Comair Lexington Crash CVR

[bomarc]

The NTSB is reported as saying the transcript to the CVR of the comair flight that crashed in Lexington, KY, USA will be out today. There will be additional bits of information without analysis too.

[Rolling-Thunderbird]

http://www.kentucky.com/multimedia/kentucky/0117ntsbrelease/361245.pdf
http://www.kentucky.com/multimedia/kentucky/0117ntsbrelease/361105.pdf

http://www.kentucky.com/multimedia/kentucky/0117ntsbrelease/356274.pdf

http://www.kentucky.com/multimedia/kentucky/0117ntsbrelease/356317.pdf

[BoeingMEL]

So, the guys first of all manage to climb aboard the wrong aircraft.... then talk almost endlessly about promotion/training/dining/wives/kids/changing diapers. Then they enter the wrong runway and fail to notice either its alignment/orientation or that it has no lights.

What a dreadful and tragic sequence of events......I wonder if I'm alone in remembering Air Florida and Potomac River? bm:=

[Dream Land]

Don't forget about the nugget on duty in the cab that cleared them for takeoff without even looking outside. :eek: :ugh:

[fox niner]

So, the guys first of all manage to climb aboard the wrong aircraft.... then talk almost endlessly about promotion/training/dining/wives/kids/changing diapers.
So? I climbed aboard the wrong aircraft occasionally over the past 12 years. Just imagine what it is like at 6 am and 40 similar aeroplanes are standing next to each other....
And guess what is most talked about on the flight deck? Yep, promotion/training/dining/wives/kids/changing diapers.

If you didn't know better, you'd say that those flight deck guys op front ALMOST resemble human beings....:ok:

[BoeingMEL]

er..fair comment fox niner... but how often did you get as far as cranking up the APU? And then lining up on the wrong (and unlit) runway? And then attempting take-off without that last compass/runway check?

No personal attack intended...my point was to draw comparisons with pre-take off conversation and distractions a la Air Florida/Potomac tragedy.

No offence intended to victims, culprits or fellow ppruners. bm

[cargo boy]

Dreamland, comments such as yours do nothing to show any of us readers that you have very much idea about where the responsibilities between controllers and pilots differ. Calling a tower controller a "nugget" because a pair of pilots made a fatal error only shows you to be one of the many enthusiasts that populate this site and habitually engage foot in mouth whilst trying to somehow show us that you know something about our jobs when in fact you know sod all as you have just proven.

And if the visibility had been marginal and the runway not visible from the tower? Would you expect the pilots to be refused take off clearance? Of course not.

It is nuggets that assume that what a controller can see from the tower cab is somehow crystal clear and floodlit that is the problem here. Those pilots made a fatal error and hopefully the rest of us will learn from their mistake. The tower controller was not responsible for the pilots error you nugget!

[fox niner]

Hey there BoeingMEL,


Mmmmmm.....point taken. I must say that we did crank up the apu, in fact the stews that came on board our aircraft were going to London, and we were going to Paris. That's when we found out we were in the wrong aluminium tube. So we walked over to the next gate. Was pretty hilarious.:\

I must say that the holes in the cheese can line up pretty rapidly, as happened in Kentucky. People make mistakes, so do airline pilots.
I make mistakes almost on a daily basis. Luckily for the passengers that I fly, I am well aware of this, and therefore try to be vigilent.;)

Let's just see what the NTSB has to say about this.

[Dream Land]

Cargo Boy, no disrespect to you, but as an ex air traffic controller (busiest a/d on the west coast) and 16K hour pilot I feel my opinion is fair, you don't have to agree with me, I won't lower myself to your level by returning your smart a$$ remark. :hmm:

[bomarc]

I hope you will all re read the transcript...I found much more interesting things buried deep inside that might mean something...

[ironbutt57]

Boeing MEL....not many parallels between Air Florida crash...that seems to be more of a misunderstanding of de-ice requirements, and performance considerations, and not realizing their engine indications were incorrect, they were in fact on the correct runway, correctly configured, just had contaminated wings and epr probe resulting in falsely high epr readings.....can think of a couple others , Delta 727 DFW forgot to select correct flap setting for take-off factors were unrelatd conversation, (apparently including a rather graphic description of a cabin crewmember)...that got released to the media during taxi..out..NWA at DTW MD-80..same basic scenario...

[patrickal]

I hope you will all re read the transcript...I found much more interesting things buried deep inside that might mean something...


Bomarc, totally agree. One of the obivous things that caught my eye was the fact that they pre-disposed themselved to lighting issues based comments about a previous flight in that there would be "lights out" all over the place. It was not clear if he was talking about himself or another crew, but it was obvious that they were expecting to see lighting issues.

When they first dial into ATIS, the report states local temperature at 24, and then states runway in use is 22. Later on, as they are talking through checklists (at 05:56:34), the FO asks what runway. "24", he asks. The captain corrects him and says 22, so they are confusing the numbers early on. The conversation about having lights out occurs immediately after this confusion.


After they get pushback clearance, the controller clears them for taxi to runway 22, and they confirm that back to him. Later, as they are taxing out, he clears them for takeoff and tells them to fly the runway heading, but never mentions 22. He obviously expects them to be where he told them to go. Whether it would be obvious to him from the tower they were not positioned correctly.

As they start rolling, the FO comments that the runway looks weird without lights, and the Captain agrees, yet alarms never go off in their heads, probably because they expected there to be lights out.

If you read all of the transcripts, including interviews, it appears only one person, an American Eagle ramp worker, realized they had turned onto the wrong runway and actually ran to the runway as they started rolling. He did not specifically state that he was trying to stop them, but that was the implied idea. He seemed to be the only really vigilant person at work that morning.

It is amazing to me to see the same types of communication and awareness failures that we have seen time and time again. Then again, doing the same thing day in and day out without issues just sets the table for something like this. Bottom line, I'm sure the NTSB will wind up holding the crew responsible.


Patrick

[RobertS975]

The CVR transcript of the Comair tragedy will give more support to the notion of "confirmation bias" as the cause of this accident. Not even the slightest hesitation that they were accelerating down the intended runway...

I have a question... when was the last time that any of you accelerated for takeoff down an UNLIT runway during the hours of darkness while operating a transport category aircraft? And lest we forget, they did pass the runway lights of the intended runway 22 shortly after commencing their t/o roll.

[Huck]

I used to fly RJ's, and I read the transcript.

I see two guys being thorough, with complete briefs and even a taxi brief from the f/o. Yeah, there was small talk - here's the deal: it is how communication is established before a flight begins. You get to know a guy's background, his experience level, his energy level - and you make it easier to communicate effectively before the motors start turning. If a guy won't engage in small talk during the preflight, then we got a problem....

Somebody tell that pr!ck in the KY paper that sterile cockpit begins after the towbar is disconnected. Yeah they chatted a little after that. And it may have contributed. But 95% of the chatter on the transcript was in the chocks.

I know Comair, I know Comair's pilots, and I'm telling you folks: if it can happen there, it can happen anywhere.

[Del Prado]

Cognitive error with the numbers? Runway 22 up to 6, soon becomes 26 in head?

What were they counting just before take off? "6 or is that 7?"

[Virgilio]

it's amazing though right now, they are using everybody pretty
efficiently. um, just shows you what they can do. like I mean I
don't have more than ten hours in a hotel, any of these days that
I've been on....
05:40:38.2
CAM-2 really.
05:40:38.7
CAM-1 ...and it's been that way for all month

This part of the transcript might explain a lot IMHO.

[DifferentVector]

The CVR transcript of the Comair tragedy will give more support to the notion of "confirmation bias" as the cause of this accident. Not even the slightest hesitation that they were accelerating down the intended runway...

And, not a single word of discussion in that 30 minutes on the CVR that the taxiway or runway lights were out - from which I'd guess they had already discussed this and the FO had shared his observation from Friday evening that the Northeast end of runway 22 had no lights working at all. The only time the subject comes up again is mid-roll, after crossing the real 22, when the FO says "dat wierd with no lights" and the Captain says "yeah." That's not proof, but it's the first point at which reality differed from his mental model, and it's the first point a comment is made.

Another framing issue was their delight that they had a very simple clearance that couldn't get "any easier that that", lessening vigilence more.

But there is still the factor of the wrong airport diagram, which is still wrong. ( http://www.naco.faa.gov/d-tpp/0701/00697AD.PDF for those who don't have charts.) The taxiway they should have been using, just west of Alpha-7, is not shown. (it's visible in the photo on wikipedia, at
http://en.wikipedia.org/wiki/Comair_Flight_5191 )

Here's one possible scenario for a different type of framing. The crew understood that A7 was going to be blocked, and got the news that the next best taxiway was in use. Whoever told them that (suppose) meant the new one, the one not shown. They looked at their charts and figured that must mean Alpha-6. They expect an intersection with no lights, no pavement markings, no signage, and four possible ways to go. They expect to see across from them 2 concrete taxiways and, to their extreme left, runway 22, which they expect to be 150 feet wide and have no lights. There is no other spot on that diagram with two concrete taxiways across from them.

But there is a place in reality with two concrete taxiways and a 150 foot wide unlit runway to their extreme left, which is where they really were.
They didn't know about the new taxiway, and they may not have realized that runway 22 was actually 150 feet wide (with only 75 usable).

So, again, nothing seemed out of place, and the decision was "really easy" - taxi to the unlit runway intersection and take the extreme left 150 foot wide runway - "impossible" to make a mistake.

It would be valuable to know what combination of barricades and signage was visible from their gate to the taxiway they took.

[Flight Safety]

Bomarc and Patrickal are right on. Anytime you're confronted with a potentially confusing or complex situation (in this case construction at KLEX), a higher level of mental vigilance is called for, in making sure that all the facts and information are mentally processed correctly.
This exchange is interesting:
05:56:49.9
CAM-2 two two up to six, white data * FMS, flaps twenty. * smokes or
breaks come back here. come into four or two two. on two two
the ILS is out. or the glideslope is, the REILS are out. the uh,
came in the other night it was like [sound similar to audible exhale]
lights are out all over the place.
05:57:07.8
CAM-1 all right.
05:57:08.4
CAM-2 right. remember this runway predicated, before we just go back
to Cincinnati.
The FO doesn't have his facts right about unservicable runway equipment. In some situations this wouldn't matter, but in a potentially confusing or complex enviroment, getting ALL the facts right matters (shows all are focused on getting the facts right). Neither the FO or PIC bother to sort out the nav aids, lighting, and other airport changes created by the construction, though both seem to be aware of the construction. Instead they subject shift right back to emergency procedures, then rapidly on to other preflight items. I believe if they had bothered to sort out the construction details together, the lack of runway lights on 26 would have stood out instantly (should these lights be out?, violates the regs?, are we on the right runway?, etc), and I also think they would have been crosschecking their taxi path and runway alignment.
Bottom line, there appears to have been no mental vigilance regarding a potentially confusing situation. When you're in such a situation, cut the chatter and focus on the details.

[411A]

It would appear that Comair pilots generally are of the lowest common demominator, if this terrible and totally unnecessary accident is any indication.
Not paying attention to business, idle chit chat, wrong airplane initially, then the wrong runway, unlit no less.
Seems to me that aircarrier certificate action by the FAA is long overdue with regard to Comair....and indeed other regional airlines, if the Comair accident is any reasonable indication.
Harsh comments, you say?
Yeah, some might agree....untill we look not far in the past at the Pinnacle FL410 fiasco.
Junior birdmen, sadly.
Just the tip of the iceberg with regard to regional airlines, I suspect.
With all this CRM parlor games nonsense requirements in the training departments now, no wonder we have accidents like this one, where very BASIC requirements go unnoticed.

[Tex]

411A,

It appears you have been reading some of my articles regarding the new CRM courses as parlor games. Thanks!

[Huck]

It would appear that Comair pilots generally are of the lowest common demominator

Then obviously, 411, you support attracting more experienced, higher caliber pilots through the raising of salaries and benefits, in accordance with the invisible hand of the free market. You are aware, aren't you, that both these guys could have made more money managing a Subway....

