CNN: FAA: Tower staffing during plane crash violated rules

[DeepModem Mom]

FAA: Tower staffing during plane crash violated rules
August 29, 2006
From Mike M. Ahlers


The yellow "X" being installed Tuesday by workers at Blue Grass Airport tells pilots that Runway 26 is closed.

WASHINGTON (CNN) -- The Federal Aviation Administration on Tuesday acknowledged that only one controller was in the tower, in violation of FAA policy, when a Comair jet crashed Sunday while trying to take off from the wrong runway in Lexington, Kentucky....

***

The acknowledgment came after CNN obtained a November 2005 FAA memorandum spelling out staffing levels at the airport. The memo says two controllers are needed to perform two jobs -- monitoring air traffic on radar and performing other tower functions, such as communicating with taxiing aircraft.

In instances when two controllers are not available, the memo says, the radar monitoring function should be handed off to the FAA's Indianapolis Center.

The FAA confirmed to CNN on Tuesday that the lone controller was performing both functions Sunday at Blue Grass Airport in violation of the FAA policy.

The FAA should have scheduled a second controller for the overnight shift or should have shifted radar responsibilities to Indianapolis Center, FAA spokeswoman Laura Brown said....

http://www.cnn.com/2006/US/08/29/plane.crash/index.html

[leftchick]

1. damn! Only two?

Two does not even seem sufficient. :(

[Renew Deal]

2. I think it's a small airport?

Not much commercial traffic.

[av8rdave]

3. As an airline pilot

I used to fly in and out of LEX a lot...it's a very low volume airport, and two controllers (in some cases one) really is sufficient.

[WhiteTara]

4. I'd say in no cases, one...

we saw the results of only one. Lots of scattered bodies.

[rocktivity]

5. DING DING DING! BareNakedLiberal, you're our grand prize winner!

I'd say in no cases, one (air traffic controller)...

I agree, if only because that one might keel over. Then what?

:headbang:
rocknation

[54anickel]

8. Or just have to take a pee....n/t

[libnnc]

9. That's what trash cans in the tower are for.n/t

[54anickel]

11. Ewwwww! For a dump too? YUK!!!!!

[DoYouEverWonder]

19. Most of the time they probably sit around not doing much

There's plenty of time to go to the bathroom. It's not like they don't know when a plane is going to be coming in.

[libnnc]

23. doesn't exactly work that way.

They can't just walk off position whenever they get the urge.

[DoYouEverWonder]

26. We're talking about a very small airport

with only a few flights a day. There's got to be a fair bit of down time on a job like that.

[WhiteTara]

31. there is always constant chatter that has to have

attention paid. Not just between the tower and pilots but tower to FAA, other tasks that have to be performed.

BTW, I am not blaming the controller, but it was on his watch. And maybe if he had NOTHING to do but watch that plane, he would have seen the pilot was screwing up. Just saying.

[AngryAmish]

34. stadium pal

[high density]

18. Ahh, but how can we afford more ATCs when

we must "finish the job in Iraq" at a couple hundred million bucks a day? I mean more ATCs would cost a few million per year, and obviously we can't afford that! We gotta get the terrarists in Eyeraq!

[MercutioATC]

27. Wrong. The controller was not at fault.

All evidence so far points to pilot error.

[Evergreen Emerald]

29. Hey Av8ravea what is your opinion...do you think

...that having only one controller contributed to the fact that the plane was on the wrong runway?

[av8rdave]

38. It's hard to say....

At a small volume airport like Lexington, it would be common for controller(s) to be on to other duties once they've cleared an aircraft for takeoff if there was no other traffic in the vicinity (which was pretty likely on a Sunday morning). It's not unusual to be cleared for takeoff well before reaching the runway on a quiet morning, so once the tower controller hears the takeoff clearance acknowledgement, they may or may not be actually looking at the aircraft as it takes off.

I haven't been to Lexington for several years, as the plane I fly now doesn't serve that airport. However, I used to fly there periodically. When taxiing to runway 22, the normal taxi route crosses the departure end of 26. When it's dark there, the layout can seem confusing from a pilot's eye view out the cockpit window vs the plan view they show on CNN.

