006, 04:34

Dream Land

28th Aug 2006, 05:21

Clearly has the appearance of an accident that involves many human factors, airport layout and taxiway closures / changes playing a big factor, KUDO's to the law enforcement officers that risked serious injury to pull out the First Officer. Condolences to all families and friends.

mingalababya

28th Aug 2006, 05:41

Surface maps are slowly making their way into cockpits via design (A-380, B 787) or as afterthoughts (EFB’s). They are long overdue.

Totally agree with you. One would have thought that this would be standard now after SQ6. :rolleyes:

N380UA

28th Aug 2006, 06:11

Loose
looking on the chart an INT T/O seems to be feasible, may however resulted in some misunderstanding in regard to TWY changes.
http://66.226.83.248/aptdiag/w240/03974.gif

captjns

28th Aug 2006, 06:21

Configuration Check.

4. Compass headings...compared, and bugs set to the DESIRED RNY HEADING

Good idea then...good idea now.

Still is... basic check trained when working on the instrument rating. Also, if the extended runway centerline is not straight up we stop and talk about it. It could be do to one of may failures associated with the complexities of the modern jet, or just lined up on the wrong runway. This can happen at airports with intersecting runways at the end with minor heading differences.

If the tower was manned, and I beleive it were... what were they during this time????

Long and the short, very sad. Hopefully some good will come from this accident.

Bigmouth

28th Aug 2006, 07:16

Yes, they should have done this and that and the other thing. And I used to do all those things everytime. But I've noticed that I don't anymore. Because I fly the same equipment on the same routes with the same people day after day after day. And everything is automated so when I miss something minor nobody notices because old George and all his wizz bang gadgets cover for me. So many times I don't even notice that I missed something. "Oops, I forgot to…. Oh well". Besides, I'm busy with the important stuff. Like bitching about my schedule, my pay, my working conditions, my boss, my wife. Yes, I've just been off for 4 days. I may even recently have had my two weeks leave on a beach or in the mountains. I'm not sick. I'm not tired. But I am sick and tired. The job is turning into a daily grind. Even though I love flying. I even think about flying when I'm working. I think about retirement and how I'll buy a sea plane and fly around the Carribean. So while thinking all this, my muscle memory has flipped all the required switches and punched all the necessary buttons and spoken all the right things into the mike and off we go for the umpteenth time.
Except that this time we lined up on the wrong @#$% runway.

hetfield

28th Aug 2006, 08:13

I don't know about conversation in that particular accident, but would correct RT procedures have prevented that accident?

What I mean is the very common read back of our US collegues like

TWR: XYZ 123 cleared for take off runway 25R
XYZ 123: Roger cleared for take off

F4F

28th Aug 2006, 08:15

That's a good one Bigmouth, thanks :D
Complacency is THE danger to avoid. Lost the sense of awareness and responsability, my thoughts shifted to roster, pay and pension, how sad!

R.I.P. all

F4F :(

Panama Jack

28th Aug 2006, 09:59

Early days for sure but one possible area for examination and possible review of SOPS - IF indeed they took the first runway they came to is this - the FAA for an outbound taxy clearance do not issue hold short instructions of any intermediate - i.e. if they were cleared to taxy to RW 22 via "Alpha" they would not be told to hold short of 26, or cleared to cross runway 26 etc, which could serve as a very appropriate reminder that there is more than one runway out there. This seems to be exclusive to the USA/FAA - I loathe it because I am wanting to specifically hear that I am cleared to cross runway "XX" etc. and they get a bit arsy if I ask for specific crossing authorisation.
Awfully sad day.
OH

Interesting point raised. I feel this is a case of US controllers knowing the rules well and sticking to their hidden meanings and signifigances.

At our airline, far far away from the USA, it is SOP that all taxi clearances should specifically include crossing instructions of other runways. If they are not included, then we are to ask for them. Coming to this airline I thought it odd, but started to see the value of it.

On a recent flight departing a major Indian airport we were cleared to taxi to the departure runway, without mention of being cleared to cross the parallel runway that lay before the takeoff runway. When I asked to confirm that we are also cleared the cross that parallel runway (as per our SOP) the prompt response was "negative, hold short" of that one too.

cool blue

28th Aug 2006, 10:07

Bigmouth
Your complacency, whilst understandable, is potentially lethal. That's why the sterile cockpit concept was introduced!
CB.

N380UA

28th Aug 2006, 10:15

Bigmouth
Your complacency, whilst understandable, is potentially lethal. That's why the sterile cockpit concept was introduced!
CB.

In addition to sterile cockpit, a sterile mind would then be equally important which brings us back to complacency in the first place.

Doors to Automatic

28th Aug 2006, 10:17

A number of people have wondered how it was possible to line up on the wrong runway.

I read on another forum that runway 22 dips towards the SW; so when lining up it looks shorter than it is because half of it is hidden from view.

Similarly 26 has a shoulder so doesn't look any narrower. In the semi-light of the morning there would therefore be few visual clues that a mistake had been made. The only clue would have been the heading indicator.

I am surprised ATC didn't notice though.

planeenglish

28th Aug 2006, 10:24

I am surprised ATC didn't notice though.
There was a report on Fox News last night regarding possible understaffing in the tower. They spoke to the Governor of Kentucky (why they asked him this question, I don't know) and he said it would be investigated.

Perhaps it was just journo mumbo crap trying to fill time and raise our perceptions of their incompetence. :rolleyes:

Best to all,
PE

Doors to Automatic

28th Aug 2006, 10:27

There was a report on Fox News last night regarding possible understaffing in the tower.

There would surely only be one controller looking after departures at an airport of that size so understaffing would be impossible :confused:

visibility3miles

28th Aug 2006, 10:37

Crash a Blow for Struggling Comair
Monday August 28, 1:01 am ET
By Dan Sewell, AP Business Writer
Fatal Crash of Jet in Kentucky Is Emotional Blow for Comair, Trying to Emerge From Bankruptcy

ERLANGER, Ky. (AP) -- The fatal crash of a Comair regional jet Sunday morning dealt an emotional blow to a commuter airline trying to emerge from bankruptcy.

"These are tough things and it's very difficult," Comair president Don Bornhorst said at a briefing in a hotel near Comair headquarters in northern Kentucky. Choking up at times, Bornhorst said he was "emotionally devastated" and said he's certain all of Comair's 6,400 employees share those feelings.

Bornhorst, a 15-year aviation industry veteran, pledged that the carrier would do all it could to help with the investigation of the crash while also keeping up normal operations.

"We all recognize that we're professionals in an industry that has these risks, and you hope and pray that these things do not happen, but when they do, the team we have at Comair is one that will work through this," said Bornhorst, who was promoted from chief financial officer to president three months ago. "We will continue to offer service to our passengers, we will do it in a certainly safe manner and with the customer service emphasis that we have always had with our flights."

Comair, a Delta Air Lines Inc. subsidiary that offers 850 flights daily to 110 cities, last suffered a crash Jan. 9, 1997, when an Embrarer 120 flying from Cincinnati to Detroit crashed in icy conditions near Monroe, Mich., killing all 29 people on board.

The carrier now flies all Bombardier CRJ's, most of them 50-passenger planes. Its 168-plane fleet also includes some 40-seaters and 70-seaters. The plane that crashed Sunday was a 50-passenger plane Comair said it bought new from Bombardier, a Montreal-based company, in January 2001. Bornhorst said the plane had "a clean maintenance record."

Bombardier has about 1,300 of the regional jets flying for a variety of carriers worldwide.

Like its parent, Atlanta-based Delta, Comair filed for Chapter 11 bankruptcy in September 2005 and has been restructuring. Both hope to emerge from bankruptcy by next summer.

Comair has been seeking concessions from its unions, and last week reported some progress after two days of negotiations with its flight attendants.

The carrier wants $7.9 million in pay and benefit cuts and work rule changes from its 970 flight attendants. A federal bankruptcy judge in July ruled that the company could void its contract, but Comair has been trying to work out an agreement. Flight attendants had said they would consider job actions if negotiations failed.

Comair earlier reached agreements with its pilots for $17.3 million in cuts and for $1 million from its mechanics, but those deals were contingent on Comair getting $8.9 million in givebacks from flight attendants. Comair met with both of those unions in early August after reducing the amount needed from the flight attendants, but neither Comair nor the unions would discuss their talks.

Comair also had to rebound from a Christmas 2004 holiday weekend debacle, in which a computer system failure forced cancellation of more than 1,000 flights.

Comair was founded in 1977 as a three-plane commuter airline and became a Delta partner in 1984 and a wholly owned subsidiary in 2000.

Delta CEO Gerald Grinstein said Sunday his company was offering Comair any help it needs in the crash aftermath.

ATC Watcher

28th Aug 2006, 11:05

Maybe (s)he was in the bathroom. :rolleyes: They said it on the news, it must be true, right?:suspect: :ouch:
PE

Let's stop this nonsense and wait to see the R/T transcripts before condeming people in advance. As far as I know it is not the duty of a TWR controller to monitor and check which runway aircraft are lined up to. If they spot a discrepancy they will of course intervene , but if they don't , you cannot start blaming individuals for this .
Have you seen the RWY threshold views from a TWR window at night ? How far some are ? how a rotating beacon can be mixed with other lights ? no to mention perspective view and flat distances at night.

It was said earlier here that the controller on duty is taking this very badly , that I can beleive and understand, and I hope he does not read this.

RobertS975

28th Aug 2006, 11:27

There generally would be only one individual working in a control tower of that size at that time of day. It is not the job of the controller to make sure that the pilots line up on the correct runway. As soon as the t/o clearance was given, the controller no doubt had other chores, such as getting a clearance for the next IFR departure etc.

In the US, a taxi clearance to the active runway is permisssion to cross any and all runways along the taxi route.

Perhaps distance/length signage will be added to the bottom of the runway number signage. But as horrible as this accident was, there have been millions of US air carrier operations since the last significant accident, back in November 2001. That is amazing!

jondc9

28th Aug 2006, 11:32

jetjackel

28th Aug 2006, 11:33

I think, that it doesn't matter what I think, but what I see is a bunch of armchair pilots babbling about an accident that has so many variables and numerous factors that its idiotic to be even speculating at this point.

How about condolences and leave it at that and let the professionals investigate. At least give the investagators a couple of days to come up with some basic facts.

The main factor in any accident or incident, is that the flight crew did what they did, and accidents are accidents.

Normally accidents are "mistakes" that have or had circumstances resulting in tragic endings, whether is design related, pilot error, etc.

FlyingConsultant

28th Aug 2006, 11:46

In the US, a taxi clearance to the active runway is permisssion to cross any and all runways along the taxi route.

I am but a frequent SLF, but this sounds very scary. Can you clarify whether this includes crossing runways that are active if there are several active runways?

thanks

CargoOne

28th Aug 2006, 11:46

Just picked up an old Jepp (mid-2000) and RWY 08-26 is shown there as 150 feet wide, so physically both runways are same width. It is just markings applied at some stage made it more narrow. So it could be one of the factors lead to mistake...

dartagnan

28th Aug 2006, 12:05

mmh, DFW authorized a MD80 for take off when I was at the intersection.
the pilot said:"and what about the plane in the middle of the runway??"...

I am very surprised that 2 pilots did such mistakes...

ATC Watcher

28th Aug 2006, 12:56

for ATC to not visually scan the runway as the plane was cleared for takeoff would be a mistake.
..............
ATC is responsible for seperating all IFR aircraft, and not to scan the runway ( and see, by extension correct runway/aircraft configuration) would be WRONG>

TWR controllers are no supermen. They have no helicopter flying above the runways to see what is going on below . Those RWYs are located sometimes miles away from their control TWRs , and they do not have infra red vison to see at night or though fog.

Again, if you have the time, if it is CAVOK, if you can see the runway from where you are, or if you have a Surface Ground Movement radar , if it works, then yes, otherwise not feasable, period. Wrong, perhaps but a fact.
At least in Europe it works like this.

----------------------------------------------
Planeenglish : sorry, read too fast, did not see the humor. I owe you one ! But I do hope the guys in LEX have access to the CISM program .

