Report: Comair Flight
My Summary Comair Flight 191, additionally marketed and apperceive as Delta Connection Flight 5191, was appointed to fly from Lexington, Kentucky, to Atlanta, Georgia, on the morning of August 27, 2006. Unfortunately the jet comatose while attempting to booty off from Blue Grass Airport in Fayette County, Kentucky. There is a ton of advice on this draft and abundant “mistakes” that possibly led to it but it seems that the majority of the accusation was put on the captain.
I acquisition this draft had assorted bodies at fault, in that if any one actuality was able to do their job professionally and accurately, this draft would not of happened and those bodies would still be animate today. The Event The aircraft was assigned by the belfry to the airport's Aerodrome 22 for the takeoff, but acclimated Aerodrome 26 instead. Aerodrome 26 was too abbreviate for a safe ascent which was about acclimated for accustomed aviation, causing the aircraft to beat the end of the aerodrome afore it could become airborne.
It comatose aloof accomplished the end of the runway, killing all 47 cartage and two of the three crew. The aboriginal administrator was the alone survivor and not the pilot in command but was aerial at the time of the accident. Matthew Kawamura 06/15/2013 Air Trans 1010 SM Errors Leading Some of these errors are of accomplishment based, acumen and or acumen based but some are a combination. 1. The flight aggregation initially boarded the amiss aircraft. A Comair access abettor noticed that the draft flight aggregation had boarded the amiss aeroplane and started its abetting ability unit.
Another aggregation access abettor notified the flight crewmembers that they had boarded the amiss airplane. The flight aggregation again shut bottomward the APU and proceeded to the actual airplane. I don’t apperceive if this is a accustomed aberration but shows me how accessible the day can alpha off wrong. That’s 3 able bodies that all absolved on the amiss alike and did not notice. Should this accept set off some alarms that article was not right? My catechism has no answers but am abiding it may accept acquired them to be abaft agenda and again add some array of stress. 2. The LEX air cartage ascendancy belfry was staffed with one ambassador at the time of the draft airplane’s preflight activities, taxi, and attempted takeoff. The ambassador was amenable for all belfry and alarm positions. I accept that if the belfry did not analysis on the alarm position and chase through on watching the aircraft. He was to accomplish abiding the aircraft was on the actual runway. According to the report, the belfry was to be manned with two people. If this was enforced, maybe the ambassador would not accept been so over formed and could accept bent the mistake.
I anticipate additionally that the ambassador had assumptions that this aggregation knew what was activity on and didn’t charge to be babysat. There had not been any issues with any alternative aircraft accepting on the amiss aerodrome that we apperceive of. 3. The aboriginal administrator began the ascent briefing, which is allotment of the afore starting engines checklist. During the briefing, he had abashing as to what aerodrome to use and stated, “he said what runway… two four,” to which the captain replied, “it’s two two. ” The aboriginal administrator connected the briefing, which included three added references to aerodrome 22. This would advance one to accept that there was no added abashing about what aerodrome to use and a additional analysis could accept adored them. 4. During the brief, the aboriginal administrator additionally acclaimed that the aerodrome end identifier lights were out and commented, “came in the alternative night it was like … lights are out all over the place. ” This reflects the affliction of the airport facilities. Sounds like a simple assignment to alter lights but we accept no answers to why this is accustomed to go on. Having had been to this airport alternative times, I can see no affair for it as connected as you are sure.
Just because alternative planes are accomplishing it doesn’t accomplish it safe. I feel a lot of actuality is chase the baton or a analysis account mindlessly because that’s how it is and is the aforementioned aftereffect at the end… Everything the aforementioned and ok. This brings in carelessness. Matthew Kawamura 06/15/2013 Air Trans 1010 SM Violations 1. During the alpha engines checklist, some adumbral actuality was activity on. The captain acicular out that the afore starting engines account had already been completed, and the aboriginal administrator questioned, “We did”? The irst administrator seems to be a little abaft the curve, the captain is activity to fast for him through the checks or aloof capital to skipped it completely. Actuality alone a aboriginal officer, who is activity to altercate and is aloof relying on the captain’s chat or not accomplishing checks properly.
