pakeha-boy
12th Apr 2007, 23:02
MYTH: The Comair (5191) tragedy speaks volumes about what inadequate rest and trying to trick human physiology and circadian rhythms can do to a crew.
FACT: [From ALPA] “ALPA's analysis does not make any statements of probable cause, but lists 32 findings relevant to the accident.” Of the 32 findings, only one speaks to the rest issues of the crew: “According to the Washington State University Fatigue Study, the flight crew was mildly impaired due to fatigue from adverse circadian phase and sleep loss.”
The entire report is available on the ALPA website. Here’s the conclusion from the actual report in its entirety:
IX. CONCLUSIONS
Because the crew had different experiences with regard to their recent operations into and out of LEX, on the morning of August 27, 2006, their individual mental perceptions at the beginning of this flight of what taxiway layout and airport lighting they would expect to see during their taxiout were different. However, as their taxi progressed, what they were seeing related to airport lighting brought their perceptions into alignment with one another. The crew was then presented with misleading taxiway signage and lighting cues that led them to believe that they were approaching runway 22; their intended runway. These cues were lighted barricades on the opposite side of the runway, the absence of taxiway lights beyond the barricades and a nearly identical taxiway to runway angular relationship that supported their confirmation bias that their position on the airport was correct. As the aircraft took position on runway 26 for takeoff, it is apparent that nothing appeared out of the ordinary to them. There were numerous visual similarities between runway 26 and runway 22. Two specific examples were the lack of runway centerline lights as expected per a local NOTAM that the lights were inoperative and the presence of a hump in the runway was visually consistent with runway 22. The crew then entered runway 26 after being cleared for takeoff and began their takeoff roll.
Comair 5191 was operating at an airport that was near the end of a 5-year construction project. Because of this construction, numerous runway and taxiway lights were inoperative and various sections of the airport / taxiway environment were closed. Because of a deficiency in the FAA / NFDC / Jeppesen chart revision process, pertinent changes to the airport configuration were not reflected in current airport diagrams. Therefore, the charts available to the crew were not consistent with the actual configuration and did not accurately reflect what they would be encountering that morning during their taxi operation. Had this anomaly in the charting process not existed, the charts that were provided to this crew and all crews operating into and out of LEX would have been correct.
At the time of the accident, there was one controller on duty at LEX. As such, his duties that morning were expanded to encompass four different controlling functions. Available evidence indicates the controller did not maintain vigilance ensuring the correct taxi route and runway were used. After the controller cleared the aircraft for takeoff, he almost immediately turned his back to address administrative duties. Had he maintained an increased level of vigilance related to controlling this aircraft, he may have noticed that the aircraft had entered the incorrect runway. As part of his duties, the controller was responsible for issuing ATIS broadcasts at LEX. Critical NOTAM information which would have enhanced the situational awareness of the crew was omitted from the ATIS broadcasts. Due to staffing issues, the controller was forced into a situation where he was working alone. A fatigue study conducted after this accident indicates that due to scheduling rotations, the controller was operating in a fatigued state.
FINDINGS
1. Air Traffic Control management did not ensure that schedules provide adequate rest prior to controllers going on duty.
2. The controller did not maintain vigilance with the taxiing aircraft to ensure that the aircraft was properly positioned on the airport prior to being cleared for takeoff.
3. The controller did not maintain vigilance with the aircraft to ensure it was departing from the correct runway.
4. The FAA did not provide adequate oversight of the construction at LEX Airport and its affect on published airport material and information.
5. The FAA did not ensure that guidelines for proper ATC facility manning were properly followed. This resulted in an increased workload for the controller at a critical phase of operation.
6. The controller did not include critical NOTAM information on the ATIS broadcasts which resulted in the crew not receiving local NOTAM that Taxiway “A” north of runway 26 was closed.
7. Jeppesen did not ensure that their data-reception program (NFDC link) had adequately captured all intended information for chart revisions.
8. LEX Airport Authority did not issue NOTAM’s identifying differences to airport signage and pavement configurations compared to published charts.
9. The flight crew did not follow Comair Standard Operating Procedures regarding thorough taxi briefings.
10. The flight crew did not correctly identify their intended departure runway.
11. The aviation industry and the FAA have not established standardized flight crew procedures to verify that their aircraft are on the proper runway.
12. The takeoff abort policy in use by Comair restricted the captain’s ability to consider runway and airport environmental factors in a possible abort decision.
13. The air traffic controller took approximately 47 seconds to alert the ARFF dispatcher after the accident had occurred.
