NTSB Blames Kentucky Crash on Pilot Error

[38tango]

Around 2 weeks after the accident the tower cleared us for takeoff right after I called for the taxi check. We told him we'd call him back when we were ready for takeoff. We hadn't even set flaps and we were cleared for takeoff. Then they cleared another aircraft right after they called for taxi as well. This aircraft told the tower the same thing, "we will call you back when were ready to depart"

Does anyone know when they were given their takeoff clearance? Yes I do think it matters.

So you're saying being cleared for takeoff from the ramp, which by the way is a whole 300 yards from the runway there, is going to cause you to use the WRONG runway? Get real dude, the controller did his job. They goofed. I'm not saying any of us is incapable of doing the same thing...but don't blame the guy in the tower for not peering over the shoulder of a professional airline crew. He provided separation, just like he's required to do.

 

[38tango]

Sterile cockpit is supposed to be in effect from the start of the start checklist to crusie or 10K whichever occurs first.

That statement is completely false. Sterile cockpit is only effective during critical phases of flight. You can be sitting in line for takeoff WITH THE BRAKES SET and discuss last night's episode of Deadwood if you feel like and no fault can be put on your for it. Those Comair guys were quiet when it mattered.
You can't use sterile cockpit for a scapegoat here. They just plain old goofed up.

 

[Papps]

So you're saying being cleared for takeoff from the ramp, which by the way is a whole 300 yards from the runway there, is going to cause you to use the WRONG runway? Get real dude, the controller did his job. They goofed. I'm not saying any of us is incapable of doing the same thing...but don't blame the guy in the tower for not peering over the shoulder of a professional airline crew. He provided separation, just like he's required to do.

The controller did his job correctly, but for whatever reason that airport layout contributed to a fatal accident. Its a very short taxi, and it would be nice if the controllers took into account how much stuff is happening in that 300yards. It would help if they held the takeoff clearance until you were clear of the short runway.

 

[jmreii]

Since some people would like to blame the airport's layout and controller, we should also blame the terrain that occasionally gets in the way of a well meaning flight path.

 

[Way2Broke]

§ 121.542 Flight crewmember duties.
(a) No certificate holder shall require, nor may any flight crewmember perform, any duties during a critical phase of flight except those duties required for the safe operation of the aircraft. Duties such as company required calls made for such nonsafety related purposes as ordering galley supplies and confirming passenger connections, announcements made to passengers promoting the air carrier or pointing out sights of interest, and filling out company payroll and related records are not required for the safe operation of the aircraft.
(b) No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft.
(c) For the purposes of this section, critical phases of flight includes all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet, except cruise flight.

Note: Taxi is defined as "movement of an airplane under its own power on the surface of an airport."

Our GOM (I work with YIP) gos one step further and defines critical phases of flight as
1. All ground ops
2. During the first 1000 ft of a climb
3. flight ops below 10000ft except cruise
4. Last 1000ft of a descent

Most GOMs have something similar in them. I do not know what Comair's GOM says nor have I even read the CVR so I can not attest to what they were trained to do and if they broke the "sterile cockpit rule." Its pretty obvious that my company uses a more conservative approach by defining the critical phase of flight on the ground as "all ground ops" instead of just when the aircraft is moving under its own power. Conservative is usually a good thing when it comes to flying.
Either way from the sounds of things it was a very small contributing factor. I am still searching for the cause of the "pilot error." Just like the NTSB spokesperson said, its frustrating not be be able to point at one event here.

What's your source for this? I'm just curious, because my copy of the FAR's never mentions anything about a "start checklist" under 121.542.

The only operations on the surface defined as sterile cockpit by 121.542 is movement of the aircraft under it's own power. I'm confused about how the aircraft can be moving under it's own power if a "start checklist" is being performed.

As someone wrote earlier, if you read the transcript, there was about a sentence each after the taxi began that violated sterile cockpit as defined by 121.542. To give this amount of conversation the amount of attention it has gotten does great disservice to those affected most by the accident...the passengers, crew members, and families, because it does distracts attention from more important factors in the accident.

 

[Way2Broke]

That statement is completely false. Sterile cockpit is only effective during critical phases of flight. You can be sitting in line for takeoff WITH THE BRAKES SET and discuss last night's episode of Deadwood if you feel like and no fault can be put on your for it. Those Comair guys were quiet when it mattered.
You can't use sterile cockpit for a scapegoat here. They just plain old goofed up.

