Posted on 08/27/2006 4:38:10 AM PDT by BigBlueJon
Edited on 08/27/2006 5:02:21 AM PDT by Admin Moderator. [history]
"How about all those Texas frontage roads that are two way? Or one-way to the freeway entrance ramp and then change to two way?"
Yeah, we like to keep non-Texans on their toes so we can cuss about 'them damn Yankee drivers', LOL.
The worst part is moving to OK from Texas and finding out they don't yield to traffic coming off the Interstate at most exits. Almost caused an accident right after the family moved up here. Sure they yelled out about the stupid Texas driver.
However, bad it is in Texas, Oklahoma is much worse with their design for traffic!
The desire to seek out all the relevant causal factors is very important. Rarely is the direct cause of a crash so immediately apparent and simple that even the NTSB can state it with relative certainty within hours of the event, but in this case it appears to be so.
But once that cause is established, whether that's hours or months after the crash, the more important work of discovering why that cause could occur begins. I agree that it seems unimaginable that two qualified and experienced commercial pilots (plus possibly a third in the jumpseat - reports conflict on whether an AirTran pilot who died in the crash was seated in the cockpit jumpseat or in the passenger cabin) could line up and attempt a takeoff on an unlighted runway different from the one they were cleared to take off on, despite many factors that should have prevented such an error. But they did, and it's of paramount importance to understand how that could have happened, in order to prevent it from ever happening again.
For example, was the crew fatigued? If so, maybe changes in crew scheduling and duty time limitations are needed so a pilot can't show up to work so tired he lines up on the wrong runway. There is a moving map that should have shown the runway centerline and that the jet was not aligned with it - did that map fail or have an error? If not, why did the pilots miss it? Maybe something as simple as changing the display colors to be more contrasting could have helped. Why didn't the pilots crosscheck the runway heading and navigational computer heading with the magnetic compass? Should it be moved to a more easily seen location in the cockpit? Were the pilots cleared for takeoff while taxiing, and thus didn't have time to see their instruments settle before beginning their takeoff role? Maybe takeoff clearances shouldn't be permitted until an aircraft is stopped at the hold short line or lined up on the runway. Why didn't the tower notice the error? Would additional tower staffing, requiring visual position confirmation before takeoff clearance is issued, or changing the way clerance readbacks are performed help? Was the recently changed taxi layout confusing? Is better signage and lighting needed for night operations, especially around construction areas? Why didn't the pilots realize the mistake in time to stop on the runway? Should a warning system be added to alert pilots who add takeoff power when they're not on their assigned runway heading? Is more situational awareness training needed?
These are just some examples of questions that come to my mind. Some or all may be irrelevant, and many other questions that I didn't put may be very important. But if saying "pilot error" and just telling pilots to "do better" was an acceptable resolution to a crash investigation, we would have been done with aviation safety improvements in about 1930. The fact is that humans are imperfect, and we have brains that evolved their processing ability in basically 2-D environments at speeds up to maybe 10mph. Getting into a cockpit of a vehicle that can move in 3-D at hundreds of mph, operated by incredibly advanced computer systems, is very much unnatural. So our system, which has made aviation by far the safest form of travel possible, is not just to look for where a pilot made an error, but to look for and eliminate any opportunity for errors to be made. It doesn't excuse the pilots or "shift blame". But it does ensure the only possible good thing that can come out of such a tragedy - the knowledge to make changes such that a similar tragedy can never happen again.
No evidence exists to suggest that signs/markings were obscured, or any of the other imaginary conditions you've intro'd into the scenario. The runway was repaved, the taxi instructions might have been different than the last time they were there. So what. You can cite only one incident, 13 years ago, when someone else was confused.
Again, the issue is pilot performance. Taxiways and runways are parts of a system that expects actors to perform as trained and accept some level of performance deviation. The system is not designed to be idiot proof. Such thinking drives up costs, decreases crew awareness and responsibility, etc.
I just spoke with another ATP, just to make sure I'm not crazy. He thinks these guys were probably chatting through taxi, or otherwise distracted, but he still can't figure out how two pilots could make this basic error. He finds it indefensible. He said the error was more egregious and less understandable than the AA pilot that snapped the rudder of the Airbus at JFK in 2001. Only thing he could think of was when two pilots repositioning a CRJ were cowboying around at the edge of the flight envelope and crashed the thing. He thought it happened about 5 years ago.
I honestly think you're abusing failure analysis and systems design practice in your suppositions of cause. Systems are designed to comprehend and mitigate reasonably avoidable risks. Systems can even comprehend reasonably predictable mistakes, but not something like this.
Once, 13 years ago, not a commercial pilot. Hardly a trend, and happened before all the allegedly confusing repaving.
That's certainly a good point...
You do aviation safety a great disservice with your post. Everyday there are thousands of flights, pilots are somehow navigating the baffling maze of runways at airports all over the country despite their schedules, poorly contrasting instruments, not settling before takeoff, not enough controllers, etc.
