(un)Holy Toledo??? Comair 5191 Pilot Called Wrong Flight Number and Destination???

09/08/2006: The NTSB needs to get a better handle on its dissemination of information. Up until now, I thought Debbie Hersman had been doing a fabulous job keeping the public informed of the NTSB’s findings with respect to the Comair 5191 crash.

Now, however, a family member of one of the victims is indicating that NTSB officials told them that a crew member mentioned the wrong flight number and destination “before initiating takeoff”.

If this is a case of someone said-someone said, then the NTSB needs to shoot that down, and fast. Otherwise, the NTSB has some leveling to do with the public. I say that because, in the days after the crash, Debbie Hersman of the NTSB indicated that the crew received correct takeoff instructions and confirmed those instructions, before taking off on the wrong runway.
This is not a matter of rocket science.

If those instructions were clearly understood, then we are still dealing with a clear case of pilot error (due to perform pre-takeoff checklist).
At any rate, the NTSB has some damage control to do now.

Comair Flight 5191: Media Still Swinging at Air

09/06/2006: Here is another case of the news media being a bunch of flaming idiots.

The control tower staffing issues at Bluegrass Airport are worth pursuing, if only to prevent runway or midair collisions.

The airport maintenance issues are also worth pursuing, if only to minimize the probability of related mishaps.

But make no mistake: none of those matters would have prevented the Comair 5191 disaster. This one was a clear-cut case of pilot error: failure to execute pre-takeoff checklist.

Given that Comair 5191 proceeded straight into takeoff roll the moment it turned onto runway 26, a second controller–even if his or her eyes were glued to the situation–would have been unable to prevent the ill-fated takeoff.

This is because–due to the shortened runway–a takeoff abort command–and confirmation thereof–would have taken too long to transpire.

The crew had less than five seconds to decide to abort the takeoff.

Had they stopped to performed their checklist before taking off, they would have noted their error (they were on the wrong heading), corrected it, and proceeded to the correct runway.

Everyone would be alive right now.

Comair Flight 5191: Media is Swinging at Air

08/31/2006: If Comair Flight 5191 had been involved in a midair collision, then the fact that the air traffic controller was operating on two hours of sleep–and was operating alone–would be pertinent. Those are matters that should be investigated in order to prevent midair collisions and related mishaps that air traffic controllers are supposed to prevent.

That said, those have no relevance to the cause of the Flight 5191 disaster. That was pilot error: failure to execute pre-takeoff checklist.

It is that simple.

I am not trying to demean the pilots or their families; they are not monsters.

This should, however, serve as a warning to pilots–from students to private pilots to airline pilots–to stick to their checklists (and NOTAMs), irrespective of how comfortable they are with their aircraft, and irrespective of how many flight hours they may have.

In most professions, those types of errors are embarassing, at worst resulting in loss of job.

But aviation is far less forgiving.

Technology Should Complement–not Substitute–a Real Professional

David Warner of Prospect, Kentucky, raises some good points in today’s Louisville Courier-Journal:

Isn’t it interesting that I can buy a $400 gizmo for my dashboard that will bark at me if I miss my turn in the dark but a pilot can’t find the right runway on a foggy morning?

The answer to that question is even more unsettling: The pilot’s union has fought more technology in the cockpit because their members want to be “jet jockeys” and not play second fiddle to a jet that can easily take off and land by itself.

The joke is that the typical passenger with a laptop has more computer horsepower than you’ll find in the cockpit. Since the vast majority of plane crashes are “pilot error,” isn’t it time for an upgrade … that doesn’t have to look out the window to see if the jet is on the correct runway?

While the case is strong for more in-cockpit technology, it should serve as a complement–and not a substitute–for a pilot who is meticulous with his or her checklists. Airlines will not be safer if pilots begin relying on technology to maintain safety.

After all, when–not if–such technology fails or malfunctions, the checklist–with all its mundanities–is the difference between a safe flight and a disaster.

Some have made comparable arguments with respect to medicine, as very impressive decision support technology–using Artificial Intelligence (AI)–exists that allows computers to perform medical diagnoses. Many financial companies use this technology to augment their management of client portfolios.

Anyone who doubts the capacities of AI needs to take it up with Garry Kasparov.

However, in the real world, batteries die at the darndest times; circuit components break down; power surges destroy electronic components; hard-drives crash; databases get corrupted; programs crash when memory runs out (and the amount of available memory is often inversely proportional to the immediacy of the situation). Automated systems do fail.

