Comair Lexington Crash - NTSB Hearing
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Comair Lexington Crash - NTSB Hearing
Looks like more details are coming out Thursday, but preliminary indications are that the crew was not briefed on current runway and taxiway conditions prior to departure
From CNN
LEXINGTON, Kentucky (AP) -- The pilots in a jet crash last summer that killed 49 people left the terminal without receiving four important airport advisories, including one that said the normal taxiway to the main runway was closed, a newspaper reported Sunday.
Investigators work near the Comair Flight 5191 crash site in August 2006 in Lexington, Kentucky.
The four updates -- called Notices to Airmen -- were missing from the flight dispatch paperwork the pilots received from Comair, the Lexington Herald-Leader reported, citing information the Air Line Pilots Association submitted to the National Transportation Safety Board.
Comair relies on prerecorded messages to get local advisories from the Blue Grass Airport, but the taxiway closing wasn't recorded that day.
Randy Harris, president of the local National Air Traffic Controllers Association, said he didn't know why the notice was omitted.
Comair Flight 5191 crashed on August 27, 2006, shortly after mistakenly taking off from the general aviation runway, killing all people aboard but one. The plane taxied to the wrong runway in the pre-dawn darkness.
Flight data recordings indicated the pilots thought they were taking off from the main runway and may have been confused by the alternate route.
The NTSB will release its findings and state a probable cause in the crash during a meeting Thursday in Washington.
http://www.cnn.com/2007/US/07/23/com....ap/index.html
From CNN
LEXINGTON, Kentucky (AP) -- The pilots in a jet crash last summer that killed 49 people left the terminal without receiving four important airport advisories, including one that said the normal taxiway to the main runway was closed, a newspaper reported Sunday.
Investigators work near the Comair Flight 5191 crash site in August 2006 in Lexington, Kentucky.
The four updates -- called Notices to Airmen -- were missing from the flight dispatch paperwork the pilots received from Comair, the Lexington Herald-Leader reported, citing information the Air Line Pilots Association submitted to the National Transportation Safety Board.
Comair relies on prerecorded messages to get local advisories from the Blue Grass Airport, but the taxiway closing wasn't recorded that day.
Randy Harris, president of the local National Air Traffic Controllers Association, said he didn't know why the notice was omitted.
Comair Flight 5191 crashed on August 27, 2006, shortly after mistakenly taking off from the general aviation runway, killing all people aboard but one. The plane taxied to the wrong runway in the pre-dawn darkness.
Flight data recordings indicated the pilots thought they were taking off from the main runway and may have been confused by the alternate route.
The NTSB will release its findings and state a probable cause in the crash during a meeting Thursday in Washington.
http://www.cnn.com/2007/US/07/23/com....ap/index.html
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I've just read the news reports on the outcome of this NTSB hearing.
sterile cockpit violations play ...
so easy to blame those who can't speak in their own defense.
oh well
sterile cockpit violations play ...
so easy to blame those who can't speak in their own defense.
oh well
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Look, there is no doubt about the sterile cockpit violation in this case, is there? The cockpit crew was in conversation about many things other than the task at hand.
The record also demonstrated a "cavalier" attitude about the checklist.
Other factors receiving considerable mention were confirmation bias, and the contributing factor of the lone tower controller deciding to do some routine non-pressing work that could have been done at any time. I believe that the Board said that the tower controller was not obligated to watch the CRJ take the active runway, but in essence, he had nothing more important to do. Also, apparently the Comair CRJ actually stopped in an odd spot to get their t/o clearance, and too bad that didn't make the controller take pause and consider that something wasn't right.
The record also demonstrated a "cavalier" attitude about the checklist.
Other factors receiving considerable mention were confirmation bias, and the contributing factor of the lone tower controller deciding to do some routine non-pressing work that could have been done at any time. I believe that the Board said that the tower controller was not obligated to watch the CRJ take the active runway, but in essence, he had nothing more important to do. Also, apparently the Comair CRJ actually stopped in an odd spot to get their t/o clearance, and too bad that didn't make the controller take pause and consider that something wasn't right.
