Document control process anyone. This may be a reminder of the importance of having the latest revision of documents. Someones life could depend on it.


http://www.cnn.com/2006/US/09/12/comair.crash.ap/index.html

Maybe also a reminder to follow and double check the documents you have. Had the pilot looked at his heading, he would have realized he was lined up on the wrong runway prior to his take-off roll.

I used to fly and I have a hard time believing the pilot / co-pilot didn't know by looking that they were on the wrong runway. There was more to the accident than an outdated airport map.

Seems to me FAA could have mistake proofed the mapFAA spokeswoman Laura Brown said Tuesday that the maps aren't changed to reflect every airport construction project, and airlines are alerted to those changes through notices to flight crews.
by posting such a message in big bold letters on every map!

Agreed! I also believe there was more to it that an outdated map. Time will tell perhaps once the investigation is complete.

Seems to me FAA could have mistake proofed the mapby posting such a message in big bold letters on every map!

The FAA requires reading NOTAMs (Notice to airmen) before every flight as part of the FARs. Far more efficient then posting an permanent advisory that would be ignored on charts or airport directories. Both of which are updated twice a year (if I remember correctly).

Contributing Factor - From the Associated Press (http://ap.org): LEXINGTON, Ky. (AP) — Months before the Comair jet crash that killed 49 people, air traffic controllers at the Lexington airport wrote to federal officials complaining about a hostile working environment in the tower and short-staffing on the overnight shift, according to letters obtained by The Associated Press.

In identical letters sent April 4 to Kentucky's senators, Republicans Mitch McConnell and Jim Bunning, a control tower worker said the overnight shift, or "mid," is staffed with two people "only when convenient to management."

The Federal Aviation Administration's guidelines called for two people to be there the morning of the Aug. 27 crash, but only one was present.

"We had a controller retire last month and now we are back to single man mids," wrote Faron Collins, a union leader for the Lexington control tower workers. "I ask you one simple question. Are two people needed on the mids for safety or not? If they are, why are they not scheduled?"

Collins said Tuesday that he sent the letters to the Washington and Kentucky offices for both senators. Bunning's spokesman Mike Reynard confirmed that his office received them, but McConnell's office said it had not located the correspondence in its computer system that tracks constituent mail.

After mistakenly turning onto a runway that was too short, the commuter jet struggled to get airborne and crashed. Investigators said the plane made the wrong turn after the lone controller on duty turned his back to do some paperwork. The co-pilot was the sole survivor; he was seriously injured.

Besides the letter to the senators, another Lexington control tower operator wrote to the FAA's Accountability Board on Dec. 1, 2005, complaining about a hostile work environment in the tower. That employee requested anonymity, fearing discipline against him.

"Not only do the vast majority of controllers worry about the security of their jobs, but this anxiety in the work place should be considered a legitimate safety concern for the flying public since controllers are not in a healthy state of mind while working traffic," he wrote.

FAA spokeswoman Laura Brown said she had no immediate comment Tuesday on the complaint.

Aha - management and resourses?

I have had one question that I have been hoping would be answered since this wreck.

Most runways that I have been on in small private planes have the runway number (which is also the last 2 numbers of the heading) in HUGE numbers at the end of the runway. Did this runway have such numbers on it? If not, why not?

Yes, there are numbers. There are other aspects which are 'unusual'. The flight departed the gate around 6 am. Sunrise that day was about 7.30 am. There were no runway lights on the runway they tried to take off on which I can hardly believe did not 'ring a bell' in the pilot's (PIC - Pilot in Command) head.

I've been on airport tarmacks as PIC during the dark - Small ones like Fulton, Missouri's little guy, and big ones like Kansas City and St. Louis. I've flown into and out of Lexington (last during the early 1980's) as PIC and it's not huge. Now, I know it can be really confusing at times out there on the tarmack, especially in the dark, but for a professional pilot this is not rocket science.

This was a stack-up of 'small' errors, but ultimately I fault the pilot / co-pilot for not being aware / alert. The taxiway edge lights and runway edge lights would have been on at that time, but the runway they tried to take off on had no runway lights on as I understand it. It just doesn't add up to me. You look down the runway as you line up with the runway and prepare for the takeoff roll and the lights are obvious. I never would have taken off during the dark on a runway that didn't have runway edge lights on and I don't know any pilots who would.

I have had one question that I have been hoping would be answered since this wreck.

Most runways that I have been on in small private planes have the runway number (which is also the last 2 numbers of the heading) in HUGE numbers at the end of the runway. Did this runway have such numbers on it? If not, why not?

See the attachment; the image probably predates the accident.

the runway number (which is also the last 2 numbers of the heading)

The first 2 numbers.

Runway 22 would be approximatly 220 degrees on the compass.
Runway 9 would be approximately 090 degrees on the compass.

If the runway is inactive there should be a big X instead of a number.