Its not "goofed up" at all for his company procedures. See the above post.

 

[Way2Broke]

The NTSB claims that "The flight crew's lack of updated maps and notices alerting them to construction that had changed the taxiway route a week earlier was not a factor in the navigation error."

How can this be true? Usually when there is construction going on Jepp puts a airport diagram in the book that is a different color than the rest of them (yellow I think). They do they for a reason. It says to the pilots, "pay attention, something is abnormal here."

 

[Way2Broke]

Ruskie. Sure they majors may do this, but corporate departments, regionals, on demand carriers, med flights, the list gos on and on DON'T. I work on demand and my "circadian rhythms" change all the time. Maybe my circadian rhythms move to a different beat, maybe something... I'm thinking like Sublime, or Johnny Cash?
My point is I still do my job safely even in the on-demand business. As the regs currently read it is not up to the company to make your schedule "circadian rhythm" friends. Instead it is up to the pilot to call fatigue when they are not medically fit to fly. I just thought I would point that out.

Here we go again....

Circadian rhythms were clearly a factor in this case. Just because a pilot had enough "rest" on the books doesn't mean he or she rested during that time. If the circadian rhythm has changed or the light/dark cycle has shifted by even an hour, the ability to rest has changed substantially. 99% of regional airline schedules are not built with respect to this medically and scientifically proven factor involving rest. Most major airlines under ALPA have built schedules to reflect these factors due to influence from their safety board.

How many times have you woken up at 4 am with plenty of rest and still felt dog tired? If you haven't, then remember the last time you had jet lag. This is similar.

 

[Papps]

Since some people would like to blame the airport's layout and controller, we should also blame the terrain that occasionally gets in the way of a well meaning flight path.

When terrain gets in the way of a well meaning flight path, the NTSB looks at nav aids, MEAs MSAs MDAs, crew performance, controllers, wx etc.

Are you saying that the layout in LEX is not at all confusing?

 

[atrdriver]

Sterile cockpit is supposed to be in effect from the start of the start checklist to crusie or 10K whichever occurs first.

You are incorrect sir. Sterile cockpit is in effect during ground operations when the aircraft is moving under its own power. The pushback, and anytime that it is stopped with the parking brake set is NOT a sterile cockpit time.

It is also quite possible that the parking brake was set when they spoke the two extraneous sentences, we don't have the DFDR data synced to the CVR. If that was the case then they didn't violate sterile cockpit AT ALL. Like someone else said, they were quiet when it counted.

 

[38tango]

Its not "goofed up" at all for his company procedures. See the above post.

I wasn't talking about the sterile cockpit part when I said goofed up.
They just thought they were somewhere they weren't. Now whether or not complete silence would have prevented that is impossible to know, but I seriously doubt any of their conversation contributed to making a wrong turn.
That runway layout was an accident waiting to happen. Even when you line up on 22 instead of 26 it looks unusually short because it has a hill that peaks in the middle.
I think some blame should be placed on the airport for not baracading 26 off since I do believe it was closed at the time of the accident.

 

[A350]

All:

All the monday morning quarterbacking will not bring these folks back....nor will it erase the suffering of the families/loved ones of those affected.

The crew was the ultimate chain breaker in this accident. Forget the sterile cockpit, forget the controller, forget the poor design of the taxiways/lack of notams etc. The simple fact is the crew chose the wrong strip of concrete. There can be mitigating factors such as the previously mentioned items and there are probably more. However, unless the CVR has them talking about how bad the taxi diagram is and/or discussing where the runway is, I suspect they had no idea they were on the wrong runway. Further, the fact there were no lights on the runway before dawn should have at least given rise to some doubt that where they were was correct.

Basically, thank your lucky stars it wasn't you and because they did, you might not in the future.

ALPA's rendition of what happened will never include pilot error. I can't think of any accident where they have said their pilots screwed up. It hurts their credibility.

A350

 

[38tango]

Well said, 350...may they all rest in peace, and let's not try to join em too soon. Safe flying all!

 

[Way2Broke]

Monday Morning Quarterbacking... I don't think so.