Engineers, pilots, physicians, database administrators, network analysts, and application developers are well-acquainted with Murphy’s Law: when those systems fail, they will fail at the worst possible times .

With pilots–as with physicians–technology can be very effective as a redundancy: a fail-safe, if you will.

However, there remains no substitute for a pilot performing pre-flight and pre-takeoff check, or a physician who researches, speaks with the patient, interprets verbal and non-verbal communication, runs tests, researches topics, and arrives at a conclusion that can withstand the scrutiny of peer (or even judicial) review.

FAA: Tower Should have Had Two Controllers

08/29/2006: The Federal Aviation Administration (FAA) is admitting that–by having only one controller in the tower on Sunday morning at Bluegrass Airport–they violated their own rule. Apparently, the controller on duty turned away to perform administrative duties as flight 5191 commenced its takeoff roll.

(In every profession, “administrative duties” are tasks that impede important work from being done.)

While I–and others–insist that the ultimate responsibility rests with the pilot-in-command (as compass headings are a fundamental part of the pre-takeoff checklist), the lack of multiple controllers serves as an aggravating factor, as this made a small margin of error even smaller.

So far, a number of things have combined to cause this disaster to happen:

(1) There were substantial renovations to the runway system, which would make things a bit confusing for a crew. (However, note of this would have been provided to the crew in the NOTAMS, or Notices to Airmen.)

(2) There was only one controller on duty in the tower. Given that there was other air traffic in the area, such multi-tasking would have complicated the job of a lone controller.

(3) The crew apparently began their preflight check on the wrong aircraft. This would have knocked them behind schedule, as they had to do this check with the correct aircraft. (Being behind schedule is cause for many a pilot to cut corners on pre-takeoff checklists.)

(4) The controller turned around after providing takeoff instructions to the crew.

(5) The crew taxied onto the wrong runway (runway 26), in spite of receiving the correct instructions (runway 22). This would have provided a compass heading of 260 degrees instead of 220 degrees.

(6) The crew failed to note the discrepancy in the heading, almost certainly due to skipping over that part of the pre-takeoff checklist.

(7) They rolled straight from taxi to takeoff, without stopping. (This is also evidence that the crew did not perform the heading check.)

Due to the fact that they were on a shortened runway, this might have made it difficult to prevent the accident even if there was a second controller in the tower. This is because the time for the controller to warn the crew, and the time required for the crew to respond to the warning–applying brakes and/or spoilers and/or thrust reversers, would have made for a very short margin of time for decision to abort takeoff.

At this point, the decisionmaker at the FAA who provided only one controller on staff needs to be grilled. Big-time. They broke their own rules.

While a second controller may not have been able to prevent this tragedy, the presence of one would certainly have been a mitigating factor, and perhaps aan abort command–when the crew began their turn onto runway 26–could have kept the crew from initiating takeoff roll.

Pilots have checklists because–among other reasons–as few aspects of flight safety should be left to those outside the aircraft as possible. If a controller misses an error, a pilot can catch it with the checklist. Those checklists include systems checks (fuel, control surfaces, hydraulics, etc.), confirmations of takeoff instructions, headings checks, and even flap settings.

But controllers are a fail-safe in cases like these. With only one controller on duty, this drastically reduced the margin of error.

Terry Meiners: It was Pilot Error

08/28/2006: Louisville radio personality Terry Meiners of WHAS–who has been a private pilot for 20 years–is reflecting exactly what I was suggesting: it was pilot error, calling it “a horrible mistake”.

When pilots are given takeoff runway instructions, Meiners makes note of:

(1) the “heading bug” that the pilot places on the compass; this allows the pilots a reference point to ensure that they are on the proper heading when they take off.

(2) the checklists that the crew perform at each point of the takeoff process. From before taxiing, during taxiing, and before takeoff roll.

(3) That the controller didn’t catch the error may be irrelevant. Sometimes, a pilot will go into takeoff roll–without stopping–as soon as the plane is on the runway. In the case of flight 5191, had the crew done this there would have been no chance for the controller to warn the crew due to the shortened runway, as the window for aborting the takeoff was probably less than five seconds.

These are standard items on which everyone from private pilots to experienced commercial pilots are drilled. And the ComAir crew had plenty of experience and skill; they were flying a twin-engine jet aircraft. Only the best pilots get a chance to fly jet airplanes.

“[How both pilot and co-pilot failed to see their errant heading] is mind-boggling.”