Dream Land

28th Aug 2006, 12:57

Just to clarify:In the US, a taxi clearance to the active runway is permisssion to cross any and all runways along the taxi route

PENKO

28th Aug 2006, 13:11

The controller could have done his job properly and cleared the aircraft for takeoff long before it reached either runway. In this scenario it would be very hard to blame the controller for missing the fact that the aircraft 'took the wrong turn'.

We do not know the details so the least we can do is to keep an open mind.

FIRESYSOK

28th Aug 2006, 13:12

Just to clarify: In the US, a taxi clearance to the active runway is permisssion to cross any and all runways along the taxi route

1. A pilot is cleared to cross all runways EXCEPT the assigned runway which is stated in the clearance.

2. It is the responsibility of the crew to understand this procedure and have thoroughly briefed and executed the taxi.

3. If a takeoff clearance has been issued prior to the aircraft reaching the approach end, it is understandable that a controller may not notice the incorrect line-up, especially with the runway ends being as close as they were.

4. In the CRJ aircraft, the FMS CDI does not necessarily align with the runway HDG or track when
in position for takeoff. It merely points to the next fix, which usually is in a direction away from the runway threshold. The FMS runway selection merely facilitates a "runway update" for position updating. UNLESS an "off the runway" SID has been programmed, in which case the alignment is to the runway heading. KLEX does not use this type of procedure.

5. A tragic series of mistakes, RIP and may God bless.

ATPMBA

28th Aug 2006, 13:23

B-737 was cleared for TO on RW 33, they went off on RW 1. It was at night, both RWs come together at that point. They got off OK and then noticed the FMS making a hard turn.
It could have been a disaster as they sometimes they park planes on RW 1.
Whaterever happended to cross referencing your DG to the RW heading as you line up?

Xeque

28th Aug 2006, 13:31

Whaterever happended to cross referencing your DG to the RW heading as you line up?

Thanks ATPMBA.

I asked this question earlier but no-one answered me.

ATPMBA

28th Aug 2006, 13:36

An old FAA Safety inspector who ran monthly safety meetings would always say, "you are your brothers keeper"

FIRESYSOK

28th Aug 2006, 13:49

Thanks ATPMBA.
I asked this question earlier but no-one answered me.

[retracted]

Human factors study clearly indicates that the mind can be fooled into thinking it's somewhere it is not. Also check the BMI accident at Kegworth. They clearly thought the problem was with one engine after retarding the throttle cleared the vibration.

noullet

28th Aug 2006, 14:20

Just a technique that I have used for years;
When taxiing out to the assigned runway I always put my heading bug on the assigned rwy heading. Furthermore, if I have no immediate use for the CDI I also align it with runway heading, I also find this technique usefull for aligning with the correct runway on circling approaches. Not saying that I couldn't line up on the wrong runway, but that's all the more reason to use every resource available.

Good technique. Also, if an FMC was aboard, & I don't know if the CRJ-200 ER has one or not, KLEX would have been entered with rwy 22, the A/C triangle would have been centered on rwy22 (between the (II) on the ND, assuming it had an ND. Most takeoffs fly rwy heading until etc. etc. and your point is well taken above.

God bless them all.

jack

Huck

28th Aug 2006, 14:23

MSNBC is reporting that the short runway was lit by runway edge lights, though it usually was not (new installation?).

No excuse, but might explain why a hurrying crew in the dark and rain might have just turned left onto the first lit runway they saw....

I used to fly RJ's into KLEX for ASA, and I know many Comair pilots. Trust me, this is no slip-shod operation. If it can happen at Comair, it can happen anywhere.

Snakum

28th Aug 2006, 15:00

How about condolences and leave it at that and let the professionals investigate.

How about not. :ugh:

Every single time an accident happens there's always some 'kin idgit screaming "Leave it to the NTSB/FAA/The Beaver!" knowing full well there will be a hundred pages of discussion and even speculation, because THAT'S WHAT PILOTS DO! Along with just about every other profession that has it's dangerous moments. Ship's crews do the same thing when there is a mishap. That's how we learn. In fact, this recent accident has driven home something I have been trained to do before any departure or arrival, and that is set the HSI to the landing/departing runway and the heading bug to the assigned/initial vector, even in severe clear daylight flying.

I used to question why ... now I know why. We discuss ... we learn. If you don't want to hear speculation after a crash you need to stay off the internet, chief. :=

FIRESYSOK

28th Aug 2006, 15:02

Good technique. Also, if an FMC was aboard, & I don't know if the CRJ-200 ER has one or not, KLEX would have been entered with rwy 22, the A/C triangle would have been centered on rwy22 (between the (II) on the ND, assuming it had an ND.

Yes it has an FMS and ND, however once in takeoff position, activation of the TOGA bars will "runway update" the FMS and is the equivalent of telling the FMS that you are on the preprogammed runway and you wish to update FMS position to that point. The addition of a GPS sensor will mitigate an incorrect update, but it will be several seconds before the GPS can correct the real aircraft position.

Translation- if you tell the FMS you're on the correct runway, and really you're not, it could be 5-10 seconds before the GPS can correct it.

The FMS in the CRJ is not a good situational awareness tool when on the airport.

Scurvy.D.Dog

28th Aug 2006, 16:27

Xeque
A final thought. If (as has been suggested but not confirmed) they were cleared to depart from the intersection then wouldn't a fully lit runway 22 have been visible to both pilots at their 10 o'clock? …. I’m on the other side of the Pacific …. Never been to Kentucky …. But I have spent some years in regional towers ….. another coupla’ questions for those with familiarity …. Is 22 lit with ‘directional’ runway edge lighting?? …. The ones we have are not ‘clearly’ visible if viewing from a side angle (light beam obviously concentrated in the approach direction)! …. another question ….. someone early on mentioned taxiway works and resurfacing …. were the taxiways between the 26 threshold and the 22 threshold re-marked and/or closed?? ….. Huck
MSNBC is reporting that the short runway was lit by runway edge lights, though it usually was not (new installation?). ….was this why the crossing 26 was lit (for taxiing purposes) ….had 26 been lit for another aircraft movement ……. would the edge lighting of 26 been the most visually prominent to the CRJ crew? ….. could they have seen the side glow from directional’s on 22(if that’s what they are) in early morning conditions …..
.
captjns
If the tower was manned, and I beleive it were... what were they during this time???? …. could be any number of things ….. based on the information provided on this thread (so it might be completely wrong) ..
.
…. the picture I have …. the jet taxiing as expected … turns left onto 26 (might have already been cleared for take-off 22) ….. how long (from a glance at an aircraft at taxiing speed) …. would you have to look away for (co-ord or any number of other tasks) to not readily see the subsequent and unexpected continued acceleration during a Take-off attempt???? …. I have no idea how the tower is physically situated and what the tower controller might see ??? …… these are just questions in my mind … few if any of these musing might be reasonable or relevant!!!
.
…. Holes in the ‘swiss cheese’ either way I guess …… :( … a terrible tragedy
.
… my thoughts are with the ATC/S, the FO …. and those left behind … :sad:

Dream Land

28th Aug 2006, 17:14

I can definitely can see that with the taxiway changes (see PDF @ post #6 compared with picture @ post #27) there might be a bit of confusion, especially if both runways were illuminated, taxiing at night with a short taxi, copying clearances and finishing checklists etc., easy mistake at that time of day.

D.L.

Two's in

28th Aug 2006, 17:26

Very seldom, if ever, are aircraft accidents caused by a single, isolated event. They are invariably the result of a chain of events that conspire to eventually cause the accident. Flight Safety initiatives and Airline Operations are intended to leverage the intellectual capital and experience acquired through others misfortunes over the years, by identifying the events or sequences that ultimately lead to accidents. SOP's, Checklists, Airfield Markings, Currency, Rest Periods, Maintenance are some of the weapons we have in our armory to prevent accidents, but being human allows us to circumvent those preventative measures. Sadly, this accident will prove to be no different to many others in that the "chain" could have been broken at a number of points, but it wasn't, and the accident occurred.

Understanding “how” the accident occurred now seems to have been largely answered, and this is crucial in ensuring that flight crews are made aware of the circumstances pertinent to this event in the shortest possible time, to avoid any repetition of those circumstances. Although it is clearly distressing, as some on this board have indicated, it is an essential part of the initial investigation to establish how the accident occurred in the shortest possible time. Grieving and condolences do not prevent further accidents, knowledge and awareness do.

Having determined the “how”, it now falls to the authorities to fully determine the "why". This is where every aspect and failure that led to the causal chain will be identified and not surprisingly, this takes a great deal of time and effort. It will be some time before the exact sequence of events is known, and some may never come to light. The point of all this is to reiterate that attempting to take off on Runway 26 was just the final act, in an as yet unknown sequence of events.

This is where the great media circus stumbles. In this age of instant gratification and instant answers, they simply do not have the mental capacity to understand a formal process that might take a year or two to complete. That is why they speculate and create their own facts around these cases. Long drawn out inquiries do not sell papers or generate viewing figures, but thankfully the media tire easily and will soon be distracted by something else, leaving the rest of us to get on without them.

The passengers and crew of Flight 5191 deserve our thoughts and prayers, but future passengers and crew equally deserve a full understanding of what went wrong and how to avoid similar events in future.

Frank Brewer

28th Aug 2006, 17:29

<< The passengers and crew of Flight 5191 deserve our thoughts and prayers, >>

Amen

Airbubba

28th Aug 2006, 17:43

August 28, 2006

Airport's Taxi Route Change Before Crash

By THE ASSOCIATED PRESS
Filed at 1:16 p.m. ET

LEXINGTON, Ky. (AP) -- The taxi route for commercial jets using Blue Grass Airport's main runway was altered a week before Comair Flight 5191 took the wrong runway and crashed, killing all but one of the 50 people aboard, the airport's director said Monday.

Both the old and new taxiways cross over the shorter general aviation runway where the commuter jet tried to take off early Sunday, Blue Grass Airport Executive Director Michael Gobb told The Associated Press.

The runway repaving was completed late on the previous Sunday, Gobb said. It wasn't clear if the Comair pilots aboard Flight 5191 had been there since the change. Comair operates that regular 6 a.m. weekend flight to Atlanta from Lexington, but another commuter airline takes over that commute during the week.

''It's slightly different than it used to be,'' said Charlie Monette, president of Aero-Tech flight school based at the airport. ''Could there have been some confusion associated with that? That's certainly a possibility.''...

http://www.nytimes.com/aponline/us/AP-Kentucky-Crash.html

BTSM

28th Aug 2006, 18:01

PaperTiger

28th Aug 2006, 18:10

Maybe the appalling RT discipline used by many American pilots is to blame.
It is a case of who can "out cool" eachother with the trendiest replies.
If the take off clearance (with runway) had been read back as opposed to just " Roger", or "Rolling", or "cleared to go" then maybe this would not have happened.Cr@p. If you THINK you're on 22 when you aren't, no amount of "proper" readbacks would have made the slightest difference.

Nobody in their right mind is suggesting they deliberately decided to use 26, surely.

Scurvy.D.Dog

28th Aug 2006, 18:47

..... do we know 22 was not readback?
.
.... even if it was ....... IMHO it would not have made much difference (assuming the crew 'thought' they were rolling 22) ..

rhovsquared

28th Aug 2006, 18:49

I'm just wondering, because someone mention the HSI/FMS setup, How come there were no checks to assure that the RWY is Correct/departure correct?. IMHO sounds like fatigue.

what a terrible accident, gives me pause, no one is above error; experienced flight crew ligned up on wrong RWY:( .

My heart goes out to the victims, May the FO be Well:),
rhov:)

HowlingWind

28th Aug 2006, 18:55

It probably provides more questions than answers, but a NY Times report now quotes the NTSB as saying that 26 was equipped with lights, but that they were inop at the time.

Early CVR transcripts show an apparently normal preflight, "but then discrepancies over planning and the eventual course of action emerged."

NTSB states there was one person on duty in the tower at the time, normal ops for KLEX.

Link to NY Times Story (http://www.nytimes.com/2006/08/28/us/28cnd-crash.html?hp&ex=1156824000&en=2ff7050aef583021&ei=5094&partner=homepage)

Scurvy.D.Dog

28th Aug 2006, 19:10

... hazy conditions? ... what was the Vis/RVR? .... early morning light?!?!
.
.... suppose it must have been light enough for the crew to 'think' it was useable?!?!

