Comair CRJ crash in Kentucky
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Life is...
Aviation is littered with traps that often only become obvious with hindsight. You read about a tragic and seemingly stupid oversight such as lining up on the wrong runway and if you are young you think, 'Ho! There is one mistake I shall never make because I am young and sharp and I always check my heading.' If you have had those razor edges worn off a bit by too many 0 dark 30 starts with small but telling errors then you think that you better go back into that big Rolodex you keep between your ears and review that.
One of the most dangerous guys I ever worked with was very, very big on his proclamations to anyone who would listen that he was just about 'stupid mistake-proof.' No prizes for guessing how he died, eh? If he'd been around to hear about that he would have been very scathing about such an elementary mistake as the one that killed him but it must have been a very different thing on the day in his cockpit.
One of the most dangerous guys I ever worked with was very, very big on his proclamations to anyone who would listen that he was just about 'stupid mistake-proof.' No prizes for guessing how he died, eh? If he'd been around to hear about that he would have been very scathing about such an elementary mistake as the one that killed him but it must have been a very different thing on the day in his cockpit.
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....
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... I am curious about this taxi clearance issue ..... can someone confirm (in a standard operating sense) that runway crossings are not necessarily issued if part of the intented taxi route .. and therfore presumably not readback also? ..... is this a US procedure to minimise R/T loading?? .... if so, is it ICAO compliant? ..A7700 .. anyone?
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.. would that be an additional 'jogger' i.e. '........ cross Rwy 26 ... Rwy 22 Clear for take off'
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... I am curious about this taxi clearance issue ..... can someone confirm (in a standard operating sense) that runway crossings are not necessarily issued if part of the intented taxi route .. and therfore presumably not readback also? ..... is this a US procedure to minimise R/T loading?? .... if so, is it ICAO compliant? ..A7700 .. anyone?
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.. would that be an additional 'jogger' i.e. '........ cross Rwy 26 ... Rwy 22 Clear for take off'
ICAO DOC4444
12.3.4.9 TO CROSS A RUNWAY
Note.— If the control tower is unable to see the crossing aircraft (e.g. night, low visibility, etc.), the instruction should always be accompanied by a request to report when the aircraft has vacated and is clear of the runway.
b) CROSS RUNWAY (number) [REPORT VACATED];
EUROCONTROL EAPPRI Doc.
c) TO CROSS A RUNWAY
PILOT/DRIVER (call sign) REQUEST CROSS RUNWAY (number..)
Note — If the control tower is unable to see the crossing aircraft or vehicle (night, low visibility, etc.), the instruction should always be accompanied by a request to report when the aircraft or vehicle has vacated the runway.
ATC (call sign) CROSS RUNWAY (number) [REPORT VACATED]
ATC (call sign) TAXI TO HOLDING POINT [number] [RUNWAY (number)] VIA (specific route to be followed), [HOLD SHORTOF RUNWAY (number)] or [CROSS RUNWAY(number)]Note — The pilot will, when requested, report “RUNWAY VACATED” when the aircraft is well clear of the runway.
CAP493:
8.4 Crossing Runways
8.4.1 If the instructions given to surface traffic involve crossing a runway in use, clearance to cross should normally be withheld until no confliction exists. However, to achieve greater efficiency of operation clearance to cross may be given subject to aircraft which are landing or taking off. The clearance shall contain sufficient information to enable the pilot of the taxying aircraft or vehicle driver to identify the other traffic and should be related to one movement only.
8.4.2 When a clearance to cross a runway in use is issued a report vacated instruction shall be included. However, this instruction may be omitted when aerodrome control has continuous sight of the aircraft or vehicle crossing
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ZH-127
I am 50 today and I have to tell you that Wileydog3's statement is observable everyday, all around wherever you happen to be.
FYI, I am a HRD consultant specializing in "soft" management issues, so I have the opportunity to explore this subject many times every year.
Human factor errors are not limited to the air transport sector, but often they bite harder as so tragically demonstrated in Kentucky.
I imagine that the two pilots were skilled and dedicated professionals who were unfortunate enough to find all the holes in the cheese lined up against them.
I am 50 today and I have to tell you that Wileydog3's statement is observable everyday, all around wherever you happen to be.
FYI, I am a HRD consultant specializing in "soft" management issues, so I have the opportunity to explore this subject many times every year.
Human factor errors are not limited to the air transport sector, but often they bite harder as so tragically demonstrated in Kentucky.
