Airline Safety: Crash of Comair 5191

This accident hit home a bit since I’ve been working on improvements to airport diagrams and other areas.

News reports tell of the horror that is always imbedded in such tragedies. And the human toll is indeed horrific when so many, so suddenly and so unexpectedly meet their end while carrying on what has become such routine business.

When I looked at the chart for LEX airport, I suspected immediately what it could have been. And it’s not so hard to imagine.

Understand that US commercial aviation is, by far, the safest way of transporting humanity ever devised. Safer than trains, much, much safer than cars and even safer than walking. But improvements remain, a fact highlighted by this accident. I believe it represents an iceberg’s tip of similar taxiing/misidentifying errors that requires us to go beyond blame and look for solutions. It is our good fortune to be in a country so willing to listen because, in this case, the best solutions must come from those who run airports and that means government.

That the pilots made a mistake is obvious from the results. But it has nothing to do with aircraft performance or voluntarily selecting the wrong runway. And it wasn’t nearly as hard a mistake to make as you might think. In fact, this same mistake has been made many, many times at far more common airports but, in those cases, with less tragic results. But hey, If you blow through an unseen stop sign and don’t get T-Boned is the mistake any different than if you did? No, you were just lucky.

Runways are numbered according to the compass direction the pilot is taking off in. North is 36 (360º), East is 9 (90º), South is 18 (180º) and West is 27 (270º). So runway 26 means the plane is pointing 260º (mostly west) on takeoff or landing and 22 means the plane is pointing 220º (southwest).

As an airline captain, I do the taxiing and am responsible for the flight so this stuff affects me. It does most pilots although few will acknowledge how much. We’ve all made mistakes and, for the most part, the system is resilient enough to prevent single mistakes from causing mishap.

There is a way to prevent this error and many more like it. Airports have already spent money on systems that have prevented other mis-identified runway accidents and they’ve been very effective. For that matter, airlines have spent loads of money on safety improvements and most have proven enormously successful. The solution to this problem is another such opportunity and fortunately won’t require so much money. 

What Happened?

There is always more to it than preliminary suspicions put forth and they are frequently wrong. But this suspicion is one that, even if it’s wrong, addresses a real problem that has occurred, will continue occurring. Fortunately, it can be corrected relatively inexpensively.

I strongly suspect that they were on their way to the intended runway 22 and came across the much-shorter runway 26. There were expecting to turn left on a runway and takeoff. When runway 26 presented itself first, they turned and launched. Recent runway construction and pilot experience with the unmodified airport could have played a part, too. There could have been an intersection takeoff planned, too, that may have been a factor. Either way, it likely had nothing to do with planned performance and had everything to do with simply turning down the wrong runway.

That is a surprisingly easy mistake to make. I’ve almost bit on it myself and many pilots HAVE done so. Houston Hobby (see diagram in right column) airport has a similar arrangement and numerous (including airline) pilots have taken off on the wrong runway under even better conditions. Fortunately for them, that wrong runway was a lot longer.

Once that mistake was made there wasn’t much opportunity to correct it. If the pilots tried to liftoff early, they made have used up whatever energy was present and got airborne briefly or tried to stop and went off on the ground at high speed. What to do after such an error is not covered in any training. We must concentrate on how to prevent the error.

What Can Be Done?

Of course there is an easy solution: the pilot can look at his heading instrument when lining up on the runway. But there’s a lot going on right then and it’s an easy thing to miss. I’d be willing to bet that, on any given takeoff, only about 15% of pilots look at their heading before pouring on the power. Maybe we can improve that percentage and indeed score some improvement but the real way to prevent this is with airport lighting and automated warnings. 

1. Airports that allow extremely low visibility operations already have a system in place to prevent mis-identifying runways in the fog. I propose that whenever a taxiway approaches a runway, a row of blinking yellow lights, like what’s installed at low-vis airports, be installed and used. Secondly, whenever a taxiway CROSSES a runway, blinking yellow lights line the taxiway path on the left and right. These should be installed in certain hot spots (like HOU) where there is the highest risk of committing the error.

2. Pilots are instructed, as they are now, that they never cross blinking yellow lights without a specific clearance to do so. An even better route would be for the blinking lights to be turned off when pilots can cross them although that would increase the controllers workload, a risk that itself must be mitigated.

3. Airplanes that have graphic display capability (as most now do) be equipped with taxi diagrams that display the aircraft’s current position and the assigned runway (entered by the pilot). If the entered runway does not meet some basic minimums, it flags the situation and would require override by the pilot to accept.

4. We now program our departure runway into the airplane’s flight management computer (FMC). So why not have the system warn us if a takeoff is attempted on the wrong runway. If it senses the wrong runway passing 40 knots (information it has) then it issues a verbal “runway, check runway” which is a mandatory reject. A safe, easy low-speed reject in this case would have prevented a number of very serious aviation accidents.

At right is the diagram for Houston’s Hobby airport. A similar or worse situation exists there that could and has caused the same mistake that took 49 lives in Lexington. The modified diagram above is available for use at no charge providing credit is given to www.footflyer.com. The unmodified diagrams are U.S. Government property and may be copied freely. Full resolution versions are available here. 

Conclusion

This type of error is too easy and too common. Hopefully these, or better, solutions will be implemented and the lives lost won’t be completely in vain.

My heart goes out to the loved ones and surviving pilot for what has been such a life changing tragedy.