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I repeat, it wasn't the tower's fault.
No ZH-127. You fail to understand the concept of pilot in command along with its attendent authority and responsibility. Your bleating on about ATC's short comings is naive to the point of being vacuous. How many thousands of hours of captain's time in air transport operations do you have in your log book? Should you ever acquire any, you'll get the point.
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Originally Posted by XL5
(Post 2808462)
No ZH-127. You fail to understand the concept of pilot in command along with its attendent authority and responsibility. Your bleating on about ATC's short comings is naive to the point of being vacuous. How many thousands of hours of captain's time in air transport operations do you have in your log book? Should you ever acquire any, you'll get the point.
The captain has ultimate responsibility over the safety of his aircraft. Regardless of the instructions given to him/her by ATC, the book stops with the captain. The point i am trying to make is that whilst not the controllers fault, if there were more than one controller on duty at LEX the chances of avoiding this accident would have been massively increased. Therefore, by its own admission of guilt, the FAA is partly at blame too. I am not saying that the controller is at fault. Read what i am saying, and engage your logic. I am not disagreeing with you about the responsibility of the captain of any aircraft. :ugh: |
DanAir1-11 Let us all be mindful of the effects that unfounded or misguided speculation can have. I am deeply concerned at the direction in which some of the 'ATC' speculation is heading. Whilst it is most certainly only natural for professionals to hold a profound interest in events affecting our livelehood and that of our compatriots, we must be mindful that 'other' persons also have access to this forum, and it is possible that their intentions may be somewhat different from our own. (no inference made here-in please note) Also, we have to be mindful of the possible detrimental effects our speculations and postulations may have on those persons concerned. It is not so long ago that a controller (no names nor organisations need be mentioned) was brutally murdered in the 'aftermath' of a terrible accident over Germany. (you all know to which incident I am referring) We ALL have an obligation as professionals, current or retired, to discuss this incident with the utmost of care and respect for all parties concerned. . ..the event you mention is foremost in my mind unfortunately uninformed and irresponsible comment in the media may have contributed to that hideous outcome :sad: . to carefully point out and/or question possible circumstances may reduce the likelihood of the media playing the blame game whilst poking around in the dark someone referred earlier to systemic .. seems there might have been rather that individual responsibility . Isnt it better to flesh out 'sytemic' before people are wrongly tared and therefore placed at potentially greater personal risk! :mad: . .. the hounds will hunt irrespective! :hmm: . . How many of us could have been in any of those seats that morning .... and really truly honestly say that could not have happened to me :uhoh: . Well??? . As has been said . lots of possible issues in this one . :( my best wishes go to the FO and the ATC .. treat them well!! |
Accident investigations are NOT about apportioning blame. It's about working out what (normally human) factors were involved, and how to try and stop it happening again.
As usual it was a combination of factors, errors, and bad luck that in the end all the 'holes in the cheese' lined up and an accident happened. Any one thing out of many could have prevented this but it didn't. All we can do is try and learn from it and and perhaps put in extra safety measures or rules or procedures that may help stop it again. This is a terrible ACCIDENT and no one person or persons are to blame. I for one was careful yesterday lining up that I had the correct runway and will be more careful in the future. |
I speak with experience of ground ops at European airports - so a quick question:
The rwy 22 holding point stop bar would have been de-selected as the aircraft had been cleared to lineup / position & hold; were there no taxiway centre line lights on the taxiway that would have been illuminated across the concrete element of rwy 26 over to the rwy 22 hold? |
XL5
no doubt that the PIC is the final authority and has the final responsibility for a safe flight. BUT in aviation we help each other keep things safe. As in a previous post, I mentioned to ATC that a fuel truck was on the runway in my case and I declined to takeoff. WE WATCH EACH OTHER and help each other and if we don't a hell of a lot of controllers just might be decertified. There Should have been a controller scanning the runway...there wasn't, and bam...does that make it the controllers fault? no does that make the system in need of improvement? yes If a radar controller issued a clearance for an apch to one airport and saw on his screen the plane going in the opposite direction, shouldn't he say something? AVIATION SAFETY is everyone's business. A real controller would know that. |
Please be aware that lawyers will be reading this thread and getting ready to proposition the families of the deceased. http://www.kreindler.com/kreindler_n...Flight5191.htm |
jondc9 ..... most ATC staff will agree with you on that , everyone in aviation works together , mostly as independent teams . However managers these days seem to have different thoughts on the subject . Money is the bottom line , the LEX accident seems to prove my point . Certainly from my personal experience , managers decry experts' (read , the people DOING the job's opinion) with a "no , no , that's not true" when their ideas are challenged . "Risk factors" and "Stake-holders view" are the current "management" phrases . There needs to be a distinct management 'culture change' before things change for the better . Money is NOT everything .