Airbubba

28th Aug 2006, 20:52

Does anyone know if these pilots were graduates of the COMAIR academy?

The captain was a graduate of the Comair Academy, now the Delta Connection Academy, according to this article:

http://www.ajc.com/news/content/news/stories/0828pilot.html

He was also a Rutgers graduate with a degree in economics.

There was an AirTran pilot onboard, not sure if he was in the cockpit at the time of the crash.

Audio of today's noon NTSB press conference is posted here:

http://multimedia.realcities.com/ramgen/kentucky/ComairCrashAudio/20060828_NTSBMorningPressConferenceEdit.mp3

daz211

28th Aug 2006, 21:24

_Capt. Jeffrey Adam Clay of Burlington, Ky., hired by Comair in 1999.

_Kelly J. Heyer, 27, of Cincinnati, flight attendant hired by Comair in 2004.

_Jon Hooker, 27, of London, Ky., a newlywed leaving on his honeymoon, according to his former baseball coach at the University of Kentucky, Keith Madison.

_Scarlett Parsley, 23, of London, Ky., who had married Hooker in a fairy tale ceremony Saturday, according to Madison and other friends.

_Mike Finley, 52, of Corbin, Ky., owner of Finley Fun Center, according to his son, David Taylor.

_Charles Lykins of Naples, Fla., according to friend Paul Richardson of Winchester, Ky.

_Les Morris of Lexington, Ky., according to son-in-law Rick Queen.

_Larry Turner of Lexington, Ky., associate Dean for University of Kentucky Extension and Director of Cooperative Extension Service, according to the university.

_Pat Smith, 58, a member of Habitat for Humanity International's board of directors, according to Habitat for Humanity.

_George Brunacini, of Albuquerque, N.M., owner of Bona Terra Farms in Georgetown, Ky., according to a family member who didn't want to be identified.

_Jeff Williams, 49, a horse trainer working at Thoroughbred Training Center in Lexington, Ky., according to his brother Kim.

_Dan Mallory, 55, of Bourbon County, Ky., who ran Meadow Haven Farm, according to his wife.

_Judy Ann Rains, of Richmond, Ky., according to an unidentified family member.

_Paige Winters, 16, of Leawood, Kan., according to her mother, Joan Winters.

_Thomas Fahey, 26, of Leawood, Kan., according to his father, Kevin Fahey.

_Carole Bizzack, 64, of Lexington, Ky., wife of an Eastern Kentucky University Regent, according to university spokesman Marc Whitt.

_Marcie Thomason, 25, of Washington, D.C., daughter of Bill Thomason, administrative manager of Mill Ridge Farm in Lexington, Ky., according to Chuck Wolfe, spokesman for the state Environmental and Public Protection Cabinet.

_Homer Combs Sr. of Lexington, Ky., vice president of Systems Design Group, according to the company.

_Diane Combs of Lexington, Ky., wife of Homer Combs and an employee of Systems Design Group, according to the company.

_C.W. Fortney II, an Air Tran pilot from Stanton, Ky., according to Air Tran.

SpringbokCapt

28th Aug 2006, 22:01

I have got to tell you guys that as a capt for Comair, this is a very uneasy time for us and reading through some of the speculations here is very diffucult to take it all in. Comair training is exceptionally meticulous and highly detailed. I find it hard to believe that this was any kind of training or procedure error. I believe that there are a lot of factors here to the eventual accident and i am sure that it will all be brought to light very soon. I hope that all of you out there can support us. I pray for all those souls on board.

Sobelena

28th Aug 2006, 22:35

Whilst not detracting from the sentiments you express SpringbokCaptain, for those not in the know, I would venture to suppose that you work for Comair, South Africa, an entirely different airline to the U.S. Comair.

Astra driver

28th Aug 2006, 23:07

One of the many ironies of operating a “sophisticated” transport aircraft is that your rental car will probably be better equipped for surface guidance (GPS driven map) than the aircraft you are in.
A piece of paper (10-9) and a wet compass for guidance…..that is (along with signage) the normal way to find your way around some of the busiest and most complex airports in the world.
Surface maps are slowly making their way into cockpits via design (A-380, B 787) or as afterthoughts (EFB’s). They are long overdue.
Honeywell has a system that may have saved the day:
http://www.honeywell.com/sites/aero/Egpws-Home3_CCF7A28FC-6C26-D079-2790-034BE25C93E7_HC67C985B-0401-E441-1C50-134E407D99FE.htm
And others are working on similar systems.

I have the pleasure of occasionally flying a GIIB that is equiped with this honeywell system, and I can attest that it is a great aid to have in the cockpit, while there is no guarantee that it could have prevented this accident, it would have provided 4 additional cues that would have told them which runway they were on;

1.) A complete Jeppesen airport diagram presented with real time aircraft location presented in moving map format.

2.) An aural warning when approaching rwy;
"Approaching runway 26"

3.) An aural anouncement when on rwy;
"On runway 26"

4.) A runway distance remaining anouncement;
"three thousand five hundred feet remaining"

An excelent and easy system to use. One wonders, given that the FAA is putting priority on reducing runway incursions, that this accident may become the impetus to require all air carriers to install such a system.

gwillie

29th Aug 2006, 00:04

http://www.kentucky.com/mld/kentucky/15382605.htm

DanAir1-11

29th Aug 2006, 00:13

for ATC to not visually scan the runway as the plane was cleared for takeoff would be a mistake.

Fine, except that in the half light of morning, or earlier, the controller could well have done (and probably did) a visual, and would have seen a set of strobes and lights at the intersection, as he/she would have fully expected ('if' this was an intersection t/o, which has still not been established) What he/she would not have been able to establish, would have been orientation whilst the a/c was at the intersect. There can only be approx 40 degrees difference in heading orientation of the a/c at the intersect between the two rws. Once rolling, it would take a few seconds for the controller to register that the a/c was on the wrong rwy. Again, the light and brg difference early in the roll would make this difficult to detect until sadly it would have been too late. So let us not be too hasty in speculating the twr has erred here.

Regards
DA1-11

jondc9

29th Aug 2006, 00:17

DA1-11 and ATC watcher.

I've spent time in towers around the country...they are quite tall with huge windows as you know.

If parts of the airport are not visible to the tower, a note is made on the charts to let pilots know.

If there was ONE controller at KLEX and he was being forced to do too many things to NOT LOOK OUT THE HUGE WINDOW, then the system needs fixing.

AND one plane with all landing lights on should have been quite distinct especially if taking off on a runway WITH NO LIGHTS.

j

david foster

29th Aug 2006, 00:25

GA pilot here. How standard are moving-map GPSes in airline cockpits? Is it safe to assume that this plane probably had one, or not?

Do these GPSes have a zoom capability that would show the airport layout, or would a separate device, like the Honeywell system mentioned above, be required for that?

DanAir1-11

29th Aug 2006, 00:54

FYI Chaps

Runway 8/26
Dimensions: 3500 x 75 ft. / 1067 x 23 m
Surface: asphalt/concrete, in poor condition
CONC IS SEVERELY CRACKED.
Weight bearing capacity: Single wheel: 12500 lbs

Runway edge lights: medium intensity
MIRL RY 08/26 OTS INDEFLY.
RUNWAY 8 RUNWAY 26
Latitude: 38-02.339143N 38-02.433593N
Longitude: 084-36.574985W 084-35.855642W
Elevation: 969.5 ft. 972.6 ft.
Gradient: 0.3 0.3
Traffic pattern: left left
Runway heading: 085 magnetic, 081 true 265 magnetic, 261 true
Markings: basic, in fair condition basic, in fair condition
Runway end identifier lights: yes
REIL OTS INDEFLY.
Touchdown point: yes, no lights yes, no lights
Obstructions: 25 ft. tree, 400 ft. from runway, 150 ft. right of centerline, 8:1 slope to clear 17 ft. pole, 552 ft. from runway, 39 ft. left of centerline, 20:1 slope to clear

source - http://www.airnav.com/airport/KLEX

Regards

DA1-11

Airbubba

29th Aug 2006, 02:28

Some information from the 10 pm NTSB briefing in LEX:

Aircraft takeoff weight was 49,087 lbs. according to the load manifest.

The manufacturer calculates that 3539 feet are required to rotate at this weight.

Runway 26 lights have been inop for years and cannot be turned on by the tower.

Runway 22 centerline lights were OTS, the other lights on Runway 22 were reported on by a witness.

The FO was flying pilot.

Takeoff roll was 29 seconds.

A comment was made during the takeoff that the runway lights were out.

137 knots was the max airspeed attained.

The captain called '100 knots', 'rotate'.

No calls from ATC during the takeoff roll.

A team is out tonight taxiing a Comair RJ to see what the perpective was for the crew in the darkness. People are also in the tower to check visibilty of the taxiing plane.

Engines were turning, spoilers and T/R's were stowed, no evidence of braking.

The aircraft rolled off runway 26, left a trail of all three landing gear on the grass, went through the boundary fence, went up a berm and became airborne, cleared a barbed wire fence and hit a tree line. The wreckage was about 900 feet past the tree line.

The FO is still in critical condition and has not been interviewed.

The FDR had 51 hours of data, 33 flights.

Many of the investigators are going to CVG on Tuesday to interview management and pilots at Comair and to retrieve training and personnel records.

Cross-eyed

29th Aug 2006, 03:12

http://i110.photobucket.com/albums/n107/pauwilso/Airportdiag.gif
http://i110.photobucket.com/albums/n107/pauwilso/ComairDiag.gif
http://i110.photobucket.com/albums/n107/pauwilso/Comairphoto.jpg
Photos and diagram from kentucky.com Lexington Herald-Leader

Also from the Herald-Leader:

[Meanwhile, a former Delta Airline pilot said yesterday that flying out of Blue Grass Airport can be confusing and that straying onto the wrong runway would have been “an easier mistake than people generally would think.”

“It looks like a no brainer ... but it is possible to be kind of confused,” Russ Whitney said.

Among other things, Whitney said, the main Runway 22 has a crown or hump, so that pilots taking off cannot initially see the southern two-thirds of the runway. As a result, Whitney said, Runway 22 and the shorter Runway 26 can look as though they are the same length.

“I’ve taxied out there and gotten kind of confused, and had to make absolutely sure that I was on the right runway,” he said. “I have taxied out ... and said to the co-pilot, ‘Is this the right one?’”]

DesiPilot

29th Aug 2006, 04:33

I worked as an FO over a year flying CRJ's. I can tell you from my personal experience that an FO is really really busy while taxiing out. Not only we have to run the checklist but have to calculate TO performance, V speeds, feed the info in the system.

We had ACARS on our planes and everything was done through ACARS and still we were very busy. I understand COMAIR does not have ACARS and the FO has to manually calculate all the numbers while taxiing.

So, the FO may not be looking outside where the aircraft was taxiing. Also if they were flexing, it may increase that 3539' length.

A very sad day in aviation.

Scurvy.D.Dog

29th Aug 2006, 04:45

jondc9
DA1-11 and ATC watcher.
.
I've spent time in towers around the country...they are quite tall with huge windows as you know.
.
If parts of the airport are not visible to the tower, a note is made on the charts to let pilots know. .. what about the haze?If there was ONE controller at KLEX and he was being forced to do too many things to NOT LOOK OUT THE HUGE WINDOW, then the system needs fixing. …. we do not know that was the case!AND one plane with all landing lights on should have been quite distinct especially if taking off on a runway WITH NO LIGHTS.… what is the position of the tower relative to the runways?? …. could they see the runways that morning?? ….. any (P)SMR display at Kentucky? …. squat switches might have precluded transponder transmission?!?!
.
… either way …. There were lots of factors in this one ….. lets not unfairly tar any individuals!!!

