KLEX Mishap - Comair 5191

August 27, 2006, lagging airport, atc and aircraft design system caused Comair flight 5191 to crash while attempting to depart on a runway that was too short in Lexington, Kentucky. Forty-nine lives were lost. NTSB has the Federal mandate to determine probable cause, the Air Line Pilots Association does not. Remember Reason's swiss cheese? The Reason/Swiss-cheese reframe that the party submissions (ALPA especially) pushed against the NTSB's "flight crew failed to..." probable cause. The Board's finding put the pilots as the proximate cause; the party process documented the latent conditions that pre-loaded the trap and stripped away the redundant defenses, so that a normal-sounding taxi error became fatal. Here's the map, by layer.

Stack them and the picture the parties drew is unmistakable: a first-encountered, unlit, crowned, chart-mismatched runway, reached by a freshly-changed taxi route, with the external cross-check (a second controller) administratively removed and no cockpit position-alert installed — every redundant defense degraded before the crew ever moved the thrust levers. Under Reason's model, the pilots didn't cause the accident so much as inherit an already-holed system and become its last, failed defense. That's precisely the substitution-test result: swap in a rested, competent crew and, on a bad enough morning, many would take the same first runway.

The active failure (the last slice of cheese)

Comair 5191, CRJ-100, Blue Grass (KLEX), 0606 local, 27 Aug 2006. Cleared for Runway 22 (7,003 ft); taxied onto and departed Runway 26 (3,501 ft); overran, struck terrain/trees; 49 of 50 fatal, FO Polehinke sole survivor. NTSB probable cause: failure to use available cues to confirm position + failure to cross-check; contributing: non-pertinent conversation during taxi (sterile-cockpit breach).

That's the last line of defense failing. Everything below is what the parties argued had already failed upstream.

Airport design / surface geometry

Reconfigured taxi route from recent construction. The airfield had just been repaved and Taxiway A realigned. The new routing took aircraft across the Runway 26 threshold to reach Runway 22 — 26's entrance came first and sat right where the crew's mental model expected the run-up to the active. The geometry itself created the ambiguity.

Humped/crowned Runway 8-26. The crest hides the far end from the threshold, so the "this runway is too short" cue was not visually available from where they lined up. You can't see the deficiency you're about to launch into.

Signage/markings degraded or transitional during construction — hold-position and surface-painted guidance were part of the party critique of positive-position cues.

Runway lighting

Runway 26 edge lights were OFF (it wasn't the active); Runway 22's were on. Taxiing into a black hole was itself an anomaly — a crewmember audibly remarked on the darkness/lack of lights — but it was rationalized and pressed. ALPA's HF read: the lighting state was a negative cue (absence of expected light) rather than a positive alert, and humans are poor at catching missing cues under time pressure and expectation bias.

Charts / Jeppesen currency

The airport diagrams (both government and Jeppesen) lagged the construction. The chart in the cockpit did not fully depict the as-built taxiway state the crew was driving through, so the one tool meant to rebuild ground picture disagreed with the pavement. Chart-to-world mismatch is a classic latent condition — you can brief perfectly off a chart that's already wrong.

NOTAMs / ATIS

The taxiway/construction change was covered by NOTAM, but buried in the volume and format — the parties' recurring complaint that safety-critical NOTAMs are undifferentiated from noise (this case is often cited in the later NOTAM-reform push). "Right information, wrong salience" — which is your "right info, wrong time" refrain for this case.

ATC staffing / the tower (the redundant human defense that wasn't there)

One controller doing two jobs. A single controller worked both tower and radar/TRACON positions, contrary to an FAA staffing directive requiring two controllers on that midnight shift. He issued the takeoff clearance, then turned away to perform administrative/radar traffic-count duties and did not monitor the takeoff roll — so the wrong-runway lineup went uncaught. NTSB judged that even a second controller might not have been looking at the right moment, but ALPA/NATCA argued the staffing violation removed the last external cross-check and reflected fatigue (the controller had very little sleep). That's a management/latent failure, not a controller-skill failure.