Sadly, lots of experience–coupled with fatigue at early-morning hours–can lead even the best pilots to cut corners with checklists. These pilots were probably very good professionals who just plain screwed up.

In my job–as an information technology professional–even a very bad mistake is relatively harmless: no one goes to the hospital; no one dies; the worst that can happen is professional embarassment (loss of job), and even then I’d have to do something egregiously wrong.

In the case of aviation, however, Newtonian physics puts you behind the 8-ball. As Warwick at 3NailsMinistries said, “the Law of Gravity has not been repealed.” Neither have Newton’s First or Second Laws of motion for that matter. Aviation can be unforgiving of otherwise innocuous mistakes.

That’s why pilots have checklists.

Ultimately, I’d say we will see three things happen as a result of this:

(1) Bluegrass Airport will ensure that at least two controllers are in the tower at all times
(2) There will be a push for electronic warning systems, in the event of improper runway selection.
(3) There will be a renewed push on pilots to execute their checklists.

Airline Crash in Lexington: ComAir Flight 5191 Took Off From Wrong Runway

08/27/2006: Airline disasters in Kentucky are rare; today’s crash of ComAir Flight 5191 is in fact the worst such crash in Kentucky history. The total death toll is 49. The first officer–James M. Polehinke–is the only survivor. He is in critical condition at University of Kentucky Hospital.

According to WHAS in Lexington, it has been confirmed that the plane–which crashed just after takeoff–took off from the wrong runway, and that there was one contoller in the tower at the time.

This could either be controller error–in which the contoller provided the wrong instruction to the pilot–or the pilot failing to follow directions according to the takeoff checklist. A serious issue will be whether takeoff clearance from that runway was requested and/or granted.

Unforunately, the runway used for takeoff was 3,500 feet; however, according to the most immediate information I am finding, the CRJ-200 needs 5,800 feet to take off when fully-loaded. (WHAS is saying 5,009 feet, but I’m seeing 5,800. However, that difference is moot, as–either way–there is a catastrophic variance between takeoff distance required and runway length.)

The plane was at almost full capacity–it seats 50. At this point, there has been no indication that there was an engine failure which, on takeoff, would have been a double whammy.

UPDATE: It is also being reported–by WHAS in Lexington–that there was a small amount of rain at the time, and that there was some downdraft. Whether or not the strength of this would have been sufficient to bring down an aircraft has not been confirmed. However, combined with a short runway, the flight may not have had sufficient airspeed to withstand even a mild wind disturbance.

UPDATE 2: According to CNN, the flight was cleared for takeoff on runway 4-22, which was 7,000 feet long. Instead, the crew used runway 8-26. The latter was for general aviation–small craft–and only 3,500 feet in length.

Possible factors: crew fatigue, failure by crew to relay takeoff instructions in the checklist, failure by controller to alert aircraft that wrong runway is being used (this is possible if that lone controller was directing incoming aircraft).

UPDATE 3: That report of rain may have been inaccurate, as–according to the National Weather Service in Louisville–winds were only about 10 mph and the rain had cleared out at 6 am, the approximate time of takeoff. There were no visibility restrictions and no clouds.

This is looking more and more like pilot error due to failure to follow portions of the checklist. Takeoff instructions to the crew from the controller would have been detailed down to the turn directions, and the pilot is responsible for confirming to ensure that the proper runway is being used before taking off. In this case, the ultimate buck stops with the pilot-in-command.
The crew had ample flight experience, including with the CJ-200. Then again, a pilot with lots of experience flying early in the morning could easily be tempted not to use the checklist. Failure to do that is a very common cause for accidents on takeoff and landing. One of the worst of which was Northwest Airlines Flight 255 from Detroit (August 16, 1987). This killed 148 passengers, 6 crew, and two motorists on I-94. A 4-year-old girl, shielded from the flames by her mother, survived.

Correction: Cecilia Cichan–the lone survivor of Northwest Airlines Flight 255–was not shielded by her mother (as was reported at the time…I remember those like it happened yesterday!). What makes her survival all the more miraculous is that her mom was found several feet from where Cecilia was found.

UPDATE 4: WHAS in Lexington is reporting that Doppler images from this morning are in fact indicating that there was a small storm that quickly dissipated, which happened to be right at the spot where the crash occurred. (This would contradict the initial reports out of the National Weather Service in Louisville.) Winds were estimated at about 20 mph at the time. The role–if any–that may have played in the accident is only ascertainable from the flight data recorders. We await the official word from the NTSB.

