CMR Crash CVR released.

[bailout]

Geez, its just horrible.. You can read the whole thing and anyone one of us could have been in either seat..

 

[V-1]

http://www.kentucky.com/mld/kentucky/need_to_map/16482769.htm

Detailed NTSB reports including complete CVR transcript with times, background on the pilots, interview with the controller on duty, the tower manager, etc.

One thing I found interesting is that at no point did the tower controller, or the Comair F.O. use the runway number in their conversations after the taxi clearance. I always thought this was normal procedure, and I've always thought it was sloppy procedure when a controller didn't specify a runway.


RDO-2

"churliser" [at your leisure spoken very fast] Comair one twenty

one ready to go.

06: 05:17.7
TWR ​

Comair one ninety one, Lexington uh, tower, fly runway heading,

cleared for takeoff.

(Deleted for this post, insignificant)​

06: 05:21.0
RDO-1 ​

runway heading, cleared for takeoff, one ninety one.​

Here's an excerpt from the interview with the controller on duty:

When asked if it was good operating practice to restate the runway in a takeoff clearance, he
said, “In hindsight, it should be done. But it’s not required when there is one runway in use.
When it’s busy and we’re using both runways then I do.”​

Controller's sleep in previous 72 hours:​

Mr. Damron’s Sleep schedule in the 72 hours before the accident:
Sleep
Start Time
Sleep
Stop Time
Sleep
Period Duration
Wed-Thurs 0130-0145 0915 07:15
Thurs-Fri 2230 0715 08:45
Fri-Sat 2230 0540 07:10
Sat-Sun 1530 1730 02: 00​

Another excerpt from the controller interview:​

Asked whether there were any sources that could have alerted him to the fact that Flight 5191 was taxiing onto wrong runway, Mr. Damron said, “Not that I’m aware of.” Asked whether it would have been possible for him to detect it visually out the tower window, Mr. Damron said, “It might have been, yeah.”​

The controller also mentions low morale at the facility due to ongoing contract negotiations.​

As posted above, there's a lot of blame to go around on this one.​

Looks like USA Today is planning to run tomorrow with a "Pilots broke sterile cockpit rule" type story. In the article posted online, it mentions, among other things, the Captain remarking "whoa" 1/2 second before initial impact.​

​

 

[Stifler's Mom]

Sorry that this accident even happened, but hopefully we can all learn from it. Fly safe!

 

[Amish RakeFight]

Looks like USA Today is planning to run tomorrow with a "Pilots broke sterile cockpit rule" type story. In the article posted online, it mentions, among other things, the Captain remarking "whoa" 1/2 second before initial impact.

​

​

You know, I was gonna say something about the lack of a sterile cockpit but felt I might be heavily chastised, so refrained, but they did violate the sterile cockpit rule. For what it's worth, yeah it happens people like to chat, but you know what, maybe, just maybe it might have freed up some time to give a second glance at things and allocate more grey matter to the very critical phase of flight.

Here's some interesting fodder about it.

http://asrs.arc.nasa.gov/directline_issues/dl4_sterile.htm


I'd suggest we all take a minute to refesh ourselves.


.

 

[LowlyPropCapt]

You know, I was gonna say something about the lack of a sterile cockpit but felt I might be heavily chastised, so refrained, but they did violate the sterile cockpit rule. For what it's worth, yeah it happens people like to chat, but you know what, maybe, just maybe it might have freed up some time to give a second glance at things and allocate more grey matter to the very critical phase of flight.

Here's some interesting fodder about it.

http://asrs.arc.nasa.gov/directline_issues/dl4_sterile.htm


I'd suggest we all take a minute to refesh ourselves.


.

You may indeed be chastised and flamed... But that doesn't mean you are not right!

I am as guilty as anyone about staying sterile on the ground. This accident underscores the importance of remaining vigilant even when no percieved threat exists, because that is when good ol' human error will kill you. A lesson learned (again) for me, and I hope everyone else too.

Reading that CVR transcript was a very tough read for me, and I am not afraid to admit it. The poor CA was talking about his kids (same age as mine), then made a simple mistake that could get anyone.

Be careful out there.

 

[Oakum_Boy]

Is it just me, or does this thing make you want to get out of the business. How much garbage can pilots deal with before it starts to invade everything you do. It seems all anyone at the regionals does anymore is contemplate how to get out. This career has gone down the ********************ter farther than can be fished out, I'm afraid.

 

[172driver]

Biggest thing I noticed that can contribute to this thread is that the remark about the lights being out was well after the thrust set call, probably around 60-80 kts. Indicates to me that the rwy appeared to be lit when they were lined up and they only noticed the lack of lights after going up and over the hill at the intersection of 26 and 22. I have mentioned before that the placement of the 22 rwy lights could easily appear to be aligned with 26 since they are at the four corners of the rwy intersection. I doubt if they saw anything suspicious until cresting the hill.

Add to this the constant construction at LEX, vague notams, lax/fatigued controllers, pilots off their sleep rhythms flying together for the first time, and a preconception by the crew of lights being out...somewhere, and you have the chain.