If the preliminary reports are accurate, it was a terrible mistake. While I'm not trying to excuse it, what apparently happened isn't as far fetched or ridiculous a mistake as one might think at first glance.

Regards,

Dave

[Evergreen Emerald]

57. Thanks

I figured it was something like that. Perhaps the airport will now fix that layout issue.

[av8rdave]

58. What they could really do to help

is just keep the one IFR runway (22) open and permanently close the rest. With the traffic volume at LEX, it would make everyone's live's simpler (and apparently safer).

[libnnc]

6. Well imagine-fucking-that!!!

FAA taking responsibility for something the ATC UNION (NATCA) has been SCREAMING about FOR YEARS!!!!!!

:grr: :grr: :grr: :grr: :grr: :grr: :grr: :grr: :grr:

I'm an ATC spouse. My partner used to work the "mids" by herself for years.

The controller involved was alone because he was scheduled to work alone. Not his fault. Controllers can't fly the airplanes for these people.

Pilot error + Inadequate staffing = DEATH

Edit to add: SEE WHAT HAPPENS WHEN THE FAA TRYS TO SAVE A BUCK NOT SCHEDULING AN EXTRA PERSON BECAUSE THEY DON'T WANT TO PAY NIGHT DIFFERENTIAL?!?!? SEE WHAT HAPPENS WHEN YOU PUT A $ AMOUNT ON SAFETY?!?!?

and Marion Blakey wants to run the FAA like a business......

SEE WHAT FUCKING HAPPENS??????

[libnnc]

7. kick 'cause I'm pissed.

[Xithras]

10. I fly out of an airport with NO controllers

I own partial interest in a plane that we keep hangared at a public airport that doesn't even have a tower (O27 for you interested pilots). There's nobody to tell us where to go, we just DO.

The responsibility for the crash lies with the air crew, and nobody else. It's ultimately their responsibility to determine whether they're on the correct runway, and these guys didn't. Since traffic controllers don't generally LOOK at the airplanes anyway, I fail to see what difference a second controller would have made.

[karlrschneider]

15. Same here, I fly from KMKO and H68 neither have towers.

I also fly out of KTUL often which has a whole gang of them.

edit: by the way I have seen your airport on the way to Modesto. ;-)

[Jacobin]

45. Yup. Pilots screwed up

Its not the tower's duty to tell the pilot how to drive the plane, only that he is cleared to the correct runway.

[karlrschneider]

12. So they are saying that shifting responsibility to Indianapolis is better

than having one warm body in the LEX tower? That makes no fucking sense at all. Maybe they should have had 2 people according to their 'memo'(I don't think that mandates 'policy' necessarily), but there are plenty of airports with ZERO controllers that handle traffic just fine.

[Eugene]

13. AP: NTSB: Lexington Controller Had Back Turned

NTSB: Lexington Controller Had Back Turned


Tuesday August 29, 2006 11:16 PM

AP Photo KYER103

By JEFFREY McMURRAY

Associated Press Writer

LEXINGTON, Ky. (AP) - The lone air traffic controller on duty the morning
Comair Flight 5181 crashed cleared the jet for takeoff, then turned his back
to do some "administrative duties" as the aircraft veered down the wrong runway,
a federal investigator said Tuesday.

The crash killed 49 people - everyone on board except first officer James
Polehinke, who was in critical condition Tuesday.

-snip-

The air traffic controller had an unobstructed view of the runways and had cleared
the aircraft for takeoff from the longer runway, said National Transportation Safety
Board member Debbie Hersman.

Then, "he turned his back to perform administrative duties," Hersman said. "At that
point, he was doing a traffic count."

-snip-

Full article: http://www.guardian.co.uk/worldlatest/story/0,,-6046364,00.html

[karlrschneider]

14. I have to say one more time - the controllers are NOT responsible

to ensure pilots don't fuck up. And I almost always spare no effort to defend one of my fellow
pilots any time I think they're being unfairly accused of error but I also have many good friends who
are controllers and they deserve the same consideration.

[Turley]

62. "Administrative duties"

I think that means he was doing the other part of his job which is to make sure nearby aircraft don't crash into each other in minair. They make it sound like he was filling out a requisition for paper clips or something.

