Comair Lexington Crash CVR

[Sqwak7700]

Originally Posted by 411A

Crew 'fatigue?'
Phooey.
They had the mandated rest, and that should be sufficient.
Sorry, so-called fatigue, as well as poor pay are red herrings with this accident.

You just don't get it, do you dude.

Not everything is black and white. Regulations are built for black and white. But the real world is grey, with many hidden, underlying factors.

I don't care if they had a scheduled 30 hour overnight. That doesn't mean that they were well rested, does it? Maybe there were un-controlable factors that influenced their rest. For example, what where the conditions at the hotel? Where they scheduled for an early departure following a series of late departures?

I'm not debating that the accident was not the crew's fault. They messed up, there is no debating that. But most pilots these days would agree that accidents have many contributing factors. Without these, the accident may have happened, or it may have not.

We can't say to pilots "stop making mistakes". That doesn't work. What we can do, is analyze procedures and modify them to make it less likely that this type of accident occurs again.

[Midland63]

Originally Posted by 411A

In short, do the job (properly) for which you are being paid, and stop using fatigue and duty/flight time limitations as an excuse for poor performance.

411A,

From my perspective as a humble SLF, the issue is (or should be) not "Should pay and conditions etc. affect airline safety?" but "As a matter of fact, do they?"

If they do (or might do), then the issue needs to be identified and addressed.

M63

[bomarc]

Huck and 411A are both right about some things:

to huck... I would like to meet you and I am sure you would see things like I do...and God Bless your dad for telling you to fly a cessna like a 747. but I will tell you this...fly a 747 like a cessna too...always know where you are and where you can land PRONTO if you need to , and not by pushing a button.


Did poor pay cause this accident? no.

411A...yes you are manly for flying the 411 series...keep up with those leg exercises. and you are quite right, no V1. ;-)

To 411A. yes, you are right, pay shouldn't matter. the trouble is, something has happened to airline flying and to the younger folks flying the planes. something NOT GOOD. I ask you...what would have happened to the pilots if at 06:00 they both called their crew scheduling and told them:
"we are not well rested enough to fly...we can take off at 10 am if you like."



To both of you, isn't it possible that there is a less than stellar leadership and hiring process at comair? a less than steller operations and training department?

Is it possible (and I believe likely) that the captain signed on with the comair training academy, paid some serious dough, and got mediocre training as a pilot? and of course, what goes around comes around...so being comair trained, comair got the wheat that they sewed?

note that the copilot who didn't go to the comair ab initio training world was the first to notice the lack of lights?


and what of training? my airline, and others say: if you aren't at flying speed by the last 1000' of runway (windshear) firewall power and pull up!(if you can't stop safely of course)...how come comair didn't? don/'t they teach that?

of course how can one know if you only have 1000' of runway left if there are no lights, or instrument markings on the runway (I would like to see a picture of runway 26)?



fatigue...sure...and comair could have a policy: IF YOU ARE FATIGUED DON"T FLY AND WE will not fire you or dock you any pay...safety first.

and they could mean it...but I'll bet you that they don't!

And ALPA could be a little more forceful and tell the pilots> FATIGUED? don't fly, call in and let people know AND WE WILL HIRE THE BEST LAWYERS in the country to defend you, and provide supplemental pay while you are grounded without pay.


There is so much more to this, and it is mearly a symptom of a very sick industry.

ALPA should challenge the laws allowing the potus to order pilots back to work after a strike...gott be unconstitutional! ;-)


And yes, I have flown 3 round trips from Boston to Sewark, er I mean NEWARK without auto land, with 2 jet engines and had multiple runway changes. and for some reason we did it at 16,000' on the way to newark...doing a lot of flying over New jersey below 7000' (with our landing lights extended & on to avoid the GA stuff)

[Flight Safety]

I find I'm almost completely in agreement with 411A. One of his more interesting comments:

But, when was the last time a professional jet transport crew attempted departure on an unlit runway, during the hours of darkness, and at the same time failed to note that the runway magnetic track was positively NOT what it was supposed to be?
To NOT notice these very basic errors, leads me to believe that the crew was not properly trained, and further, that the specific airline has poor standard procedures.

I'm not saying that other factors shouldn't be looked into, because they should. But I agree with 411A that these ARE basic errors. Clearly there seems to be a weakness in the safety culture and related training at the airline. If you want to point a finger somewhere else besides the crew (and look for accountability elsewhere), then pointing it at the safety culture might be the next best place. Maybe the investigation will uncover something useful here.

