Wingman Debriefing: Several Readers Opine on Comair Accident

Several readers expressed their views on Wingman's assertion that "Available Technologies Might Have Saved Comair 5191," and reader, David E. Grilley, who pointed out that pilots need to check their compass on runway line-up.

David E. Grilley wrote:

"Gentlemen, I'm sorry, but as a primary flight instructor, I distinctly remember teaching my students to check their compass on runway line-up.  While new technology is great, sometimes it is a failure to follow basic principles that gets us in a bind like this."

Tom Farrier wrote:

"Both Mr. Grilley and Wingman raise valid points.  Too frequently, pilots seem to forget they have heading indicators until they're airborne.  In December of 1999, a United crew that got turned around in low visibility while taxiing in at Providence (PVD) possibly could have avoided some confusion if they'd observed themselves taxiing on a heading obviously askew from that of their intended taxiway (although a closed runway they expected to encounter en route to the terminal was on a similar heading).  By the same token, relying on heading alone isn't much better; in October of 2000 a Singapore Airlines crew came to grief after trying to take off from a closed runway at Taipei (TPE) parallel to their assigned departure runway.

The FAA has tried hard to solve these problems with both education and a variety of anti-incursion aids, most particularly the standardized runway and taxiway signage that was mandated some years back.  Still, there are local "gotchas" at almost every large airport - taxiways that change names, number/letter combinations that lend themselves to confusion when observed in poor lighting or visibility at taxiing speeds, etc.  From a purely objective standpoint, there probably isn't a way to reduce human error in the surface environment much further without some kind of technology that really helps situational awareness in a tangible manner, such as GPS-driven depictions of the airport with "own position," i.e., moving map displays of some type.  And, until the cost of such solutions comes down significantly, there probably won't be many GA-friendly solutions to help the bulk of the flying community.

Finally, I'd respectfully suggest to the entire Flight Tech Online readership that the Lexington tragedy is looking more and more like a classic multiple-link chain of causality.  Hopefully, the aviation community will take to heart the various speculations and theories currently in circulation as valid issues for self-examination, while realizing this investigation has a long way to go."

Reader David Sims wrote:

"Surely Mr. Grilley's argument falls apart when he says "...sometimes it is a failure to follow basic principles that gets us in a bind like this." It is exactly because humans are fallible and procedures, for whatever reason, are not followed to the letter that devices that alert us to possible errors should be encouraged."

Reader Marcel Martineau wrote:

"The problem is that a very small moment of inattention or distraction can be sufficient for the crew to make a fatal mistake especially if something has been changed such as a taxiway that leads to intersecting runways, the sun in the eyes, expediency... There are also several factors which need to be considered.  The fatigue level of the pilots, each pilot state of mind, the synergy between them, their experience level, the culture within an airline, and the level of CRM [crew resource management] exercised in this case must be considered. Often, depending on the experience level on a particular type of aircraft, a authority role reversal can occur in the cockpit or a crew member can fail to play the safety role expected by any member of a crew.

The danger is not only taking off on the wrong runway but landing on the wrong runway or even landing at the wrong airport. The challenge for a crew is to constantly concentrate on the task at hand even after doing the same thing thousands of times.  The challenge for Flight Operations Managers is to develop Standard Operating Procedures that will cater to such dangers."

09-19-2006.

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