[LisaM]

16. Aren't the scab controllers all about ready to retire?

I heard a couple of years ago that the FAA was facing a mass retirement issue, since so many of them started at the same time. If that's true, then this incident could be one of many like this on the horizon (just what the airline industry needs).

[Scout1071]

20. Those "scabs" have been working their ass off for 25 years to keep

our skies safe. I know many, many air traffic controllers and they are all good people.....even the ones getting ready to retire.

[WhiteTara]

32. truth is that if they hadn't taken those jobs

the FAA would have been upgraded and towers would have had their equipment upgraded rather than let the raygun destroy our aviation system. But instead of standing with their brethren and demanding better equipment (IIRC the strike was over safety not money). But again it was profits first and people second. The number of near misses grows every day and our equipment just gets older and here we are.

I know the controller was not responsible, but he is there to aid the pilots and if he had been watching, he might have been able to save those people. But instead, we have lots of people's lives shattered and a controller who will never be the same again.

[Scout1071]

37. It is true that the facilities are outdated.

I've been in a major facility recently and surprised how outdated it is. But don't blame the controllers. Those "scabs" hate Reagan as much as the next controller. I know for a fact that to this day they will not refer to Ronald Reagan Washington National Airport, but rather Washington National Airport. I would be much more concerned with what they are planning to replace those retiring controllers. They are providing less training and half the pay of current controllers. How would you feel knowing that the person next to you is making twice what you are for the same job? They are also cutting all their benefits and vacation time. The Bush administration is doing to the FAA what it did to FEMA......destroying it. I have no problem with air traffic controllers getting more vacation time than the average Joe. They deserve it. Most of my friends that are controllers spent at least 6 years in the military and another 4 training to become a controller. About as much time and training to become a Doctor. So, I have no problem with higher salaries and more vacation.

Yes, we can agree that it is becoming more dangerous by the day to fly because of the incompetence of those running the FAA (Marion Blakely.) Something needs to be done sooner than later or we will certainly see more of these incidents.

[WhiteTara]

50. I've never minded money and percs

it's the fact that they didn't say, "my fellow controllers are right. We need better equipment or no one can work and the public is unsafe." Instead, they took the jobs, hate the guy who put them in place. I feel like they cheated us the public by taking the scab jobs without demanding the same equipment upgrade. Sorry, somehow I have lost the capacity to grant lots of slack. I know a Delta retired pilot who recently cheered Raygun's firings because it showed who was boss. I wonder how happy he is now that he is poor.

[N90ATC]

51. WTF?

I only wish you knew what you were talking about. The equipment has improved over the intervening 25 years. Calling people "scabs" 25 years later is rather McCarthyesque. And thanks for all your support. LOL

[libnnc]

22. Actually, most of the PATCO controllers were re-hired

absorbed into the agency during the Clinton administration.

"Scab" is a pretty nasty word, especially when you don't know what the fuck you're talking about.

[LisaM]

36. I do know what I'm talking about

Reagan had secretly-trained replacements ready when he fired the PATCO workers (who'd endorsed him, ironically). The controllers might have been working hard for 25 years, but that just proves my point. They are all going to retire at once, and we will have a shortage of controllers. I don't think those people should have stepped in as replacements.

[N90ATC]

39. You Have NO Idea What You're Talking About

There were no secretly trained replacements for the PATCO guys. The Reagan admin just raided the military. As said above, many of the PATCO guys were rehired under Clinton & are still working. This airport was recently subjected to reduced staffing by the FAA manager on site & that's what caused this horrible event. 49 dead. If you're truly outraged, email your Congress members & tell them to stop letting the Bush admin fuck around with controllers & those who fly. They've come up with all sorts of doozies lately & many of us were fearful that something bad would happen. Blood is on Marion Blakey's hands & she should be fired.

[libnnc]

42. *loud applause*

:toast:

And welcome to DU too :hi:

[N90ATC]

43. Thanks!

I've lurked for quite a while & have long enjoyed your posts...Very informative.

[LisaM]

46. Well I agree with that

Privatizing the FAA is not a good thing.

