Re: OT: The Real Culprit

On Thu, 31 Aug 2006 08:40:27 -0400, "George Z. Bush"
<georgezbush@xxxxxxxxxxxxxxxxxx> wrote:

The National Transportation Safety Board, as it is charged to do, is now
investigating the causes of the recent commuter crash at Lexington, Ky that took
49 lives with but one survivor (the copilot) in the hospital in critical
condition.

As they almost inevitably do, you can just about bet the farm that they're going
to hang the biggest part of the horns on the aircrew for the mishap. What will
almost inevitably be glossed over in their findings other than reporting on how
thoroughly they examined the issue will be the question of crew rest prior to
the flight. If the crew proved to have slept for six hours, they'll undoubtedly
find that it should have been enough to enable them to maintain the high level
of alertness that all aircrews flying the public around need in order to do
their jobs safely. The flying public is not supposed to notice that apart from
the time spent in the air, all of the time they spend in their preflight
preparations and in postflight cleanup and reporting responsibilities also
represent a drain on the aircrew's stamina and alertness. But they will be the
convenient scapegoats (usually posthumously......but that doesn't matter).

What's starting to come out now, which is what makes this event different from
most of the others, is the level of manning in the airport control facility. It
appears that only one controller was on duty in the tower, and he was
functioning on only THREE hours of sleep. He didn't choose to work on that
little sleep.....his job mandated it. It should surprise no one that he wasn't
nearly as attentive to what was going on on his taxiways as he should have been
were it not for the fact of his level of rest and he being forced to do two jobs
by himself. Apart from the inevitable nightmares the poor sod is going to have
for years to come over the 49 lives lost because he was distracted and not
paying attention, the NTSB will undoubted hang part of the horns on him.

But isn't the real culprit the invisible bureaucrat who decided that because
traffic at that hour was minimal, the tower and ground control could safely be
operated by one person when two were in fact required? The chances are
excellent that (1) he'll never be identified to the public by name, (2) he'll
never be disciplined or (perish the thought) fired for his poor judgement and
(3) just to make sure that the Peter Principle is still alive and well, he'll be
promoted to a higher level where his shortcomings and inadequacies will remain
hidden.

Maybe even more to the point, isn't the system itself the real culprit because
it's configured to decide the point at which extra money should be spent to
provide for the flying public's safety? Should money ever be a limiting factor
when the public who provides that money climbs aboard an aircraft expecting a
safe flight? Please keep in mind that we're not talking about inventing a new
type of control system, we're only talking about paying for another employee's
salary and percs.

A good analysis, but at the basic level there's virtually no way the
primary cause can be anything other than crew error. Certainly
crew-rest could play a part and tower manning in violation of
expressed FAA policy might be contributing factors, but the will
happen point came with the crew error.

Some things I learned over the years, and although my "crew-based"
transport experience is minimal and even embarrassing, some factors
apply even in small, fast jets.

1.) Always know your taxi route.
2.) Know your clearance.
3.) Know the regulations.
4.) Know your departure.
5.) Check your heading.
6.) "Tune and identify" then set up the departure heading index (AKA
"Bug")
7.) Brief your crew on the departure.
8.) Check heading against mag compass against expected at lineup.

These guys apparently didn't know that you can't operate off an
unlighted runway in the dark.

They didn't check heading.

They didn't relate heading to departure route.

They didn't do a line speed check at 1000 or 2000' to verify
acceleration or those pesky distance remaining billboards along the
runway.

No way this can be hung on the depot level maintenance or the airdrome
officer.



Ed Rasimus
Fighter Pilot (USAF-Ret)
"When Thunder Rolled"
www.thunderchief.org
www.thundertales.blogspot.com
.

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