Report: Comair Flight

My Summary Comair Flight 191, also marketed and enjoy as Delta Connection Flight 5191, was scheduled to fly from Lexington, Kentucky, to Atlanta, Georgia, on the morning of direful 27, 2006. Unfortunately the jet crashed while attempting to take off from Blue Grass Airport in Fayette County, Kentucky. There is a ton of information on this adventure and numerous mistakes that possibly led to it but it seems that the majority of the blame was empower on the passkey.I find this accident had multiple people at fault, in that if any one person was able to do their job professionally and accurately, this accident would not of happened and those people would still be alive today. The Event The aircraft was assign by the tower to the airports Runway 22 for the mockery, but used Runway 26 instead. Runway 26 was too slight for a safe takeoff which was typically used for general aviation, causing the aircraft to overrun the stop over of the lead before it could become airborne.It crash ed unless past the end of the runway, killing all 47 passengers and deuce of the three crew. The initiative officer was the only survivor and not the pilot in command but was flying at the time of the accident. Matthew Kawamura 06/15/2013 Air Trans 1010 SM Errors Leading Some of these errors are of skill based, judgment and or perception based but some are a combination. 1. The dodging crew initially postinged the wrong aircraft. A Comair ramp agent noticed that the accident career crew had boarded the wrong airplane and simoleonsed its auxiliary power unit.another(prenominal) company ramp agent notified the flight crewmembers that they had boarded the wrong airplane. The flight crew then shut down the APU and proceeded to the correct airplane. I dont know if this is a common mistake but shows me how easy the day can start off wrong. Thats 3 professional people that all walked on the wrong plane and did not notice. Should this have set off some alarms that something was not ri ght? My question has no answers but am sure it whitethorn have caused them to be behind schedule and then add some sort of stress. 2. The LEX air traffic break tower was staffed with one ascendance at the time of the accident airplanes preflight activities, taxi, and attempted takeoff. The controller was responsible for all tower and radar positions. I believe that if the tower did not bar on the radar position and follow through on watching the aircraft. He was to make sure the aircraft was on the correct runway. According to the report, the tower was to be manned with devil people. If this was enforced, maybe the controller would not have been so over worked and could have caught the mistake.I think also that the controller had assumptions that this crew knew what was loss on and didnt need to be babysat. There had not been any issues with any other aircraft getting on the wrong runway that we know of. 3. The first officer began the takeoff briefing, which is part of the bef ore starting engines checklist. During the briefing, he had confusion as to what runway to use and stated, he said what runway two four, to which the captain replied, its two two. The first officer continued the briefing, which included three additional references to runway 22. This would lead one to believe that there was no more(prenominal) confusion about what runway to use and a second check could have saved them. 4. During the brief, the first officer also noted that the runway end identifier lights were out and commented, came in the other night it was like lights are out all over the place. This reflects the care of the airport facilities. Sounds like a simple proletariat to replace lights but we have no answers to why this is allowed to go on. Having had been to this airport other times, I can see no concern for it as want as you are sure.Just because other planes are doing it doesnt make it safe. I feel a lot of stuff is follow the leader or a check list mindlessly be cause thats how it is and is the same result at the end Everything the same and ok. This brings in carelessness. Matthew Kawamura 06/15/2013 Air Trans 1010 SM Violations 1. During the start engines checklist, some shady stuff was overtaking on. The captain pointed out that the before starting engines checklist had already been completed, and the first officer questioned, We did? The irst officer seems to be a flyspeck behind the curve, the captain is going to fast for him through the checks or fair(a) wanted to skipped it completely. Being only a first officer, who is going to argue and is just relying on the captains word or not doing checks properly.This also may be standard cheating around the industry. Who will blow the spill the beans? 2. The flight crew engaged in conversation that was not pertinent to the operation of the flight. This would be violating the sterile cockpit rules during critical moments. Matthew Kawamura 06/15/2013 Air Trans 1010 SM possibly a sterile coc kpit could of helped? Three people messing around sounds like fun but seem to forget about the other people on board who depend on them to be professional. Environmental The crew, tower, weather and plane all seemed to be good to go from the reports. The runway had lighting issues and the charts had some issues. 1. Runway 4/22 had high intensity runway lights that worked and also had centerline lights and runway end identifier lights, but they were out of service at the time of the accident because of a construction project.If more care would of been put in place to how this affects the pilots, and listened to pilot complaints this should not of been an issue. 2. The charts showed the taxiway configuration at the completion of the construction project that was not completed. I couldnt figure out what all the before and after charts meant, but the bottom line is that the charts in use were out of date and or didnt show proper information which could have caused more confusion for the crew.Supervision 1. The captain began a discussion with the first officer about which of them should be the flying pilot to ATL. The captain offered the flight to the first officer, and the first officer accepted. Matthew Kawamura 06/15/2013 Air Trans 1010 SM The captain delegated to the first officer and then seemed to upsurge through the check list and the first officer seemed to not be quite on the ball. The first officer let the captain take control of the check list, this in turn led to inadequate supervision and failure to correct.Organizational influence For the pilots, they seemed to be way relaxed not worried about what was going on around them. This was just another flight even though there was a lot around them going wrong to include the lights and short briefs. Seems that there is no checks to see how people work when no one is watching. For the tower, He seemed relaxed at his job also. He did some presuming and thought he didnt have to babysit professionals. He saw the Comair airplane make a turn toward what he presumed to be runway 22, which was the last time he observed the airplane.The controller stated that, after he saw the airplane make this turn, he turned away and faced the tower cabs center ease so that he could begin the traffic count. Verbal guidance from the FAAs vice president of terminal services, stated that facilities with radar and tower responsibilities were to be staffed with two controllers on the midnight shift so that the functions could be split, although both controllers could be colocated in the tower. There seemed to be checks and the tower continued how they wanted.Sounds like there should have been two controllers on duty so this puts people higher in the chain of command at being relaxed and not needing to worry cause it wont happen to them. The Complete Chain IMO ( In my opinion) 1. I think the first link to the chain of events that led to this crash was when they boarded the wrong plane. This may have put them behi nd and then started the short cutting of briefs and procedures. Maybe it was just the beginning of their laziness and nothing cloud of have changed it. 2. The charts and lighting situation may have caused more confusion in the cockpit. 3.If the tower had two people, it may have helped out one of the controllers and allowed him the time to watch and make sure they were on the correct runway. The first two points being corrected still may not have prevented this accident but certainly the third would have prevented it unless they just didnt listen. Solutions 1. Better taxi brief and follow. 2. Use check list and not shortcut. 3. Sterile cockpit. 4. Rest periods modified and day/night shift crews. 5. CRM prepare 6. Random safety checks 7. Fix lighting and make better 8. Look out the window for cues. Matthew Kawamura 06/15/2013 Air Trans 1010 SMNTSB determination The National cargo ships Safety Board determines that the probable cause of this accident was the flight crewmembers failur e to use available cues and aids to identify the airplanes location on the airport surface during taxi and their failure to cross?check and verify that the airplane was on the correct runway before takeoff. Contributing to the accident were the flight crews nonpertinent conversation during taxi, which resulted in a loss of positional awareness, and the Federal Aviation Administrations failure to require that all runway crossings be authorized only by specific air traffic control clearances.