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************************************************************
NTSB PRESS RELEASE
************************************************************
National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: July 26, 2007
SB-07-38
************************************************************
NTSB DETERMINES COMAIR 5191 FLIGHT CREW FAILED TO USE
AVAILABLE CUES TO DETERMINE LOCATION DURING TAKEOFF
************************************************************
Washington, DC -- The National Transportation Safety Board
today determined the probable cause of the Comair flight
5191 accident in Lexington, Kentucky was the flight crew's
failure to use available cues and aids to identify the
airplane's location on the airport surface during taxi and
their failure to cross check and verify that the airplane
was on the correct runway before takeoff. Contributing to
this accident were the flight crew's nonpertinent
conversation during taxi, which resulted in loss of
positional awareness and the Federal Aviation
Administration's failure to require that all runway
crossings be authorized only by specific air traffic control
clearances.
"This accident was caused by poor human performance," said
NTSB Chairman Mark V. Rosenker. "Forty-nine lives could
have been saved if the flightcrew had been concentrating on
the important task of operating the airplane in a safe
manner."
On August 27, 2006, about 6:07 a.m., Comair flight 5191, a
Bombardier CRJ-100, (N431CA) crashed upon takeoff from Blue
Grass Airport in Lexington, Kentucky. The flight crew was
instructed to take off from runway 22, an air carrier runway
that is 7,003 feet long. Instead, the flight crew lined up
the airplane on runway 26, a 3,501-foot-long runway, and
began the takeoff roll. Runway 26 crosses runway 22 about
700 feet south of the runway 22 threshold. Of the 47
passengers and 3 crewmembers onboard, 49 were fatally
injured and one (the first officer) received serious
injuries. Impact forces and a postcrash fire destroyed the
airplane.
As a result of this accident, the safety Board made the
following recommendations:
To the Federal Aviation Administration:
1. Require that all 14 Code of Federal Regulations
Part 91K, 121, and 135 operators establish
procedures requiring all crewmembers on the flight
deck to positively confirm and cross check the
airplane's location at the assigned departure
runway before crossing the hold short line for
takeoff.
2. Require that all Code of Federal Regulations Part
91K, 121, and 135 operators install on their
aircraft cockpit moving map displays or an
automatic system that alerts pilots when a takeoff
is attempted on a taxiway or a runway other than
the one intended.
3. Require that all airports certified under 14 Code
of Federal Regulations Part 139 implement enhanced
taxiway centerline markings and surface painted
holding position signs at all runway entrances.
4. Prohibit the issuance of a takeoff clearance during
an airplane's taxi to its departure runway until
after the airplane has crossed all intersecting
runways.
5. Revise Federal Aviation Administration Order
7110.65, "Air Traffic Control," to indicate that
controllers should refrain from performing
administrative tasks, such as the traffic count,
when moving aircraft are in the controller's area
of responsibility.
The Safety Board reiterated two previously issued
recommendations to the FAA:
Amend 14 Code of Federal Regulations (CFR) Section
91.129(i) to require that all runway crossings be
authorized only by specific air traffic control
clearance, and ensure that U.S. pilots, U.S. personnel
assigned to move aircraft, and pilots operating under
14 CFR Part 129 receive adequate notification of the
change.
Amend Federal Aviation Administration Order 7110.65,
"Air Traffic Control," to require that, when aircraft
need to cross multiple runways, air traffic
controllers an issue explicit crossing instruction for
each runway after the previous runway has been
crossed.
Previously issued recommendations to the FAA resulting from
this accident include:
Require that all 14 Code of Federal Regulations Part
121 operators establish procedures requiring all
crewmembers on the flight deck to positively confirm
and cross-check the airplane's location at the
assigned departure runway before crossing the hold-
short line for takeoff.
Require that all 14 Code of Federal Regulations Part
121 operators provide specific guidance to pilots on
the runway lighting requirements for takeoff
operations at night.
Work with the National Air Traffic Controllers
Association to reduce the potential for controller
fatigue by revising controller work-scheduling
policies and practices to provide rest periods that
are long enough for controllers to obtain sufficient
restorative sleep and by modifying shift rotations to
minimize disrupted sleep patterns, accumulation of
sleep debt, and decrease cognitive performance.
Develop a fatigue awareness and countermeasures
training program for controllers and for personnel who
are involved in the scheduling of controllers for
operational duty that will address the incidence of
fatigue in the controller workforce, causes of
fatigue, effects of fatigue on controller performance
and safety, and the importance of using personal
strategies to minimize fatigue. This training should
be provided in a format that promotes retention, and
recurrent training should be provided at regular
intervals.
