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.

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

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:=

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

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....:ok:

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

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!

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.

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. :hmm:

I hope you will all re read the transcript...I found much more interesting things buried deep inside that might mean something...

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...

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

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.

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.

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?"

This part of the transcript might explain a lot IMHO.

Another confirmation bias possiblity
 

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.

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:
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.

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.

411A,

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

Then obviously, 411, you support attracting more experienced, higher caliber pilots through the raising of salaries and benefits, in accordance with the invisible hand of the free market. You are aware, aren't you, that both these guys could have made more money managing a Subway....

Seem to remember a major hickup years'n'years ago with some charter outfit which had parked 4 planes overnight. Nobody was sure which plane went where so it came as it must, pilots for Glasgow, cabin for London, Pax for Manchester and baggage for Birmingham. Now fill in all variations of the above and you'll get what the other 3 planes had. Took until lunch to sort out. Oh, yea, and 2 of the planes were off blox when the cabin announcement got people shouting "waitaminite!!" in a big chorus.....

Huck is right about a few things. I wrote a lengthy analysis of this CVR transcript and its meanings ...way beyond the sterile cockpit stuff.

And HUCK is quite right, a bit of small talk is vital to "team building" in the cockpit.

I won't publish my analysis here, yet. I will attempt to have it published where it will do more good, somehow the public must understand what airline flying in the USA is becoming.

When it is published elsewhere, I may reprint it here.

And guys, there is so much more in the transcript than what you have already mentioned...read it like your life depends on it...every word...don't skip anything.
===
the following is to be taken with a grain of salt and not reflect the tragedy of the Lexington accident...if you think you will read it the wrong way, don't read it at all.

Huck is right too about managing a subway restaurant/sandwich shop.
The question to modern pilots is this: is it easier to hit on a babe with the line: I fly for comair and make crappy $, or I manage a subway and make crappy sandwiches but twice as much money as that comair guy?

The salary at Comair has absolutely nothing to do with this KLEX accident, and it more than likely would have happened if the crews salary was twice what it was.
The VERY basic fact is, poor training combined with a culture that is NOT safety oriented, which is confirmed by the CVR transcript.
These Comair guys are there simply because they hope to either have (eventually) the regional salaries higher (not likely to happen) or they hope to get hired by a major carrier....where they will find declining salaries, and there is positively nothing that they or ALPA/APA can do about it.
Period.
If bigger bucks are required (to hit on the babes etc) then these guys might as well try Subway management.
Indeed, by the looks of the transcript perhaps this is where they belong.:ugh:
In short, shape up, or ship out.

Dude, you are such a jack-ass. The salary at Regional airlines in general is indicative of the tough conditions that pilots working there have to face. It goes hand in hand with how overworked and fatigued they are. Sometimes I wish that non-pilot morrons like 411A would stick to commenting on ****t they know more about (ie, nothing). I really don't think PPrune is for you.
:=

Having read the transcript, the only thing that is really clear to me is that they were both extremely tired and not thrilled about their jobs. Most of the conversation is spent talking about "moving on". Not to mention how the FO called for the briefing even though it had already been completed. Less than 10 hours on overnights? That probably includes time traveling to and from the hotel and going through the ridiculous TSA loops.

This should be a wake up call to the FAA and NTSB. They guys messed up, there is no covering that. But what needs to be scrutinized is that they were definetely affected by Fatigue. This should be "the straw that broke the camels back" for overhawling the Duty/Flight time limitations. They are outdated and something needs to be done to ensure the proper rest of crewmembers. :D

Dude?
Oh dear, 7700, you do indeed use the same terms that the Pinnacle guys did, just before they fell out of the sky from FL410...which clearly indicated the level of experience the regional guys have.
How very sad.
When you get to my level (25K hrs, the last 19K in command in heavy jet transports...and still flying 'em) of experience, 7700, you can tell me ALL about your problems.:rolleyes:
Fatique?
Find another job.
The duty/flight time regulations have been used as a whipping boy for years by some malcontent pilots that many times simply fail to do the job for which they were hired.
Perhaps Subway is indeed more suited for these folks.

In short, find another job if you don't like the one you have now.
Rather basic, actually.

http://news.yahoo.com/s/ap/20070118/...tucky_crash_25


Louise Roselle, one of the attorneys representing victims' families, said the pilots' conversation about searching for other jobs reinforces one of the central issues in the lawsuits related to the crash. "It reinforces how Comair has been treating its pilots," Roselle said.