I imagine that the two pilots were skilled and dedicated professionals who were unfortunate enough to find all the holes in the cheese lined up against them.
... preflight the wrong aircraft until corrected by ramp persnnel
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A number of different triggers could have revealed this... talking to the ground crew for engine start-push back, when no passengers showed up near departure time, when the agent came looking for the pilots, when the next crew showed up, when the Capt gave the pax a weather briefing for ATL and they were going elsewhere.
VERY unlikely they would have gotten off the gate BUT it has happened.
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I'm not saying that they dont happen, they do happen.
The point im trynig to get across is that if i made silly mistakes in my job, although the immediate effect of that mistake wouldnt be that severe, the repercusions to myself would be severe.
I.e. if i made a silly mistake such getting my figures wrong, the company would lose a deal, and there is no doubt in my mind that i would lose my job. For that reason, i ensure that i dont make silly mistakes. I make mistakes, but not silly mistakes which shouldn't happen.
Its hard to give an example with out explaining my job, which would take all afternoon. I hear what and understand what you guys and girls are saying, and i appreciate most of what is being said.
The guys flying were no doubt professional and accurate, but they still made a silly stupid mistake (or so it looks - dont want to cast dispersions), the mistake shouldnt have been made, and would have been stopped by a simple two second check.
Its like me walking into a meeting with our directors to talk about supplier engagement processes and rates, without checking my figures before hand. I just wouldn't do it.
In the same way as i've had it hammered into me since my first flight, check your compass upon line up with centreline.
Anyway, enough of this speculation, obviously we are all going to view the cause of this differently, some are taught different things by FI's etc.
One thing that can be certain, is that the aviation world needs to learn from this disaster to ensure it never happens again. If this happens, and there are no crashes such as this again.. then perhaps those people didnt die in vain.
RIP.
The point im trynig to get across is that if i made silly mistakes in my job, although the immediate effect of that mistake wouldnt be that severe, the repercusions to myself would be severe.
I.e. if i made a silly mistake such getting my figures wrong, the company would lose a deal, and there is no doubt in my mind that i would lose my job. For that reason, i ensure that i dont make silly mistakes. I make mistakes, but not silly mistakes which shouldn't happen.
Its hard to give an example with out explaining my job, which would take all afternoon. I hear what and understand what you guys and girls are saying, and i appreciate most of what is being said.
The guys flying were no doubt professional and accurate, but they still made a silly stupid mistake (or so it looks - dont want to cast dispersions), the mistake shouldnt have been made, and would have been stopped by a simple two second check.
Its like me walking into a meeting with our directors to talk about supplier engagement processes and rates, without checking my figures before hand. I just wouldn't do it.
In the same way as i've had it hammered into me since my first flight, check your compass upon line up with centreline.
Anyway, enough of this speculation, obviously we are all going to view the cause of this differently, some are taught different things by FI's etc.
One thing that can be certain, is that the aviation world needs to learn from this disaster to ensure it never happens again. If this happens, and there are no crashes such as this again.. then perhaps those people didnt die in vain.
RIP.
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I'm not saying that they dont happen, they do happen.
The point im trynig to get across is that if i made silly mistakes in my job, although the immediate effect of that mistake wouldnt be that severe, the repercusions to myself would be severe.
I.e. if i made a silly mistake such getting my figures wrong, the company would lose a deal, and there is no doubt in my mind that i would lose my job. For that reason, i ensure that i dont make silly mistakes. I make mistakes, but not silly mistakes which shouldn't happen.
Its hard to give an example with out explaining my job, which would take all afternoon. I hear what and understand what you guys and girls are saying, and i appreciate most of what is being said.
The guys flying were no doubt professional and accurate, but they still made a silly stupid mistake (or so it looks - dont want to cast dispersions), the mistake shouldnt have been made, and would have been stopped by a simple two second check.
Its like me walking into a meeting with our directors to talk about supplier engagement processes and rates, without checking my figures before hand. I just wouldn't do it.
In the same way as i've had it hammered into me since my first flight, check your compass upon line up with centreline.
Anyway, enough of this speculation, obviously we are all going to view the cause of this differently, some are taught different things by FI's etc.
One thing that can be certain, is that the aviation world needs to learn from this disaster to ensure it never happens again. If this happens, and there are no crashes such as this again.. then perhaps those people didnt die in vain.
RIP.
