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.


Related: Click here to view all posts on this blog about Comair Flt 5191.

Pilot error cited as cause of Comair Flight 5191 accident

Be prepared to hear a lot about 'sterile cockpit' rules during your next recurrent training. It's one of several topics that are likely to be emphasized in the wake of the synopsis report issued today by the NTSB on completion of their investigation of the crash of Comair Flight 5191 at LEX last August 27.

You'll recall that Comair Flight 5191, a CRJ-100, crashed at Bluegrass Airport in Lexington, Kentucky after taking off from the wrong runway. Forty-nine passengers and two crew members were lost. The only survivor was the first officer, who was critically injured.

Yesterday's NTSB report about the accident blames the flight crew for the accident cites "the flight crewmembers’ 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" as the probable cause.

The report also concludes that "the flight crew’s nonpertinent conversations during taxi, which resulted in a 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" were contributing causes.

Here are all of the 28 specific conclusions published in the NTSB synopsis report [NTSB/AAR-07/05] issued earlier today:

1. The captain and the first officer were properly certificated and qualified under Federal regulations. There was no evidence of any medical or behavioral conditions that might have adversely affected their performance during the accident flight. Before reporting for the accident flight, the flight crewmembers had rest periods that were longer than those required by Federal regulations and company policy.
2. The accident airplane was properly certified, equipped, and maintained in accordance with Federal regulations. The recovered components showed no evidence of any structural, engine, or system failures.
3. Weather was not a factor in this accident. No restrictions to visibility occurred during the airplane’s taxi to the runway and the attempted takeoff. The taxi and the attempted takeoff occurred about one hour before sunrise during night visual meteorological conditions and with no illumination from the moon.
4. The captain and the first officer believed that the airplane was on runway 22 when they taxied onto runway 26 and initiated the takeoff roll.
5. The flight crew recognized that something was wrong with the takeoff beyond the point from which the airplane could be stopped on the remaining available runway.
6. Because the accident airplane had taxied onto and taken off from runway 26 without a clearance to do so, this accident was a runway incursion.
7. Adequate cues existed on the airport surface and available resources were present in the cockpit to allow the flight crew to successfully navigate from the air carrier ramp to the runway 22 threshold.
8. The flight crewmembers’ nonpertinent conversation during the taxi, which was not in compliance with Federal regulations and company policy, likely contributed to their loss of positional awareness.
9. The flight crewmembers failed to recognize that they were initiating a takeoff on the wrong runway because they did not cross-check and confirm the airplane’s position on the runway before takeoff and they were likely influenced by confirmation bias.
10. Even though the flight crewmembers made some errors during their preflight activities and the taxi to the runway, there was insufficient evidence to determine whether fatigue affected their performance.
11. The flight crew’s noncompliance with standard operating procedures, including the captain’s abbreviated taxi briefing and both pilots’ nonpertinent conversation, most likely created an atmosphere in the cockpit that enabled the crew’s errors.
12. The controller did not notice that the flight crew had stopped the airplane short of the wrong runway because he did not anticipate any problems with the airplane’s taxi to the correct runway and thus was paying more attention to his radar responsibilities than his tower responsibilities.
13. The controller did not detect the flight crew’s attempt to take off on the wrong runway because, instead of monitoring the airplane’s departure, he performed a lower-priority administrative task that could have waited until he transferred responsibility for the airplane to the next air traffic control facility.
14. The controller was most likely fatigued at the time of the accident, but the extent that fatigue affected his decision not to monitor the airplane’s departure could not be determined in part because his routine practices did not consistently include the monitoring of takeoffs.
15. The FAA’s operational policies and procedures at the time of the accident were deficient because they did not promote optimal controller monitoring of aircraft surface operations.
16. The first officer’s survival was directly attributable to the prompt arrival of the first responders; their ability to extricate him from the cockpit wreckage; and his rapid transport to the hospital, where he received immediate treatment.
17. The emergency response for this accident was timely and well coordinated.
18. A standard procedure requiring 14 Code of Federal Regulations Part 91K, 121, and 135 pilots to confirm and cross-check that their airplane is positioned at the correct runway before crossing the hold short line and initiating a takeoff would help to improve the pilots’ positional awareness during surface operations.
19. The implementation of cockpit moving map displays or cockpit runway alerting systems on air carrier aircraft would enhance flight safety by providing pilots with improved positional awareness during surface navigation.
20. Enhanced taxiway centerline markings and surface painted holding position signs provide pilots with additional awareness about the runway and taxiway environment.
21. This accident demonstrates that 14 Code of Federal Regulations 91.129(i) might result in mistakes that have catastrophic consequences because the regulation allows an airplane to cross a runway during taxi without a pilot request for a specific clearance to do so.
22. If controllers were required to delay a takeoff clearance until confirming that an airplane has crossed all intersecting runways to a departure runway, the increased monitoring of the flight crew’s surface navigation would reduce the likelihood of wrong runway takeoff events.
23. If controllers were to focus on monitoring tasks instead of administrative tasks when aircraft are in the controller’s area of operations, the additional monitoring would increase the probability of detecting flight crew errors.
24. Even though the air traffic manager’s decision to staff midnight shifts at Blue Grass Airport with one controller was contrary to Federal Aviation Administration verbal guidance indicating that two controllers were needed, it cannot be determined if this decision contributed to the circumstances of this accident.
25. Due to an on-going construction project at Bluegrass Airport, the taxiway identifiers represented in the airport chart available to the crew was inaccurate and the information contained in a local NOTAM about the closure of taxiway Alpha was not made available to the crew via ATIS broadcast or in their flight release paperwork.
26. The controller’s failure to ensure that the flight crew was aware of the altered taxiway, a configuration was likely not a factor in the crew’s inability to navigate to the correct runway.
27. Because of the information in the local notice to airmen (NOTAM) about the altered taxiway, a configuration was not needed for the pilots’ wayfinding task. The absence of the local NOTAM from the flight release paperwork was not a factor in this accident.
28. The presence of the extended taxiway centerline to taxiway A north of runway 8/26 was not a factor in this accident.

