The LEX crash - A CRM view

[[email protected]]

If as PNF you notice that the PF has just turned on to the wrong runway
to commence the takeoff roll, are you permitted to alert him (can't see
why not, actually, if lives are likely to be on the line) to it or are
you expected to just shut up and let him make the call? Presume for the
moment that the Capn is PF, which I hear wasn't the case in the LEX
incident...

Ramapriya

[Jay B]

wrote:
> If as PNF you notice that the PF has just turned on to the wrong runway
> to commence the takeoff roll, are you permitted to alert him (can't see
> why not, actually, if lives are likely to be on the line) to it or are
> you expected to just shut up and let him make the call? Presume for the
> moment that the Capn is PF, which I hear wasn't the case in the LEX
> incident...
>
> Ramapriya

I would think that CRM (Cockpit (or Crew) Resource Management)
techniques would suggest yes, you should speak up.

Jay B

[Slider]

This publication from the UK CAA explains a bit more about CRM.

regards

S

[Slider]

Sorry - here's the link....


http://www.caa.co.uk/docs/33/CAP720.PDF

[Andrew Sarangan[_1_]]

Jay B wrote:
> wrote:
> > If as PNF you notice that the PF has just turned on to the wrong runway
> > to commence the takeoff roll, are you permitted to alert him (can't see
> > why not, actually, if lives are likely to be on the line) to it or are
> > you expected to just shut up and let him make the call? Presume for the
> > moment that the Capn is PF, which I hear wasn't the case in the LEX
> > incident...
> >
> > Ramapriya
>
> I would think that CRM (Cockpit (or Crew) Resource Management)
> techniques would suggest yes, you should speak up.
>
> Jay B

I don't care what what CRM says, but if someone is about to kill you,
you should not only speak up, but take physical control of the
situation.

[Jay B]

Andrew Sarangan wrote:
> I don't care what what CRM says, but if someone is about to kill you,
> you should not only speak up, but take physical control of the
> situation.

Not exactly what the proponents of CRM would say is proper procedure
but...

Point well taken.

Jay B

[Ron Lee]

"Jay B" > wrote:

>Andrew Sarangan wrote:
>> I don't care what what CRM says, but if someone is about to kill you,
>> you should not only speak up, but take physical control of the
>> situation.
>
>Not exactly what the proponents of CRM would say is proper procedure
>but...
>
>Point well taken.

If a copilot is about to do something that will kill many people a
verbal response...maybe two... is all he gets before any and all
physical means are implemented.

Ron Lee

[Kingfish]

Jay B wrote:
> Not exactly what the proponents of CRM would say is proper procedure
> but...
>
> Point well taken.
>

What bugs me about this whole thing is the stink the media (and some
politicians) made about the single controller issue. IIRC that KY
airport has a handful of operations on the overnight shift - so why
would they need a second controller? Granted, if the controller hadn't
been doing something else he might have caught the mistake but I don't
think this is a glaring deficiency in tower staffing. The other thing
that bothers me is that *both* pilots were oblivious to being on the
wrong runway. When I fly the Pilatus (private charter) the checklist
requires us to set the heading bug on the runway - it's part of the
line-up check. I'm sure Comair has a similar checklist to the one we
use, and I'm amazed something like this could happen.

[John Gaquin]

> wrote in message .

> If as PNF you notice that the PF has just turned on to the wrong runway
> to commence the takeoff roll, are you permitted to alert him ....

Not permitted, .... required.

[Doug[_1_]]

Heck YES! Things like this is exactly why passenger carrying aircraft
have TWO pilots. Essentially, both pilots should agree, especially on
something as basic as this. If either pilot disagrees, the issue should
be worked out until there is an agreement. In a dispute, captain
prevails, but ANY good captain should carefully consider his copilot's
opinion.

wrote:
> If as PNF you notice that the PF has just turned on to the wrong runway
> to commence the takeoff roll, are you permitted to alert him (can't see
> why not, actually, if lives are likely to be on the line) to it or are
> you expected to just shut up and let him make the call? Presume for the
> moment that the Capn is PF, which I hear wasn't the case in the LEX
> incident...
>
> Ramapriya

[James Robinson]

wrote:

> If as PNF you notice that the PF has just turned on to the wrong runway
> to commence the takeoff roll, are you permitted to alert him (can't see
> why not, actually, if lives are likely to be on the line) to it or are
> you expected to just shut up and let him make the call? Presume for the
> moment that the Capn is PF, which I hear wasn't the case in the LEX
> incident...

In the LEX incident, the captain had to steer the aircraft and line it up
on the runway, since he is the only one with access to the tiller on that
type of aircraft. The FO then took over for the takeoff. Therefore, each
had a hand in the decision to use the runway.

