Comair CRJ crash in Kentucky
Dog Tired
Your post has merit and deserves recognition.
The matter of what to do about it here is the subject of another thread which, I hope, will be addressed...eventually.
By the way, I have a real ATPL.
Best wishes.
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I am troubled that in this tragic context you would make such a statement out of the blue, without suggesting a way for me (eg) to verify the assertion.
CNN says many things, few of them trustworthy, but where did they say that?
FAA says many things, generally with foundation, but where did they say that? Or possibly did CNN say that FAA said that?
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This is from the NY Times:
LEXINGTON, Ky., Aug. 29 — The Federal Aviation Administration issued an order nine months ago banning air traffic controllers from being assigned to work solo, with responsibility for both radar and ground observations. But that change was not carried out at the Blue Grass Airport here, where a jet took a wrong turn early Sunday onto a runway that was too short and crashed before the lone controller on duty could notice the error.
The change was ordered in November 2005, after an overloaded controller at the Raleigh-Durham, N.C., airport directed two planes to come too close together. Internal memos show that the air traffic manager in Lexington was trying to solve the problem on the overnight shift by getting radar responsibility transferred to a round-the-clock center in Indianapolis that handles mostly high-altitude traffic, but he did not succeed.
The F.A.A. said late Monday it would add a second controller to the tower on the midnight shift at the Blue Grass Airport during the weekends, even though the field handles only about one plane an hour between midnight and 6 a.m. On Sunday at about 6 a.m., a Comair regional jet was cleared for takeoff on a 7,000-foot runway but turn into the airport’s other runway, which is only 3,500 feet long, and crashed in the woods just beyond the airport fence, killing 49 of the 50 people aboard.
This evening, a member of the National Transportation Safety Board, Deborah Hersman, said the airport’s lone controller on duty had told investigators that he authorized the Comair crew to depart from runway 22, saw the plane on the taxiway that leads to both runways and turned his back to complete some administrative work.
The plane took 29 seconds from the beginning of its takeoff l to the crash in the woods; the controller heard the explosion.
Laura J. Brown, an F.A.A. spokeswoman, said the agency’s order in November was not a new policy, but rather an effort to enforce a longstanding policy that had somehow fallen into disuse. The F.A.A. headquarters only learned of the staffing situation at the Blue Grass Airport after Sunday’s crash, she said.
But an official of the air traffic controllers union said the solo staffing was not unusual. Andrew J. Cantwell , vice president for the southern region of the National Air Traffic Controllers Association, asserted that airports at Duluth, Minn., and Savannah, Ga., operated the same way, and that at some other airports, if a controller called in sick, the F.A.A. would not pay overtime to bring in a replacement.
The change was ordered in November 2005, after an overloaded controller at the Raleigh-Durham, N.C., airport directed two planes to come too close together. Internal memos show that the air traffic manager in Lexington was trying to solve the problem on the overnight shift by getting radar responsibility transferred to a round-the-clock center in Indianapolis that handles mostly high-altitude traffic, but he did not succeed.
The F.A.A. said late Monday it would add a second controller to the tower on the midnight shift at the Blue Grass Airport during the weekends, even though the field handles only about one plane an hour between midnight and 6 a.m. On Sunday at about 6 a.m., a Comair regional jet was cleared for takeoff on a 7,000-foot runway but turn into the airport’s other runway, which is only 3,500 feet long, and crashed in the woods just beyond the airport fence, killing 49 of the 50 people aboard.
This evening, a member of the National Transportation Safety Board, Deborah Hersman, said the airport’s lone controller on duty had told investigators that he authorized the Comair crew to depart from runway 22, saw the plane on the taxiway that leads to both runways and turned his back to complete some administrative work.
The plane took 29 seconds from the beginning of its takeoff l to the crash in the woods; the controller heard the explosion.
Laura J. Brown, an F.A.A. spokeswoman, said the agency’s order in November was not a new policy, but rather an effort to enforce a longstanding policy that had somehow fallen into disuse. The F.A.A. headquarters only learned of the staffing situation at the Blue Grass Airport after Sunday’s crash, she said.
But an official of the air traffic controllers union said the solo staffing was not unusual. Andrew J. Cantwell , vice president for the southern region of the National Air Traffic Controllers Association, asserted that airports at Duluth, Minn., and Savannah, Ga., operated the same way, and that at some other airports, if a controller called in sick, the F.A.A. would not pay overtime to bring in a replacement.
