Comair CRJ crash in Kentucky

[DownIn3Green]

Smoke and Mirrors

I've watched this thread from it's inception, and in my opinion, there are so many "experts" lambasting the "system", and villifying ATC that the bottom line is being obscured.

I was a CTO (Control Tower Operator) from 1975 - 1985 and also hold several RAPCON (Radar Approach Control) ratings.

It is not ATC's job to insure the cockpit crew takes off on the assigned runway.

The 7110.65 does in fact clearly state that a clearence to take off or land will not be issued over the groung control frequency.

When I worked "mids" in the tower, the flight would call for taxi on ground control, and I would instruct them to contact me on "tower" for takeoff, "when ready".

In the LEX scenario, I can envision the Comair flight getting taxi instructions from the controller who then instructed them to contact "tower".

If it was me in this situation, I would aknowledge the flight, observe it's position on the movement area, and traffic permitting, clear him for takeoff on the assigned runway.

I would visually scan the runway for any obstructions, and in DAYLIGHT visually observe the flight for any abnormalities (smoke from engines, panels open, etc) and then go about my other mandated duties.

To say that ATC should have seen this flight depart on the wrong runway at night from the vantage point of the tower is absurd.

Further BS is all of the other "experts" saying ATC should have called for this flight to "abort" is equally wrong. FAA Handbook 7110.65 does not allow a controller to accept command of the aircraft...i.e.-Comair XXXX ABORT YOUR TAKEOFF...

The correct ATC response would be "COMAIR XXXX Cancel Takeoff Clearance...(reason)..i.e. vehicle on runway". It would then be up to the Captain to make his/her decision.

As 411A and others have said, the crew on this one screwed the pooch. Don't try to point blame on anyone else. (Training, ATC, FAA [charts are bad?] etc...

[barit1]

Cool it, DownIn3Green, I don't think many pilots here would quarrel with you.

[jondc9]

down in 3 green

A question:

Should the rules/regs now be changed to make sure the controller verifies proper lineup with assigned runway, not only for takeoff but for landing?

jon

EDIT: The rest of your post was inflammatory and has been removed.

[old,not bold]

Originally Posted by 411A

What do you suggest, Leclairage?
Jail the concerned First Officer just like the Greek authorties did with a Swiss Air Captain years ago, with an overrun at ATH with a DC-8?

Well....

If I enter a motorway on the wrong slip road, drive 5 miles against the flow of traffic, ie on the wrong side of the motorway, and cause a death, I will be prosecuted for causing death by dangerous driving. This is a quite rare occurrence, but it happens.

My defence will bring forward all the reasons I did that...tired, in a rage at something, confusing signing, and so on. Many of these might be valid.

The court will decide my culpability on the facts presented, and if I am partially or wholly to blame they will sentence me in accordance with the law.

The fact that this process will happen is a powerful way of preventing the mistake in the first place. Not the only way, of course, but a compelling one.

Now, why should a pilot be allowed a special dispensation from the normal process of law? At first sight, there is a case for saying that the FO, as one of the operating crew with a duty to perform, was partly or wholly to blame, and he should answer that case. If a court exonerates him, good. If not he should pay the appropriate penalty. If the procedures he was following, and thereby those who wrote/approved them, were at fault, this will be his defence, and if successful those people will have to account for what they did.

I see nothing wrong with a process of retribution. People died here, and they should not have done.

And that's why we'll all be a bit more careful in the future.

[gofer]

ONB.

Well said Sir.

A pilot if properly trained should have learnt, know, understand, agree and accept the risks of the responsibilities, otherwise he should not accept the helm (stick or whatever).

[jondc9]

regarding the law and pilots

why not place pilots in jail for this?

captain is already dead

f/o was not in command

laws in the US do not provide for criminal punishment for accidents

the real question, if the system is indicted, is:

will the CEO of comair go to jail?
j

[barit1]

Not to be flippant - but this thread has degenerated to a rerun of Ernie Gann's "Band Of Brothers", in which a 727 captain was jailed for "deliberately crashing" his ship in Taiwan. There was even a system-induced navigational error in the book.

[HotDog]

barit1, you have beaten me to it. This is getting from the sublime to the ridiculous. Nobody is going to jail, sadly you can not bring back the dead. The only winners will be the ambulance chasing lawyers.

[747boy]

Just wondering if anyone has thought about the possibility that there may have been one or more frequent flyers on the flight who used the airport on a regular basis and would have known the layout of the airport and may have realised that the wrong runway was being used. What would be the protocol in this case for a passenger to alert the crew.

