Comair CRJ crash in Kentucky

[barit1]

One characteristic of the human in a complex system - or so I was taught long ago - is that it is better to be "in the loop", actively controlling the machine, than passively monitoring either an automated system or another human's actions.

In this case the FO was probably engrossed with ancillary duties during taxi, not monitoring (or at best intermittently monitoring) the taxi operations performed by the captain. CRM was likely low on the totem pole, and as a result the FO's situational awareness was seriously degraded when he took control for TO.

At least that's the way I model this situation in MY head. How would the outcome have been different had it been the captain's leg? Hard to tell, because the FO would still have the paperwork etc., perhaps "out of the loop", and might not have caught the wrong heading.

Comments welcome.

[jondc9]

barit1

I tend to agree with your views. I ask myself this: who mentioned the lack of runway lights on the CVR?

If it was the captain, why not key the mic (RT to you footballers across the pond) and say: where are the runway lights?

If it was the copilot who mentioned it, why didn't the captain, using excellent CRM skills, resolve the question by a number of means? Certainly the answer, "who needs 'em" ( not found to be stated , but used for effect) would be unacceptable.

If anyone has the data, I would love to know the flying time totals for the two pilots.

[Scurvy.D.Dog]

HotDog
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.. funny you should mention cameras … was talking with a colleague the other day (prior to this accident) regarding types of automation that might be employed in aerodrome operations …. Most of it is pie in the sky stuff at the moment simply because of the inability to replace the Mk 1 eyeballs in the tower with something that is cost neutral or better and as effective ..
not going to get into an argument regarding replacing Tower ATC’s with something else as I am certain it cannot be done as too many holes would exist in the system in and around the aerodrome, as well as being necessarily more restrictive than Tower ATC’s in any event ….. it is a whole other subject that would make this thread look like a nursery rhyme
… however, cameras and displays in the tower raise a few issues:-
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- as with radar, it could (in the wrong conditions) distract the ADC from looking where they should be looking
- Where do you put these monitors in the tower cab (real estate is often tight in the glass tree)
- The legalese surrounding when it is used would necessarily be very complicated
- In the context of this accident would it have changed the result … not unless the ATC happened to be looking at it at the time .. they may not for all the reasons raised here
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In a practical sense, a system that has an audible trigger is far better as the ATC would hear it and react no matter what they were doing at the time. Similar in design to ‘Clearance Adherence Monitors’ used in enroute radar in Oz.
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.. now that all sounds peachy, and I hope before long it will become the reality …. But .. the reality is that lots of development has to occur before you can really use it in an aerodrome sense i.e.
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Surface surveillance systems (ADS or Radar based) would need to be fed into a surface display that was smart enough to pick up (perhaps from electronic strips) the taxi route and runway for departure …. The system could be set up with alarm thresholds that alert if the aircraft is detected deviating from the expected clearance or crossing a holding point without the appropriate clearance ….. alarms could be redundant using beam triggers (like door alarms in shops) across taxiways and runways as a back up if the ADS/Radar is inop ….. it can be done ..
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Aural alerts are your best chance of highlighting an error that has not been detected visually (that applies equally to Pilots and ATC’s)
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…. In that sense …. had the CRJ turned onto 26 and started to roll …. If ATC system aural alerts were available … the ATC would hear ……WOULD then look (no doubt in stunned disbelief) …. What the F* …..followed immediately by … Stop Stop Stop …
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.. lots of ‘fark’ and ‘****e’ and other expletives ……. but no funerals!!!!
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Perhaps this accident will provide some catalyst for investment design and implementation of these sorts of risk controls, this example is only one of many that might be considered in the wash-up!
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Disclaimer:- I am in no way interested in or promoting ATM systems of this kind, merely a personal view based on experience!
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.. night all

[None]

The "new" accident investigation

http://www.srv.se/upload/F%C3%B6reby...ey%20dekker%22

[ChristiaanJ]

Scurvy Dog,
IIRC they had just repaved part of the area and modified the taxy routes (which may well have been one of the contributing factors).

So a good chance that your hypothetical ATM system would not yet have been re-installed correctly, or somebody with a digger having cut some vital cables.

Admittedly one more hole in the cheese to line up.... but it sounds as if this cheese already hade enough holes for one more not to make much differences.

[Beanbag]

A low-tech alternative to HotDog's cameras might be those movable red & white striped fences that LHR puts across closed taxiways. If they put one of those across the entrance to 26 when it got dark and removed it at first light it would've prevented this incident without closing the runway to daytime GA operations.

[Mad (Flt) Scientist]

Wouldn't that prevent people using the GA runway as a taxiway, though (which I presume is a valid option)?

[jondc9]

using runway 26 as a GA taxiway at night without lights doesn't sound too bright (pun) either

j

[Airbubba]

You'd be amazed how well an airport marks closed runways and taxiways after a crash like this.