[John Gaquin]

> wrote in message .

>....I asked because if reports of my country are anything to
> go by, quite a bit of patronizing prevails in the flight deck towards
> the FO...

From its very inception, the whole notion of a CRM program has had to deal
with ingrained cultural issues such as you describe, whether the culture in
question be nation based, airline based, or merely cockpit based. And the
problem was, and to a degree sometimes still is universal. It is not only
Asian, or third-world cultures, for example, that frown upon a "lowly" FO
questioning a Cpt about a decision. This exact problem - the unassailable
Captain, if you will- was a contributing factor in the Tenerife collision,
among others.

[Peter Duniho]

"Kingfish" > wrote in message
ups.com...
> What bugs me about this whole thing is the stink the media (and some
> politicians) made about the single controller issue. [...]

Just par for the course. As I'm sure you know, the media, politicians, and
general public (who are all too happy to believe whatever the media and
politicians tell them, if it means they avoid actually using their brain)
consistently fail to "get it".

That sort of thing used to bug me. I suppose it still does, at some level.
But mostly I just wind up thinking "oh well, people being stupid, again".

I guess one could analyze this particular situation and try to understand
why the "controller at fault" scenario is so compelling to everyone. Maybe
something about human nature to prefer to blame a person whose life wasn't
at risk. Or maybe it's just the most obvious failure to follow a rule,
making it an "easy out" for people "thinking" (and I use the word loosely)
about the accident. But in the end, it all comes down to the usual "didn't
bother to think about it" that plagues so much of our society.

Pete

[Jose[_1_]]

> Just par for the course. As I'm sure you know, the media, politicians, and
> general public (who are all too happy to believe whatever the media and
> politicians tell them, if it means they avoid actually using their brain)
> consistently fail to "get it".
>
> That sort of thing used to bug me. I suppose it still does, at some level.
> But mostly I just wind up thinking "oh well, people being stupid, again".

As other threads here have shown, =we= are the "general public" when it
comes to topics outside our own expertise. The key is to recognize this.

Jose
--
"Never trust anything that can think for itself, if you can't see where
it keeps its brain." (chapter 10 of book 3 - Harry Potter).
for Email, make the obvious change in the address.

[Steven P. McNicoll[_1_]]

"Kingfish" > wrote in message
ups.com...
>
> What bugs me about this whole thing is the stink the media (and some
> politicians) made about the single controller issue. IIRC that KY
> airport has a handful of operations on the overnight shift - so why
> would they need a second controller? Granted, if the controller hadn't
> been doing something else he might have caught the mistake but I don't
> think this is a glaring deficiency in tower staffing. The other thing
> that bothers me is that *both* pilots were oblivious to being on the
> wrong runway. When I fly the Pilatus (private charter) the checklist
> requires us to set the heading bug on the runway - it's part of the
> line-up check. I'm sure Comair has a similar checklist to the one we
> use, and I'm amazed something like this could happen.
>

Many assume that had the required second controller been on duty he may have
caught the flight crew's error. Had the two controller policy been followed
the second controller wouldn't have been in the tower cab, he'd have been
working in the TRACON. TRACON's don't have windows.

[Newps]

> "Kingfish" > wrote in message
> ups.com...
>
>>What bugs me about this whole thing is the stink the media (and some
>>politicians) made about the single controller issue. IIRC that KY
>>airport has a handful of operations on the overnight shift - so why
>>would they need a second controller? Granted, if the controller hadn't
>>been doing something else he might have caught the mistake but I don't
>>think this is a glaring deficiency in tower staffing.


It's possible the second controller may have caught it. It is up to
them where they want to work the radar position. If they work it from
the TRACON then it wouldn't have mattered. If he chose to work radar
from the tower cab then he may have seen it. Here it's just personal
preference where the radar position is during the mid shift. Some guys
work it upstairs, some down.

[Peter Clark]

On Fri, 22 Sep 2006 21:16:36 GMT, "Steven P. McNicoll"
> wrote:

>
>"Kingfish" > wrote in message
ups.com...
>>
>> What bugs me about this whole thing is the stink the media (and some
>> politicians) made about the single controller issue. IIRC that KY
>> airport has a handful of operations on the overnight shift - so why
>> would they need a second controller? Granted, if the controller hadn't
>> been doing something else he might have caught the mistake but I don't
>> think this is a glaring deficiency in tower staffing. The other thing
>> that bothers me is that *both* pilots were oblivious to being on the
>> wrong runway. When I fly the Pilatus (private charter) the checklist
>> requires us to set the heading bug on the runway - it's part of the
>> line-up check. I'm sure Comair has a similar checklist to the one we
>> use, and I'm amazed something like this could happen.
>>
>
>Many assume that had the required second controller been on duty he may have
>caught the flight crew's error. Had the two controller policy been followed
>the second controller wouldn't have been in the tower cab, he'd have been
>working in the TRACON. TRACON's don't have windows.
>

And even if there were 2, in the case of that airport doesn't the
sight line from the tower mean it would still be unlikely a second
controller would have been able to visually determine which runway it
was lined up on?

