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NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: July 26, 2007
SB-07-38
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NTSB DETERMINES COMAIR 5191 FLIGHT CREW FAILED TO USE
AVAILABLE CUES TO DETERMINE LOCATION DURING TAKEOFF
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Washington, DC -- The National Transportation Safety Board
today determined the probable cause of the Comair flight
5191 accident in Lexington, Kentucky 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. Contributing to
this accident were the flight crew's nonpertinent
conversation during taxi, which resulted in loss of
positional awareness and the Federal Aviation
Administration's failure to require that all runway
crossings be authorized only by specific air traffic control
clearances.
"This accident was caused by poor human performance," said
NTSB Chairman Mark V. Rosenker. "Forty-nine lives could
have been saved if the flightcrew had been concentrating on
the important task of operating the airplane in a safe
manner."
On August 27, 2006, about 6:07 a.m., Comair flight 5191, a
Bombardier CRJ-100, (N431CA) crashed upon takeoff from Blue
Grass Airport in Lexington, Kentucky. The flight crew was
instructed to take off from runway 22, an air carrier runway
that is 7,003 feet long. Instead, the flight crew lined up
the airplane on runway 26, a 3,501-foot-long runway, and
began the takeoff roll. Runway 26 crosses runway 22 about
700 feet south of the runway 22 threshold. Of the 47
passengers and 3 crewmembers onboard, 49 were fatally
injured and one (the first officer) received serious
injuries. Impact forces and a postcrash fire destroyed the
airplane.
As a result of this accident, the safety Board made the
following recommendations:
To the Federal Aviation Administration:
1. Require that all 14 Code of Federal Regulations
Part 91K, 121, and 135 operators establish
procedures requiring all crewmembers on the flight
deck to positively confirm and cross check the
airplane's location at the assigned departure
runway before crossing the hold short line for
takeoff.
2. Require that all Code of Federal Regulations Part
91K, 121, and 135 operators install on their
aircraft cockpit moving map displays or an
automatic system that alerts pilots when a takeoff
is attempted on a taxiway or a runway other than
the one intended.
3. Require that all airports certified under 14 Code
of Federal Regulations Part 139 implement enhanced
taxiway centerline markings and surface painted
holding position signs at all runway entrances.
4. 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.
5. Revise Federal Aviation Administration Order
7110.65, "Air Traffic Control," to indicate that
controllers should refrain from performing
administrative tasks, such as the traffic count,
when moving aircraft are in the controller's area
of responsibility.
The Safety Board reiterated two previously issued
recommendations to the FAA:
Amend 14 Code of Federal Regulations (CFR) Section
91.129(i) to require that all runway crossings be
authorized only by specific air traffic control
clearance, and ensure that U.S. pilots, U.S. personnel
assigned to move aircraft, and pilots operating under
14 CFR Part 129 receive adequate notification of the
change.
Amend Federal Aviation Administration Order 7110.65,
"Air Traffic Control," to require that, when aircraft
need to cross multiple runways, air traffic
controllers an issue explicit crossing instruction for
each runway after the previous runway has been
crossed.
Previously issued recommendations to the FAA resulting from
this accident include:
Require that all 14 Code of Federal Regulations Part
121 operators establish procedures requiring all
crewmembers on the flight deck to positively confirm
and cross-check the airplane's location at the
assigned departure runway before crossing the hold-
short line for takeoff.
Require that all 14 Code of Federal Regulations Part
121 operators provide specific guidance to pilots on
the runway lighting requirements for takeoff
operations at night.
Work with the National Air Traffic Controllers
Association to reduce the potential for controller
fatigue by revising controller work-scheduling
policies and practices to provide rest periods that
are long enough for controllers to obtain sufficient
restorative sleep and by modifying shift rotations to
minimize disrupted sleep patterns, accumulation of
sleep debt, and decrease cognitive performance.
Develop a fatigue awareness and countermeasures
training program for controllers and for personnel who
are involved in the scheduling of controllers for
operational duty that will address the incidence of
fatigue in the controller workforce, causes of
fatigue, effects of fatigue on controller performance
and safety, and the importance of using personal
strategies to minimize fatigue. This training should
be provided in a format that promotes retention, and
recurrent training should be provided at regular
intervals.
Require all air traffic controllers to complete
instructor-led initial and recurrent training in
resource management skills that will improve
controller judgment, vigilance, and safety awareness.
Earlier this year, the Board issued the following
recommendation to the National Air Traffic Controller
Association:
Work with the Federal Aviation Administration to
reduce the potential for controller fatigue by
revising controller work-scheduling policies and
practices to provide rest periods that are long enough
for controllers to obtain sufficient restorative sleep
and by modifying shift rotations to minimize disrupted
sleep patterns, accumulation of sleep debt, and
decreased cognitive performance.
A synopsis of the Board's report, including the probable
cause and recommendations, is available on the NTSB's
website, www.ntsb.gov, under "Board Meetings." The Board's
full report will be available on the website in several
weeks.
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NTSB Media Contact: Terry N. Williams
(202) 314-6100
[email protected]
there is more to this accident than the NSTB dreamed of