Comair MEC Submits Analysis on Flight 5191 Accident to NTSB
http://www.alpa.org/DesktopModules/ALPA_Do...00&Tabid=73
For 7 months, the Comair MEC Accident Investigation team, ALPA's Accident Investigation Board, and ALPA staff have worked alongside the National Transportation Safety Board to investigate the factors involved in this accident, analyze the data, and develop the factual record.
As part of the NTSB process, ALPA and other parties to the investigation have the opportunity to submit their analysis to the NTSB for consideration in the Board's final report. Last week, the Comair MEC team did just that by submitting a 128-page report.
ALPA's analysis does not make any statements of probable cause, but lists 32 findings relevant to the accident. In addition, the report offers 24 proposed safety recommendations to the NTSB for its consideration as it finalizes its investigative report. Areas of emphasis in the ALPA analysis are runway signage and marking, charting, airport construction and lighting, pilot and controller fatigue, NOTAMs, and ATC procedures. The report contains a detailed human factors analysis, which evaluates how the above-mentioned areas of emphasis played role in the accident.
The NTSB will now review the submissions of all parties as the Board moves toward concluding its report. The next major step in the NTSB's process will tentatively come in late July, when the Board members will assemble publicly to discuss and issue their final report.
On pages 71-78, this report deals with ATC issues and NOTAM issuance. On page 71A. Accident Summary, the report states that the controller was working four ATC positions. One of these functions should have been turned over to Indianapolis ARTCC, that of Radar Departure Control. Whenever the tower was manned with only one controller, the rule was that the tower controller was not supposed to be handling those duties. It goes on to state that after clearing Comair 191 for takeoff, CD had a "brief exchange with Eagle Flight 882", than turned his attention to administrative tasks inside the tower cab. What is doesn't say is that this "brief exchange with Eagle Flight 882" was all the time that the controller had to catch Comair 191 rolling on the wrong runway and save the lives of 49 people. At the time CD started taking the traffic count, he should have seen the fireball and pulled the crash phone instead of doing the traffic count. Since there was over a two minute delay in alerting the airport fire equipment, it can only be assumed that CD actually did the traffic count and other things before noticing that he had a disaster on his hands.
On page 76 of the report, it states "Eight seconds after the controller issued the final takeoff clearance to Comair 5191 he had a 14 second communication exchange with the previously departed Eagle Flight 882 aircraft. Immediately after the conclusion of this exchange, the controller immediately turned away from the local control position to handle his administrative duties. In his actual interview to the NTSB, the controller stated that after he issued the takeoff clearance, he turned to the center console to do the traffic count." In this excerpt, the controller does not mention his exchange with EGL 882. However the ATC Facual Report clearly makes the point that once the controller's departure duties were completed, his attention was turned away from the scope and onto administrative duties (traffic count).
That is 22 seconds after CD issued the takeoff clearance before he started doing the traffic count. We know that CD issued the takeoff clearance at 06:06:12. We know that Comair was at takeoff power at 06:06:15. We know the time of V1 for Comair was 06:06:29. There is no question where the stricken aircraft was when CD started the traffic count at 06:06:32. Remember that V1 was too far down the shorter runway and was too late to stop, so CD would have had to catch Comair during his "brief exchange with Eagle Flight 882". I say again, traffic count had NOTHING to do with this tragic loss of life.
On page 77, second paragraph, the report states...Further in his interview with the NTSB, the controller stated that after he cleared Comair 5191 for takeoff, he looked at the D-BRITE (radar display) but could recall seeing Comair 5191 again. He was also asked in his interview what he could have done to prevent the accident. He replied "he probably would not do the traffic count at that time" If he saw Comair 5191 again after issuing a takeoff clearance, why didn't he canceled his takeoff clearance?
This report makes no mention of the over two minute delay in pulling the crash phone. It isn't as if CD pulled it right away the the crash personnel were sleeping and didn't answer the phone for over two minutes. I have posted earlier that in all the years I was a controller, I can't remember waiting over about 4 seconds for crash personnel to pick up the phone, even in the middle of the night.
You can download the tape and listen to CD pull the phone. I must say that the crash personnel sounded quite awake and alert. It's located at....
http://www.faa.gov/data_statistics/acciden...t/comair_tapes/
The tape runs from 1002 CUT to 1013 CUT. The accident occurred at approximately 1006 CUT or 4 minutes into the tape. The Crash phone was pulled at 6:30 into the tape. That is at 1008:30 CUT and 2 1/2 minutes after the accident.
On page 81 of the report, there is a discrepancy. The report states CD was talking with crash personnel at 1007:30. This is still 90 seconds after the accident. Then on page 125, which is also labelled pages 17 at the end of the report, under Table 4-Fatigue-related errors identified during the 30 minutes preceding the accident for the accident ATC.