The NTSB synopsis report also set forth a number of safety recommendations arising from the above conclusions, which I will post tomorrow.


Related: Click here to view all posts on this blog about Comair Flt 5191.

NTSB: Crew to blame for Comair Flight 5191 accident

The National Transportation Safety Board (NTSB) has concluded its investigation of the Comair Flight 5191 accident. Comair Flight 5191, a CRJ-100, crashed on takeoff from Bluegrass Airport in Lexington, Kentucky early on the morning of August 27, 2006. Forty-nine passengers and two crew members were lost. The only survivor was the first officer, who was critically injured.

Regarding probable cause, the synopsis of the NTSB's report on the Comair 5191 accident, issued today, concludes:

The National Transportation Safety Board determines that the probable cause of this accident was the flight crewmembers’ 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 the accident were the flight crew’s nonpertinent conversations during taxi, which resulted in a 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. [NTSB/AAR-07/05]

In addition to ruling on probable cause for the accident, the NTSB report also issued numerous safety recommendations for the FAA to consider -- some new, some reiterated. In summary, the safety recommendations focus on the need for:

1. improved flight deck procedures
2. the implementation of cockpit moving map displays or cockpit runway alerting systems
3. improved airport surface marking standards
4. ATC policy changes in the areas of taxi and takeoff clearances and task prioritization

A press release that announced the issuance of the NTSB's report quoted the NTSB Chairman Mark Rosenker, who said, "This accident was caused by poor human performance. 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."

The NTSB synopsis issued today will be followed at a later date by the Board's final report, which will include the Board’s rationale for the conclusions, probable cause, and safety recommendations.

Related: Click here to view all posts on this blog about Comair Flt 5191.

What caused the crash of Comair Flight 5191?

An interesting article in today's Lexington Herald-Leader summarizes the points raised by various groups about what caused the crash of Comair Flight 5191 on August 27, 2006. The views were included in documents submitted to the National Transportation Safety Board (NTSB) as contributions to its investigation of the accident at Lexington, Kentucky in which 49 of the 50 souls on board perished.

While the Herald-Leader article provides a good quick reference, using bullet points, here's some expansion on the newspaper summary, based on a reading of the actual documents.

The document submitted by Comair, Inc., the company operating the accident aircraft, acknowledges that the conduct of its flight crew contributed to the accident, but states that "it would be simple but inaccurate to conclude that the only cause of this tragic accident was a mistake by Comair's well-trained and experienced flight crew." In support of that argument, the document comments at length on the airline's internal safety management process.

The Comair document cites inadequate runway surveillance by the air traffic controller on duty at the time of the accident as a contributing factor. In addition, Comair notes that the Jeppesen and NACO (National Aeronautic Charting Office) charts used by its pilots had incorrect information, and that a NOTAM about the taxiway used that morning also was inaccurate.