Unless you've seen that hill though, or can picture it, it's hard to imagine the picture they saw when beginning the t/o. I bet it looked completely normal until they were at least 1500 ft down the rwy. Scary. Could definitely have happened to any of us.

 

[Corona]

Biggest thing I noticed that can contribute to this thread is that the remark about the lights being out was well after the thrust set call, probably around 60-80 kts. Indicates to me that the rwy appeared to be lit when they were lined up and they only noticed the lack of lights after going up and over the hill at the intersection of 26 and 22. I have mentioned before that the placement of the 22 rwy lights could easily appear to be aligned with 26 since they are at the four corners of the rwy intersection. I doubt if they saw anything suspicious until cresting the hill.

It's unclear to me whether the lights were on or not. I can't believe that two airline pilots would depart from an unlit runway, since it's illegal at nighttime under 121 or 135.

The media report I saw made a big deal about the non-relevant chat, then mentioned later that it happened before they started taxi, which rendered the criticism moot. (Haven't read the full transcript.)

I have some concerns about the controller, too. First, he changed his story about seeing the airliner on Ry 26, then said he didn't. Second, he didn't watch the airplane taxi out or take off. On the few visits I've done to control towers, the controllers were very observant of the traffic they were managing regardless of the workload. This controller, far as I can read, didn't have a workload. The Comair flight was the only traffic. I rarely rip on ATC; and I could be entirely wrong here, but I do have concerns...

C

 

[SSDD]

I was in the hotel room watching CNN and asking myself if this could happen to me. I mean one of the first things I learned in instrument training was to check the heading indicator against the compass...about two hours later we're taxing out and ground cleared us to 16L. As we approached the parallel taxiway, I started to turn towards 34R until the F/O said "the OTHER 16L"...so yeah on any given day!

 

[mamba20]

Wow, after reading the transcript of that it almost seems like they came damn close to making it.

 

[CaptDave]

http://news.yahoo.com/s/ap/20070118/ap_on_re_us/kentucky_crash_25

From the article above:

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.

 

[COOPERVANE]

Wow, after reading the transcript of that it almost seems like they came dang close to making it.

Yeah, I thought that too. Sounds like they might have if not for the grass berm at the end of the runway.

RIP

 

[172driver]

It's unclear to me whether the lights were on or not. I can't believe that two airline pilots would depart from an unlit runway, since it's illegal at nighttime under 121 or 135.

You quoted my post, but it's obvious you didn't understand it. Let me try again. The lights for 26 were not on. In fact, they haven't been on in years. However, it is my opinion that the crew's perception was that they were departing on a lit runway until well into the t/o roll. Visual illusion created by the lights for 22, the fact that the two thresholds are very close together, and that the intersection of the two rwys is on an upslope that you can't see over.

 

[Rally]

I have been in GA aircraft twice that started TO rolls on wrong runways, we stoped and the a/c would not have crashed. Asked these news people how many times they stumble or make mistakes on their jobs, the difference is, if the right things happen at the wrong moment even the simplest mistake will take our lifes. This is what I always tell people when they say, how stupid is that? And I ask, how many times have you made mistakes at YOUR job? Can or did it kill you?
The bad thing about aviation and I guess the good is we learn from peoples mistakes so they don't happen again, when it comes down to it, its our brothers that keep us out of trouble as to not repeat the past. There will be alot learned from this accident so that maybe someday 500 people don't die, that does'nt take the heartbreak away, but aviation is still a developing process. Who knows, maybe someday instead of hearing "flaps flaps" (on takeoff if they or misconfigured) we will hear "Check line up, check line up" but I guess there is only so much we can do before the computers are flying the aircraft and we are watching. Ultimately these pilots were responsible, but I would be so careless if I thought that this could'nt happen to any of us.

 

[embraerjetpilot]

Like someone else said on this thread, reading that transcript reminds me of a common day for us. Nothing is different reading up to takeoff except that we know this story ends badly. It hits home more than anything I've seen about keeping vigilant.

 

[Huck]

Back in the turboprop days, we used to set the HSI to the localizer on the departing runway. Even if there were no ILS, I'd set it anyway, just to give me that big needle pointing the right way in case of V1 cut....

I'm suprised no one has mentioned the Chinese taking off on an Anchorage taxiway, 80 degrees off assigned runway direction:

http://aviation-safety.net/photos/graphics/20020125-0-1.gif

 

[ultrarunner]

ASA just recently implemented a procedure for both the Capt and FO to cross check the aircraft's heading against the runway's magnetic heading and to physically verify the actual runway number painted on the ground.

That'll work in a perfect world. So, you now no longer have intersection take-off approvals? What happens when visibility or contamination precludes you from seeing the actual runway number?

 

[Stifler's Mom]

That'll work in a perfect world. So, you now no longer have intersection take-off approvals? What happens when visibility or contamination precludes you from seeing the actual runway number?

You are correct. With the latest storm in the midwest, we took off on a partially snow covered runway. Match the heading with the runway alignment, and back all movements on the taxiways with the 10-9 page.

Do the best with what we have.

 

[bandit317]

So close to making it. Probably would have if they didn't use FLEX. Very sad.

