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Comair Lexington Crash CVR

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Comair Lexington Crash CVR

Old 17th Jan 2007, 12:54
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Comair Lexington Crash CVR

The NTSB is reported as saying the transcript to the CVR of the comair flight that crashed in Lexington, KY, USA will be out today. There will be additional bits of information without analysis too.
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Old 17th Jan 2007, 17:56
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http://www.kentucky.com/multimedia/k...ase/361245.pdf
http://www.kentucky.com/multimedia/k...ase/361105.pdf

http://www.kentucky.com/multimedia/k...ase/356274.pdf

http://www.kentucky.com/multimedia/k...ase/356317.pdf

Last edited by Rolling-Thunderbird; 17th Jan 2007 at 18:12.
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Old 18th Jan 2007, 00:54
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Lexington Crash..

So, the guys first of all manage to climb aboard the wrong aircraft.... then talk almost endlessly about promotion/training/dining/wives/kids/changing diapers. Then they enter the wrong runway and fail to notice either its alignment/orientation or that it has no lights.

What a dreadful and tragic sequence of events......I wonder if I'm alone in remembering Air Florida and Potomac River? bm
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Old 18th Jan 2007, 02:28
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Don't forget about the nugget on duty in the cab that cleared them for takeoff without even looking outside.
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Old 18th Jan 2007, 07:32
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So, the guys first of all manage to climb aboard the wrong aircraft.... then talk almost endlessly about promotion/training/dining/wives/kids/changing diapers.
So? I climbed aboard the wrong aircraft occasionally over the past 12 years. Just imagine what it is like at 6 am and 40 similar aeroplanes are standing next to each other....
And guess what is most talked about on the flight deck? Yep, promotion/training/dining/wives/kids/changing diapers.

If you didn't know better, you'd say that those flight deck guys op front ALMOST resemble human beings....
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Old 18th Jan 2007, 07:48
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Comair Lexington...

er..fair comment fox niner... but how often did you get as far as cranking up the APU? And then lining up on the wrong (and unlit) runway? And then attempting take-off without that last compass/runway check?

No personal attack intended...my point was to draw comparisons with pre-take off conversation and distractions a la Air Florida/Potomac tragedy.

No offence intended to victims, culprits or fellow ppruners. bm
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Old 18th Jan 2007, 08:00
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Dreamland, comments such as yours do nothing to show any of us readers that you have very much idea about where the responsibilities between controllers and pilots differ. Calling a tower controller a "nugget" because a pair of pilots made a fatal error only shows you to be one of the many enthusiasts that populate this site and habitually engage foot in mouth whilst trying to somehow show us that you know something about our jobs when in fact you know sod all as you have just proven.

And if the visibility had been marginal and the runway not visible from the tower? Would you expect the pilots to be refused take off clearance? Of course not.

It is nuggets that assume that what a controller can see from the tower cab is somehow crystal clear and floodlit that is the problem here. Those pilots made a fatal error and hopefully the rest of us will learn from their mistake. The tower controller was not responsible for the pilots error you nugget!
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Old 18th Jan 2007, 08:31
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Hey there BoeingMEL,


Mmmmmm.....point taken. I must say that we did crank up the apu, in fact the stews that came on board our aircraft were going to London, and we were going to Paris. That's when we found out we were in the wrong aluminium tube. So we walked over to the next gate. Was pretty hilarious.

I must say that the holes in the cheese can line up pretty rapidly, as happened in Kentucky. People make mistakes, so do airline pilots.
I make mistakes almost on a daily basis. Luckily for the passengers that I fly, I am well aware of this, and therefore try to be vigilent.

Let's just see what the NTSB has to say about this.
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Old 18th Jan 2007, 08:43
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Cargo Boy, no disrespect to you, but as an ex air traffic controller (busiest a/d on the west coast) and 16K hour pilot I feel my opinion is fair, you don't have to agree with me, I won't lower myself to your level by returning your smart a$$ remark.

