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To: Painful

I don't get this desire to seek ephemeral causal factors for what was obviously negligent behavior on behalf of the pilots. If I were to roll out of bed at 5AM tomorrow and jump in the car, get on the freeway going the wrong direction, and hit a school bus head-on, would you be calling for better signs, RFID chips on my car, the ramp, etc?

The mistake made by these guys is inexcusable in the extreme. Taking off on the wrong runway at an airport that only has one active, all-weather, commercial runway is not about the big, bad FAA, it's about a basic failure in performance. Would we accept such behavior from a physician or other professional entrusted with scores of lives.

What's tragic is the loss of innocent life. What's tragic is the pilots' failure to note the six to seven obvious indications that they were on the wrong runway. As a frequent flier, I am not in any way interested in explaining away the pilots' personal responsibility for this incident. They screwed up at a basic task.

If you don't think so, ask an experienced ATP if he/she can figure how two veteran pilots could have made such a fundamental error at a familiar, uncomplicated airport. The two I've spoken with since the crash are not just puzzled, they're pissed.


882 posted on 08/28/2006 1:10:59 PM PDT by usafsk ((Know what you're talking about before you dance the QWERTY waltz))
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To: usafsk
What's tragic is the pilots' failure to note the six to seven obvious indications

I heard there were several markers they had to blow off to get lined up on the wrong runway. Is the pre-flight available tp the public?

884 posted on 08/28/2006 1:18:11 PM PDT by don-o (Proudly posting without reading the thread since 1998. (stolen from one cool dude))
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To: usafsk
The mistake made by these guys is inexcusable in the extreme. Taking off on the wrong runway at an airport that only has one active, all-weather, commercial runway is not about the big, bad FAA, it's about a basic failure in performance. Would we accept such behavior from a physician or other professional entrusted with scores of lives.

I don't think you'll get much disagreement there. That said, there's a legitimate rationale behind designing your processes such that even negligent behavior might be avoided. If you were to do some failure mode effect analysis, and the outcome of taking off on the wrong runway is near certain death for the passengers, then the FAA might be justified in instituting additional process controls no matter how small the probability of occurrence.

893 posted on 08/28/2006 2:43:27 PM PDT by NittanyLion
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To: usafsk

"I don't get this desire to seek ephemeral causal factors for what was obviously negligent behavior on behalf of the pilots.  ... The mistake made by these guys is inexcusable in the extreme."

Nobody here is making excuses for the pilots.  They failed miserably in one of their primary duties, verifying the correct runway.  The speculation and questions raised are a normal part of trying to determine all of the causal factors, so they can be addressed, corrected if possible, and hopefully avoid similar occurrences.  The NTSB will ask the same questions and a lot more, then issue a report.   They will recommend changes to rules, regulations, runway design and markings, etc. - if they conclude that such recommendations would be useful in preventing future tragedies.

The answer to your question in your example is YES, if  'other factors' warranted it.  To illustrate, let's restate your example and add a few 'other factors'.

  1. "If I were to roll out of bed at 5AM tomorrow and jump in the car, get on the freeway going the wrong direction, and hit a school bus head-on, would you be calling for better signs, RFID chips on my car, the ramp, etc?"
  2. Assume you usually travel west on the freeway to get to work.
  3. The highway department, during the night, has permanently closed the eastbound side of the freeway (for several miles) and rerouted the eastbound traffic to the westbound side.
  4. The westbound traffic has been detoured to the new bypass toll road which has the westbound side recently completed, but not the eastside.
  5. The detour sign at the entrance ramp you use was missing or obscured.
  6. You take your usual ramp and 'bam', hit a school bus head-on.

Yes, you would be negligent and your mistake would be inexcusable.  However, to prevent similar accidents in the future, the other factors must be addressed.

Sound farfetched?  Not really.  In Texas, we have some state highways that have very wide grassy medians - as wide as 50 yards or more in some spots.  Many of these highways do not have over/under passes, but instead, have cross-overs.  That is, a side street or FM road crosses the highway which might have a 65 or 70 mph speed limit.  Many of these cross-overs do not have stop-lights or even street lights and very limited hard-to-see signs, so at night it is really treacherous to cross or turn onto the highway.  Turning left from one of the side streets or FM roads can be especially hazardous at night if the median is wide and traffic is light.  You can wind up driving into oncoming traffic very easily.  Most accidents at these intersections usually involve strangers unfamiliar with the area, but sometimes even locals mess up.  (Many of these highways are being upgraded with better designs, but it's a long, slow process.)