The point im trynig to get across is that if i made silly mistakes in my job, although the immediate effect of that mistake wouldnt be that severe, the repercusions to myself would be severe.
I.e. if i made a silly mistake such getting my figures wrong, the company would lose a deal, and there is no doubt in my mind that i would lose my job. For that reason, i ensure that i dont make silly mistakes. I make mistakes, but not silly mistakes which shouldn't happen.
Its hard to give an example with out explaining my job, which would take all afternoon. I hear what and understand what you guys and girls are saying, and i appreciate most of what is being said.
The guys flying were no doubt professional and accurate, but they still made a silly stupid mistake (or so it looks - dont want to cast dispersions), the mistake shouldnt have been made, and would have been stopped by a simple two second check.
Its like me walking into a meeting with our directors to talk about supplier engagement processes and rates, without checking my figures before hand. I just wouldn't do it.
In the same way as i've had it hammered into me since my first flight, check your compass upon line up with centreline.
Anyway, enough of this speculation, obviously we are all going to view the cause of this differently, some are taught different things by FI's etc.
One thing that can be certain, is that the aviation world needs to learn from this disaster to ensure it never happens again. If this happens, and there are no crashes such as this again.. then perhaps those people didnt die in vain.
RIP.
Please define 'silly mistake' and 'stupid mistake' as different from just a 'mistake'.
My point is there are mistakes and there are violations. One is unintentional and the other is intentional. Could be I don't see them but I can't find any violations... only a series of mistakes by LOTS of people, not just the crew.
And you are right. THIS accident will not be repeated but there will be another accident if not in the airline industry, in some other industry where humans do repetitive tasks but where failure comes with a high price. Someone will mistakenly think the valves on a nuclear plant are reading erroneously, leave the bow unlocked when the ferry departs... etc.
An example.. here in the States a phone number is 10 digits. It is a relatively simple task with a very simple keypad. Ever place a phone call and do it incorrectly so you dialed the wrong number, dialed a number for Friend A when you meant to call Friend B? How does one explain such a 'stupid mistake' for such a simple task one does over and over and over....
You might argue flying an airplane is very different from dialing a phone number and you would be correct in a manner. But let's say you know that there is the possibility that if you dial the wrong number, your phone will explode and kill you. The first times you dial, you are VERY careful but after a few years of dialing the phone with no consequence you still know the phone can explode but what does your experience base tell you?
We live in the center.. at one end is the event so remote we think it will never happen (9-11) and at the other end is the event that happens frequently but we think we know the risks (driving in rush hour traffic where fatal crashes occur every day) and can compensate. And then in a few brief seconds, everything is re-arranged.
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Please define 'silly mistake' and 'stupid mistake' as different from just a 'mistake'.
My point is there are mistakes and there are violations. One is unintentional and the other is intentional. Could be I don't see them but I can't find any violations... only a series of mistakes by LOTS of people, not just the crew.
And you are right. THIS accident will not be repeated but there will be another accident if not in the airline industry, in some other industry where humans do repetitive tasks but where failure comes with a high price. Someone will mistakenly think the valves on a nuclear plant are reading erroneously, leave the bow unlocked when the ferry departs... etc.
An example.. here in the States a phone number is 10 digits. It is a relatively simple task with a very simple keypad. Ever place a phone call and do it incorrectly so you dialed the wrong number, dialed a number for Friend A when you meant to call Friend B? How does one explain such a 'stupid mistake' for such a simple task one does over and over and over....
You might argue flying an airplane is very different from dialing a phone number and you would be correct in a manner. But let's say you know that there is the possibility that if you dial the wrong number, your phone will explode and kill you. The first times you dial, you are VERY careful but after a few years of dialing the phone with no consequence you still know the phone can explode but what does your experience base tell you?
We live in the center.. at one end is the event so remote we think it will never happen (9-11) and at the other end is the event that happens frequently but we think we know the risks (driving in rush hour traffic where fatal crashes occur every day) and can compensate. And then in a few brief seconds, everything is re-arranged.
My point is there are mistakes and there are violations. One is unintentional and the other is intentional. Could be I don't see them but I can't find any violations... only a series of mistakes by LOTS of people, not just the crew.
And you are right. THIS accident will not be repeated but there will be another accident if not in the airline industry, in some other industry where humans do repetitive tasks but where failure comes with a high price. Someone will mistakenly think the valves on a nuclear plant are reading erroneously, leave the bow unlocked when the ferry departs... etc.