Last edited by Dream Land; 18th Jan 2007 at 10:17.
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Old 18th Jan 2007, 09:03
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I hope you will all re read the transcript...I found much more interesting things buried deep inside that might mean something...
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Old 18th Jan 2007, 12:57
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Boeing MEL....not many parallels between Air Florida crash...that seems to be more of a misunderstanding of de-ice requirements, and performance considerations, and not realizing their engine indications were incorrect, they were in fact on the correct runway, correctly configured, just had contaminated wings and epr probe resulting in falsely high epr readings.....can think of a couple others , Delta 727 DFW forgot to select correct flap setting for take-off factors were unrelatd conversation, (apparently including a rather graphic description of a cabin crewmember)...that got released to the media during taxi..out..NWA at DTW MD-80..same basic scenario...
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Old 18th Jan 2007, 15:49
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Originally Posted by bomarc
I hope you will all re read the transcript...I found much more interesting things buried deep inside that might mean something...

Bomarc, totally agree. One of the obivous things that caught my eye was the fact that they pre-disposed themselved to lighting issues based comments about a previous flight in that there would be "lights out" all over the place. It was not clear if he was talking about himself or another crew, but it was obvious that they were expecting to see lighting issues.

When they first dial into ATIS, the report states local temperature at 24, and then states runway in use is 22. Later on, as they are talking through checklists (at 05:56:34), the FO asks what runway. "24", he asks. The captain corrects him and says 22, so they are confusing the numbers early on. The conversation about having lights out occurs immediately after this confusion.


After they get pushback clearance, the controller clears them for taxi to runway 22, and they confirm that back to him. Later, as they are taxing out, he clears them for takeoff and tells them to fly the runway heading, but never mentions 22. He obviously expects them to be where he told them to go. Whether it would be obvious to him from the tower they were not positioned correctly.

As they start rolling, the FO comments that the runway looks weird without lights, and the Captain agrees, yet alarms never go off in their heads, probably because they expected there to be lights out.

If you read all of the transcripts, including interviews, it appears only one person, an American Eagle ramp worker, realized they had turned onto the wrong runway and actually ran to the runway as they started rolling. He did not specifically state that he was trying to stop them, but that was the implied idea. He seemed to be the only really vigilant person at work that morning.

It is amazing to me to see the same types of communication and awareness failures that we have seen time and time again. Then again, doing the same thing day in and day out without issues just sets the table for something like this. Bottom line, I'm sure the NTSB will wind up holding the crew responsible.


Patrick
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Old 18th Jan 2007, 15:54
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The CVR transcript of the Comair tragedy will give more support to the notion of "confirmation bias" as the cause of this accident. Not even the slightest hesitation that they were accelerating down the intended runway...

I have a question... when was the last time that any of you accelerated for takeoff down an UNLIT runway during the hours of darkness while operating a transport category aircraft? And lest we forget, they did pass the runway lights of the intended runway 22 shortly after commencing their t/o roll.
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Old 19th Jan 2007, 12:52
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I used to fly RJ's, and I read the transcript.

I see two guys being thorough, with complete briefs and even a taxi brief from the f/o. Yeah, there was small talk - here's the deal: it is how communication is established before a flight begins. You get to know a guy's background, his experience level, his energy level - and you make it easier to communicate effectively before the motors start turning. If a guy won't engage in small talk during the preflight, then we got a problem....

Somebody tell that pr!ck in the KY paper that sterile cockpit begins after the towbar is disconnected. Yeah they chatted a little after that. And it may have contributed. But 95% of the chatter on the transcript was in the chocks.

I know Comair, I know Comair's pilots, and I'm telling you folks: if it can happen there, it can happen anywhere.
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Old 19th Jan 2007, 12:53
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Cognitive error with the numbers? Runway 22 up to 6, soon becomes 26 in head?

What were they counting just before take off? "6 or is that 7?"
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Old 19th Jan 2007, 13:48
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it's amazing though right now, they are using everybody pretty
efficiently. um, just shows you what they can do. like I mean I
don't have more than ten hours in a hotel, any of these days that
I've been on....
05:40:38.2
CAM-2 really.
05:40:38.7
CAM-1 ...and it's been that way for all month
This part of the transcript might explain a lot IMHO.
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Old 19th Jan 2007, 15:28
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Another confirmation bias possiblity

Originally Posted by RobertS975
The CVR transcript of the Comair tragedy will give more support to the notion of "confirmation bias" as the cause of this accident. Not even the slightest hesitation that they were accelerating down the intended runway...
And, not a single word of discussion in that 30 minutes on the CVR that the taxiway or runway lights were out - from which I'd guess they had already discussed this and the FO had shared his observation from Friday evening that the Northeast end of runway 22 had no lights working at all. The only time the subject comes up again is mid-roll, after crossing the real 22, when the FO says "dat wierd with no lights" and the Captain says "yeah." That's not proof, but it's the first point at which reality differed from his mental model, and it's the first point a comment is made.