I am not Monday morning quarterbacking I am observing the mistakes that were made so that I can learn from them to make myself a better pilot. To do otherwise is a disservice to yourself. Face it, they made mistakes and while tragic it is acceptable to discuss them.

 

[pilotyip]

atrdrvier you may be right I might be applying our company procedures.

 

[Dumb Pilot]

ALPA's rendition of what happened will never include pilot error. I can't think of any accident where they have said their pilots screwed up. It hurts their credibility.

If they had any you mean

 

[Papps]

If they had any you mean

Dude you don't have to be union if you don't want to. Just take that contract and burn it. Tell alpa to quit pulling dues. Then you can fly FAA regs. And then after they fire you for not wanting to accept a trip that takes you to 34 in 7 you can go apply at target. as the midnight toilet boy...because believe me you are more expendable than you will ever realize.

Its a hard industry. These guys lost sleep and days off just so you can get a few nights a month home with the wife, and all you do is crap on them in an anonymous forum. You have no idea how bad non union flying can be. How about 24/7 on call every day...no scheduled days off 30 minute show times after the pager goes off. No sick days No personal days No scheduled days off, no vacations. You brats owe these guys your lives and a few beers. They spent more for safety and pilots QOL than even your rich daddy and mommy would be willing to spend on you, and they don't even know your name. They are weak now, but times are changing and they will get your pay and QOL back. Until then don't slam on the only real friends you have in this business.

 

[mayoplane]

I agree with you, brother.

lets face it. 1. Most crews break sterile cockpit. 2. Waking up at o dark thirty will make you a zombie no matter how much sleep you had. 3. the taxi ways in LEX are confusing at that end of the airport, and i can see how that mistake could be made. 4. Most regionals will keep you in a perma-fatigue condition unless you a very high energy person.

I guess what im saying is that they messed up, but its a mistake that all of us could make.

Come on guys. Forget about the airport layout, fatigue, ATC clearances.

Why are we afraid to say that they messed up?!!! They simply messed up. As pilots, we should know better than to take off from a wrong runway. Let's admit that first, then talk about the possible contributing factors.

I also can't stop thinking....if Pinnacle crew were the ones who had this accident, would you be having the same discussions, or it would be more like...

1. This is why I will never put myself or my family on 9E even if they were the only airlines with available seats.

2. This is what happens when you let bunch of people with 300 total hours fly CRJs.

These things can happen to any of us. Let's just learn from it and move on.

 

[pilotyip]

You have no idea how bad non union flying can be. How about 24/7 on call every day...no scheduled days off 30 minute show times after the pager goes off. No sick days No personal days No scheduled days off, no vacations.

Not all non-unions fit this description

 

[Dumb Pilot]

Its a hard industry.

You have what? 10 years in this industry?

Papps please, tell your SJS buddies about it OK.

 

[Wankel7]

Its kinda hard reading this....but if you are interested here is the transcript.

http://hosted.ap.org/dynamic/files/...t_recorder.pdf?SITE=DCUSN&SECTION=TOP_STORIES

 

[PCL_128]

Come on guys. Forget about the airport layout, fatigue, ATC clearances.

Why are we afraid to say that they messed up?!!! They simply messed up. As pilots, we should know better than to take off from a wrong runway. Let's admit that first, then talk about the possible contributing factors.

Every single one of us could have made the same mistake. There was a confluence of factors in this case that made this accident much more likely than at most airports. A closed runway that wasn't marked as closed, a NOTAM that referred to lights being out, no NOTAMs about the closed taxiways, understaffed ATC facilities, and the list goes on and on.

To point our fingers at the crew helps no one. There were dozens of things here that had nothing to do with the crew that need examining and fixing. Will the NTSB report highlight these items? I doubt it. From the media reports of how the hearing went, it sounds like there will be very little talk in the report about these factors. That's a disservice to all of the dead crew and passengers, not to mention the sole survivor who has to live with this the rest of his life.

 

[Way2Broke]

Its kinda hard reading this....but if you are interested here is the transcript.

http://hosted.ap.org/dynamic/files/...t_recorder.pdf?SITE=DCUSN&SECTION=TOP_STORIES

Thank you for posting that. It was a educational read. It reads to me that most of the chat was before taxi. Its frustrating to read because like someone else said they simply messed up and went to the wrong runway. Its just that simple. Of course there are things that could have been done that would have prevented the accident.
Here is what I am taking from this accident: from now on I will be extra diligent to check the heading with the runway heading. It also reiterates that pilots are the first line of safety and that you can not rely on ATC to cover you butt. Also, always have the airport diagram out and track where you are. Keep up the situational awareness.

