In the aftermath of the deadly postcrash fire, one of the NTSB's most important duties will be to answer the questions of why, after 30 years of the FAA's mandating safer, slow-to-burn materials in airliners, the jet cabin burst into flames so intense that only one person, co-pilot James M. Polehinke, survived.

The accident at Lexington ended almost five years without a major airline accident in the United States, but the rest of the story is that the five-year safety streak was an unprecedented result of finally learning to anticipate human mistakes and insulate against them before they metastasize into an accident.

In other words, it's never enough to just order people not to fail. We have to build the system to safely absorb human screwups, and for the most part our success rate in doing that has been spectacular.

In the 15 to 25 major contributing factors that the NTSB will eventually discuss in issuing a final report on Comair 5191 (in perhaps a year or more), every one will need to be addressed and solved.

But in this case, we're very lucky, because a single, universal procedure can be added that will prevent this type of accident from ever occurring again — a procedure prohibiting takeoff unless the nonflying pilot repeats the runway the flight is cleared to use, and the flying pilot reads in full the compass heading of the aircraft as it sits aligned with the runway.

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Written by Guest on 2006-11-18 21:37:31

Written by Guest on 2006-09-10 19:41:35 The crew was not on a continuous duty. The FO flew in Friday night (over 24 hours) and the Captain deadheaded in Saturday afternoon.

POINTS TO PONDER Written by Guest on 2006-09-10 18:55:08 Just a reminder that ground effect starts at ONE wingspan. It is greatest at 10% of the wingspan, but unfortunately due to FAA test questions, most remember the "ground effect is greatest" within one half of a wing span. (a true statement, but short on the big picture.)    Did this COMAIR crew have a stand up overnight? That would quite possibly account for their decreased sharpness. Ever do a stand up over night? (Less than 8 hours of sleep, as the assigned trip is CONTINUOUS DUTY, and therefore does not require a full 8-9 hours off of the clock.     Anthony Michaels  Capt.  F-27, B-737, DC-9, MD-80, A-319,   A-321

Risk Factors Written by Guest on 2006-09-09 16:06:29 Nice job as usual by John. I have felt and suggested that the heading for each taxiway be posted on the taxiway signs and the Jepp Charts along with the taxiway designation so that you could check your taxi progress and imporve situational awareness. For example if you are on taxiway Delta with a 90 degree heading and your next taxiway will be Juliet and you should be turning to a heading of 150 degrees. That could prevent some of us from getting on the wrong taxiway or at least help us discover a mistake sooner. This would also get the crew used to comparing present position with aircraft heading up to and including the active runway prior to t/o power application. We have all made taxi mistakes and we need all the help we can get to prevent future mistakes. Needless to say this could help offset the negative results of 13 hour domestic duty days, short overnites, lousy hotel rooms, no breakfast, airport construction, fog, weather, mel's etc. that all lead to what can cause a crew mistake.

USAF ret. Written by Guest on 2006-09-09 15:11:31 When did they stop teaching the basics of checking the mag compass and ADF with the runway heading before starting the TO roll?

Risk Factors Written by Guest on 2006-09-02 20:03:54 Mr. Nance's piece is thoughtful and compassionate, most appropriate in the present circumstances. One item he didn't mention is the under-emphasis in most flight training programs on risks. Risks sit atop a three-legged stool supported by risk awareness, risk assessment/evaluation, and risk management/mitigation. Most airline operations deal with known risks through the dispatch function which ensures most critical elements of upcoming flights are reviewed and cleared by a second pair of eyes. What's often missing is the mental attitude of the pilots to go beyond the dispatch function and carefully consider risks that may have an adverse effect on the flight -- items such as closed or unlighted runways, construction equipment on taxiways, lights/signs out of service, reduced visibility or obstructions, etc. It appears the Comair pilots (there were three in the cockpit) overlooked visual cues on the way to the cleared runway. There may also have been some distractions along the way inasmuch as they initially boarded and powered up the wrong airplane for their flight. As Nance pointed out, there are many opportunities for error in any flight, and errors are much easier to commit when distractions are present. And, to the extent that there was a level of complacency or distractions in the cockpit arising from the prospective repetition of a well-learned procedure (i.e., an early-morning departure from a virtually deserted airport), it would make the errors of commission and omission that much easier. Again, a regimen of risk awareness, assessment and mitigation might have interrupted the chain of events leading to the accident. The flight environment is selective in the harshest terms. On each flight and for each pilot, a series of problems is presented for the pilot and flight managers to solve. Many are ubiquitous and easily resolved while others are simple but life threatening if, for whatever reasons) are overlooked or improperly resolved. The Comair flight appears to fall into the latter category.

Written by Guest on 2006-08-30 17:08:39 Tower was manned by one controller. Takeoff power probably was set right away. Unfortunately they probably set "reduced thrust" which is used on longer runways (which they thought they were on) in order to save the engines. About 90% of all takeoffs are done using reduced thrust.

Written by Guest on 2006-08-30 17:03:21 IF he had used ALL the 09 end of the runway, and set max t/o power within one and a half lenghths of the aircraft (as I do; per A/C certification) he might have been able to save it by aggressive rotation. Who knows? BTW; Was the Tower manned?

Written by Guest on 2006-08-30 14:54:33

good article Written by Guest on 2006-08-29 23:24:48 definately think that should be the final item on the checklist.

Good article Written by Guest on 2006-08-29 21:46:02 You did a good job with that, Mr. Nance. One additional factor that I have yet to see mentioned anywhere is that rwy 22 and 26 both slope up in the middle, making it impossible, even in daylight, to see the end.

Written by Guest on 2006-08-29 20:44:45 John Nance knows his stuff. He is about the only aviation expert that any TV News outlet can call an aviation expert. There is one thing that John Nance should've done is to check Nov'05 directive from FAA about how many controllers on duty should be at the commercial airport like KLEX is. The answer is 2, one for Radar one for Ground. How many were at the KLEX on Sun morning... one.  Oh and there is a procedure to check the heading vs runway, it is in the takeoff checklist at # 2 on my list.

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