Taipei does the big glowing 'X' markers and has red flashing lights all over the place when a runway is closed for maintenance...

[411A]

Well, lets see.
First it was, oh gosh, the crew made a mistake in trying to depart on the wrong runway because they were tired, after a short nitestop.
Opps, apparently not true, as they had quite a long time off, considering.
Then it was...it must be the controllers fault. But when you think about it, the tower controller told these Comair folks to takeoff on runway 22, but of course, they did not.
They departed on a runway that was apparently not lighted, while it was still dark, which seems to be rather a bad idea.
So, what DO we have?
Well, the NTSB will certainly look at this nasty accident closely, and more than likely will come to the conclusion that...
Well guess what, the FD crew screwed up.
Certainly not the first time, nor will it be the last, as far as accidents go.
Still, there will be a large percentage of pilots who will certainly maintain...the SYSTEM failed.
Quite frankly, this is total BS, the flight deck crew concerned screwed it up, NOT anyone else.
If they could not look down at the directional indicator and determine that the runway they lined up on was incorrect, they had positively no business on the FD to begin with.
Period.

[Loose rivets]

While this may be all true, it does not get away from the prime question. Why did a crew, that was faultless yesterday, make this mistake today?


For my money, having more and more tedious little tasks to do while taxiing is a major contributing factor. Seeing the top of my young colleagues' heads while taxiing used to be a major irritation to me, but of course they were doing their job as per the book...God help us.

[Scurvy.D.Dog]

... has anyone revealed the actual assigned heading for the accident flight!!

[fireflybob]

411A, yes it seems from the evidence so far that mistakes were made on the flightdeck but nevertheless any accident is a "failure" from a systems point of view.

Years ago the expression "pilot error" was often used to explain the cause of an accident but we have, I hope, moved on. The route causes of this accident (and others) may stem from, for example, training and selection of pilots, the safety culture of the Company (and I mean from Board level downwards), the lighting systems at the airport, the numbers and training systems for the ATCOs on duty etc etc. It may be true that the crew "screwed up" but we need to find out WHY to prevent a reoccurence.

It is very often the case that when an accident occurs, many more "near misses" have occured on previous occasions where an accident has not resulted. The MOR system exists so it would be interesting to know if other pilots have nearly made this "mistake" and whether it has been reported?

In conclusion, 411A, I do agree that we are talking about quite basic matters but it is in the interests of all the aviation community to discover what really leads to experienced professionals to make what appear to be basic errors.

[wileydog3]

Originally Posted by 411A

So, what DO we have?
Well, the NTSB will certainly look at this nasty accident closely, and more than likely will come to the conclusion that...
Well guess what, the FD crew screwed up.
Certainly not the first time, nor will it be the last, as far as accidents go.
Still, there will be a large percentage of pilots who will certainly maintain...the SYSTEM failed.
Quite frankly, this is total BS, the flight deck crew concerned screwed it up, NOT anyone else.
Period.

You are exactly right and 411A you would do well on the NTSB. You have correctly placed blame on the crew. PILOT ERROR. And the crew and the passengers paid the final price for this 'screw up'.

Personally, I think you may have a calling as a check airman. You seem to be able to find fault and place blame with dead-on accuracy. You have succinctly pointed out WHAT happened and really who cares why it happened or how it evolved? You nailed the crew.

You may, however, be about 15-20 years behind the times but there are still many training outfits who could use your talents be it in the nuclear industry (Chernobyl, 3 Mile Island), shipping (Herald of Free Enterprise), energy (Bhopal), and of course aviation.

Well done.

(For a bit more education, you might google around and see if you can find a report, A Just Culture, which tries to go beyond classification and assignment of blame to explanation and a study of why things get 'screwed up')

[chuks]

Hunt them down!

I found 411A's take on this interesting, as usual. No, sorry, make that 'fascinating.' If one accepts his logic then it raises another question: How do we identify these people who are prone to gross error?

Logically you could make a start by saying that anyone who makes small mistakes should be banned from the Flight Deck (FD) since logic would state that they have shown a propensity for error. Unfortunately, everyone makes mistakes so that is a non/starter.

There"s a sort of self-certification at work when people respond to apparent errors like this one by stating that they of course would never make such a one. May we take it that 411A is one of these fortunate souls? He belongs on the FD where the crew of the accident aircraft clearly did not. Proof of this is that he has never made such a big mistake. Well, the accident crew could have said the same thing for most of their careers as well!

On the other hand, yes, you could easily point to the accident crew"s small mistake of going to the wrong aircraft on the day of the fatal accident. Might one take that as a marker for the big mistake to follow? Should we have some sort of error-tracking system in place? Forget to do up your zip and you find yourself banned from the FD for a week, say?