[N90ATC]

47. Agreed but...

Have you written/called your Congress members? Things are going to go to hell in 2 years or less as 25% of the staff retires. It's not like they can just hire immediate replacements. It takes about 3 years to certify in the en route centers & a year or two in the towers/approach controls. Blakey is the worst FAA administrator ever & should be FIRED!

[LisaM]

48. I will call them.

Thanks for the info.

[LostinVA]

17. Thank you, Ronald Reagan

[maseman]

21. Some posts above

This is the pilots fault. They were cleared to taxi to the active runway which was 26, not 22. Every airplane has a DG (directional guidance) that shows which way they are going. A runway heading is actually a direction. If they turned onto runway 22 (which they did) they should have noticed they were on heading 220 degrees and not 260 degrees.

Also, as you roll an airplane down the runway you are obviously looking ahead and at the instruments. With two pilots one had to notice before they rotated (pulled the nose up to take off) that they were on the short runway. Although they could have aborted take-off and most likely ran off the end of the runway they must have made a split decision to go for it and try to take off. Well, we know the end results.

I always try to teach my flight students that running a plane off the end of the runway at 50 or 60 knots and banging up the landing gear, nose gear, propeller, etc. is better then trying to take off and then crashing with usuallu much worse results. These pilots must have gotten gutsy and decided to rotate and lost the plane to stalling.

Very sad. This should not have happened.

[sleipnir]

24. My thoughts also

I first heard about this and realized what happened after seeing a quick photo of the crash site and airport.

The lack of a trail of debris led me to believe that the plane attempted to rotate too early, gained a failed period of airborne status, stalled and crashed promptly into the woods.

There's more than pilot error to blame with this crash. That much I am certain of. There has NEVER been a fatal accident in the US in recent history that was completely attributable to pilot error. My guess is the weather, runway illumination, confusing taxiways and perhaps a malfunctioning instrument or indicator panel will also be to blame.

The only incident that comes to mind that in my wide research that can be given almost 100% to pilot error was the Aeroflot incident that involved the pilot giving control to his teenage son, which plunged the plane into an uncontrollable spin/stall. That's pilot error.

[maseman]

28. You're correct

There are always multiple factors that effect an accident. Seems to be the rule of 3. If three different things go wrong the chances of an accident/crash grow dramatically.

In this case it could have been hard to see (which it is at dawn or dusk), poor runway lighting, early morning/tired pilots or controller, etc. I guess they had recently changed a taxiway and also paved. I assume the new pavement had the runway headings painted on them. I can't imagine it would be legal for an active runway to not have the numbers painted on them yet.

[alfredo]

35. There was a cell of thunderstorms heading right at the runway

they were on. There were downdrafts associated with this storm. Though it didn't cause the crash, it stacked the cards against them even more than they were.


BTW, the survivor of the crash is showing some improvement. He is still in a coma, but his vital signs are getting better.


The other accident that killed seven is in very difficult terrain. Body parts are mixed in with scattered parts of the plane. It could take days to recover the body parts.



One thing you may want to know. I don't know if it has any relevance to the accident, but the crew boarded the wrong plane and had to be instructed as to what plane they were to be flying. Depending on their reaction to the mistake they could have been a bit distracted by that incident.

[bling bling]

54. I saw a show about that one.

I saw a Nat'l Geographic show on that crash, and in this one too there was also more to blame about that accident than just the pilot. Apparently the pilot had set the auto-pilot function and his teenage son was pretending to fly. He was turning the steering wheel back and forth. There was a glitch, so to speak, that the pilot wasn't aware of where if you turned the steering wheel just enough it would automatically de-activate the auto-pilot. So AP was turned off when the son "steered" without anybody realizing what had happened.

It's still 98% the pilots fault. But the airline manufacturer discovered the "glitch" played a role in the accident and promptly made a change so that in the future, the auto-pilot would stay on even if the steering wheel was moved back and forth.

[karlrschneider]

30. Um, you have the runways reversed. 22 is the long one

they rolled on 26. DG is Directional Gyro. ;-)

http://flightaware.com/resources/airport/KLEX/APD/AIRPORT+DIAGRAM

[maseman]

61. You are correct

I only looked at the runway layout once a week ago. I'm a little rusty on the terms anymore as I haven't been flying now for a few years. Need to get back into it.