14. The first ARFF vehicles were delayed approximately 38 seconds while a security gate was opened for the vehicle.
15. The first responders to the accident scene rapidly discovered the first officer within the wreckage, extricated him from the aircraft at great risk to themselves, and drove him to the hospital, saving his life.
16. The 2 ARFF vehicles that responded to the accident site had digital video recording devices on them. However neither vehicle’s devices were activated to record the response and accident scene.
17. A system to display the accident location to the controller would have allowed him to assist the ARFF vehicles in responding more rapidly and directly.
18. The controller in the tower had the height advantage in seeing the accident location. However, the he did not provide directional assistance to the ARFF vehicles in locating the site after the initial accident notification.
19. While the controller followed all required procedures for issuing a valid takeoff clearance, FAA Takeoff Clearance orders as found in 7110.65(R) are inadequate.
20. Two additional incidents of aircraft inadvertently accessing runway 26 occurred after the LEX accident. A local ATC SOP change was then put in place to not clear runway 22 traffic for takeoff until after they had passed over runway 26.
21. RAAS technology that exists today and is already certified on the CL-65-2B19, but not currently installed, would have increased the accident crew’s situational awareness.
22. RAAS technology can be operational on CL-65-2B19 aircraft within a short period of time.
23. The FAA can facilitate the approval of Electronic Flight Bags with airport electronic display showing own-ship position that, if installed, will help raise crew positional awareness to a high level.
24. According to the Washington State University Fatigue Study, the flight crew was mildly impaired due to fatigue from adverse circadian phase and sleep loss.
25. According to the Washington State University Fatigue Study, the air traffic controller was moderately impaired due to fatigue from adverse circadian phase and sleep loss.
26. The flight crew’s perception of their location on the airport was altered by not receiving the NOTAM regarding taxiway “A” being closed north of runway 26.
27. The flight crew’s perception their location on the airport was altered by the mismatch between airport signage and the airport diagram they had available.
28. Due to the workload of the first officer, he was not able to adequately monitor the captain’s progress while taxiing.
29. The air traffic controller missed an opportunity to catch the crew’s error when they were holding short of runway 26 prior to calling for takeoff clearance.
30. The air traffic controller missed another opportunity to catch the crew’s error when they began their takeoff roll on runway 26.
31. Since the crew expected to see many lights out of service on runway 22, this was confirmed by what they saw on runway 26.
32. There were no specific procedures or technologies utilized that would have helped the flight crew members verify they were on the correct runway.
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FACT: [From ALPA] “ALPA's analysis does not make any statements of probable cause, but lists 32 findings relevant to the accident.” Of the 32 findings, only one speaks to the rest issues of the crew: “According to the Washington State University Fatigue Study, the flight crew was mildly impaired due to fatigue from adverse circadian phase and sleep loss.”
The entire report is available on the ALPA website. Here’s the conclusion from the actual report in its entirety:
IX. CONCLUSIONS
Because the crew had different experiences with regard to their recent operations into and out of LEX, on the morning of August 27, 2006, their individual mental perceptions at the beginning of this flight of what taxiway layout and airport lighting they would expect to see during their taxiout were different. However, as their taxi progressed, what they were seeing related to airport lighting brought their perceptions into alignment with one another. The crew was then presented with misleading taxiway signage and lighting cues that led them to believe that they were approaching runway 22; their intended runway. These cues were lighted barricades on the opposite side of the runway, the absence of taxiway lights beyond the barricades and a nearly identical taxiway to runway angular relationship that supported their confirmation bias that their position on the airport was correct. As the aircraft took position on runway 26 for takeoff, it is apparent that nothing appeared out of the ordinary to them. There were numerous visual similarities between runway 26 and runway 22. Two specific examples were the lack of runway centerline lights as expected per a local NOTAM that the lights were inoperative and the presence of a hump in the runway was visually consistent with runway 22. The crew then entered runway 26 after being cleared for takeoff and began their takeoff roll.
Comair 5191 was operating at an airport that was near the end of a 5-year construction project. Because of this construction, numerous runway and taxiway lights were inoperative and various sections of the airport / taxiway environment were closed. Because of a deficiency in the FAA / NFDC / Jeppesen chart revision process, pertinent changes to the airport configuration were not reflected in current airport diagrams. Therefore, the charts available to the crew were not consistent with the actual configuration and did not accurately reflect what they would be encountering that morning during their taxi operation. Had this anomaly in the charting process not existed, the charts that were provided to this crew and all crews operating into and out of LEX would have been correct.
