New safety recommendations from the National Transportation Safety Board
(NTSB) concerning pilot errors on airport surfaces include the use of moving
maps and automatic pilot alerting systems.
The NTSB on July 26 ruled that the primary cause of the Aug. 27, 2006
early morning fatal crash of Comair Flight 5191, a Bombardier CRJ-100 regional
jet (N431CA), during takeoff from Blue Grass Airport in Lexington, KY, was pilot
The Safety Board said the flight deck crew repeatedly missed "abundant
cues" that should have alerted them of the fact that they were taking off from
the wrong runway. Forty-seven passengers and three crewmembers were on board.
Only the first officer survived and is recovering from critical injuries. The
captain had passed the controls to the first officer for takeoff.
After an eleven-month probe, Safety Board investigators determined that
the two-man crew failed to react to sure signs that they were taking off from
the much shorter general aviation runway versus the air carrier runway.
"It's very clear to us that the crew made a mistake. Their heads just
weren't in the game here," said NTSB Member Debbie Hersman. Steven Chealander,
another Safety Board member and former airline pilot, said "there comes a time
for the flight crew to take responsibility. There were cues there. The flight
deck crew was not doing their jobs. Human error far outweighs system errors in
Specifically, the NTSB ruled that the probable cause of the Comair
regional jet accident was "the flight crew's failure to use available cues and
aids to identify the airplane's location on the airport surface during taxi and
their failure to cross check and verify that the airplane was on the correct
runway before takeoff.
New NTSB recommendations to the Federal Aviation Administration resulting
from the Comair fatal accident include a requirement that all Part 91K, 121, and
135 operators equip their aircraft either with moving map displays or an
automatic system that alerts pilots when a takeoff is attempted on a runway
other than the one intended. Current Electronic Flight Bags (EFBs) offer such
devices and Honeywell's Runway Awareness and Advisory System (RAAS) is an
available alerting technology.
Other procedural, good practice and signage recommendations made by the
Safety Board include:
* Require all Part 91K, 121 and 135 operators to advise flight deck crews
to positively confirm and cross check the airplane's location at the assigned
departure runway before crossing the hold short line for takeoff.
* Require airports certificated under Part 139 implement enhanced taxiway
centerline markings and surface painted holding position signs at all runway
* Prohibit the issuance of a takeoff clearance during an airplane's taxi
to its departure runway until after the airplane has crossed all intersecting
* Revise air traffic controller work rules to prohibit controllers from
performing administrative tasks, such as traffic counts, when moving aircraft
are in the controller's area of responsibility.