An example.. here in the States a phone number is 10 digits. It is a relatively simple task with a very simple keypad. Ever place a phone call and do it incorrectly so you dialed the wrong number, dialed a number for Friend A when you meant to call Friend B? How does one explain such a 'stupid mistake' for such a simple task one does over and over and over....
You might argue flying an airplane is very different from dialing a phone number and you would be correct in a manner. But let's say you know that there is the possibility that if you dial the wrong number, your phone will explode and kill you. The first times you dial, you are VERY careful but after a few years of dialing the phone with no consequence you still know the phone can explode but what does your experience base tell you?
We live in the center.. at one end is the event so remote we think it will never happen (9-11) and at the other end is the event that happens frequently but we think we know the risks (driving in rush hour traffic where fatal crashes occur every day) and can compensate. And then in a few brief seconds, everything is re-arranged.
What happened at LEX was complacency through and through, not a calculated risk. They didn't say.. "hey 'dave' think since we done take offs loads of times we can get away with doing it on 26 as opposed to 22?"
I ride a motorcycle, in the first 12 months of it i did 40,000 miles i began to get complacent, and had a nasty smash. I have never got complacent since. About anything. I have since that smash done 150,000 incident free miles, and i am constantly aware and never complacent. Ive done the same journey time and time and time again, i know ever single square inch of the road surface, what gear to be in, where the road goes, which houses are around which bends. I know the guy with his dog will be outside the newsagents at about 8.00am every weekday... but i still am not complacent.. cos i still dont know what car is coming around the next bend. I still dont know if around that long smooth sweeping right hander theres a pile of horse manure dropped in the road.
When crossing the road, it only takes a few seconds to be ABSOLUTELY sure, there is nothing coming, rather than just glancing and then sprinting out into traffic.
Checking your compass on line up only takes a few seconds, and saves you from taking off on a runway half the length as the designated one.
Sure, the guys doing it had done it hundreds, if not thousands of times before.. still no excuse to get complacent.
I've ridden that road thousands of times.. it aint no excuse to get complacent.
I've crossed the busy junction outside my office when the traffic is on a green light thousands of times, it aint no excuse to get complacent.
I've made mistakes, we all have. Im not saying that ive never been the victim of human error, i have, many times - my own human error... i got complacent and smashed the bike, and my legs.
Thats the point im trying to get across here. It may not be what you agree with, thats fine, but that is be opinion.
"They'd done it many times before, therefore they made a human error and took off from the wrong runway...." thats a piss poor excuse for 49 deaths.
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No embarrassment at all, will probably happen more than once during a career. Either mild annoyance at the ramper/dispatcher, or a self-deprecating chuckle; a more severe reaction would be unexpected. As to whether it had any bearing on subsequent events I'll leave to the experts and (hopefully) the FO's account.
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Once again, you confuse things. . An excuse is a request for a waiver from known standards. I am NOT offering an excuse. I am simply trying to say 1) things break and 2) people make mistakes. These guys missed cues as did others.
Let's try it another way.. you say you are always aware of what is going on. Next time you go to sleep, when you are sound asleep, please tell us.
Let's try it another way.. you say you are always aware of what is going on. Next time you go to sleep, when you are sound asleep, please tell us.
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Once again, you confuse things. . An excuse is a request for a waiver from known standards. I am NOT offering an excuse. I am simply trying to say 1) things break and 2) people make mistakes. These guys missed cues as did others.
Let's try it another way.. you say you are always aware of what is going on. Next time you go to sleep, when you are sound asleep, please tell us.
Let's try it another way.. you say you are always aware of what is going on. Next time you go to sleep, when you are sound asleep, please tell us.
When i go to sleep, i arent flying an airplane with 47 people in the back. 
In exactly the same way that if i'm driving, and i'm tired, i wont push on.. i'll stop and take a nap.
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"I aren't flying..."
Was that an intentional violation of English syntax and constructs or a mistake? And were you aware of the mistake when you sent it?
I think you are being complacent with the language....
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A number of different triggers could have revealed this... talking to the ground crew for engine start-push back, when no passengers showed up near departure time, when the agent came looking for the pilots, when the next crew showed up, when the Capt gave the pax a weather briefing for ATL and they were going elsewhere.
VERY unlikely they would have gotten off the gate BUT it has happened.
VERY unlikely they would have gotten off the gate BUT it has happened.
