Crash of Flight 5191

Errors are reported, but never eliminated

“It was my first (position) of the day. I had just come from my daughter’s birthday party and my mind was not on ATC,” or air traffic control.

That’s what a controller at Blue Grass Airport wrote in a March 2004 report in which he or she described directing an incoming B737 into the path of an outgoing plane that holds from 68 to 74 passengers.

The controller realized the mistake - as did the pilots who saw each other - and got them on separate paths before they crashed into each other. But the controller knew he or she had “messed up big time” and filed the report explaining what happened with NASA’s Aviation Safety Reporting System.

“I was very lucky that ACR Y (aircraft Y) saw ACR X (aircraft X),” wrote the controller, whose name was redacted from the report.

“I hope this helps, I was very complacent and not busy at all. This scared me and all within 3 mins (minutes) of sitting down. Like I said, my mind was still at my little girl’s birthday party.”

Pilots, controllers and others involved in aviation are trained to focus on their jobs, but it isn’t always possible.

And that’s one reason NASA maintains the Air Safety Reporting System data and analyzes it, said program director Linda J. Connell.

“We research the human factors to learn from what people can tell us,” she said.

This report is one of 99 filed voluntarily with the ASRS system about the Lexington airport or planes flying above Lexington. Of those, three reports indicate a near-miss in the air.

Near-miss is a very subjective term, said Dana Siewert, director of Aviation Safety at the University of North Dakota. What appears too close to one person may not be to another.

But in one of the reports about a near-miss between two planes above Lexington, the tower told one of the planes to “clb (climb), clb now.”

The pilot disconnected the auto-pilot and got out of the way.

“My guess would be that would be pretty close,” said Siewert.

Jim Burin, director of technical programs for the Flight Safety Foundation in Alexandria, Va., noted that there have been only six major accidents worldwide this year -- counting Comair 5191 -- out of about 17 million airplane departures.

But that also shows, Burin said, that mistakes still can happen despite all the technological aids available to air crews.

“In any accident, it’s a chain of events, not one single event,” he said. “In this case you had the controller and the lights and the taxiway and the air crew. Unfortunately, in a few instances, everything just lines up and something bad happens.”

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