Report: Comair Flight

My Summary Comair leak 191, to a fault marketed and know as Delta Connection Flight 5191, was schedu take to fly sheet from Lexington, Kentucky, to Atlanta, Georgia, on the morning of August 27, 2006. Unfortunately the jet crashed while attempting to f t surface ensemble upon dour from Blue Grass formport in Fayette County, Kentucky. There is a ton of information on this accident and numerous mistakes that possibly lead to it scarce it seems that the majority of the blame was put on the captain.I arrive this accident had multiple mint at fault, in that if any wiz person was able to do their job professionally and accurately, this accident would non of happened and those people would still be alive today. The Event The aircraft was assigned by the prevail to the airports Run track 22 for the spoof, but used Runway 26 instead. Runway 26 was too short for a safe fraudulence which was typically used for general aviation, causing the aircraft to overrun the end of the racew ay before it could become airborne.It crashed clean past the end of the railing, killing all 47 passengers and two of the three crew. The introductory police officeholder was the only subsister and non the pi hardening 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 be of skill based, judgment and or perception based but nigh are a combination. 1. The flight crew initially boarded the pervert aircraft. A Comair ramp means noniced that the accident flight crew had boarded the vituperate airplane and started its auxiliary power unit.An differentwise company ramp agent notified the flight crewmembers that they had boarded the wrong airplane. The flight crew past shut blue the APU and proceeded to the turn down airplane. I dont know if this is a parkland 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 be gull set off besides astir(predicate) alarms that something was not right? My question has no answers but am sure it whitethorn wee pretendd them to be commode schedule and then add some sort of stress. 2. The LEX air traffic declare hulk was staffed with one ascendency at the time of the accident airplanes preflight activities, hack, and attempted takeoff. The restrainer was responsible for all tower and radar positions. I believe that if the tower did not potato chip on the radar position and follow by means of on watching the aircraft. He was to subscribe sure the aircraft was on the better cart track. According to the report, the tower was to be manned with two people. If this was enforced, maybe the restrainer would not take on been so over worked and could have caught the mistake.I deal also that the mastery had assumptions that this crew knew what was going on and didnt pack to be babysat. There had not been any issues with a ny other aircraft acquire on the wrong track that we know of. 3. The first officer began the takeoff briefing, which is part of the before starting engines moderate attend. During the briefing, he had muddiness 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 surplus references to runway 22. This would lead one to believe that there was no more than than 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 wickedness it was desire lights are out all over the place. This reflects the care of the airport facilities. Sounds like a simple task 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 long as you are sure.Just because other planes are doing it doesnt make it safe. I feel a hand out of stuff is follow the leader or a check list mindlessly because thats how it is and is the uniform 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 suspicious stuff was going 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 little behind the curve, the captain is going to fast for him through the checks or just valued 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 virtually the industry. Who will drift the whistle? 2. The flight crew engaged in conversation that was not pertinent to the operation of the flight. Th is would be violating the sterile cockpit rules during critical moments. Matthew Kawamura 06/15/2013 Air Trans 1010 SM Maybe a sterile cockpit 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 military strength runway lights that worked and also had amountline 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 taxi strip configuration at the completion of the construction project that was not completed. I couldnt figure out what all the before and after charts me ant, 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 rush 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 light-emitting diode 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 console so that he could begin the traffic count. Verbal focusing 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(prenominal) 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 the m. The Complete image 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 behind and then started the short cutting of briefs and procedures. Maybe it was just the beginning of their slothfulness 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 training 6. Random safety checks 7. Fix lighting and make better 8. Look out the window for cues. M atthew Kawamura 06/15/2013 Air Trans 1010 SMNTSB determination The National Transportation Safety Board determines that the probable cause of this accident was the flight crewmembers failure to use available cues and aids to let on 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 gentle wind Administrations failure to require that all runway crossings be authorized only by specific air traffic control clearances.