OKFINE

29th Aug 2006, 04:46

Yes indeed a sad confluence of events. Not to appear sarcastic but I assume there were NOTAMS regards the runways during the resurfacing etc. The crew flew into the airport so had a view of the field with its idiosyncracies. Sometimes merde s'arrive. I know a chap who started an A-320 with the thrust levers NOT at idle. This despite a ramp check, a before start check and an ecam warning "thrust lever move". I guess some times we see what we want to see. God rest their souls.:cool:

archae86

29th Aug 2006, 04:47

137 knots was the max airspeed attained.
The captain called '100 knots', 'rotate'.

If these calls were in close proximity, and if 100 knots is appreciably below standard rotation speed for the conditions, may this suggest captain at this point realized a problem, and thought the chances better at trying to fly out than to do a very high speed over-run?

Anyone care to post an estimate of rotation speed for the given conditions?

flyguykorea

29th Aug 2006, 04:50

Aircraft takeoff weight was 49,087 lbs. according to the load manifest. The manufacturer calculates that 3539 feet are required to rotate at this weight.
Runway 8/26 Dimensions: 3500 x 75 ft.
Thirty-nine feet. Must have been desperately close.

A good argument for keeping as much runway available as you can when lining up. I remember from an old Boeing instructional video "runway behind you, is runway you can't use during a RTO". While a RTO doesn't apply in this situation, it clearly shows that every little bit may have counted. I guess at this stage we don't know if they had a rolling or standing takeoff, but I would presume that they would have lost 100ft or so in the line-up.

Rongotai

29th Aug 2006, 04:52

Looking at the maps and photos posted by Cross-Eye I am struck by the possibility of confirmation bias factors in this accident. By this I mean the cognitive habit of seeing what you expect to see and discounting contrary information if it is not jarringly contradictory. This appears to have been an important factor in the Erebus accident, with the crew 'seeing' McMurdo Sound because that is what they expected to see.
If so then it isn't necessary to postulate fatigue, but the overall early light environment does come heavily into play, together with the change of the taxiway configuration.
One of the problems with confirmation bias is that it can happen to anyone at any time - even the very best in optimal conditions - and that it is the one cognitive phenomenon that can easily be magnified in a well-functioning CRM environment.
If my speculation is correct I would then want to suggest that when reconfiguring airport layouts there be positive identification of the risk of producing taxiway and runway patterns that are sufficiently similar that they might induce confirmation bias errors. The pre-existing configuration shown would make such an error difficult (not impossible) to make, but the new layout increases the risk markedly.

Ignition Override

29th Aug 2006, 05:30

JonDC9:
Many of these 'contributors' might have little aviation experience, or they (pilots do this?) assume that that a Tower Controller (supervising at least 3 frequencies + some telephones?) can/could always notice and keep track every aircraft location and direction of movement, as you already tried to clarify. Maybe the CRJ in Lexington had its left or right landing light deferred per MEL on the flight release. Even a nosegear taxilight could be inop., in order to keep Dispatch reliabilty high.

At larger airports, very experienced ground controllers (ATC) easily lose track of which aircraft is holding at a taxiway intersection or a de-icing 'pad' due to wx or security glitch delays, as happened to us tonight at a large midwestern airport.

Low visibility happens very quickly even after a very hot, dry summer.
Right now, seen from the ground by these hotels, fog appears to be forming over Lansing, MI. It was only 18*C when we arrived earlier, with the dewpoint at 17*, altimeter 29.84: the first cool temp I've seen since a vacation in Normandy France in May. What a relief from down south :D .

Brit50483

29th Aug 2006, 05:44

Looking at the maps posted by Cross-eyed in post #158, it struck me that the left turn onto R26 from taxiway Alpha (about 140 degrees) looks almost eaxactly the same as the left turn they used to make from the now disused taxiway onto R22.

By comparison, the turn now required off Alpha to get to R22 is about 90 degrees, markedly different.

Maybe they made the 'same' turn they always made and saw a runway ahead of them ...

Metro man

29th Aug 2006, 05:55

Since the SIA accident at Taipei, Singapore regs require the departure runway to be identified. We do this twice, on taxi check departure runway/SID in the box, and on line up "Departure runway XX identified" both pilots. Either check the signs at the holding point, the numbers on the runway or the heading on the nav display(remember if parallel runways available)

Sensible Garage

29th Aug 2006, 07:52

shoot me if I'm wrong but can't be far off

Field elev 979'
press assumed 1015/2992
tep assumed 15
wind zero assumed
anti ice off
bleed zero (on APU)
APR armed
dry
20 deg flaps
TOGW 49086
take off distance 5629'
V1 131
VR 135
V2 140
VFTO 181
%N1 92.8

I've no idea how they come up with 3539 feet...
100 knots for VR does not sound possible to me in a CRJ200

A7700

29th Aug 2006, 07:55

for ATC to not visually scan the runway as the plane was cleared for takeoff would be a mistake.
I recall being cleared for takeoff on long runway at KMRY, beautiful day, clear and a million, only plane on airport.
I asked controller if he was sure I was cleared for takeoff...he got quite irate at my question.
the problem was a fuel truck on the runway about 4000 feet from threshold.
HE hadn't even LOOKED at the runway and cleared me for takeoff. KMRY is noted for fog, lucky that day it was clear enough for me to see.
ATC is responsible for seperating all IFR aircraft, and not to scan the runway ( and see, by extension correct runway/aircraft configuration) would be WRONG>

ICAO DOC4444

7.1.1.2 Aerodrome controllers shall maintain a
continuous watch on all flight operations on and in the vicinity
of an aerodrome....Watch shall be maintained by visual
observation

7.10.1 Control of aerodrome surface traffic
in conditions of low visibility
Note.— These procedures apply whenever conditions are
such that all or part of the manoeuvring area cannot be visually monitored from the control tower.

7.10.1.1 When there is a requirement for traffic to
operate on the manoeuvring area in conditions of visibility
which prevent the aerodrome control tower from applying
visual.......then 7.10.1.1.1 and 2 = PROCEDURAL CONTROL

Note.— The Manual of Surface Movement Guidance and
Control Systems (SMGCS) (Doc 9476) provides guidance on
surface movement guidance and control components and
procedures for low visibility operations

At night, with in addition some rain showers and haze, the controller can only count on the pilot's reports. Even with an SMR you can only assume that a runway is vacated when the pilot declared he has done it.

fepate

29th Aug 2006, 09:28

...
take off distance 5629'
...
I've no idea how they come up with 3539 feetYour figure is the accelerate/stop/go balanced field length, no? The pertinent figure here is the actual distance to liftoff with all engines operating.
100 knots for VR does not sound possible to me in a CRJ200After going off-road, through a fence and approaching a clump of trees it may be worth a try, though.

Scurvy.D.Dog

29th Aug 2006, 10:08

A7700
ICAO DOC4444
.
7.1.1.2 Aerodrome controllers shall maintain a
continuous watch on all flight operations on and in the vicinity
of an aerodrome....Watch shall be maintained by visual
observation …. in a literal sense, explain to me how any ADC or SMC in any tower can ‘practically’ comply with this ….. it is impossible to ‘watch’ everything all of the time …. !!!Australian CASR Part 172 Manual of Standards
.
10.10.2.5 ATC must maintain, as far as possible, a continuous visual watch to detect and determine the position, and ensure the safety of, aircraft. .. is a more reflective/achievable requirement!
.
.. all of that Quote from 4444 may well have been complied with to the letter (in a reasonable and practical sense)!
.
.. a clue might be that (apparently from an earlier post) ATC did not say anything during the takeoff attempt and (one assumes) the subsequent accident sequence!
.
……seems to this observer that ATC were unaware of the problem (for reasons unknown to us at this point) … otherwise an alert/warning/stop instruction could have been issued!

edited for grammar

Scurvy.D.Dog

29th Aug 2006, 11:33

http://www.kentucky.com/mld/kentucky/15385913.htm
.
Hersman said yesterday that one person was on duty in the control tower Sunday morning, which she said was not unusual on the midnight shift at Blue Grass Airport.
.
The Patriot News in Harrisburg, Pa., reported last November that the FAA sent a directive advising smaller airports to schedule two controllers on the midnight shift. An FAA spokeswoman yesterday denied the existence of such a directive.
.
But David Katzman, the Michigan pilot and attorney, said that a single controller on duty essentially would be doing the work of three people -- communicating with other air controllers, coordinating movements on the taxiways, and directing airspace around the airport.
.
It would be easy to become distracted, Katzman said.
.
According to FAA spokeswoman Kathleen Bergen, Lexington once had two controllers working the weekend overnight shift. But the FAA reduced that to one four or five months ago after an unexpected drop in air traffic at Lexington, she said.
.
Bergen said the FAA will return to a two-controller overnight shift at Lexington this weekend. She declined to say whether that is because of Sunday's accident.
.
….hmmm

RatherBeFlying

29th Aug 2006, 12:19

An airport is a big place and an ATCO has several duties; so, may not be watching a particular a/c if/when the crew screws up.

We can be sure that the ATCO on duty dearly wishes s/he spotted the mistaken lineup in time to prevent the accident.

But pilots are big boys and girls who are expected to know their way around and ATCOs are not school crossing guards.

bobusse

29th Aug 2006, 12:25

A7700

29th Aug 2006, 12:35

…. in a literal sense, explain to me how any ADC or SMC in any tower can ‘practically’ comply with this ….. it is impossible to ‘watch’ everything all of the time …. !!! .. is a more reflective/achievable requirement!edited for grammar

So, I agree but explain to me ( 30 years of OPS ATC business at a major european airport) why not a single ICAO state member has requested the Air navigation council to modify in a more realistic way this "quite impossible procedure" along the last 50 years....

Del Prado

29th Aug 2006, 12:36

ATCO having several duties,perhaps,surely even,but what are their priorities,handle the phones or watch outside?

If the ATCO doesn't answer the phones (say to get a release on a departure) there won't be any movements outside to watch.

kellykelpie

29th Aug 2006, 12:57

I agree with the previous comments about confirmation bias as a contributing factor. This affects everybody at some point (e.g. taking a wrong turn in a car).

The 747-400 has software that warns of runway misalignment when takeoff thrust is applied and aircraft heading is different from FMGC runway (the runway the aircraft thinks it will takeoff on). If the CRJ had that I think this accident could have been avoided.

We need a systems approach to prevent similar accidents in the future as I think this could have happened to most. Lets start with mandating this software in all large RPT aircraft.

Xeque

29th Aug 2006, 13:07

This is, in no way, an attempt to prempt the results of the ongoing investigation. However (and in the meantime) ....

It would be a relatively easy thing for airport operators to ensure that the runway numbers are painted in a position that is visible from the flight deck AFTER the aircraft has lined up. Looking at the available photos of 22 and 26 at KLEX I'm not at all sure that this is so today.

All airlines as part of their SOP's should make it mandatory that crews check the DI with the Magnetic Compass and against the known runway direction BEFORE committing to takeoff.

No doubt someone will flame me for stating the obvious but, perhaps, it really does need to be stated (or re-stated) in the light of this tragic accident.

barit1

29th Aug 2006, 13:11

Ky. Governor Ernie Fletcher seeks closure (http://www.wcpo.com/news/2006/local/08/28/plane_fletcher.html) of LEX r/w 26
:rolleyes:

forget

29th Aug 2006, 13:14

Quote - 'The 747-400 has software that warns of runway misalignment when takeoff thrust is applied and aircraft heading is different from FMGC runway (the runway the aircraft thinks it will takeoff on). If the CRJ had that I think this accident could have been avoided'.

Modifying aircraft takes year - and $$$$. If getting positional information direct to pilots is the goal then modify the airfields - and be done with it. Cessna 150 to 777, and everything in between.

Hear Taxiway Message at

http://www.groundmarker.com/info.asp

fox niner

29th Aug 2006, 13:19

Xeque,

I totally agree. Look at this photo. When taxiing from the apron and turning left to cross 26 and enter the next taxiway to runway 22, one can easily miss the big 26 on the beginning of the runway. If you accidentally turn too far to the left and line up on runway 26, the big number is behind you....

http://i110.photobucket.com/albums/n107/pauwilso/Comairphoto.jpg

You know how it goes...busybusybusy, oh yeah a left turn, and here is the runway. Let's go.....