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For real jondc9?
A fuel truck on the runway? A fuel truck? The ubiquitous tongue in cheek simulator scenario for a low level go-around and you, jondc9 the magnificent, self appointed mouth piece of aviation safety driven by a selfless urge of altruism, is the one pilot in ten's of thousands to actually live the scenario of a fuel truck on the runway for real? I suspect it is you, and not the alleged fuel truck, which is full of gas.
Captain, Clearance, Compass, Chart 10-9, Crew. End of story. |
jondc9 WE WATCH EACH OTHER and help each other and if we don't a hell of a lot of controllers just might be decertified. There Should have been a controller scanning the runway... there wasn't, and bam...does that make it the controllers fault? No does that make the system in need of improvement? Yes If a radar controller issued a clearance for an apch to one airport and saw on his screen the plane going in the opposite direction, shouldn't he say something? . .. it is a bit like saying (based soley on your descriptions) you were cleared for take-off twice whilst the runway was occupied!! ... you saw the truck and did not go .... the system failed safe!!! .... mind you I find it a little odd that you site this example without explaining the circumstances of how or why it happened! ....not very fair in the current context!!! AVIATION SAFETY is everyone's business. A real controller would know that. . .... .... to those on this thread engaged in a purile pissing contest ..... leave it out ... this is neither the time nor the place .... there is far to much at stake to behave like Imbeciles!! |
AVIATION SAFETY is everyone's business. A real controller would know that by jondc9 |
it is amazing that you find so much wrong with the idea that a controller should look out the window and watch an airliner takeoff. that looking out the window might be more important than tending to "administrative duties".
FAA has admitted 2 controllers should have been on duty. XL5...should a controller just issue a clearance and not see that it is followed? |
I don't think anyone is trying to pin the responsibility of this tragic accident on ATC, that said though, I feel the question of what the controller was doing is a legitimate one, as a previous Facility rated controller at the busiest (military) airport on the west coast I can't imagine what would be more important than keeping an eye on traffic that is cleared for takeoff . .. I am sure your question will be asked and answered in due course! . jon there is nothing wrong with the premise of looking out the window . There are lots of things that might interrupt that scan and/or re-scan though . the same for Pilots yes?!?! :ouch: |
Complacent - Inattentive or Just Tired ?
This is the third time in a few weeks when something tragic and disastrous has been discussed, that plain common sense and attention to detail would have prevented.
Incorrect power settings on a 747 at Halifax, inattention to which engine was shut down in a C-5 at Dover and now an apparent failure to pick the correct runway on a familiar airfield. I stress that I am a lowly Cherokee driver but I certainly know my rotation speed and as I have to drive over the numbers at the threshold (not to mention seeing the marker board at the stop bar with the runway designator as I leave the taxiway) simple attention pretty much ensures a correct runway choice. The one thing this tells me is that in whatever we do and wherever we go, we have to attend to all the details and never stop questioning ourselves ... am I in the right place, doing the right thing, at the right time ???? Some mistakes are just too expensive to make. DGG :confused: |
scurvy dog
yes, many things can stop your scan...but if the SYSTEM says 2 controllers should have been on duty and only ONE was on duty, there is room for improvement. NO one wants ATC to be in command of aircraft, but the lowest private in the army should tell the highest general that his fly is open if it is. it benefits all of us. |
jon .. yes, many things can stop your scan...but if the SYSTEM says 2 controllers should have been on duty and only ONE was on duty, there is room for improvement. ... was it contingency staffing?? .... a potential minefield either way :uhoh: |
jon .. yes, many things can stop your scan...but if the SYSTEM says 2 controllers should have been on duty and only ONE was on duty, there is room for improvement. ... was it contingency staffing?? .... a potential minefield either way :uhoh: |
Lexington paper reports FO was initially in an induced coma. He has emerged from the coma but is still unconscious and in critical condition. According to his mother, he wasn't originally scheduled to fly on Sunday. He arrived in Lexington early Saturday morning, Capt. arrived Saturday afternoon. Crew arrived at KLEX about 05:15 Sunday and fired up APU in what eventually turned out to be the wrong aircraft before boarding N431CA.