So, it would actually seem that the rather basic option of a different job was being considered. Perhaps they'd even filed applications with dodgy third rate operators - bags of duty with no fatigue issues, just like old 411A.

System Factors at LEX
 

Here's a short list of "system factors" that seem to have been at work, not "causal", but any one of which might have changed the outcome it it had been different:

* the airport has a rise (hill) in the middle of it.
* Runway 26 was 150 feet wide, but shown on the airport diagram as 75 feet wide.
* The lights were out at the takeoff end of runway 22 for something like 30 minutes, the samewindow of time as when the First Officer arrived friday night and noted the situation.
* The airport diagram did not correspond to reality, lacking the extra runway. The airport diagrams that are current are still not updated. The small versions of the airport diagrams on the instrument procedure plates make it look like there is a closed runway that comes all the way down to runway 26, marked by an "X", even though the larger diagram shows there is a gap (from the one marked with several "x" flags.)
* There is at least one possible confusion of route to the takeoff point that the diagram discrepancy allows, in which a sharp left turn onto a 150-foot wide runway at the end of the taxiing made perfect and unambiguous sense.
* Only the pilot in the left hand seat could steer the nosewheel steering, which separated the pilot in command (the first officer) from the activity that was done incorrectly by the senior Captain in the left-hand seat.
* Unquestioned cultural convention demands that the higher ranking officer sit on the left side, even though it would make more sense in this aircraft to have the pilot in command sit on that side.
* The tower was understaffed, and the lone occupant was (correctly) busy with other traffic at the crucial few seconds when he otherwise might have idly watched flight 5191 taxi into position and noted the error. It wasn't the tower responsibility to do that, but it could have occured and caught the problem.
* The only person who noticed the error, apparently, a ramp worker, had no way to communicate by radio to the aircraft and his attempt to run to the runway and wave down the plane did not succeed.
* The aircraft was not equipped with the $18,000 piece of equipment that would have automatically detected the runway error and alerted the crew, possibly because the airline was in bankruptcy proceedings.
* The crew seemed to behave as if operating in violation of FAA regulations was something they were routinely expected to just do and shut up about - judging from the fact that they continued to attempt a takeoff from an unlit runway, even though the first officer sighed when he commented that the lights were out all over the place.

These are intended to be a list of factors beyond individual performance that are potential intervention points to prevent similar events in the future.

Do I have those right?

training and culture are a huge part of this accident.

as to the 18000dollar piece of equipment...there is already a localizer receiver on the plane...tune it to runway 22 ils (gs ots, but loc ok) and the "needle" would center up if the plane was on the correct runway.


ask comair if they trained their pilots to do that?


demanding excellence as standard by the company would help...but there is a quid pro flo there.

also note that comair was in talks to lower pay to all employees at the time or approx time of the accident...

You get what you pay for. As things shake out in this industry, why would anyone with any ability or talent want to go into it. I love to fly, but if I was going to make peanuts for a flying career I would have gone into another endeavor and then flown on the side. Why would any highly trained military pilot leave for what is becoming available in the civilian world? The flying public that pays $4 for a latte and then surfs the internet for an hour to save 10 cents on a ticket are going to get exactly what they pay for. This is just a wake up call for what is on the horizon. Management may think they can buy an aircraft with all the latest doo dads that anyone can fly but when it comes down to it, experience, talent, dedication, and many other factors make the individual pilot the only reason the system works so well today.

Thus the stellar safety record of the supplemental world. Keep telling yourself it's working.

You do understand, don't you, that the above-quoted statement is a violation of the FAR's?

Ditto Midland at EGLL in the late 'eighties. The "November" stands.

It tends to focus the attention of the passengers....

r

No, not harsh at all. One question, though: how do you feel about KLM and Pan Am pilots?

I hate to say "ditto", but I just did. :D

411A, regional guys flying jets are some of the most experienced in the industry. They fly 4-6 leg days, 4-5 days a week in some of the most chalenging airspace/weather out there. You probably never did any time at a regional. Right now you probably start briefing 500 miles from your destination for an ILS into a 12000ft runway. I would love to see you do a BOS-EWR with delays, low weather and 3 runway changes on final. Remember, no autothrottle or autoland.
In this job, you never stop learning, but I bet you decided you knew enough a long time ago. The only good news is that with so many hours you are probably pretty close to retiring or kicking the bucket.