You guys are killing me with this stuff. You ought to work for the NTPEB - National Transportation Pilot's Excuses Board. No effort needs to be expended here to make the skies safer. The 5191 crew has issued a NOTAM for everyone on making sure you're on the right runway.
Please, if there are any ATPs on this thread, would you weigh in on this topic. I've got three that say these guys screwed up in a way that no one ever should, or could have imagined.
The main object is not to assess blame but to prevent crashes. Saying that a crash occurred because of negligence does nothing to prevent crashes. The system must be made as "stupid-proof" as possible. Lowering failure rates almost always happens because the process is improved, not because people perform the same old processes better. Telling everyone to be "extra craeful" does nothing. Behavior will almost always drift back to its previous state.
I'm sure that negligent and foolish mistakes happen all the time in our aviation system. However, crashes are rare, and getting rarer. This is because of the multiple redundancies built into the system, often from lessons learned from crashes.
Very good post. In my industry we view these things in much the same way. When a person errors, I will go out of my way to fix process or system issues in addition to disciplining the person. Certainly there's a threshold where the additional checks or process steps exceed the cost we can bear, but when people's lives are at stake that threshold is generally higher than might be considered reasonable in many other industries.
Read every single post here. You are exactly right.
I noticed the same thing.
White faded numbers on old concrete, in the dark, with wet surface. Drive down an old stretch of Interstate, under the same conditions, and it's sometimes hard to see the lane markings.
That said, there's a compass in the cockpit for a reason.
So is your point that we shouldn't attempt to make improvements, because most of the time things are good enough? I agree that you won't find a pilot anywhere, including me, who disagrees with the statement that the pilots of OH191 blew it, big time, that it never should have happened, and that absent some new contradictory evidence there is no excuse for it.
What I don't understand is your apparent objection even to looking into any factors that could have contributed to this seemingly unthinkable mistake. You seem to agree that there should have been no way this crash could have happened - yet it did. Isn't it important to understand why something went wrong in a way no one had thought possible before?
Look at it another way - from the perspective of previous accidents. Crashes have been caused because pilots forgot to set takeoff flaps and slats. That's obvious and inexcusable pilot error - so does that mean configuration warning alarms and sterile cockpit rules are a bad idea? Pilots have descended below the glideslope or flown off course and crashed into terrain - again, clear pilot error, but does it mean that terrain warning alerts are just an "excuse" for "bad pilots"?
Aviation safety is enhanced when the chains leading up to crashes are analyzed and thoroughly understood and, if necessary, steps are taken to prevent or at least minimize the chance of any link in that chain ever forming again. Like it or not, pilots are in fact subject to human factors, and now that we know there is some combination of those factors that can lead to two qualified and experienced pilots taking off from the wrong runway, the only wise course of action is to determine what that combination of factors is so we can figure out whether there are any reasonable steps that can be taken to reduce or eliminate them. I really don't think you'll find another pilot, ATP or otherwise, who will disagree with that statement; I'm certain you won't find an NTSB investigator or FAA safety employee who will.
Second Controller Added To Tower For Weekend Overnight Shift At Blue Grass Airport
http://www.msnbc.msn.com/id/14553611/
Pilot In Fatal Jet Crash Was From South Jersey
WCAU-TV
8:44 a.m. EDT August 28, 2006
Federal investigators say a takeoff on the wrong runway caused Sunday's Comair jet crash in Lexington, Ky. Video:Pilot Was South Jersey Native
The plane crashed shortly after takeoff.
Forty-nine people on the plane were killed. Only the co-pilot survived. He is in critical condition.
The pilot, who also died in the crash, was identified as 35-year-old Jeffrey Clay, who grew up in Vineland, in Cumberland County, N.J. Clay grew up in South Jersey and attended Rutgers, but was living in Kentucky with his wife and two daughters.
The Delta Comair commuter was headed from Lexington to Atlanta.
Officials said the jet used a runway that was too short.
Investigators already are examining some key airport evidence to find out how such a mistake could have happened.
"We have ground scars at the end of runway 2-6, as well as some preliminary information from the flight data recorder that shows the aircraft was lined up on a heading of 2-6," said Debbie Hersmann of the National Transportation Safety Board.
The fatal crash is the United States' worst airline disaster in nearly five years.
You left Texas for Oklahoma?
Why?
(hmmm - don't answer that. I don't think I want to know, LOL.)
"But if saying "pilot error" and just telling pilots to "do better" was an acceptable resolution to a crash investigation, we would have been done with aviation safety improvements in about 1930."
Well said. And the examples of the questions that need to be answered are excellent and precisely on target. Thanks for your insight and common sense.
Exactly. It's not about excusing the pilots, because really, I don't think that's possible in this circumstance. Everybody knows they screwed up. It's about making it that much more difficult for something like this to ever happen again.
}:-)4
Was this young woman a FReeper?
They were closing Kelly AFB and had a choice between Robins AFB GA and Tinker AFB. That was no competition. Oklahoma and Tinker AFB won hands down.
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