I have an up to date map of Pontiac, MI in my car - but that did not stop me from turning the wrong way onto a one way street a couple months ago. I've driven there many times, there are signs - just a lack of attention on my part - thankfully no accident.

There are many possible factors in this accident - confusing runway layout, new construction, fatigue, darkness. There are also many actions that could have possibly prevented it but did not "align right" to stop it - checking heading against runway, controller not watching, not noticing narrow/cracked/unlit runway...

It will take awhile for the NTSB to work out what the actual causes were - but it is looking like human error, which is pretty much inevitable if humans are involved.

Some other things to consider:
* On average 119 people were killed every day in highway accidents last year. Most did not make national headlines (Based on number of 43,443 in 2005 pulled from a USA Today article)

* Tens of thousands of flights took off and landed that day without incident.
* Millions of flights have taken off and landed since the last major crash.

Overall the aviation system is working - the occasional accident going to happen.

Good thoughts especially when thinking of a Zero Defects policy... :notme:

The first 2 numbers.

Runway 22 would be approximatly 220 degrees on the compass.
Runway 9 would be approximately 090 degrees on the compass.

If the runway is inactive there should be a big X instead of a number.

I stand corrected. I just knew that there are numbers, and the system has something to do with the heading. If the numbers were there, the landing lights on the plane would have illuminated them, no?

Good thoughts especially when thinking of a Zero Defects policy... :notme:

It seems that these are the three salient issues:

Pilot and first officer both miss runway markings
Pilot and first officer both fail to check compass heading
Controller in tower turns away to do paperwork and doesn't verify that the plane is on the correct runway.Aside from whether or not the recent construction affected the problem, and whether or not there were illuminated signs (other than the markings on the runways themselves) that were disregarded or inoperative, what we see is a confluence of three highly unlikely occurrences. And I mean that they were individually improbable, so the likelihood that all three would happen concurrently is exponential. So preventive action is probably not warranted, except... it seems like the most effective preventive action that could be taken would be to have a second controller in the tower as the FAA guidelines mandate. In other words, it seems that the likelihood of the accident would have been drastically reduced if the FAA had just followed its own advice.

If the numbers were there, the landing lights on the plane would have illuminated them, no?

Probably. There's a lot going on at that point in the process. I can't say I always looked for runway numbers as a primary cue, but usually I did look for it as a 'confirmation'. I will say at larger airports I depended a lot upon ground controllers to tell me if I was screwing up, particularly if I was a 'transient'. But with all the various cues, no runway lights would have stopped me cold even if I saw a runway number.

If the numbers were there, the landing lights on the plane would have illuminated them, no?

Possibly. Planes don't normally taxi with landing lights on unless entering or crossing an active runway, so depending on when they switched them on based on where the nose of the plane was pointing. My guess would also be that since there would be little or no air traffic at 6 am, they probably did not hold on the runway prior to takeoff. It was probably turn, line up while rolling, and throttle up. A CRJ will use up 3500 feet of runway pretty quick on a takeoff roll, so there would not be much time to react once they realized the mistake.

So preventive action is probably not warranted, except... it seems like the most effective preventive action that could be taken would be to have a second controller in the tower as the FAA guidelines mandate. In other words, it seems that the likelihood of the accident would have been drastically reduced if the FAA had just followed its own advice.

Especially since the airport was operating under "adverse conditions" i.e. there was construction going on. It is one thing to cut a few corners under normal operating conditions, but to understaff the control tower when the potential for error is at an elevated level seems just plain stupid.

It's sort of like control charting - only in reverse. Normally, an "out of control" situation leads to a search for potential special causes. Here, a "special cause" of variation was already known (the construction). Although it hadn't yet produced an "out of control" situation, the likelihood was increased. It would only make sense to apply preventative actions to ensure that the "special cause" would not in fact lead to future "out of control" (literally!) situations. And the simplest preventative action is to at a minimum follow standard safety procedures.

Tim F

Planes don't normally taxi with landing lights on unless entering or crossing an active runway

I always taxied with landing lights on if it was dark out, but I flew small planes. I would leave them on until I was in the air on my climb out, especially at uncontrolled aorports. I can't remember if there were any rules on when they have to be on. It's been over 20 years since I have flown as a pilot so I have no idea what today's practice is / rules are.

what we see is a confluence of three highly unlikely occurrences. And I mean that they were individually improbable, so the likelihood that all three would happen concurrently is exponential.Yes, indeed. I would wager that just one, or maybe even two of those occurences would not have resulted in an accident. Accidents usually happen when several things stack up to your disadvantage, which is something I have experienced first hand. Yes, I have pranged too, but I was able to walk away from it.

In other words, it seems that the likelihood of the accident would have been drastically reduced if the FAA had just followed its own advice.I agree, that is the obvious conclusion.

/Claes