When NTSB chairman Mark Rosenker asked two of his Safety Board compatriots–both erstwhile airline pilots–whether they ever took off into “a black hole,” both answered in the negative.
The NTSB knows that Comair Flight 5191 crashed on takeoff from the Lexington (Ky.) Blue Grass Airport because the runway was too short; what it has not determined is why two high-time airline pilots stopped briefly at the hold-short line for 3,501-foot-long Runway 26 and then turned onto it instead of crossing and continuing on to their assigned Runway 22.
Investigators are perplexed as to why the crew missed visual clues that they were on the wrong runway. With the captain handling taxiing duties and the first officer running checklists, the Bombardier CRJ100 stopped alongside the lighted runway marker, which clearly indicated Runway 26, not Runway 22. After holding short for 46 seconds at Runway 26 while the first officer completed his before-takeoff checklist, the captain taxied onto Runway 26 and aligned the aircraft before handing it off to the first officer.
With the first officer, who would be the pilot flying to Atlanta, at the controls the airplane began its takeoff roll. It ran off the end of the runway and hit the airport perimeter fence, trees and terrain. The captain, flight attendant and all 47 passengers were killed. The seriously injured first officer who was at the helm for the takeoff was the only survivor. He has told investigators he has no recollection of the crash.
The aircraft was destroyed by impact forces and post-crash fire. Night VMC prevailed at the time of the 0606 EDT crash, about one hour before sunrise. There was no illumination from the moon and no precipitation.
The NTSB determined that the probable cause of the accident was the flight crewmembers’ failure to use available cues and aids to identify the airplane’s location on the airport surface during taxi and their failure to cross-check and verify that the airplane was on the correct runway before takeoff.
Contributing to the accident were the flight crew’s non-pertinent conversations during taxi, which resulted in a loss of positional awareness, and the FAA’s failure to require that all runway crossings be authorized only by specific ATC clearances.
“I think this accident was all about complacency,” said NTSB member Kathryn Higgins. It “was caused by poor human performance,” agreed chairman Rosenker. “Forty-nine lives could have been saved if the flight crew had been concentrating on the important task of operating the airplane
in a safe manner.”
Deborah Hersman, the board member at the scene of the Aug. 27, 2006, accident, said the crash was frustrating because there was no “ah ha” moment where investigators might pinpoint a single, simple cause. NTSB director of aviation safety Tom Haueter said the investigation was difficult because of “complex human performance issues.”
While taxiing from the airline ramp to the Runway 22 threshold, the pilots violated the sterile-cockpit rule with 40 seconds of non-pertinent conversation. The NTSB said that distraction likely contributed to loss of positional awareness, and the captain’s abbreviated taxi briefing also contributed to that.
“The flight crew’s noncompliance with standard operating procedures, including the captain’s abbreviated taxi briefing and both pilots’ non-pertinent conversation, most likely created an atmosphere in the cockpit that enabled the crew’s errors,” the NTSB said.
Runways and taxiways at the airport were undergoing reconstruction, but the crew did not receive a local notam advising about the work, and the lone controller had not included it in the ATIS broadcast.
The controller did not notice that the flight crew had stopped short of the wrong runway because he did not anticipate problems with the airplane’s taxi to the correct runway and was paying more attention to his radar duties than his tower responsibilities.
“The controller did not detect the flight crew’s attempt to take off on the wrong runway because, instead of monitoring the airplane’s departure, he performed a lower-priority administrative task that could have waited until he transferred responsibility for the airplane to the next air traffic control facility,” investigators said.
The Safety Board acknowledged that the controller was “most likely” fatigued at the time of the accident but added that the extent to which fatigue affected his decision not to monitor the airplane’s departure could not be determined.
NTSB staff investigators criticized the controller for turning his back to perform administrative tasks and recommended that his actions be listed as a contributing factor. In a split vote, the board members decided that the controller’s action did not contribute directly to the crash.
A photo re-creation of what the pilots of Flight 5191 should have seen when they held short at the threshold of Runway 26 clearly showed the taxiway Alpha/Runway 26 sign and in the distance one indicating taxiway Alpha/Runways 4-22.
“How did this crew miss this?” asked board member Steven Chealander. He pointed out that the pilots mentioned Runway 22 ten times on the cockpit voice recording.
The taxi clearance allowed the crew to taxi across Runway 26 en route to the assigned takeoff runway. As the airplane accelerated down the unlit, VFR daylight-only runway, the first officer commented, “That is weird with no lights.” The captain responded, “Yeah” and then called out “V one, rotate” followed by “whoa.”
The flight data recorder indicated that the pilots had the heading bug set to 227 degrees, which corresponded closely with the 226-degree magnetic heading for Runway 22 as depicted on their Jeppesen airport chart.
As a result of the accident, the Safety Board recommended that the FAA require Parts 91K, 121 and 135 operators to have crewmembers on the flight deck positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold-short line for takeoff. Operators also would be required to install moving-map displays or an automatic system that alerts pilots when a takeoff is attempted on a taxiway or a runway other than the one intended.
The NTSB also recommended that Part 139 airline airports implement enhanced taxiway centerline markings and surface- painted holding position signs at all runway entrances.
Finally, the Board recommended that the FAA prohibit the issuance of takeoff clearance during an airplane’s taxi to its departure runway until after the airplane has crossed all intersecting runways and order controllers to refrain from performing administrative tasks when moving aircraft are in the controller’s area of responsibility.