In the 5191 accident, we lost a friend, a son, a brother, an uncle and a fellow crewmember. He will forever be remembered along with the other 48 people who died that morning…

An Aviation Accident is a tragic event caused by a series of factors. However even just one factor can change a person’s life forever…

So how do we stop these So how do we stop these events from happening?events from happening?

Flight 5191An Accident Waiting To Happen

That did happen.

Flight History

• Departed Lexington Blue Grass (LEX)• Arrived Atlanta Hartsfield Jackson In’t

(ATL)• Canider Regional Jet CRJ-100• N431CA• 3 Flight Crew Memebers

• 2 Pilots, Jeff Clay and James Polehinke• 1 F/A Kelly Heyer

• Flight Pattern that morning

The Human Factors Issues Behind 5191

• Pilots– Breaking Sterile Cockpit Rules– Sleep deprived?

• Wrong CRJ to begin with

• Air Traffic Controller– One On Duty– FAA mandated Two– Turned His Back

• Counted Strips

Workload Management ATC

• One on Duty• IND center• LEX Tower/Ground• Counting Strips

• Runway 26 Versus 22• 26 is unlit• 26 is lighter pavement then 22.

(Concrete vs. Asphalt) • 22 is lit

Blue Grass Runway Simulation

Actual Time of the impact was 0604

Simulation set at Simulation set at

•0602AM•Date set to 08/27

•Similar Cockpit Viewing used

Runway 22 is over here!Runway 22 is over here!

Taxi Route to 22 on Taxi Route to 22 on 08/27/0608/27/06

Normal Taxi Route to Normal Taxi Route to 22 when Taxiway 22 when Taxiway Alpha was openAlpha was open

First Set to Day to see where we are….you can see the taxiways very well. Now what happens when we set it to right before sunrise?

Rotating Red Lights Indicating Closed Taxiway

New Procedures called for pilots to taxi via this taxiway…can you see it?

Pilots Didn’t see Runway 26 Pilots Didn’t see Runway 26 Position MarkerPosition Marker

Pilots Didn’t see Runway 26 Pilots Didn’t see Runway 26 Position MarkerPosition Marker

Runway 22 is over here!Runway 22 is over here!

Taxi Route to 22 on Taxi Route to 22 on 08/27/0608/27/06 Normal Taxi Route to Normal Taxi Route to

22 when Taxiway 22 when Taxiway Alpha was openAlpha was open

Simulation set at 0602AM August 27th

CST On FS04

Actual Crash 0604 AM

Normal Procedure

• (not actual instruction)• Taxi over 26, and

Hold short at 22 on Alpha.

August 27th Procedure:

• (not actual instruction)• Construction

Closed Alpha (X)• New Instruction

was to take Alpha 1 ( )

What Happened Actually

On the wrong runway.

No Centerline lighting?No Centerline lighting?

HEADING?!?!?!?HEADING?!?!?!?

Had they been on the right runway

HEADING?!?!?!?HEADING?!?!?!?

Centerline lightingCenterline lighting

Assessment Vs. Decision Making

• Dr. Endsly• In other words an internal

representation convinced the crew they were on the correct runway.

• It was because how THEIR MINDS assessed the conditions around them led them to believe they were on the right runway

• The world in their minds did not match the reality outside the cockpit.

The General Aviation Runway

• What is the purpose of them?

So I turned to the Experts….

• ATC/Runway Info • Dr. Marvin Smith

• Human Factors Info • Dr. Kelly Neville

Interview with Doc Smith

• General Aviation Runways Expedite Traffic

• Why they wont go away• CAPACITY ISSUES• The industry is beyond operating capacity

Doc Smith Con’t

• GA Runways supplement to Larger Runways• Allow controllers to clear the big boys on

the regular runway while following clearance

• Helps Spacing Issues

Doc Smith Con’t

• Runways can’t be lengthened • $$• EPA

• EPA• Extensions of Runways Is a hassle• “Everyone gets in an uproar when we

displace a few snakes, birds, and squirrels.” ~Doc Smith~

Where does the Burden Lie?

So then From a Human Factor Standpoint:

• People make errors• Typical circumstances or co-

occurring events • Impossible to anticipate

• “If they can't be anticipated, they can't be prevented.” ~Dr. Neville~

So what do we have to do?

• “Ensure that it's impossible for a commercial jet to initiate take-off procedures on a GA runway”• How?

• I honestly don’t know . This is why I’m here, to find these things out so it never happens again!

Just A little more guys I promise!

Color• The Difference in color of the taxiways and

runways can lead to massive confusion!

There is minimal Difference between where the runway begins and if you are on a taxiway

With the runways being asphalt, the color is different.

Other Places

• Look Familiar?

• Yet Daytona Beach has CRJ and M88 traffic just like LEX

ATL Issue with RWY 28/10

• During low visibility conditions the section of concrete that extends from the runway over I-285 could be mistaken as a taxiway.

• This section of concrete is the same color as the runway.

• Yellow chevrons in this area may appear to be taxi lines.

• These hazards are NOT depicted on the Jeppesen ATL 10-9 page.

Bridge is same

color as RunwayChevrons?

Big Deal

You better remember the high

speed is on the left and before the bridge?

You better remember the high speed is

before the bridge?

Taxiway Bridge is

IDENTICAL to runway Bridge!

You better remember the high

speed is on the left and before the bridge?

Chevrons? Big Deal

Chevrons? Big Deal

High Speed Turnoff is same color as runway AND

bridge!

Oops I thought

that was a taxi line…Down the

embankment

Runway 28/10

Runway 28/10

Conclusions and Findings

• PILOT ERROR• The CRJ didn’t gain enough speed to

get off the 3500 foot General Aviation Runway

• A number of breakdowns in human factors led to the crash

• The captain and first officer did not follow Comair’s sterile cockpit rules

• Loss of situational awareness led to wrong runway

• Pilots not cross checking compass heading

• Pilots failure to abort the takeoff even before rolling due to lack of illumination

• Air Traffic Controller• One on duty with two mandated

Into the future

• Education!• Never stop learning

• Verify• Compass Heading• When In Doubt, Don’t!• Read back with Proper

phraseology

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