Can outdated paper charts really cause an aircraft accident?

The latest from Comair regarding the crash of flight 5191 is that the crew had outdated charts for the airport, and that due to construction at the Blue Grass airport they may have been confused. Newspapers talk about the missing air traffic controller, and everyone is looking for someone or something to blame. Human nature, I guess.

However, let's examine this a bit closer. Who has the most interest in assigning blame ? The airline? The insurance company. The flight crew? The air traffic controllers? The Blue Grass airport? Could a piece of paper really cause an aircraft to crash on takeoff?


Well, let's take a look. The insurance company will typically provide a limit of liability on an aircraft like this somewhere between $ 100,000,000 and $ 500,000,000 - a lot of money, right? Well, most insurance carriers split up or share the risk with other insurance companies. For example, let's say the primary insurance company takes the first $ 10,000,000 of liability, and then purchases excess liability coverage from another carrier, or reinsurer. So, their liability is limited to just $ 10,000,000 - certainly an acceptable level of risk/reward to stay in business.

Then, the first reinsurer may take the limit from $ 10,000,000 to $ 50,000,000. Not too tough because they can provide that limit across many air carriers, so their maximum exposure is $ 40,000,000. From $ 50,000,000 to $ 100,000,000 another reinsurer takes that risk, and so on.

So, none of the insurance carriers are going out of business because of this loss, and they WILL pay! No reason to worry about blame here.

The flight crew? Well, Part 91 of the Federal Aviation Regulations (FAR's) Section 91.3 - Responsibility and authority of the pilot in command states "(a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft." Not much wiggle room here, is there? And, I guarantee you that the pilot(s) are extremely distressed and would not dodge responsibility even if they could. Nothing here to gain from blaming someone/something else.

The air traffic controllers? Again, looking at FAR 91.3 (a) it simply is not their responsibility. One, two or three controllers might not have made a difference, but in any case it is still the flight crews responsiblity.

The Blue Grass airport? Well, under the FAR's they are required to issue NOTAMS when there are activities on the airport which affect airport operations. NOTAMS are Notices to Airmen which the pilot in command is required to read and understand before undertaking operations at the airport. These are usually provided in the briefing packet the pilot gets prior to takeoff, and in many cases are broadcast over the ATIS (Air Traffic Information System) frequency at the airport, and which flight crews should always listen to.

So, where does that leave us? The airline. Yes, they have a vested interest in assigning blame anywhere but on the airline and the flight crew. After all, they are in the business of providing safe transportation to the public. If the public believes the airline and/or its employees are unsafe, it will affect the bottom line. Therefore, the out of date chart is to blame. But, who provides those charts to the crew? Ah ha, the airline.
Back to square one.

I am not judging, nor opining as to the actual cause of the accident, but in the end we are left with FAR 91.3 (a). What do you think?

FLy safe - Crusty Captain
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Are aircraft accidents similar in cause?

On June 27, 2005 an aircraft piloted by John T. Walton, son of Wal-Mart founder Sam Walton, crashed in the Grand Teton National Park in Wyoming. What most people don’t know, however, is that John Walton was an accomplished pilot with over 9,400 hours of flying time, and that he flew his own Cessna Citation CJ single pilot jet aircraft.

However, he did not die in the Citation Jet. Rather, his interest in aviation was quite broad, and that the aircraft he was flying was an experimental category light sport aircraft (LSA) which he assisted in building. The aircraft was a CGS Hawk Two Place Arrow ultra light aircraft constructed of aluminum tubing and covered with Dacron. The windshield was Lexan and sewn into the Dacron fabric.

Mr. Walton had a number of small incidents with this aircraft after he purchased it. For example, when he took delivery of the aircraft in West Virginia he performed several flights in the aircraft. On one of these flights he left a cordless drill on top of the engine which fell off during flight and damaged the aircraft’s propeller.

A second incident occurred when the pilot was transporting the aircraft to Wyoming and landed in Burwell, Nebraska to refuel. During his takeoff a piece of luggage fell from the rear of the airplane and returned to the airport to retrieve the luggage. Apparently the landing gear of the aircraft was damaged upon landing back at the airport. He then completed his flight to Jackson, Wyoming.

Although he had been offered on-site assistance from the aircraft manufacturer, Mr. Walton decided to repair the aircraft himself. The accident flight was the third one since the hard landing in Nebraska and since the subsequent repairs. It appears that the pilot experienced control movement problems which led to the fatal accident.

An examination of the wreckage at the accident site uncovered an inspection mirror which had been severely damaged, having been bent in half like a taco, as if it had jammed somewhere in the aircraft. While it was not possible to determine if the mirror had jammed in the controls, it seems a possible explanation given the previous incidents which occurred with this pilot.

This leads me to the tie-in with the Comair 5191 accident. Again, most accidents occur before the pilot ever gets into the aircraft. Having a personal wealth of over $ 18 Billion and plenty of piloting time (9,400 hours) does not insure that you will not get bitten in the ass by a silly mistake.

Keep your wings level and your eyes moving!

Crusty Captain.

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Comair 5191

Comair 5191 - what happened? As a pilot I have a difficult time trying to figure out how this accident occurred. An experienced crew who had previously flown into this airport before without incident.

When I learned to fly many years ago in West Texas my instructor used to carry a rolled up newspaper, and any time my head wasn't moving, my eyes were not moving or I was simply gazing out the window at the scenery, he would whack me on the back of the head! The point was - pay attention!

Later in life, as a flight instructor, I noticed that newer pilots were fascinated, almost mesmerized, by all of the bells and whistles which had found their way into the aircraft cockpit. For example, the CRJ100 has a Collins Pro Line 4 Avionics suite consisting of six tube EFIS (Electronic Flight Instrument System). Each of these tv like tubes can display an array of information for the flight crew ranging from engine instrumentation to weather radar and navigation information. You cans see how the cockpit display looks in the photograph above.

The crew were cleared to taxi to and depart from runway 22 at the Lexington Blue Grass airport, but for some reason took off on the 3500 foot runway 26. Given all of the information available to them, it is hard to understand how they could have made this mistake.

All airport runways are marked with their approximate magnetic heading in very large luminescent white paint. In other words, on the end of the runway it would say the runway heading. All a pilot has to do is look out the window to see these numbers! Further, heading information is displayed prominently on the EFIS screens. The date on the CRJ200 (which is similar to the CRJ100) can be found here:

Back to when I learned to fly. The first thing we were taught to do when we taxiied onto the active runway was to set our DG (Directional Gyro) which had to be reset every time the engine was started. These instruments were called "steam gauges" as opposed to the "glass cockpits" of todays aircraft. In glass cockpits all of this is taken care of for you automatically - so - no need to set the DG.

Let us hope that the co-pilot recovers and we find out what really happened. All pilots have known that accidents usually start well before the crew ever reaches the aircraft. Its all about attitude.

Have a great day! "Crusty Captain"

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