Aircraft / cockpit design

No runway-awareness technology. RAAS (Honeywell Runway Awareness and Advisory System) and moving-map/position-awareness tech existed and could have annunciated "on 26" or a short-field warning — not installed. The absence of an engineered alert meant the only wrong-runway detector left was the two tired humans.

Heading cross-check not procedurally forced. The HSI would read ~260 vs assigned 220 — a 40° disagreement — but nothing in the SOP required a heading-to-clearance confirmation call at the hold. The design/procedure didn't make the cheapest cross-check mandatory.

Organizational / physiological

Early-morning, back-of-clock departure — circadian low for both crew after a minimum rest period, at the time 8 hours vs current 10 and the lone controller; fatigue as a performance-degrader across all the humans in the loop simultaneously.

Sterile-cockpit deviation as normalized practice, not a one-off character flaw — the HF framing is that non-pertinent taxi chatter was industry-common, i.e., a latent normalization, which is why the fix is systemic (procedure/culture), not "these two talked too much."

The through-line

Stack them and the picture the parties drew is unmistakable: a first-encountered, unlit, crowned, chart-mismatched runway, reached by a freshly-changed taxi route, with the external cross-check (a second controller) administratively removed and no cockpit position-alert installed — every redundant defense degraded before the crew ever moved the thrust levers. Under Reason's model, the pilots didn't cause the accident so much as inherit an already-holed system and become its last, failed defense. That's precisely the substitution-test result: swap in a rested, competent crew and, on a bad enough morning, many would take the same first runway.

Or you could argue that the runway was too short, a universal design flaw.

NEWWS - Nutrition-Exercise-Water-Wellness-Sleep

 Fitness for Duty

NNutrition

EExercise

WWellness

WWater

SSleep

Stop asking if you're not broken.
Start proving you're ready.

NEWWS replaces the I'M SAFE checklist with five affirmative actions and a 72-hour lookback.

---

Every pilot learns I'M SAFE — but when was the last time it actually changed our decision to fly? For most of us, the honest answer is never. I'M SAFE asks us to look for what's wrong, and healthy people tend to answer "nothing" and move on. That's not a character flaw; it's how the checklist is built. NEWWS flips the question. Instead of screening for illness, impairment, or stress we may not recognize in yourself, NEWWS asks what we actively did to show up ready: did we fuel the body with real nutrition today, move with deliberate exercise, invest in mental wellness, stay hydrated with water, and protect our sleep? Five affirmative actions, checked against a 72-hour lookback. It's the difference between "I'm not sick" and "I'm prepared." One is a minimum. The other is a standard.

Whether we're student pilots building habits on day one or chief instructors shaping a program culture, NEWWS belongs in our mission prep right alongside the weather brief and the aircraft preflight. Add it to the FRAT. Put it on the dispatch board. Make it part of the conversation before the first engine starts. Training programs that normalize NEWWS aren't just teaching risk management — they're building aviation professionals who take ownership of the one system no mechanic can inspect: themselves. I'M SAFE served its era. NEWWS is how we train the next one.

Signal Charlie#NEWWS #AviationSafety #FitnessForDuty #FlightTraining #SafetyII
                             I've been in aviation since 1980, from turning wrenches to watching the world turn beneath me at 41,000 feet. A successful career takes prep. Pros Prepare. For more information on prep and coaching, check out Dr. Abigail Powell's webpage on mental health: The Aviation Therapist and Coach  it's a great place to find ideas and answers. Fly Smart

Aviation = Learning a New Language

16 May 26:

There are many new words and acronyms to learn in aviation, an entire new language...fuselage, elevator, FAA, NMS, Roger, Over, Unable...If you are just getting started, I would start learning the alphabet and numbers.

Learning Air Traffic Control (ATC) radio communications phraseology is essential for maintaining clarity, consistency, and safety in aviation operations. One of the most critical elements outlined in Federal Aviation Administration (FAA) Airman Information Manual (AIM) Section 4‑2‑7 is the use of the International Civil Aviation Organization (ICAO) phonetic alphabet. This standardized alphabet assigns distinct words to each letter (e.g., “Alpha” for A, “Bravo” for B) to eliminate confusion that may arise from similar-sounding letters, accents, or poor radio quality.

