NTSB Advocates Advanced Cockpit Devices for Runway Safety

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

error.

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

this case."

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

entrances.

* Prohibit the issuance of a takeoff clearance during an airplane's taxi

to its departure runway until after the airplane has crossed all intersecting

runways.

* 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.

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