Require all air traffic controllers to complete
instructor-led initial and recurrent training in
resource management skills that will improve
controller judgment, vigilance, and safety awareness.
Earlier this year, the Board issued the following
recommendation to the National Air Traffic Controller
Association:
Work with the Federal Aviation Administration to
reduce the potential for controller fatigue by
revising controller work-scheduling policies and
practices to provide rest periods that are long enough
for controllers to obtain sufficient restorative sleep
and by modifying shift rotations to minimize disrupted
sleep patterns, accumulation of sleep debt, and
decreased cognitive performance.
A synopsis of the Board's report, including the probable
cause and recommendations, is available on the NTSB's
website, www.ntsb.gov, under "Board Meetings." The Board's
full report will be available on the website in several
weeks.
-30-
NTSB Media Contact: Terry N. Williams
(202) 314-6100
[email protected]
there is more to this accident than the NSTB dreamed of
NTSB PRESS RELEASE
************************************************************
National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: July 26, 2007
SB-07-38
************************************************************
NTSB DETERMINES COMAIR 5191 FLIGHT CREW FAILED TO USE
AVAILABLE CUES TO DETERMINE LOCATION DURING TAKEOFF
************************************************************
Washington, DC -- The National Transportation Safety Board
today determined the probable cause of the Comair flight
5191 accident in Lexington, Kentucky was the flight crew's
failure to use available cues and aids to identify the
airplane's location on the airport surface during taxi and
their failure to cross check and verify that the airplane
was on the correct runway before takeoff. Contributing to
this accident were the flight crew's nonpertinent
conversation during taxi, which resulted in loss of
positional awareness and the Federal Aviation
Administration's failure to require that all runway
crossings be authorized only by specific air traffic control
clearances.
"This accident was caused by poor human performance," said
NTSB Chairman Mark V. Rosenker. "Forty-nine lives could
have been saved if the flightcrew had been concentrating on
the important task of operating the airplane in a safe
manner."
On August 27, 2006, about 6:07 a.m., Comair flight 5191, a
Bombardier CRJ-100, (N431CA) crashed upon takeoff from Blue
Grass Airport in Lexington, Kentucky. The flight crew was
instructed to take off from runway 22, an air carrier runway
that is 7,003 feet long. Instead, the flight crew lined up
the airplane on runway 26, a 3,501-foot-long runway, and
began the takeoff roll. Runway 26 crosses runway 22 about
700 feet south of the runway 22 threshold. Of the 47
passengers and 3 crewmembers onboard, 49 were fatally
injured and one (the first officer) received serious
injuries. Impact forces and a postcrash fire destroyed the
airplane.
As a result of this accident, the safety Board made the
following recommendations:
To the Federal Aviation Administration:
1. Require that all 14 Code of Federal Regulations
Part 91K, 121, and 135 operators establish
procedures requiring all crewmembers on the flight
deck to positively confirm and cross check the
airplane's location at the assigned departure
runway before crossing the hold short line for
takeoff.
2. Require that all Code of Federal Regulations Part
91K, 121, and 135 operators install on their
aircraft cockpit moving map displays or an
automatic system that alerts pilots when a takeoff
is attempted on a taxiway or a runway other than
the one intended.
3. Require that all airports certified under 14 Code
of Federal Regulations Part 139 implement enhanced
taxiway centerline markings and surface painted
holding position signs at all runway entrances.
4. Prohibit the issuance of a takeoff clearance during
an airplane's taxi to its departure runway until
after the airplane has crossed all intersecting
runways.
5. Revise Federal Aviation Administration Order
7110.65, "Air Traffic Control," to indicate that
controllers should refrain from performing
administrative tasks, such as the traffic count,
when moving aircraft are in the controller's area
of responsibility.
The Safety Board reiterated two previously issued
recommendations to the FAA:
Amend 14 Code of Federal Regulations (CFR) Section
91.129(i) to require that all runway crossings be
authorized only by specific air traffic control
clearance, and ensure that U.S. pilots, U.S. personnel
assigned to move aircraft, and pilots operating under
14 CFR Part 129 receive adequate notification of the
change.
Amend Federal Aviation Administration Order 7110.65,
"Air Traffic Control," to require that, when aircraft
need to cross multiple runways, air traffic
controllers an issue explicit crossing instruction for
each runway after the previous runway has been
crossed.
