Comair Flight 191 Case

Comair Flight 191, also marketed and know as Delta Connection Flight 5191, was scheduled to fly from Lexington, Kentucky, to Atlanta, Georgia, on the morning of August 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 accident and numerous “mistakes” that possibly led to it but it seems that the majority of the blame was put on the captain.

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 assigned by the tower to the airport's Runway 22 for the takeoff, but used Runway 26 instead. Runway 26 was too short for a safe takeoff which was typically used for general aviation, causing the aircraft to overrun the end of the runway before it could become airborne.

It crashed just past the end of the runway, killing all 47 passengers and two of the three crew. The first officer was the only survivor and not the pilot in command but was flying at the time of the accident.  Errors Leading Some of these errors are of skill based, judgment and or perception based but some are a combination.

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• The flight crew initially boarded the wrong aircraft. A Comair ramp agent noticed that the accident flight crew had boarded the wrong airplane and started its auxiliary power unit.
• Another 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 don’t know if this is a common mistake but shows me how easy the day can start off wrong. That’s 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 right? My question has no answers but am sure it may have caused them to be behind schedule and then add some sort of stress.
• The LEX air traffic control tower was staffed with one controller at the time of the accident airplane’s preflight activities, taxi, and attempted takeoff. The controller was responsible for all tower and radar positions. I believe that if the tower did not check 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 two 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 going on and didn’t need to be babysat. There had not been any issues with any other aircraft getting on the wrong runway that we know of.

The first officer began the takeoff briefing, which is part of the before 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, “it’s 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 confusion about what runway to use and a second check could have saved them.

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 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 doesn’t make it safe. I feel a lot of stuff is follow the leader or a check list mindlessly because that’s how it is and is the same result at the end… Everything the same and ok. This brings in carelessness.

During the start engines checklist, some shady 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 wanted to skipped it completely. Being only a first officer, who is going to argue and is just relying on the captain’s word or not doing checks properly.

This also may be standard cheating around the industry. Who will blow the whistle?

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. 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 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 couldn’t 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 didn’t 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. 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 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 didn’t 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 cab’s center console so that he could begin the traffic count. Verbal guidance from the FAA’s 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 won’t happen to them. The Complete Chain IMO ( In my opinion)

•  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 nothing cloud of have changed it.
• The charts and lighting situation may have caused more confusion in the cockpit.
• 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 didn’t listen.

Solutions

• Better taxi brief and follow.
•  Use check list and not shortcut.
•  Sterile cockpit.
• Rest periods modified and day/night shift crews.
• CRM training
• Random safety checks
• Fix lighting and make better
• Look out the window for cues.

NTSB 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 identify the airplane’s 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 crew’s nonpertinent conversation during taxi, which resulted in a loss of positional awareness, and the Federal Aviation Administration’s failure to require that all runway crossings be authorized only by specific air traffic control clearances. ”

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