[AN2 Driver]

Hey there BoeingMEL,
Mmmmmm.....point taken. I must say that we did crank up the apu, in fact the stews that came on board our aircraft were going to London, and we were going to Paris. That's when we found out we were in the wrong aluminium tube. So we walked over to the next gate. Was pretty hilarious.:\


Seem to remember a major hickup years'n'years ago with some charter outfit which had parked 4 planes overnight. Nobody was sure which plane went where so it came as it must, pilots for Glasgow, cabin for London, Pax for Manchester and baggage for Birmingham. Now fill in all variations of the above and you'll get what the other 3 planes had. Took until lunch to sort out. Oh, yea, and 2 of the planes were off blox when the cabin announcement got people shouting "waitaminite!!" in a big chorus.....

[bomarc]

Huck is right about a few things. I wrote a lengthy analysis of this CVR transcript and its meanings ...way beyond the sterile cockpit stuff.

And HUCK is quite right, a bit of small talk is vital to "team building" in the cockpit.

I won't publish my analysis here, yet. I will attempt to have it published where it will do more good, somehow the public must understand what airline flying in the USA is becoming.

When it is published elsewhere, I may reprint it here.

And guys, there is so much more in the transcript than what you have already mentioned...read it like your life depends on it...every word...don't skip anything.
===
the following is to be taken with a grain of salt and not reflect the tragedy of the Lexington accident...if you think you will read it the wrong way, don't read it at all.

Huck is right too about managing a subway restaurant/sandwich shop.
The question to modern pilots is this: is it easier to hit on a babe with the line: I fly for comair and make crappy $, or I manage a subway and make crappy sandwiches but twice as much money as that comair guy?

[411A]

The salary at Comair has absolutely nothing to do with this KLEX accident, and it more than likely would have happened if the crews salary was twice what it was.
The VERY basic fact is, poor training combined with a culture that is NOT safety oriented, which is confirmed by the CVR transcript.
These Comair guys are there simply because they hope to either have (eventually) the regional salaries higher (not likely to happen) or they hope to get hired by a major carrier....where they will find declining salaries, and there is positively nothing that they or ALPA/APA can do about it.
Period.
If bigger bucks are required (to hit on the babes etc) then these guys might as well try Subway management.
Indeed, by the looks of the transcript perhaps this is where they belong.:ugh:
In short, shape up, or ship out.

[Sqwak7700]

The salary at Comair has absolutely nothing to do with this KLEX accident, and it more than likely would have happened if the crews salary was twice what it was.
The VERY basic fact is, poor training combined with a culture that is NOT safety oriented, which is confirmed by the CVR transcript.
These Comair guys are there simply because they hope to either have (eventually) the regional salaries higher (not likely to happen) or they hope to get hired by a major carrier....where they will find declining salaries, and there is positively nothing that they or ALPA/APA can do about it.
Period.
If bigger bucks are required (to hit on the babes etc) then these guys might as well try Subway management.
Indeed, by the looks of the transcript perhaps this is where they belong.:ugh:
In short, shape up, or ship out.

Dude, you are such a jack-ass. The salary at Regional airlines in general is indicative of the tough conditions that pilots working there have to face. It goes hand in hand with how overworked and fatigued they are. Sometimes I wish that non-pilot morrons like 411A would stick to commenting on ****t they know more about (ie, nothing). I really don't think PPrune is for you.
:=

Having read the transcript, the only thing that is really clear to me is that they were both extremely tired and not thrilled about their jobs. Most of the conversation is spent talking about "moving on". Not to mention how the FO called for the briefing even though it had already been completed. Less than 10 hours on overnights? That probably includes time traveling to and from the hotel and going through the ridiculous TSA loops.

This should be a wake up call to the FAA and NTSB. They guys messed up, there is no covering that. But what needs to be scrutinized is that they were definetely affected by Fatigue. This should be "the straw that broke the camels back" for overhawling the Duty/Flight time limitations. They are outdated and something needs to be done to ensure the proper rest of crewmembers. :D

[411A]

Dude?
Oh dear, 7700, you do indeed use the same terms that the Pinnacle guys did, just before they fell out of the sky from FL410...which clearly indicated the level of experience the regional guys have.
How very sad.
When you get to my level (25K hrs, the last 19K in command in heavy jet transports...and still flying 'em) of experience, 7700, you can tell me ALL about your problems.:rolleyes:
Fatique?
Find another job.
The duty/flight time regulations have been used as a whipping boy for years by some malcontent pilots that many times simply fail to do the job for which they were hired.
Perhaps Subway is indeed more suited for these folks.

In short, find another job if you don't like the one you have now.
Rather basic, actually.

[XL5]

http://news.yahoo.com/s/ap/20070118/ap_on_re_us/kentucky_crash_25


Louise Roselle, one of the attorneys representing victims' families, said the pilots' conversation about searching for other jobs reinforces one of the central issues in the lawsuits related to the crash. "It reinforces how Comair has been treating its pilots," Roselle said.

So, it would actually seem that the rather basic option of a different job was being considered. Perhaps they'd even filed applications with dodgy third rate operators - bags of duty with no fatigue issues, just like old 411A.

[DifferentVector]

Here's a short list of "system factors" that seem to have been at work, not "causal", but any one of which might have changed the outcome it it had been different:

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

These are intended to be a list of factors beyond individual performance that are potential intervention points to prevent similar events in the future.

Do I have those right?

[bomarc]

training and culture are a huge part of this accident.

as to the 18000dollar piece of equipment...there is already a localizer receiver on the plane...tune it to runway 22 ils (gs ots, but loc ok) and the "needle" would center up if the plane was on the correct runway.


ask comair if they trained their pilots to do that?


demanding excellence as standard by the company would help...but there is a quid pro flo there.

also note that comair was in talks to lower pay to all employees at the time or approx time of the accident...

[JustAnothrWindScreen]

You get what you pay for. As things shake out in this industry, why would anyone with any ability or talent want to go into it. I love to fly, but if I was going to make peanuts for a flying career I would have gone into another endeavor and then flown on the side. Why would any highly trained military pilot leave for what is becoming available in the civilian world? The flying public that pays $4 for a latte and then surfs the internet for an hour to save 10 cents on a ticket are going to get exactly what they pay for. This is just a wake up call for what is on the horizon. Management may think they can buy an aircraft with all the latest doo dads that anyone can fly but when it comes down to it, experience, talent, dedication, and many other factors make the individual pilot the only reason the system works so well today.

[Huck]

Fatique? (sic)
Find another job
Thus the stellar safety record of the supplemental world. Keep telling yourself it's working.

You do understand, don't you, that the above-quoted statement is a violation of the FAR's?

[Midland 331]

Seem to remember a major hickup years'n'years ago with some charter outfit which had parked 4 planes overnight. Nobody was sure which plane went where so it came as it must, pilots for Glasgow, cabin for London, Pax for Manchester and baggage for Birmingham. Now fill in all variations of the above and you'll get what the other 3 planes had. Took until lunch to sort out. Oh, yea, and 2 of the planes were off blox when the cabin announcement got people shouting "waitaminite!!" in a big chorus.....

Ditto Midland at EGLL in the late 'eighties. The "November" stands.

It tends to focus the attention of the passengers....

r

[flyboyike]

It would appear that Comair pilots generally are of the lowest common demominator, if this terrible and totally unnecessary accident is any indication.
Not paying attention to business, idle chit chat.....

Harsh comments, you say?


No, not harsh at all. One question, though: how do you feel about KLM and Pan Am pilots?

[The Big Bunny DC-9]

I know Comair, I know Comair's pilots, and I'm telling you folks: if it can happen there, it can happen anywhere.
I hate to say "ditto", but I just did. :D

[Sqwak7700]

411A, regional guys flying jets are some of the most experienced in the industry. They fly 4-6 leg days, 4-5 days a week in some of the most chalenging airspace/weather out there. You probably never did any time at a regional. Right now you probably start briefing 500 miles from your destination for an ILS into a 12000ft runway. I would love to see you do a BOS-EWR with delays, low weather and 3 runway changes on final. Remember, no autothrottle or autoland.
In this job, you never stop learning, but I bet you decided you knew enough a long time ago. The only good news is that with so many hours you are probably pretty close to retiring or kicking the bucket.

(Edited by moderator DANNY)

[Ignition Override]

Sqwak7700:

You might be new on the Pprune website.

There are many experienced pilots here who, based upon not just their experience levels but also on their searching for factors which contributed to accidents, want to help broaden the big picture behind many accidents. This might help the rest of us better anticipate what can go wrong either at a given airport or in a new situation.
These seem to be in the majority (although at first glance, other non-pilots often want you to believe that they are pilots).

There can be a very tiny minority of real pilots who appear to have been, based upon their comments, never involved in any accident, incident, nor even a mistake. Truly super-human, apparently able to fly for 30 hours without a mistake in planning, c0ckpit 'flow-patterns', crew-coordination or judgement. Not just a "5-striper", but maybe wearing 6 strips. :cool:
Most impressive-at least from the anonymity of a distant computer monitor and keyboard.

Of course this impression is only based upon their comments on Pprune by way of their ability to quickly and accurately judge others by excluding any and all external factors, including correct Jepp. charting or not.
We continue to be impressed by this unprecedented ability to avoid any mistakes, under whichever conditions.

The books which I've found interesting, i.e. "Fate Is The Hunter" (Gann), "Flying The Hump" etc, were written by superior pilots who enjoyed long and colorful careers, but admitted to some mistakes, and avoided the self-centered desire to appear superior to all other fellow pilots. The late Len Morgan also wrote valuable books.

[Clandestino]

Thank you Ignition Override, I´ve just got the notion of posting something similar, when I observed your post and saw you sparred me the effort.

In real world, 411A is worldwide (in)famous L1011 instructor, I guess he still flies sims. 411A is the type of airplane he owns. Most of things listed here (http://www.chucknorrisfacts.com/) are applicable to 411A too.

As for the Lexington disaster, bear in mind that:Whenever we talk about a pilot who has been killed in a flying accident, we should all keep one thing in mind. He called upon the sum of all his knowledge and made a judgment. He believed in it so strongly that he knowingly bet his life on it. That his judgment was faulty is a tragedy, not stupidity. Every instructor, supervisor, and contemporary who ever spoke to him had an opportunity to influence his judgment, so a little bit of all of us goes with every pilot we lose.


I´ve got this one from Skygod. (http://www.skygod.com/quotes/safety.html)

[411A]

Hmmm, lets see.
A young guy (or gal) wants to be an airline pilot.
So, out they go and obtain their ratings and get hired by a regional airline.
Even Comair perhaps.
Especially Comair, and I suspect that many of the guys there eventually expected Delta to absorb the operation, and they would have a DAL seniority number.
Ain't gonna happen, and never will, which is perhaps just as well, as DAL is bankrupt anyway.
Pensions gone, etc.
Anyway, these folks are hired by the regional into the RHS of a nice shiney new jet.
So far, so good.
Before being hired, they are informed of...
Salary.
Working conditions.
If they agree, and agree is the operative word, they proceed to ground school, where in addition to systems knowledge about the airplane, they receive information about flight and duty time limitations, as laid down by the company, and the FAA.
There it is, in black and white, for 'em to read and (hopefully) understand.
Then on to sim, line training etc, and presto, a newly minted jet transport First Officer.
What's one of the first items on their agenda that they complain about?
Salary, and duty/flight time limitations.
Oh dear... 'we are tired, we never see our families, we don't make enough to make ends meet.'
Well, so what?
You wanted to be an airline pilot, and now you are one.
Welcome to the club.
Tough beans.
Cry me a river.
Not happy in your present position?
Write your Congressman about changing the flight/duty time regulations, and if you really are unhappy, I expect Subway is accepting applications.
However, if you decide that airline flying is really what you want to do as an ongoing career, then pay attention to what you are doing on the FD, and don't attempt departure on an unlit (and too short) runway.
In short, do the job (properly) for which you are being paid, and stop using fatigue and duty/flight time limitations as an excuse for poor performance.:=

[Huck]

However, if you decide that airline flying is really what you want to do as an ongoing career, then pay attention to what you are doing on the FD[....]

OK, I'll go along with that. My father, who retired after 31 years red-book NWA as a whale LCA, told me when I started: operate that Cessna like I was captain of a 747. It is a habit that has served me well.