 

[Amish RakeFight]

Hey Bandit-

Your avatar looks like one of those new VLJ's with USAir colors!

Funny.

 

[601Pilot]

So close to making it. Probably would have if they didn't use FLEX. Very sad.

It was the first flight of the day, so they probably were not using FLEX power. What's the rule at Comair?

 

[PCL_128]

So close to making it. Probably would have if they didn't use FLEX. Very sad.

The takeoff was made using full thrust.

 

[AerroMatt]

That'll work in a perfect world. So, you now no longer have intersection take-off approvals? What happens when visibility or contamination precludes you from seeing the actual runway number?

I spent 4 winters in the upper midwest flying Cessna 300 and 400 series aircraft for a 135 operator. We often flew from runways that were either partially covered or fully covered by snow to the point where you could not see the numbers. It was all too easy to line up on a wrong intersecting runway during poor visibility, so our SOP during taxi included checking alignment of the HSI against the compass and setting the heading bug to the departure runway heading. Once aligned on the runway, there was one last check of the heading bug. If it wasn't within 10 degrees of the actual heading indicated on the HSI, it was time to stop and find out why.

When I became CP for a 135 commuter we were flying EFIS equipped aircraft, but I incorporated into our SOP the heading bug being set to the departure runway during taxi and the double-check prior to adding power for takeoff, along with callouts by both the PF and PNF. Now that I'm in the corporate world, I still use this SOP on every flight.

Could it really be that Comair did not have something like this in their SOP prior to this accident? I'm wondering how their POI allowed such an oversight for so many years. This time, it proved to be a real killer.

 

[Nindiri]

The takeoff was made using full thrust.

They briefed flex thrust at the gate. Did something change on the way out?

 

[wmuflyguy]

It was the first flight of the day, so they probably were not using FLEX power. What's the rule at Comair?

We can use flex thrust on the first flight of the day.

 

[homerjdispatch]

The takeoff was made using full thrust.

Reread the trascript. They briefed flex takeoff.

 

[ultrarunner]

I haven't re-read the transcript, but it sounds as if Eagle called for taxi after Comair, and took off first. I suspect their gate was closer? But in any event, the Comair crew would have seemed to be unaware that Eagle took off from a different runway.

 

[DornierPilot]

But for the grace of God,...

This accident is an example of what could happen to any of us.

After reading the various reports (and if I'm interpreting them correctly), I have a few thoughts.

It sounds like the Captain may have just completed IOE 3 to 4 weeks earlier.
I think the F/O was older than the Capt.
The F/O mentioned that he had flown in the other night and "lights were out all over the place."

Looking at the Human Factors, this scenario can lead to a role reversal with the Captain relinquishing some decision making to the F/O. Had the F/O more specifically briefed the Captain that he had come in the other night and the 22 runway lights were working, but the centerlines, touchdown and REIL's were out, that might have been more helpful.

It appears that the F/O was surprised himself during the takeoff roll. He must have been thinking, "I didn't remember ALL the lights being out?", while the Captain (remembering the F/O's statement in the blocks) probably thought, "He did mention that 'Lights were out all over the place'".

The F/O also briefed "short taxi". At first blush, I thought that was good - giving the Capt heads up. But I suppose it could have added to the complacency of the Capt turning left too soon. Again, maybe it would have been better to be more specific and say, "short taxi - cross 26, then left onto 22.

Having flown most of my career out of smaller airports, non-tower, etc. anytime I'm operating out of a field that has runways that, if used, will kill me - I try to make a point of where they are and avoid them.

Tragically, this accident reads like so many others where there are many links that could have been broken, had someone put forth a little more effort. I personally have upped my own attention to detail.

RIP

 

[172driver]

Could it really be that Comair did not have something like this in their SOP prior to this accident? I'm wondering how their POI allowed such an oversight for so many years. This time, it proved to be a real killer.

Comair's SOP calls for bugging rwy heading or the assigned hdg, if a turn is to be made at 400' AGL. In this case, rwy hdg should have been bugged. However, I can't tell you how many people I flew with there who would pull on to the rwy and center the bug that I had set at the gate. Obviously, not the best practice. This continued to happen even after the accident and there has been zero change to the SOP's. I'm assuming due to concern by the company over liability.

Reread the trascript. They briefed flex takeoff.

It was, however, a full thrust takeoff according to FDR data. Sometimes it's misbriefed, sometimes it's briefed before the thrust setting is calculated, but I assure you full thrust was required and used with a 49,000 lb airplane out of LEX.

 

[AerroMatt]

Comair's SOP calls for bugging rwy heading or the assigned hdg, if a turn is to be made at 400' AGL. In this case, rwy hdg should have been bugged. However, I can't tell you how many people I flew with there who would pull on to the rwy and center the bug that I had set at the gate. Obviously, not the best practice. This continued to happen even after the accident and there has been zero change to the SOP's. I'm assuming due to concern by the company over liability.

Thank you for answering my question. This means that flight crew either skipped over part of the SOP, or they simply were complacent and didn't notice when they lined up on 26 that their Hdg bug was 40 degrees off the nose before centering the bug. Ouch! That is painful to all of us.