Crash's legacy could be safety advances

Aug. 25--It took less than a year for the National Transportation Safety Board to complete its investigation into the crash of Comair Flight 5191, determine the probable cause and issue its recommendations.

But aviation experts say the legacy of whether aviation safety will improve as a result of the crash hinges on whether the Federal Aviation Administration enacts any of those recommendations.

"If those recommendations are implemented, if the FAA gets serious about this, it will improve the future of aviation," said Paul Czysz, a retired aeronautics professor at St. Louis University. "If they don't, if they leave it the way it is, it could have a negative effect because it isn't solving a problem."

Questions remain about how many recommendations the FAA will act on because several of the same recommendations were made years ago but weren't implemented, said Jim Burnett, a former NTSB chairman.

For example, in 1989, the NTSB recommended that the FAA require flight crews to cross-check the heading indicator with the runway heading. The heading cross-check was not part of Comair's operations manual, nor was it required to be by the FAA.

Burnett, now an attorney and transportation safety consultant, said he thinks the FAA will do something in response to most, if not all, of the recommendations, but "the question is how thorough they will all be."

"There's a tendency to correct one thing and without correcting them all, nothing is solved," Burnett said.

While the NTSB awaits the FAA's response, many of the recommendations are being implemented by some airlines and airports, Deborah Hersman, the NTSB member who was in Lexington after the crash, wrote in an e-mail to the Herald-Leader. "The regulatory action is needed, but the voluntary compliance demonstrates that the recommendations are reasonable."

Some airlines have changed their policies regarding verification and confirmation on the correct departure runway and prohibited operations on unlit runways, said Hersman, who will be in Lexington on Sunday and Monday for public and private memorial services.

Last month, the NTSB made a number of recommendations to the FAA regarding Comair 5191. They included requiring pilots to confirm and cross-check the airplane's location on the assigned runway before takeoff; requiring airports to implement enhanced taxiway centerline markings and painted holding position signs at runway entrances; requiring specific air traffic control clearance when an aircraft crosses a runway; and prohibiting controllers from issuing takeoff clearance until after an airplane has crossed all intersecting runways.

Comair 5191 crashed after attempting to take off from the wrong runway at Blue Grass Airport on Aug. 27, 2006. The plane attempted to use the shorter, general aviation runway at Blue Grass, instead of the main runway that was twice as long. Forty-nine people died; only the first officer survived.

After a yearlong investigation, the NTSB concluded that the probable cause of the crash rested in mistakes made by the pilots, most notably their failure to realize they were in the wrong place.

So far, the FAA has shown a good-faith effort to study some of the recommendations and implement others, said Capt. Terry McVenes, the Air Line Pilots Association executive air safety chairman.

Last week, the FAA hosted a runway safety symposium with aviation industry leaders and put together a 60-day short-term plan that includes reviewing cockpit procedures and air traffic control clearance procedures and beginning safety reviews at airports where wrong-runway departures and runway incursions are a concern. The agency also promised to study the feasibility of advancing the deployment of global positioning technology in planes.

The FAA also urged 73 airports with high occurrences of runway incursions to install enhanced runway markings within the next 60 days rather than a September 2008 deadline. Blue Grass recently added enhanced markings to its runways at the request of the FAA.

"It was a commitment to actually do some of these things people have been talking about and recommending over the last couple of years," McVenes said.

Even before the symposium, the FAA had begun making some changes locally.

In the last year, the FAA has staffed the Blue Grass tower with two air traffic controllers on the overnight shift (there was only one on duty the morning of the crash), added enhanced runway markings and required controllers to issue a take-off clearance only after an aircraft has crossed the general aviation runway that intersects the airport's main 7,000-foot runway.

On the day of the NTSB hearing last month, the FAA announced plans to make changes in how pilots receive notices about changes at local airports across the nation. The agency will eliminate local notices (known as Notices to Airmen, or NOTAMs) which are not distributed nationally. Local notices are currently issued by airports to notify pilots about airfield operations such as lawn mowing and taxiway closings, but critics say the Comair crash exposed holes in that system.

On the morning of the crash, the crew did not have several local NOTAMs, including one about the taxiway that had been closed because of a major runway construction project. The airport faxed those notices to Comair, but they weren't given to the crew. The NTSB determined that the missing notices were not a factor in the accident.

Starting in October, the information that used to be issued in a local NOTAM will be stored and distributed electronically throughout the United States, the FAA said.

The key lesson from Comair 5191 is that the "aviation system requires constant vigilance and attention to every detail," Hersman wrote.

It doesn't matter that a flight crew or controller has performed the same checklist or duty for years. Aviation professionals need to perform as if each flight is the only one they are responsible for, she said.

"Everyone in the aviation system must maintain the highest level of vigilance and precision -- lives depend on it."

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