At the time of the accident, there was one controller on duty at LEX. As such, his duties that morning were expanded to encompass four different controlling functions. Available evidence indicates the controller did not maintain vigilance ensuring the correct taxi route and runway were used. After the controller cleared the aircraft for takeoff, he almost immediately turned his back to address administrative duties. Had he maintained an increased level of vigilance related to controlling this aircraft, he may have noticed that the aircraft had entered the incorrect runway. As part of his duties, the controller was responsible for issuing ATIS broadcasts at LEX. Critical NOTAM information which would have enhanced the situational awareness of the crew was omitted from the ATIS broadcasts. Due to staffing issues, the controller was forced into a situation where he was working alone. A fatigue study conducted after this accident indicates that due to scheduling rotations, the controller was operating in a fatigued state.
FINDINGS
1. Air Traffic Control management did not ensure that schedules provide adequate rest prior to controllers going on duty.
2. The controller did not maintain vigilance with the taxiing aircraft to ensure that the aircraft was properly positioned on the airport prior to being cleared for takeoff.
3. The controller did not maintain vigilance with the aircraft to ensure it was departing from the correct runway.
4. The FAA did not provide adequate oversight of the construction at LEX Airport and its affect on published airport material and information.
5. The FAA did not ensure that guidelines for proper ATC facility manning were properly followed. This resulted in an increased workload for the controller at a critical phase of operation.
6. The controller did not include critical NOTAM information on the ATIS broadcasts which resulted in the crew not receiving local NOTAM that Taxiway “A” north of runway 26 was closed.
7. Jeppesen did not ensure that their data-reception program (NFDC link) had adequately captured all intended information for chart revisions.
8. LEX Airport Authority did not issue NOTAM’s identifying differences to airport signage and pavement configurations compared to published charts.
9. The flight crew did not follow Comair Standard Operating Procedures regarding thorough taxi briefings.
10. The flight crew did not correctly identify their intended departure runway.
11. The aviation industry and the FAA have not established standardized flight crew procedures to verify that their aircraft are on the proper runway.
12. The takeoff abort policy in use by Comair restricted the captain’s ability to consider runway and airport environmental factors in a possible abort decision.
13. The air traffic controller took approximately 47 seconds to alert the ARFF dispatcher after the accident had occurred.
14. The first ARFF vehicles were delayed approximately 38 seconds while a security gate was opened for the vehicle.
15. The first responders to the accident scene rapidly discovered the first officer within the wreckage, extricated him from the aircraft at great risk to themselves, and drove him to the hospital, saving his life.
16. The 2 ARFF vehicles that responded to the accident site had digital video recording devices on them. However neither vehicle’s devices were activated to record the response and accident scene.
17. A system to display the accident location to the controller would have allowed him to assist the ARFF vehicles in responding more rapidly and directly.
18. The controller in the tower had the height advantage in seeing the accident location. However, the he did not provide directional assistance to the ARFF vehicles in locating the site after the initial accident notification.
19. While the controller followed all required procedures for issuing a valid takeoff clearance, FAA Takeoff Clearance orders as found in 7110.65(R) are inadequate.
20. Two additional incidents of aircraft inadvertently accessing runway 26 occurred after the LEX accident. A local ATC SOP change was then put in place to not clear runway 22 traffic for takeoff until after they had passed over runway 26.
21. RAAS technology that exists today and is already certified on the CL-65-2B19, but not currently installed, would have increased the accident crew’s situational awareness.
22. RAAS technology can be operational on CL-65-2B19 aircraft within a short period of time.
23. The FAA can facilitate the approval of Electronic Flight Bags with airport electronic display showing own-ship position that, if installed, will help raise crew positional awareness to a high level.
24. According to the Washington State University Fatigue Study, the flight crew was mildly impaired due to fatigue from adverse circadian phase and sleep loss.
25. According to the Washington State University Fatigue Study, the air traffic controller was moderately impaired due to fatigue from adverse circadian phase and sleep loss.
26. The flight crew’s perception of their location on the airport was altered by not receiving the NOTAM regarding taxiway “A” being closed north of runway 26.
27. The flight crew’s perception their location on the airport was altered by the mismatch between airport signage and the airport diagram they had available.
28. Due to the workload of the first officer, he was not able to adequately monitor the captain’s progress while taxiing.
29. The air traffic controller missed an opportunity to catch the crew’s error when they were holding short of runway 26 prior to calling for takeoff clearance.
30. The air traffic controller missed another opportunity to catch the crew’s error when they began their takeoff roll on runway 26.
31. Since the crew expected to see many lights out of service on runway 22, this was confirmed by what they saw on runway 26.
32. There were no specific procedures or technologies utilized that would have helped the flight crew members verify they were on the correct runway.
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