898 posted on 08/28/2006 3:15:30 PM PDT by RebelTex (Help cure diseases: http://www.freerepublic.com/focus/f-news/1548372/posts)
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To: usafsk
I don't get this desire to seek ephemeral causal factors for what was obviously negligent behavior on behalf of the pilots.

The desire to seek out all the relevant causal factors is very important. Rarely is the direct cause of a crash so immediately apparent and simple that even the NTSB can state it with relative certainty within hours of the event, but in this case it appears to be so.

But once that cause is established, whether that's hours or months after the crash, the more important work of discovering why that cause could occur begins. I agree that it seems unimaginable that two qualified and experienced commercial pilots (plus possibly a third in the jumpseat - reports conflict on whether an AirTran pilot who died in the crash was seated in the cockpit jumpseat or in the passenger cabin) could line up and attempt a takeoff on an unlighted runway different from the one they were cleared to take off on, despite many factors that should have prevented such an error. But they did, and it's of paramount importance to understand how that could have happened, in order to prevent it from ever happening again.

For example, was the crew fatigued? If so, maybe changes in crew scheduling and duty time limitations are needed so a pilot can't show up to work so tired he lines up on the wrong runway. There is a moving map that should have shown the runway centerline and that the jet was not aligned with it - did that map fail or have an error? If not, why did the pilots miss it? Maybe something as simple as changing the display colors to be more contrasting could have helped. Why didn't the pilots crosscheck the runway heading and navigational computer heading with the magnetic compass? Should it be moved to a more easily seen location in the cockpit? Were the pilots cleared for takeoff while taxiing, and thus didn't have time to see their instruments settle before beginning their takeoff role? Maybe takeoff clearances shouldn't be permitted until an aircraft is stopped at the hold short line or lined up on the runway. Why didn't the tower notice the error? Would additional tower staffing, requiring visual position confirmation before takeoff clearance is issued, or changing the way clerance readbacks are performed help? Was the recently changed taxi layout confusing? Is better signage and lighting needed for night operations, especially around construction areas? Why didn't the pilots realize the mistake in time to stop on the runway? Should a warning system be added to alert pilots who add takeoff power when they're not on their assigned runway heading? Is more situational awareness training needed?

These are just some examples of questions that come to my mind. Some or all may be irrelevant, and many other questions that I didn't put may be very important. But if saying "pilot error" and just telling pilots to "do better" was an acceptable resolution to a crash investigation, we would have been done with aviation safety improvements in about 1930. The fact is that humans are imperfect, and we have brains that evolved their processing ability in basically 2-D environments at speeds up to maybe 10mph. Getting into a cockpit of a vehicle that can move in 3-D at hundreds of mph, operated by incredibly advanced computer systems, is very much unnatural. So our system, which has made aviation by far the safest form of travel possible, is not just to look for where a pilot made an error, but to look for and eliminate any opportunity for errors to be made. It doesn't excuse the pilots or "shift blame". But it does ensure the only possible good thing that can come out of such a tragedy - the knowledge to make changes such that a similar tragedy can never happen again.

903 posted on 08/28/2006 3:43:52 PM PDT by Turbopilot (iumop ap!sdn w,I 'aw dlaH)
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To: usafsk

It is

I remember when I was 16 I had a job at a radio station, made a 2000 dollar mistake by not putting someones commercial on a monthly rotation. I was scolded, came home upset and told my mom. I expected my mom to be the soft understanding, sweet woman that she is to tell me it is all okay, well I got that later on, but first I got a lecture. You make mistakes when you are not fully concentrating on what you are doing. You should be thinking A to B to C. not about D and Z when you have not reached point A. It is obvious that the pilots were not committed to making sure they got from A to B. the reason is that they were not thinking enough. It is your job to find out if the price of a 2 liter cola has increased if you are working at a grocery store. It is your job to know what time the top 40 countdown comes on at a radio station, even if the airing time changes due to a football game or something. The pilots could have easily read and studied the new configuration, infact I believe they had a personal responsibility to know as much about the Lexington Airport as possible reguardless of standards.

intrestingly enough, my mother told me that in her job as a nurse, if she give someone the wrong med, they could die. These pilots had 48 lives in their hands and they did not accept that to the point where they could have made sure, took the time and made sure they knew what they were doing.

visualize atleast twice before you do, my mom also said.

and they she told me that the only perfect man on the earth was Jesus and that we will all make mistakes.

I guess some mistakes are just so damn big that perfection looks so perfect and easy in 20/20.

sometimes you are just in the wrong place at the wrong time. sometimes your mind is in the wrong place at the wrong time.


925 posted on 08/28/2006 11:30:30 PM PDT by se_ohio_young_conservative (God makes us strong for alittle while so that we can protect the weak.)
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