Lexington Herald-Leader Additional from Louisville, Kentucky paper |
I don't know what signage is used at LEX, but if it's anything near the ICAO standard this is what they look like:http://www.advancedairportequipment....runwaysign.gif
And yes, the sign is illuminated from inside. It takes some serious fatigue to see 22 when this kind of sign says 26. However the arrival time of the pilots the previous day (reported in later posts) does not raise any glaring circadian rhythm adjustment issues. So what kind of sign is there where the taxiway meets 26? Perhaps because it's just a g/a runway, there's no ICAO standard sign and unfamiliarity with the airport led them to take 26 for 22. |
Although there's been no NTSB comment so far, what about the deadhead crew in the jump seat? Could this have added a distraction factor?
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Originally Posted by barit1
(Post 2808927)
Although there's been no NTSB comment so far, what about the deadhead crew in the jump seat? Could this have added a distraction factor?
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Did the latter claim, boarding the wrong aircraft, also come from the NTSB briefing? |
etrang, I wondered that myself after seeing that reported in several news sources. I didn't see the NTSB briefing, and I can't find where any are transcribed anywhere. This is the best summary I've been able to find of last night's briefing, which says "nothing out of the ordinary" was noticed after the crew arrived. Yet, as airbubba mentions, the Lexington paper quotes the NTSB as saying a ramp worker reported they had boarded the wrong plane.
At a press briefing Tuesday evening, NTSB spokesperson Debbie Hersman released new details pertaining to the familiarity of the crew and the air traffic controller with Lexington's Blue Grass Airport. She said that NTSB investigators conducted interviews with several crew and airport workers directly involved with Flight 5191 the day of the crash. Tuesday morning the NTSB air traffic control team interviewed the controller on duty at time of accident, as well as the ramp worker. The interviews concluded that the crew checked in at 5:15 a.m., picked up their paperwork and boarded the aircraft. Nothing out of the ordinary was noticed. According to Hersman, the air traffic controller had been at the airport for 17 years, and was fully qualified to perform his duties on the day of the accident. Air Traffic Controller: Timeline Of Events On Accident Day
They tested from 10:30 to around 1:00 in the morning.. The airport groups had representatives on board, and took turns documenting, observing, and re-enacting what the crew in Flight 5191 may have experienced before takeoff. A representative was also in the air traffic control tower, to get a perspective of the visibility of the aircraft. Hersman noted that 135 knots was the rotation speed needed to launch the aircraft. Background of Flight Captain and First Officer Captain, Jeffrey Clay
In this particular aircraft, the tiller that steers the aircraft on ground was on the captain's side only. According to the NTSB investigations update, Captain Jeffrey Clay taxied the aircraft to runway 26, before handing over control to First Officer Jim Polehinke for takeoff. Runway 26 remains closed until further notice. |
Originally Posted by HowlingWind
(Post 2808875)
Crew arrived at KLEX about 05:15 Sunday and fired up APU in what eventually turned out to be the wrong aircraft before boarding N431CA.