[av8rdave]

40. I agree this shouldn't have happened. However,

in transport aircraft, the stats on high speed aborts aren't good. Performance data is based on "worst case" scenario, which is engine failure at or near V1. (It's important to note that this data is based on the correct runway). Once in the high speed regime (between approximately 80 knots and V1) engine failure becomes one of the very few reasons to abort a takeoff, and the training we receive emphasizes this. Statistically, the safer path when at or near v1 in a multiengine jet is to continue the takeoff and treat the problem as an airborne situation.

Sadly, had the crew tried to abort this one at the time they realized they were in trouble, the results would have been pretty much the same. On that runway, they were committed to an accident pretty early in the takeoff roll.

An accident is usually the result of a chain of circumstances, a wrong runway obviously being a late link in that chain. While heading should be checked at the beginning of the roll, one can envision circumstances (a nearly expired wheels up time, tight spacing on an inbound aircraft, etc) where a crew gets in a rush to commence the takeoff roll.

Hopefully, you teach your students that when they feel rushed is the time to be the MOST methodical and thorough. Unfortunately, even experienced crews aren't immune from falling into the "rush into mistakes" trap.

Regards,

Dave

[av8rdave]

41. oops...replied to wrong posting

See my posting above (the longer one)

Regards,

Dave

[WhiteTara]

53. I was wondering what the ramifications would be

of reaching no return and still trying to stop would do. If they had aborted and tried to stop the plane, do you think there would have been a possiblity of survivors? I guess what was at the end of the runway would have a lot to do with it, but I read they were trying to pull up over the trees.

[av8rdave]

59. a multiengine jet on a high speed abort off the end of the runway

would likely have had similar results as what occurred. Again, the training is to continue when committed to high speed. Again, the assumption of all of this is that you're on the planned runway and you are capable of flight (a transport aircraft with an engine failed or tires failed is still capable of flight if the malfuntion occurs at high speed - assuming the correct runway). Our training is that a takeoff is NEVER aborted beyond V1 unless there is some reason it is incapable of flight (both engines failed or a structural/flight control problem).

The crew may have never been aware of the runway error. Once the takeoff roll starts, the focus is on the aircraft performance and directional control. Once V1 is reached (decision speed) the aircraft is committed to the "go" decision. V1 is the end of the decision process. V1 for runway 22 would have been easily reached even on the shorter, incorrect runway. Unfortunately, being the wrong runway, the crew would have had no acceptable choices at that speed.

Someone who has flown out of LEX may be able to clarify or correct me on this, but if memory serves, the long runway is somewhat "crowned," so that it appears to be much shorter than it is when you are at the start of the takeoff roll. (I may have this confused with another airport - there have been way too many of those over the years.) That could also lead the crew to not suspect a problem initially.

[WhiteTara]

64. thanks. I thought that

"no return" meant just that. I am so sorry for all those people, both dead and grieving. I am sure the controller will never be the same. It's a tragedy for all. I still think that there should have been 2 people, even if it is slow. But I'm sure the risk assesment tables say it's cheaper to kill some people than pay 2 people all the time. Damn the corporations.

[av8rdave]

65. That's pretty much it...

There is no amount of second guessing or "heartfelt sympathy" from the suits or the government that can make things right for those who are lost and grieving.

As obvious as the cause may seem, the best anyone can do is unearth every possible factor that led to the accident and do whatever it takes to prevent a similar tragedy.

[karlrschneider]

66. I haven't gone into LEX for years but I -think- I recall that

but I might be thinking of CRW, not sure. I read someplace this morning that the 4/22 lights were
inop a few days (nights) ago and perhaps they were thinking that was still the case and thught maybe
the 8/26 was the one with the functioning lights.* I guess I can see that happening and I don't know
the CRJ checklist but for ME, runway heading has -always- been the final item on mine. I got into
that habit from reading Ernest Gann's "Fate is the Hunter" when I was in school - he wrote about
taking off in zero-zero condx (not something I'd attempt but then I ain't Gann ;-))

* but the approach plates clearly show the 8/26 lights are inop UFN, maybe they didn't notice that.
Maybe the 1st officer can provide some info if and when he recovers...hopefully.
KS

[fasttense]

25. Well if repug congressmen, the crazy king george

and immigrants don't have to follow the law or "rules" why should anyone else?

