WASHINGTON -- From the moment they entered the cockpit of their regional jet in Lexington, Ky., until they bounded off the end of the wrong runway, the pilots of Comair Flight 5191 missed numerous cues that should have prevented the accident.
According to records released Wednesday by the National Transportation Safety Board (NTSB), an air traffic controller instructed the pilots to go to the correct runway, and they repeated the information several times. The pilots passed signs that showed where they were. Cockpit gauges provided subtle indicators that they were in the wrong place.
And, instead of seeing the customary lights, they entered an unlit runway in the pre-dawn darkness. In spite of all that, the pilots aboard the Bombardier CRJ-100 bound for Atlanta apparently did not notice they were on the wrong runway, accelerating more than 150 mph on a strip of pavement that was far too short for their size of plane to take off.
Flight 5191 sped past the end of the runway, slammed through a fence and a row of trees and burst into flames as it came to rest in a pasture next to Blue Grass Airport on Aug. 27. The impact and fire killed 49 of the 50 people aboard.
"(That) is weird with no lights," co-pilot James Polehinke said while the jet roared down the runway. Polehinke, who was at the controls during the attempted takeoff, is the only survivor. He has said he does not remember the crash.
"Yeah," Captain Jeffrey Clay replied, according to a transcript of the cockpit recording.
Several airline pilots have said they are puzzled that the Comair crew would continue in spite of the dark runway.
"That's really significant," said John Cox, a retired pilot who operates a safety consulting firm. During his time as a pilot at US Airways, pilots were told they could not take off at night without lights, Cox said.
However, the NTSB found that not all airlines prohibit such takeoffs. Comair had no such rule. Comair spokeswoman Kate Marx said the airline intends to "take whatever steps necessary" to improve safety.
As with many accidents, dozens of mistakes and misunderstandings occurred that may have led to the accident, according to the more than 50 reports released by the NTSB.
As for the dark runway, some lights were out along the larger runway because of construction work. "Came in the other night, it was, like, lights are out all over the place," Polehinke told Clay about 10 minutes before the takeoff attempt.
Pilot Ben Berman, who has written about aviation safety, said most airline crews would have stopped to talk about the dark runway. He said it is possible that both pilots thought the construction explained the lack of lights.
Another factor that could have confused the pilots was a new taxi route to Runway 22, which they were supposed to use. A Federal Aviation Administration recording that pilots listen to for airport information had mentioned the changes the day before the accident, but the recording Clay and Polehinke heard had no such information.
Investigators are also looking at air traffic staffing. The FAA had recently required that two controllers work at all times, but only one was working at the time of the crash.
Controller Christopher Damron, who cleared Flight 5191 for takeoff, told investigators he did not think staffing was an issue. He said he saw the jet turn toward what he thought was the correct runway and looked away to do paperwork. A short time later he heard a noise and saw fire west of the airport.
According to the cockpit transcript, the pilots were busy as they readied for the first flight of the day, but they also engaged in small talk. The FAA prohibits non-essential talk during critical phases of flight, including taxiing. The NTSB has not ruled on whether the pilots violated the regulation.
Clay taxied the jet onto the shorter runway, then turned the controls over to Polehinke.
"All yours, Jim," Clay said.
Fifteen seconds after Polehinke's comment about the lights, Clay called out a routine command to pull up the jet's nose because it had attained enough speed to begin lifting off. The first indication the crew knew something was wrong came a half-second later.
"Whoa," Clay said. A second after that, he uttered an expletive, followed by the sound of the jet hitting something.
The crash was the first to kill passengers on a U.S. airline jet flight in nearly five years, breaking an unprecedented string of safe years. The NTSB has not officially determined why the crash happened.