[Newps]

Peter Clark wrote:


>>
>
>
> And even if there were 2, in the case of that airport doesn't the
> sight line from the tower mean it would still be unlikely a second
> controller would have been able to visually determine which runway it
> was lined up on?

It would have been obvious if they had been watching.

[Peter Duniho]

"Newps" > wrote in message
. ..
> It's possible the second controller may have caught it. It is up to them
> where they want to work the radar position. If they work it from the
> TRACON then it wouldn't have mattered. If he chose to work radar from the
> tower cab then he may have seen it.

It doesn't matter whether the controller would have been in a position to
view the airplane or not. The apparent claim (by the media, politicians,
etc. that the person posting as "Kingfish" is talking about) is that the
*cause* of the accident was due to the missing controller. That is, the FAA
is at fault because they didn't follow their policy.

But had a second controller been present, and had that second controller not
noticed the airplane departing on the wrong runway (just as the first
controller also did not notice), the second controller would not have been
held to be at fault. It's not his job to ensure pilots depart from the
correct runway. So the absence of the second controller also cannot be said
to be the cause of the accident.

Pete

[Newps]

Peter Duniho wrote:

> "Newps" > wrote in message
> . ..
>
>>It's possible the second controller may have caught it. It is up to them
>>where they want to work the radar position. If they work it from the
>>TRACON then it wouldn't have mattered. If he chose to work radar from the
>>tower cab then he may have seen it.
>
>
> It doesn't matter whether the controller would have been in a position to
> view the airplane or not. The apparent claim (by the media, politicians,
> etc. that the person posting as "Kingfish" is talking about) is that the
> *cause* of the accident was due to the missing controller. That is, the FAA
> is at fault because they didn't follow their policy.
>
> But had a second controller been present, and had that second controller not
> noticed the airplane departing on the wrong runway (just as the first
> controller also did not notice), the second controller would not have been
> held to be at fault. It's not his job to ensure pilots depart from the
> correct runway. So the absence of the second controller also cannot be said
> to be the cause of the accident.
>


Two different issues. The FAA was not at fault in any event. The
second controller may have caught, may not have.

[Steven P. McNicoll[_1_]]

"Peter Clark" > wrote in message
...
>
> And even if there were 2, in the case of that airport doesn't the
> sight line from the tower mean it would still be unlikely a second
> controller would have been able to visually determine which runway it
> was lined up on?
>

I don't know, it's hard to say for certain just by looking at the airport
diagram. But if the controller is held responsible for this accident
because he failed to advise the crew they were departing on a runway other
than the one they were cleared to takeoff from then the remedial action must
be a transfer of authority from the cockpit to the tower cab.
Responsibility and authority go hand in hand.

[Gary Drescher]

"Peter Clark" > wrote in message
...
> And even if there were 2, in the case of that airport doesn't the
> sight line from the tower mean it would still be unlikely a second
> controller would have been able to visually determine which runway it
> was lined up on?

Using the tower view in MS Flight Simulator, you can see the difference
clearly (be sure to position the control tower properly). A plane lined up
on 22 points partly toward the tower; on 26 it does not. That difference
should be especially conspicuous if the plane's landing lights are on in the
dark.

The plane's orientation when holding short is even more dramatically
different for the two runways (assuming that the plane is perpendicular to
the hold-short line, which seems to be what airliners do). From the tower's
point of view, a plane holding short for 26 points about 45 degrees to the
right; a plane holding short for 22 points about 45 degrees to the left.
(Can a plane be cleared for takeoff before it has even taxied to the runway?
I've never received such a clearance, but I don't know whether it would be
against the rules.)

--Gary

[Steven P. McNicoll[_1_]]

"Gary Drescher" > wrote in message
. ..
>
> Using the tower view in MS Flight Simulator, you can see the difference
> clearly (be sure to position the control tower properly). A plane lined up
> on 22 points partly toward the tower; on 26 it does not. That difference
> should be especially conspicuous if the plane's landing lights are on in
> the dark.
>

Perhaps the plane didn't have any lights turned on.