The importance of ICAO phonetics lies in reducing miscommunication, which can lead to serious operational errors. In busy or high-stress environments, such as approach or departure control, even a minor misunderstanding of a call sign, runway assignment, or instruction could result in runway incursions or loss of separation. By using universally recognized phonetic words, pilots and controllers ensure that critical information is transmitted and received accurately, regardless of language background or audio interference.

AIM 4‑2‑7 emphasizes that correct phraseology promotes efficient communication while minimizing the need for repetition. It also supports international interoperability, allowing pilots and controllers from different countries to communicate effectively under ICAO standards. Ultimately, mastering phonetic communication is a foundational skill for aviation professionals and a key contributor to the global aviation safety system.

Table 4‑2‑2: ICAO Phonetic Alphabet

Letter	Word	Letter	Word
A	Alpha	N	November
B	Bravo	O	Oscar
C	Charlie	P	Papa
D	Delta	Q	Quebec
E	Echo	R	Romeo
F	Foxtrot	S	Sierra
G	Golf	T	Tango
H	Hotel	U	Uniform
I	India	V	Victor
J	Juliett	W	Whiskey
K	Kilo	X	X-ray
L	Lima	Y	Yankee
M	Mike	Z	Zulu

There are also signal flags associated with the international code, and sometimes there is a crossover when Navy ships are conducting flight operations.

Safety Culture TRAIL

 26 Mar 26:

WIthin a safety policy we look at the culture of an organization...we want people to share information, identify hazards, recommend improvements and be adaptive to taking action. There is a lot of talk of a "Just" culture but "Trust" is a term better suited to the continuous improvement process. 

We've identified "TRAIL" as an acronym for desired culture traits within an organization:

Trust

Report

Adapt

Inform

Learn

We see a lot of these same skills in crew resource management.

Leave a trail of safety on the continuous improvement path for others to follow. 

Fly Smart,

Clark

NTSB's Probable Cause(s) for the 2025 DCA Midair Collision

08 Feb 26: 

The NTSB's probable cause(s) for the 2025 DCA midair collision point to systemic failures within the Federal Aviation Administration (FAA) and U.S. Army, including poorly designed helicopter routes near airline approach paths, inadequate controller staffing and training, failure to implement safety recommendations (like ADS-B In), and lack of data sharing, leading to an unsustainable situation where visual separation relied on overwhelmed controllers and pilots couldn't effectively "see and avoid".





Image Credit: NTSB


Probable cause should be plural, probable causes...I submit that we should just make a list of all human and material factors that contributed, and skip the probability exercise. The NTSB does that, by their listing of findings.

The important takeaway are the 50 recommendations, that we work together to take action on mitigating risk throughout the National Airspace System (NAS). 

FMI: NTSB Investigation Details



Probab​​​le Cause(s)


​​​We determined that the probable cause(s) of this accident were the
-FAA’s placement of a helicopter route in close proximity to a runway approach path;
-their failure to regularly review and evaluate helicopter routes and available data, and
-their failure to act on recommendations to mitigate the risk of a midair collision near Ronald Reagan Washington National Airport; as well as
-the air traffic system’s overreliance on visual separation in order to promote efficient traffic flow without consideration for the limitations of the see-and-avoid concept. 

Also causal was
-the lack of effective pilot-applied visual separation by the helicopter crew, which resulted in a midair collision.

Additional causal factors were
-the tower team’s loss of situation awareness and degraded performance due to the high workload of the combined helicopter and local control positions and
-the absence of a risk assessment process to identify and mitigate real-time operational risk factors, which resulted in misprioritization of duties, inadequate traffic advisories, and
-the lack of safety alerts to both flight crews.

Also causal was the Army’s failure to ensure pilots were aware of the effects of error tolerances on barometric altimeters in their helicopters, which resulted in the crew flying above the maximum published helicopter route altitude. 

