NTSB: Comair crash was caused by pilots' mistakes

Controller not a contributing factor, says board


WASHINGTON - The National Transportation Safety Board determined on Thursday that the probable cause of the crash of Comair Flight 5191 was a series of errors by the plane's flight crew.

After a day-long hearing, the board cited two failures by the plane's pilot and co-pilot as the cause of the crash: the flight crew's failure to use cues and aides to identify the aircraft's location; and the flight crew's failure to cross-check and verify that the airplane was on the correct runway before takeoff.

The five-member board identified two contributing factors to the crash:

_the flight crew's non-pertinent conversations during taxi to the runway, which resulted in them losing awareness of their position.

_and the FAA's failure to require that all pilots receive authorization from air traffic control before crossing a runway.

The board also considered a staff recommendation to include a third contributing factor: the air traffic controller's performance of an administrative task not directly related to flight safety. However, the board narrowly voted to remove that factor from the official listing of causes.

After ruling on the cause, the NTSB made several safety recommendations to the Federal Aviation Administration. Those included requiring pilots and co-pilots to cross-check and confirm that they are on the correct runway; requiring that cockpits be fitted with electronic maps or displays that would alert pilots if they are on the wrong taxiway or runway; enhancing taxiway markings; and telling air traffic controllers to refrain from performing administrative functions while they are supposed to be monitoring the safety of an aircraft.

The board reiterated some earlier recommendations, including additional guidance for using unlit runways and urging the FAA to deal with issues related to fatigue among air traffic controllers.

The conclusions came after more than 13,000 man hours of investigation over 11 months.

Despite that investigation and more than 1,000 pages of evidence, federal investigators struggled at times Thursday to find a clear-cut answer to the same question that has frustrated them since Aug. 27, the day of the crash: How did two experienced pilots, navigating a simple, straightforward airport, take off from the wrong runway?

And why did they take off from an unlit runway - a black hole? - asked National Transportation Safety Board chairman Mark V. Rosenker.

That "is the most troubling aspect of this investigation," Rosenker said.

In the only public hearing it will hold on the crash, the NTSB attempted to delve into the minds of pilots Jeffrey Clay and James Polehinke to find answers in the crash that killed 49 people near Blue Grass Airport in Lexington. Polehinke was the only survivor of the crash.

Many questions remained as the board went into what NTSB member Debbie Hersman described as "the briar patch of human behavior." Hersman was the NTSB member on the scene of the Lexington crash.

"It did not take long for all of us to realize that no matter how many people we interviewed, no matter how many documents we reviewed, no matter how much evidence we collected, the accident would offer up no easy explanations for us," Hersman said Thursday. "No simple solutions.

There would be no moment where we could point to one thing and say, `Aha, that is what caused this accident.'"

Hersman described the Comair crash as the "most searing" she's been involved in - because of the loss of life and because there was no single, clear cause, such as a mechanical problem.

Throughout the hearing, board members discussed the several cues that the pilots missed that should have warned them they were on the wrong, too-short runway, and how they chatted about irrelevancies.

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