Plane & Pilot
Friday, February 1, 2008

What If?


Asking the eternal, unanswerable question


ntsbIn every accident, there’s a chain of events or conditions leading to the outcome. Break one of the links in the chain, and the accident can be avoided, at least in theory. The individual links leading to the crash of Comair flight 5191 at Lexington, Ky., on August 27, 2006, aren’t big ones like an engine failing or running out of fuel. The NTSB’s final report indicates plenty of opportunities to change the course of events. There’s almost a compulsion to ask over and over again, “what if?”
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ntsbIn every accident, there’s a chain of events or conditions leading to the outcome. Break one of the links in the chain, and the accident can be avoided, at least in theory. The individual links leading to the crash of Comair flight 5191 at Lexington, Ky., on August 27, 2006, aren’t big ones like an engine failing or running out of fuel. The NTSB’s final report indicates plenty of opportunities to change the course of events. There’s almost a compulsion to ask over and over again, “what if?”

The accident occurred before dawn, during night visual meteorological conditions. Instead of using runway 22 for takeoff, which was 7,003 feet long by 150 feet wide, the flight crew lined up on runway 26, a GA runway used only for day VFR. Runway 26 was 3,501 feet by 150 feet, with paint markings limiting the usable width to 75 feet. The runway edge lights, marking the 150-foot width, had been disconnected in 2001.

The captain and first officer checked into the airport at 5:15 a.m. The captain held an ATP certificate. He had 4,710 hours (3,082 on Bombardier regional jets, of which 1,567 were as pilot in command). The first officer also was an ATP; he had 6,564 hours (3,564 in Bombardiers).

The pilots picked up the paperwork for the flight and entered one of two Comair regional jets on the ramp. They were then notified that they were in the wrong plane. The flight crew shut down the auxiliary power unit and moved to the correct airplane. Could going into the wrong airplane have created a belief that they’d made their mistake for the day and it would all be uphill from that point?

Once settled in, the flight crew again began preboarding preparations. The cockpit voice recorder contained material beginning at 5:36 a.m. The captain conducted a “flight compartment safety inspection.” As the captain and first officer continued preparation, they discussed, among other things, a colleague who wanted a transfer to better-paying airlines. At 5:48, the CVR picked up the airport’s ATIS information as it was monitored in the cockpit. The ATIS specified that runway 22 was in use. The CVR doesn’t indicate that the flight crew discussed the contents of the ATIS. What if they had and that led to the topic of the airport’s layout?

At 5:49:42, the first officer radioed Lexington clearance delivery. There was one controller in the tower who was working clearance delivery, ground control, local control and a radar position. The FAA had put out verbal guidance calling for two controllers on the overnight shift at the Blue Grass Airport tower, but an air-traffic manager had decided to staff the midnight shifts with one controller. The NTSB said that the controller’s workload wasn’t excessive; they couldn’t determine whether the presence of only one controller contributed to the accident. What if there had been two on duty?




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