(Edited by moderator DANNY)

Sqwak7700:

You might be new on the Pprune website.

There are many experienced pilots here who, based upon not just their experience levels but also on their searching for factors which contributed to accidents, want to help broaden the big picture behind many accidents. This might help the rest of us better anticipate what can go wrong either at a given airport or in a new situation.
These seem to be in the majority (although at first glance, other non-pilots often want you to believe that they are pilots).

There can be a very tiny minority of real pilots who appear to have been, based upon their comments, never involved in any accident, incident, nor even a mistake. Truly super-human, apparently able to fly for 30 hours without a mistake in planning, c0ckpit 'flow-patterns', crew-coordination or judgement. Not just a "5-striper", but maybe wearing 6 strips. :cool:
Most impressive-at least from the anonymity of a distant computer monitor and keyboard.

Of course this impression is only based upon their comments on Pprune by way of their ability to quickly and accurately judge others by excluding any and all external factors, including correct Jepp. charting or not.
We continue to be impressed by this unprecedented ability to avoid any mistakes, under whichever conditions.

The books which I've found interesting, i.e. "Fate Is The Hunter" (Gann), "Flying The Hump" etc, were written by superior pilots who enjoyed long and colorful careers, but admitted to some mistakes, and avoided the self-centered desire to appear superior to all other fellow pilots. The late Len Morgan also wrote valuable books.

Thank you Ignition Override, I´ve just got the notion of posting something similar, when I observed your post and saw you sparred me the effort.

In real world, 411A is worldwide (in)famous L1011 instructor, I guess he still flies sims. 411A is the type of airplane he owns. Most of things listed here are applicable to 411A too.

As for the Lexington disaster, bear in mind that:I´ve got this one from Skygod.

Hmmm, lets see.
A young guy (or gal) wants to be an airline pilot.
So, out they go and obtain their ratings and get hired by a regional airline.
Even Comair perhaps.
Especially Comair, and I suspect that many of the guys there eventually expected Delta to absorb the operation, and they would have a DAL seniority number.
Ain't gonna happen, and never will, which is perhaps just as well, as DAL is bankrupt anyway.
Pensions gone, etc.
Anyway, these folks are hired by the regional into the RHS of a nice shiney new jet.
So far, so good.
Before being hired, they are informed of...
Salary.
Working conditions.
If they agree, and agree is the operative word, they proceed to ground school, where in addition to systems knowledge about the airplane, they receive information about flight and duty time limitations, as laid down by the company, and the FAA.
There it is, in black and white, for 'em to read and (hopefully) understand.
Then on to sim, line training etc, and presto, a newly minted jet transport First Officer.
What's one of the first items on their agenda that they complain about?
Salary, and duty/flight time limitations.
Oh dear... 'we are tired, we never see our families, we don't make enough to make ends meet.'
Well, so what?
You wanted to be an airline pilot, and now you are one.
Welcome to the club.
Tough beans.
Cry me a river.
Not happy in your present position?
Write your Congressman about changing the flight/duty time regulations, and if you really are unhappy, I expect Subway is accepting applications.
However, if you decide that airline flying is really what you want to do as an ongoing career, then pay attention to what you are doing on the FD, and don't attempt departure on an unlit (and too short) runway.
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.:=

OK, I'll go along with that. My father, who retired after 31 years red-book NWA as a whale LCA, told me when I started: operate that Cessna like I was captain of a 747. It is a habit that has served me well.

This crew commited an error, as in so many accidents. That should not, however, stop us from looking at all the other links in the chain, should it, 411A?

By the way, how much rudder pedal force is needed during a V1 cut in the 411? Isn't it ~125 pounds? Quite the aircraft....

V1?
 

No V1 with the 411, Huck, it's a CAR 3 certificated aeroplane.
Now, as to rudder force to keep it straight in the air, with one engine unserviceable/propeller feathered, at the published Vmca speed/max weight, it would be 140 pounds...which, oddly enough, is about the same as an old straight pipe powered B707-300 with an outboard engine failed at rotation.
Yeah, I've flown these too, extensively.
Now, to look at the reasons why the Comair accident occured, a rather long investigation by the NTSB will certainly be necessary.
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.
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.