[Sqwak7700]

Originally Posted by Flight Safety

I find I'm almost completely in agreement with 411A. One of his more interesting comments:
I'm not saying that other factors shouldn't be looked into, because they should. But I agree with 411A that these ARE basic errors. Clearly there seems to be a weakness in the safety culture and related training at the airline. If you want to point a finger somewhere else besides the crew (and look for accountability elsewhere), then pointing it at the safety culture might be the next best place. Maybe the investigation will uncover something useful here.

You are right Flight Safety. They are basic errors. Almost as basic as say...taking off without being cleared to takeoff. Hard to believe, but someone made that mistake in Tenerife and the deadliest aviation accident occurred. I guess you could also say it is as basic as setting the flaps for takeoff. Who forgets that, right?? In my airline, and I was always taught, you check the flaps before takeoff. And I'm sure Continental and NWA both had procedures in place to prevent that, but somehow that very simple detail was missed in Michigan and Texas.

Well guess what, humans are human. They make mistakes, and that is gonna keep happening for as long as we exist. What we can do, is learn from our mistakes, not just say "I learned better because I was taught in my academy that you do this and that, so I would never do that". It doesn't matter how old you are, where you were trained and what your flight time is. ****t happens and we can either through blame back and forth or we can look for ways to prevent it.

I have no doubt in the world that from what I can interpret on the CVR, the FO and CA were tired. They were both yawning throughout the recording, and the FO called for the briefing twice. That is a really good indicator that he wasn't firing on all cylinders.

Be advised, fatigue is like intoxication or worse. You are not performing at your best, but even worse, you don't know it. It is the things you don't know that you don't know which will kill you.

[ZAGORFLY]

Originally Posted by Dream Land

Don't forget about the nugget on duty in the cab that cleared them for takeoff without even looking outside.

Is simply terrible to read our pilots reading back "two two " knowing that they will inexorably meet their end heading 26 instead .
The airport map is still there at goggle earth and once again I take your attention to the fact that the number 26 was in the left of the aircraft taxing and no further ground mark are visible when you enter the RW26. If they had continued the taxi those wheels would have touched the RW22 marks at the ground. Was a prerequisite to check the magnetic heading with the clearance? Anyway this to say that the airport layout had its contributing factor to this disaster.

[the_hawk]

please allow me a question from the SLF and vATC side: the runway designator was not used in both takeoff clearance and readback - and this point is discussed alongside more "important" topics here if at all - does that mean this is common practice and not worth discussing or do you all agree that it didn't have an impact on this accident and is not worth discussing for safety reasons?

[Telstar]

The Hawk I want to know the same thing. The Americans have got to accept that there R/T standards are apalling and are contributing to accidents, without taking it as a slight on their nationalistic pride. This is not about Europe Vs. the US. It is a flight safety issue.

I will forever wonder that if the controller had prefixed the takeoff clearance with the runway in use and the crew had readback the full clearance including the runway prefix a light bulb may have gone off in someones head.

I think the final hole in the swiss cheese lining up could have been prevented by proper phraseology like this:

TWR: Cleared for takeoff Runway 22
Comair: Cleared for takeoff Runway 26
TWR: STOP! Wrong runway!

[Huck]

does that mean this is common practice

Unfortunately, in the U.S., I have noticed that phraseology is somewhat lax sometimes, especially when it is late or early, in a small town versus a city, or when the controllers and pilots "know" each other, i.e. recognize each other.

I try to always read back the runway number, and even emphasize it a little - not for the controller so much, but for any other pilots on the frequency, to give them better situational awareness. Let's say someone was on final approach and the controller forgot and cleared you for takeoff on the same runway.....

[Midland 331]

Originally Posted by Telstar

The Hawk I want to know the same thing. The Americans have got to accept that there R/T standards are apalling and are contributing to accidents. I will forever wonder that if the controller had prefixed the takeoff clearance with the runway in use and the crew had readback the full clearance including the runway prefix a light bulb may have gone off in someones head.
I think the final hole in the swiss cheese lining up could have been prevented by proper phraseology like this:
TWR: Cleared for takeoff Runway 22
Comair: Cleared for takeoff Runway 26
TWR: STOP! Wrong runway!

Absolutely!

A high-hours long-haul NW captain once propsed that a huge difference could be made to the US runway incursion problem by more thorough signage.

r

[Phil Space]

As someone who is an old pilot and and not a bold pilot I suggest it comes down to being complacent. Auusie Croc guy Steve Irwin was over the hump where he no longer feared death because he "knew it all". Aeroplanes are like crocs...very docile but with a big bite when you are not expecting it. This laid back crew were bored and neither captain or co pilot thought there was anything out there to bite them. Tired, bored, complacent...call it what you like. This and the MK accident at Halifax are both down to one thing. PILOT ERROR

At least the MK crew just took themselves out!