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If there was a policy that there should be 2 people in the tower, presumably there was a reason for that policy, and we are told that the reason was that there was a specific history of sole officers making high risk mistakes.
In this case there was a single officer, but he nevertheless made no mistake because he had discharged his dutes to the RJ correctly, according to his SOPs. If the SOPs were deficient, then that too is a management issue. As I read this thread I take it that even if there had been two officers on duty there was no requirement to observe the RJ line up on the correct runway, but there might have been a better chance of this being noticed.
What distresses me about these sorts of discussion is how readily the they come to focus on the individuals who might or might not have made mistakes, and how easily it drifts away from the systemic traps that increase the chances that an error will occur.
We know that people make 'mistakes' - even the very best. We know what kinds of mistakes there are and how they happen. We know the things we can do to systems to reduce the probabilities that mistakes will happen. We also make quite calculated cost trade off decisions about how much error reduction we will buy.
But in this case it seems that the error reduction opportunity that could have saved this aircraft had no, or very little, cost, and that the risk was highly predictable. I refer to the reconfiguration of the taxiways that, as I read the plans posted, could have been analysed in five minutes in a planning meeting to confirm pretty precisely the likely increase in the frequency of incorrect runway identification that was being built in.
In this case there was a single officer, but he nevertheless made no mistake because he had discharged his dutes to the RJ correctly, according to his SOPs. If the SOPs were deficient, then that too is a management issue. As I read this thread I take it that even if there had been two officers on duty there was no requirement to observe the RJ line up on the correct runway, but there might have been a better chance of this being noticed.
What distresses me about these sorts of discussion is how readily the they come to focus on the individuals who might or might not have made mistakes, and how easily it drifts away from the systemic traps that increase the chances that an error will occur.
We know that people make 'mistakes' - even the very best. We know what kinds of mistakes there are and how they happen. We know the things we can do to systems to reduce the probabilities that mistakes will happen. We also make quite calculated cost trade off decisions about how much error reduction we will buy.
But in this case it seems that the error reduction opportunity that could have saved this aircraft had no, or very little, cost, and that the risk was highly predictable. I refer to the reconfiguration of the taxiways that, as I read the plans posted, could have been analysed in five minutes in a planning meeting to confirm pretty precisely the likely increase in the frequency of incorrect runway identification that was being built in.
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Thanks, but no thanks, just that most of the links or sources I try to verify leave me hanging. Subsequent to my post I am hearing on the radio that FAA guidelines were violated by having only a single controller on duty at Bluegrass. When this is coming out over a variety of networks I am inclined to believe it better. My point was, to the original poster (sorry I forgot the name), not that his news was incorrect, but that it would be good to provide some way to verify the assertion, like a link or anything, rather than just say "CAA sez FAA sez XYZ sez blablablabla," what is how I read it.
Sure, I can go to CAA and FAA and XYZ and fumble around for about an hour and a half and come up with nothing. A solid source for a new tidbit of information would make me happier.
Sure, I can go to CAA and FAA and XYZ and fumble around for about an hour and a half and come up with nothing. A solid source for a new tidbit of information would make me happier.
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Can someone reference a link that clarifies if there was only one controller on duty vs. one controller in the tower? Until now, I was fairly certain that there were always at least two controllers on duty at KLEX though most times one was in the tower handling clearance delivery/ground/tower duties and the other in the radar room handling the two approach/departure sectors. Is the official position that there was only one controller handling ALL duties?
Also, ATIS provided info that the centerline lights on RW22 were inoperative. It's possible that when the Captain (pilot not flying) lined them up on 26 and there were no lights, he, the FO (pilot flying), and the AirTran pilot in the jumpseat all may have just rationalized "lights inoperative on 22" and didn't give it a second thought, even as they crossed the intersection with 22 on the takeoff roll. Past that, they wouldn't have had any indication they had used up all the runway until the number 8 came into view of their landing lights, no?
