NTSB Comair Flight 5191 report: Safety recommendations

As promised in yesterday's post about the release of the NTSB report on Comair Flight 5191, today I'll set forth the safety recommendations from the synopsis report (just for the record). Most of the NTSB's recommendations are addressed to the FAA; one is directed to the National Air Traffic Controllers Association (NATCA), the labor union representing air traffic controllers in the United States.

Here are the new safety recommendations from the NTSB's synopsis report on the investigation of the Comair Flight 5191 accident investigation that are specifically related to pilots, piloting, and aircraft operation at airports:

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. This required guidance should be consistent with the guidance in Advisory Circular 120‑74A and Safety Alert for Operators 06013 and 07003. (A-07-XX)
2. Require that all 14 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. (A-07-XX)
3. Require that all airports certificated under 14 Code of Federal Regulations Part 139 implement enhanced taxiway centerline markings and surface painted holding position signs at all runway entrances. (A-07-XX)
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. (A-07-XX)
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. (A-07-XX)

Previously issued recommendations reiterated in this report:

• 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. (A-00-67)
• Amend FAA Order 7110.65, “Air Traffic Control,” to require that, when aircraft need to cross multiple runways, air traffic controllers issue an explicit crossing instruction for each runway after the previous runway has been crossed. (A-00-68)
• 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. (A-06-83)
• 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. (A-06-84)

The rest of the recommendations are about, or specifically addressed to, air traffic controller issues. See the synopsis report for details of those.

Remember: these are NTSB recommendations, not new regulations. It is now up to the FAA whether or not to implement or otherwise act upon the recommendations.

Readers who have opinions or observations about the accident or the NTSB's report are invited to share them in the comments section below this post. Should you not wish to be identified, you are welcome to comment anonymously.


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