Previously issued recommendations to the FAA resulting from
this accident include:
Require that all 14 Code of Federal Regulations Part
121 operators establish procedures requiring all
crewmembers on the flight deck to positively confirm
and cross-check the airplane's location at the
assigned departure runway before crossing the hold-
short line for takeoff.
Require that all 14 Code of Federal Regulations Part
121 operators provide specific guidance to pilots on
the runway lighting requirements for takeoff
operations at night.
Work with the National Air Traffic Controllers
Association to reduce the potential for controller
fatigue by revising controller work-scheduling
policies and practices to provide rest periods that
are long enough for controllers to obtain sufficient
restorative sleep and by modifying shift rotations to
minimize disrupted sleep patterns, accumulation of
sleep debt, and decrease cognitive performance.
Develop a fatigue awareness and countermeasures
training program for controllers and for personnel who
are involved in the scheduling of controllers for
operational duty that will address the incidence of
fatigue in the controller workforce, causes of
fatigue, effects of fatigue on controller performance
and safety, and the importance of using personal
strategies to minimize fatigue. This training should
be provided in a format that promotes retention, and
recurrent training should be provided at regular
intervals.
Require all air traffic controllers to complete
instructor-led initial and recurrent training in
resource management skills that will improve
controller judgment, vigilance, and safety awareness.
Earlier this year, the Board issued the following
recommendation to the National Air Traffic Controller
Association:
Work with the Federal Aviation Administration to
reduce the potential for controller fatigue by
revising controller work-scheduling policies and
practices to provide rest periods that are long enough
for controllers to obtain sufficient restorative sleep
and by modifying shift rotations to minimize disrupted
sleep patterns, accumulation of sleep debt, and
decreased cognitive performance.
A synopsis of the Board's report, including the probable
cause and recommendations, is available on the NTSB's
website, www.ntsb.gov, under "Board Meetings." The Board's
full report will be available on the website in several
weeks.
-30-
NTSB Media Contact: Terry N. Williams
(202) 314-6100
[email protected]
there is more to this accident than the NSTB dreamed of
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Synopsis:
http://www.ntsb.gov/Publictn/2007/AAR-07-05.htm
Presentations:
http://www.ntsb.gov/events/2007/Lexi...sentations.htm
http://www.ntsb.gov/Publictn/2007/AAR-07-05.htm
Presentations:
http://www.ntsb.gov/events/2007/Lexi...sentations.htm
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I wonder how many of those NSTB recommendations will be implemented.
Some of them seem superfluous... progressive taxi instructions from runway crossing to runway crossing until the active is reached, for example. Even for unlit runways at night?
Some of them seem superfluous... progressive taxi instructions from runway crossing to runway crossing until the active is reached, for example. Even for unlit runways at night?
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Remember, when you fly in the U.S. you may not have all notams...
L notams won't be local much longer
When the NTSB convenes July 26 to discuss the Comair Flight 5191 accident last August at Blue Grass Airport (Lexington, Kentucky), the issue of notams is likely to come up.
Information has been given to the NTSB, contending that the pilots of that flight never saw the L notams (local notams) that would have told them the primary taxiway to their assigned runway (Runway 22) was closed, that the "distance remaining" signs were out of service, and that the shorter Runway 26 was unlit and for daytime-use only. The crew attempted to take off on Runway 26 in the dark and ran off the end.
"We have been advocating changes to the antiquated notam system for more than 10 years," said Melissa Rudinger, AOPA vice president of regulatory affairs. "And by the end of this year, pilots should finally have universal access to L notams."
AOPA is serving on an FAA safety analysis working group that is conducting one final review before the agency puts L notams into the national distribution system.
The reason they aren't currently has much to do with history and old technology. The FAA used to transmit everything by teletype, which could handle only a limited amount of information. The abbreviations in today's weather reports and notams are a legacy of that "low bandwidth" system where every single character was precious.
Local notams are limited to simple airport issues, such as taxiway lights and construction, fuel availability, equipment working near the runway, etc. L notams are retained at the area flight service station and aren't distributed to other stations or the DUAT/DUATS system. That makes them hard to get unless you know to ask for them.
But soon you won't have to ask, possibly as early as this fall.
And AOPA is working with the FAA for other improvements to notams as well. A little farther down the road, the FAA will add additional coding to notam text, which will permit automated systems to "parse" the data.