A document submitted by NATCA (the National Air Traffic Controllers Association), states flatly, "The probable cause of the accident was Comair 5191 crew's failure to maintain situational awareness while taxiing for departure as well as failure of the crew to ascertain that the runway they were taking off from was the assigned departure runway." In support of their view, they include in their document excerpts of the pre-departure conversation between the two pilots, and between the flight crew and the air traffic controller, as transcribed from the aircraft's Cockpit Voice Recorder (CVR). The conversations, NATCA contends, show that the crew did not maintain the 'sterile cockpit' requirement while they were taxiing, and that this probably compromised their situational awareness.

NATCA cites the FAA's failure "to properly staff the Air Traffic Control tower" as a contributing factor. NATCA notes that there was only one controller on duty in the tower at Lexington at the time of the accident, while FAA directives actually required that there be two controllers on duty on that shift -- one for tower functions, and one for radar functions. NATCA's document cites a list of 31 discrete activities carried out by the lone controller in the tower in the 23 minutes immediately preceding the accident. They use this list to illustrate the task load placed on this single individual, noting that 14 of the 31 activities should have been carried out by a radar controller.

A third document was that submitted by the the Director of Operations of Lexington's Blue Grass Airport, the site of the accident. This document also cites the CVR transcript as evidence for the "loss of situational and location awareness by the flight crew" and violation of sterile cockpit procedures. This led to "the positioning of the airplane incorrectly on Runway 26." The airport management's document goes on to cite "at least eight examples of inattention and lack of focus by the flight crew, especially the First Officer, all of which illustrated the lack of professionalism by the pilots."

In their own defense, the airport management's document states that the airport taxiways, markings, lights and signage all complied with safety standards and certification requirements of the FAA. They point a finger of blame at the FAA and Jeppesen for publishing and distributing inaccurate charts and diagrams of the airport runways and taxiways, while mentioning that a NOTAM issued by the airport did provide "correct information to supplement the existing charts and diagrams."

The fourth document in this set was submitted by the Air Line Pilots Association (ALPA), the union representing the flight crew of Comair Flight 5191. At 127 pages in length, ALPA's submission is the lengthiest. Here is the Overview from that document (reparagraphed for easier reading).

As a party to this investigation, the Air Line Pilots Association, International (ALPA) has identified numerous safety concerns which will be addressed in this document.

Some of the areas of concern are as follows: First, numerous changes to the airport’s layout were not accurately presented to the crew.

Second, some of the Notices to Airman (NOTAM) reflecting the changes to the airport were not made known to the accident crew.

Third, ALPA has identified several human factor concerns relating to situational awareness including fatigue and workload management.

Fourth, our investigation has identified areas of concern regarding air traffic control policy and procedures which led to inadequate staffing, fatigue, and lack of controller vigilance.

Finally, poor coordination between the air traffic controller and the airport crash and rescue personnel delayed the first responders. Additionally, lack of proper emergency locator equipment caused further delay when personnel were not immediately able to accurately locate the wreckage location.

The document goes on to present an extensive analysis, with numerous illustrations, and ALPA's recommendations regarding each of the points. In all, the ALPA document's findings detail 35 discrete items that they found contributed to the accident.

The ALPA document concludes that the flight crew were given misleading information from taxiway signage and lighting cues, which led them to believe that their aircraft was in the correct position for takeoff on Runway 22, when in fact they had entered Runway 26. In addition, ALPA cites a "deficiency in the FAA/NFDC/Jeppesen chart revision process," such that the charts available to the crew "did not accurately reflect what they would be encountering that morning during taxi operations."

The ALPA document also cites understaffing at the Lexington air traffic control tower on the morning of the accident, and acknowledges that the controller "was operating in a fatigued state." But unlike the other documents, which focus on the FAA's failure to ensure that the tower was adequately staffed, the ALPA document focuses on the actions of the controller himself, stating:

Available evidence indicates the controller did not maintain vigilance ensuring the correct taxi route and runway were used. After the controller cleared the aircraft for takeoff, he almost immediately turned his back to address administrative duties. Had he maintained an increased level of vigilance related to controlling this aircraft, he may have noticed that the aircraft had entered the incorrect runway. As part of his duties, the controller was responsible for issuing ATIS broadcasts at LEX. Critical NOTAM information which would have enhanced the situational awareness of the crew was omitted from the ATIS broadcasts.

This is an unusually long post for this blog, I know. If you have read this far, you must have a keen interest either in this specific accident, or in the aviation accident investigation process. In either case, I encourage you to read all of the documents mentioned in this post.

Many thanks to the Herald-Leader for publishing the links to the documents.

Comair sues FAA over crash of flight 5191

Today it was announced that Comair has filed suit against the Federal Aviation Administration (FAA). The regional airline contends that the FAA was negligent in having only one air traffic controller on duty in the tower at Lexington, Kentucky's Bluegrass Airport on the morning last August 27 when Comair Flight 5191 crashed after attempting to take off from the wrong runway.