All right then, 411A, what controls do we put in place to identify those who 'don't belong,' sniffer dogs trained to respond to the potential to make gross errors or what? The impossibility of finding humans with zero potential for error is exactly why we have to fall back on this notion of achieving safety in a systematic way.

I was exposed to a very similar attitude to 411A's early in my career when I was flying with ex- US Air Force pilots. They had a little fable that was a serious sort of joke about collecting bonus points. It went sort of like: Get something right and you get a 'pat on the back.' Ten 'pats on the back' earned you one 'Attaboy!' Ten 'Attaboy!s' got you one 'Go get 'em!' But one 'Aw sh*t!' cancelled the whole lot.

I took this for a crude attempt at identifying people who would not make gross errors. Of course ex- Air Force people form a fairly elite pilot group, having been very carefully selected and trained, so that such a crude way of achieving safety would be more workable than with the general pilot population.

I also found that people with this belief system were quite reluctant to shift their thinking to the later notion of achieving safety by moving to a systems-based approach. They tended to cling to the system they had grown up in, probably not least because they had paid a high price to be part of that system.

Curiously they also tended to cling to such things as alcohol abuse as part of the same system for denoting superior airmen so that I thought their faith in their system was not strictly based on logic. On the other hand, while I had been well-acquainted with their system I was not part of it so that they took my scepticism mostly for carping from an outsider, a non-elite.

I remember being condescended to by this one fellow as the last three inches of his tie were sopping wet from having been dipped into his glass of 'Old Setter' and ice that was cradled in his crotch since the flight was over and all we were now doing was taxying back to our hangar. Hey, he was ex- Air Force and I was just some young punk who knew nothing! Fair or not, that sort of thing does tend to make you sceptical of people who take this old-fashioned approach to safety. You just have to wonder what else they took with them from their early experiences in aviation.

When we shift to the systems-based approach to safety we undervalue the qualities of the individual pilots. It would be like moving from flying the Space Shuttle to operating a lift, say. The safer the system becomes, the closer we get to the idea ('ideal,' perhaps?) that 'anyone can be a pilot.' On the other hand, unless someone here can tell me of a reliable way to identify those of us who may make a gross error (assuming that is only a few of us) then I think we have to move past the old way of thinking to try to improve the new systems-based way of implementing safety.

One marker is that the NTSB itself has the objective of finding causes for accidents rather than assigning blame. Just look here at how many of us prefer to play the blame game before all the facts are laid out. Not just blame the pilots but blame ATC, blame the lighting, blame the darkness... that's not very useful but it makes people feel better, poor things.

[ChristiaanJ]

If only one pilot, after reading this thread, has said to her/himself: "Well, come to it, I usually don't check runway heading either... Maybe I should..." and does so in the future, this thread already will have served its purpose.

A "chain of events" led to this accident.
That "chain of event" is still lying in wait to claim some more victims.
The more we are aware of each of those events, the less likely they are to jump up and bite us.

[HotDog]

There will be an explanation and a "most probable" cause in the official findings of the enquiry into this tragic accident, other than the glaring error of the choice of wrong runway. However a lot of people may not say it but will think: "there by the grace of God.....".

[Scurvy.D.Dog]

... just one life saved as a result of these discussions, then the time and words are worthwhile!
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.... it is not (should not be) about individual blame!
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.. there is an oft' used saying in Aviation
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.. there are those who have made mistakes ... and those that are going to ... and those who say they haven't are liars!
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.. ..... there but for the grace of god .. indeed!

[411A]

>>All right then, 411A, what controls do we put in place to identify those who 'don't belong,'....<<

You don't need these kind of 'controls', chuks, but what you DO need is to actually LEARN from others mistakes.
Take my reference to PanAmerican many pages back.
They were at the forefront in the passenger jet age, and found thru many hard lessons some of the common mistakes that you COULD make with a jet aeroplane, and adjusted their operating procudures accordingly.
The 'configuration check' that I mentioned before, as the absolute last item on the before takeoff checklist, is a perfect example.
PanAm had a nasty incident at KSFO which prompted this checklist change, so they actually DID something about it.
When I attended 707 training many years ago at PanAmerican, I found they had some really good ideas.

Configuration check:

Flaps ...set and confirmed at the proper setting
Stab trim...in the takeoff range
Spoilers.... down.

And, last but not least,

HSI's...compared, and the heading bug set to the runway assigned.

One airline where I operated, added one other,

Flight director modes...set as desired.


It can generally be presumed that IF you have your aeroplane configured properly, and pointed in the right direction, on the runway assigned, the takeoff and climb will be successful.

It really doesn't get anymore basic than that, in my view.

[PaperTiger]

Originally Posted by Scurvy.D.Dog

... has anyone revealed the actual assigned heading for the accident flight!!

The particular clearance issued is presumably 'sealed' for the investigation, but COM191 normally filed direct Bowling Green, 234deg true. http://flightaware.com/live/flight/COM191