NTSB: Comair crash was caused by pilots' mistakes

Controller not a contributing factor, says board


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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