Jeppesen not at fault in Comair crash

[d328pilot]

http://www.forbes.com/feeds/ap/2008/06/30/ap5169810.html


LEXINGTON, Ky. - A federal judge has ruled a company that designed an
outdated airport chart wasn't responsible for the Comair plane crash that
killed 49 people, a judgment that relies in part on sealed testimony from
co-pilot James Polehinke, the lone survivor.

Judge Karl Forester's summary judgment concludes Jeppesen Sanderson wasn't
to blame in the Aug. 27, 2006, crash of Comair 5191, in which the jet took
off from a too-short runway at Blue` Grass Airport.

Lawyers for Polehinke and the crew members killed in the crash had blamed
Jeppesen in part for the accident because the chart in the cockpit that
morning failed to reflect a taxiway barrier that forced planes to take a
slightly different route to the main runway.

However, in Forester's ruling Friday he found no evidence the Comair pilots
relied on that chart when they steered the jet onto the wrong runway. The
10-page ruling includes some of the first information from a deposition
lawyers took of Polehinke. That deposition and others in the case have not
been released to the public.

Forester said Polehinke testified he couldn't recall the Jeppesen charts
being used by either pilot that morning, and he insisted there was no
confusion in the cockpit. Polehinke said as a practice, he only used the
charts when he thought he needed help navigating an airport.

"This does not establish any probability that either pilot was actually
using the chart to guide the taxi on the day of the accident or that the
chart misled them," Forester wrote. "Instead, the inferences from the
evidence are to the contrary."

While Forester acknowledges that the chart didn't reflect the taxiway
barrier the morning of the crash, he said the company's map didn't need to
be updated because the information was given to pilots in another form,
known as notices to airmen or NOTAMs.

Jeppesen's design of Blue Grass Airport was overdue for an update, but that
update would have come earlier in August, and it wouldn't have reflected the
barrier either, Forester found.

Calls to Jeppesen and Polehinke's attorneys were not immediately returned
Monday.

 

[CFI2766]

What a crock of crap.

It wasn't Jepp's fault because there was a NOTAM? I know these are the rules we live under, but if I were briefed on every notam before every flight, I'd never get off of the ground.

Also, I think that there is probably more to the FOs testimony than was referenced for the interview. Obviously, as the deposition was sealed, but still gives the possibility that the FO was quoted out of context.

 

[Scapegoat]

On the other hand, what pilot looks at a 10-9 to see if they are on the proper runway. I'm sure the deposition by the F/O says it all. And i'm sure its not pretty.
But you are right on Notams. They are a joke and they never get read because we dont have the time to decifer all the crap.
-Alex

 

[DAS at 10/250]

What a crock of crap.

if I were briefed on every notam before every flight, I'd never get off of the ground.

Are you serious? Checking the NOTAM's is a joint responsibility between the crew and the dispatcher.

Let me know which regional you work for.

 

[DAS at 10/250]

They are a joke and they never get read because we dont have the time to decifer all the crap.
-Alex

I think that your professionalism is a joke. You really don't have 5 minutes to scan through the NOTAM's?

 

[EatinRamen]

Amazing... I always look at the 10-9 charts before I taxi and during the approach briefing. And like the previous guy said, it only takes a few minutes to scan through the notams or brief the closures you copied off the ATIS.

I was very surprised to read that Polehinke admitted he rarely used his taxi diagram. That right there is a violation of most company's operating procedures.

 

[d328pilot]

You wouldn't fly without checking the weather and usually the NOTAMs are right after the weather. You do check the weather right?

 

[DXR-Beavis]

Jepp is not at fault in this deal. Yes their chart was not completely accurate, but it wouldn't have mattered. For what it's worth, the NACO/NOS chart was different but not accurate either. Neither matched the aerial photos taken that sorry day. Actually nice to see the judge not allowing tort lawsuits of everyone involved whether they helped cause this thing or not. That stuff all comes from the airport authority just like notams.

Fact is much of that was local notams which were not dissiminated to operators....thus not on the release. Maybe should've been more on the ATIS, but would that have stopped this? Maybe raised a bit more awareness?