Contributing factors include:

• -​The limitations of the traffic awareness and collision alerting systems on both aircraft, which precluded effective alerting of the impending collision to the flight crews;
• -An unsustainable airport arrival rate, increasing traffic volume with a changing fleet mix, and 
• -airline scheduling practices at DCA, which regularly strained the DCA ATCT workforce and degraded safety over time;
• -The Army’s lack of a fully implemented safety management system, which should have identified and addressed hazards associated with altitude exceedances on the Washington, DC, helicopter routes;
• -The FAA’s failure across multiple organizations to implement previous NTSB recommendations, including ADS-B In, and to follow and fully integrate its established safety management system, which should have led to several organizational and operational changes based on previously identified risks that were known to management; and
• -The absence of effective data sharing and analysis among the FAA, aircraft operators, and other relevant organizations.

Excellent Resources

25 Jan 26:

I'm teaching Crew Resource Management this semester and reviewing some excellent resources from the FAA Safety Team and General Aviation Joint Safety Committee (GAJSC).

FAA Safety Brief Magazine

GAJSC Monthly Fly Safe Topics, Safety Enhancements (SE), Reports & Documents, News Briefs, Newsletter and Partners

Fly Smart!

Kent

The Wide World of GA Flying

 

15 Sep 25: 

The September/October 2025 issue of FAA Safety Briefing magazine explores the tremendous variety of general aviation and focuses on the new perspectives and skills you'll need to consider when moving on to a different type of flying. 

Download the September/October 2025 issue or use the links below to read each article online. 

Fly Smart!

ICAO Top 10 Safety Challenges

 20 Jul 25:

ICAO Top 10 Safety Challenges...2 more and we can have  Dirty Dozen

1. Runway incursions and excursions
2. Controlled flight into terrain
3. Midair collisions
4. Loss of control–in flight
5. Turbulence
6. System component failure–non-powerplant
7. Abnormal runway contact
8. Insufficient funding for modernization
9. Shortages of qualified personnel
10. Poor safety data collection systems

Some of these items have been on the list since the inception of flight, while others have come and gone with the introduction of new technologies and systematic approach to reducing negative effects of human error in the aerospace system. 

Imagine if the Wright Brothers and Charles Taylor could have seen this engine?

We've come a long way, especially with the affordability and capabilities of flight simulators.

What items are on your Top Ten, and how can we reduce the risk?

Aviation Safety Tribal Knowledge

 06 Jun 25:

A safety slogan from my Brother in Law..."Don't be the topic of the next safety standdown."

From AOPA, who reshared them from other sources:

These time-honored quotations reveal the topics pilots think (and talk) most about: emergencies, aeronautical decision making, aircraft design, and flying technique. And many are imbued with exaggeration and flying’s pervasive gallows humor.

“Any landing you can walk away from is a good one.”

“Any landing where the airplane is reusable is a great one.”

The meaning of most of these maxims is obvious, but some include subtle messages, too. Here, in no particular order, are some of the most widely circulated.

Aerial emergencies:

“The first thing to do is wind your watch.”
Think things through, and don’t make a bad situation worse by compounding the problem. Get the checklist out, consider your options, and don’t rush.

“In an emergency, undo the last thing you did.”
Sometimes pilot actions produce seemingly unrelated problems. For example, if your airplane starts an uncommanded roll to the left moments after you turn on the cockpit heater, try turning off the heater—even if those two actions seem to have nothing to do with one another. Sometimes correlation really is causation.

“If faced with a forced landing, fly as far into the crash as possible.”
Aviation icon and test pilot R.A. “Bob” Hoover said this, and he would know having survived multiple aircraft accidents during his long and storied career. Whatever happens, the priority is to maintain control of the aircraft.

“Keep flying until the last part stops moving.”
Don’t give up, even when a situation seems dire.

“It’s Bernoulli that matters in an emergency—not Marconi.”

Concentrate on the physics (defined by Daniel Bernoulli) of flying the airplane, not talking on the aircraft radio (invented by Guglielmo Marconi).

“Aviate, navigate, communicate.”
Fly the airplane first. Then find your way. Once those things are accomplished you can talk on the radio.