This crew commited an error, as in so many accidents. That should not, however, stop us from looking at all the other links in the chain, should it, 411A?

By the way, how much rudder pedal force is needed during a V1 cut in the 411? Isn't it ~125 pounds? Quite the aircraft....

[411A]

No V1 with the 411, Huck, it's a CAR 3 certificated aeroplane.
Now, as to rudder force to keep it straight in the air, with one engine unserviceable/propeller feathered, at the published Vmca speed/max weight, it would be 140 pounds...which, oddly enough, is about the same as an old straight pipe powered B707-300 with an outboard engine failed at rotation.
Yeah, I've flown these too, extensively.
Now, to look at the reasons why the Comair accident occured, a rather long investigation by the NTSB will certainly be necessary.
But, when was the last time a professional jet transport crew attempted departure on an unlit runway, during the hours of darkness, and at the same time failed to note that the runway magnetic track was positively NOT what it was supposed to be?
To NOT notice these very basic errors, leads me to believe that the crew was not properly trained, and further, that the specific airline has poor standard procedures.
Crew 'fatigue?'
Phooey.
They had the mandated rest, and that should be sufficient.
Sorry, so-called fatigue, as well as poor pay are red herrings with this accident.

[Sqwak7700]

Crew 'fatigue?'
Phooey.
They had the mandated rest, and that should be sufficient.
Sorry, so-called fatigue, as well as poor pay are red herrings with this accident.

You just don't get it, do you dude. :ugh:

Not everything is black and white. Regulations are built for black and white. But the real world is grey, with many hidden, underlying factors.

I don't care if they had a scheduled 30 hour overnight. That doesn't mean that they were well rested, does it? Maybe there were un-controlable factors that influenced their rest. For example, what where the conditions at the hotel? Where they scheduled for an early departure following a series of late departures?

I'm not debating that the accident was not the crew's fault. They messed up, there is no debating that. But most pilots these days would agree that accidents have many contributing factors. Without these, the accident may have happened, or it may have not.

We can't say to pilots "stop making mistakes". That doesn't work. What we can do, is analyze procedures and modify them to make it less likely that this type of accident occurs again.

[Midland63]

In short, do the job (properly) for which you are being paid, and stop using fatigue and duty/flight time limitations as an excuse for poor performance.:=

411A,

From my perspective as a humble SLF, the issue is (or should be) not "Should pay and conditions etc. affect airline safety?" but "As a matter of fact, do they?"

If they do (or might do), then the issue needs to be identified and addressed.

M63

[bomarc]

Huck and 411A are both right about some things:

to huck... I would like to meet you and I am sure you would see things like I do...and God Bless your dad for telling you to fly a cessna like a 747. but I will tell you this...fly a 747 like a cessna too...always know where you are and where you can land PRONTO if you need to , and not by pushing a button.


Did poor pay cause this accident? no.

411A...yes you are manly for flying the 411 series...keep up with those leg exercises. and you are quite right, no V1. ;-)

To 411A. yes, you are right, pay shouldn't matter. the trouble is, something has happened to airline flying and to the younger folks flying the planes. something NOT GOOD. I ask you...what would have happened to the pilots if at 06:00 they both called their crew scheduling and told them:
"we are not well rested enough to fly...we can take off at 10 am if you like."



To both of you, isn't it possible that there is a less than stellar leadership and hiring process at comair? a less than steller operations and training department?

Is it possible (and I believe likely) that the captain signed on with the comair training academy, paid some serious dough, and got mediocre training as a pilot? and of course, what goes around comes around...so being comair trained, comair got the wheat that they sewed?

note that the copilot who didn't go to the comair ab initio training world was the first to notice the lack of lights?


and what of training? my airline, and others say: if you aren't at flying speed by the last 1000' of runway (windshear) firewall power and pull up!(if you can't stop safely of course)...how come comair didn't? don/'t they teach that?

of course how can one know if you only have 1000' of runway left if there are no lights, or instrument markings on the runway (I would like to see a picture of runway 26)?



fatigue...sure...and comair could have a policy: IF YOU ARE FATIGUED DON"T FLY AND WE will not fire you or dock you any pay...safety first.

and they could mean it...but I'll bet you that they don't!

And ALPA could be a little more forceful and tell the pilots> FATIGUED? don't fly, call in and let people know AND WE WILL HIRE THE BEST LAWYERS in the country to defend you, and provide supplemental pay while you are grounded without pay.


There is so much more to this, and it is mearly a symptom of a very sick industry.

ALPA should challenge the laws allowing the potus to order pilots back to work after a strike...gott be unconstitutional! ;-)


And yes, I have flown 3 round trips from Boston to Sewark, er I mean NEWARK without auto land, with 2 jet engines and had multiple runway changes. and for some reason we did it at 16,000' on the way to newark...doing a lot of flying over New jersey below 7000' (with our landing lights extended & on to avoid the GA stuff)

[Flight Safety]

I find I'm almost completely in agreement with 411A. One of his more interesting comments:
But, when was the last time a professional jet transport crew attempted departure on an unlit runway, during the hours of darkness, and at the same time failed to note that the runway magnetic track was positively NOT what it was supposed to be?
To NOT notice these very basic errors, leads me to believe that the crew was not properly trained, and further, that the specific airline has poor standard procedures.
I'm not saying that other factors shouldn't be looked into, because they should. But I agree with 411A that these ARE basic errors. Clearly there seems to be a weakness in the safety culture and related training at the airline. If you want to point a finger somewhere else besides the crew (and look for accountability elsewhere), then pointing it at the safety culture might be the next best place. Maybe the investigation will uncover something useful here.

[Sqwak7700]

I find I'm almost completely in agreement with 411A. One of his more interesting comments:
I'm not saying that other factors shouldn't be looked into, because they should. But I agree with 411A that these ARE basic errors. Clearly there seems to be a weakness in the safety culture and related training at the airline. If you want to point a finger somewhere else besides the crew (and look for accountability elsewhere), then pointing it at the safety culture might be the next best place. Maybe the investigation will uncover something useful here.

You are right Flight Safety. They are basic errors. Almost as basic as say...taking off without being cleared to takeoff. Hard to believe, but someone made that mistake in Tenerife and the deadliest aviation accident occurred. I guess you could also say it is as basic as setting the flaps for takeoff. Who forgets that, right?? :rolleyes: In my airline, and I was always taught, you check the flaps before takeoff. And I'm sure Continental and NWA both had procedures in place to prevent that, but somehow that very simple detail was missed in Michigan and Texas.

Well guess what, humans are human. They make mistakes, and that is gonna keep happening for as long as we exist. What we can do, is learn from our mistakes, not just say "I learned better because I was taught in my academy that you do this and that, so I would never do that". It doesn't matter how old you are, where you were trained and what your flight time is. ****t happens and we can either through blame back and forth or we can look for ways to prevent it.

I have no doubt in the world that from what I can interpret on the CVR, the FO and CA were tired. They were both yawning throughout the recording, and the FO called for the briefing twice. That is a really good indicator that he wasn't firing on all cylinders.

Be advised, fatigue is like intoxication or worse. You are not performing at your best, but even worse, you don't know it. It is the things you don't know that you don't know which will kill you.:D

[ZAGORFLY]

Don't forget about the nugget on duty in the cab that cleared them for takeoff without even looking outside. :eek: :ugh:

Is simply terrible to read our pilots reading back "two two " knowing that they will inexorably meet their end heading 26 instead .
The airport map is still there at goggle earth and once again I take your attention to the fact that the number 26 was in the left of the aircraft taxing and no further ground mark are visible when you enter the RW26. If they had continued the taxi those wheels would have touched the RW22 marks at the ground. Was a prerequisite to check the magnetic heading with the clearance? Anyway this to say that the airport layout had its contributing factor to this disaster.

[the_hawk]

please allow me a question from the SLF and vATC side: the runway designator was not used in both takeoff clearance and readback - and this point is discussed alongside more "important" topics here if at all - does that mean this is common practice and not worth discussing or do you all agree that it didn't have an impact on this accident and is not worth discussing for safety reasons?

[Telstar]

The Hawk I want to know the same thing. The Americans have got to accept that there R/T standards are apalling and are contributing to accidents, without taking it as a slight on their nationalistic pride. This is not about Europe Vs. the US. It is a flight safety issue.

I will forever wonder that if the controller had prefixed the takeoff clearance with the runway in use and the crew had readback the full clearance including the runway prefix a light bulb may have gone off in someones head.

I think the final hole in the swiss cheese lining up could have been prevented by proper phraseology like this:

TWR: Cleared for takeoff Runway 22
Comair: Cleared for takeoff Runway 26
TWR: STOP! Wrong runway!

[Huck]

does that mean this is common practice

Unfortunately, in the U.S., I have noticed that phraseology is somewhat lax sometimes, especially when it is late or early, in a small town versus a city, or when the controllers and pilots "know" each other, i.e. recognize each other.

I try to always read back the runway number, and even emphasize it a little - not for the controller so much, but for any other pilots on the frequency, to give them better situational awareness. Let's say someone was on final approach and the controller forgot and cleared you for takeoff on the same runway.....

[Midland 331]

The Hawk I want to know the same thing. The Americans have got to accept that there R/T standards are apalling and are contributing to accidents. I will forever wonder that if the controller had prefixed the takeoff clearance with the runway in use and the crew had readback the full clearance including the runway prefix a light bulb may have gone off in someones head.
I think the final hole in the swiss cheese lining up could have been prevented by proper phraseology like this:
TWR: Cleared for takeoff Runway 22
Comair: Cleared for takeoff Runway 26
TWR: STOP! Wrong runway!

Absolutely!

A high-hours long-haul NW captain once propsed that a huge difference could be made to the US runway incursion problem by more thorough signage.

r

[Phil Space]

As someone who is an old pilot and and not a bold pilot I suggest it comes down to being complacent. Auusie Croc guy Steve Irwin was over the hump where he no longer feared death because he "knew it all". Aeroplanes are like crocs...very docile but with a big bite when you are not expecting it. This laid back crew were bored and neither captain or co pilot thought there was anything out there to bite them. Tired, bored, complacent...call it what you like. This and the MK accident at Halifax are both down to one thing. PILOT ERROR

At least the MK crew just took themselves out!

[patrickal]

As someone who is an old pilot and and not a bold pilot I suggest it comes down to being complacent. Auusie Croc guy Steve Irwin was over the hump where he no longer feared death because he "knew it all". Aeroplanes are like crocs...very docile but with a big bite when you are not expecting it. This laid back crew were bored and neither captain or co pilot thought there was anything out there to bite them. Tired, bored, complacent...call it what you like. This and the MK accident at Halifax are both down to one thing. PILOT ERROR
At least the MK crew just took themselves out!
This is true in any profession which requires a heightened sense of awareness at all times. It can be part of work dissatisfaction, fatique, boredem, etc., but these are all just a part of a bigger problem. The key to success is to keep a "culture of discipline" alive and active at all times. This means having some sort of process, or triggers in your process, that constantly bring you head back into the game and make sure you are not missing anything. This is probably easier to do in a military environment (although you still wind up with things like the C5/Dover Delaware incident), but much harder to maintain in a commercial environment. It requires committment from both management AND crews, along with the unions. It has to be self policing, and in short, MUST become part of the culture. It also requires individual commitment to not allow others to get complacent, even when it feels like you are preaching, or being a geek.

These guys were no different than anyone else doing theirjob in any other profession. They were 75% in the game, talking about things that were not important, and not catching the clues around them that were screaming at them.

I have worked with professional organizations for almost 30 years, at both consulting and management levels, and although I am not a pilot, I do know that you cannot change inherent problems if you do not change the culture. This transcript screams of a cultural problem. You can wish that it were not so, or vehemently disagree, but that's what it is, and EVERYONE has to commit to fix it.
Patrick

[PaperTiger]

The Hawk I want to know the same thing. The Americans have got to accept that there R/T standards are apalling and are contributing to accidents, without taking it as a slight on their nationalistic pride. This is not about Europe Vs. the US. It is a flight safety issue.
I will forever wonder that if the controller had prefixed the takeoff clearance with the runway in use and the crew had readback the full clearance including the runway prefix a light bulb may have gone off in someones head.
I think the final hole in the swiss cheese lining up could have been prevented by proper phraseology like this:
TWR: Cleared for takeoff Runway 22
Comair: Cleared for takeoff Runway 26
TWR: STOP! Wrong runway!I think the general consensus is they believed they were on 22 all the time. Unlikely then that any amount of additional verbiage would have corrected that fundamental error. In your scenario they surely would simply have replied "cleared takeoff 22" and continued down 26.