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It is an interesting question, for in all liklihood, the other Comair CRJ on the LEX ramp was the early AM departure for CVG. The fuel and flight time to CVG would be far less than the ATL route. You'd think there would be all kind of issues before the pilot would sign that dispatch paper!
That they went to the wrong gate is, IMHO, not a big factor but the time lost in the preflight may be a factor... less time to preflight the correct machine.
And often the events do not happen in a fixed order (ie, maintenance, refueling, catering, etc). We see this frequently as a distraction and when checklist items are missed due to a high task loading.
Also, FWIW, the airplane stopped at the back of my head. I didn't necessarily think "I have 5 people behind me" when I was in the Lear or "I have more than 200 behind me" in the 767 or solo in my Swift "it's only me".
I considered the pax's comfort but when it came/comes to safety, my focus was primarily on getting my fanny up and down safely in one piece and without bending metal or breaking glass. IF I accomplished that goal, the others were taken care of also.
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As Long As Money Rules
As long as money rules and shareholder returns are more important than making a bit, and and meeting minimum standards is the acceptable way to do business,these unfortunate things will happen.
The current scenario is always to avoid blame and place it on somebody else.
The loss nof life is most unfortunate.
The current scenario is always to avoid blame and place it on somebody else.
The loss nof life is most unfortunate.
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Interesting discussion
Somebody much wiser than me once told me if you don't make any mistakes you aren't doing very much. Holds true even today.
Having said that, I flew into Lexington, the Tuesday before the Kentucky Derby in early May of this year. I remember thinking during landing and take-off that the only things around were fields and horse farms for as far as the eye could see. There was no dangerous maneouvors over highways, buildings, mountains. Just a very smooth descent and take-off. For what it's worth, and I know it was just getting light, I can't imagine the pilot not seeing the trees at the end of Runway 26 way before he clipped them. Wouldn't that have rung some alarm bells as the longer runway is pretty free of any obstructions? Add to that, the longer runway runs right in front of the terminal which would be lit at that time of day. It's tough to believe neither pilot (at least so far in NTSB reports) noticed the terminal wasn't there.
A terrible tragedy and the only winners will be the lawyers as usual.
Newarksmells
Having said that, I flew into Lexington, the Tuesday before the Kentucky Derby in early May of this year. I remember thinking during landing and take-off that the only things around were fields and horse farms for as far as the eye could see. There was no dangerous maneouvors over highways, buildings, mountains. Just a very smooth descent and take-off. For what it's worth, and I know it was just getting light, I can't imagine the pilot not seeing the trees at the end of Runway 26 way before he clipped them. Wouldn't that have rung some alarm bells as the longer runway is pretty free of any obstructions? Add to that, the longer runway runs right in front of the terminal which would be lit at that time of day. It's tough to believe neither pilot (at least so far in NTSB reports) noticed the terminal wasn't there.
A terrible tragedy and the only winners will be the lawyers as usual.
Newarksmells
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Originally Posted by Wileydog3
"Reliability is a two edge sword. After you have done task A 10,000 times, it is hard to keep the 'wow' factor and the edge sharp for the 10,001th time."
I think RWY confirmation is Extremely important, despite prior work load, SOPs/checklist are designed for prevent the dulling of senses with time or fatigue, and as we see here, are just as important as config. and perf. check
Rule Books Are Paper,... They Will Not Cushion A Sudden Meeting Of Stone And Metal E.K.G.
rhov
Last edited by rhovsquared; 3rd Sep 2006 at 03:13. Reason: wrong quote
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English variations
if the York that ZH-127 hails from, is the York int'North, then he's only stating it the local way.
Thought's are with all involved.
C o' G
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Here $18K worth of prevention
But my casual observation (actually going back long before my tenure on the planet) is that every new safety alert, every new murphy-proofing, winds up creating a "Whew! Needn't worry about that any more!" complacency, and thus a new and improved generation of Murphies is brought into the world.
Safety alert? Fine, but one has to experience "soft" failures now and then, to anticipate and avoid the "hard" ones.
But my casual observation (actually going back long before my tenure on the planet) is that every new safety alert, every new murphy-proofing, winds up creating a "Whew! Needn't worry about that any more!" complacency, and thus a new and improved generation of Murphies is brought into the world.
Safety alert? Fine, but one has to experience "soft" failures now and then, to anticipate and avoid the "hard" ones.