This additionally may be accustomed cheating about the industry. Who will draft the whistle? 2. The flight aggregation affianced in chat that was not pertinent to the operation of the flight. This would be actionable the antiseptic cockpit rules during analytical moments. Matthew Kawamura 06/15/2013 Air Trans 1010 SM Maybe a antiseptic cockpit could of helped? Three bodies messing about sounds like fun but assume to balloon about the alternative bodies on lath who depend on them to be professional. Environmental The crew, tower, acclimate and alike all seemed to be acceptable to go from the reports. The aerodrome had lighting issues and the archive had some issues. 1. Aerodrome 4/22 had aerial acuteness aerodrome lights that formed and additionally had centerline lights and aerodrome end identifier lights, but they were out of account at the time of the draft because of a architecture project.
If added affliction would of been put in abode to how this affects the pilots, and listened to pilot complaints this should not of been an issue. 2. The archive showed the taxiway agreement at the achievement of the architecture activity that was not completed. I couldn’t amount out what all the afore and afterwards archive meant, but the basal band is that the archive in use were out of date and or didn’t appearance able advice which could accept acquired added abashing for the crew.
Supervision 1. The captain began a altercation with the aboriginal administrator about which of them should be the aerial pilot to ATL. The captain offered the flight to the aboriginal officer, and the aboriginal administrator accepted. Matthew Kawamura 06/15/2013 Air Trans 1010 SM The captain delegated to the aboriginal administrator and again seemed to blitz through the analysis account and the aboriginal administrator seemed to not be absolutely on the ball. The aboriginal administrator let the captain booty ascendancy of the analysis list, this in about-face led to bare administration and abortion to correct.
Organizational access For the pilots, they seemed to be way airy not afraid about what was activity on about them. This was aloof addition flight alike admitting there was a lot about them activity amiss to accommodate the lights and abbreviate briefs. Seems that there is no checks to see how bodies assignment back no one is watching. For the tower, He seemed airy at his job also. He did some audacious and anticipation he didn’t accept to babysit professionals. He saw the Comair aeroplane accomplish a about-face against what he accepted to be aerodrome 22, which was the aftermost time he empiric the airplane.
The ambassador declared that, afterwards he saw the aeroplane accomplish this turn, he angry abroad and faced the belfry cab’s centermost animate so that he could activate the cartage count. Verbal advice from the FAA’s carnality admiral of terminal services, declared that accessories with alarm and belfry responsibilities were to be staffed with two controllers on the midnight about-face so that the functions could be split, although both controllers could be colocated in the tower. There seemed to be checks and the belfry connected how they wanted.
Sounds like there should accept been two controllers on assignment so this puts bodies college in the alternation of command at actuality airy and not defective to anguish account it won’t appear to them. The Complete Alternation IMO ( In my opinion) 1. I anticipate the aboriginal articulation to the alternation of contest that led to this blast was back they boarded the amiss plane. This may accept put them abaft and again started the abbreviate acid of briefs and procedures. Maybe it was aloof the alpha of their apathy and annihilation billow of accept afflicted it. 2. The archive and lighting bearings may accept acquired added abashing in the cockpit. 3.
If the belfry had two people, it may accept helped out one of the controllers and accustomed him the time to watch and accomplish abiding they were on the actual runway. The aboriginal two credibility actuality adapted still may not accept prevented this draft but absolutely the third would accept prevented it unless they aloof didn’t listen. Solutions 1. Bigger auto abrupt and follow. 2. Use analysis account and not shortcut. 3. Antiseptic cockpit. 4. Rest periods adapted and day/night about-face crews. 5. CRM training 6. Random assurance checks 7. Fix lighting and accomplish bigger 8. Look out the window for cues. Matthew Kawamura 06/15/2013 Air Trans 1010 SM
NTSB assurance “The National Transportation Assurance Lath determines that the apparent account of this draft was the flight crewmembers’ abortion to use accessible cues and aids to analyze the airplane’s area on the airport apparent during auto and their abortion to cross?check and verify that the aeroplane was on the actual aerodrome afore takeoff. Contributing to the draft were the flight crew’s nonpertinent chat during taxi, which resulted in a accident of positional awareness, and the Federal Aerodynamics Administration’s abortion to crave that all aerodrome crossings be accustomed alone by specific air cartage ascendancy clearances. ”
Order a unique copy of this paper