[bomarc]

we will never know if the accident could have been prevented had the controller said: runway 22 cleared for takeoff.

nor can we blame the controller...there are huge slangisms used by atc in america...so be careful.



I mentioned excellence as its own reward...management should try that too.


and I will say this as a general safety alert and concern. at any airport in the USA where construction is underway, ask for /demand PROGRESSIVE TAXI INSTRUCTIONS to the runway required by you the pilot. yes, I know most of us could figure it out ourselves, but I THINK YOU GET THE IDEA>

[RobertS975]

This is true in any profession requires a heightened sense of awareness at all times. It can be part of work dissatisfaction, fatique, boredem, etc., but they are all just a part of a bigger problem. The key to success is to keep a "culture of discipline" alive and active at all times. This means having some sort of process, or triggers in your process, that constantly bring you head back into the game and make sure you are not missing anything. This is probably easier to do in a military environment (although you still wind up with things like the C5/Dover Delaware incident), but much harder to maintain in a commercial environment. It requires committment from both management AND crews, along with the unions. It has to be self policing, and in short, MUST become part of the culture. These guys were no different than anyone else doing there job in any profession. They were 75% in the game, talking about things that were not important, and not catching the clues around them that were screaming at them.
I have worked with professional organizations for almost 30 years, at both consulting and management levels, and although I am not a pilot, I do know that you cannot change inherent problems if you do not change the culture. This transcript screams of a cultural problem. You can wish that it were not so, or vehemently disagree, but that's what it is, and EVERYONE has to commit to fix it.
Patrick


This is one of the most insightful posts that I have seen on this board. Everybody should read it a couple of times!

I am a practicing physician as well as a pilot. This post could be talking about the world of medicine as easy as the world of professional aviation.

[Dagger Dirk]

Telstar said: "I think the final hole in the swiss cheese lining up could have been prevented by proper phraseology like this:
TWR: Cleared for takeoff Runway 22 etcf etc"
.
Midland 331 said: "A high-hours long-haul NW captain once proposed that a huge difference could be made to the US runway incursion problem by more thorough signage."
.

But Maybe: if there was a facility for the controller to re-phase the brilliance on the runway lighting as he issued the take-off clearance (perhaps via a foot treadle).....
Most runway lights are stage-stepped in brilliance. If the runway lights brightness dropped to stage 1 and then via a timer over 3 to 5 seconds, stepped up from 1 through 2,3,4,5 etc then there would be no doubt in a lined up pilot's mind (and any a/c on finals would know that another aircraft is about to launch on that same runway). Might cover the night-time case anyway.
.
Alternatively, (and works for daytime low visibility also), have the PAPI's do a very quick cyclic light-show (as in "Close Encounters of the Third Kind")
That might be a smarter add-on use of the PAPI's than the FAA's proposed FAROS system.... and would just require a cheap bit of Radio-Shack circuitry in the Tower's lighting console.

[NIMFLT]

Only one runway nominated on the ATIS. Only one runway lit. In this situation I assume it's normal procedure not to include the runway number in clearances other than the taxi clearance.
If the tower controller is not looking out the window when he clears the aircraft for takeoff, then he/she is not providing any additional safety over a non towered airport. The runway should be scanned prior to the takeoff or landing clearance and just prior to the aircraft landing or taking off if there is any gap between these occurances.
It seems that undermanning has really taken it's toll here as the tower controller was busy with jobs that a ground controller would have been doing.

[Sqwak7700]

I agree NIMFLT. The crew were complacent, but so was the controller. It is just as big a mistake as lining up on the wrong runway as it is to clear an aircraft for TO without looking out of the window. That really shows a lack of staffing that the FAA needs to evaluate. Hard to believe that with all the taxes on aviation, that some of that money can't find its way to properly staffing ATC. I'll trade 1000 TSA agents for 1 Air traffic controller anytime of day. :D

One idea, I saw a picture of some airports in Scandinavia and noticed that the runways were painted yellow. I can only assume that this is done due to the amounts of snow that they get, but it made me think. I wonder if painting runways in a unique color would help the situation. One thing for sure, airport markings need to be overhauled and simplified enough so that even a caveman could navigate them. They need to be more intuitive and some airports need to simplify their layouts.

[Crossunder]

Sqwak7700:
Well said!:D
The TSA couldn't prevent this. But adequate funds for ATC and airport equipment etc. could have. Or maybe we should put the TSA people in charge of flying the airplanes as well. As you know, the TSA never makes mistakes, know all and everything and are super-human. ;)
At least the poor pax and pilot died with no harmful liquids (like 200ml of H2O) in their baggage. :ugh:

[pls8xx]

I'm not a pilot, so I'm not about to comment on blame, cause, or prevention of this accident. But I feel I should pass on things I have learned from my career.

For over thirty years I spent work days making observations of alpha-numeric data and recording it in a log book, sometimes hundreds of observations a day. An error of even a single number would have a negative outcome, each and every time.


The first year I had an error every few weeks. The second year I had only three or four errors. The last 20 years I had no errors, none, nada, zero.

The human brain is not set for long periods of maximum concentration. But with practice one can train their mind to go from casual to maximum concentration and back to casual at will.

It appears to me that flight, and particularly preparation for flight, requires a multitude of settings and instrument observations. My guess is that some of you occasionally make an error, probably more often than you think. If you were writting all observations in a log and the instruments were also recording the same, a comparision of the two, and getting docked a days pay for each error would soon change how you operate.

Here are some of my tricks to getting it right every time as applied to pilots. When making an observation, vocalize exactly what you see. Say it out loud at the very time you are actually looking at the setting. For example, if the instrument is a light that can be green , yellow, or some other color, you should not say good, check, on/off, or some other meaning expressed by the instrument. If it is a green light, say the word "green" while looking directly at the light.

Your mind can play tricks on you. Look at an instrument hundreds of times where the light is always green, say the word "check". One day the light will be yellow, but your mind will anticipate "green". You are apt to say "check" and move on. But if you have been saying "green" and one day the light is yellow, when you look at the instrument and say green, your eyes say yellow and your mind rebels. For it to work you must be looking at the light at the instance you say the word.

Vocalize exactly what you see, not what an oberservation means. If it is a gage, digital or analog, read the value! I suppose there must be a heading indicator on the panel. If one of the pilots of the Comair had looked at it and said out loud "azimuth 259", would we be reading this thread?

If a lever or other setting has an indicator that points to words or numbers, say exactly those words while you read them. For example, if a flap setting indicator points to the number "2" meaning 20%, say the word "two" not check or 20%.

The other member of the flight crew is going to think you are an absolute nut case. But you will live to retirement, he may not.

[JustAnothrWindScreen]

Your mind can play tricks on you. Look at an instrument hundreds of times where the light is always green, say the word "check". One day the light will be yellow, but your mind will anticipate "green". You are apt to say "check" and move on. But if you have been saying "green" and one day the light is yellow, when you look at the instrument and say green, your eyes say yellow and your mind rebels. For it to work you must be looking at the light at the instance you say the word.


I like the way you think. Running checklists and doing things by rote time after time after time leads to exactly what you state. My company required exact phraseology for each response and many of them were "check". Before I retired, I used to give the copilots fits because I did exactly what you recommend rather than the rote "check". Whenever I did it by rote, the words flowed out in perfect order but they didn't always agree with what I had answered for.

[flyblue]

pls8xx,
First of all, I agree with a lot of what you say. I also find your system very good, and sure will use it. Thank you for sharing your experience with us :)
The only thing that I don't fully agree with, is that it would lead to 0 errors (not doubting it might have worked with you). Our brain is made in such a way that in some cases, we'll hear "turn right", think "turn right", repeat "turn right" and happily turn left. We sometimes see and hear what we expect to see and hear. In case you don't know it already, have a look at James Reason's Human Error and Absent Minded?: Psychology of Mental Lapses and Everyday Errors.
It is indeed possible to reduce to a minimun the risk of error, using checklists and other tools, but not to 0 I'm afraid, especially in case of fatigue or other issues that could affect the performance.

[Flight Safety]

I'd like to add my own experience to what pls8xx said.

My work environment is complex and I make many decisions everyday that have both serious and not so serious consequences, and some of the tasks I perform have zero tolerance for errors. I don't use a single strategy to prevent errors for these decisions and tasks, but use a variety of task specific strategies to prevent the errors. What the various error prevention strategies have in common is that they each have some form of double checking of the task I just did, or the decision I just made. From experience I've found that I often make mistakes, but always catch them before they produce anything serious.

This is a mental discipline I've developed over the years and it serves me well. I don't waist energy on strategies for decisions with minimal consequences, but only on those decisions with serious consequences. As part of my professionalism, I've also learned to recognize that certain conditions and circumstances raise the consequence levels, and so require greater diligence in the decision making processes.

When fatigued, I recognize that my ability to process relevant information and to make the correct decisions is reduced. If I'm fatigued and still have to make the decisions, then I do a form of mental "load shedding" to get rid of everything in my environment that's not essential, so I can concentrate and make the right decisions. When I know I'm too fatigued to make the right decisions, then I postpone making the decisions until later when I'm more rested, and I know I can process all the information accurately.

This mental discipline is sometimes boring and tedious, but is very necessary when the consequences of a wrong decision are just too serious.

[v1r8]

So, the guys first of all manage to climb aboard the wrong aircraft.... then talk almost endlessly about promotion/training/dining/wives/kids/changing diapers.
This tells you they where...... NORMAL COMMERCIAL PILOTS !
Got your PPL yet?:rolleyes:

[MungoP]

FS

Nicely put and what we all like to practise but this bit...

"When I know I'm too fatigued to make the right decisions, then I postpone making the decisions until later when I'm more rested, and I know I can process all the information accurately."

Oh... what luxuary....

[EDDNHopper]

pls8xx, flyblue, and fs have got it right.

It is called "cognitive dissonance" (=acting differently from what you see, hear...) and plays a vital role in risk construction and reduction. Many procedures, including communication, still don´t sufficiently take cognitive dissonance into account.

[paull]

People had make referenced to chit chat about kids etc., but what are the thoughts? I'm not a pilot but for my early morning car drive the radio is banned (particularly if the screen-blower is full on!) until out onto the highway and settled in. That's my equivalent of the cruise. There is a whole process of getting oneself in the right frame of mind for doing something and surely banning chit-chat unless the seat belt sign is off would hardly be onerous would it? Apologies if that is already the rule.

[pls8xx]

First I would like to thank the forum for not flaming a non pilot for posting. It would seem that my post was taken in the light it was given, something for consideration, to be used or discarded as one sees fit.

I could have done a better job of explaining the technique I proposed. Most all of us have seen the football reciever who thinks to run before the ball is caught. The result is a dropped pass, a lapse of mental discipline.

The important thing in reading an instrument is to move the raw information from the instrument to the brain, without making any translation or interpretation in the process. Once the mind has captured the raw data, then, and only then, should evaluation begin. See what I'm saying? Catch the ball first.

There are a lot of people who go to work every day at an occupation from which they may not come home. It might be a plane crash, a semi that missed the curve, a pile of logs that rolled unexpectedly, a construction trench that colapsed, or a farm tractor roll-over. Dead is dead.

There are some common traits to accidents that pop up all over, such as complacency and over-confidence. I characterize over-confidence as an absense of reasonable fear.

The career carpenter who loses his fear of the power saws he uses, cuts his fingers off. If you have met as many carpenters as me you have seen those missing fingers. I think of pilots as a pretty safe bunch of guys. If they made pilots out of carpenters no one in his right mind would get on a plane.

I own a big Craftman's table saw. I was afraid of it the first time I used it. Thirty years later, I'm still afraid of it. The thing can hurt you in the blink of an eye. From early on, every time I reach for the switch, I pause to ask myself "Are you sure you know what is about to happen?" Did I have my mind on the set-up, or was I just going through the motions? Do I feel good about this? Maybe I waste a lot of time re-checking things, but I do still have all my fingers.

