CVR transcript, Comair/Lexington accident

wsuffa said:
Awful lot of chatter between the pilots about their jobs and such...
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I kind of thought the same thing. It wouldn't seem as much of an issue while sitting at the gate but once you push back, I'd think it should be an "all business" effort until you're at altitude and stable.

I've never flown on the flight deck of an airliner but it makes sense why I'm pushed as far as "sterile cockpit" is concerned during my commercial training.
 
Sure didn't sound like two guys who had responsibility for that many lives.

Lesson to be learned here: Complacency kills.


James Dean
 
The no lights thing should've been a giveaway to say "Hey, what's our heading? This isn't 22..."
 
Humm, a lot of distractions in there. It's easy for us to sit outside and say that but I'm sure they have had many takeoffs doing the exact same thing.

I guess the lesson is to never let down your gard.
 
I also note that an Eagle flight took off just before them - from the correct runway.
 
What is so distressing is that they actually recited the "line up" checklist item- even when they failed to actually achieve it. Complacency is a constant enemy.
 
wsuffa said:
I also note that an Eagle flight took off just before them - from the correct runway.
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I noticed that too. I wonder which way they were facing at that point. If they were able to see the Eagle take off, I don't know how they could have missed it - The ramp at LEX is like RIGHT THERE.
 
can you imagine being a family member and reading this?

also, can you imagine your very last conversation being recorded and published?
 
That's too bad really. We can speculate about the cause--but I'm willing to bet these were two respectable pilots that had the cards fall in the wrong order. I know that they could have did this or that differently--but that's just not what happened.

There was 17 seconds from their no lights comment to their death. These 17 seconds were accelerating down the runway with them paying attention to the engines, airspeed, and probably not looking at the runway as much as they should have been. Who knows what they were thinking--They probably weren't thinking.

I know that I personally talk about things unrelated to the flight when I'm flying--but I don't think I do it to that extent and I'm flying a much slower, simpler aircraft that is less prone to one error killing hundreds.

All people can do is learn from this and move on.
 
OK, guys, lets parse this.

At 6:02:01, Comair calls ready to taxi and gets clearance to do so.

At 6:02:12, Eagle was cleared for takeoff. That was 4 seconds after Comair got taxi clearance. Depending on where Comair's gates are, they may have never seen Eagle take off. Especially if they were facing the other way.

http://download.aopa.org/ustprocs/20061221/airport_diagrams/00697AD.PDF

At 6:05:17, Comair was cleared for takeoff and they acknowledged the clearance. At that point, at 6:05:41 they completed the line up checklist. "Transponder on, Packs on, Bleeds closed." That is the end of the checklist. What follows, "Cleared for takeoff, runway heading. Six Grand" is just a repeat of the takeoff clearance, not part of the checklist. Verifying runway heading, while good technique, and should have been done, was not part of the checklist as indicated by the recording.

Just a point of order. I am not defending what they did, but lets not put more into this than is actually there.
 
If I'd lost a family member or employee on that flight, I'd sue their ass out of existence.

And people wonder why I refuse to fly the regionals. . .

-JD
 
I know LEX pretty well.

http://204.108.4.16/d-tpp/0612/00697AD.PDF

The Delta/Comair gates are generally (or at least they were the last time I was there) along the south side of the terminal. The airplane should have been facing the runways when getting taxi clearance.

That being said, Greg's right - there is no way to know if they saw the Eagle flight take off.

Sad situation - but hopefully we'll all learn something.
 
Greg Bockelman said:
OK, guys, lets parse this.

At 6:02:01, Comair calls ready to taxi and gets clearance to do so.

At 6:02:12, Eagle was cleared for takeoff. That was 4 seconds after Comair got taxi clearance. Depending on where Comair's gates are, they may have never seen Eagle take off. Especially if they were facing the other way.
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Good catch Greg... And I do not believe the crew of the Comair flight would have been able to see the Eagle's takeoff without leaning way forward so they could see back and to the left.