Scurvy.D.Dog

29th Aug 2006, 13:51

A7700
So, I agree but explain to me ( 30 years of OPS ATC business at a major european airport) why not a single ICAO state member has requested the Air navigation council to modify in a more realistic way this "quite impossible procedure" along the last 50 years.... .... Oz did in the CASR MoS ... member states are free to vary as they determine appropriate .... maybe (and I do not know) there is some other US law tenet that provides for 'reasonable actions' etc
.
Assuming that the runways were clearly visible!... the number of eyes might also be considered causal ….. I guess the number of eyes at ‘a major European airport’ might be different? ….
.
.. IMHO the threshold number position is relevant! …. from the photos, both runway threshold identifiers would not be taxied over and therefore not immediately apparent!
.
... I am curious about this taxi clearance issue ..... can someone confirm (in a standard operating sense) that runway crossings are not necessarily issued if part of the intented taxi route .. and therfore presumably not readback also? ..... is this a US procedure to minimise R/T loading?? .... if so, is it ICAO compliant? ..A7700 .. anyone?
.
.. would that be an additional 'jogger' i.e. '........ cross Rwy 26 ... Rwy 22 Clear for take off'

Iron City

29th Aug 2006, 14:00

A7700 and Scurvy:

The accepted practice has been that the State regulations can differ from the ICAO Convention and Annexes but you are supposed to file a difference with ICAO. Not real familiar with Annex 3 (airports) that Doc 4444 contributes to, but wouldn't hang my hat on it and depend on it.

May come as a surprise to some but many times States do not file differences, and from what I've seen in the other volumes I deal with the States that are the most prolific and punctual on this papperwork are the ones that have the least differences.

Usual practice/rule in US for a taxi clearance is to identify any runways that are to be crossed (ACME 123 taxi to the active 34 via bravo, cross 27" or "ACME 123 taxi to the active 34 via bravo, hold short of 27" and then the a/c reads back...tends to reduce runway incursions. Rule says that when you are cleared to taxi to some runway via some taxiway you are (implicitly) cleared to cross any intermediate runways.

Scurvy.D.Dog

29th Aug 2006, 14:07

Iron City .... quite right and agreed! :ok:
.
.... does 26 have those reflective 'cats eyes' on the edges adjacent the runway edge lights (I believe they are used in some locations in case of lighting failure at a critical phase of flight)??

forget

29th Aug 2006, 14:11

It's interesting what's painted on the runway versus what you'd expect to be painted.

http://i21.photobucket.com/albums/b270/cumpas/RW.jpg

Airbubba

29th Aug 2006, 14:12

I've no idea how they come up with 3539 feet...
100 knots for VR does not sound possible to me in a CRJ200

The 3539 feet was to "rotate the nosewheel", I was typing notes while watching the press conference live on an internet feed and may not have made myself clear. '100 knots' is a standard callout, not rotation speed. It is '80 knots' with most Boeing and Airbus operators from my experience. It is a time to check that the engines are spooled up, all airspeed indications agree and is somewhat of a demarcation line between a low speed and high speed abort decision.

On aircraft with very good braking in an RTO (or on a long runway), V1 and Vr are often the same and many operators only call "Rotate".

misd-agin

29th Aug 2006, 14:31

"if the intent is to fly start rotating with 1000' remaining, regardless..."

Typically terminology for windshear departures. I think it could apply in this case.

ATC Watcher

29th Aug 2006, 15:30

It is quite amazing to see a lot of people here which have registered here as ATPL holders having such a poor knowledge on a Tower Controller responsibilities.:hmm:

The list of those responsibilities and duties is very long in some airports, and can be a challenge for a single person but I can assure you that confirming in which runway aircraft are lined up before issuing a take off clearance is not of that list.

I am also 99% sure that if the controller had seen it or had a doubt he would have said something. No controller in his right mind would have done otherwise.

As to judge on the priorities ( e.g. telephone versus looking out ) you have to be on the spot to do that . It is very cheap afterwards to say you did not have your priorities in order, should have done this instead of that and it would have saved 50 lives...I have heard that argument before in court on another accident and frankly, this made me sick just to watch the controller listening to that.

forget

29th Aug 2006, 21:20

From CNN. FAA acknowledges it violated staffing policies with only one air traffic controller on duty at airport when Comair jet crashed Sunday, killing 49 people.

mini

29th Aug 2006, 23:53

Sounds like its going to be the same old story... the "Auditors" arrive after the battle and bayonet the wounded. :hmm:

fantom

30th Aug 2006, 00:47

It is quite amazing to see a lot of people here which have registered here as ATPL holders having such a poor knowledge on a Tower Controller responsibilities.:hmm:
Sir,or Madam,
Your post has merit and deserves recognition.
The matter of what to do about it here is the subject of another thread which, I hope, will be addressed...eventually.
By the way, I have a real ATPL.
Best wishes.

kansasw

30th Aug 2006, 00:50

From CNN. FAA acknowledges it violated staffing policies with only one air traffic controller on duty at airport when Comair jet crashed Sunday, killing 49 people.
Velly intelesting, can you provide a link or any kind of verification?
I am troubled that in this tragic context you would make such a statement out of the blue, without suggesting a way for me (eg) to verify the assertion.
CNN says many things, few of them trustworthy, but where did they say that?
FAA says many things, generally with foundation, but where did they say that? Or possibly did CNN say that FAA said that?

RiverCity

30th Aug 2006, 01:04

This is from the NY Times:
LEXINGTON, Ky., Aug. 29 — The Federal Aviation Administration issued an order nine months ago banning air traffic controllers from being assigned to work solo, with responsibility for both radar and ground observations. But that change was not carried out at the Blue Grass Airport here, where a jet took a wrong turn early Sunday onto a runway that was too short and crashed before the lone controller on duty could notice the error.
The change was ordered in November 2005, after an overloaded controller at the Raleigh-Durham, N.C., airport directed two planes to come too close together. Internal memos show that the air traffic manager in Lexington was trying to solve the problem on the overnight shift by getting radar responsibility transferred to a round-the-clock center in Indianapolis that handles mostly high-altitude traffic, but he did not succeed.
The F.A.A. said late Monday it would add a second controller to the tower on the midnight shift at the Blue Grass Airport during the weekends, even though the field handles only about one plane an hour between midnight and 6 a.m. On Sunday at about 6 a.m., a Comair regional jet was cleared for takeoff on a 7,000-foot runway but turn into the airport’s other runway, which is only 3,500 feet long, and crashed in the woods just beyond the airport fence, killing 49 of the 50 people aboard.
This evening, a member of the National Transportation Safety Board, Deborah Hersman, said the airport’s lone controller on duty had told investigators that he authorized the Comair crew to depart from runway 22, saw the plane on the taxiway that leads to both runways and turned his back to complete some administrative work.
The plane took 29 seconds from the beginning of its takeoff l to the crash in the woods; the controller heard the explosion.
Laura J. Brown, an F.A.A. spokeswoman, said the agency’s order in November was not a new policy, but rather an effort to enforce a longstanding policy that had somehow fallen into disuse. The F.A.A. headquarters only learned of the staffing situation at the Blue Grass Airport after Sunday’s crash, she said.
But an official of the air traffic controllers union said the solo staffing was not unusual. Andrew J. Cantwell , vice president for the southern region of the National Air Traffic Controllers Association, asserted that airports at Duluth, Minn., and Savannah, Ga., operated the same way, and that at some other airports, if a controller called in sick, the F.A.A. would not pay overtime to bring in a replacement.

Rongotai

30th Aug 2006, 01:54

If there was a policy that there should be 2 people in the tower, presumably there was a reason for that policy, and we are told that the reason was that there was a specific history of sole officers making high risk mistakes.
In this case there was a single officer, but he nevertheless made no mistake because he had discharged his dutes to the RJ correctly, according to his SOPs. If the SOPs were deficient, then that too is a management issue. As I read this thread I take it that even if there had been two officers on duty there was no requirement to observe the RJ line up on the correct runway, but there might have been a better chance of this being noticed.
What distresses me about these sorts of discussion is how readily the they come to focus on the individuals who might or might not have made mistakes, and how easily it drifts away from the systemic traps that increase the chances that an error will occur.
We know that people make 'mistakes' - even the very best. We know what kinds of mistakes there are and how they happen. We know the things we can do to systems to reduce the probabilities that mistakes will happen. We also make quite calculated cost trade off decisions about how much error reduction we will buy.
But in this case it seems that the error reduction opportunity that could have saved this aircraft had no, or very little, cost, and that the risk was highly predictable. I refer to the reconfiguration of the taxiways that, as I read the plans posted, could have been analysed in five minutes in a planning meeting to confirm pretty precisely the likely increase in the frequency of incorrect runway identification that was being built in.

kansasw

30th Aug 2006, 02:17

Thanks, but no thanks, just that most of the links or sources I try to verify leave me hanging. Subsequent to my post I am hearing on the radio that FAA guidelines were violated by having only a single controller on duty at Bluegrass. When this is coming out over a variety of networks I am inclined to believe it better. My point was, to the original poster (sorry I forgot the name), not that his news was incorrect, but that it would be good to provide some way to verify the assertion, like a link or anything, rather than just say "CAA sez FAA sez XYZ sez blablablabla," what is how I read it.

Sure, I can go to CAA and FAA and XYZ and fumble around for about an hour and a half and come up with nothing. A solid source for a new tidbit of information would make me happier.

Cross-eyed

30th Aug 2006, 04:10

Can someone reference a link that clarifies if there was only one controller on duty vs. one controller in the tower? Until now, I was fairly certain that there were always at least two controllers on duty at KLEX though most times one was in the tower handling clearance delivery/ground/tower duties and the other in the radar room handling the two approach/departure sectors. Is the official position that there was only one controller handling ALL duties?
Also, ATIS provided info that the centerline lights on RW22 were inoperative. It's possible that when the Captain (pilot not flying) lined them up on 26 and there were no lights, he, the FO (pilot flying), and the AirTran pilot in the jumpseat all may have just rationalized "lights inoperative on 22" and didn't give it a second thought, even as they crossed the intersection with 22 on the takeoff roll. Past that, they wouldn't have had any indication they had used up all the runway until the number 8 came into view of their landing lights, no?

Loose rivets

30th Aug 2006, 05:21

.............Captain (pilot not flying) lined them up on 26 and there were no lights, he, the FO (pilot flying), and the AirTran pilot in the jumpseat all may have just rationalized "lights inoperative on 22" and didn't give it a second thought, even as they crossed the intersection with 22 on the takeoff roll..........

Yes that occurred to me. And if the captain was looking to the right, or fine-tuning the settings the active runway lights could have flashed past and been missed altogether.

G-CPTN

30th Aug 2006, 06:24

How about the Flight Deck Crew were 'familiar' with the airport and were keen to get on with the flight ASAP. Under such circumstances 'assumptions' may be made. If the work-load was heavy during the taxi-out, further assumptions may have been made, and when they reached the 'end' of the taxiway a rolling start (turn 45 left - let's go).
Likewise the ATCO. "These guys know what they're doing (!). Work to do etc etc"

I'm not accusing ANY of deriliction of duty (although 'to the letter' there may well have been), but a scenario which might explain the unfortunate sequence of events. The presence of the guest in the jump-seat (if, in fact he WAS there) was a further possible distraction (or an incentive to show him how slick their operation was).

Like most disasters, several holes in the cheese need to line up. The two survivors (the FO and the ATCO) may well bear the brunt of the blame.

The underlying cause is probably laxness with regard to the taxiway modification (from the airport AND the crew's point of view). Maybe even the ATCO . . .

It is possible to be TOO comfortable with familiarity. Any of a number of checks would probably have averted this event.

All circumstantial, but MY 2 cents worth.

Airbubba

30th Aug 2006, 06:49

The presence of the guest in the jump-seat (if, in fact he WAS there) was a further possible distraction (or an incentive to show him how slick their operation was).

I agree as I wrote a few pages earlier but the jumpseat rider was in the cabin for takeoff according to the latest NTSB briefing. Also, there was a little confusion on the preflight, the pilots boarded the wrong plane and started the APU before a ramp worker alerted the crew to the error.

