Thursday, August 31, 2006

Crash Opinions: Technology/Human Factors

Flight 5191:
It is understandable to have questions and opinions..."who should have? who could have?" Why didn't technology fix this problem? All indications up to this point make it presumable that this tragedy was not a case of a tech breakdown, but instead, a basic...a very basic...series of teamwork, communication, leadership and execution failures.
No matter how sexy the bells and whistles in one's cockpit are, the human element still exists.
Today's Washington Post has a follow up article from Del Quentin Wilber ...Series of Errors...where it outlines the chain of mistakes that were key in facilitating this disaster.
The important thing to remember here is that there was not just one causal factor here. Here seem to be a few:
*A "rolling go" (hasty take off, no stop on the runway from the taxiway. Some carriers and departments do not allow this practice. On time departure and arrival stats are not always good measures for efficiency!)
*A sleepy crew (very difficult to control this. Impossible?)
*A confusing NOTAM (notice to airmen, re the lighting change on the rwys and altered taxi instructions)
*Failed/incomplete cockpit crosschecks
A] heading: rwy 22 should be oriented pretty closely to a 220 degree hdg, rwy 26 would be a 40 deg deviation from that: 260-ish hdg. Significant.
B] runway length remaining: next time you are on an airplane, look at the the big numbered signs that populate the sides of the runway, every thousand feet. These signs are "runway remaining" in thousands of feet, indicators. The pilots know by weight and temperature and power and elevation preflight calculations how far the plane will take to get airborne and at what speed they can safely rotate to fly away. They know, before the flight, at what speed and at what distance remaining they can safely abort the takeoff to avert catastrophe, such as this. Either this was not calculated, calculated properly, or cross-checked in the cockpit while on the takeoff roll.
*And finally, the last line of defense, an inattentive teammate in the tower.
There are more issues that will surface, I am certain. But for sure, this was a human error. It was a teamwork breakdown: pilot-copilot-controller. As mentioned in Mr. Wilber's Post article, any one link in this chain would have stopped this tragedy from occurring. It is a bitter pill to swallow.

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