[patrickal]

Originally Posted by Phil Space

As someone who is an old pilot and and not a bold pilot I suggest it comes down to being complacent. Auusie Croc guy Steve Irwin was over the hump where he no longer feared death because he "knew it all". Aeroplanes are like crocs...very docile but with a big bite when you are not expecting it. This laid back crew were bored and neither captain or co pilot thought there was anything out there to bite them. Tired, bored, complacent...call it what you like. This and the MK accident at Halifax are both down to one thing. PILOT ERROR
At least the MK crew just took themselves out!

This is true in any profession which requires a heightened sense of awareness at all times. It can be part of work dissatisfaction, fatique, boredem, etc., but these are all just a part of a bigger problem. The key to success is to keep a "culture of discipline" alive and active at all times. This means having some sort of process, or triggers in your process, that constantly bring you head back into the game and make sure you are not missing anything. This is probably easier to do in a military environment (although you still wind up with things like the C5/Dover Delaware incident), but much harder to maintain in a commercial environment. It requires committment from both management AND crews, along with the unions. It has to be self policing, and in short, MUST become part of the culture. It also requires individual commitment to not allow others to get complacent, even when it feels like you are preaching, or being a geek.

These guys were no different than anyone else doing theirjob in any other profession. They were 75% in the game, talking about things that were not important, and not catching the clues around them that were screaming at them.

I have worked with professional organizations for almost 30 years, at both consulting and management levels, and although I am not a pilot, I do know that you cannot change inherent problems if you do not change the culture. This transcript screams of a cultural problem. You can wish that it were not so, or vehemently disagree, but that's what it is, and EVERYONE has to commit to fix it.
Patrick

[PaperTiger]

Originally Posted by Telstar

The Hawk I want to know the same thing. The Americans have got to accept that there R/T standards are apalling and are contributing to accidents, without taking it as a slight on their nationalistic pride. This is not about Europe Vs. the US. It is a flight safety issue.
I will forever wonder that if the controller had prefixed the takeoff clearance with the runway in use and the crew had readback the full clearance including the runway prefix a light bulb may have gone off in someones head.
I think the final hole in the swiss cheese lining up could have been prevented by proper phraseology like this:
TWR: Cleared for takeoff Runway 22
Comair: Cleared for takeoff Runway 26
TWR: STOP! Wrong runway!

I think the general consensus is they believed they were on 22 all the time. Unlikely then that any amount of additional verbiage would have corrected that fundamental error. In your scenario they surely would simply have replied "cleared takeoff 22" and continued down 26.

[bomarc]

we will never know if the accident could have been prevented had the controller said: runway 22 cleared for takeoff.

nor can we blame the controller...there are huge slangisms used by atc in america...so be careful.



I mentioned excellence as its own reward...management should try that too.


and I will say this as a general safety alert and concern. at any airport in the USA where construction is underway, ask for /demand PROGRESSIVE TAXI INSTRUCTIONS to the runway required by you the pilot. yes, I know most of us could figure it out ourselves, but I THINK YOU GET THE IDEA>

[RobertS975]

Originally Posted by patrickal

This is true in any profession requires a heightened sense of awareness at all times. It can be part of work dissatisfaction, fatique, boredem, etc., but they are all just a part of a bigger problem. The key to success is to keep a "culture of discipline" alive and active at all times. This means having some sort of process, or triggers in your process, that constantly bring you head back into the game and make sure you are not missing anything. This is probably easier to do in a military environment (although you still wind up with things like the C5/Dover Delaware incident), but much harder to maintain in a commercial environment. It requires committment from both management AND crews, along with the unions. It has to be self policing, and in short, MUST become part of the culture. These guys were no different than anyone else doing there job in any profession. They were 75% in the game, talking about things that were not important, and not catching the clues around them that were screaming at them.
I have worked with professional organizations for almost 30 years, at both consulting and management levels, and although I am not a pilot, I do know that you cannot change inherent problems if you do not change the culture. This transcript screams of a cultural problem. You can wish that it were not so, or vehemently disagree, but that's what it is, and EVERYONE has to commit to fix it.
Patrick

This is one of the most insightful posts that I have seen on this board. Everybody should read it a couple of times!

I am a practicing physician as well as a pilot. This post could be talking about the world of medicine as easy as the world of professional aviation.

[Dagger Dirk]

Runway Positive IDENT (in low vis - day or night)

Telstar said: "I think the final hole in the swiss cheese lining up could have been prevented by proper phraseology like this:
TWR: Cleared for takeoff Runway 22 etcf etc"
.
Midland 331 said: "A high-hours long-haul NW captain once proposed that a huge difference could be made to the US runway incursion problem by more thorough signage."