Today I'm going to imagine that I am a pilot. One of the first things I'm going to do is adopt a philosophy that goes something like this: "I am the pilot. I may make a mistake. I might kill myself and a lot of other people too. But I am not about to let anyone else kill me. I am the pilot."

So I'm out on the runway, the SOP complete, ready to roll. Or am I? Start down that runway and in a matter of seconds I will be past the Point of Commitment, at which time the plane sustains flight long enough to go around and land, or I'm dead. If there is to be any reassessment of the situation. it has to be done before the roll.

So I lean back in my seat and say the words "T minus 20, fly or die." Why? Because I want both feet planted on reality. I may have done a hundred take-offs with this plane on this runway. That won't save my hide today. The only thing that matters is the situation today, right now. I might just take a minute to think things through. Or ten. Hell, I might sit here til they come tow the plane onto the grass. The decision to go or re-evaluate is mine. But the reality really is "T minus 20. fly or die."


One of my favorite quotes of Will Rogers ...

There are three kinds of men. The one that learns by reading. The few who learn by observation. The rest of them have to pee on the electric fence for themselves.

[patrickal]

I could have done a better job of explaining the technique I proposed. Most all of us have seen the football reciever who thinks to run before the ball is caught. The result is a dropped pass, a lapse of mental discipline.....

There are three kinds of men. The one that learns by reading. The few who learn by observation. The rest of them have to pee on the electric fence for themselves.

pls8xx,

What your saying is part of what I spoke of when I mentioned a "culture of discipline". Your are dead on when you speak of having to maintain the level of respect and fear of what you are doing and the implications of doing it wrong. The challenge is that it becomes very difficult to maintain that level of awareness and focus on your own. That is where it become incumbent for the organization as a whole to support and encourage this activity. I would think that is the overall goal of CRM, but obviously the dew is off that lily.

There are a number of obvious reasons why we seem to be seeing more failures that are based not wrong thinking per say, but in lack of awareness. More automated process in the aircraft, a society where distraction is becoming more the norm, an industry that seems to care less about it's employees are but a few of the causes. But whatever the causes are, and no matter how numerous they are, when someone sits down in the front seat of an airlplane, everything in the processes that are used should be centered on focusing attention, and maintaining it. No one should feel awkward about making sure the rest of the crew is equally focused. That is where the change in culture has to take place. I too am not a pilot, but I can clearly see cultural changes are crucial to keeping air travel as safe as it can be.

Patrick

[Sqwak7700]

I own a big Craftman's table saw. I was afraid of it the first time I used it. Thirty years later, I'm still afraid of it. The thing can hurt you in the blink of an eye. From early on, every time I reach for the switch, I pause to ask myself "Are you sure you know what is about to happen?" Did I have my mind on the set-up, or was I just going through the motions? Do I feel good about this? Maybe I waste a lot of time re-checking things, but I do still have all my fingers.

Today I'm going to imagine that I am a pilot. One of the first things I'm going to do is adopt a philosophy that goes something like this: "I am the pilot. I may make a mistake. I might kill myself and a lot of other people too. But I am not about to let anyone else kill me. I am the pilot."

So I'm out on the runway, the SOP complete, ready to roll. Or am I? Start down that runway and in a matter of seconds I will be past the Point of Commitment, at which time the plane sustains flight long enough to go around and land, or I'm dead. If there is to be any reassessment of the situation. it has to be done before the roll.

That is very good advise pls8xx. But you need to keep something in mind. I will refer back to your tablesaw analogy;

Do you get up at 4:00am and go straight to your workshop to turn on the saw? On your way to the saw, do you get into the wrong workshop? Just as you are going through your mental preparations to switch it on, do 3 different people come in and ask you to hurry up?

This isn't meant as a wise-ass coment, it is just an example of the pressures put on pilots to do a safety-related job with many, many distractions. You do raise a very good point, which is to take your time to pay attention to your task at hand. That, IMHO, is the most important tool in our arsenal to prevent accidents. The second is the guy next to you doing the same thing. Unfortunately, we got rid of the third pilot. They use to act as a barrier and filter to all the people who use to come in to the cockpit during heavy workload periods. Let's hope we never get rid of number two. When we do, I'll make sure to buy ****t-loads of Greyhound and Amtrak stock.

As one goes through their aviation carreer, you meet and fly with many different pilots. But there are some that stand out, ones that you really learn from. I can say that out of the many pilots that I really admire and learned from, the one quality they all shared was that they were very patient and slow with there operation. Always taking their time to let things progress at their own pace. Things happened when they happened, and no-one was ever rushed. That means no-one rushed us, but also means that we don't rush anyone else. Be it another crewmember, a fueler, ATC, or even maintenance.

For some reason, some people in this industry are hell bent on keeping to the all important schedule. When is the last time that someone came into an operating room to tell the doctor that they should operate quicker cause there are patients waiting for their turn? You can't rush safety. Yet people think that it is OK to rush the person that will transport you through the air, 6miles above terra firma, at 85% the speed of sound in an alluminum/fiberglass tube. Just as dangerous is rushing the guy who is loading 120 metric tonnes of combustible liquid into the same tube in which you will be ridding. Or even the guy who is tightening the bolt that fastens the wheel that allows you to roll to a speed of 180mph when you leave the ground. You get the point.

Now, as the Captain, one of the most important things you must do is set the tone. If you come running into the cockpit and right away start rushing, you are gonna pressure the team of people arround you into the same trap, even if they are fighting to slow themselves down. Even if you don't say a word, they are gonna read your body language and follow you down that path. People try to avoid conflict, so they won't interpret the danger and just try to take on the higher workload of rushing through their job.

I always briefed my flight attendants and FOs that they take their time and that any delay we take will be my responsibility. I will back them up 100% and they need not worry. My only concern is that they do their job to the best of their ability and take their time.

If you see maintenance on the airplane when you arrive at the gate, then wait until they get off the airplane to begin your duties. Even if you don't tell them to hurry, they will instantaneously start to hurry when they see you start to do your job. That's how we humans operate, we are funny creatures.

I believe that there are certain pressures that Managers can put on their crews to hurry. You could have a policy that makes pilots explain their delays, like my previous job. Even if you don't punish late departures, just calling someone into the office to explain themselves is enough to deter them from taking their time and doing things right.

This pressure isn't always exerted in a negative way. For example, I believe SWA pays their pilots extra for arriving early. Now, I've met my share of pilots, and one thing I can say for sure is that we have some seriously tight people in our ranks. Some will do anything for a little extra money. I don't know if SWA still has this policy, but I know that they had the BUR and MDW accidents during this policy. And I've seen some other incidents with SWA aircraft that, although funny, could have led to serious implications under different circumstances.

So how did this time pressure come to be? I think that flying has become so routine that people have forgotten the underlying danger. The low accident record is attributable to the professionalism of all people involved in aviation. Not just crews, but aircraft builders and everybody else that is part of the complex puzzle that makes up this great industry. :D Accidents have become so rare that everybody knows that flying is safer than driving to the airport. But maybe we need to remind them that as safe as flying might be, the chances of turning your body into cornflake-sized pieces during a car accident are very rare, but pretty common in an aircraft accident.

So please, take your time and remember that a late arrival is better than never. That is where we as pilots earn our money; making sure that all these distractions and influences don't keep us from professionaly doing our job.:ok:

[Huck]

Now, as the Captain, one of the most important things you must do is set the tone.

Back when I was PIC, I always included this in the preflight brief: "I run checklists slow, I taxi slow, and I fly slow. If anything ever happens to me, I want everyone to say, 'Wasn't that the guy that was so slow?' " A much better reputation to have than the opposite.

On the other hand, I was a young DC10 F/O at an ACMI carrier when we showed up at 4 am for a departure from Chicago to Basel. The departure had already slipped 4 hours. The captain said, "I want to be starting engines at 5am."

Well, there were maintenance logbook issues to be resolved, and more fuel to be put on, and at 5 am we were nowhere near ready.

The PIC had an absolute sh!t-fit, screaming that we were late, we were supposed to be out at 5, what the hell was wrong with us. I let him rant for awhile then pointed out meekly that the 5 am thing was SELF-IMPOSED, that obviously neither the company nor the customer gave a wet slap about an on-time departure, that all this tension just makes it worse.

Thing was, he was a good guy and a great pilot otherwise. I think alot about that flight.....

[barit1]

One of my favorite quotes of Will Rogers ...

There are three kinds of men. The one that learns by reading. The few who learn by observation. The rest of them have to pee on the electric fence for themselves.

... and ... there are those who never learn.

[bomarc]

sadly, the discipline spoken of by the previous posters is no longer "cool". or with it, or HIP, or HEP or whatever.

Laid Back is where its at, right chicky baby.


non cool:

taxichart on approach clip

veryify runway with localizer

watch for runway markings to measure runway remaining.

using full power takeoffs with full planes.


===


cool:


being laid back.

not worrying about charts, I got it all memorized


not wearing glasses you need.


each takeoff and landing is the same routine thing...it ain't brain surgery...it ain't a lunar landing.


==

[Fokker28]

411A, you're absolutely right. We regionals know nothing of professionalism, standardization, and high training standards. That's why this kind of thing could only happen at a regional. No major would every do anything like that. Or like forgetting to set the flaps on an MD-80 departure, or descending a perfectly flyable airplane into a swamp because a gear indicator was burned out, or trying to fly a 6 degree glideslope to a short runway in a 737, touching down halfway down the runway at over 180 kts, or...

You really don't know what you're talking about.


Oh, and has anyone proven that the crew wasn't GIVEN the wrong a/c assignment in the first place? That has happened to me more than once.

[barit1]

These guys (http://www.ntsb.gov/ntsb/brief.asp?ev_id=20070123X00090&key=1)blew the pre-takeoff-checks too. It's sad what you can miss when your guard is down.

Fortunately no pax.

[Riverman]

Just another lonely 'nugget'...

Eye on the Sky Worthy of Praise
Controller averted possible jet crash

January 27, 2007 - Pensacola News Journal

Veteran air traffic controller J.D. Smith of Pensacola is going to Washington to be honored with a major safety award for averting a possible disaster last fall at Pensacola Regional Airport.

Smith will be honored Monday by the National Air Traffic Controllers Association for his action that prevented an incoming Northwest Airlink passenger jet from landing on a runway that was closed and littered with heavy machinery and debris.

He will receive the Archie League Medal of Safety Award, named for the nation's first air traffic controller.

In announcing the award, the Association said Smith's "keen awareness of the airspace prevented a possible major runway accident from occurring."
"This save is remarkable for several reasons," said NATCA Southern Region Safety Representative Perry Doggrell. "For him to notice a plane was lined up on the wrong runway, two or three miles out from the airport, from a radar screen is incredible. There were no windows, so he could not look outside and see the aircraft approaching. He only had his radar screen."

Full Article
http://www.pensacolanewsjournal.com/apps/pbcs.dll/article?AID=/20070127/NEWS01/701270323/1006

[chickenlittle]

.

To Whom It May Concern:

The FAA has told us that the lone controller at Lexington tower turned his back on Comair 191 and was busy with "administrative duties, traffic count" after he cleared Comair191 for takeoff while it was on the wrong runway. Initially, he admitted seeing Comair on the wrong runway and later changed his testimony..

The FAA released the tapes the other day and I downloaded it from their site at....

http://www.faa.gov/data_statistics/accident_incident/comair_tapes/

If you download the ATC Communications audio (MP3) tape there and play it, you can hear Diane English, an FAA employee, say she made the tape from 0944 Coordinated Universal Time - 1026 Coordinated Universal Time on August 27, 2006. The accident occurred at 1006 Coordinated Universal Time.

If you want to understand what happened, download the tape and play it while you read the following information....

At 06:52 into the tape, Comair 191 calls clearance delivery for his clearance to Atlanta.