Verifying runway heading, while good technique, and should have been done, was not part of the checklist as indicated by the recording.
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I'd hope that every airline now has it in their checklist...

Greg, do your opspecs address the issue of using a runway without lights? Also, if you were the captain, and your op specs did not address that, would you take off? Actually, a better question would be, if you did NOT take off because the runway had no lights, would you be called on the carpet for making a good judgement call if the op specs either didn't address the issue, or specifically allowed for a takeoff with no lights?

I'm wondering if there isn't maybe a little too much "go" pressure from the companies.
 
wsuffa said:
The Delta/Comair gates are generally (or at least they were the last time I was there) along the south side of the terminal. The airplane should have been facing the runways when getting taxi clearance.

That being said, Greg's right - there is no way to know if they saw the Eagle flight take off.
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Bill,

I doubt it. Even if they were on the southern gates, the threshold of 22 isn't visible unless they were on the gate right on the corner.

I can't believe they're even keeping 8-26 open. I've flown in and out of LEX several times, and driven past many more, and I've never used, or heard anyone be cleared for, or seen anyone using that runway. IIRC it's not in very good condition either.
 
flyingcheesehead said:
Greg, do your opspecs address the issue of using a runway without lights? Also, if you were the captain, and your op specs did not address that, would you take off? Actually, a better question would be, if you did NOT take off because the runway had no lights, would you be called on the carpet for making a good judgement call if the op specs either didn't address the issue, or specifically allowed for a takeoff with no lights?
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Not Greg but I know that under Part 135 we can't take off or land on an unlit runway at night so I imagine that Part 121 is the same way.

I had two instances when I couldn't get the runway lights on, once landing and once taking off. Both times I waited to have the airport manager come out and turn them on manually. Coincidentally both flights were air ambulance and I wasn't questioned about it by my company either time. I would have been in more trouble if they found out I had taken off or landed without runway lights.
 
Greg Bockelman said:
OK, guys, lets parse this.
...
At that point, at 6:05:41 they completed the line up checklist. "Transponder on, Packs on, Bleeds closed." That is the end of the checklist....
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My ignorance betrays me again (something to which you have all become accustomed); I assumed that the "line up" checklist had something to do with verifying alignment on the proper runway, cross-matching assigned runway and the aircraft's heading, and cross-checking mag compass with the DG(s).
 
Beside the fact that they did not cross check the runway heading.....The "no lights" and the runway signs indicating the amount of runway left should have been a clue to abort.
 
SCCutler said:
My ignorance betrays me again (something to which you have all become accustomed); I assumed that the "line up" checklist had something to do with verifying alignment on the proper runway, cross-matching assigned runway and the aircraft's heading, and cross-checking mag compass with the DG(s).
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Thats alright, Spike. That is why I hang around here. To keep you guys honest. :rofl:
 
I suggest that over 50% of us never check DG alignment with assigned runway, even SINCE this crash. Test yourself after your next flight..."Did I.....or did I forget??"
Its also possible that with very bright landing & recog lights, the lack of runway lights is not that noticable.
As much as we want to blast these guys, I think they are not that different from most of us, and there are going to be much less subtle ways to prevent this crash from happening again.
 
Let'sgoflying! said:
I suggest that over 50% of us never check DG alignment with assigned runway, even SINCE this crash. Test yourself after your next flight..."Did I.....or did I forget??"
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That's because I'm usually off in 500 feet. Now that I think about it though--that is a poor excuse.. Just because I can takeoff doesn't mean that I'm taking off of a runway that won't cause a potential runway conflict.
 
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And almost all the time, we "don't need to". We're taking off on the same runway, only runway at the field, and ... And so we don't internalize it; so we forget to verify the runway when we visit large airports.