A 20 mph wind may not seem like much, but if an airplane is struggling to gain altitude after taking off from a runway that was too short, even such an otherwise innocuous shift of wind could have dropped that plane right into the trees.

So far, the confirmed dead include:

(1) Horse trainer Jeff Williams

(2) Jonathan Walton Hooker–a former UK baseball player–and his wife, Scarlet Catherine Parsley. They were just married last night.

(3) Patrick Smith, a member of the International Board of Habitat for Humanity. He was heading for Gulfport, Mississippi for the anniversary of the Hurricane Katrina disaster.

(4) Jeffrey Clay, the Captain. A Vineland, New Jersey native, he was not far from my former stomping grounds (the ‘burbs of Philadelphia).

(5) Kelly Heyer, the flight attendant.

The really good news: Hats off to the first responders–who included a Lexington Police Officer–who were on the scene almost immediately, who pulled First Officer James M. Polehinke from the wreckage. Hopefully, he will make it.

The really bad news (and there will be lots of it as the cases unfold): A 16-year-old girl was killed on the flight. Her mom–who was supposed to be on that flight as well–was bumped at the last minute. I’ll be praying for that poor mom who now must bury her 16-year-old child.

UPDATE 5: The NTSB is saying that this was a CRJ-100, not a CRJ-200. The former is the older version of the same aircraft. However, the takeoff distance seems to be the same. Converting the given distance–1,768 meters–to feet gives about 5,800 feet. Ergo, the smaller runway still would have been equally problematic.

UPDATE 6: The NTSB (and WHAS Lexington) are reporting that the aircraft crashed through the perimeter fence. This is significant in that it would have been at least as contributory to the accident as any speculative wind gust. This is because the fence could have caused structural damage to the wings, control surfaces, and also the engine that would have hindered the flight from gaining altitude.

One respondent asked if the crew could have tried to abort the takeoff once they realized they were on the wrong runway. While that is possible, that would have been an extremely high-risk maneuver, as given the shorter runway–the “decision speed”; i.e., the speed past which aborting the takeoff is not possible–would be lower than for the longer runway.

I would suggest that–more than likely–they attempted to take off because aborting would have been more certain disaster given the shorter reaction time required for aborting. Aborting a takeoff on such a short runway–with a jet aircraft–would have been very difficult even if the crew had recognized their error early. Short runway=RAZOR THIN margin of error.

UPDATE 7: Another factor that has not been mentioned as a contributor is the possibility that the plane could have been overloaded. The CRJ-100 seats 50, and there were 47 passengers and three crew (50 people). Depending on the total weight of the luggage–and the total weight of the passengers–it is possible that the plane may have been overloaded.

Coupled with the takeoff on a short runway, if this were the case it would have been an aggravating factor.

In aerospace terms, overloading causes the center of gravity to fall behind the “aerodynamic center”, which makes the aircraft “statically unstable”.

In layman’s terms, it means you will be absolutely unable to fly the plane safely.

Ultimately, the loading of the aircraft is the responsibility of the pilot-in-command, but even he or she is at the mercy of the available instrumentation and/or their estimation skills. Depending on the instrumentation, that part is not always an exact science.

It’s easy to make all those hypothetical weight and balance calculations at a desk; it’s another matter when you have real loading situations at 6 in the morning on a Sunday.

UPDATE 8: In a briefing currently in progress, the NTSB indicated that when the aircraft began acceleration, “it continued accelerating until it crashed”. That would indicate that there was no attempt to abort the takeoff. (I expected that because–given that the runway was too short–such an evasive move would have carried even more risk than attempting to complete the takeoff once any error might have been recognized. Once the takeoff roll had commenced, the crew probably had three seconds or less to decide to abort the takeoff.)

UPDATE 9: According to radio station WVLK in Lexington, the crew had arrived in Lexington at about 12:30 am on Sunday. If this account is confirmed as fact, then crew fatigue is going to be a huge contributory factor.

Given that Flight 5191 crashed at 6:07 am, the crew likely had less than 4 hours of sleep. Such fatigue has been known to cause flight crews to get lax with their checklists, and this case is almost clearly a failure to execute the checklist. (The runway number includes the heading; the controller had provided the correct heading; and the crew failed to confirm before takeoff that the plane was pointed at the correct heading– that is a checklist issue.)

American Airlines Flight 1420 (Little Rock, AR, 01 June 1999) is a prominent example of this, as crew fatigue was listed as a contributory factor as to why the pilots failed to ensure that the spoilers were extended after the aircraft had touched down. (That was a failure to execute the checklist.)