Also, ATIS provided info that the centerline lights on RW22 were inoperative. It's possible that when the Captain (pilot not flying) lined them up on 26 and there were no lights, he, the FO (pilot flying), and the AirTran pilot in the jumpseat all may have just rationalized "lights inoperative on 22" and didn't give it a second thought, even as they crossed the intersection with 22 on the takeoff roll. Past that, they wouldn't have had any indication they had used up all the runway until the number 8 came into view of their landing lights, no?
Psychophysiological entity
.............Captain (pilot not flying) lined them up on 26 and there were no lights, he, the FO (pilot flying), and the AirTran pilot in the jumpseat all may have just rationalized "lights inoperative on 22" and didn't give it a second thought, even as they crossed the intersection with 22 on the takeoff roll..........
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How about the Flight Deck Crew were 'familiar' with the airport and were keen to get on with the flight ASAP. Under such circumstances 'assumptions' may be made. If the work-load was heavy during the taxi-out, further assumptions may have been made, and when they reached the 'end' of the taxiway a rolling start (turn 45 left - let's go).
Likewise the ATCO. "These guys know what they're doing (!). Work to do etc etc"
I'm not accusing ANY of deriliction of duty (although 'to the letter' there may well have been), but a scenario which might explain the unfortunate sequence of events. The presence of the guest in the jump-seat (if, in fact he WAS there) was a further possible distraction (or an incentive to show him how slick their operation was).
Like most disasters, several holes in the cheese need to line up. The two survivors (the FO and the ATCO) may well bear the brunt of the blame.
The underlying cause is probably laxness with regard to the taxiway modification (from the airport AND the crew's point of view). Maybe even the ATCO . . .
It is possible to be TOO comfortable with familiarity. Any of a number of checks would probably have averted this event.
All circumstantial, but MY 2 cents worth.
Likewise the ATCO. "These guys know what they're doing (!). Work to do etc etc"
I'm not accusing ANY of deriliction of duty (although 'to the letter' there may well have been), but a scenario which might explain the unfortunate sequence of events. The presence of the guest in the jump-seat (if, in fact he WAS there) was a further possible distraction (or an incentive to show him how slick their operation was).
Like most disasters, several holes in the cheese need to line up. The two survivors (the FO and the ATCO) may well bear the brunt of the blame.
The underlying cause is probably laxness with regard to the taxiway modification (from the airport AND the crew's point of view). Maybe even the ATCO . . .
It is possible to be TOO comfortable with familiarity. Any of a number of checks would probably have averted this event.
All circumstantial, but MY 2 cents worth.
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The presence of the guest in the jump-seat (if, in fact he WAS there) was a further possible distraction (or an incentive to show him how slick their operation was).
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Gentlemen & Ladies,
Let us all be mindful of the effects that unfounded or misguided speculation can have. I am deeply concerned at the direction in which some of the 'ATC' speculation is heading. Whilst it is most certainly only natural for professionals to hold a profound interest in events affecting our livelehood and that of our compatriots, we must be mindful that 'other' persons also have access to this forum, and it is possible that their intentions may be somewhat different from our own. (no inference made here-in please note) Also, we have to be mindful of the possible detrimental effects our speculations and postulations may have on those persons concerned. It is not so long ago that a controller (no names nor organisations need be mentioned) was brutally murdered in the 'aftermath' of a terrible accident over Germany. (you all know to which incident I am referring) We ALL have an obligation as professionals, current or retired, to discuss this incident with the utmost of care and respect for all parties concerned.
Best regards
DA1-11
Let us all be mindful of the effects that unfounded or misguided speculation can have. I am deeply concerned at the direction in which some of the 'ATC' speculation is heading. Whilst it is most certainly only natural for professionals to hold a profound interest in events affecting our livelehood and that of our compatriots, we must be mindful that 'other' persons also have access to this forum, and it is possible that their intentions may be somewhat different from our own. (no inference made here-in please note) Also, we have to be mindful of the possible detrimental effects our speculations and postulations may have on those persons concerned. It is not so long ago that a controller (no names nor organisations need be mentioned) was brutally murdered in the 'aftermath' of a terrible accident over Germany. (you all know to which incident I am referring) We ALL have an obligation as professionals, current or retired, to discuss this incident with the utmost of care and respect for all parties concerned.