Fatalism:

“Time to spare, travel by air.”
Yes, flying is plagued by weather, mechanical, and other delays.

“If the engine quits at night, turn on your landing light. If you don’t like what you see, turn it off.”
Dark humor. Besides, your airplane may not have electrical power after the engine quits. (More “dark” humor, as it were.)

“The second happiest day of your life is when you buy an airplane. The happiest is when you sell it.”
This is only true of some airplanes, not all of them, sometimes due to cost and maintenance. Pilots often feel deep and lasting regret after selling an airplane.

“If it ain’t Boeing, I ain’t going.”
Grammatically questionable Airbus shade.

“Please God, don’t let me [mess] up.”
Also known as Chuck Yeager’s prayer, but originally said with a potent F-bomb.

Aeronautical decision-making:

“It’s better to be on the ground wishing you were in the air than in the air wishing you were on the ground.”
True—but being on the ground wishing you were in the air is still regrettable.

“Start at the NTSB hearing and work backwards.”
When considering a course of action, think about how you might try to explain it to the inquisitors if things go badly.

“Takeoffs are optional. Landings are mandatory.”
What goes up must come down. On a related note, “There are more airplanes in the ocean than submarines in the sky.”

“Better to land downhill than downwind.”
Beware downwind landings, particularly in tailwheel airplanes, because of the possible loss in directional control during rollout.

“Speed is life.”
This saying, coined by a U.S. Navy combat pilot, has broader aviation applications.

“Always leave yourself an out.”
Pilots need to have a Plan B. Not a bad policy for life on the ground, either.

"The only time you’ve got too much gas is when you’re on fire.”
Having lots of fuel provides options—but it’s possible to have too much of a good thing. Think heavy loads, high elevations, and hot days.

“There are old pilots and bold pilots, but there are no old bold pilots.”
Good point, but overstated. Old bold pilots do exist. They’re just rare (or lucky).

Aircraft design:

“Never fly the A-model of anything.”
This military maxim contains an irrefutable truth that aviation learns from bitter experience, and later versions of any aircraft are likely to contain improvements.

“An airplane that looks good flies good.”
Aesthetics matter. A Spitfire is sure to fly more gracefully than a Lancaster. But looks can be deceiving. A de Havilland Beaver and North American T–6 look bulbous, yet they’re delightfully responsive and well balanced in the air.

“There’s no substitute for horsepower.”
Amen. And no replacement for displacement. Excess power can get pilots out of tight situations.

“The Cub is the safest airplane ever made. It can just barely kill you.”
Yes. See previous quote about horsepower.

Technique

“Push forward and the houses get bigger. Pull back and the houses get smaller.”
Except when the airplane stalls, spins, or exceeds 90 degrees of bank.

“Pitch plus power equals performance.”
Aircraft attitude and power produce repeatable results.

“Fly it all the way to the chocks.”
Pay attention and stay engaged whenever the airplane is in motion.

“If you think you might be approaching a dock too fast, you are.”
Many seaplane pilots have learned this lesson the hard way, and they’ve got dinged and scraped floats to prove it.

“Never run out of airspeed, altitude, and ideas at the same time.”
Airspeed and altitude create energy and options for pilots. Landings are the only time pilots should intentionally lack both airspeed and altitude—but they should still have ideas.

“The three most useless things in aviation are altitude above you, runway behind you, and fuel in the truck.”
Same concept as the previous statement about airspeed, altitude, and ideas. Don’t pass up the safety margin that more runway, additional altitude, and extra fuel can provide.

dave.hirschman@aopa.org

NASA Aviation Safety Reporting System and Safety Management Systems

 26 Apr 25:

Working on SMS implementation and wondering how to get a reporting database up and running? The folks at NASA have been administering the Aviation Safety Reporting System (ASRS) for the FAA for almost 50 years now. Analysts have coded and archived over 2 million reports, and the deidentified report database can be searched online.

