BR715-A1-30
Topic Author
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Comair Flt. 191... What Caused It?

Mon Oct 22, 2007 10:50 pm

I'm not talking about "taking off on the wrong runway", but I'm trying to figure out how something like this could happen?

It seems as though both pilots were "fairly experienced" and one would think that if they turned onto a runway, and saw no lights, they may question it.

I've read pieces of the accident report on NTSB.gov, and it just seems to me like some form of stupidity was involved here.

Millions of people each year trust their lives to professionals in the flight deck, and so many technological advances have been made to prevent accidents like this, but of course, human error will ALWAYS occur in situations.

My question is this; Why didn't the pilots check EVERY instrument before taking off. I mean, even in Flight Sim, I always check my instruments just to make sure that nothing is hindered. Also, with the advanced EFIS, why is there not a warning that chirps "WRONG RUNWAY" if the aircraft reaches a certain speed on the wrong heading?

I'm just mind boggled at how easy this accident could have been prevented.
Puhdiddle
 
atct
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RE: Comair Flt. 191... What Caused It?

Mon Oct 22, 2007 11:33 pm

Quoting BR715-A1-30 (Thread starter):
I'm just mind boggled at how easy this accident could have been prevented.

To pretty much quote everyone with alot of experience,

"The mistakes happen when you're bored and in the drone zone"

Basically this means the most mundane tasks that you do daily when you arent paying attention are the ones that jump up and bite ya in the butt.

ATCT
Trikes are for kids!
 
airtran737
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RE: Comair Flt. 191... What Caused It?

Mon Oct 22, 2007 11:39 pm

The roots cause of this accident just like many others boils down to human error. It takes a series of unfortunate events to happen in succession to cause an accident, and unfortunately that day it happened. I really wish that it hadn't happened, my old crashpad roommate was jumpseating on that flight and lost his life, so did a lot of other innocent people. We all hope that lessons are learned from it and applied to the future, but it can always happen again.
Nice Trip Report!!! Great Pics, thanks for posting!!!! B747Forever
 
upsmd11
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RE: Comair Flt. 191... What Caused It?

Tue Oct 23, 2007 12:14 am

I had to take a flight to LEX last week when the CO Express SDF flight was very late. It was strange landing there, being on the right runway but then coming through the terminal where all of those trusting souls walked before they boarded that fateful flight. My heart goes out to the families and the victims for the terror they must have felt during and after the horrible crash. I live close by in Louisville and often come through Versailles past the LEX airport right where the crash happened. This hit so close to home when it happened and there were even people from a company I sell to on the flight -- though I didn't know them.

Cheers,
John
 
cbphoto
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RE: Comair Flt. 191... What Caused It?

Tue Oct 23, 2007 6:08 am

Quoting BR715-A1-30 (Thread starter):
fairly experienced

You would be surprised, but this is actually where most of the smaller mistakes happen. When a pilot becomes experienced, they also become complacent. After all a pilot who has thousands of hours, had preformed thousands of takeoffs and it doesn't take much, especially when you are tired and all to overlook one small mistake. This one just so happened to be a tragic mistake!!
RIP to all on board!!
ETOPS: Engines Turning or Passengers Swimming
 
FlyASAGuy2005
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RE: Comair Flt. 191... What Caused It?

Tue Oct 23, 2007 6:19 am

What I have never come to understand is how did they even end up turning on the short runway? To get to the commercial runway, you have to taxi PAST the short one. Maybe i'm making things seem to simple but if someone can post the airport diagram you'll see what I mean.
What gets measured gets done.
 
tcfc424
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RE: Comair Flt. 191... What Caused It?

Tue Oct 23, 2007 7:20 am

It is never one thing that causes an accident. There are a ton of things that lead up to an accident, any of which could prevent the accident from occurring. From what I understand (not laying blame...simply stating possibilities to prevent) the main factors were 1) fatigue, 2) taxiway construction, 3) NOTAM's stating lighting problems, 4) Overworked/fatigued/understaffed ATC, 5)complacency, 6) Incorrect airport diagrams.