Considering a :45 minute report time which includes time spent collecting the dispatch, walking to the wrong aircraft, boarding it, stowing bags and beginning to prepare it, to disembarking that airplane, and repeating the same steps on the new airplane- this could leave as few as :20 minutes before the airplane left the gate. Not much time considering the cockpit check, preflight preparation and mass and balance which is all done by hand. Having said all that, it sounds like a very typical day on the job for a regional pilot and I'm sure for many of you here regardless of what or where you fly. That's the scary part. |
Originally Posted by barit1
(Post 2808849)
This may be apocryphal -
A tower operator observed an aircraft wheels up on approach and let him proceed to land in that condition. Asked if he saw the situation, he said "Yes". Asked why he didn't warn the pilot, he said "Because if we take on that responsibility, we'll be held liable if we miss one some day." :ugh: |
as a previous Facility rated controller at the busiest (military) airport on the west coast I can't imagine what would be more important than keeping an eye on traffic that is cleared for takeoff, just my 2 cents. No matter how much the book says "never stop watching the traffic", when the ATIS is so old it's eligible for pension, the last snowtam sendt was 2 hrs ago, the field maintenance chief has called 3 times to coordinate XX (and the list goes on.....) , yeah, you drop the ball. Is it right? No! |
Yet, as airbubba mentions, the Lexington paper quotes the NTSB as saying a ramp worker reported they had boarded the wrong plane. ...Ms. Hersman said that picking the wrong runway was the crews second mistake; when the two pilots arrived at 5:15 a.m., they started up the power generator on the wrong airplane and had to be redirected by a ramp worker... Ms. Hersman is doing a good job with the briefings although her background is in surface transportation, not air transport. According to her official bio she is a certified Child Passenger Safety Technician and holds a commercial drivers license with passenger, school bus, and air brake endorsements. |
Thanks for the clarification on that, airbubba. Apparently the WCPO folks missed that little detail.
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ATC responsibility
From the other thread, on landing at EPKS instead of EPPO
http://www.pprune.org/forums/showthread.php?t=239414
Originally Posted by Ptkay
(Post 2797609)
I think a factor in this last incident was a similar incident
with a Cessna 172 training night-VFR approches to EPPO and missing the field. The lady controler was not allowed to give them suggestions, although she saw on the radar screen what was happening, since the radar system was (and still is) not certified. She did warn them anyway, saved their lives (they were low on fuel and managed to do emergency landing on a frozen lake instead of hitting the town), but was later punished for the breach of procedures. :ugh: It sounds absurd, but so it is. :yuk: After this incident (February) probably noone in charge of approach was brave enough to interfere with pilots decisions by this recent incident. :ugh: a 737 landig at a wrong airfield, luckily with no injuries... |
I have never been to Lexington. I would suggest though that an airfield with a throughput of just over 1.6 million pax does NOT require 2 ADC guys. The FAA say that 2 should be on duty I suspect that is one tower and one RADAR guy.The two functions CANNOT be combined(so JonDC the OTHER GUY MIGHT NOT EVEN HAVE BEEN IN THE SAME PART OF THE TOWER) .I work at a tower which shifts in excess of 4.5 million pax per annum and I am FREQUENTLY working alone doing clearance delivery ,ground,air...it is NORMAL.Scan the runway...clear? cleared take off...have I ever looked away and answered a phone? been distracted by a vehicle..or other traffic elsewhere on the airfield..of course!The aircraft then uses the wrong runway.........
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This is my first post on the "stick and rudder" side of PPRuNe, so be nice to an old man. You aviators who are somewhat grey of head will remember when the bean counters took your FE/2nd Officer out of the cockpit. One less set of eyes. Well, when the FAA decided to run the mid-watch at smaller facilities with one guy downstairs in radar and one guy in the tower, we too, lost a vital set of eyes. I am ashamed of the many times I have practiced "clear 'em and forget 'em" in order to keep up with the paperwork.
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Originally Posted by RatherBeFlying
(Post 2808901)
It takes some serious fatigue to see 22 when the sign says 26.
And that also applies to the other poster(s) wondering why they didn't see the end in time to abort - no REILs. |
For those contributors who have sought to blame someone, or like many of us who find it difficult to withhold thoughts of blame, then read: Punishing People or Learning from Failure.