DanAir1-11

30th Aug 2006, 07:34

Gentlemen & Ladies,

Let us all be mindful of the effects that unfounded or misguided speculation can have. I am deeply concerned at the direction in which some of the 'ATC' speculation is heading. Whilst it is most certainly only natural for professionals to hold a profound interest in events affecting our livelehood and that of our compatriots, we must be mindful that 'other' persons also have access to this forum, and it is possible that their intentions may be somewhat different from our own. (no inference made here-in please note) Also, we have to be mindful of the possible detrimental effects our speculations and postulations may have on those persons concerned. It is not so long ago that a controller (no names nor organisations need be mentioned) was brutally murdered in the 'aftermath' of a terrible accident over Germany. (you all know to which incident I am referring) We ALL have an obligation as professionals, current or retired, to discuss this incident with the utmost of care and respect for all parties concerned.

Best regards

DA1-11

Sunfish

30th Aug 2006, 07:45

Please be aware that lawyers will be reading this thread and getting ready to proposition the families of the deceased.

qsyenroute

30th Aug 2006, 08:00

If blame is required to be stuck in the control tower then look to the system:

1. SMCGS with an adequate warning system (its called software coded parameters) could have prevented this

2.As In the Überlingen accident the “system” did not allow for adequate ATC cover. Trust me this situation is endemic. And will run and run until legislation requires a two person Tower (as a commercial cockpit need requires two)

3.ICAO regulations require a pilot take-off clearance to be read-back in full. “Roger” is the classic insufficient reply.

forget

30th Aug 2006, 08:09

If blame is required to be stuck in the control tower then look to the system:
1. SMCGS with an adequate warning system (its called software coded parameters) could have prevented this.

qsyenroute. I'm genuinely baffled as to how SMGCS would have prevented this. SMGCS may alert a controller when two targets (aircraft) are getting too adjacent, but how would it warn of a single aircraft moving onto the 'wrong' runway?

qsyenroute

30th Aug 2006, 08:37

qsyenroute. I'm genuinely baffled as to how SMGCS would have prevented this. SMGCS may alert a controller when two targets (aircraft) are getting too adjacent, but how would it warn of a single aircraft moving onto the 'wrong' runway?

Utilising data derived from mode-s extended squitter information, SMGCS could be parameterised to include within its safety logic a warning when an aircraft type (stored on its database) lines up on a runway that has a TORA below that aircraft’s minimum required field length

ZH-127

30th Aug 2006, 08:54

http://news.bbc.co.uk/1/hi/world/americas/5297340.stm

US crash air control understaffed

http://newsimg.bbc.co.uk/media/images/42028000/jpg/_42028418_wreckage-ap203.jpg The crash was the worst in the US for five years

The only air traffic controller on duty when a plane crashed in Kentucky on Sunday, killing 49 people, had his back turned at the time, investigators said.

He failed to notice the plane had taken the wrong runway as it tried to take off, as he had turned away "to perform administrative duties", officials said.

The runway was too short and the Comair CRJ-100 crashed shortly after take-off.

The Federal Aviation Administration admitted it broke its own rules in putting only one controller on duty.

"This controller did not have visual contact with the aircraft," said Debbie Hersman, a member of the National Transportation Safety Board.

The man was not named but had been working at the Lexington airport for 17 years and was fully qualified, Ms Hersman said.

At the crucial moment "he was doing a traffic count", she said.

The plane's pilots were apparently unaware that take-off procedures at the airport had changed only a week earlier.
They used a 3,500ft (1,050m) runway, meant for small aircraft, instead of the one next to it, which was twice as long.

Experts said the plane needed at least 5,000 ft (1,524m) of runway.

The air traffic controller had cleared the aircraft for take-off from the longer runway, but turned away and therefore failed to see it advance up the wrong strip, Ms Hersman said.
http://newsimg.bbc.co.uk/media/images/42021000/jpg/_42021780_runway26_ap203b.jpg Runway 26 was not designed for use by commercial jets

The aircraft, bound for Atlanta, went down in woods about a mile (1.6km) from Lexington's Blue Grass Airport at about 0610 (1010 GMT) on Sunday.

The only survivor of the crash was the co-pilot, first officer James Polehinke, who was at the controls at the time of the crash.

He remains in a critical condition in hospital.

Doctors said it was miraculous that he was alive, as he had broken bones throughout his body, including in his face and spine.

His mother, Honey Jackson, urged people not to blame him for the crash.

"He could die at any moment," she said. The crash is the worst US air accident since November 2001, when an American Airlines plane came down in Queens, New York, shortly after take-off from JFK airport, killing 265 people.

Well that answers my question above!! :ugh:

brain fade

30th Aug 2006, 09:01

ZH-127

30th Aug 2006, 09:20

Dont get me wrong, i am not insinuating that blame is resting on the controller. At the end of the day, the captain of the aircraft has ultimate control and responsibility of the aircraft at all times.

It would seem however that the FAA's decision to understaff LEX was a possible contributory factor to this tragedy.

That is not to say the controller is at fault, he is not.

XL5

30th Aug 2006, 09:20

ZH-127

30th Aug 2006, 09:23

Tower under-staffed or tower over-staffed: totally irrelevant. There was nothing wrong with the clearance as issued and there was nothing wrong with the assigned runway - but the aircraft didn't use the assigned runway. Only one person is ultimately responsible and he's paid the price, so have all of his passengers.

Agreed!

However the FAA should share some of the burden in the blame. If the tower wasnt understaffed, one of the controllers would have noticed the error (or at least had a better chance of noticing it). Besides, its FAA's OWN RULES not to have just one controller on duty.

qsyenroute

30th Aug 2006, 09:25

I wonder about the way some blame is being eased toward ATC here.
Could some ATC'er post the exact meaning of the phrase 'cleared for take off'. For example, is it the controllers duty to ascertain the runway is clear? That the correct runway is being used etc. etc. Or is it, particularly for the second of these, solely the responsibility of the flight crew?
Ta.

ICAO Doc 4444 Air Traffic Management

CHAPTER 7. PROCEDURES FOR AERODROME CONTROL SERVICE

7.1.1.2 Aerodrome controllers shall maintain a continuous watch on all flight operations on and in the vicinity of an aerodrome as well as vehicles and personnel on the manoeuvring area. Watch shall be maintained by visual observation, augmented in low visibility conditions by radar when available

7.8.4.3 Subject to 7.8.4.2, the take-off clearance shall be issued when the aircraft is ready for take-off and at or approaching the departure runway, and the traffic situation permits. To reduce the potential for misunderstanding, the take-off clearance shall include the designator of the departure runway.

And this is the closest ICAO gets to the subject……..

7.3.1.4 OBSTRUCTED RUNWAY
In the event the aerodrome controller observes, after a take-off clearance or a landing clearance has been issued, any obstruction on the runway likely to impair the safety of an aircraft taking off or landing, such as a runway incursion by an aircraft or vehicle, or animals or flocks of birds on the runway, appropriate action shall be taken as follows:
a) in all cases inform the aircraft concerned of the obstruction and its location on the runway;
b) cancel the take-off clearance for an aircraft which has not started to roll;
c) instruct a landing aircraft to go around.

XL5

30th Aug 2006, 09:37

ZH-127

30th Aug 2006, 09:45

No ZH-127. You fail to understand the concept of pilot in command along with its attendent authority and responsibility. Your bleating on about ATC's short comings is naive to the point of being vacuous. How many thousands of hours of captain's time in air transport operations do you have in your log book? Should you ever acquire any, you'll get the point.

You're missing the point i'm trying to make.

The captain has ultimate responsibility over the safety of his aircraft. Regardless of the instructions given to him/her by ATC, the book stops with the captain.

The point i am trying to make is that whilst not the controllers fault, if there were more than one controller on duty at LEX the chances of avoiding this accident would have been massively increased. Therefore, by its own admission of guilt, the FAA is partly at blame too. I am not saying that the controller is at fault.

Read what i am saying, and engage your logic. I am not disagreeing with you about the responsibility of the captain of any aircraft. :ugh:

Scurvy.D.Dog

30th Aug 2006, 10:02

DanAir1-11
Let us all be mindful of the effects that unfounded or misguided speculation can have. I am deeply concerned at the direction in which some of the 'ATC' speculation is heading. Whilst it is most certainly only natural for professionals to hold a profound interest in events affecting our livelehood and that of our compatriots, we must be mindful that 'other' persons also have access to this forum, and it is possible that their intentions may be somewhat different from our own. (no inference made here-in please note) Also, we have to be mindful of the possible detrimental effects our speculations and postulations may have on those persons concerned. It is not so long ago that a controller (no names nor organisations need be mentioned) was brutally murdered in the 'aftermath' of a terrible accident over Germany. (you all know to which incident I am referring) We ALL have an obligation as professionals, current or retired, to discuss this incident with the utmost of care and respect for all parties concerned.…. Sage advice!:ok:
.
..the event you mention is foremost in my mind …… unfortunately uninformed and irresponsible comment in the media may have contributed to that hideous outcome :sad:
.
…… to carefully point out and/or question possible circumstances may reduce the likelihood of the media playing the blame game whilst poking around in the dark
… someone referred earlier to ‘systemic’ ….. seems there might have been … rather that individual responsibility …. Isn’t it better to flesh out 'sytemic' before people are wrongly tared and therefore placed at potentially greater personal risk! :mad:
.
.. the hounds will hunt irrespective! :hmm:
.
…. How many of us could have been in any of those seats that morning .... and really truly honestly say ‘that could not have happened to me’ :uhoh: ……. Well???
.
As has been said …. lots of possible issues in this one …. :( my best wishes go to the FO and the ATC ….. treat them well!!

Propellerhead

30th Aug 2006, 10:03

Accident investigations are NOT about apportioning blame. It's about working out what (normally human) factors were involved, and how to try and stop it happening again.

As usual it was a combination of factors, errors, and bad luck that in the end all the 'holes in the cheese' lined up and an accident happened. Any one thing out of many could have prevented this but it didn't. All we can do is try and learn from it and and perhaps put in extra safety measures or rules or procedures that may help stop it again.

This is a terrible ACCIDENT and no one person or persons are to blame. I for one was careful yesterday lining up that I had the correct runway and will be more careful in the future.

GK430

30th Aug 2006, 10:03

I speak with experience of ground ops at European airports - so a quick question:
The rwy 22 holding point stop bar would have been de-selected as the aircraft had been cleared to lineup / position & hold; were there no taxiway centre line lights on the taxiway that would have been illuminated across the concrete element of rwy 26 over to the rwy 22 hold?

jondc9

30th Aug 2006, 10:27

XL5

no doubt that the PIC is the final authority and has the final responsibility for a safe flight.

BUT in aviation we help each other keep things safe. As in a previous post, I mentioned to ATC that a fuel truck was on the runway in my case and I declined to takeoff.

WE WATCH EACH OTHER and help each other and if we don't a hell of a lot of controllers just might be decertified.

There Should have been a controller scanning the runway...there wasn't, and bam...does that make it the controllers fault? no

does that make the system in need of improvement? yes

If a radar controller issued a clearance for an apch to one airport and saw on his screen the plane going in the opposite direction, shouldn't he say something?

AVIATION SAFETY is everyone's business. A real controller would know that.

Airbubba

30th Aug 2006, 10:57

Please be aware that lawyers will be reading this thread and getting ready to proposition the families of the deceased.

Do ya think?

http://www.kreindler.com/kreindler_news/news_current/2006-08-Comair-Flight5191.htm

zed3

30th Aug 2006, 11:00

jondc9 ..... most ATC staff will agree with you on that , everyone in aviation works together , mostly as independent teams . However managers these days seem to have different thoughts on the subject . Money is the bottom line , the LEX accident seems to prove my point . Certainly from my personal experience , managers decry experts' (read , the people DOING the job's opinion) with a "no , no , that's not true" when their ideas are challenged . "Risk factors" and "Stake-holders view" are the current "management" phrases . There needs to be a distinct management 'culture change' before things change for the better . Money is NOT everything .

XL5

30th Aug 2006, 11:02

A fuel truck on the runway? A fuel truck? The ubiquitous tongue in cheek simulator scenario for a low level go-around and you, jondc9 the magnificent, self appointed mouth piece of aviation safety driven by a selfless urge of altruism, is the one pilot in ten's of thousands to actually live the scenario of a fuel truck on the runway for real? I suspect it is you, and not the alleged fuel truck, which is full of gas.

