In the 5191 accident, we lost a friend, a son, a brother, an uncle and a fellow crewmember. He will forever be remembered along with the other 48 people who died that morning… An Aviation Accident is a tragic event caused by a series of factors. However even just one factor can change a persons life forever… So how do we stop these events from happening?

Flight 5191 An Accident Waiting To Happen That did happen.

Flight History Departed Lexington Blue Grass (LEX) Arrived Atlanta Hartsfield Jackson Int (ATL) Canider Regional Jet CRJ-100 N431CA 3 Flight Crew Memebers 2 Pilots, Jeff Clay and James Polehinke 1 F/A Kelly Heyer Flight Pattern that morning

The Human Factors Issues Behind 5191 Pilots – Breaking Sterile Cockpit Rules – Sleep deprived? Wrong CRJ to begin with Air Traffic Controller – One On Duty – FAA mandated Two – Turned His Back Counted Strips

Workload Management ATC One on Duty IND center LEX Tower/Ground Counting Strips

Runway 26 Versus is unlit 26 is lighter pavement then 22. (Concrete vs. Asphalt) 22 is lit

Blue Grass Runway Simulation Actual Time of the impact was 0604 Simulation set at 0602AM Date set to 08/27 Similar Cockpit Viewing used

Runway 22 is over here! Taxi Route to 22 on 08/27/06 Normal Taxi Route to 22 when Taxiway Alpha was open First Set to Day to see where we are….you can see the taxiways very well. Now what happens when we set it to right before sunrise?

Rotating Red Lights Indicating Closed Taxiway New Procedures called for pilots to taxi via this taxiway…can you see it?

Pilots Didnt see Runway 26 Position Marker

Runway 22 is over here! Taxi Route to 22 on 08/27/06 Normal Taxi Route to 22 when Taxiway Alpha was open Simulation set at 0602AM August 27 th CST On FS04 Actual Crash 0604 AM

Normal Procedure (not actual instruction) Taxi over 26, and Hold short at 22 on Alpha.

August 27 th Procedure: (not actual instruction) Construction Closed Alpha (X) New Instruction was to take Alpha 1 ( )

What Happened Actually

On the wrong runway. No Centerline lighting? HEADING?!?!?!?

Had they been on the right runway HEADING?!?!?!? Centerline lighting

Assessment Vs. Decision Making Dr. Endsly In other words an internal representation convinced the crew they were on the correct runway. It was because how THEIR MINDS assessed the conditions around them led them to believe they were on the right runway The world in their minds did not match the reality outside the cockpit.

The General Aviation Runway What is the purpose of them?

So I turned to the Experts…. ATC/Runway Info Dr. Marvin Smith Human Factors Info Dr. Kelly Neville

Interview with Doc Smith General Aviation Runways Expedite Traffic Why they wont go away CAPACITY ISSUES The industry is beyond operating capacity

Doc Smith Cont GA Runways supplement to Larger Runways Allow controllers to clear the big boys on the regular runway while following clearance Helps Spacing Issues

Doc Smith Cont Runways cant be lengthened $$ EPA Extensions of Runways Is a hassle Everyone gets in an uproar when we displace a few snakes, birds, and squirrels. ~Doc Smith~

Where does the Burden Lie?

So then From a Human Factor Standpoint: People make errors Typical circumstances or co- occurring events Impossible to anticipate If they can't be anticipated, they can't be prevented. ~Dr. Neville~

So what do we have to do? Ensure that it's impossible for a commercial jet to initiate take-off procedures on a GA runway How? I honestly dont know. This is why Im here, to find these things out so it never happens again!

Just A little more guys I promise!

Color The Difference in color of the taxiways and runways can lead to massive confusion! There is minimal Difference between where the runway begins and if you are on a taxiway With the runways being asphalt, the color is different.

Other Places Look Familiar? Yet Daytona Beach has CRJ and M88 traffic just like LEX

ATL Issue with RWY 28/10 During low visibility conditions the section of concrete that extends from the runway over I-285 could be mistaken as a taxiway. This section of concrete is the same color as the runway. Yellow chevrons in this area may appear to be taxi lines. These hazards are NOT depicted on the Jeppesen ATL 10-9 page.

Bridge is same color as Runway Chevrons? Big Deal You better remember the high speed is on the left and before the bridge? You better remember the high speed is before the bridge? Taxiway Bridge is IDENTICAL to runway Bridge! You better remember the high speed is on the left and before the bridge? Chevrons? Big Deal High Speed Turnoff is same color as runway AND bridge! Oops I thought that was a taxi line… Down the embankment Runway 28/10

Conclusions and Findings PILOT ERROR The CRJ didnt gain enough speed to get off the 3500 foot General Aviation Runway A number of breakdowns in human factors led to the crash The captain and first officer did not follow Comairs sterile cockpit rules Loss of situational awareness led to wrong runway Pilots not cross checking compass heading Pilots failure to abort the takeoff even before rolling due to lack of illumination Air Traffic Controller One on duty with two mandated

Into the future Education! Never stop learning Verify Compass Heading When In Doubt, Dont! Read back with Proper phraseology

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