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By Dr. Simon Bennett
The August 27 crash of a Comair CRJ100 at Lexington holds at least two important lessons. First, it demonstrates the importance of active learning -- that is, of applying lessons from similar incidents. Second, it shows how latent errors (also known as resident pathogens) can combine to produce active errors. Given that the NTSB may take up to a year to publish its final report, it might be helpful to consider the facts as currently known from a safety science perspective.
One of the most useful theories in the field of safety science is that of isomorphic learning. There are two stages to isomorphic learning: 1) the investigation of failure, i.e. passive learning, and 2) the implementation of lessons learned, i.e. active learning.
The type of error seen at Lexington on August 27, 2006 was not unique. Indeed, a similar incident occurred at the airport in 1993 (see Aviation Safety Reporting System report number 256788). As on August 27, the pilots of a commercial jet airliner lined up on Runway 26 instead of Runway 22. Fortunately, their error was spotted by the Tower controllers who cancelled the aircraft's clearance. The Narrative section of ASRS 256788 listed various contributory factors. They included the weather (it was raining), the Tower's request for an immediate takeoff (which may have put the pilots under pressure) and layout. The Narrative suggested that the airport operator should "clarify multiple RWY ends". If this suggestion had been acted on, the later fatal accident might have been averted.
If we view the 1993 incident in context, we see that it is far from unique. As reported in the August 28 edition of USA Today: "Aviation incident databases include hundreds of cases of pilots attempting to land or take off on the wrong runways." Pilots also attempt to land or take off on taxiways. For example, in February 2002 an Air France Airbus tried to take off from a taxiway in Lisbon. Controllers spotted the error and stopped the take off.
Most spectacularly, crews have landed at the wrong airport. For example, in 2006 an Eirjet-operated Airbus landed at the wrong airport in Northern Ireland. These and other incidents, like the 2001 collision at Linate in Italy which cost...