Captain, Clearance, Compass, Chart 10-9, Crew. End of story.

Scurvy.D.Dog

30th Aug 2006, 11:08

jondc9
WE WATCH EACH OTHER and help each other and if we don't a hell of a lot of controllers just might be decertified. …… jon comon that’s a given ….. how many times a day around the world do controllers do just that ….. picking up errors that no one would expect or predict … unless you have worked the job, it is difficult to understand!! … it is however a reality! .... have you ever had your bacon saved by ATC??? There Should have been a controller scanning the runway... .. do you know that he/she did not scan the runway (22) prior to or during the issuance of the T/off clearance?? … no … there wasn't, and bam...does that make it the controllers fault? No… correct!does that make the system in need of improvement? Yes … depends on the findings of the NTSB .. and then those parts of the 'system' indentifed and how much those individual factors were considered contributory!If a radar controller issued a clearance for an apch to one airport and saw on his screen the plane going in the opposite direction, shouldn't he say something? ….. if he/she saw it … yes … of course … your point is??
.
.. it is a bit like saying (based soley on your descriptions) you were cleared for take-off twice whilst the runway was occupied!! ... you saw the truck and did not go .... the system failed safe!!! .... mind you I find it a little odd that you site this example without explaining the circumstances of how or why it happened! ....not very fair in the current context!!!AVIATION SAFETY is everyone's business. A real controller would know that. ….. in my experience, every RPT Pilot, ATC (and dare I say it GA) operates to that end ….. I do not care for your imputation to the contrary! :suspect:
.
.... .... to those on this thread engaged in a purile pissing contest ..... leave it out ... this is neither the time nor the place .... there is far to much at stake to behave like Imbeciles!!

Dream Land

30th Aug 2006, 11:15

AVIATION SAFETY is everyone's business. A real controller would know that by jondc9 Yes I think we can agree on this statement, I don't think anyone is trying to pin the responsibility of this tragic accident on ATC, that said though, I feel the question of what the controller was doing is a legitimate one, as a previous Facility rated controller at the busiest (military) airport on the west coast I can't imagine what would be more important than keeping an eye on traffic that is cleared for takeoff, just my 2 cents. :confused:

jondc9

30th Aug 2006, 11:21

it is amazing that you find so much wrong with the idea that a controller should look out the window and watch an airliner takeoff. that looking out the window might be more important than tending to "administrative duties".

FAA has admitted 2 controllers should have been on duty.

XL5...should a controller just issue a clearance and not see that it is followed?

Scurvy.D.Dog

30th Aug 2006, 12:10

I don't think anyone is trying to pin the responsibility of this tragic accident on ATC, that said though, I feel the question of what the controller was doing is a legitimate one, as a previous Facility rated controller at the busiest (military) airport on the west coast I can't imagine what would be more important than keeping an eye on traffic that is cleared for takeoff ….. how many eyes in that tower? … does the ADC have other duties such as coordination etc etc? …. Do they ever take there eyes off the manoeuvring area??
.
….. I am sure your question will be asked and answered in due course!
.
jon … there is nothing wrong with the premise of looking out the window …. There are lots of things that might interrupt that scan and/or re-scan though …. the same for Pilots yes?!?! :ouch:

Dave Gittins

30th Aug 2006, 12:24

This is the third time in a few weeks when something tragic and disastrous has been discussed, that plain common sense and attention to detail would have prevented.
Incorrect power settings on a 747 at Halifax, inattention to which engine was shut down in a C-5 at Dover and now an apparent failure to pick the correct runway on a familiar airfield.
I stress that I am a lowly Cherokee driver but I certainly know my rotation speed and as I have to drive over the numbers at the threshold (not to mention seeing the marker board at the stop bar with the runway designator as I leave the taxiway) simple attention pretty much ensures a correct runway choice.
The one thing this tells me is that in whatever we do and wherever we go, we have to attend to all the details and never stop questioning ourselves ... am I in the right place, doing the right thing, at the right time ????
Some mistakes are just too expensive to make.
DGG :confused:

jondc9

30th Aug 2006, 12:26

scurvy dog

yes, many things can stop your scan...but if the SYSTEM says 2 controllers should have been on duty and only ONE was on duty, there is room for improvement.

NO one wants ATC to be in command of aircraft, but the lowest private in the army should tell the highest general that his fly is open if it is.

it benefits all of us.

barit1

30th Aug 2006, 12:40

jon
.. yes, many things can stop your scan...but if the SYSTEM says 2 controllers should have been on duty and only ONE was on duty, there is room for improvement. …no argument and no doubt there will be some difficult questions asked on that score! …. hope a proper ‘safety assessment’ was done to reduce the coverage (as apparently happened in the months previous) …. particularly if it is inconsistent with stated FAA policy of two bod’s?!
... was it contingency staffing?? .... a potential minefield either way :uhoh:

Scurvy.D.Dog

30th Aug 2006, 12:49

HowlingWind

30th Aug 2006, 12:55

Lexington paper reports FO was initially in an induced coma. He has emerged from the coma but is still unconscious and in critical condition. According to his mother, he wasn't originally scheduled to fly on Sunday. He arrived in Lexington early Saturday morning, Capt. arrived Saturday afternoon. Crew arrived at KLEX about 05:15 Sunday and fired up APU in what eventually turned out to be the wrong aircraft before boarding N431CA.

Lexington Herald-Leader (http://www.kentucky.com/mld/kentucky/15394392.htm)

Additional from Louisville, Kentucky paper (http://www.courier-journal.com/apps/pbcs.dll/article?AID=/20060830/NEWS0104/608300650/1008)

RatherBeFlying

30th Aug 2006, 13:11

I don't know what signage is used at LEX, but if it's anything near the ICAO standard this is what they look like:http://www.advancedairportequipment.com/products/runwaysign.gif
And yes, the sign is illuminated from inside.

It takes some serious fatigue to see 22 when this kind of sign says 26.

However the arrival time of the pilots the previous day (reported in later posts) does not raise any glaring circadian rhythm adjustment issues.

So what kind of sign is there where the taxiway meets 26? Perhaps because it's just a g/a runway, there's no ICAO standard sign and unfamiliarity with the airport led them to take 26 for 22.

barit1

30th Aug 2006, 13:24

Although there's been no NTSB comment so far, what about the deadhead crew in the jump seat? Could this have added a distraction factor?

hetfield

30th Aug 2006, 13:26

Although there's been no NTSB comment so far, what about the deadhead crew in the jump seat? Could this have added a distraction factor?

If seated in the cabin, no.

Airbubba

30th Aug 2006, 13:47

Did the latter claim, boarding the wrong aircraft, also come from the NTSB briefing?

Yep. It is citied in the Lexingon Herald-Leader link a couple of posts before yours.

HowlingWind

30th Aug 2006, 13:48

etrang, I wondered that myself after seeing that reported in several news sources. I didn't see the NTSB briefing, and I can't find where any are transcribed anywhere. This is the best summary I've been able to find of last night's briefing, which says "nothing out of the ordinary" was noticed after the crew arrived. Yet, as airbubba mentions, the Lexington paper quotes the NTSB as saying a ramp worker reported they had boarded the wrong plane.

At a press briefing Tuesday evening, NTSB spokesperson Debbie Hersman released new details pertaining to the familiarity of the crew and the air traffic controller with Lexington's Blue Grass Airport.

She said that NTSB investigators conducted interviews with several crew and airport workers directly involved with Flight 5191 the day of the crash.

Tuesday morning the NTSB air traffic control team interviewed the controller on duty at time of accident, as well as the ramp worker.

The interviews concluded that the crew checked in at 5:15 a.m., picked up their paperwork and boarded the aircraft.

Nothing out of the ordinary was noticed.

According to Hersman, the air traffic controller had been at the airport for 17 years, and was fully qualified to perform his duties on the day of the accident.

Air Traffic Controller: Timeline Of Events On Accident Day

Scanned the radar display
Saw no air traffic
Had a clear, unobstructed view of the runway
Cleared Flight 5191 to takeoff from runway 22
Last time he saw the aircraft was when it was taxied to runway 22
Said the pilot did not sound confused or disoriented
Turned around to perform administrative duties in the tower
The NTSB performed taxi tests late Monday night. Investigators followed the path of the accident aircraft, from the ramp to runway 26, and did the same with runway 22.

They tested from 10:30 to around 1:00 in the morning..

The airport groups had representatives on board, and took turns documenting, observing, and re-enacting what the crew in Flight 5191 may have experienced before takeoff.

A representative was also in the air traffic control tower, to get a perspective of the visibility of the aircraft.

Hersman noted that 135 knots was the rotation speed needed to launch the aircraft.

Background of Flight Captain and First Officer

Captain, Jeffrey Clay

7 years with Comair
Hired November 1999
Became captain in 2004
Burlington, Kentucky resident
Rode as a passenger on a flight to Lexington on August 26, arrived at 3:30 p.m.
Had been in Lexington's airport six times in past two years, the last time being in June.
First officer, Jim Polehinke

Employed by Comair since 2002
Lone survivor
Arrived in Lexington as a crew member on Flight 9471 from JFK Airport to Lexington at 2:00 a.m. on August 26
Last in Lexington in May, had been in and out of the airport a total of 10 times in past two years.
Flying pilot of accident flight.

Often the captain taxis an aircraft onto the taxi way, and positions the aircraft on the runway for takeoff before handing over control the the first officer, which was the case in this incident.

In this particular aircraft, the tiller that steers the aircraft on ground was on the captain's side only.

According to the NTSB investigations update, Captain Jeffrey Clay taxied the aircraft to runway 26, before handing over control to First Officer Jim Polehinke for takeoff.

Runway 26 remains closed until further notice.

From WCPO-TV, Cincinnati (http://www.wcpo.com/news/2006/local/08/29/ntsb_presser.html)

FIRESYSOK

30th Aug 2006, 14:07

Crew arrived at KLEX about 05:15 Sunday and fired up APU in what eventually turned out to be the wrong aircraft before boarding N431CA.

I believe that this information is key to understanding that they were probably fatigued, and the time wasted preparing the wrong aircraft could have been as many as fifteen mintues due to the safety check and APU fire test, maintenance logbook check, etc., etc.

Considering a :45 minute report time which includes time spent collecting the dispatch, walking to the wrong aircraft, boarding it, stowing bags and beginning to prepare it, to disembarking that airplane, and repeating the same steps on the new airplane- this could leave as few as :20 minutes before the airplane left the gate. Not much time considering the cockpit check, preflight preparation and mass and balance which is all done by hand.

Having said all that, it sounds like a very typical day on the job for a regional pilot and I'm sure for many of you here regardless of what or where you fly. That's the scary part.

Stuck_in_an_ATR

30th Aug 2006, 14:16

This may be apocryphal -

A tower operator observed an aircraft wheels up on approach and let him proceed to land in that condition.

Asked if he saw the situation, he said "Yes".

Asked why he didn't warn the pilot, he said "Because if we take on that responsibility, we'll be held liable if we miss one some day."

:ugh:

Unfortunatlely, that's the approach exhibited by the ATC VERY often - at least where I fly... Guys, please try to remember that the main goal is not to be okay with all the procedures, but to avoid accidnets at all cost...

M609

30th Aug 2006, 14:46

as a previous Facility rated controller at the busiest (military) airport on the west coast I can't imagine what would be more important than keeping an eye on traffic that is cleared for takeoff, just my 2 cents.

Nothing....but as a rated controller at an airport where we work SPO (single person operations) with ADI and APS duties for some HRS late/early each day, I can tell you this:

No matter how much the book says "never stop watching the traffic", when the ATIS is so old it's eligible for pension, the last snowtam sendt was 2 hrs ago, the field maintenance chief has called 3 times to coordinate XX (and the list goes on.....) , yeah, you drop the ball.

Is it right?

No!

Airbubba

30th Aug 2006, 14:55

Yet, as airbubba mentions, the Lexington paper quotes the NTSB as saying a ramp worker reported they had boarded the wrong plane.