Not a CRJ pilot (indeed, still just a student pilot!:( ), but it seems that they are doing everything "right". But you can sense a level of complacency. In the nuclear industry one of the major shticks is "questioning attitude". Always question everything, before, during, and after an evolution.

We are all fallible; we all have the potential to err.

Stay safe, y'all.

Jim
 
flyingcheesehead said:
Bill,

I doubt it. Even if they were on the southern gates, the threshold of 22 isn't visible unless they were on the gate right on the corner.

I can't believe they're even keeping 8-26 open. I've flown in and out of LEX several times, and driven past many more, and I've never used, or heard anyone be cleared for, or seen anyone using that runway. IIRC it's not in very good condition either.
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You don't need the threshold visible... you see the relative motion of the aircraft taking off.

If you've flown in there, you know that the DL gates are the ones closest to TacAir. As you leave the TacAir ramp, relative motion on 22 is very apparent. It helps the situational awareness. I've never left at that hour of the morning, but I'd expect the push to leave 'em facing west (same direction as exiting the TacAir ramp)

I've also never seen anyone use that runway. I've used 4 and 22 every time I've landed. They're lit up like christmas trees.
 
flyingcheesehead said:
...Also, if you were the captain, and your op specs did not address that, would you take off? Actually, a better question would be, if you did NOT take off because the runway had no lights, would you be called on the carpet for making a good judgement call if the op specs either didn't address the issue, or specifically allowed for a takeoff with no lights?

I'm wondering if there isn't maybe a little too much "go" pressure from the companies.
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Regardless of "go pressure", surely you could ask the tower to turn on the lights. They just accepted a wierd situation and went with it instead of pausing to wonder why there were no lights and asking for them to be turned on.

I can honestly say that I've maybe checked my DG once against the runway heading. I'm not sure that's really the ultimate problem here, though. I'd say it had more to do with constant banter on the flight deck resulting in a total loss of situational awareness. They weren't following along their taxiing with an airport diagram and checking taxiway markers to make sure they knew where they were. If they had a sterile cockpit, they would have been focused on the job at hand.

I actually wonder if there's another root cause as well. I don't know anything about the individuals, so this is just slanderous speculation. However, I've noticed something disturbing with a lot of young, male pilots (which I believe both of these were). There's a fair amount of macho posturing going on, where they're trying so hard to look cool and relaxed and like they've done this a million times before, that they get sloppy. A fair number of CFIs that I've met have actually been really poor roll models in this respect. I personally have felt pressure to be less meticulous and anal about things like checklists and calculations from other young male pilots.

I can envision a situation where two newish regional pilots don't know eachother that well and each is trying to be Mr. Cool, relaxed guy. So neither one is willing to say, "Ok, conversation over, I need to concentrate now because I'm not that familiar with this airport. We can talk more when we're cruising."

Pure speculation, but the transcript can be read that way.

Chris
 
Why didn't one of the two tower controllers cancel their takeoff clearance?
 
jesse said:
I know that I personally talk about things unrelated to the flight when I'm flying--but I don't think I do it to that extent and I'm flying a much slower, simpler aircraft that is less prone to one error killing hundreds.

All people can do is learn from this and move on.
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You are also not contracted to cockpit sterility below 10,000'. What I read was unprofessional.
 
Greg Bockelman said:
Verifying runway heading, while good technique, and should have been done, was not part of the checklist as indicated by the recording.

Just a point of order. I am not defending what they did, but lets not put more into this than is actually there.
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Interesting, because from Day 1 T/O 1 of flight instruction I was taught to verify my DG against the RW heading before takeoff.
 
Let'sgoflying! said:
Its also possible that with very bright landing & recog lights, the lack of runway lights is not that noticable.
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Up close maybe, but when you turn onto the runway and you can't see exactly where it goes or the other end? That should be blatantly obvious.