I know it was early morning but I also wondered if the position of the Terminal Building (which I presume was illuminted to some degress) relative to the aircraft's position as it started it's take off roll provided any visual indication that they were on the wrong runway.

[DownIn3Green]

jondc9

I thank the mods for editing your post, although it didn't bother me. To answer your assinine question, neither. You think you know everything, you go figure it out.

As for changing the ATC regs, yeah, why don't we do that? I'll just call my senator and tell him some nitwit with experience in "over 120 different airplanes" doesn't like the way things are...

Good grief man, ATC is not in command of the a/c. The Captain is, although in your case that may be questionable....

[Rongotai]

Originally Posted by old,not bold

Well....


I see nothing wrong with a process of retribution. People died here, and they should not have done.

And that's why we'll all be a bit more careful in the future.

The analogy does not hold. The research evidence is quite clear - in jobs where there are very strong pre-entry training requirements and continuous competency checks that exist because those jobs involve the safety of others, for example pilots and doctors, retribution oriented mechanisms for dealing with errors INCREASE the risk to the public. Where the entry barriers are low , for example truck drivers and ourselves as motorists, fear of retribution DECREASES the risk.

That is not to say that retribution should not be part of the mix if used appropriately, but by using the motoring analogy to justify retribution oriented approaches to aviation safety you are voting to increase your statistical risk of harm.

[rhovsquared]

I'm quite sure that the families of the pax in this flight will be compensated, believe me I think the FO has been 'punished' enough. as I said / implied before COMAIR should rethink it SOP for RWY conf. because of this accident [i'm assuming it was SOP because no pilot is dumb enough not to follow their SOP].

Lastly,I agree with 411A and others who think old time basic flying comportment needs to be reemphasised, because the smoking hole that results from these degraded skills doesn't care about whether or not you have a glass cockpit...all pilots need to remember that AVIATION DON'T LOVE YOU
and even a Cherokee will kill you Quick !!!..it don't care either


Happy Chandelles and Safe Flying To All
rhov

[broadreach]

747boy,

Frequent flyers would have to know the airport layout and the aircraft's performance specs sufficiently well to realise they were wrongly lined up on an inadequate runway. At night or early dawn, mist? Not really likely.

Add to that the natural reluctance of any passenger to second-guess the flight deck at that crucial time. A zillion thoughts might pass though your head but, if you are a frequent flyer or even another pilot, you know that's NOT the time to yell out.

[vapilot2004]

Lexington airport maps wrong

This just arrived in the inbox:

BY ALEXANDER COOLIDGE | ENQUIRER STAFF WRITER
Comair is warning flight crews to exercise "extreme caution" at Lexington's Blue Grass Airport because published diagrams of its taxiway signs and markings aren't accurate.

The warning came as investigators continue to study why Comair Flight 5191 ended up on the wrong runway Aug. 27. The CRJ-100 crashed after an attempted takeoff from a runway that was too short.

A lingering question has been whether construction at the airport and a taxiway layout that some pilots previously called confusing played roles in the tragedy, which killed 49.


Federal officials in August sent a notice alerting flight crews about construction at the airport, which included changes to taxiways as well as a repaving of the main runway - the one that Flight 5191 should have used.

The Federal Aviation Administration issues such notices for a variety of reasons. In this case, it was to alert crews that the path to Lexington's main runway had shifted.

Comair spokeswoman Kate Marx stressed that the latest warning the Erlanger-based regional carrier e-mailed to its pilots Monday followed a routine, periodic update of diagrams of the Lexington airport issued on Friday.

In the e-mail, Steve Briner, one of about five chief pilots at Comair, said: "Published airport diagrams do not reflect actual airport signage and markings. Exercise extreme caution during all ground operations."

While she declined to comment on the ongoing investigation into what caused Comair Flight 5191 to take off from the wrong runway, she said all Comair pilots flying out of Lexington would have been updated on ongoing construction at the airport through regular notices from the airline and the FAA.

Comair officials said the e-mail is part of its efforts to provide pilots the most up-to-date information on conditions at the airport. Comair officials said they couldn't say whether the new airport diagram will be revised.

"Comair will continue to distribute updated information as soon as it is available," Marx said.

Officials with Comair's charting company, Englewood, Colo.-based Jeppesen, said they updated the Blue Grass Airport diagram after the crash as part of a review process that follows any accident. The last diagram of the Lexington airport was issued by the Boeing subsidiary Jan. 27.

