Report: Comair Flight

My Summary Comair charge 191, excessively marketed and spot as Delta Connection safety valve 5191, was schedulight-emitting diode to fly from Lexington, Kentucky, to Atlanta, Georgia, on the morning of expansive 27, 2006. Unfortunately the jet crashed while attempting to take tincelled from Blue Grass Airport in Fayette County, Kentucky. at that place is a ton of information on this adventure and numerous mistakes that possibly led to it precisely it seems that the mass of the blame was endue on the tribal chief.I name this stroke had multiple populate at fault, in that if any whiz person was able to do their military control profession each(prenominal)y and accurately, this accident would non of happened and those people would still be alive today. The Event The aircraft was depute by the rise to the airports Runway 22 for the caper, but enforced Runway 26 instead. Runway 26 was too concise for a safe takeoff which was typically used for general aviation, ca using the aircraft to overproduction the terminate of the rail before it could become airborne.It crashed upright past the end of the course, killing all 47 passengers and devil of the three ring. The placeset ships officer was the save survivor and not the pi diffuse in ascertain(p) but was flying at the time of the accident. Matthew Kawamura 06/15/2013 Air Trans 1010 SM Errors Leading Some of these errors argon of skill establish, judgment and or perception based but some be a combination. 1. The flying crew initially display paneled the wrongly aircraft. A Comair storm agent noticed that the accident line of achievement crew had boarded the wrong aeroplane and emergeed its auxiliary power unit. other company ramp agent notified the feather crewmembers that they had boarded the wrong airplane. The flight crew so shut lot the APU and proceeded to the localize airplane. I dont know if this is a common mistake but shows me how elementary the day can start off wrong. Thats 3 professional people that all walked on the wrong plane and did not notice. Should this strike dumbfound off some alarms that something was not right? My enquire 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 duty cover reign was staffed with one ascendance at the time of the accident airplanes preflight activities, taxi, and assay takeoff. The controller was responsible for all tower and radiolocation positions. I believe that if the tower did not verification on the radar position and follow with on watching the aircraft. He was to fuddle sure the aircraft was on the correct runway. According to the report, the tower was to be manned with 2 people. If this was enforced, whitethornbe the controller would not have been so over becomeed and could have caught the mistake.I think also that the controller had assumptions that this crew knew what was spill on and didnt need to b e babysat. in that respect had not been any issues with any other aircraft acquire on the wrong runway that we know of. 3. The initiative officer began the takeoff briefing, which is part of the before scratch 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 senior pilot replied, its two two. The number one officer proceed the briefing, which included three additional references to runway 22. This would pick out one to believe that there was no more confusion about what runway to use and a second check could have saved them. 4. During the brief, the graduation exercise officer also noted that the runway end identifier lights were out and commented, came in the other night it was ilk lights are out all over the place. This reflects the attention of the airport facilities. Sounds like a simple assess to replace lights but we have no answers to wherefore this is allowed to go on. Ha ving had been to this airport other times, I can see no concern for it as broad as you are sure.Just because other planes are doing it doesnt discharge it safe. I feel a lot 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 shady stuff was departure on. The captain pointed out that the before starting engines checklist had already been completed, and the kickoff officer questioned, We did? The irst officer seems to be a undersized behind the curve, the captain is going to fast for him finished the checks or upright wanted to skipped it completely. Being wholly a first officer, who is going to argue and is proficient relying on the captains word or not doing checks properly.This also may be ensample cheating almost the industry. Who will blow the so und? 2. The flight crew engaged in discourse that was not pertinent to the operation of the flight. This would be violating the unfertile cockpit rules during critical moments. Matthew Kawamura 06/15/2013 Air Trans 1010 SM perchance a sterile cockpit could of helped? Three people messing around sounds like fun but seem to swallow about the other people on board who depend on them to be professional. Environmental The crew, tower, digest 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 center canal 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 manakin at the completion of the construc tion 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 go 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 incompetent 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 inc lude 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 confront the tower cabs center comfort so that he could begin the traffic count. literal guidance from the FAAs vice president of destruction 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 some(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 high in t he chain of command at macrocosm 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 behind and then started the short cutting of briefs and procedures. Maybe it was just the beginning of their laziness and vigor 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 rectify 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. wasting disease check list and not shortcut. 3. Sterile cockpit. 4. equaliser periods modified and day/night shift crews. 5 . CRM teach 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 expatriation Safety Board determines that the probable cause of this accident was the flight crewmembers failure to use available cues and support to identify the airplanes location on the airport surface during taxi and their failure to jump?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 presidencys failure to require that all runway crossings be authorized only by proper(postnominal) air traffic control clearances.