[Ron Lee]

"Steven P. McNicoll" > wrote:

>
>"Gary Drescher" > wrote in message
. ..
>>
>> Using the tower view in MS Flight Simulator, you can see the difference
>> clearly (be sure to position the control tower properly). A plane lined up
>> on 22 points partly toward the tower; on 26 it does not. That difference
>> should be especially conspicuous if the plane's landing lights are on in
>> the dark.
>>
>
>Perhaps the plane didn't have any lights turned on.

Regardless, the pilots were responsible. Trying to shift or allocate
blame to the tower/FAA is idiotic.

Ron Lee

[Jose[_1_]]

> Regardless, the pilots were responsible. Trying to shift or allocate
> blame to the tower/FAA is idiotic.

Maybe part of the problem is that we call them "controllers". The FAA
is trying to go to "non-towered" rather than "uncontrolled" airports,
due to public perception. Maybe the title "air traffic controller"
should be changed to "air traffic coordinator". This may have an effect
on public perception which would lower the value of the political
currency garnered by shifting blame to the "controllers" who were
"obviously out of control"...

Jose
--
"Never trust anything that can think for itself, if you can't see where
it keeps its brain." (chapter 10 of book 3 - Harry Potter).
for Email, make the obvious change in the address.

[Judah]

"Steven P. McNicoll" > wrote in
ink.net:

> Many assume that had the required second controller been on duty he may
> have caught the flight crew's error. Had the two controller policy been
> followed the second controller wouldn't have been in the tower cab, he'd
> have been working in the TRACON. TRACON's don't have windows.

A second pilot aboard the aircraft surely would have caught the error as
well.

Oh wait, there was a second pilot aboard the aircraft...

[Steven P. McNicoll[_1_]]

"Ron Lee" > wrote in message
...
>
> Regardless, the pilots were responsible. Trying to shift or allocate
> blame to the tower/FAA is idiotic.
>

You're absolutely correct on both points.

[Steven P. McNicoll[_1_]]

"Judah" > wrote in message
. ..
>
> A second pilot aboard the aircraft surely would have caught the error as
> well.
>
> Oh wait, there was a second pilot aboard the aircraft...
>

Apparently neither of them was looking out the window.

[WRE]

Are you kidding....I would never open my mouth if someone was about to do
something that was going to kill me...I would just it there quietly and
die.....


> wrote in message
ups.com...
> If as PNF you notice that the PF has just turned on to the wrong runway
> to commence the takeoff roll, are you permitted to alert him (can't see
> why not, actually, if lives are likely to be on the line) to it or are
> you expected to just shut up and let him make the call? Presume for the
> moment that the Capn is PF, which I hear wasn't the case in the LEX
> incident...
>
> Ramapriya
>

[Judah]

"Steven P. McNicoll" > wrote in
ink.net:

>
> "Judah" > wrote in message
> . ..
>>
>> A second pilot aboard the aircraft surely would have caught the error as
>> well.
>>
>> Oh wait, there was a second pilot aboard the aircraft...
>>
>
> Apparently neither of them was looking out the window.

Nor at the proper instruments on their panel.

The point is that all this conjecture about a second controller being able to
save the day is a bunch of hogwash. Even if it were relevant, which it isn't,
there's no reason to think that anything would have been different had a
second controller been working at that moment.

Mistakes happen, and it's unfortunate. But 3 professionals were too busy with
other things to catch the mistake. Why is there any reason to think that a
4th would have been any less so?

[Neil Gould]

Recently, Kingfish > posted:

> [...]The other thing
> that bothers me is that *both* pilots were oblivious to being on the
> wrong runway. When I fly the Pilatus (private charter) the checklist
> requires us to set the heading bug on the runway - it's part of the
> line-up check. I'm sure Comair has a similar checklist to the one we
> use, and I'm amazed something like this could happen.
>
If you pull onto the runway and set your bug to the runway you THINK
you're on without verifying it against the compass or some other piece of
gear, you haven't improved your safety one bit. OTOH, I'd be surprised if
the Comair didn't have a number of additional checks to make, such as GPS,
that should have exposed the error prior to rolling.

Neil

[Ron Lee]

B A R R Y > wrote:

>On Sat, 23 Sep 2006 18:17:06 GMT, Judah > wrote:
>
>>
>>Oh wait, there was a second pilot aboard the aircraft...
>
>There were actually (3), no?
>
>It'll be interesting if the final NTSB report shows the off-duty pilot
>as a distraction.

Was another (third) off duty pilot in the cockpit? I have heard that
rumor but have not heard a factual account that he was in (or would
even fit) in the cockpit.

