COMAIR FLIGHT 5191 CRASH DURING TAKE-OFF FROM WRONG RUNWAY AT LEXINGTON, KENTUCKY Gaurav Shukla (2012CE10351) & Rajat Jain (2012CE10385)

ABSTRACT: This report explains the accident which involved a Bombardier CL-600-2B19, N431CA, operated by Comair, Inc., which crashed during the take-off from Blue Grass Airport, Lexington, Kentucky on august 27, 2006. The aircraft was assigned the airport's runway 22, but instead it used runway 26 for take-off. Runway 26 was too short for a safe take-off, which caused aircraft to overrun the end of the runway before it could become airborne. It crashed just past the end of the runway. All 47 passengers and two of the three crew members were killed in the incident. THE INCIDENT:

Comair Flight 5191, was a scheduled United States (US) domestic passenger flight from Lexington, Kentucky, to Atlanta, Georgia. On August 27, 2006, at around 06:07 EDT, the Bombardier Canadair Regional Jet 100ER that was being used for the flight crashed in attempt to take off from Blue Grass Airport in Fayette County, Kentucky, four miles (6 kilometres) west of the district of the City of Lexington. The aircraft was supposed to take-off from the airport's runway 22, but used runway 26 instead. Based upon an estimated take-off weight of 22,265 kg, the manufacturer calculated a speed of 138 knots and a distance of 1,141 m would have been needed for rotation (increasing nose-up pitch), with more runway needed to achieve lift-off. But the overall length of runway 26 was just 1100m as compared to runway 22 whose length was 2135m. Hence, Runway 26 was too short for a safe take-off which caused the aircraft to overrun the end of the runway before it could lift off. At a speed approaching 100 knots, the pilots understood that it’s weird for runway to have no lights, but the flight data recorder gave no indication that either pilot ever tried to abort the take-off as the aircraft accelerated to 137 knots.

Pilots called for rotation but the aircraft sped off the end of the runway before it

could lift off. It then struck a low earthen wall which was adjacent to a ditch, and then became momentarily airborne. It then clipped the airport perimeter fence with its landing gear, and got smashed into trees, which separated the fuselage and flight deck from the tail. Aircraft hit the ground about 300 m from the end of the runway. Forty-nine of the 50 people on board died in the accident; most of them died instantly in the initial impact. The resulting fire destroyed the aircraft. All 47 passengers and two of the three crew members were killed in the incident. The flight's first officer was the only survivor. Among the deceased, were 42 US nationals, 3 Canadians and 2 Japanese citizens. James Polehinke, who the first officer was the only survivor and suffered serious injuries including multiple broken bones, a collapsed lung, and severe bleeding.

CAUSE OF ACCIDENT:

In the National Transportation Safety Board (NTSB) report on the crash, the investigators found that most likely cause of the accident was pilot’s error. The board stated that the two pilots Clay and Polehinke ignored clues that they were on the wrong runway. They also failed to confirm their position on the runway and talked too much, in violation of "sterile cockpit" procedures. The air traffic controller was required to maintain visual

contact with the aircraft but after aircraft cleared for the take-off, he got back to perform administrative duties and did not see the aircraft taxi to the runway. Comair accepted the responsibility for the crash but also put the blame on the airport authorities for poor runway signs and marking.

Figure 1: Approximate paths at Blue Grass Airport with blue indicating desired path via Runway 22 & red indicating actual path via Runway 26, ending at approximate crash site with X marking the closed taxiway.

During the investigation of the case, the Federal Aviation Administration discovered that tower staffing levels at Blue Grass Airport violated an internal policy as mentioned in a November 16, 2005, memorandum that stated the requirement of two controllers during the overnight shift. One required for the tower working clearance, ground, and tower frequencies, and the other one, either in the tower or remotely at Indianapolis Centre, working TRACON (radar). At the time of the accident, there was a single controller in the tower who was performing both the radar and the tower duties. On August 30, 2006, the FAA announced that Lexington and the other airports with similar traffic levels, must be staffed with two controllers in the tower around the clock effective

immediately. After the accident Comair announced that all of its pilots had been using an airport map with outdated information at the time of the crash.

CONCLUSIONS:

The captain and the first officer were properly certificated and qualified under Federal regulations. The first officer and the captain believed that the airplane was on runway 22 when they taxied onto runway 26 and under this confirmation bias they initiated the take-off roll. The flight crew did recognize that something was wrong with the take-off but it was well beyond the point from which the airplane could be stopped on the remaining available runway. The airplane was properly certified, equipped, and maintained in accordance with Federal regulations. There was no evidence of any structural, engine, or system failures from recovered components.

The flight crewmembers did not cross-check and confirm the airplane’s position on the runway before take-off and thus failed to recognize that they were on the wrong runway. The flight crew’s noncompliance with standard operating procedures which included the captain’s abbreviated taxi briefing and also both pilots’ non-pertinent conversation, most likely created an atmosphere in the cockpit that caused the crew’s errors. It was also observed that weather was not a primary factor in the cause of the accident. Moreover, fatigue was also ruled out from being the primary cause of accident as the pilots were sufficiently rested. There was no visibility issue during the airplane’s taxi to the runway and the attempted take-off. The controller also failed to detect the flight crew’s attempt to take off on the wrong runway because he preferred to perform a lower-priority administrative task instead of monitoring the airplane’s departure that

could have waited until he transferred responsibility for the airplane to the next air traffic control facility. He didn’t notice that flight crew has stopped the plane just before the wrong runway as he didn’t anticipate any issues with the airplane’s taxiing to the correct runway. Due to the construction project taking place at Blue Grass Airport, the taxiway identifiers represented in the airport chart available to the flight crew were inaccurate also the crew were not informed about the closure of taxiway A.

This information could have been made available to them via automatic terminal information service broadcast or the flight release paperwork. A standard procedure requires Code of Federal Regulations Part 91K, 121, and 135 pilots to confirm and cross-check that the airplane is positioned at the correct runway before crossing the hold short line and initiating a take-off would help to improve the pilots’ positional awareness during surface operations. The installation of cockpit moving map displays and cockpit runway alerting systems aboard the aircraft would enhance flight safety by providing pilots with improved positional awareness during surface navigation. Moreover, there should be enhanced taxiway centreline markings with surface painted holding position signs to provide pilots with additional awareness about the runway and taxiway environment. After the occurrence of the accident, runway 26 was replaced by a new runway which was not crossing runway 22, hence making the risk of confusion less likely.

REFERENCES:

• NTSB Final Report (2007). “Attempted Take-off from Wrong Runway Comair Flight 5191 Bombardier CL-600-2B19, N431CA Lexington, Kentucky on August 27, 2006” <http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR0705.pdf> (25-10-2015).

• “FAA Registry–Aircraft No.” <http://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=N431CA> (25-10-2015).

• Ortiz, Brandon (2007-08-28). "Polehinke Files Suit in Crash: Remembering flight 5191". <http://www.accessmylibrary.com/coms2/summary_0286-32739321_ITM> (25-10-2015).

• Jeffrey McMurray (August 27, 2006). "Comair plane took off from wrong runway". <http://web.archive.org/web/20060907044841/> (25-10-2015).

• Brandon Ortiz (2008-01-25). "Lawyer claimed 5191 victims shared blame Defense by Co-Pilot to Be Withdrawn". <http://theairlinewebsite.com/topic/385030-lawyer-claimed-crash-victims-shared-blame/> (25-10-2015).