More than likely at that time of the day, LEX tower had one controller doing tower/ground/clearance. There was also *probably* one controller doing TRACON, as UPS inbounds on the DARBY arrival pass through LEX airspace for about 60 seconds before being handed off to Louisville approach.

This will be a very interesting, yet tragic, case study in human factors when all is said and done with the investigation.

 

I think we will find many contributing factors associated with this accident. Of these, I think crew rest, crew procedures, and ATC staffing will be the most significant areas to look into.

Just some thoughts,
There are usually three obvious visual cues and one not so obvious for pilots to observe when taking a runway. 1.The holdshort signage for that particular runway which identifies the hold runway, 2.the runway markings, and 3.the compass heading/HSI heading once the runway has been taken. These are some pretty blatant and basic cues for even the most green of pilots. Also, the less obvious visual cue would be to simply look down the length of the runway after taking position. If it were me, I would think something was amiss when looking down the length of a 3500ft runway as opposed to a 5000+ft runway. This would become even more pronounced as you started your takeoff roll and see the end coming up fast. Not to second guess, but there had to be some point at least half way down the runway when you say "hey this is wrong...ABORT". Something somewhere broke down at it most basic point.

I personally think (just guessing) that crew rest and the "hurry up for an ontime departure" factor will come into play. I sincerely hope that ALPA will use this horrific accident (if facts come to light) to push both the FAA and the airlines to address crew rest shortcomings in the regs. Hopefully the media will jump on this as well in order to aid ALPAs cause if they so choose to take it on.

While I don't know that it is the towers responsibility to watch the aircraft takeoff, I do wonder if the rwy 26 lights were on. This would be unacceptable especially if they were NOTAMed out. Also, I thought I read that the runway itself was closed for repairs. If so, why weren’t there proper closure markings? Also, in light of this accident and others in the past, should we now require the Tower to explicitly watch every departure off of every runway for every airport (if this is not the case already)? If so, there is a definite staffing problem.

I really think there will be many players who should get the finger pointed at them, but unfortunately as with most tragic aircraft accidents we know who will get the majority of the blame.

My thoughts and prayers do go out to all who were affected by this accident.

 

In any major aviation accident there is never one thing that causes it. There is a series of events that come together and create a tragic end.

Some possible factors:
Crew workload just prior to accident.
As a CR2 FO, I can attest that during a short taxi out on a first flight of the day your workload is higher than usual as you have more checks to do.

Tower workload:
Was there only one controller on-duty at the time of the accident?

Wx:

Airport Facility:
Were the rwy lights on the short rwy on or off at the tx

The ultimate question for the NTSB is why did this experienced crew attempt to t/o from the wrong rwy and why the tower controller didn’t warn the crew of the error prior to issuing t/o clearance.

 

Or they can just emphasize the importance of doing something right the first time. i.e., how NOT to make a mistake.

 

Other things to consider, Comair always uses flaps 20 for t/o and as this was a first flight they would not have been using reduced thrust. With this in mind they would have needed about 135-140kts of airspeed to t/o safely. With 3500' of rwy, could they have firewalled thrust levers and rode the stick shacker to a safe climbout?

 

Thank you for that amazing insight.

 

I'm not going to speculate on the hows or the what whys they got into this terrible situation but I will say a strongly contributing factor may have been fatigue. With a 6 o'clock departure you are going to be tired. Even with a long overnight if your schedule is turning around from a late start to an early start. The body's circadian rythm doesn't have time to catch up. Now if this was a minimum rest overnight (which i HATE doing) then fatigue is definately a factor in here. Combine this with a change in circadian rythm and it is very easy to see how mistakes happen.

Unfortunately the FAA allows companies to let these situations occur. A while back in a thread about fatigue I mentioned that the FAA has no pressure to change anything unless blood is spilled. Since it unfortunately has been in this case I really hope the NTSB examines the fatigue aspect of this accident so that thier findings will put pressure on the FAA.

My condolences to the family and crew of flight 191. Especially to the FO who will have the hardest time of anyone dealing with this tragedy.

 

If you look at the other post under the rumway 26 pictures you will see that the airport boundry fence is damaged, but it apprears that the entire aircraft did not come in to contact with it. Also look at the trees. About 25 feet up or so is where they are sheered off. It looks like they did try what you suggested. Problem is that there is not a part 25 clearance plain there. They hit the trees and and once that happens there is not much that you can do. Lets all learn from this.

 

It has been widely stated that a reduced rest overnight was not a factor in this case. The crew was not on a nap/standup/highspeed/CDO.

I prefer early starts personally, but that's just me...

 

I know I'm stating the obvious, but sometimes we lose sight of the basics and they need to be reviewed and re-emphasized.