Ron Lee

[Steven P. McNicoll[_1_]]

"Judah" > wrote in message
. ..
>
> Nor at the proper instruments on their panel.
>

Perhaps they neglected to turn on instrument lights as well.


>
> Mistakes happen, and it's unfortunate. But 3 professionals were too busy
> with
> other things to catch the mistake. Why is there any reason to think that a
> 4th would have been any less so?
>

What other thing might the two professionals in the cockpit have been too
busy with?

[Steven P. McNicoll[_1_]]

"Neil Gould" > wrote in message
m...
>
> If you pull onto the runway and set your bug to the runway you THINK
> you're on without verifying it against the compass or some other piece of
> gear, you haven't improved your safety one bit. OTOH, I'd be surprised if
> the Comair didn't have a number of additional checks to make, such as GPS,
> that should have exposed the error prior to rolling.
>

I think it unlikely the crew would have to set the DG to the compass.

[Judah]

"Steven P. McNicoll" > wrote in
ink.net:

> What other thing might the two professionals in the cockpit have been too
> busy with?

I have no idea. I wasn't there. But I would hate to think that they took off
on the wrong runway intentionally.

[James Robinson]

(Ron Lee) wrote:

> B A R R Y > wrote:
>
>> Judah > wrote:
>>>
>>> Oh wait, there was a second pilot aboard the aircraft...
>>
>> There were actually (3), no?
>>
>> It'll be interesting if the final NTSB report shows the off-duty
>> pilot as a distraction.
>
> Was another (third) off duty pilot in the cockpit? I have heard that
> rumor but have not heard a factual account that he was in (or would
> even fit) in the cockpit.

There was a deadheading AirTran pilot on the flight. Given he was from
another airline, by FAA security rules, he would not have been allowed into
the cockpit, but would have been riding in the back.

[Steven P. McNicoll[_1_]]

"Judah" > wrote in message
. ..
>
> I have no idea. I wasn't there. But I would hate to think that they took
> off
> on the wrong runway intentionally.
>

Well, they must have been doing something other than what they were supposed
to be doing. It's pretty clear that neither one of them was performing the
duties of "pilot".

[[email protected]]

That actually wasn't the point of my asking. Ok let me phrase it this
way... if this exact thing had happened on a 20,000 foot runway with no
other traffic in sight, you'd still not have pointed out the error as
PNF?

Ramapriya


WRE (remove nospam) wrote:
> Are you kidding....I would never open my mouth if someone was about to do
> something that was going to kill me...I would just it there quietly and
> die.....
>
>
> > wrote in message
> ups.com...
> > If as PNF you notice that the PF has just turned on to the wrong runway
> > to commence the takeoff roll, are you permitted to alert him (can't see
> > why not, actually, if lives are likely to be on the line) to it or are
> > you expected to just shut up and let him make the call? Presume for the
> > moment that the Capn is PF, which I hear wasn't the case in the LEX
> > incident...
> >
> > Ramapriya
> >

[Neil Gould]

Recently, Steven P. McNicoll > posted:

> "Neil Gould" > wrote in message
> m...
>>
>> If you pull onto the runway and set your bug to the runway you THINK
>> you're on without verifying it against the compass or some other
>> piece of gear, you haven't improved your safety one bit. OTOH, I'd
>> be surprised if the Comair didn't have a number of additional checks
>> to make, such as GPS, that should have exposed the error prior to
>> rolling.
>>
>
> I think it unlikely the crew would have to set the DG to the compass.
>
If not, then how is setting the DG much help in determining the runway
that one is on?

Neil

[Judah]

"Steven P. McNicoll" > wrote in
. net:

>
> "Judah" > wrote in message
> . ..
>>
>> I have no idea. I wasn't there. But I would hate to think that they
>> took off on the wrong runway intentionally.
>>
>
> Well, they must have been doing something other than what they were
> supposed to be doing. It's pretty clear that neither one of them was
> performing the duties of "pilot".

Exactly.

[Steven P. McNicoll[_1_]]

"Neil Gould" > wrote in message
m...
>
> If not, then how is setting the DG much help in determining the runway
> that one is on?
>

I assume that airplane had a slaved system. Actually looking at the DG
would have been a great help in determining they were on the wrong runway,
they just don't set the DG.

[Jay B]

I could be wrong, but I think there was a particular level of sarcasm
in WREs post?

Jay B

[[email protected]]

Jay B wrote:
> I could be wrong, but I think there was a particular level of sarcasm in WREs post?
>
> Jay B


Of course there was - but then when even the PF is a qualified pilot
and not some stewardess, such sarcasm is merely misplaced; it isn't
like some dunce at the wheel is trying to kill you! My rejoinder should
convey better what I was intending to ask.

Ramapriya