Christopher Damron, operating initials CD, the lone controller, was working four positions. (1) Flight data/clearance delivery(FD/CD) where he had to contact center and transmit clearances to aircraft on one frequency, (2) Ground Control (GC) where he had to issue taxi clearance and watch taxiing aircraft on ramp and taxiways on another frequency, Local Control (LC) where he had to watch aircraft on the runway and in the traffic pattern in the control zone out to five mile radius on a third frequency, and Radar Departure Control (DC) where he had to give heading to fly for arrivals and departures below 10,000 ft. on a fourth frequency. This is not too much to handle if things fall in a staggered sequence, but when you get busy, someone has to wait. You can't talk on four frequencies at once or talk to ten aircraft at once. In the business, it's called going "Down the tubes". During the day, all these positions are manned and in addition the local control position can be split between two controllers. There is a supervisor and cab coordinator (CC) also who monitor all positions to insure safe operations. I have a photo I took a LGB where you can see ten controllers in the tower cab.

As you listen to the tape, you will see that CD doesn't have a lot of time to catch his breath in the minutes before Comair is cleared for takeoff. After that, he has nothing to do. He let his guard down. These times show it to some degrees but his transmissions are sometimes lengthy and there is little time between each transmission.

At 06:58, CD issues Comair his clearance to ATL and..
At. 07:12 Comair reads back the clearance and admits he missed his arrival route into ATL. CD had to spell it out for him.

At 13:30 CD makes a blanket broadcast that the ATIS has changed to Bravo and the new altimeter setting is 30.00.

At 13:54, the controller, operating initials Charley Delta, calls ARTCC. He doesn't key his microphone while dialing (old rotary pulse phone) but has to key in to talk to center at 13:58. That is when you hear CD breathing and the music in the background from the radio. He unkeys his mike at 14:05 and the music can no longer be heard. We hear it again at 14:09 when he keys in. ARTCC hasn't come up on the line so the music can only be in the tower cab. At 14:08, ARTCC comes on the line and CD requests a release on Skywest 6819. Center releases him and CD gives his initials and hangs up at 14:12. The music stops at that time.

At 16:04 into the tape, Comair 191 advises he is about to push back.
At 16:09, ATC responds Roger, advise ready for taxi.
At 16:11, Comair says Roger.

At 16:32 into the tape, Eagleflight 882 calls for taxi and at 16:43 he taxis him to RWY22.
At 17:26, Skywest 6819 calls for takeoff clearance at RWY22
At 17:30, ATC says Thanks, turn right heading 270, Runway 22, cleared for takeoff. Since there was only one active runway, it is not required that ATC specify the runway when issuing takeoff clearance.
At 17:35, Skywest 6819 acknowledges cleared for takeoff.

At 18:33, Eagle 882 calls ready for departure
At 18:36, ATC replies, Eagle 882, roger, hold short.
At 18:40, Eagle 882 acknowledges, Hold short of the runway.

At 18:57, Comair 191 advises he is ready for taxi instructions and states that he has Alpha. At 13:30 the ATIS changed to Bravo and he was not aware that the ATIS had changed .This means he has listened to the Airport Terminal Information Service (ATIS) on a separate frequency which gives him the active runway, winds, altimeter setting, and other NOTAMS (Notice To Airman) about taxiway closures, instrument approach outages, lights out of service, etc. You can also hear it on the phone, as well. In the government pages of the white pages, it's under Transportation, Department of, FAA, ATIS. To his credit, CD caught this and re-issued and winds and altimeter to Comair.

At 19:02, Comair 191 acknowledges that he is to taxi to rwy 22.
At 19:09, CD clears Eagle 882 for takeoff
At 19:11 CD calls radar contact on Skywest 6819 and gives him further instrutions.

At 20:27, CD calls radar contact on Eagle 882 and gives clearance to 10,000FT.

At 20:48 CD goes on the land line and dials center (ARTCC).
At 20:55 CD again keys his mike and we hear the music. While waiting for center, Skywest 6819 can be heard on the speaker in the background saying he is passing 10,000ft.and requesting a turn to 300 degrees to avoid weather. CD approves his request and immediately center comes on the line and CD request a release on Comair. He had to be watching Comair approaching the approach end of the short runway because he call for the release in advance of him arriving at runway 22.


At 21:09 CD keys his mike and again we hear the music and hear him tapping the flight progress strip for Comair191 on the console. He asked center for a release on Comair and center issues the release, CD gives his initials and hangs up the line.

He immediately calls another sector and requests the 300 heading for Skywest 6819 to "get around some weather", but he had already approved the turn for Skywest.

At 21:19, CD tells Skywest 6819 to contact center.
At 21:23 Skywest acknowledges the frequency change.

At 21:25 CD gives Eagle 882 a new heading
At 21:30 Eagle882 acknowledges the turn.

At 22:07 Comair 121 transmits that he is ready to go.

At 22:10 CD says Comair 191, Lexington Tower, fly runway heading, cleared for takeoff.

If Comair 191 is at the approach end of the wrong runway, he is nowhere near runway 22. In an interview CD acknowledges that he saw Comair 191 on the wrong runway and NOT on the taxiway to runway 22, but 30 minutes later changed his testimony.

At 22:14 Comair acknowledged fly runway heading, cleared for takeoff.

CD immediately focuses back on Eagle 882 and ...

At 22:17 CD asked Eagle 882 if the heading he gave him worked for him or did he want a further turn to the northwest of the weather that's ahead of him.

At 22:23 Eagle 882 says "That looks fantastic, thank you very much"

CD missed the response and...

At 22:25 CD transmits "Say again, please" to Eagle 882, while Comair is rolling on the wrong runway. He is NOT doing traffic count as the FAA is telling us.

At 22:26, Eagle882 repeats "This heading looks great,

At 22:30, CD is probably looking at the radar scope as he is talking to Eagle 882 and giving him a frequency change to center.

This is 16 seconds after he cleared Comair for takeoff and he hasn't seen him rolling on the wrong runway. He was supposed to scan his runway when he cleared him for takeoff and should have noticed him on the wrong runway. He claimed he did see him on the wrong runway but said nothing to him and didn't cancel his takeoff clearance.

It's odd that a station agent for American Eagle saw Comair on the wrong runway, but the controller claims he saw nothing,..... eventually.

Here's the articles...

http://www.kentucky.com/mld/kentucky/16486163.htm

and..

http://www.kentucky.com/mld/kentucky/news/local/16486135.htm?source=rss&channel=kentucky_local

In this second article, it states....

Damron told investigators that he did not know the plane had taken off from the wrong runway until a union official, who had reviewed radar data, told him. If Comair would have taken off on the right runway, he would have contacted tower on departure and CD would have issued radar contact. CD should have been at the radar scope waiting for Comairs call instead of doing the traffic count.

According to the other tape I downloaded at the FAA site at...

http://www.faa.gov/data_statistics/accident_incident/comair_tapes/

this one labeled..

ATC Phone Call to Fire and Rescue audio (MP3)*

CD pulled the crash phone and reported the aircraft crash, (an Alert III ) at 06:29 into the tape.

Again, the crash phone recording was narrated by Diane English. The tape runs from 1002 CUT-1013CUT on August 27, 2006

That means that CD pulls the hook at 1008:30 CUT. That is about 2 1/2 minutes after the crash. Traffic count doesn't take 2 1/2 minutes to perform. The accident occurred at about 1006 CUT. CD had to be doing something else for that other two minutes. What could he have been doing for all that time? Maybe he took the clipboard over to the radio to change stations. He wouldn't have gone to the bathroom when he was expecting a call from Comair.

He tells the crash crew that the aircraft is off the approach end of runway 8. That is the departure end of runway 26. 80 plus 180 degrees is 260, BUT then he tells the crash crew the aircraft took off of runway 22. I can't understand how he thought Comair took off runway 22 and ended up off the departure end of runway 26. If he took off of 22, he would have had to go off the right side of runway 22 before he got halfway down the runway.

If there would have been a second controller working the radar scope, CD could have been watching his runway a lot closer, but that is no excuse when the runway is the primary responsibility. CD wasn't focusing on his primary responsibility, the runway, but let his attention focus in the wrong direction dealing with radar traffic in the air. Traffic count had nothing to do with this accident.

CD had three departures in a short period of time with a lot of coordination with ARTCC. He is listening to music in the background. If he did the traffic count when he was finished talking with Eagle882, Comair was at the departure end of runway 26 or colliding into the trees off the departure end. Comair crashed before he started the traffic count. He should have seen it happening. CD should have been watching his runway. Aircraft in the air pose little threat to safety compared to ones on the runway.

CD never did tell us why he wasn't looking at the radar scope and telling Comair that he had radar contact on him. He should have been wondering why no radar target showed up at the departure end on runway 22. The traffic count scenario is just smoke and mirrors.

Today, I read an article about the FAA refusing to have weather band radios in the control towers siting it would be a distration. Here's the article....

http://blogs.usatoday.com/weather/2007/01/radars_yes_radi.html

According to a spokeswoman from the FAA, the decision to pull the radios seeks to limit distractions for controllers and ensure safe operation of the airspace.

We had a radio with a cd player in the tower cab at MYF and we used to bring our own cd's to work and listen to them while working traffic. Once at LGB tower, we had a portable TV in the tower cab watching a football game and I forgot to take it home when the tower closed. The next morning, the chief saw it and demanded to know who's it was. I confessed and he chewed my butt until I promised him it would never happen again.


Traffic count should be done on the hour and is a secondary function. The crash occurred at about 6 minutes after the hour. Six minutes prior to the accident, CD was busy with Eagle882 ready for departure. Traffic count is not important. CD had three departures and all he had to do was write down 0-2-0-0-0 on a clipboard to complete the traffic count, Takes all of two seconds. Comair was on the wrong runway for close to 25 seconds.

Here is some inside information for the layman, you don't have to turn your back on the runway to do traffic count. You read the numbers off the counter in front of you and put them on a clipboard, again, in front of you. He should have been watching his radar scope when Comair was no longer on the runway, again in front of him. There is NO reason to turn your back.

The pilot and first officer were given toxicology tests after the crash but I have never heard of a controller being tested for drugs or alcohol following and accident or incident. We hear of the TSA people reporting pilots when they smell alcohol on their breath and they have been pulled off of airliners and registered massive amounts of alcohol in their systems.

Since the 70's, control towers that used to be above the terminals were moved across the airport and the public never came in contact with us if we didn't want them around. At Christmas, pilots used to drop off gifts for us, it's an old tradition. We got candy and cookies, but the main item offered to us was booze, and lots of it. Why would you want to give your controller a bottle of scotch, I never understood it. When I tell people about all the drugs being used on the job, the number one response I get is "Well, it's a really stressful job, isn't it?" I guess they feel if you are in a stressful job, you ought to be able to shoot up a little heroin now and then.

The FAA knows that the public knows nothing about the functions of a control tower and it is easy to "hoodwink" the masses. Now you know the truth.

I came across a letter to AvWeb from a controller claiming things are worse now than when I blew the whistle. AvWeb has been able to confirm her identity. Her letter is at ....

http://www.avweb.com/eletter/archives/avflash/286-printable.html

I have been at this for close to 20 years now. Who is looking out for the safety of the flying public? The FAA ALWAYS says safety is their number one concern. If that was true, they wouldn't have hired one on my co-workers after he had been busted twice in the US Navy for trafficing in drugs. And another who would come to work drunk once a week. They would not have hired me when they knew I had vision problems. But they fired me when I had seen it all too many times and told my chief we were getting tipped off about random drug testing and over half of us were using on the job. He was the one who tipped us off the day before the drug team arrived so we could switch shifts with a non-using controller, if we could find one. And the guy who the chief told was the guy who was dealing all the drugs.

I have played tapes of telephone calls with my co-workers where they admit knowledge of druguse on the job to my Congressman, Duncan Hunter, and to the press in San Diego. Nothing is done. I have sent the tapes to the Aviation Subcommittee of Congress and to the White House. Nothing is done.

Who is going to stop this from happening again and again. We have been ignored, attacked, and accused of having our own agenda by the press, government officials, and family members of such tragedies as TW800, Swissair111, Egyptair990, and ValuJet 592. Now one of the Comair191 family members has asked me to remove him from my mailing list.

We are the head wiring experts from Boeing and the Dept. of Defense, airline pilots, two FAA lead airline inspectors, an FAA security expert who reported problems at Boston Logan and resigned after the FAA cooked his reports (before 9/11), an airline mechanic, and the inventor of the smoke hood for airline cockpits. Everyone talks about wanting to make sure nothing like this happens again, but when we give them what they need to do something about it, it's "shoot the messenger".

