FOR IMMEDIATE RELEASE: July 26, 2007 SB-07-38

NTSB DETERMINES COMAIR 5191 FLIGHT CREW FAILED TO USE AVAILABLE CUES TO DETERMINE LOCATION DURING TAKEOFF

Washington, DC -- The National Transportation Safety Board today determined the probable cause of the Comair flight 5191 accident in Lexington, Kentucky was the flight crew's 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 this accident were the flight crew's nonpertinent conversation during taxi, which resulted in loss of positional awareness and the Federal Aviation Administration's failure to require that all runway crossings be authorized only by specific air traffic control clearances.

"This accident was caused by poor human performance," said NTSB Chairman Mark V. Rosenker. "Forty-nine lives could have been saved if the flightcrew had been concentrating on the important task of operating the airplane in a safe manner."

On August 27, 2006, about 6:07 a.m., Comair flight 5191, a Bombardier CRJ-100, (N431CA) crashed upon takeoff from Blue Grass Airport in Lexington, Kentucky. The flight crew was instructed to take off from runway 22, an air carrier runway that is 7,003 feet long. Instead, the flight crew lined up the airplane on runway 26, a 3,501-foot-long runway, and began the takeoff roll. Runway 26 crosses runway 22 about 700 feet south of the runway 22 threshold. Of the 47 passengers and 3 crewmembers onboard, 49 were fatally injured and one (the first officer) received serious injuries. Impact forces and a postcrash fire destroyed the airplane.

As a result of this accident, the safety Board made the following recommendations:

To the Federal Aviation Administration:

1. Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross check the airplane's location at the assigned departure runway before crossing the hold short line for takeoff.
2. Require that all Code of Federal Regulations Part 91K, 121, and 135 operators install on their aircraft cockpit 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.
3. Require that all airports certified under 14 Code of Federal Regulations Part 139 implement enhanced taxiway centerline markings and surface painted holding position signs at all runway entrances.
4. Prohibit the issuance of a takeoff clearance during an airplane's taxi to its departure runway until after the airplane has crossed all intersecting runways.
5. Revise Federal Aviation Administration Order 7110.65, "Air Traffic Control," to indicate that controllers should refrain from performing administrative tasks, such as the traffic count, when moving aircraft are in the controller's area of responsibility.

The Safety Board reiterated two previously issued recommendations to the FAA:

Amend 14 Code of Federal Regulations (CFR) Section 91.129(i) to require that all runway crossings be authorized only by specific air traffic control clearance, and ensure that U.S. pilots, U.S. personnel assigned to move aircraft, and pilots operating under 14 CFR Part 129 receive adequate notification of the change.

Amend Federal Aviation Administration Order 7110.65, "Air Traffic Control," to require that, when aircraft need to cross multiple runways, air traffic controllers an issue explicit crossing instruction for each runway after the previous runway has been crossed.

Previously issued recommendations to the FAA resulting from this accident include:

Require that all 14 Code of Federal Regulations Part 121 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane's location at the assigned departure runway before crossing the hold- short line for takeoff.

Require that all 14 Code of Federal Regulations Part 121 operators provide specific guidance to pilots on the runway lighting requirements for takeoff operations at night.

Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decrease cognitive performance. Develop a fatigue awareness and countermeasures training program for controllers and for personnel who are involved in the scheduling of controllers for operational duty that will address the incidence of fatigue in the controller workforce, causes of fatigue, effects of fatigue on controller performance and safety, and the importance of using personal strategies to minimize fatigue. This training should be provided in a format that promotes retention, and recurrent training should be provided at regular intervals.

Require all air traffic controllers to complete instructor-led initial and recurrent training in resource management skills that will improve controller judgment, vigilance, and safety awareness.

Earlier this year, the Board issued the following recommendation to the National Air Traffic Controller Association:

Work with the Federal Aviation Administration to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance.

A synopsis of the Board's report, including the probable cause and recommendations, is available on the NTSB's website, www.ntsb.gov, under "Board Meetings." The Board's full report will be available on the website in several
weeks.

NTSB Media Contact: Terry N. Williams
(202) 314-6100
williat@ntsb.gov

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