I watched yesterday's NTSB briefing live on a CNN Pipeline video feed. Debbie Hersman briefed the media on the crew boarding the wrong aircraft:

...Ms. Hersman said that picking the wrong runway was the crew’s second mistake; when the two pilots arrived at 5:15 a.m., they started up the power generator on the wrong airplane and had to be redirected by a ramp worker...

http://www.nytimes.com/2006/08/29/us/29cnd-crash.html?_r=1&ref=us&oref=slogin

Ms. Hersman is doing a good job with the briefings although her background is in surface transportation, not air transport. According to her official bio she is a certified Child Passenger Safety Technician and holds a commercial drivers license with passenger, school bus, and air brake endorsements.

HowlingWind

30th Aug 2006, 15:24

Thanks for the clarification on that, airbubba. Apparently the WCPO folks missed that little detail.

Ptkay

30th Aug 2006, 15:25

From the other thread, on landing at EPKS instead of EPPO

http://www.pprune.org/forums/showthread.php?t=239414

I think a factor in this last incident was a similar incident
with a Cessna 172 training night-VFR approches to EPPO
and missing the field.
The lady controler was not allowed to give them suggestions,
although she saw on the radar screen what was happening,
since the radar system was (and still is) not certified.
She did warn them anyway, saved their lives
(they were low on fuel and managed to do emergency
landing on a frozen lake instead of hitting the town),
but was later punished for the breach of procedures.
:ugh:
It sounds absurd, but so it is. :yuk:
After this incident (February) probably noone in charge of
approach was brave enough to interfere with pilots decisions
by this recent incident.
:ugh:

Such ATC responsibility avoidance resulted this time in
a 737 landig at a wrong airfield, luckily with no injuries...

eastern wiseguy

30th Aug 2006, 15:33

I have never been to Lexington. I would suggest though that an airfield with a throughput of just over 1.6 million pax does NOT require 2 ADC guys. The FAA say that 2 should be on duty I suspect that is one tower and one RADAR guy.The two functions CANNOT be combined(so JonDC the OTHER GUY MIGHT NOT EVEN HAVE BEEN IN THE SAME PART OF THE TOWER) .I work at a tower which shifts in excess of 4.5 million pax per annum and I am FREQUENTLY working alone doing clearance delivery ,ground,air...it is NORMAL.Scan the runway...clear? cleared take off...have I ever looked away and answered a phone? been distracted by a vehicle..or other traffic elsewhere on the airfield..of course!The aircraft then uses the wrong runway.........

OldSchoolATC

30th Aug 2006, 15:53

This is my first post on the "stick and rudder" side of PPRuNe, so be nice to an old man. You aviators who are somewhat grey of head will remember when the bean counters took your FE/2nd Officer out of the cockpit. One less set of eyes. Well, when the FAA decided to run the mid-watch at smaller facilities with one guy downstairs in radar and one guy in the tower, we too, lost a vital set of eyes. I am ashamed of the many times I have practiced "clear 'em and forget 'em" in order to keep up with the paperwork.

PaperTiger

30th Aug 2006, 16:02

It takes some serious fatigue to see 22 when the sign says 26.I may be wrong (can't keep up), but wasn't 26 completely dark ? That would include the designator board I think, so they actually saw no sign before lining up; but if you are absolutely convinced you're doing it right then a "missed" sign is an insignificant factor which likely didn't even register.

And that also applies to the other poster(s) wondering why they didn't see the end in time to abort - no REILs.

alf5071h

30th Aug 2006, 16:30

For those contributors who have sought to blame someone, or like many of us who find it difficult to withhold thoughts of blame, then read: Punishing People or Learning from Failure. (www.hufag.nl/archief/huf03_dekker.pdf)

If you then decide to use responsibility instead of blame see: Systems Safety (www.webresearch.co.nz/docs_public/CaveCreekPaper.pdf) , in particular page 19:-

“Responsibility lies with those who could act but do not,
it lies with those who could learn but do not, and
for those who evaluate it can add to their capacity to make interventions which might make all our lives the safer.”

Also see:
Reconstructing human contributions to accidents. (www.lusa.lu.se/upload/Trafikflyghogskolan/TR2001-01_ReconstructingHumanContributionstoAccidents.pdf)

Beyond the Organizational Accident. (http://qhc.bmjjournals.com/cgi/reprint/13/suppl_2/ii28)

Dream Land

30th Aug 2006, 17:57

I stress that I am a lowly Cherokee driver but I certainly know my rotation speed and as I have to drive over the numbers at the threshold (not to mention seeing the marker board at the stop bar with the runway designator as I leave the taxiway) simple attention pretty much ensures a correct runway choice. By Dave G,

Please don't try to equate flying your Cherokee with the responsibilities of the two RJ pilots, they are both very busy during this time of the flight, add to that the time of day and new taxi procedures that began a week prior, if only it was as simple as doing a mag check and pouring the coals to it.

D.L. :=

jondc9

30th Aug 2006, 18:56

sadly, I'll bet a cherokee driver with an old DG and whiskey compass would have checked his heading on line up.

With such a short taxi, flipping Vspeed cards, checking acars w&b and everything else, maybe they should have stopped and finished everything before crossing the runway hold bars.

I know the pressure to hurry...but

Kalium Chloride

30th Aug 2006, 19:02

I stress that I am a lowly Cherokee driver

Don't put yourself down - you've the same responsibility to safe flight as someone in an RJ or a 747. It's the people who think they're somehow more important, because the dials in their cockpit go up to 11, who need to extract their heads from their lower colons before they start believing their own hype.

It doesn't matter how complicated your aircraft is, or how many bars you have on your shoulder, you'll be just as dead if you don't keep an eye on the bigger picture.

You keep right on checking those runway numbers, Mr Cherokee driver. I, for one, will taxi more happily knowing you're doing exactly that.

ATC Watcher

30th Aug 2006, 19:34

Respect , Mr( or Mrs ?) Kalium Chloride, very wise and nicely written.

alf5071h : quoting Reason and Dekker , the " new View" etc.. is always good, reading their work is even better ( but in reality very few really do ) , but applying what they recommend is in fact close to utopia with our modern Employers : Airlines and especially our ANSPs ( ATC companies ) .

I think that generally man feel safer if he can identify a scapegoat instead of challenging the system around him .If that scapegoat is in the other camp ( i.e outside his sphere of influence ) the better.

The attitude of Skyguide concerning Ueberlingen ( because it was mentioned earlier here ) comes to my mind as a perfect example of this.

fepate

30th Aug 2006, 20:12

surely not

30th Aug 2006, 20:13

Interesting to note that there have been several threads from time to time on here where Captains and future captains (FO's) have argued vehemently that the Captain is in absolute control and authority over his aeroplane and can override just about anyone in ATC and Ground Ops. Yet there are several on here trying to give ATC the blame for issuing correct instructions to a crew who then, for whatever reason, got it very wrong.

Either you have the responsibility or you don't guys. From what I have read on here in the reports, the ATC guy did nothing wrong. He did his job as required by his employer and by law. That he might have noticed the aircraft was in the wrong place is peripheral surely? The crew however would appear to have had an off day at the office starting with boarding the wrong plane, and culminating with people losing their lives.

The question that needs to be answered is why did an experienced crew make such a basic error? Were they rushing because they were late off stand due to boarding the wrong aircraft and trying to make time up? Did they think they knew the airport so well they didn't concentrate in the same way that sometimes when you get your car out of the drive to go somewhere you automatically turn one way when you need to go the other?

From what I have read so far I don't know the answer, but I don't think the manning levels of ATC were significant. They might, with luck, have prevented the consequence of the crew making an error as a reactive measure, but they wouldn't have prevented the crew taking the wrong turn. The mistake which caused the accident is the one that needs to be remedied.

barit1

30th Aug 2006, 20:38

From what I've seen in this and the in ATC forum, administrative duties can often override what the pilots seem to expect from ATC. This in no way implies the tower op's fault, merely that ATC management and the pilot community may expect different things of the "guys with eyes".

If this accident investigation brings this factor into open debate, then safety will have been served, and we'll all benefit. Just keep the lawyers out of it.

jondc9

30th Aug 2006, 20:55

of course ATC responsibility is the seperation of IFR aircraft...that was done.

BUT

there are secondary safety responsibilities...sadly the allocation of resources by the FAA for the last 25 years has been a little short of ideal in my mind.

no, we won't place blame on the controller, but wouldn't he be a hero now if he had saved the plane?

yes the PILOT in command is responsible. that's the regs, but certainly there will be some additional factors to consider and they will come out...wondering which pilot noticed the runway lights were not lit?

and THE LAWYERS ARE CHAMPING AT THE BITS. And I can see how comair will have to pay quite a bit, the FAA a little bit, the airport a little bit.

Globally

30th Aug 2006, 20:59

As a 747-400 capt, I think there are way too many administrative requirements that can sometimes distract the operating crew from paying attention to what's going on outside the cockpit. While training new FOs during line ops, I've had to take all paperwork and the flight plan out of the hands of the FO during taxi-out sometimes and stored it on my own side compartment so the FO will focus on what's going on outside the cockpit. From writing down deadheading crewmember names, amendments to the release, block out fuel, etc.. and getting the "Off" message ready to send, the FOs are sometimes totally engrossed in the paperwork and not the operation. Time to put down the clipboard and pen, and look out the window and pay attention to what's going on. Let's get back to the fundamentals. The "Off" message can wait, so can writing down everything else, except perhaps the ATC clearance. And those places like Prestwick and Delhi, where we get the clearance while taxiing out for takeoff - I suggest those airports change the procedures and give us the clearance in the blocks prior to push.

jondc9

30th Aug 2006, 21:38

I agree with globally.

May I further suggest that the FAA allows controllers past mandatory retirement age to do paperwork while allowing the other controllers to look out the window.

perhaps one gets too old to be sharp at looking out the window, but paperwork is paperwork ande can be done over.

seacue

30th Aug 2006, 22:34

I think you'll find that the tower staffing level is one more example of the pressure to save money. Federal expenditures for Entitlements (Social Security, Medicare, Medicaid, etc), Military spending and interest on the debt comprise most of the Budget. The modest fraction which is left gets squeezed. It pays for the FAA, NTSB, NOAA (Weather Service and aero charts), National Parks and the myriad other Federal activities. Yes, we pay fees for some of these activities, but the squeeze would be even tighter without them - and some fees aren't spent in order to make the budget look nearer balanced or just go into the General Fund.

So I expect reduced tower staffing is another example of saving money - as is the elimination of weather observers in some places.

Tarq57

30th Aug 2006, 23:04

Originally posted by jondc9

no, we won't place blame on the controller, but wouldn't he be a hero now if he had saved the plane?

Probably not, as the event would never have made the media. Controller "saves" occur reasonably often and tend to remain low key. Eg spotting in time someone with the gear up; a hatch open, unusual vapour/smoke, taxiing the wrong way etc.

I try to learn from these horrible events to sharpen my game up. Others I know do, too.
The best incident is the one you can do something to prevent happening, if you perceive its' imminence.

Scurvy.D.Dog

31st Aug 2006, 01:18

jon … you are not being fair to the ATC!
.
… think about what we know from the NTSB so far
.
- dark/early light
- Taxiways and Runway 22 lit
- Crossing runway not lit
- Controller and pilots referred to runway 22 in transmissions
- Controller observed aircraft taxiing towards the departure runway (22)
- Two crew commercial jet
- No other applicable traffic
.
.. are you saying the ATC should have considered it even remotely possible that this aircraft might use an un-notified, unlit and unsuitable crossing runway in the dark ….. .
.
I for one could quite easily have made the same deductions as the duty ATC and assumed (in any logical sense of the word) I could attend to other duties as there was nothing ‘sensibly’ to go wrong …. I dare say many others would have too!!
.
… prioritising tasks is what we do … do we stop doing everything else just in case?? . .. how many aircraft do you think the system would move then??? … would you be up in arms about delays
.
…. how many eyes is enough? … would it have made any difference in this case .. we will never know!!
.
.. you cannot have it both ways!!!
.
… please stop attempting to apportion veiled blame towards the unfortunate ATC! := … there is much riding on this for the individual concerned ……… IMHO it was not their fault! :suspect: