NTSB: Comair crash was caused by pilots' mistakes

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.

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.

In fact, a minute after the plane began taxiing out, "the crew engaged in 40 seconds of non-pertinent conversation," he said. Then, as the plane waited for 50 seconds before turning to take off, the crew had multiple cues they were in the wrong place.

"There is not one single bit of information that the staff looked at that could have caused this accident, except for the non-pertinent conversation," Sedor said.

The safety board began the afternoon with a discussion of the air-traffic control tower. Only one controller was on duty the morning of the crash, even though FAA rules said there should have been two. The air traffic controller had two opportunities to possibly avert the accident, said Bill Bramble, senior human performance investigator.

The pilots stopped the airplane short of the general aviation runway for 50 seconds, Bramble said. The controller then had an opportunity to stop the airplane during the 28 seconds it took the airplane to reach take-off speed, he said.

Still, "it is unlikely a second controller assigned to the tower position would have detected the wrong runway takeoff," Bramble said.

"This decision did not contribute to the circumstances of the accident."

Hersman disagreed with Bramble. She said the board didn't have enough information to say whether a second controller would have helped.

"We don't know if it made a difference or not," Hersman said. "There are too many moving parts in this."

The board talked at length about the controller who was on duty, Christopher Damron, and whether his inattention contributed to the crash. The controller told investigators that he cleared the plane for takeoff, then turned his back to perform an administrative task.

Some members of the board said tending to that administrative task instead of monitoring the safety of the plane was a judgment error.

The NTSB already has made several recommendations to the FAA as a result of the Lexington crash, including that the FAA order commercial airlines to require pilots to cross-check their instruments to ensure that they're taking off from the correct runway; and that the FAA require airlines with scheduled commercial service to provide specific guidance to pilots for runway lighting requirements at night.

In a later series of recommendations, the NTSB called on the FAA and the National Air Traffic Controllers Association to change scheduling policies and to increase awareness of the dangers of sleep deprivation among controllers.

The NTSB also recommended that controllers receive annual training.

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(c) 2007, Lexington Herald-Leader (Lexington, Ky.).

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