Failed to include NOTAMA-1682 to ATIS's Alpha and Bravo.
Waited until known high workload period to perform administrative task
Failed to notice aircraft had stopped at hold short for runway 26.
Failed to notice aircraft was holding at runway 26 when they requested takeoff clearance.
Failed to notice aircraft taking runway 26 after receiving takeoff clearance.
After hearing explosion, delay of 40-45 seconds before alerting ARFF.
Played no role in assisting ARFF with crash site location.
The report states that lack of sleep may have played a part in these errors. As I have said in my earlier postings, I have never seen controllers stay up all night on the mid shift since I became a controller in 1968 and my father, who was also a controller, got caught sleeping on the mid by the airport manager at MSP.
I have seen supervisors who were supposed to be in the tower cab with us bring pillow and sleeping bag to work and sleep in the break room below the cab. The rest of us went to sleep after the last scheduled arrival or departure and would wake up for the morning departure flights. It is entirely possible that CD got only 2 hours sleep because he planned on catching 5 hours sleep at work that night. There is no sense in watching the rotating beacon spin around for five hours and doing the crossword puzzle. If CD managed to get 5 hours sleep, we should not be listing fatigue as a cause for these errors.
The report goes into great detail about the 8 minute response time to the accident scene on the part of crash personnel and states the response time would have been much faster if they had not taken the most direct route. It states that after the controller alerted ARFF about the crash, he turned his attention to administrative duties again, this time he was making entries into the tower log about the accident instead of assisting ARFF personnel.
On page 72 of the report, it states that CD omitted critical information from the new ATIS (Bravo). When Comair called for taxi, he stated that he had information Alpha, the old ATIS. As I mentioned in earlier posts, CD did catch this and advised Comair that the ATIS had changed, but didn't issue that changes to Comair and the report states that this was a critical error.
Here's a link to an open letter to the NTSB I sent last week...
http://www.usaviation.com/forums/index.php?showtopic=36569
It's my understanding that the NTSB will be issuing the final report on the crash as early as tomorrow, July 26,2007. Let's see what the NTSB says about these issues. My guess is that there will be many omissions of these facts.
James Bergquist
Air Safety Activist
[email protected]
http://users.sdccu.net/chickenlittle
http://www.alpa.org/DesktopModules/ALPA_Do...00&Tabid=73
For 7 months, the Comair MEC Accident Investigation team, ALPA's Accident Investigation Board, and ALPA staff have worked alongside the National Transportation Safety Board to investigate the factors involved in this accident, analyze the data, and develop the factual record.
As part of the NTSB process, ALPA and other parties to the investigation have the opportunity to submit their analysis to the NTSB for consideration in the Board's final report. Last week, the Comair MEC team did just that by submitting a 128-page report.
ALPA's analysis does not make any statements of probable cause, but lists 32 findings relevant to the accident. In addition, the report offers 24 proposed safety recommendations to the NTSB for its consideration as it finalizes its investigative report. Areas of emphasis in the ALPA analysis are runway signage and marking, charting, airport construction and lighting, pilot and controller fatigue, NOTAMs, and ATC procedures. The report contains a detailed human factors analysis, which evaluates how the above-mentioned areas of emphasis played role in the accident.
The NTSB will now review the submissions of all parties as the Board moves toward concluding its report. The next major step in the NTSB's process will tentatively come in late July, when the Board members will assemble publicly to discuss and issue their final report.
On pages 71-78, this report deals with ATC issues and NOTAM issuance. On page 71A. Accident Summary, the report states that the controller was working four ATC positions. One of these functions should have been turned over to Indianapolis ARTCC, that of Radar Departure Control. Whenever the tower was manned with only one controller, the rule was that the tower controller was not supposed to be handling those duties. It goes on to state that after clearing Comair 191 for takeoff, CD had a "brief exchange with Eagle Flight 882", than turned his attention to administrative tasks inside the tower cab. What is doesn't say is that this "brief exchange with Eagle Flight 882" was all the time that the controller had to catch Comair 191 rolling on the wrong runway and save the lives of 49 people. At the time CD started taking the traffic count, he should have seen the fireball and pulled the crash phone instead of doing the traffic count. Since there was over a two minute delay in alerting the airport fire equipment, it can only be assumed that CD actually did the traffic count and other things before noticing that he had a disaster on his hands.