[kestrel91316]

33. It's obvious that the FAA is incompetent. We'll just have to privatize atc

I shouldn't have to add this, but here it is: :sarcasm:

[OzarkDem]

44. Treating Air Traffic Control like McDonalds

Thanks, Bush!

[RamboLiberal]

49. Wrong runway wasn't Comair crew's only preflight error

http://www.cnn.com/2006/US/08/30/plane.crash/index.html

As Comair Flight 5191 began rolling down the wrong runway, the lone air traffic controller on duty at Lexington's Blue Grass Airport was busy with paperwork. And the 47 passengers onboard were unaware that the flight crew had started that Sunday morning by mistakenly getting onto another plane.

<snip>

Turning onto the wrong runway was not the only mistake the crew made Sunday, according to the NTSB. When they arrived at the airport at 5:15 a.m., the captain and first officer boarded the wrong plane and turned on the power before a ramp worker pointed out their mistake. (Watch the NTSB describe the latest findings -- 7:27)

Hersman said it was the flight's captain, Jeffrey Clay, who taxied the aircraft into position at the start of the wrong runway. Clay then turned over the controls to the co-pilot, James Polehinke, who was flying the plane when it crashed. Hersman said that was standard procedure since only the captain can reach the tiller used to steer the plane while it's on the ground.

<snip>

A longtime pilot familiar with Blue Grass Airport told the Lexington newspaper that the airport is confusing and getting onto the wrong runway is easier than it sounds.

Russ Whitney told the paper that Runway 22, the one Flight 5191 should have been on, has a hump in the middle, so pilots cannot see the whole thing as they begin takeoff. Runway 22 and the much shorter Runway 26 can appear to be the same length, he said, according to the newspaper.

[karlrschneider]

52. I don't consider the "wrong plane" part significant, really...

It was probably at the 'wrong' gate and would have been discovered eventually and even that isn't a huge safety issue, one CRJ looks pretty much like every other one especially if it's configured the same as others in the same airline. It isn't uncommon for people to get into the wrong car in a big parking lot - and keys aren't needed to fire up an airplane generally.

That said, I still can't figure out how an experienced pilot could line up on an UNLIGHTED runway
in the dark and 40 degrees off the correct heading. It just doesn't make any sense to me. :eyes:

[RamboLiberal]

56. I figured that too - thought the more interesting part was the

fact that in the story they mention the longer runway having that hump that disturbs it's sightline. I share your puzzlement about them even discussing the lack of lights then continuing down the runway.

Only thing I'd comment about getting on the wrong plane is that they may have been a bit tired. Don't know about you pilots, but I'm sure not at my sharpest mentally at that time in the morning, especially when it's still dark.

[av8rdave]

60. The wrong ariplane isn't that unusual at all

At first glance, you're right - the mistake doesn't seem to make sense. However, a series of events can lead to what seems a ridiculous error. It does happen in this business. Usually, when the investigation is complete, it's discovered that if any of the chain of circumstances had been corrected or noticed, the accident would not have occurred. It is likely that the commencement of the takeoff roll on the wrong runway was the end of a series of events or mistakes that led to it.

[dennis00]

63. lack of lights

There was a report that the pilots may have been confused by an earlier advisory that the runway lights were not working. My question is why are there trees at the end of runways? Why not clear the trees to create an emergency buffer zone in case of engine failure or some other emergency. A recent commuter flight from St. Louis to a smaller airfield in Missouri went down when inattentive pilots descended low and came down on a grove of trees at the end of the runway. Two survivors from nearly fifty passengers, and only because they were seated near an emergency exit. I think there should be several hundred yards of nothing at the end of runways.

[alfredo]

55. Air Traffic Controller only had 2 hours sleep.

Heard that on WTVQ Lexington's ABC affiliate.