"What that will really mean is that in the future you will get only those notams that apply to your flight, and not notices about laser light displays 100 miles off your course or flight restrictions in Afghanistan," said Rudinger.
L notams won't be local much longer
When the NTSB convenes July 26 to discuss the Comair Flight 5191 accident last August at Blue Grass Airport (Lexington, Kentucky), the issue of notams is likely to come up.
Information has been given to the NTSB, contending that the pilots of that flight never saw the L notams (local notams) that would have told them the primary taxiway to their assigned runway (Runway 22) was closed, that the "distance remaining" signs were out of service, and that the shorter Runway 26 was unlit and for daytime-use only. The crew attempted to take off on Runway 26 in the dark and ran off the end.
"We have been advocating changes to the antiquated notam system for more than 10 years," said Melissa Rudinger, AOPA vice president of regulatory affairs. "And by the end of this year, pilots should finally have universal access to L notams."
AOPA is serving on an FAA safety analysis working group that is conducting one final review before the agency puts L notams into the national distribution system.
The reason they aren't currently has much to do with history and old technology. The FAA used to transmit everything by teletype, which could handle only a limited amount of information. The abbreviations in today's weather reports and notams are a legacy of that "low bandwidth" system where every single character was precious.
Local notams are limited to simple airport issues, such as taxiway lights and construction, fuel availability, equipment working near the runway, etc. L notams are retained at the area flight service station and aren't distributed to other stations or the DUAT/DUATS system. That makes them hard to get unless you know to ask for them.
But soon you won't have to ask, possibly as early as this fall.
And AOPA is working with the FAA for other improvements to notams as well. A little farther down the road, the FAA will add additional coding to notam text, which will permit automated systems to "parse" the data.
"What that will really mean is that in the future you will get only those notams that apply to your flight, and not notices about laser light displays 100 miles off your course or flight restrictions in Afghanistan," said Rudinger.
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I think there is so much more to this accident.
The FAA certified the pilots, the airline, the airport, the airline's training department, flight ops manual, the check airman from the airline, and staffed the control tower.
So let's blame the pilots.
God Forbid we actually look into all of the above.
The FAA certified the pilots, the airline, the airport, the airline's training department, flight ops manual, the check airman from the airline, and staffed the control tower.
So let's blame the pilots.
God Forbid we actually look into all of the above.
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Not quite sure how you conclude that the NTSB just blames the pilots and doesn't address any other issues.
There are 13 SRs listed in the synopsis. (One of which is already closed/superceded)
Of the 12 active recommendations, only one addresses the actions of the crew. (The one about requiring "all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold short line for takeoff")
All the other address such things as ATC procedures, runway lighting standards, additional warning systems in the cockpit, and so on.
But, frankly, there's no way they could have left the crew out of the "probable cause". Even if others created the opportunity for an accident, the actions of the crew were required to bring it to reality.
There are 13 SRs listed in the synopsis. (One of which is already closed/superceded)
Of the 12 active recommendations, only one addresses the actions of the crew. (The one about requiring "all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold short line for takeoff")
All the other address such things as ATC procedures, runway lighting standards, additional warning systems in the cockpit, and so on.
But, frankly, there's no way they could have left the crew out of the "probable cause". Even if others created the opportunity for an accident, the actions of the crew were required to bring it to reality.
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I wonder how many of those NSTB recommendations will be implemented.
I got blasted in another thread for complaining about taxi/cross/takeoff clearances. Some consolation the NTSB seems to agree with me though.
PaperTiger stated that there are not enough ATC controllers working in the US.
A newspaper article, either the "Wall Street Journal" or "New York Times" (for what it is worth...) claimed several months ago that the FAA wanted to hire new controllers at 10% less salary, but increase the workload 10%.
This caught my attention, realizing that many controllers are beginning to retire.
Just out of curiosity, how many days had the Comair crew been on duty in their last seven days? Unless they were both flying many "high speed" overnights (we call them "illegals"), how many duty days over 10 hours had they worked during the last few days before the tragedy?
As a side note, although there is no direct correlation between experience and safety, how much have CRJ FO new-hire experience levels in the US as a whole dropped since the Comair accident?
A newspaper article, either the "Wall Street Journal" or "New York Times" (for what it is worth...) claimed several months ago that the FAA wanted to hire new controllers at 10% less salary, but increase the workload 10%.
