NTSB: Comair crash was caused by pilots' mistakes

Controller not a contributing factor, says board


Investigators told the board that the pilots made a series of errors as they prepared to taxi to the runway and take off. They first got on the wrong airplane, then they had an abbreviated taxi briefing before heading toward the runway. Also, the pilots discussed extraneous subjects, including their families and their jobs, before and during the taxi.

At one point, Polehinke referred to the wrong flight number (121 instead of 191).

NTSB Vice Chairman Robert Sumwalt said the flight crew crossed a line between maintaining a relaxed cockpit and being unprofessional.

"There were some things that were done in that cockpit that should not have been done, and there were some things that weren't done that should have been done," Sumwalt said.

Sumwalt said NTSB interviews showed that the crew members were viewed favorably by their peers.

"The truth is, it doesn't matter how long you've been doing this, how good you are, how good your reputation is, how good your last landing is," Sumwalt said. "All that really matters to those people sitting in the back of your airplane is that you get them safely to their destination. Frankly, they deserve and expect each and every flight to be operated with the utmost precision and the utmost professionalism."

"The appropriate and available cues were there to make the decisions that day," NTSB member Steven Chealander said. "The flight crew didn't do their job. They didn't take the responsibility serious enough to do the job using those cues, and they took off from the wrong runway.

"The human errors far outweigh the system errors in this case."

NTSB investigators said they will propose five safety recommendations for the board to vote on. It also would recommend that the board reiterate two others. The NTSB already has proposed seven safety recommendations to the Federal Aviation Administration as a result of the crash.

Evan Byrne, chairman of the NTSB's human factors group, said the agency will have some recommendations about enhanced taxiway signs and cockpit moving map displays.

The cockpit moving map display would show the flight crew where the pilots are at the airport, including whether they are lined up on the correct runway. The NTSB is recommending that moving map displays be required in planes.

Rosenker said that the board's recommendations are necessary because the problems that contributed to the Lexington crash "must never happen again."

Hersman said that Clay and Polehinke had potentially confusing charts and signs, were not given notices of a taxiway closure, were looking at a reconstructed taxiway and that lights were out at various times and various places.

The crew did not have several local notices (known as Notices to Airmen, or NOTAMs) that morning. The missing NOTAMs included one about a 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.

At the same time, the local notices should have been included on the ATIS, a radio frequency that pilots listen to with pre-recorded notices and information about changes at the airport. The local notice information had been on the ATIS in days before the crash, but it wasn't there Aug. 27. NTSB investigators said it's unclear why the air traffic controller did not record the local notice information on the ATIS that morning.

Finally, the runway/taxiway charts being used by the crew were out of date and did not accurately reflect changes on the ground because of construction.

"Things were not as they were normally at this airport," Hersman said.

"It's very clear to us this crew made a mistake, but the question is what enabled them to make this mistake," Hersman said. "I know the challenge here is that they didn't voice any confusion.

"The aviation system is supposed to have redundancy," Hersman said, outlining the omitted notices and reading an extensive warning provided after the crash by another airline. "It's just a shame this information wasn't there before the accident."

The NTSB investigator-in-charge, Joseph Sedor, said that the crew had illuminated signs, blue taxiway lights, runway markings, barricades and a very dark forward view instead of the well-lighted runway they should have expected. And there were no indications that the crew thought they were in the wrong place.

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