If you then decide to use responsibility instead of blame see: Systems Safety , in particular page 19:- “Responsibility lies with those who could act but do not, it lies with those who could learn but do not, and for those who evaluate it can add to their capacity to make interventions which might make all our lives the safer.” Also see: Reconstructing human contributions to accidents. Beyond the Organizational Accident. |
I stress that I am a lowly Cherokee driver but I certainly know my rotation speed and as I have to drive over the numbers at the threshold (not to mention seeing the marker board at the stop bar with the runway designator as I leave the taxiway) simple attention pretty much ensures a correct runway choice. By Dave G, D.L. := |
sadly, I'll bet a cherokee driver with an old DG and whiskey compass would have checked his heading on line up.
With such a short taxi, flipping Vspeed cards, checking acars w&b and everything else, maybe they should have stopped and finished everything before crossing the runway hold bars. I know the pressure to hurry...but |
I stress that I am a lowly Cherokee driver It doesn't matter how complicated your aircraft is, or how many bars you have on your shoulder, you'll be just as dead if you don't keep an eye on the bigger picture. You keep right on checking those runway numbers, Mr Cherokee driver. I, for one, will taxi more happily knowing you're doing exactly that. |
Respect , Mr( or Mrs ?) Kalium Chloride, very wise and nicely written.
alf5071h : quoting Reason and Dekker , the " new View" etc.. is always good, reading their work is even better ( but in reality very few really do ) , but applying what they recommend is in fact close to utopia with our modern Employers : Airlines and especially our ANSPs ( ATC companies ) . I think that generally man feel safer if he can identify a scapegoat instead of challenging the system around him .If that scapegoat is in the other camp ( i.e outside his sphere of influence ) the better. The attitude of Skyguide concerning Ueberlingen ( because it was mentioned earlier here ) comes to my mind as a perfect example of this. |
Originally Posted by RatherBeFlying
(Post 2808901)
I don't know what signage is used at LEX, but if it's anything near the ICAO standard this is what they look like:http://www.advancedairportequipment....runwaysign.gif
And yes, the sign is illuminated from inside. It takes some serious fatigue to see 22 when this kind of sign says 26. However the arrival time of the pilots the previous day (reported in later posts) does not raise any glaring circadian rhythm adjustment issues. So what kind of sign is there where the taxiway meets 26? Perhaps because it's just a g/a runway, there's no ICAO standard sign and unfamiliarity with the airport led them to take 26 for 22. |
Interesting to note that there have been several threads from time to time on here where Captains and future captains (FO's) have argued vehemently that the Captain is in absolute control and authority over his aeroplane and can override just about anyone in ATC and Ground Ops. Yet there are several on here trying to give ATC the blame for issuing correct instructions to a crew who then, for whatever reason, got it very wrong.
Either you have the responsibility or you don't guys. From what I have read on here in the reports, the ATC guy did nothing wrong. He did his job as required by his employer and by law. That he might have noticed the aircraft was in the wrong place is peripheral surely? The crew however would appear to have had an off day at the office starting with boarding the wrong plane, and culminating with people losing their lives. The question that needs to be answered is why did an experienced crew make such a basic error? Were they rushing because they were late off stand due to boarding the wrong aircraft and trying to make time up? Did they think they knew the airport so well they didn't concentrate in the same way that sometimes when you get your car out of the drive to go somewhere you automatically turn one way when you need to go the other? From what I have read so far I don't know the answer, but I don't think the manning levels of ATC were significant. They might, with luck, have prevented the consequence of the crew making an error as a reactive measure, but they wouldn't have prevented the crew taking the wrong turn. The mistake which caused the accident is the one that needs to be remedied. |
From what I've seen in this and the in ATC forum, administrative duties can often override what the pilots seem to expect from ATC. This in no way implies the tower op's fault, merely that ATC management and the pilot community may expect different things of the "guys with eyes".
If this accident investigation brings this factor into open debate, then safety will have been served, and we'll all benefit. Just keep the lawyers out of it. |
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