ASRS is the Global Gold Standard, compared to siloed databases that are accessible only be a few analysts. 7400+ Safety Alert Messages, 527 issues of the Callback newsletter, 7600+ search requests have been generated as a result.

We are peeking over the horizon at improved methods to create and communicate safety intelligence. One way is to share this QR code to the ASRS, on websites, business cards, stickers...who will be the first air operator to put a big graphic on the side of their aircraft? United?

Some folks are using QR code stickers placed on aircraft components to help guide mechanics to proper, up to date manuals. Creative! We use Adobe to generate free QR codes. 

FMI: https://asrs.arc.nasa.gov/report/electronic.html

Reporting is the key driver of risk management, Safety Risk Management is one of the Pillars of a Safety Management System (SMS). What is the future of SMS? System Wide Safety, which relies on reporting to create in-time aviation safety intelligence.

Fly Safe Fact Sheets and Cleared for Takeoff blog

25 Apr 25: 

The FAA has a website with Fly Safe Fact Sheets that cover a variety of General Aviation safety topics. The links take us to a 2 page fact sheet that is visually interesting, covers the high points and has links to additional references: 

Fly Safe Fact Sheet

There is also a link to the well designed Cleared for Takeoff blog:

Cleared for Takeoff

Now if we can just get the name changes to "Fly Smart."

Take care in the air and keep a sharp lookout for traffic through the big glass panel, aka the windshield. Spring flying brings everyone out, most mid airs happen on beautiful clear days, especially around visual reporting points or in proximity to airports or near departure and approach corridors for commercial traffic.

Pop quiz: How far away from this hovering helo should we stay in our light GA airplane?

Fly Smart,

"Clark"

Airport Wildlife Warning

 

Aerial Hot Spots

11 Apr 25:

Threat: Aerial Hot Spot

Mitigation: Keep away from arrival corridors when having a fun VFR day. And check in with ATC to get some separation assurance.

Fly Smart,

Clark

Collision Avoidance

Pilot's Role in Collision Avoidance
Collision Avoidance
Advisory Circular 90-48E

Remember Herb's Rules to Live By:
1. Use a Checklist.
2. Look outside
3. Never fly hard IFR in a single engine aircraft

Visual Scan and Collision Avoidance
-Most midair collisions occur near airports, during daylight hours and in VFR conditions. Early detection is crucial to avoiding collisions, since it takes about 12.5 seconds to realize you are on a collision course and to do something about it.

-Degraded physical condition = degraded vision.

-Environmental conditions such as night time and low visibility degrade vision.

-Vestibular and visual disturbances can create motion and visual illusions.

-Spend 2/3 to 3/4 of scan time outside cockpit.

-Proper visual scanning procedures, eye movements of 10 degrees, focusing one to two seconds on each segment of the sky, 60 degrees left and right, 10 degrees up and down. Day=central vision, night=peripheral. Know that central focal vision is severely degraded at night, so peripheral vision is needed.

-“See and avoid” concept requires vigilance be maintained at all times, regardless whether the operation is IFR or VFR.

-Poor scanning = increased collision risk.

-Proper clearing procedures in all phases of flight.

-Know your aircraft’s blind spots. Turn on all lights in the pattern, and keep in mind that folks using night vision systems may not see all of those lights due to wavelengths outside the NVS operating specifications.

Hanger Talk: There is something special about flashing the wing lights or ground handling lights at night at another aircraft that is off in the distance, like ships passing at sea. A special hello to fellow aviators.

-Know your blind spot, located in the central focal vision where the optic nerve attaches. That is why traffic that is on a constant bearing, decreasing range to your aircraft "suddenly appear." One example is the 2025 nighttime collision near KDCA Reagan National airport.

-Aircraft speed differential and collision risk, converging at 300 knots = 36 seconds to react.

-Greatest collision risk: Airways, VORs, within 25 nm of airports, enroute, at or below 8,000 feet, day, VMC.

“Clear left, clear right, above and below”

-Slow down and live is one defensive tactic, especially in the pattern. 

-"Look with your ears" also, listen to radio calls to build situational awareness of where the traffic is. If a tower is running split frequency operations with customers on both VHF and UHF frequencies, our awareness needs to be higher than whatever the highest level is. 