The press could report these crimes, but they refuse to let the people know the truth in our land of the free. I have told reporters that if they get this story past their editor, the next big story they will be working on is the bear problem at the dump. How can our President say people are jealous of our freedom?

Now YOU know the truth about what happened to Comair191. The NTSB final report will say that the controller had his back turned away from the runway and nothing more. If you don't believe me, look at how the NTSB covered up the crash of VJ592 and screwed over the families there. You can read all about it on my website at....

http://users.sdccu.net/chickenlittle

The Congress won't let me testify because they can't have everyone knowing the real story about aviation safety and the way they are watching over the system. We will just have to hear about more innocent people dying by the hundreds over and over again. I will be wasting my time for decades to come.

Regards,


James Bergquist
Air Safety Activist
Former USAF and FAA air traffic controller
Former San Diego Country NATCA representative

[nooluv]

Sounds like the truth is coming to light!!

James Bergquist
Air Safety Activist
Former USAF and FAA air traffic controller
Former San Diego Country NATCA representative

[XL5]

The only truth which has come to light is the advisability of having chart 10-9 open and viewable for consultation along with checking the heading bug when in position. A truth which may come to light is that of First Officers (and perhaps even Captains) being so saturated by check lists and the house-keeping duties involving V speeds and numbers that situational awareness during the taxi phase is lost. The reason as to why the takeoff was continued along an unlit runway will never be understood.

Tuning localizer receivers for runway confirmation prior to takeoff is pure fluff, whistle blowing referenced to ATC for this particular accident is nothing more than an irrelevant tilting at the windmills which belong to a different (personal) agenda.

[RatherBeFlying]

Definitely we can see that the controller was a very busy man keeping lots of balls in the air.

As far as the music is concerned, it may have helped keep him alert on the graveyard shift. Whether it was a distraction depends on the volume. A sports event would be a far greater distraction.

Assuming the tower is located in the terminal building, it seems the thresholds for Rwys 26 and 22 are pretty much in line; so, it would not be that hard to fall to the illusion that Comair was at 22 instead of 26 in the dark if all he could see was the lights.

[RobertS975]

I asked this question much earlier in this thread, and I do not think anyone answered it. How unusual, how rare, is it to have a transport aircraft take off before sunrise on an unlit runway?

[Flight Safety]

I believe it's illegal.

[Dream Land]

Great post! :D

[Huck]

FAR Part 121 carriers Operations Manuals typically allow a takeoff at night with "inoperative" runway lighting, provided adequate visual reference is available, and leaning heavily on Captain's discretion. In other words, if something bad happens it's his fault.

[nooluv]

huck. far part 121............?????

[Huck]

It's not a reg (I don't think). It's part of the flight ops manual written by the airline and approved by the FAA. It is as binding as a regulation for that airline's pilots. I don't have a copy of Comair's FOM, but I do have another....

[bomarc]

Huck:

I must disagree with you about your interpretation of the regulations regarding takeoff/night/unlit etc.


While many FAR 121 0perators ( this is the US federal regulation codes for most airlines in the USA...scheduled air carriers ), have a sort of waiver allowing for instrument takeoffs without certain lighting systems, including runway edge lights as long as adequate visual reference exists, IT IS NOT A WAIVER OF regulations clearly saying you need runway lights (or authorized flare pots) for takeoff at night. The time of the comair crash was legally not day and runway lights WERE required.

Over the years there has been much confusion about the above.

But seldom do pilots check the legal time of sunrise prior to takeoff...could there have been enough light to THINK that it was daylight? we will probably never know...at least till the same day this year, with similiar wx conditions etc.


how often does it happen? or how often does it kill people?

[Jerricho]

Just as a little heads up folks, Mr Chickenlittle has started 2 lovely little threads in the ATC forum on this subject, and isn't exactly forthcoming in entering into logical discussion with some controller types who are questioning his "interpretation" of the transcripts. I really wish he would try to answer his critics rather than run away again.

[RobertS975]

But my original point in asking the question was to better understand how unique the experience of a takeoff roll down an unlit runway must have been for this crew. Even more disturbing, the runway lights of the correct intended runway 22 were lit. And these lights were passed very early in the t/o roll, early enough to allow for a throttle back and a re-evaluation of just what was happening had those lights registered on this flight crew.

Lots of clues and cues were missed by this crew, and they have paid for their mistakes dearly, one with his life and one severely disabled. The culture that allowed this happen must be what is closely studied and remedied.

[Flight Safety]

I believe FAR 121.590 is the relevant FAR, which reads in part:

(2) For an airplane carrying passengers at night, the pilot may not take
off from, or land at, an airport unless--
(i) The pilot has determined the wind direction from an illuminated wind
direction indicator or local ground communications or, in the case of
takeoff, that pilot's personal observations; and
(ii) The limits of the area to be used for landing or takeoff are clearly
shown by boundary or runway marker lights. If the area to be used for takeoff
or landing is marked by flare pots or lanterns, their use must be approved by
the Administrator.

[Flight Safety]

On a related point;

We've all been puzzled about why the pilots tried to takeoff from an unlit runway. I found this Reuters article dated from August 28th, the day after the crash (meaning it could have incorrect information):

http://www.topix.net/content/reuters/0123595333302954457637946058380536564416

It says in part:

Instead, the Comair jet, bound for Atlanta before dawn on Sunday in a light rain, took runway 26. That runway is half as wide and half as long as runway 22 and was unlit, Hersman said in a media briefing.

One possible explanation involved a temporary advisory to pilots warning of lighting outages on the longer runway that expired the day before the crash, aviation sources said.

However, the co-pilot of the ill-fated Comair flight flew into the airport on Friday night when the top half of the runway, where planes begin their takeoffs, had been dark. Aviation experts said he might have been unaware the advisory had been lifted and mistook the dark runway for the correct one.

Today I read again a post by a Delta pilot in the original thread from the crash, that runway 22 has a hump in the middle, making it impossible to see the lower (southern) 2/3rds of the runway until you get near the top of the hump. I assume the "top half" of the runway discussed above would be the northern takeoff end of 22. If the facts above are true, then the takeoff on 26 would have looked the same to the FO, as he thought runway 22 should have looked, if the lights on the "top half" were out. He may also have known he would not be ble to see the lights on the southern end before reaching the hump. Others have pointed out that 26 is in fact 150 ft wide, the same as 22, but only 75 ft are marked and used, so in the dark the width would easily look the same. All of this could explain the comments on the CVR transcript regarding the runway lights.

Question, is anyone aware of a notam or temporary advisory indicating lights were out on the top half of 22, on the Friday preceeding the Sunday accident?

The facts from the article may be wrong, but could come close to explaining the fateful decisions made that morning. Holes in the cheese lining up (i.e. additional confusion), as some have said.

(edited to add the following comment)

Due to the taxiway arrangment on that Sunday, the runway numbers for 26 would have been behind the aircraft when it turned onto 26, as shown in photos in the original accident thread. The runway numbers would have been behind the aircraft on either runway on that day. If the above information about runways lights for 22 is true, then it seems to me that 26 would have looked almost the same as 22, except for the compass heading.

[Hold West]

er..fair comment fox niner... but how often did you get as far as cranking up the APU? And then lining up on the wrong (and unlit) runway? And then attempting take-off without that last compass/runway check?

I worked an RJ recently on a very short, early morning leg. Cleared them for approach, sent them to CTAF (so early the tower wasn't open yet), a couple minutes later they are back on frequency, missed approach. I asked them what was up, they said "We have to go back [to their departure point] and pick up a flight attendant".:ooh:

[bomarc]

flight safety is quite right about the FAR 121.590.

Hold West...this may not be as nutty as you might think...the plane may have been empty, ferrying to a new trip...pilots may have been told initially that a flight attendent was already at the new airport and off we go into the wild blue yonder...only to get a message from the company that the f/a was somewhere back at the ranch...rather than land and have to get redispatched, a quick go around was much easier on the paperwork and reduced the cycles on the plane by one.

Airline flying is like making sausage...if you saw it being made, you might stay on the ground (round?;-0 )

[Hold West]

So, if you can post your garbage on more than one forum, I can cross-post my reply. Moderators, trim us both out if this is bad!

Well, starting to play the game a bit here, I can see your statements are utterly incorrect as you try to shade the controller's actions at the critical moments.

At 22:25 CD transmits "Say again, please" to Eagle 882, while Comair is rolling on the wrong runway. He is NOT doing traffic count as the FAA is telling us.

Wrong. The aircraft is NOT rolling down the runway at this point (and why can't you quote the UTC times, given the plethora of sources, unless you are trying to obscure the facts?). The transmission you reference above is made at 1005:33 UTC. According to the FDR, the aircraft did not commence moving after the takeoff clearance until 1005:22, commences the left turn on the runway 1005:39, and stops the turn (but not the aircraft), lined up on runway 26 at 1006:00, simultaneously as the N1s start to rise to takeoff thrust. The airspeeds actually start to increase at 1006:05.

At 22:30 [1005:37], CD is probably looking at the radar scope as he is talking to Eagle 882 and giving him a frequency change to center.

This is 16 seconds after he cleared Comair for takeoff and he hasn't seen him rolling on the wrong runway. He was supposed to scan his runway when he cleared him for takeoff and should have noticed him on the wrong runway.

Wrong again, it's 20 seconds after the takeoff clearance, which was issued at 1005:17. And, it's two seconds before the aircraft begins the left turn to line up on the runway. The aircraft is not yet "rolling" on the wrong runway, and in fact is not yet on any runway.

As to the "scan the runway" issue, I personally scan the runway before I issue the takeoff clearance. That clearance was given at 1005:17, while the aircraft was stopped on the taxiway short of runway 26, according to the FDR. Note too that the distance from the correct and incorrect runway positions is very short, and on the same sight-line from the tower - take a look at the sat pictures or airport diagram. Again, if the controller scanned the length of runway 22 at 1005:17, he would have seen an aircraft on more-or-less the right part of the airport, still on a taxiway, and no reason to withhold takeoff clearance.

The critical moments where the controller could have possibly had an effect on the outcome were between 1006:00, when the aircraft completed its turn to line up on runway 26, and about 1006:24, when the aircraft passed through 100 knots, and (my assumption) probably could no longer have stopped on the runway, and thus an accident was inevitable. V1 was not reached until 1006:31, but that was calculated for the longer runway length.

The controller thus had about 24 seconds to notice the aircraft starting a rolling takeoff on runway 26. I have no idea what he did during this 24 second period, and the tape is silent. If he says he looked down or turned away for a while to perform other duties, there is no reason to disbelieve him.

It's odd that a station agent for American Eagle saw Comair on the wrong runway

By the station agent's statement, he was doing nothing else but watching the aircraft head out. The controller had other things to do, being that he was alone in the tower, since the tower manager was not providing FAA-required staffing for the shift.

That means that CD pulls the hook at 1008:30 CUT. That is about 2 1/2 minutes after the crash.

Utterly incorrect. The CVR records "sound of impact" at 1006:33. The controller initiates the call to the FD at 0607:23. That's 50 seconds later.

What could he have been doing for all that time? Maybe he took the clipboard over to the radio to change stations.

A stupid, evil statement. Your facts are wrong, therefore your assumptions are even more so.

He tells the crash crew that the aircraft is off the approach end of runway 8. That is the departure end of runway 26. 80 plus 180 degrees is 260, BUT then he tells the crash crew the aircraft took off of runway 22.

He told them that because that's where the aircraft actually was. He obviously looked out the window, and told them what he saw, in relation to the runways. And at that point, as far as he knew, the aircraft DID take off from runway 22.

Bergquist rambles on with many more baseless assumptions that he does NOT have the background knowledge to make. They depend on the layout of the tower cab, among other things, and we don't know anything about that. None of it holds water.

Any response there, Chicken-man?

[Jerricho]

I think Mr Little doesn't want to discuss "the facts".......he just wants to shove them down your throat.

[bomarc]

All pilots are capable of making mistakes that end in tragedy.

Instilling the discipline and "excellence" takes time and effort by many. It also takes money.

