LEXINGTON, Kentucky_Federal investigators released their final report Tuesday on last summer's deadly crash of a Comair flight in Kentucky, finding that the pilots were primarily responsible but making safety recommendations that extend to the control tower and elsewhere.
The report by Mark Rosenker, chairman of the National Transportation Safety Board, came a year and a day after the Aug. 27, 2006, crash at Lexington's Blue Grass Airport. Of the 50 people aboard, only co-pilot James Polehinke survived.
The report, issued about a month after the board voted on its conclusions, reiterates that the primary cause was a failure by pilot Jeffrey Clay and Polehinke to notice clues they were going down the wrong runway. Comair Flight 5191 crashed because the general aviation strip was too short for the commercial jet.
However, only one of the five safety recommendations deals with steps the pilots should take - to confirm the airplane's runway location before takeoff. Two of the recommendations were aimed at air traffic controllers.
Not only should pilots check to make sure they are on the right runway, the NTSB concluded, but the controller shouldn't clear any plane for takeoff until it has crossed all intersecting runways and taxiways.
Taking that step, Rosenker wrote, "would reduce the likelihood of wrong runway takeoff events."
The report also recommended that controllers be prohibited from performing administrative tasks, such as traffic counts, while aircraft are moving in the controller's area of responsibility.
The Lexington controller turned his back to do an administrative task and did not see the accident. The NTSB members ultimately voted 3-2 that he was not to blame, but Rosenker stressed that controllers need to prioritize their time better.
"Administrative tasks should not have priority over radar and tower monitoring tasks," Rosenker wrote, concluding such a step could help a controller prevent "flight crew errors."
The NTSB also recommended that commercial airplanes be fitted with a cockpit system that either alerts pilots if they are heading the wrong way or gives them a moving map display to see updated taxiway conditions. Its fifth safety recommendation was that regional airports enhance markings in the center of runways and all runway entrances - a step Blue Grass Airport has already taken.
The controller got only two hours of sleep between a double shift the morning of the crash, but the NTSB decided it could not determine what role that played in the accident. Rosenker praised the Federal Aviation Administration for taking steps to rotate shifts and reduce fatigue.
In its public meeting last month, the five board members were unanimous in identifying pilot error as the cause. However, Deborah Hersman, who led the investigation in Lexington, issued a concurring opinion earlier this month that concluded other factors also should have been listed.
Controller not a contributing factor, says board
The transcript revealed that the flight crew "did not follow Comair's general cockpit procedures," Comair spokeswoman Kate Marx said.
Transcript reveals pilot taxied plane onto wrong runway, possibly as a result of defying sterile cockpit policy.
Although the NTSB has not concluded its investigation, it said that the airport had appropriate runway and taxiway signs.