From the Advisory Circular:

"13.1 Scanning at Night. Scanning at night depends almost entirely on peripheral vision. This is due in part to the night-blind spot that involves an area between 5 and 10 degrees wide in the center of the visual field. A pilot can compensate for the night-blind spot through “off-center” viewing, which requires looking approximately 10 degrees above, below, or to either side of an object. To better perceive a dimly lit object in a certain direction, the pilot should scan the area around the object rather than looking directly at the object. Short stops of a few seconds in each scan will help detect the light and its movement. Note that conflicting ground lights at night increase the difficulty of detecting other aircraft. Also, avoid blinding others while taxiing by not using strobe or landing lights until on the active runway for takeoff. 

Note: Pilots utilizing a Night Vision Imaging System (NVIS), such as night vision goggles (NVG), must be aware that some light-emitting diode (LED) obstruction and aircraft anticollision lighting may not be visible through the NVG. When flying with NVG, pilots should also be looking around the binocular assembly frequently, outside of the NVG view, to detect lighting that may not be visible through the NVG."

Back to Special Emphasis Items

References:
Pilot Handbook of Aeronautical Knowledge

FAR/AIM

Aviation Instructors Handbook

Instrument Flying Handbook

Active Failures of the National Airspace System (NAS)

31 Jan 25:

Dr. James Reason's Swiss Cheese model is often used as a visual model to show how active failures work their way through the latent risk holes in defensive layers (controls) of a system.

(Image Credit: Unknown)

In the case of the recent midair collision over the Potomac, the holes in the National Airspace System (NAS) cheese were big enough to fly a Sikorsky Blackhawk through...

Investigators will quickly determine the Who What When Where and How of what happened in this tragic mishap. Now we must ask, Why? And keep asking, so that we can create solutions that eliminate the multiple severe hazards that exist within the NAS in latent form, in order to keep this from happening again.

Fly Smart

"Clark" Kent

PS: The 2 dimensional, static sliced cheese model gets us thinking about the challenge, while in reality all of the cheese is melted together as a fondue and moving through space and time.

11 Feb 24:

I created a forum today for Aviation Safety Officers (you) to share safety knowledge in the General Aviation Community, hosted for free on groups.io.

I joined the FAATeam 20 years ago to bring years of safety program experience as a military Aviation Safety Officer and Air Line Pilots Association Accident Investigator to the GA community, and currently volunteer at the Richmond FSDO. We have learned a lot and would like to continue the conversation in this "Knowledge Cafe," so please consider checking in with your tips and questions, so we can continue to improve our airspace system. Fly Smarter Kent 2009 FAASTeam Rep of the Year

Click here to join the discussion: https://groups.io/g/AviationSafetyOfficer.

Sleep Hygiene

 Good NEWWS - Nutrition - Exercise - Water - Wellness - Sleep

Here's a few more sleep more tips we've hear through the years...

-Before you sleep and write down things we don’t want to forget. The evening “brain dump” helps strengthen memory and helps us fall asleep more easily. Keep a pen and pencil next to the bed in case other ideas wake us up mid slumber.

-Turn off non-essential ringers and haptics before sleeping.

-A heavy meal too close to bedtime, especially protein, sends a signal to the brain that we plan to be up for a while. 

-The body goes into systems check and repair mode while sleeping, especially during deep REM. As a result of decreased blood flow there can be some stiffness in the morning. A warm shower will help get the blood flowing again and reduce stiffness.

- Favorite sleep science term - Zeitgeber - Sleep/Wake cycles are diurnal, tied to the sun. If we need to sleep during the day, we have blackout curtains and don't peek outside. Once sunlight hits the eyeballs the body thinks it's time to be awake! And don't be surprised if there is a little sleep disruption during full moons, our ancestors found that was a good time to hunt.

Kayaking provides exercise, wellness and sleep benefit. Take healthy snacks like an orange and some water to check all of the NEWWS blocks.

More Good NEWWS for our health.