This was a tragic human error. A wrong turn. The few things that could've stopped it did not. FO was busy. Neither checked heading. ATC controller had his back turned. No other airplanes on the surface to yell stop.

The fact that there were no lights on runway 26 was well known. Notam was around for years. They turned onto 26 ~500 feet down the runway. Sadly the intersection with 4/22 (with its white lights) was about where your scan would normally be as you start into the takeoff roll, and it has a bit of a crown, they couldn't really see much past it. Notice the comment about lights out happened a few seconds after going through the intersection. NTSB tested this twice and gave brief mention to it in the final report. Chose to crucify the crew for one non-pertinent remark during taxi out instead of addressing some real human factors issues that occured.

Lots of heat came down on the dispatch side of things too, but, in reality, there was nothing the dispatcher could've done to stop it. I liken it to putting a remark on the release saying lower the gear before you land. That's why they call 'em accidents. Sad that such a simple mistake turned into such a tragedy. Capt was a good guy with a nice family.

Bottom line is Jeppesen's liability in this case is the equivalent of Rand McNally's if I accidentally turn onto an interstate exit ramp to enter the freeway and have a headon with a bus.

 

[sinkrate]

What a crock of crap.

It wasn't Jepp's fault because there was a NOTAM? I know these are the rules we live under, but if I were briefed on every notam before every flight, I'd never get off of the ground.

You will get away with that 9,999 times. The one time you don't you and the people behind you die. Your attitude is of one of the hardest problems to correct for safety training organizations in any industry. It is human nature. People make decisions based on the chance of success or failure, for that one particular instance. "Don't worry, I've done this a hundred times and it always works". I have seen this statement end careers in this industry and kill people in another industry. They never consider the cost of failure. In this example the chance of failure is almost nil but the consequence of failure is dire. It is human nature to accept this risk and a large training problem to train them not to accept it. Once an individual starts down this road it becomes a learned behavior that is very difficult to 'unlearn' - even after the individual has an incident that enlightens him. That is why we have the 'rules' you seem to disdain, we can't trust our self discipline. The other end of this issue is just as big a problem. That is things that have a high risk of failure but have no negative consequence when you do fail, only a benefit when you succeed. People will not take that chance - they don't want to be seen as a failure even though consistently taking that risk will be beneficial. Yes - I have the background to say this. I was heavily envolved in accident investigation and safety in an industry that kills a lot more employees than this one and have been involved in training/safety in this industry for two decades. Human factors don't change from one industry to the next - we are all human.

 

[CFI2766]

You will get away with that 9,999 times. The one time you don't you and the people behind you die. Your attitude is of one of the hardest problems to correct for safety training in any industry. It is human nature. People make decisions based on the chance of success or failure, for that one particular instance. "Don't worry, I've done this a hundred times and it always works". They rarely consider the cost of failure. In this example the chance of failure is almost nil but the consequence of failure is dire. It is human nature to accept this risk and a large training problem to train them not to accept it. Once an individual starts down this road it becomes a learned behavior that is very difficult to 'unlearn' - even after the individual has an incident that enlightens him. That is why we have 'rules', we can't trust our self discipline. The other end of this issue is just as big a problem. That is things that have a high risk of failure but have no negative consequence when you do fail, only a benefit when you succeed. People will not take that chance - they don't want to be seen as a failure even though consistently taking that risk will be beneficial. Yes -I have the background to say this. I was heavily envolved in accident investigation and safety in an industry that kills a lot more employees than this one and have been involved in training/safety in this industry for two decades. Human factors don't change from one industry to the next - we are all human.

With respect, it's not an 'attitude' problem. It's reality in the airline business, especially the cut-throat, CDO/Nap filled, one RFP away from being out of work, regional airline business.

(I'm gonna play devil's advocate here for a paragraph or two. Understand, I probably have the same, or possibly even more extensive bias towards conservative choices and planning that any safety department would have anywhere.)

What you are essentially saying is that as an aircrew, you need to have 'rules' to check everything. This is good sentiment, and looks great in the training department. Sadly, this sentiment also looks great on paper when being examined in a courtroom.