"We noticed differences between our chart that was out in the field versus what was supposed to be charted for that airport," spokesman Eric Anderson said. "What is on that chart now is what the FAA says should be on there."

Anderson said Jeppesen would work with the FAA and Comair to clarify any discrepancies.

FAA spokeswoman Laura Brown said the diagram issued by Jeppesen depicts the airport after construction.

A federal database of anonymous pilot complaints shows there have been cases of runway confusion at Lexington in the past. There have been at least two incidents - one in 1991 and another 1993 - where pilots were cleared for takeoff from the main runway at Blue Grass Airport but taxied onto the same wrong runway used by Comair 5191, NASA's Aviation Safety Reporting System said.

[HowlingWind]

A Cincinnati TV station reported that the NTSB told families of the victims the crew had announced the wrong flight number and destination (Toledo) prior to departure. Normally a small thing, to be sure, but given some of the other preflight mixups one that is probably getting additional scrutiny, if true. Presumably NTSB would know this from the CVR; why they might pass it on to family members at this stage is beyond me.

As for the FO, only info seems to be he's still recovering in hospital.

This is not exactly breaking news as the news item is dated 8 September, but I don't recall seeing it in this thread. Apologies if it's been previously mentioned.

[Airbubba]

HRH Sheikh Maktoum of DXB is at LEX today in his 747SP after buying racehorses across the street at Keeneland a couple of days ago.

Looks like not all of the lawyers are going after Comair, the Sheikh just got hit with a camel jockey suit:

http://www.latimes.com/news/nationwo...adlines-nation

I heard that all checklists and configuration changes are completed before leaving the ramp, for example. That way they can still taxi fast but with fewer distractions.

I rode on a Delta 767 cockpit jumpseat a while back. The before takeoff checklist must have been written by James A. Michener. It had all this compasses checked and gyros aligned stuff, the Brits would have been envious. I think the Boeing company '76 before takeoff checklist has only one item, flaps.

[discountinvestigator]

Back to my question...

The new maps published by for the time of the accident by the FAA were inaccurate.
The FAA maps at the time of the accident did not have the signage on them.
The FAA maps at the time of the accident did not have the markings on them.

I do not have the Jepps for the day in question, but I can give you comments if somebody has a copy of the version that the crew were using.

Now, back to my question, and you might find that it is vital to the potential cognitive errors on the flight deck at the time, were the red lights which sit across the old taxiway (and appear right in front of you as you come to the 26 hold), there or not at the time of the accident? Do not look at the charts to figure this one out, the FAA one is wrong, so you won't get what I am talking about.

Happy landings

Discount

[captjns]

Originally Posted by discountinvestigator

The new maps published by for the time of the accident by the FAA were inaccurate.
The FAA maps at the time of the accident did not have the signage on them.
The FAA maps at the time of the accident did not have the markings on them.

Happy landings

Discount

The maps may have been outdated, however the compass systems were fully functioning. RWY 22 equates to 220 degrees and 26 equates to 260 degrees.

The FAA maps may not have had the markings on them, but the track line for the extended runway is presented on the PND. I would think that departing on the wrong runway would give a real visible indication that something is askew.

At then end of the day constant situational awareness is essential to a safe operation, no matter the experience level of the crew.

Bottom line the whole incident ts just plain tragic.

[jondc9]

I think we all remember the term: "sucker hole". A sucker hole can attract a pilot who wants to maintain visual reference, a short cut if you will from a long drawn out instrument approach.


consider: if this had been a minimum visibility takeoff ( I don't know comair's ops specs, but lets say 1/4 mile) the crew probably would have looked at the compass/dg etc. might even have had the localizer for 22 up.

If the takeoff had been done in full night, even in good visibility, the crew might have checked the compass.


But here the crew was above basic VFR with things brightening up minute by minute (though still dark).

There is a huge imperative to fly visually almost deep in ourselves. Witness how many people "duck" the glide slope after breaking out of an instrument approach. Witness how many landings at the wrong airport, even in planes with GPS and other goodies.

"Visual" flying is often easier and more efficent than instrument flying. However we must impress upon our fellow pilots effective discipline in this relm. (with proper cross checks of instruments, instruments on occasion can lie).


j

[barit1]

My humble apology if this question has been answered, but how unusual is it for a scheduled operator to take off on a dark, unlit runway? I've never heard of such a thing, and I think it REALLY strange, a recipe for a wreck if I ever heard one.