This caught my attention, realizing that many controllers are beginning to retire.
Just out of curiosity, how many days had the Comair crew been on duty in their last seven days? Unless they were both flying many "high speed" overnights (we call them "illegals"), how many duty days over 10 hours had they worked during the last few days before the tragedy?
As a side note, although there is no direct correlation between experience and safety, how much have CRJ FO new-hire experience levels in the US as a whole dropped since the Comair accident?
The report places heavy responsibility on the pilots, and although other safety aspects are cited, the implied blame is unfair.
The investigation struggled with several human aspects, but still reverts to many of the old views of human error.
If this accident had involved a ‘component’ breaking, then there would have been a full report on the failure mode, design specification, manufacturing aspects, and checking process; yet for the crew who are cited to have failed, there is a scarcity of detail to explain how this happened.
It is unrealistic to expect a human design spec, or manufacturing schedule for comparison, but background information on the crew’s training and checking may have provided additional information, and whilst the ‘mode of human failure’ might be impossible to determine with certainty, there could at least be some informed speculation that the industry could benefit from.
If there was confirmation bias, what did it consist of, what influenced it?
Why connect apparently inconsequential errors with fatigue, there are many reasons for error, usually spread between the human thinking process and the situation they faced. The information available did not indicate that fatigue was a problem, but other details identified opportunity for error and that the pilots suffered loss of situation awareness, but apparently it was not established that they ever acquired an appropriate awareness.
Why did the crew hold such a strong belief that there were on the correct runway – sufficiently strong to result in an accident?
Focusing on the pilots as the cause due to their failure is like using James Reason’s ‘Swiss Cheese’ model showing that the last slice had holes in it – thus that slice was ‘to blame’ for the accident. Other aspects (cheese slices) were considered as contributions, suggesting that these too had ‘holes’, but without showing that they all lined up, i.e. if you had closed the hole would it have prevented the accident.
The industry needs to look at accidents from the other end of the Swiss Cheese model. It’s the slices preceding the pilots which should be protecting them; these defences should minimise the opportunity for error or the occurrence of hazardous situations. Therefore as applicable, these ‘other’ slices should carry equal accountability with that of the pilots.
Pilots have to deliverer a safe operation which includes maintaining self discipline and a high level of professional behaviour – personal accountability. If, as the report suggests, these qualities were lacking then the reason for this should be discussed in the report; then perhaps the industry might avoid another sticking plaster of soft defences involving new procedures or a reinforcement of an impracticable ‘sterile’ concept.
A good reminder would include the need to report potential hazards – it has been reported elsewhere there was at least one occasion where a pilot encountered confusion during taxi.
The need for RAAS type equipment is good recommendation; it is an additional resource to trigger the attention to error, but so too would be appropriate CRM training that requires ‘trigger points’ in briefings and mental plans for specific checks, as well as the appropriate identification of non normal aspects.
A dominating point, in this and other accidents, is the deviation from normal operations. The existence of a new and unannounced (to the crew?) taxi pattern. The industry needs to fill the gaps in the non normal operations – it appears that these situations cause many problems.
Is the poor identification of these differences or poor situation awareness a sign of complacency (by everyone - all of the cheese slices)?
On a positive note – well done the KLEX fire and rescue crews, and the support teams and hospitals in Lexington.
The investigation struggled with several human aspects, but still reverts to many of the old views of human error.
If this accident had involved a ‘component’ breaking, then there would have been a full report on the failure mode, design specification, manufacturing aspects, and checking process; yet for the crew who are cited to have failed, there is a scarcity of detail to explain how this happened.
It is unrealistic to expect a human design spec, or manufacturing schedule for comparison, but background information on the crew’s training and checking may have provided additional information, and whilst the ‘mode of human failure’ might be impossible to determine with certainty, there could at least be some informed speculation that the industry could benefit from.
If there was confirmation bias, what did it consist of, what influenced it?
Why connect apparently inconsequential errors with fatigue, there are many reasons for error, usually spread between the human thinking process and the situation they faced. The information available did not indicate that fatigue was a problem, but other details identified opportunity for error and that the pilots suffered loss of situation awareness, but apparently it was not established that they ever acquired an appropriate awareness.
Why did the crew hold such a strong belief that there were on the correct runway – sufficiently strong to result in an accident?
