The System Failed, 49 Killed
As a frequent flyer, this almost makes me physically sick to think about the systemic problems, the combinations of errors, and the multiple human errors that led to this horrible tragedy. Calling errors “Common” seems to point to things that are systemic rather than being individual-driven. Sure, a person (or people) made mistakes. But, we need to account for that in our system design. We really need lean thinking, real problem solving, and less blame. The system needs to be error proofed.
The USA Today headline above is the least “blame-y” of many I saw today. Was it strictly “pilot error?” Some headlines will blame him. Why were the broken runway lights not fixed?
“The planning discussions with air traffic controllers and the flight crew were about a takeoff from runway 22,” a 7,000-foot runway suited for jets at Lexington's Blue Grass Airport, National Transportation Safety Board member Debbie Hersman said.
Instead, the Comair jet, bound for Atlanta on Sunday morning, took runway 26. That runway is half as long as runway 22 and was unlit because its runway lights were out of service, Hersman said in a media briefing.
The aviation system failed. Many things went wrong. Many mistakes were made. Why can't we be more proactive and error proof this system? Will we see a headline that says “System Kills 49 Passengers?” Unlikely. Will we just blame a dead man and move on? Why don't aircraft systems warn the pilot that he is literally pointed in the wrong direction? The planes have gyroscopes that can tell their compass position.
Why don't we have ground radar systems (or sensors in the runways) that would warn and flag them “HEY, WRONG RUNWAY???”. I read articles that said “it was the pilot's responsibility” to be on the correct runway. I'm all for personal responsibility, but when human lives are at stake, we need SYSTEMS to protect us from human error, well designed systems. We need a high-priority national effort to use FMEA and other proactive problem solving methods NOW. We need to rely on process and “creativity” over spending millions on high-tech solutions (not that high-tech can't play a role). But high-tech takes time (see the slow rollout of ground radar). Process improvement can be immediate if we focus on the right things.
We need to do better.
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