The PIC was ultimately responsible, however if any one of the above events/factors had been removed, the likelihood of the crash happening would have dropped immensely. ANY of those things.

5191 was a horrific crash, and baffling. Because of it, however, I hope that right-seaters AND left-seaters not only verbally say the heading is good, I hope the BOTH look and ensure.

As a ramper, I hear the pre-dep checklists being completed on our regionals (always open mike) and am sometimes confused, but at the same time relieved when they find a discrepancy. I am relieved they are REALLY checking and verifying, but at the same time I am confused at how things are incorrect. I guess I am not in the cockpit and have no idea what they are really talking about, but some of the "discrepancies" I have heard include wrong runways (17L instead of 17R, or vice-versa) incorrect alt settings, and conflicting departure instructions.

I guess as long as they check and verify and catch the mistake, everything winds up good.
 
FlyASAGuy2005
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RE: Comair Flt. 191... What Caused It?

Tue Oct 23, 2007 9:28 am

One time I overheard the captain telling the FO that they were not at the correct trim. Not sure if that is verified again after push-buck but I would guess that it would be an issue if you reach you speeds and is having trouble pulling up.
What gets measured gets done.
 
Cubsrule
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RE: Comair Flt. 191... What Caused It?

Tue Oct 23, 2007 4:21 pm

Quoting FlyASAGuy2005 (Reply 5):
What I have never come to understand is how did they even end up turning on the short runway? To get to the commercial runway, you have to taxi PAST the short one.

I've heard from a couple of private pilots in Kentucky (who have used LEX both in daylight and in the dark) that the change immediately prior to the accident was somewhat confusing. I'm not sure it's as easy as it looks on paper.
I can't decide whether I miss the tulip or the bowling shoe more
 
FlyASAGuy2005
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RE: Comair Flt. 191... What Caused It?

Tue Oct 23, 2007 4:26 pm

Yeah, I giess it would be pretty obvious with daylight but night-time is a different story...
What gets measured gets done.
 
Transpac787
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RE: Comair Flt. 191... What Caused It?

Tue Oct 23, 2007 4:31 pm

This picture shows how relatively easy it was to make that mistake.



Quoting BR715-A1-30 (Thread starter):
it just seems to me like some form of stupidity was involved here.

Could be stupidity, could be a lot of other factors in play. Fatigue comes to mind as a huge one.
 
wjcandee
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RE: Comair Flt. 191... What Caused It?

Tue Oct 23, 2007 11:40 pm

Quoting Transpac787 (Reply 10):
This picture shows how relatively easy it was to make that mistake

And what was the heading again? It was also easy NOT to make that mistake.
 
redflyer
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RE: Comair Flt. 191... What Caused It?

Wed Oct 24, 2007 12:02 am

Quoting Wjcandee (Reply 11):
And what was the heading again? It was also easy NOT to make that mistake.

 checkmark 

Even if they didn't take the time to look at the heading indicator, the next OBVIOUS clue would have been the darkened runway. In fact, didn't one of the pilots make a comment about the runway lights being off as they were barrelling along towards oblivion?
My other home is in the sky inside my Piper Cherokee 180.
 
Transpac787
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RE: Comair Flt. 191... What Caused It?

Wed Oct 24, 2007 1:02 am

Quoting Wjcandee (Reply 11):
It was also easy NOT to make that mistake.

I think the crew was on a continuous-standup, which means they did the RON with the aircraft, arriving at 11p or some late hour, and taking the plane out again at 600am. So again, fatigue played a major role in this accident in both the crew and the ATC'er who later came under scrutiny. Anyhow, the fatigue probably was the main reason for the complacency in the crew to not reference the mag-compass before begining the takeoff roll.

Quoting RedFlyer (Reply 12):
In fact, didn't one of the pilots make a comment about the runway lights being off as they were barrelling along towards oblivion?