Focusing on the pilots as the cause due to their failure is like using James Reason’s ‘Swiss Cheese’ model showing that the last slice had holes in it – thus that slice was ‘to blame’ for the accident. Other aspects (cheese slices) were considered as contributions, suggesting that these too had ‘holes’, but without showing that they all lined up, i.e. if you had closed the hole would it have prevented the accident.
The industry needs to look at accidents from the other end of the Swiss Cheese model. It’s the slices preceding the pilots which should be protecting them; these defences should minimise the opportunity for error or the occurrence of hazardous situations. Therefore as applicable, these ‘other’ slices should carry equal accountability with that of the pilots.
Pilots have to deliverer a safe operation which includes maintaining self discipline and a high level of professional behaviour – personal accountability. If, as the report suggests, these qualities were lacking then the reason for this should be discussed in the report; then perhaps the industry might avoid another sticking plaster of soft defences involving new procedures or a reinforcement of an impracticable ‘sterile’ concept.
A good reminder would include the need to report potential hazards – it has been reported elsewhere there was at least one occasion where a pilot encountered confusion during taxi.
The need for RAAS type equipment is good recommendation; it is an additional resource to trigger the attention to error, but so too would be appropriate CRM training that requires ‘trigger points’ in briefings and mental plans for specific checks, as well as the appropriate identification of non normal aspects.
A dominating point, in this and other accidents, is the deviation from normal operations. The existence of a new and unannounced (to the crew?) taxi pattern. The industry needs to fill the gaps in the non normal operations – it appears that these situations cause many problems.
Is the poor identification of these differences or poor situation awareness a sign of complacency (by everyone - all of the cheese slices)?
On a positive note – well done the KLEX fire and rescue crews, and the support teams and hospitals in Lexington.
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I've got to agree (as usual) with Mad.
Regardless of what else is deficient or in error in the aviation world, the crew is responsible for situational awareness through cross-checks. If you haven't learned this by now, please warn me which airline you work for, because I don't want my friends or family placed in your hands.
(Dear me, is that a bit strong?)
Regardless of what else is deficient or in error in the aviation world, the crew is responsible for situational awareness through cross-checks. If you haven't learned this by now, please warn me which airline you work for, because I don't want my friends or family placed in your hands.
(Dear me, is that a bit strong?)
Fixing the Notam system is long over due. You get a ton of garbage, I've had ones printed with warnings on Afganistan, but quite important bits seem to get left out.
On my IR checkride I had up to date plates and a Notam list pulled from an official source. The examiner went and checked some of the printed Notams and there was a notamed change in an IAP we were going to use, over 6 months old, that was not on the plates!!
20driver
On my IR checkride I had up to date plates and a Notam list pulled from an official source. The examiner went and checked some of the printed Notams and there was a notamed change in an IAP we were going to use, over 6 months old, that was not on the plates!!
20driver
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But, frankly, there's no way they could have left the crew out of the "probable cause". Even if others created the opportunity for an accident, the actions of the crew were required to bring it to reality.
This operation could have easily taken place at an airport without an operating tower, let's not blame it on ATC.
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barit1 (baritone)
you indicate a crew that can't retain position awareness should let you know which airline they work for so you can avoid them.
unless you get a better answer, you should assume they work everywhere.
you indicate a crew that can't retain position awareness should let you know which airline they work for so you can avoid them.
unless you get a better answer, you should assume they work everywhere.
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bomarc - help me out here. Are you disputing my wild assertion...
Regardless of what else is deficient or in error in the aviation world, the crew is responsible for situational awareness through cross-checks.
My comments were not suggesting that the accident was ATC's fault. Neither should primary blame be put on just the pilots.
How can very non-standard signs and barriers be allowed?
My comments were intended to clarify the impression that ATC's staffing seems to be stretched to such a point that maybe the FAA copies the common US airline 'role models' these days. Staffing budgets are primary, safety and quality might somehow take care of themselves-but as long as all liability can be pinned on the pilots, then so what?
How can very non-standard signs and barriers be allowed?
My comments were intended to clarify the impression that ATC's staffing seems to be stretched to such a point that maybe the FAA copies the common US airline 'role models' these days. Staffing budgets are primary, safety and quality might somehow take care of themselves-but as long as all liability can be pinned on the pilots, then so what?