To all pilots out there...every takeoff, every approach, every landing demands your highest level of skill and attention. Being laid back might be a warning you are about to be Laid to rest.

ANything short of your highest level of attention is shortchanging aviation.


However, we should demand the same from everyone in aviation. Especially the FAA. There are warnings for flights at too low an altitude...there should have been a warning for wrong runway operations.


I am guessing another accident in the unwarned regime may happen. Anyone out there thinking along these thoughts should post their scenarios.

[Fokker28]

By far the most effective 'warning' for the money: another body in the tower cab.

We'll never danger-proof the world, folks. The trick is to minimize the danger in the most cost effective manner.

[vapilot2004]

NTSB (according to Kentucky.com news source) released the following overlay of CVR transcript and a timeline graphic here (http://www.kentucky.com/multimedia/kentucky/0117ntsbrelease/mapcockpitoverlay.pdf) in PDF format.

[RobertS975]

Interesting overlay... the FO comments on the lack of runway lights just as they are coming upon the lit runway 22... obviously, plenty of time for an abort. If only...

[tenpiloto]

Those of you who continue to put blame on the controller need to think about some things: First, regionals still operate into uncontrolled airports--no controller to blame in that scenario. Secondly, during many operations (low vis, night, etc.), controllers are not able to see the aircraft unless they have ground radar (very rare).

If there is any chance, due to runway/taxiway geometry, that finding the correct runway entrance is a little more difficult, then the crew should be even more on guard, using every means available to identify the runway--and they had two, probably 4, depending on the Nav Display selections, right in front of them--HEADING INDICATIONS!!! This was simply disgusting pilot error--stop trying to deflect the blame from these guys.

Maybe the FAA should make age 40 the max, then you young know-it-alls could really get in the left seat quickly and exhibit the undoubtedly flawless performance of youth.

[threemiles]

2 comments
1. "Line-up check's complete" was before line-up, heading was 040 at that time
2. Comair one ninety one, taxi to runway two two. altimeter three
zero zero zero and the winds are two zero zero at eight.
Taxi clearance to 22 would have required a "crossing 26 approved" imo

[Dream Land]

3mile, no need for that in the states, a clearance to a runway is just that.


Tenpilot, after reading the responsibilities of the controller that morning, I now realize that no one can adquately man both approach control and tower positions safely, I think most of that type of post came from ex atco's like myself with previous local control experience, I stand corrected.

[Flight Safety]

Agree with RobertS975. Another visual clue missed was the crossing runway crossed the wrong way, from right to left, instead of left to right. If 22 was lit, then this would have been more obvious. There would have been time to abort if this was noticed. Again, the diagram shows that the runway numbers would have been behind the aircraft on either runway.

[Huck]

3mile, no need for that in the states, a clearance to a runway is just that.


A stupid fecking rule if there ever was one.

I ALWAYS request clearance to cross ANY enroute runway, regardless if it is active or not. The consequences are just too severe....

[Flight Safety]

At this point, the lessons I'm taking away from this accident are these:


Always check heading prior to advancing throttles for TO.
For airports under construction, verify available runways your AC can safely use, then make certain you are using one of them.
For larger airports under construction with parallel runways, checking heading prior to advancing throttles is not good enough (I recall not long ago the SA 744 destroyed on TO using a parallel runway under construction). Therefor use additional means to verify correct runway.

[bomarc]

flight safety

I listed the surest way to know the runway, tune up the localizer...especially at airports with multiple parallel runways.

huck, you are right...even though a clearance to a runway is a clearance to cross...always say as you approach the other runways, VERIFY XXX CLEARED TO CROSS RUNWAY XXX

[Scurvy.D.Dog]

.. the unique U.S system of ‘implied’ crossing clearance enroute to departure runway has always bemused me. I guess the main driver has been unloading the SMC frequency (seems brave given the possible implications) .. another one that gets me all goosed up and tingly is the practice of ‘clear to land’ when in a sequence queue (in the same league as conditional line-up clearances IMHO) … I mean if ****e turns to trumps (freq fail, runway occupied by preceding departure abort or landing debacle) and the subsequent aircraft has already been cleared to land .. well .. who knows what might result? … empirical data and experience might suggest the problem does not exist .. YET … in any event, it seems counter intuitive to me! … that said, the question remains, one of risk management and resources I guess!
.
.. there is no doubt we all learn from tragedies like LEX … I will say though, (irrespective of the conversation on the flight deck) … IMHO, this crew were led into this accident sequence by a number of other unrelated factors i.e.
.
- outside visual reference confusing (similarity of expectation), without sufficient error triggers (markings, signs etc)
- normalised deviation (expected lighting outages)
- pre-departure flight deck workload, including CRM difficulties from ground steering necessitating the captain taxiing to line-up (FO head down until on centreline, Captain head-out the front during the whole exercise …which is just asking for an instrument cross check error IMHO)
- Lack of automated aural error queues to the crew on the flight deck (avionics) and the ATC (SMD + position alarms)
.. in this day and age, there is no excuse for the presence of any of these holes in the cheese !
.
… the old maxim comes to mind ..
.
' …. you think safety is expensive ... try having an accident!' :ooh: :(

[GearDown&Locked]

Scurvy.D.Dog, I agree with your analisys. IMHO the most important thing here is that it can really happen to anyone. :suspect:

GD&L

[DownIn3Green]

Several points:

I am one of those dinosaurs who happen to agree with 411A on this one.

The controller is not at fault. His responsibility is to scan the rwy prior to or at the same time as issuing the take-off clearance.

All runways that are open are "active". Any one or more of them may or may not be "in use".

Any pilot who insists on "verifying" his clearance to cross any and all runways along his assigned taxi route to his assigned runway may find his flight headed to the "penalty box" at ATL, ORD, or LAX, etc.

With the FAA and FBI redacting the controller's name from the public access reports, Mr. Chicken ***t must feel like a real man revealing his identity.

When the FAA made the rest regs, and Comair applied them to their schedules, I'm sure no one counted on the Captain having his family coming to visit on a 10 hour (legal) layover, especially with 2 small children who are suffering from colds.

Learn from this crew's mistake...don't try to excuse it.

[RobertS975]

http://news.yahoo.com/s/ap/20070222/ap_on_re_us/kentucky_crash_1

[DownIn3Green]

:= := :=

At the risk of being "politically incorrect", why don't we bring all of our troops home from overseas, close our borders, and boost our domestic budget????

Oops!!!...That won't work because then the US Gov't would have more money to squander on OUR Gov't Workers, whom if the truth be told, would all but one be sleeping in a low-level ATC Facility during an overnight (mid) shift such as LEX...

Of course the facility would be properly "staffed", but what would the point be???

The lawsuit may or may not prevail, but it's still a smoke screen...

The crew "screwed the pooch" and there's no escaping that....

[nugpot]

I'm all for blaming controllers ;) , but in this case the controller did not clear them to take off on the wrong runway and neither did he physically take control of the aircraft and set them up to fail.

True, he could have been the one to break the chain of events, but the pilots are the last barrier, and they failed.

[bomarc]

many of the safety nets that were normally expected in aviation are now gone. blame ronald reagan and firing atc'ers...blame the FAA for shortening the course in becoming a controller.

blame the fact that in 1980, the majority of atc'ers had a private pilot license or better and had a feeling for the situation.

and yes, blame the pilots, who probably were never tested on runway line up and identification.

so many short cuts these days...save fuel, save money...but so rarely do we hear SAVE LIVES!

[barit1]

And yet the safety statistics continue to improve. We must be doing something wrong.

[bomarc]

statistics are numbers...people are people.

this accident was preventable.

[Ignition Override]

Bomarc: Save lives?

You must be kidding. That might affect operating costs.

Most airlines are so well-insured for an aircraft hull loss that they and the FAA understand the cost/benefit ratios used in the present outsourcing madness.

The only goal right now is to save money, no matter what the effect on flight operations safety. Any Pprune readers who do not believe this should read about what tragedies (and near-tragedies this winter) happened since 1978 in the US which can be directly linked to US airline deregulation. One of our jets almost took off this winter with only ONE wing de-iced.

The de-icing crew apparently missed it, but luckily the passengers noticed and spoke up.

[barit1]

No, folks: the airlines' objective is not to SAVE money - it's to MAKE money. Anyone who doesn't understand this pre-econ-101 principle needs to go back to class.

The cold fact of the matter is that whatever advantage airlines enjoyed in a regulated (pre-80s) environment, only the top few % of the population flew with any frequency. Deregulation has employed MANY more pilots & other staff, the result of a LOT more pax who can afford the competitive prices.

Safety is a non-issue in the big picture. Does anyone remember the high rates flight crew had to pay for life insurance 40 years ago? Higher air fares will simply force more pax out of the relatively safe aluminium tube into private cars. How safe is that?

[bomarc]

ignition overide

is that information (post dereg) available in one source? I agree with you


to baritone(barit1)...if their job is to make money, they have failed .

I sincerely believe that a re-regulated industry that adds to the cost of the ticket an amount needed to increase safety/security would be a good thing. Enforcing minimum standards for all airlines would be a good thing.

[Ignition Override]

BOMARC:
You are probably already aware of this book, by career pilot (C-141, B-727...) and aviation attorney John J. Nance: "Blind Trust-How Deregulation Has Jeopardized Airline Safety and What You Can Do About It".

We moved out of "King Willy's" realm this winter and I can not find certain books, or I would gladly provide a long quote about the direct links between US deregulation and the accidents at new airlines which enjoyed rapid growth, by way of the lack of traditional levels of corporate and federal supervision, i.e, Air Florida, Valuejet and many others.

Don't forget just who appoints certain cabinet and sub-cabinet level officials...

It is highly likely that one of the next Pprune responses will be to define the
phrase 'traditional supervision' etc, i.e. as when former Pres. Clinton said to the federal investigators "Define the word IS".

P.S: Unknown to the public, Mr. Nance's first edition of "Splash of Colors", about the growth and demise of Braniff Airlines, was never released.
It allegedly had something to do with problems in (built into?) the American (AMR) computer reservations system, Sabre, and certain "irregularities", whereby a Braniff flight might still have seats available, but somehow the AMR computer system allegedly indicated 'otherwise'. That is all that can be discussed in public about that topic.
Y'all have a nice Shiner Bock evening!

[Big-Flame-Out]

IANAP (I am not a Pilot)

Could someone explain where the aeroplane id is located, and why it is not #1 on pilots' checklist?

Also why (for purposes other than maintenance) there is any need for an aeroplane identifier apart from the registration number?

[barit1]

If crew are boarding a jetway from the front end, the registration (or tail #) is probably not visible. So there's often a fleet # somewhere on the nose, in smaller characters, but readily visible to boarding crew.

[canyonblue737]

Most ID numbers for an airplane at most companies are simply the first 3 digits of the registration number which of course is on the tail, but also usually on the nose gear doors. The mistake can happen as easily as any, you check a sheet and it says plane "701" and you go out in the cold and see "601" and mess it up and get in. Trust me after a couple minutes you realize the mistake or someone points it out to you, it never gets to the point you go off flying the wrong airplane, nor is it a sign of a bad pilot. Imagine you are a cop and get assigned a different car each day... someday in the lot you will try to climb in the wrong one, it is just bound to happen.

[bomarc]

our fleet has the "N" number on the instrument panel...sometimes with a lovely little plaque, sometimes with a laundry marker ...gear door also and tail of course

[AirRabbit]

Hey 3-mile - just for information...
FAA Handbook 7110.65 Air Traffic Control:
a. When authorizing a vehicle to proceed on the movement area, or an aircraft to taxi to any point other than an assigned takeoff runway, absence of holding instructions authorizes an aircraft/vehicle to cross all taxiways and runways that intersect the taxi route. If it is the intent to hold the aircraft/vehicle short of any given point along the taxi route, issue the route, if necessary, then state the holding instructions.
b. When authorizing an aircraft to taxi to an assigned takeoff runway and hold short instructions are not issued, specify the runway preceded by “taxi to,” and issue taxi instructions if necessary. This authorizes the aircraft to “cross” all runways/taxiways which the taxi route intersects except the assigned takeoff runway. This does not authorize the aircraft to “enter” or “cross” the assigned takeoff runway at any point.