I have said it before and I will say it again. We should always try to learn something from every accident. Back when I was studying for the FOI I remember reading that a professional pilot is always learning. For some reason that stuck with me.

 

[Morning Wood]

How about you pin the blame on DAL Management for the RFP that went out a week before this accident.

If you want to blame it on DAL's RFP, how about blaming DAL's bankruptcy?

 

[Morning Wood]

Yip, I agree with this statement. My point is when will the NTSB wake up and quit blaming accidents on "pilot error". Most accidents are caused by some type of pilot error. My concern is what caused them to make the error. Current airport diagrams would have helped in this case. Not breaking sterile cockpit rules would have helped. Procedures confirming the correct runway with the heading would have helped (private pilot stuff here). What caused the pilot error? That's what is important.

Calling it pilot error is just too generic to satisfy my need to learn something from this accident. There is a quote that gos something like this, "learn from others mistakes, you will not live long enough to make them all yourself." Thats how I think about NTSB reports, and that is how I do my best to keep myself out of them.

A current 10-9 might have helped, but how many of us have it out at every single airport we go to, even after this accident? Learning what lead to this accident is one thing, but learning from it and doing something to not repeat it is another.

The fact that two other flights departed without incident prior to Comair is likely the biggest reason why 5191's crew is being blamed for this.

 

[Crossky]

The fact that the closed taxiway notams weren't published in the paperwork the crew had, or that they didn't have a Yellow Jepp 10-8 showing it, or that the ATIS didn't have it, and controller didn't mention it once, or mention a suitable taxi route, WILL be declared a contributing factor in this accident IMO. If it's not that will be unfair the pilots.

As a result of an almost serious runway incursion I had at a very busy airline airport this past spring, I religiously verbally brief all unfamiliar airport taxis before hand. It helps me and my crew definitely.

Check the link to the LEX diagram.
http://204.108.4.16/d-tpp/0707/00697AD.PDF

or http://www.airnav.com/airport/KLEX

I believe that A7 was closed for construction. From the departure end of RWY26, Comair 5191 would've had to taxi down 26 and back taxi down 22 to get in position to properly TO on RWY22.

Why didn't the controller give appropriate taxi instuctions to Comair 5191 or make sure visually that they took off on the correct runway, especially under the altered taxiway layout conditions?

 

[Mr Wu]

Come on guys. Forget about the airport layout, fatigue, ATC clearances.

You cannot forget about these things because they were all factors in the accident, regardless of what the NTSB say. The truth remains that the crew did line up on the wrong runway but the last clear chance to avoid the accident lay with the tower. They are the ones that are there every day, are the ones that were understaffed, and should have verified that the aircraft on the takeoff roll was on the right runway. They are FAA employees and the charter of the FAA is to promote air safety. The controller failed in his job and by extension the FAA also failed.

 

[~~~^~~~]

The pushback...is NOT a sterile cockpit time.

Are you sure? I'm not. We just reviewed a case last week where the Capt. was violated for eating during push back. The FAA's point was apparently that communications with the ramp & tug driver could be impeded by a mouth full of Moe's. That "wreckless" catch all.... again.

 

[atrdriver]

Are you sure? I'm not. We just reviewed a case last week where the Capt. was violated for eating during push back. The FAA's point was apparently that communications with the ramp & tug driver could be impeded by a mouth full of Moe's. That "wreckless" catch all.... again.

The cockpit crew is not responsible for the movement of the aircraft. The tug driver is handling the driving, and the wingwalkers are responsible for collision avoidance. Yes, I can see where not being able to communicate with the pushback crew would be a problem, but how many times have you pushed without a headset because theirs was broken? I know where you work, so I know that it has happened, just as it did to me. You can't communicate with them then, so what is the difference?

But I know where you are coming from, they wanted to piss test me after a tug drove into my ATR, when we were parked at C31, with the doors open, and the chocks in, just because I happened to be sitting in the cockpit.