An article about the lawsuit, published on Forbes.com  reports:

Comair claims the FAA should have staffed the control tower with two controllers. The lone controller on duty that morning had turned away to do some administrative tasks before Comair Flight 5191 tried to take off.

FAA spokeswoman Laura Brown said if a second controller had been on duty, that person would have been staffing the aiport's radar, watching flights in the air from the tower or a windowless room at the base of the tower.

"The FAA disagrees there was any negligence on its part," she said.

The lawsuit, which seeks unspecified damages, follows a previous suit in which Comair that the FAA failed to inspect and approve construction along the taxiway that led to the runway that Flight 5191 should have taken. The FAA was dismissed from that lawsuit earlier this week, although the airport is still a defendant.

Comair 5191 CVR transcript released

The National Transportation Safety Board (NTSB) has released the Cockpit Voice Recorder(CVR) transcript from the Comair Flight 5191 accident that occurred on August 27, 2006.

Comair Flight 5191, a CRJ-100, crashed on takeoff from Bluegrass Airport in Lexington, Kentucky. Forty-nine passengers and two crew members were lost. The only survivor was the first officer, who was critically injured.

Click the link below to download the official transcript of the Cockpit Voice Recorder (CVR) for that flight. [43 page 'PDF' file]

Comair flight 5191: CVR transcript

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Update on Comair 5191 accident

The National Transportation Safety Board (NTSB) has released an update on the investigation into the cause of the crash of Comair CRJ-100 aircraft in Lexington, Kentucky last month. Comair Flight 5191 crashed on takeoff, killing 49 of the 50 souls on board.

An NTSB press release, issued today (see link below) says that the on-scene portion of the investigation into the cause of the accident has been completed. Here are the findings, to date:

Accident Sequence

Flight 5191, from Lexington, Kentucky to Atlanta, Georgia, was the third of three airplanes scheduled to take off in the early morning. The previous two departures took off without incident from runway 22. Flight 5191 was also cleared to taxi to runway 22 and subsequently cleared for takeoff; however, the airplane attempted to take off from runway 26. According to recorded information, the aircraft began its takeoff roll, accelerated to a maximum of about 137 knots, ran off the end of the runway through the airport perimeter fence, and impacted trees on an adjacent horse farm. The entire sequence took about 36 seconds. The airplane was destroyed by impact forces and a post-crash fire.

Aircraft Wreckage

Witness marks on scene indicate that all three landing gear were on the ground as the airplane exited the runway. The main wreckage was located approximately 1,800 feet from the end of the runway. Both engines were examined at the accident site and no evidence of pre-impact failure was noted and the thrust reversers were stowed. The flaps were found in the takeoff position and no problems were noted with any other airplane system or structure. The wreckage from flight 5191 has been moved to a storage facility in Georgia.

Recorders

The flight data recorder (FDR) and the cockpit voice recorder (CVR) were recovered immediately and have provided valuable information. Investigators are continuing to extract data from the flight recorders, the air traffic control tape recordings and airport video surveillance cameras. FDR data indicate that the airplane stopped near the end of runway 26 for about 45 seconds before the flight was cleared for takeoff. The airplane was cleared for takeoff and 6 seconds later started to taxi onto runway 26. It took about 36 seconds for the airplane to taxi onto runway 26 and complete the turn before power was increased to initiate the takeoff. FDR vertical accelerometer data indicate that the airplane departed the end of the runway about 32 seconds after the takeoff was initiated. The FDR recording ended about 4 seconds later. Time correlation of those data continues.

Operations/Human Performance

Operations/Human Performance group has completed initial follow-up interviews at Comair headquarters in Covington, KY. The group conducted airport observations under day and night conditions; a simulator observation of Comair taxi and takeoff procedures; and interviews with multiple persons including: ramp personnel, flight instructors, check airmen, and several pilots who had flown with the accident flight crew. These interviews provided investigators with information about procedures and techniques used by pilots for taxi and takeoff runway identification and information about the accident flightcrew. Additionally, the Director of Corporate Safety for Comair and FAA personnel responsible for oversight of the Comair certificate were interviewed. The group gathered relevant documents pertaining to the accident flight, flight crew training and evaluation, operations of the CRJ100, and oversight of the airline. Investigators are now reviewing interview summaries and documentation to identify areas for further investigation and evaluation. The group continues to evaluate the pilot actions that led to the attempted takeoff on runway 26.