On page 76 of the report, it states "Eight seconds after the controller issued the final takeoff clearance to Comair 5191 he had a 14 second communication exchange with the previously departed Eagle Flight 882 aircraft. Immediately after the conclusion of this exchange, the controller immediately turned away from the local control position to handle his administrative duties. In his actual interview to the NTSB, the controller stated that after he issued the takeoff clearance, he turned to the center console to do the traffic count." In this excerpt, the controller does not mention his exchange with EGL 882. However the ATC Facual Report clearly makes the point that once the controller's departure duties were completed, his attention was turned away from the scope and onto administrative duties (traffic count).
That is 22 seconds after CD issued the takeoff clearance before he started doing the traffic count. We know that CD issued the takeoff clearance at 06:06:12. We know that Comair was at takeoff power at 06:06:15. We know the time of V1 for Comair was 06:06:29. There is no question where the stricken aircraft was when CD started the traffic count at 06:06:32. Remember that V1 was too far down the shorter runway and was too late to stop, so CD would have had to catch Comair during his "brief exchange with Eagle Flight 882". I say again, traffic count had NOTHING to do with this tragic loss of life.
On page 77, second paragraph, the report states...Further in his interview with the NTSB, the controller stated that after he cleared Comair 5191 for takeoff, he looked at the D-BRITE (radar display) but could recall seeing Comair 5191 again. He was also asked in his interview what he could have done to prevent the accident. He replied "he probably would not do the traffic count at that time" If he saw Comair 5191 again after issuing a takeoff clearance, why didn't he canceled his takeoff clearance?
This report makes no mention of the over two minute delay in pulling the crash phone. It isn't as if CD pulled it right away the the crash personnel were sleeping and didn't answer the phone for over two minutes. I have posted earlier that in all the years I was a controller, I can't remember waiting over about 4 seconds for crash personnel to pick up the phone, even in the middle of the night.
You can download the tape and listen to CD pull the phone. I must say that the crash personnel sounded quite awake and alert. It's located at....
http://www.faa.gov/data_statistics/acciden...t/comair_tapes/
The tape runs from 1002 CUT to 1013 CUT. The accident occurred at approximately 1006 CUT or 4 minutes into the tape. The Crash phone was pulled at 6:30 into the tape. That is at 1008:30 CUT and 2 1/2 minutes after the accident.
On page 81 of the report, there is a discrepancy. The report states CD was talking with crash personnel at 1007:30. This is still 90 seconds after the accident. Then on page 125, which is also labelled pages 17 at the end of the report, under Table 4-Fatigue-related errors identified during the 30 minutes preceding the accident for the accident ATC.
Failed to include NOTAMA-1682 to ATIS's Alpha and Bravo.
Waited until known high workload period to perform administrative task
Failed to notice aircraft had stopped at hold short for runway 26.
Failed to notice aircraft was holding at runway 26 when they requested takeoff clearance.
Failed to notice aircraft taking runway 26 after receiving takeoff clearance.
After hearing explosion, delay of 40-45 seconds before alerting ARFF.
Played no role in assisting ARFF with crash site location.
The report states that lack of sleep may have played a part in these errors. As I have said in my earlier postings, I have never seen controllers stay up all night on the mid shift since I became a controller in 1968 and my father, who was also a controller, got caught sleeping on the mid by the airport manager at MSP.
I have seen supervisors who were supposed to be in the tower cab with us bring pillow and sleeping bag to work and sleep in the break room below the cab. The rest of us went to sleep after the last scheduled arrival or departure and would wake up for the morning departure flights. It is entirely possible that CD got only 2 hours sleep because he planned on catching 5 hours sleep at work that night. There is no sense in watching the rotating beacon spin around for five hours and doing the crossword puzzle. If CD managed to get 5 hours sleep, we should not be listing fatigue as a cause for these errors.
The report goes into great detail about the 8 minute response time to the accident scene on the part of crash personnel and states the response time would have been much faster if they had not taken the most direct route. It states that after the controller alerted ARFF about the crash, he turned his attention to administrative duties again, this time he was making entries into the tower log about the accident instead of assisting ARFF personnel.
On page 72 of the report, it states that CD omitted critical information from the new ATIS (Bravo). When Comair called for taxi, he stated that he had information Alpha, the old ATIS. As I mentioned in earlier posts, CD did catch this and advised Comair that the ATIS had changed, but didn't issue that changes to Comair and the report states that this was a critical error.
Here's a link to an open letter to the NTSB I sent last week...
http://www.usaviation.com/forums/index.php?showtopic=36569
It's my understanding that the NTSB will be issuing the final report on the crash as early as tomorrow, July 26,2007. Let's see what the NTSB says about these issues. My guess is that there will be many omissions of these facts.
James Bergquist
Air Safety Activist
[email protected]
http://users.sdccu.net/chickenlittle
