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.