Runway Safety - Incursions and Excursions

26 Jan 24:

I've been involved with aviation safety for 40 years now, beginning as a Tech Pubs Librarian in our Marine Corps Fighter Squadron to Accident Investigator  Instructor with the Air Line Pilots Association. We've had two severe threats plaguing us ever since more than one airplane tried to operate in the same area, runway COLLISIONS and runway EXCURSIONS. We have developed a slew of defenses against the threats, but there is still high potential for accidents during takeoff and landing with an associated catastrophic consequence.

We can not accept the threats as they currently are. So how do we reduce or eliminate the runway threats? 

Tactically, For Today:

1. Increase awareness tailored to each operating area. Check out the NASA Aviation Safety Reporting (ASRS) database for your airports and the FAA's new safety videos From The Flight Deck.

2. Brief threats with your team. Your team includes hangar flying, ATC, FBO, Dispatch, passenger...Complex taxiways? Night? Low visibility? High traffic? Crosswinds? Non-towered field? Multiple runways in use? Crossing runways?

3. Take specific actions to reduce (mitigate) or eliminate the the potential threats. Some examples, taxi slow, lights on to cross runways, pick a runway with better winds, stabilized approach, fly the aircraft at all times from chocks to chocks.

4. ACTIVELY LOOK, LISTEN AND LIVE. 

Herb's Rules to Live By;

-Look outside

-Use a checklist

-Never fly hard IFR in a single engine aircraft

Our Mentor (Herb)

Strategically, Tomorrow:

1. If we see something, say something. Hazards should be identified to the nearest person who can take action to fix the problem, and also fill out a safety report through the NASA ASRS, We can't fix what we don't know, and the problem may be at more than just one airport.

2. Engage your team members at every level, to increase your awareness and the awareness of the entire at Global Airspace System (GAS). 

3. Fly Smart

Kent Lewis

2009 FAASTeam Rep of the Year

(850) 449-4841 lewis.kent@gmail.com

Bio: Herb Albert Webber, the best pilot I ever flew with. A kind person and quiet leader. 

Herb was born on October 3, 1923 in Cloquet, Minnesota and graduated from Cloquet High School in 1941.

Herb was an Airline Transport Pilot, flight instructor, and an FAA safety counselor and was type rated and qualified to fly numerous large and small jets, turbo props, and single engine air planes.

After graduating from high school, Herb joined The United States Army Air Corps where he served honorably in WW II (1942 to 1944) and flew the B-17G bomber as a Second Lieutenant and pilot. While stationed in Carlsbad, New Mexico for training he met and married the love of his life, Geraldine (Gerry) Marie Webber. They were married for 70 years before her passing on March 29, 2015.

In 1955, he moved his family to Arlington to begin his career in commercial aviation working for American Airlines flying Boeing 707s and 747s along with several other commercial aircraft. He retired from American Airlines as a Captain in 1983. Herb continued to work in the airline industry in various capacities providing training, check rides, and flight checks for up and coming pilots. In August of 1989 Herb accepted a job as Captain with TAG flying the Boeing 707-138B for TAG to the Middle East and other parts of the world. He flew for TAG until January of 2004. After leaving TAG, from 2004 to 2010, Captain Webber flew various aircraft, including a Conquest 441-II, one of his favorites, across the USA as an employee for Hilliard Energy, Ltd. As if Captain Webber did not have enough to do, from September 2001 to 2014 he also flew for Van Bortel Aircraft. While at Van Bortel he selected pilots, provided check rides for customers and employees, scheduled pilots, performed flight tests on airplanes out of maintenance, and picked up new aircraft from the Cessna factory.

In his spare time Captain Webber was a Colonel in the Commemorative (Confederate) Air Force air shows where he flew the B-17G, Sentimental Journey, and several other WWII aircraft all over the US and Canada. When Captain Webber Flew West he was the oldest employed corporate pilot in America and had logged over 42,700 hours of flying time.

Herb's proudest accomplishments in life were wrapped around Gerry Webber, the love of his life for over 70 years, his three children, his grandchildren, and his lifetime love for flying.