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NTSB Blames Kentucky Crash on Pilot Error

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In spite of all else, the crew could have prevented the accident.

No doubt. And in a situation like this, primary and final responsibility for the safety of the flight rests with the crew.

But most accidents have not a single cause, but a chain of events where you start to lose options and the end result is a tragic accident.

I'm just saying many factors besides the crew's actions CONTRIBUTED to the accident. The NTSB report shows that only 1 of the panel members pushed to have those factors and others listed as contributing factors.

By the same token, having more than one overworked controller in the tower, a violation of FAA regs, COULD have prevented the accident also. (no guarantee, but it might have)

The NTSB has historically shown an alarming tendency to slap "pilot error" as the final and only last word on their reports.
 
Fatigue, is not a dirty word, if you are too fatigued to fly, you call off. However if you are supposed to be legally rested and are not, it may be a different problem. Fatigue may have been a subtle factor in the crew's performance, but the break down of cockpit discipline was the major factor.

.

I'd be calling in fatigue for every show before 6 am if I followed your advice. Trying to force yourself to bed abnormally early and then waking up abnormally early as well results in very poor quality sleep.
 
Don't take this post the wrong way...all I'm sayingis that I think there was a lot of inappropriate conversation for 2 guys that are supposedly fatigued.

Or maybe the fatigue caused a lack of decision making ability. If you have never had this happen you will. Just hope while your in this state of fatigue your mistake is'nt as big as theirs.

I look at Comair and their constant threats of closing down, pay reductions, poor scheduling, understaffing the airline, and most of all their general lack of respect for the 6500 people they employ.
 
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I look at Comair and their constant threats of closing down, pay reductions, poor scheduling, understaffing the airline, and most of all their general lack of respect for the 6500 people they employ.

Comair???? Sounds like you're describing just about any regional!
 
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.
 
Papps-

You are absolutely right! Anyone who has taxied in KLEX would know that it is confusing down at that end. It can easily be confused especially in poor lighting and charts that fail to id the changes.

When management tells us that we pilots are not very important and our pay should reflect that stand, we should remind them how important we are...the only people that could have stopped that tragedy were the two up front. Evidently, noone else shares any responsibility.
 
In spite of all else, the crew could have prevented the accident.

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.
 
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All this talk of "sterile cockpit", and if you actually read the transcript, they uttered about 2 sentences that were not flight related from the time they started moving under their own power and brake release. Those two sentences didn't cause this accident. Maybe an updated 10-9 page would have helped, but the new one wasn't issued until 2 weeks after the accident. Maybe their heads weren't in the game, but it certainly wasn't their chatter the distracted them, at least now when "sterile cockpit" was in effect.
 
Sterile cockpit is supposed to be in effect from the start of the start checklist to crusie or 10K whichever occurs first.
 
Sterile cockpit is supposed to be in effect from the start of the start checklist to crusie or 10K whichever occurs first.

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, crewmembers, and families, because it does distracts attention from more important factors in the accident.
 
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.
 
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.
 
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.
 
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.
 
§ 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.
 
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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.
 
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."
 
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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.
 
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?
 
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.
 
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