I believe they did, just a few seconds before reaching the end of the runway. I think this is the same case during the SQ 747 crash some years ago, that the crew remarked about the absence of runway lights just before begining the takeoff roll.
 
DualQual
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RE: Comair Flt. 191... What Caused It?

Wed Oct 24, 2007 1:06 am

Quoting Cubsrule (Reply 8):

I've heard from a couple of private pilots in Kentucky (who have used LEX both in daylight and in the dark) that the change immediately prior to the accident was somewhat confusing. I'm not sure it's as easy as it looks on paper.



Quoting FlyASAGuy2005 (Reply 5):
What I have never come to understand is how did they even end up turning on the short runway? To get to the commercial runway, you have to taxi PAST the short one. Maybe i'm making things seem to simple but if someone can post the airport diagram you'll see what I mean.

Cubsrule hit the nail on the head. I think there was construction also going on at the time and that can add to confusion. Hell just the other night at EWR the captain and I had to verify with ground that we were in fact turning on the correct taxiway because it was dark and with the construction we were both a little confused. And we are based there and have thousands of hours taxiing around the place. That said, there are multiple things that add up to create the error chain. For whatever reason(s) the heading was not noted to be incorrect, the unlit runway didn't cause anyone to say "this is wrong". Unfortunately in this case all the holes in the layers of the swiss cheese aligned and allowed the error to get through.
There's no known cure for stupid
 
pilotpip
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RE: Comair Flt. 191... What Caused It?

Wed Oct 24, 2007 6:56 am

Quoting Transpac787 (Reply 13):

I think the crew was on a continuous-standup, which means they did the RON with the aircraft, arriving at 11p or some late hour, and taking the plane out again at 600am. So again, fatigue played a major role in this accident in both the crew and the ATC'er who later came under scrutiny. Anyhow, the fatigue probably was the main reason for the complacency in the crew to not reference the mag-compass before begining the takeoff roll.

Both had more than 12 hours rest prior to the departure.

LEX has a horrible layout. Add to that the construction that was going on. A number of taxiway signs and lights were down as a result. The crew got complacent, the controller got complacent and sadly people died.

We talked a lot about this one during indoc and I decided to add a little thing to our before takeoff checklist. Right after I complete it I say whatever our instructions were out loud and look at the runway markings to verify.
DMI
 
sq452
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RE: Comair Flt. 191... What Caused It?

Wed Oct 24, 2007 8:15 am

How is the lone survivor doing? Any word? I believe it was the FO and he was in pretty bad condition last I heard...
SIN > CVG > BOS
 
BR715-A1-30
Topic Author
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RE: Comair Flt. 191... What Caused It?

Wed Oct 24, 2007 1:36 pm

AirTran737 is right.. It does take a series of unfortunate events to cause an accident. But what I don't get is how a mistake such as this can be possible. When they turned on RWY 26, they did not see the appropriate lights, the magnetic compass read 266, which is nowhere NEAR 22.

And if I had been that ATC Controller... The report said that he claims he had "other stuff to do". Well, at a time like that, If I had other things to do, and I cleared a flight for takeoff, I would at least watch to make sure nothing happened, such as FOD ingestion, Uncontained Failure, ETC.

Also, I don't care how experienced I would be.. If I ever turned onto a runway that didn't have any lights, not only would I verify all of my instruments, but I would radio ATC and ask them to verify my position BEFORE the takeoff roll.

The Pilot is ultimately responsible for many lives behind him. Those people, and their families have entrusted this person with the lives of their loved ones. If someone gave me that responsibility, I may be late in departing, or arriving, but the most that would matter to me was that I arrive at the destination safely, even if 10-15 minutes late.
Puhdiddle
 
atct
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RE: Comair Flt. 191... What Caused It?