In the real world, however, 'rules' to check everything would prohibit an airplane from ever leaving the ground. Why not sump the tanks in the aircraft, just like you did during your private training? That would be a good, safe 'rule'. Why not take a certifed scale and weigh every piece of baggage prior to being placed on the plane? That would be a good, safe 'rule'. Finally, why not send the FO out with a device to check the length of every runway as a part of their preflight? (As proven, the airport diagram, which lists the length of the runway, could be inaccurate.) That would be a good safe 'rule'.

Get where I'm going here?

The flight crew made a mistake. It cost lives. Yes, it was a preventable mistake, and yes, there should be widely disseminated training to attempt to eliminate that mistake from our collective aviation consciousness.

To ameliorate Jeppesen's responsibility in this tragic accident is just plain wrong. It's a tired, but historically accurate truth that it's far better for the existing companies (Bombardier, Jepp, and Comair) to lay the responsibility for an organizational failure on the dead or disabled flight crew.

 

[WSurf]

Are you serious? Checking the NOTAM's is a joint responsibility between the crew and the dispatcher.

Let me know which regional you work for.

I don't think he meant he never looked at the Notams. Most of us are regional pilots that fly back and forth to the same airports on a regular basis. So do I scan thru the notams on every flight? No, if I am bored I might grab the release and scan through it.

If I am flying to a place I haven't been before, or havent been in a long time. Of course most of us are gonna go over the Notams in more detail.

 

[Amish RakeFight]

On the other hand, what pilot looks at a 10-9 to see if they are on the proper runway.

But you are right on Notams. They are a joke and they never get read because we dont have the time to decifer all the crap.
-Alex

Famous last words.

NOTAMs are VERY important, as evidenced by this accident.

 

[PeanuckleCRJ]

Another issue that I've noticed is the use of heading sync on the CRJ prior to takeoff. Bug the runway alignment heading, especially on the CRJ with the crappy AHRS system on there.

Many of 9e's former Comair instructors taught that technique which I could not stand.

 

[imacdog]

Peanukle, that technique was never approved at Comair. Pilots were to bug runway heading and not hit the synch as they lined up. I never understood why people did it either, if you do that then what is the point of bugging runway heading in the first place? People do it at my current employer and it annoys me to no end, especially having been at Comair when the accident happened and knowing doing that could have played a role. Not saying they did that for sure because I don't know but it certainly wouldn't have helped.

 

[Tar Heel]

With respect it might seem like a pain but so is having to scroll down the vertical speed to 500 FPM before take off on the 200s as well. But in the long run if it promotes safety then what's wrong with that?

 

[DXR-Beavis]

I don't think he meant he never looked at the Notams. Most of us are regional pilots that fly back and forth to the same airports on a regular basis. So do I scan thru the notams on every flight? No, if I am bored I might grab the release and scan through it.

If I am flying to a place I haven't been before, or havent been in a long time. Of course most of us are gonna go over the Notams in more detail.

This is exactly true. Add to it being at LEX for a CVG based crew, right in their own back yard.
Thing is there were no published notams detailing taxiway closures/name changes/etc. Those were local notams and some/all weren't on ATIS. The biggest failure was the FAA's system, and I don't mean the ATC system. More the way notam info is distributed, especially where it relates to airport construction.

So the "probable cause" is pilot error contributing factor failure to keep a sterile cockpit. What BS. There were so many human factors issues the NTSB could've should've addressed in detail. Could have been a tremendous lesson in threat management for every airman. Instead we get an open and shut investigation. WHAT happened was open and shut. WHY it happened could be a volume of textbooks in human factors studies.

And what we get from it is even more notams--sorted by runway/taxiway/airspace. Words in our FOMs saying runway lights required at night-DUH!

New remark added to all releases: "ATTN Pilots - please ensure you read the release, weather and notams before departing. P.S. - Don't forget to start both engines prior to attempting takeoff." per Jo Blo, system chief pilot. <sarcasm light off>

 

[SpauldingSmails]

Famous last words.

NOTAMs are VERY important, as evidenced by this accident.

Ask that Shuttle crew in Cleveland about that un-important notam about the glidepath.