Best regards
DA1-11
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If blame is required to be stuck in the control tower then look to the system:
1. SMCGS with an adequate warning system (its called software coded parameters) could have prevented this
2.As In the Überlingen accident the “system” did not allow for adequate ATC cover. Trust me this situation is endemic. And will run and run until legislation requires a two person Tower (as a commercial cockpit need requires two)
3.ICAO regulations require a pilot take-off clearance to be read-back in full. “Roger” is the classic insufficient reply.
1. SMCGS with an adequate warning system (its called software coded parameters) could have prevented this
2.As In the Überlingen accident the “system” did not allow for adequate ATC cover. Trust me this situation is endemic. And will run and run until legislation requires a two person Tower (as a commercial cockpit need requires two)
3.ICAO regulations require a pilot take-off clearance to be read-back in full. “Roger” is the classic insufficient reply.
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qsyenroute. I'm genuinely baffled as to how SMGCS would have prevented this. SMGCS may alert a controller when two targets (aircraft) are getting too adjacent, but how would it warn of a single aircraft moving onto the 'wrong' runway?
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Utilising data derived from mode-s extended squitter information, SMGCS could be parameterised to include within its safety logic a warning when an aircraft type (stored on its database) lines up on a runway that has a TORA below that aircraft’s minimum required field length
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News Just in!
http://news.bbc.co.uk/1/hi/world/americas/5297340.stm
US crash air control understaffed
The crash was the worst in the US for five years
The only air traffic controller on duty when a plane crashed in Kentucky on Sunday, killing 49 people, had his back turned at the time, investigators said.
He failed to notice the plane had taken the wrong runway as it tried to take off, as he had turned away "to perform administrative duties", officials said.
The runway was too short and the Comair CRJ-100 crashed shortly after take-off.
The Federal Aviation Administration admitted it broke its own rules in putting only one controller on duty.
"This controller did not have visual contact with the aircraft," said Debbie Hersman, a member of the National Transportation Safety Board.
The man was not named but had been working at the Lexington airport for 17 years and was fully qualified, Ms Hersman said.
At the crucial moment "he was doing a traffic count", she said.
The plane's pilots were apparently unaware that take-off procedures at the airport had changed only a week earlier.
They used a 3,500ft (1,050m) runway, meant for small aircraft, instead of the one next to it, which was twice as long.
Experts said the plane needed at least 5,000 ft (1,524m) of runway.
The air traffic controller had cleared the aircraft for take-off from the longer runway, but turned away and therefore failed to see it advance up the wrong strip, Ms Hersman said.
Runway 26 was not designed for use by commercial jets
The aircraft, bound for Atlanta, went down in woods about a mile (1.6km) from Lexington's Blue Grass Airport at about 0610 (1010 GMT) on Sunday.
The only survivor of the crash was the co-pilot, first officer James Polehinke, who was at the controls at the time of the crash.
He remains in a critical condition in hospital.
Doctors said it was miraculous that he was alive, as he had broken bones throughout his body, including in his face and spine.
His mother, Honey Jackson, urged people not to blame him for the crash.
"He could die at any moment," she said. The crash is the worst US air accident since November 2001, when an American Airlines plane came down in Queens, New York, shortly after take-off from JFK airport, killing 265 people.
Well that answers my question above!!
US crash air control understaffed
The crash was the worst in the US for five yearsThe only air traffic controller on duty when a plane crashed in Kentucky on Sunday, killing 49 people, had his back turned at the time, investigators said.
He failed to notice the plane had taken the wrong runway as it tried to take off, as he had turned away "to perform administrative duties", officials said.
The runway was too short and the Comair CRJ-100 crashed shortly after take-off.
The Federal Aviation Administration admitted it broke its own rules in putting only one controller on duty.
"This controller did not have visual contact with the aircraft," said Debbie Hersman, a member of the National Transportation Safety Board.
The man was not named but had been working at the Lexington airport for 17 years and was fully qualified, Ms Hersman said.
At the crucial moment "he was doing a traffic count", she said.
The plane's pilots were apparently unaware that take-off procedures at the airport had changed only a week earlier.
They used a 3,500ft (1,050m) runway, meant for small aircraft, instead of the one next to it, which was twice as long.
Experts said the plane needed at least 5,000 ft (1,524m) of runway.
The air traffic controller had cleared the aircraft for take-off from the longer runway, but turned away and therefore failed to see it advance up the wrong strip, Ms Hersman said.