Wed Oct 24, 2007 2:57 pm

Quoting BR715-A1-30 (Reply 17):
And if I had been that ATC Controller... The report said that he claims he had "other stuff to do". Well, at a time like that, If I had other things to do, and I cleared a flight for takeoff, I would at least watch to make sure nothing happened, such as FOD ingestion, Uncontained Failure, ETC.

Please leave the job to the professionals. Your total ignorance of how the ATC system works shows in this statement. Spend a couple months working combined positions at a TRACAB and you'll see what I mean. He could have had weather forms to fill out, landline coordination for a point out, the previous departure may have false started, Comair could have been the false start so he was working in the ARTS to fix it....I could go on and on.

It has been proven that when fatiqued, people make mistakes. People also make mistakes on a daily basis. Anyone who claims to be god by saying "Ohh I cant see how this mistake can happen" clearly has no idea of how aviation, and life in general, works. How about next time you as a private pilot flies into a busy airport and you make a wrong turn on a taxiway, I'll berate you to no end saying how you could have just killed 300 people and then fill out a pilot deviation report to FSDO. It doesnt make sense to do that, its a simple mistake, correct the error and move on. Learn from it. Sadly, no matter what we do as pilots or we in the FAA do to prevent accidents and errors, they will still happen. It is human nature. The only thing we can do is decrease the likelyhood of accidents, which we do, on a daily basis.

ATCT
Pilot, ATC
Trikes are for kids!
 
wjcandee
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RE: Comair Flt. 191... What Caused It?

Wed Oct 24, 2007 3:01 pm

Bravo, ATCT. His job was to give the clearance, not to make sure that the dumbass didn't turn onto the wrong runway.
 
atct
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RE: Comair Flt. 191... What Caused It?

Wed Oct 24, 2007 3:09 pm

Quoting Wjcandee (Reply 19):
not to make sure that the dumbass didn't turn onto the wrong runway

Well I believe as a controller I do have an obligation for the "Safe....flow of air traffic" so he was a factor in the accident. I cant help but think that if the tower was properly staffed with 2 FPL's (certified controllers) that this accident could have been prevented. Possibly. We'll never know.

ATCT
Trikes are for kids!
 
airtran737
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RE: Comair Flt. 191... What Caused It?

Wed Oct 24, 2007 3:10 pm

Quoting BR715-A1-30 (Reply 17):
When they turned on RWY 26, they did not see the appropriate lights, the magnetic compass read 266, which is nowhere NEAR 22.

Many times your runway numbers and compass heading don;t align. Take ATL for example. The have five runways which all run the exact same way. Rather than name them all the same the have named them 8L-26R, 8R-26L, 9L-27R, 9R-27L, and 10-28. One of the first rules you learn as a pilot is to never set your magnetic compass to your runway heading.

Quoting BR715-A1-30 (Reply 17):
And if I had been that ATC Controller... The report said that he claims he had "other stuff to do". Well, at a time like that, If I had other things to do, and I cleared a flight for takeoff, I would at least watch to make sure nothing happened, such as FOD ingestion, Uncontained Failure, ETC.

The controller was multi tasking and assumed that the crew was paying attention to their Jepp's and knew their position. It is not an uncommon thing to have happen. If you've every taxied a plane at any class C or larger airport you will see how easy it is to get lost. LEX is a small airport with a tricky runway layout, complacency can and will kill you.

Quoting BR715-A1-30 (Reply 17):
Also, I don't care how experienced I would be.. If I ever turned onto a runway that didn't have any lights, not only would I verify all of my instruments, but I would radio ATC and ask them to verify my position BEFORE the takeoff roll.

It's practical in thought, but it wasn't dark when they took off. The runway lights aren't always on at daylight and they may not have even thought about the fact that there were no lights on the runway. Also when ATC say clear for departure on 26L or whatever runway you're on, he is also assuming that you are in the correct position.

Like I said before, it is a series of unfortunate events. That series cost me my former roommate, as well as a lot of other peoples loved ones.
Nice Trip Report!!! Great Pics, thanks for posting!!!! B747Forever

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