Wednesday, January 17, 2007

Comair Flight 5191 latest news from NTSB

New information released today by the NTSB includes cockpit-voice-recorder (CVR) information.
0117ntsbrelease/361245.pdf
0117ntsbrelease/361105.pdf
0117ntsbrelease/356274.pdf
0117ntsbrelease/356317.pdf

Data from "Rolling-Thunderbird" : Today at 19:12 (UTC)
from www.pprune.org

1 comment:

Wade said...

In terms of "framing" or "mental model" errors, there was an expectation that this would be a very easy flight. The flight plan to Atlanta was direct, and the copilot said it didn't get "any easier than that" and the captain laughed in agreement. (5:50:58)

But the key part of the cockpit voice recording is at time 5:56:49, when the copilot says: "on two two the ILS is out, or the glideslope is, the REILS are out. the uh, came in the other night it was like [sound similar to audible exhalation]lights are out all over the place."

From that we can see two things right away. First, he's somewhat sloppy about exactly what is working and what isn't - because he missed the distinction between whether the entire Instrument Landing System (ILS) was out, or just the vertical-guidance portion of it (the glideslope), leaving horizontal-guidance (runway heading) still working. (He should have gotten that from the ATIS (automated) briefing "Alpha" he listened to at 5:48:24, and also from the pre-flight notices to Airmen (NOTAMS). In fact, just the glideslope was out of service, and the horizontal heading portion of the ILS was apparently still in service.

If he didn't inform the Flight Management System that heading information was still available, he may have missed one more dobule-check on the heading that he could have used.

But the BIG point is that he also had seen the runway when he came in when, due to a short transient power failure at that time, ALL the runway lights were out at the Northeast end of runway 22, the end at which he would start the take-off. So, he is clearly not expecting the runway lights to be ON, and finding the runway that he thinks is "22" with the runway lights off does not trigger even a question to the ground control (tower) or a double-check of his location.

That's where this would normally have been detected, but now he's mentally trapped with this misconception that he seems to have shared and passed onto the Captain as well. The subject isn't even discussed as they are actually taxiing out.

And, he may in fact still be expecting them to be on at the far end (the lift-off end) of runway 22, because his only comment mid take-off is about the lack of lights. Since he'd already noted the lack of lights on the start-end, this could mean he was now surprised again that there weren't any lights at the lift-off
end.

His comment is mid-takeoff-roll at
6:06:16 "dat is wierd with no lights." and the left-seat pilot's response "yeah."

It sure would be nice to know what they're confused by at 6:05:00 with a "green extra one".