Comair CRJ crash in Kentucky

[hetfield]

Originally Posted by barit1

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

If seated in the cabin, no.

[Airbubba]

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

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

[HowlingWind]

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

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

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

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

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

Nothing out of the ordinary was noticed.

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

Air Traffic Controller: Timeline Of Events On Accident Day

• Scanned the radar display
• Saw no air traffic
• Had a clear, unobstructed view of the runway
• Cleared Flight 5191 to takeoff from runway 22
• Last time he saw the aircraft was when it was taxied to runway 22
• Said the pilot did not sound confused or disoriented
• Turned around to perform administrative duties in the tower

The NTSB performed taxi tests late Monday night. Investigators followed the path of the accident aircraft, from the ramp to runway 26, and did the same with runway 22.

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

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

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

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

Background of Flight Captain and First Officer

Captain, Jeffrey Clay

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

First officer, Jim Polehinke

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

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

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

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

Runway 26 remains closed until further notice.

From WCPO-TV, Cincinnati

[FIRESYSOK]

Originally Posted by HowlingWind

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

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

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

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

[Stuck_in_an_ATR]

Originally Posted by barit1

This may be apocryphal -

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

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

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

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

[M609]

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

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

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

Is it right?

No!

[Airbubba]

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

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

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

http://www.nytimes.com/2006/08/29/us...us&oref=slogin

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

[HowlingWind]

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

[Ptkay]

ATC responsibility

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

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

Originally Posted by Ptkay

I think a factor in this last incident was a similar incident
with a Cessna 172 training night-VFR approches to EPPO
and missing the field.
The lady controler was not allowed to give them suggestions,
although she saw on the radar screen what was happening,
since the radar system was (and still is) not certified.
She did warn them anyway, saved their lives
(they were low on fuel and managed to do emergency
landing on a frozen lake instead of hitting the town),
but was later punished for the breach of procedures.

It sounds absurd, but so it is.
After this incident (February) probably noone in charge of
approach was brave enough to interfere with pilots decisions
by this recent incident.

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

[eastern wiseguy]

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

[OldSchoolATC]

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

[PaperTiger]

Originally Posted by RatherBeFlying

It takes some serious fatigue to see 22 when the sign says 26.

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

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

[alf5071h]

For those contributors who have sought to blame someone, or like many of us who find it difficult to withhold thoughts of blame, then read: Punishing People or Learning from Failure.

If you then decide to use responsibility instead of blame see: Systems Safety , in particular page 19:-

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

Also see:
Reconstructing human contributions to accidents.

Beyond the Organizational Accident.

[Dream Land]

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

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

D.L.

[jondc9]

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

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

I know the pressure to hurry...but

[Kalium Chloride]

I stress that I am a lowly Cherokee driver

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

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

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

[ATC Watcher]

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

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

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

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

[fepate]

Originally Posted by RatherBeFlying

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

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

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

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

Looking at pictures of the runway layout, it seems that the plane would have passed the 26 sign regardless. So that wouldn't be a surprise. Also, it looks like the sign is some distance from the runway edge.

[surely not]

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

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

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

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

[barit1]

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

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