My Comair 5191 crash analysis now available

Because "systems thinking" is a difficult concept to describe, I wrote and just posted a paper analyzing a commercial aircraft disaster - the crash of Comair 5191 - in Lexington Kentucky, August, 2006. This is a full-length (30 page) analysis with pictures and diagrams and source materials, aside from the cockpit voice recorder transcripts, which are linked below. The final NTSB findings on the case are not yet out, to my knowledge.

It's a little rough around the edges, but it starts with the basic astounded question of how two, fully trained pilots, not under pressure, could taxi to and attempt to take off from the wrong runway, resulting in the death of all on-board except the one who was flying the plane, who was pulled from the flaming wreckage by a first responder. The runway was a few hundred yards too short for the plane to have made it off the ground safely.

So, it goes from "How on earth could this have happened!?" to "Oh... There but for the grace of God go I." Only the new commercial pilots on the pilot chat blogs couldn't imagine how such a thing could ever happen to them. It brought to mind the old saying "There are bold pilots, and there are old pilots." In this case, however, the rest of the world conspired to set the stage.

As with "errors" in hospitals, it typically takes a whole team of people to align their actions in the wrong way (the "swiss cheese model"), for someone to buy the gun, someone to load the gun, someone to cock the hammer, someone to hand it to the poor last guy in the chain, and that guy to pull the trigger. For legal purposes, blame is assessed one way, a way this paper does not assess. For purposes of safety engineering, and seeing where interventions might help to avoid ever having this happen again, we need to look at a whole different set of factors that set the stage for this "accident".

Please contact me if you'd like to use this paper (or a newer, better version) for instructional material. Thanks!

( Note: I am a private pilot, but I'm not a member of the NTSB or any official agency, and this analysis is a personal analysis for instructional purposes in safety engineering, not intended for legal purposes. I have no relationship that I know of to anyone involved in this case. These are all real, living people and my reconstruction may be entirely wrong. The point is to honor those who died by learning everything we can from their deaths so this won't happen again.)

Prior Posts:
Comair 5191 - Confirmation Bias and Framing (1/20/07)
Cockpit voice recorder transcripts
Washington DC Crash of Air Florida was 25 years ago - remembered
(with links to BMJ, High-reliability engineering, TEM, etc.)