Another framing issue was their delight that they had a very simple clearance that couldn't get "any easier that that", lessening vigilence more.

But there is still the factor of the wrong airport diagram, which is still wrong. ( http://www.naco.faa.gov/d-tpp/0701/00697AD.PDF for those who don't have charts.) The taxiway they should have been using, just west of Alpha-7, is not shown. (it's visible in the photo on wikipedia, at
http://en.wikipedia.org/wiki/Comair_Flight_5191 )

Here's one possible scenario for a different type of framing. The crew understood that A7 was going to be blocked, and got the news that the next best taxiway was in use. Whoever told them that (suppose) meant the new one, the one not shown. They looked at their charts and figured that must mean Alpha-6. They expect an intersection with no lights, no pavement markings, no signage, and four possible ways to go. They expect to see across from them 2 concrete taxiways and, to their extreme left, runway 22, which they expect to be 150 feet wide and have no lights. There is no other spot on that diagram with two concrete taxiways across from them.

But there is a place in reality with two concrete taxiways and a 150 foot wide unlit runway to their extreme left, which is where they really were.
They didn't know about the new taxiway, and they may not have realized that runway 22 was actually 150 feet wide (with only 75 usable).

So, again, nothing seemed out of place, and the decision was "really easy" - taxi to the unlit runway intersection and take the extreme left 150 foot wide runway - "impossible" to make a mistake.

It would be valuable to know what combination of barricades and signage was visible from their gate to the taxiway they took.
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Old 19th Jan 2007, 15:43
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Bomarc and Patrickal are right on. Anytime you're confronted with a potentially confusing or complex situation (in this case construction at KLEX), a higher level of mental vigilance is called for, in making sure that all the facts and information are mentally processed correctly.
This exchange is interesting:
05:56:49.9
CAM-2 two two up to six, white data * FMS, flaps twenty. * smokes or
breaks come back here. come into four or two two. on two two
the ILS is out. or the glideslope is, the REILS are out. the uh,
came in the other night it was like [sound similar to audible exhale]
lights are out all over the place.
05:57:07.8
CAM-1 all right.
05:57:08.4
CAM-2 right. remember this runway predicated, before we just go back
to Cincinnati.
The FO doesn't have his facts right about unservicable runway equipment. In some situations this wouldn't matter, but in a potentially confusing or complex enviroment, getting ALL the facts right matters (shows all are focused on getting the facts right). Neither the FO or PIC bother to sort out the nav aids, lighting, and other airport changes created by the construction, though both seem to be aware of the construction. Instead they subject shift right back to emergency procedures, then rapidly on to other preflight items. I believe if they had bothered to sort out the construction details together, the lack of runway lights on 26 would have stood out instantly (should these lights be out?, violates the regs?, are we on the right runway?, etc), and I also think they would have been crosschecking their taxi path and runway alignment.
Bottom line, there appears to have been no mental vigilance regarding a potentially confusing situation. When you're in such a situation, cut the chatter and focus on the details.
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Old 19th Jan 2007, 16:34
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It would appear that Comair pilots generally are of the lowest common demominator, if this terrible and totally unnecessary accident is any indication.
Not paying attention to business, idle chit chat, wrong airplane initially, then the wrong runway, unlit no less.
Seems to me that aircarrier certificate action by the FAA is long overdue with regard to Comair....and indeed other regional airlines, if the Comair accident is any reasonable indication.
Harsh comments, you say?
Yeah, some might agree....untill we look not far in the past at the Pinnacle FL410 fiasco.
Junior birdmen, sadly.
Just the tip of the iceberg with regard to regional airlines, I suspect.
With all this CRM parlor games nonsense requirements in the training departments now, no wonder we have accidents like this one, where very BASIC requirements go unnoticed.
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Old 19th Jan 2007, 16:57
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411A,

It appears you have been reading some of my articles regarding the new CRM courses as parlor games. Thanks!
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