.

But Maybe: if there was a facility for the controller to re-phase the brilliance on the runway lighting as he issued the take-off clearance (perhaps via a foot treadle).....
Most runway lights are stage-stepped in brilliance. If the runway lights brightness dropped to stage 1 and then via a timer over 3 to 5 seconds, stepped up from 1 through 2,3,4,5 etc then there would be no doubt in a lined up pilot's mind (and any a/c on finals would know that another aircraft is about to launch on that same runway). Might cover the night-time case anyway.
.
Alternatively, (and works for daytime low visibility also), have the PAPI's do a very quick cyclic light-show (as in "Close Encounters of the Third Kind")
That might be a smarter add-on use of the PAPI's than the FAA's proposed FAROS system.... and would just require a cheap bit of Radio-Shack circuitry in the Tower's lighting console.

[NIMFLT]

Only one runway nominated on the ATIS. Only one runway lit. In this situation I assume it's normal procedure not to include the runway number in clearances other than the taxi clearance.
If the tower controller is not looking out the window when he clears the aircraft for takeoff, then he/she is not providing any additional safety over a non towered airport. The runway should be scanned prior to the takeoff or landing clearance and just prior to the aircraft landing or taking off if there is any gap between these occurances.
It seems that undermanning has really taken it's toll here as the tower controller was busy with jobs that a ground controller would have been doing.

[Sqwak7700]

I agree NIMFLT. The crew were complacent, but so was the controller. It is just as big a mistake as lining up on the wrong runway as it is to clear an aircraft for TO without looking out of the window. That really shows a lack of staffing that the FAA needs to evaluate. Hard to believe that with all the taxes on aviation, that some of that money can't find its way to properly staffing ATC. I'll trade 1000 TSA agents for 1 Air traffic controller anytime of day.

One idea, I saw a picture of some airports in Scandinavia and noticed that the runways were painted yellow. I can only assume that this is done due to the amounts of snow that they get, but it made me think. I wonder if painting runways in a unique color would help the situation. One thing for sure, airport markings need to be overhauled and simplified enough so that even a caveman could navigate them. They need to be more intuitive and some airports need to simplify their layouts.

[Crossunder]

Sqwak7700:
Well said!
The TSA couldn't prevent this. But adequate funds for ATC and airport equipment etc. could have. Or maybe we should put the TSA people in charge of flying the airplanes as well. As you know, the TSA never makes mistakes, know all and everything and are super-human.
At least the poor pax and pilot died with no harmful liquids (like 200ml of H2O) in their baggage.

[pls8xx]

Brain Training

I'm not a pilot, so I'm not about to comment on blame, cause, or prevention of this accident. But I feel I should pass on things I have learned from my career.

For over thirty years I spent work days making observations of alpha-numeric data and recording it in a log book, sometimes hundreds of observations a day. An error of even a single number would have a negative outcome, each and every time.


The first year I had an error every few weeks. The second year I had only three or four errors. The last 20 years I had no errors, none, nada, zero.

The human brain is not set for long periods of maximum concentration. But with practice one can train their mind to go from casual to maximum concentration and back to casual at will.

It appears to me that flight, and particularly preparation for flight, requires a multitude of settings and instrument observations. My guess is that some of you occasionally make an error, probably more often than you think. If you were writting all observations in a log and the instruments were also recording the same, a comparision of the two, and getting docked a days pay for each error would soon change how you operate.

Here are some of my tricks to getting it right every time as applied to pilots. When making an observation, vocalize exactly what you see. Say it out loud at the very time you are actually looking at the setting. For example, if the instrument is a light that can be green , yellow, or some other color, you should not say good, check, on/off, or some other meaning expressed by the instrument. If it is a green light, say the word "green" while looking directly at the light.

Your mind can play tricks on you. Look at an instrument hundreds of times where the light is always green, say the word "check". One day the light will be yellow, but your mind will anticipate "green". You are apt to say "check" and move on. But if you have been saying "green" and one day the light is yellow, when you look at the instrument and say green, your eyes say yellow and your mind rebels. For it to work you must be looking at the light at the instance you say the word.

Vocalize exactly what you see, not what an oberservation means. If it is a gage, digital or analog, read the value! I suppose there must be a heading indicator on the panel. If one of the pilots of the Comair had looked at it and said out loud "azimuth 259", would we be reading this thread?

If a lever or other setting has an indicator that points to words or numbers, say exactly those words while you read them. For example, if a flap setting indicator points to the number "2" meaning 20%, say the word "two" not check or 20%.

The other member of the flight crew is going to think you are an absolute nut case. But you will live to retirement, he may not.