Runway 26 was not designed for use by commercial jetsThe aircraft, bound for Atlanta, went down in woods about a mile (1.6km) from Lexington's Blue Grass Airport at about 0610 (1010 GMT) on Sunday.
The only survivor of the crash was the co-pilot, first officer James Polehinke, who was at the controls at the time of the crash.
He remains in a critical condition in hospital.
Doctors said it was miraculous that he was alive, as he had broken bones throughout his body, including in his face and spine.
His mother, Honey Jackson, urged people not to blame him for the crash.
"He could die at any moment," she said. The crash is the worst US air accident since November 2001, when an American Airlines plane came down in Queens, New York, shortly after take-off from JFK airport, killing 265 people.
Well that answers my question above!!
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I wonder about the way some blame is being eased toward ATC here.
Could some ATC'er post the exact meaning of the phrase 'cleared for take off'. For example, is it the controllers duty to ascertain the runway is clear? That the correct runway is being used etc. etc. Or is it, particularly for the second of these, solely the responsibility of the flight crew?
Ta.
Could some ATC'er post the exact meaning of the phrase 'cleared for take off'. For example, is it the controllers duty to ascertain the runway is clear? That the correct runway is being used etc. etc. Or is it, particularly for the second of these, solely the responsibility of the flight crew?
Ta.
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Dont get me wrong, i am not insinuating that blame is resting on the controller. At the end of the day, the captain of the aircraft has ultimate control and responsibility of the aircraft at all times.
It would seem however that the FAA's decision to understaff LEX was a possible contributory factor to this tragedy.
That is not to say the controller is at fault, he is not.
It would seem however that the FAA's decision to understaff LEX was a possible contributory factor to this tragedy.
That is not to say the controller is at fault, he is not.
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Nothing to do with the tower.
Tower under-staffed or tower over-staffed: totally irrelevant. There was nothing wrong with the clearance as issued and there was nothing wrong with the assigned runway - but the aircraft didn't use the assigned runway. Only one person is ultimately responsible and he's paid the price, so have all of his passengers.
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Tower under-staffed or tower over-staffed: totally irrelevant. There was nothing wrong with the clearance as issued and there was nothing wrong with the assigned runway - but the aircraft didn't use the assigned runway. Only one person is ultimately responsible and he's paid the price, so have all of his passengers.
However the FAA should share some of the burden in the blame. If the tower wasnt understaffed, one of the controllers would have noticed the error (or at least had a better chance of noticing it). Besides, its FAA's OWN RULES not to have just one controller on duty.
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I wonder about the way some blame is being eased toward ATC here.
Could some ATC'er post the exact meaning of the phrase 'cleared for take off'. For example, is it the controllers duty to ascertain the runway is clear? That the correct runway is being used etc. etc. Or is it, particularly for the second of these, solely the responsibility of the flight crew?
Ta.
Could some ATC'er post the exact meaning of the phrase 'cleared for take off'. For example, is it the controllers duty to ascertain the runway is clear? That the correct runway is being used etc. etc. Or is it, particularly for the second of these, solely the responsibility of the flight crew?
Ta.
ICAO Doc 4444 Air Traffic Management
CHAPTER 7. PROCEDURES FOR AERODROME CONTROL SERVICE
7.1.1.2 Aerodrome controllers shall maintain a continuous watch on all flight operations on and in the vicinity of an aerodrome as well as vehicles and personnel on the manoeuvring area. Watch shall be maintained by visual observation, augmented in low visibility conditions by radar when available
7.8.4.3 Subject to 7.8.4.2, the take-off clearance shall be issued when the aircraft is ready for take-off and at or approaching the departure runway, and the traffic situation permits. To reduce the potential for misunderstanding, the take-off clearance shall include the designator of the departure runway.
And this is the closest ICAO gets to the subject……..
7.3.1.4 OBSTRUCTED RUNWAY
In the event the aerodrome controller observes, after a take-off clearance or a landing clearance has been issued, any obstruction on the runway likely to impair the safety of an aircraft taking off or landing, such as a runway incursion by an aircraft or vehicle, or animals or flocks of birds on the runway, appropriate action shall be taken as follows:
a) in all cases inform the aircraft concerned of the obstruction and its location on the runway;
b) cancel the take-off clearance for an aircraft which has not started to roll;
c) instruct a landing aircraft to go around.