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.
You do aviation safety a great disservice with your post. Everyday there are thousands of flights, pilots are somehow navigating the baffling maze of runways at airports all over the country despite their schedules, poorly contrasting instruments, not settling before takeoff, not enough controllers, etc.
You guys are killing me with this stuff. You ought to work for the NTPEB - National Transportation Pilot's Excuses Board. No effort needs to be expended here to make the skies safer. The 5191 crew has issued a NOTAM for everyone on making sure you're on the right runway.
Please, if there are any ATPs on this thread, would you weigh in on this topic. I've got three that say these guys screwed up in a way that no one ever should, or could have imagined.
Very good post. In my industry we view these things in much the same way. When a person errors, I will go out of my way to fix process or system issues in addition to disciplining the person. Certainly there's a threshold where the additional checks or process steps exceed the cost we can bear, but when people's lives are at stake that threshold is generally higher than might be considered reasonable in many other industries.
"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."
Well said. And the examples of the questions that need to be answered are excellent and precisely on target. Thanks for your insight and common sense.
Exactly. It's not about excusing the pilots, because really, I don't think that's possible in this circumstance. Everybody knows they screwed up. It's about making it that much more difficult for something like this to ever happen again.
}:-)4