As much as we want to blast these guys, I think they are not that different from most of us, and there are going to be much less subtle ways to prevent this crash from happening again.
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I've thought a lot about the mind processes that precede an accident, and they're not so obvious. I can lecture my students like mad, and teach them as well as I can, and their accident rate is not any better than the average.

Nobody wants to get into an accident, nobody thinks they will get into an accident or they'd never take off. The only thing that will prevent an accident is to have the mindset "An accident CAN happen to me." I'm sure the pilots on Comair 5191 were probably more toward the "We've done this hundreds of times and nothing's ever gone wrong" mindset, which is very easy to slip into, and I'd imagine that the excellent safety record of the airlines actually contributes to a certain level of complacency in the cockpit.

And no, I still don't have the solution to this problem... Although I have started telling all of my students as well as all of the people I give road tests to something similar to the above so that hopefully they can find the right attitude.
 
Henning said:
Interesting, because from Day 1 T/O 1 of flight instruction I was taught to verify my DG against the RW heading before takeoff.
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Ditto here. Was taught how to fly by a bunch of active-duty AF pilots. Checklist. Checklist. Checklist. And don't just say it. Do it.

In my both my former lines of work, complacency will kill you just as quickly and without hesitation as it will in aviation.

Regards.

-JD
 
Let'sgoflying! said:
...Its also possible that with very bright landing & recog lights, the lack of runway lights is not that noticable.
As much as we want to blast these guys, I think they are not that different from most of us, and there are going to be much less subtle ways to prevent this crash from happening again.
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CAM​
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[sound similar to increase in engine RPM]
06:06:07.8​

HOT-2​
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set thrust please.
06:06:11.7​

HOT-1​
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thrust set.
06:06:16.3​

HOT-2​
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dat is weird with no lights.
06:06:18.0​

HOT-1​
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yeah.
06:06:24.2​

HOT-1​
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one hundred knots.​
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They noticed there were no lights. It's not clear when they noticed, but they commented around the time that they spooled up the engines and before V1.

If I die doing something stupid, I don't want you guys to hold back because you all think I'm such a great guy (you think that right?). I want you to rip apart every second of my decisions and learn from it so you don't die too.

Chris
 
Let'sgoflying! said:
I suggest that over 50% of us never check DG alignment with assigned runway, even SINCE this crash. Test yourself after your next flight..."Did I.....or did I forget??"
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I didn't forget after my last flight. One of the very last things I do prior to departure is cross check my DG, WC and assigned Rny. My CFII absolutely drilled that into my head.

A good quote:
"Learn from the mistakes of others, you won't live long enough to make them all yourself."
 
cwyckham said:
If I die doing something stupid, I don't want you guys to hold back because you all think I'm such a great guy (you think that right?). I want you to rip apart every second of my decisions and learn from it so you don't die too.
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I've been on a motorcycle mailing list for about 14 years, and we all get together a few times a year for rides, etc. Kind of like here. Anyway, when someone has an accident, it doesn't matter if your a beloved member, the accident is disected in a very cold and scientific (and sometimes ruthless) manner. If you were a bonehead, you're called to the carpet and called a bonehead. All try to learn the reasons for the accident, and view their riding style to see if they can do better.
 
cwyckham said:
If I die doing something stupid, I don't want you guys to hold back because you all think I'm such a great guy (you think that right?). I want you to rip apart every second of my decisions and learn from it so you don't die too.
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I think there's a difference between looking at an accident and saying, "they did X things wrong" and ripping people because you think they were idiots. The latter is not constructive, the inference being that I am not an idiot and would never do anything so stupid. Yeah right... If planes crashed every time someone did something stupid there would be none in the sky and the ground would be littered with metal. The trick is to catch your mistakes before they blow up into something major and learn from them, as well as from the mistakes of others.
 
ApacheBob said:
Why didn't one of the two tower controllers cancel their takeoff clearance?
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Because, IIRC, there was only one and he was attending to other duties at the time. It is not a requirement that they watch the takeoff, I don't think.
 
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