Airport Information/Survival Factors

Runway 22 is 7003 feet long, 150 feet wide, and is lighted for nighttime use. Runway 26 is 3500 feet long, 150 feet wide but marked to 75 feet wide, and is not lighted and is restricted to daytime use only. In order to take off from runway 22 it is necessary to taxi across the end of runway 26. An airport construction project, begun in 2004, was still underway at LEX at the time of the accident. The project was intended to mill and repave runway 4-22 and upgrade the safety areas at both ends of runway 4-22, the main runway. This project necessitated changes to some of the taxiways and signage. The group continues to evaluate the airport taxiway and runway markings, lighting and signage as well as additional information that was available to pilots. The Airport/Survival Factors Group will also be documenting the factors that may have contributed to the loss of lives in this accident.

Air Traffic Control

At the time of the accident, there was one air traffic controller in the tower. After handling several aircraft at the beginning of his shift, there were several hours without aircraft movements. In the 20 minutes leading up to the accident, there were three departures, including Comair 5191, from LEX under his control. The ATC group has interviewed several Lexington control tower personnel and FAA air traffic personnel. The controller on duty at the time of the accident relayed the following information to investigators: he cleared the accident flight crew to take off (from runway 22) and to fly runway heading (220 degrees); after providing takeoff clearance for flight 5191, he turned away from the window to perform an administrative task (traffic count); he did not witness the accident, but heard the crash, turned around and saw fire, and immediately activated the emergency response. As in all investigations, the group will review the controller's workload and duty schedule and the tower staffing level.

Toxicological Test

Toxicology testing performed on specimens from both pilots did not detect any illicit substances or alcohol. An over the counter decongestant, pseudoephedrine, was detected at a low level in the first officer's blood.

Post Accident FAA Action

On September 1, 2006, the FAA issued a Safety Alert for Operators (SAFO), titled, "Flight Crew Techniques and Procedures that Enhance Pre-takeoff and Takeoff Safety." This alert highlights existing FAA aircraft ground operation guidance and reminds flightcrews that maximum attention should be placed upon maintaining situational awareness during taxi operations.

The Aero-News Network has published an article that raises the question of whether or not the ATIS (Automatic Terminal Information Service) recording that the crew heard on the morning of the accident was detailed enough to ensure they taxied to the correct runway.

The same article also questions details of the NOTAM regarding the taxiway at LEX.

According to FAA transcripts received by the Louisville Courier-Journal, the published NOTAMS the crew had access to were accurate, but did not explicitly direct pilots how to get to the correct runway with part of the taxiway closed. The hourly ATIS that they monitored was evidently even less clear regarding taxi instructions.

As Aero-News reported, the crew was using an outdated chart when they were cleared for Runway 22, and departed instead from the much shorter Runway 26. The aircraft crashed on takeoff.

The NOTAM on the day of the crash says: "TWY A CLSD N OF 8/26".

The pilots would have understood that to mean "Taxiway A closed north of Runway 8/26." In other words, the part of the taxiway to get to Runway 22 beyond 26 was closed.

The new NOTAM issued after the crash tells pilots exactly where to taxi. It reads "LEX TWY A7 CLOSED (UNDER CONSTRUCTION) USE TMPRY TWY A NRTH OF 8/26 FOR ACCESS TO AER 22." This identifies the specific part of Taxiway A that is closed and directs pilots to use a temporary taxiway to get to Runway 22.

It is safe to assume the Blue Grass ATIS is now equally explicit regarding taxi instructions.

The only survivor was the flight's First Officer James Polehinke, who was believed to be at the controls at the time of the accident. An Associated Press article published on Forbes.com and elsewhere says that Mr. Polehinke's leg as been amputated, and that he faces several additional surgeries to repair fractures, one involving his spinal cord. Family members have said that the badly injured pilot has no memory of the accident.

Sources: Update on NTSB Investigation into the Crash of Comair Flight 5191 - NTSB News
Was Lexington ATIS, NOTAM Too Vague? - Aero-News.net
Plane Crash Survivor Has Leg Amputated - Forbes.com

Technorati Tags: aircraft accidents, airlines, Comair, Comair Flight 5191, National Transportation Safety Board, NTSB

Comair Flight 5191 aftermath

The tragic accident that happened on Sunday, August 27, in Lexington took the lives of 49 souls on board Comair Flight 5191. Our hearts go out to the families and colleagues of all who were aboard that flight, and we extend our sympathy to the entire Comair family.

We send well wishes to F/O James Polehinke, the lone survivor of Comair Flight 5191, and hope that he will recover fully from his injuries.

Like most people in the country -- and especially those in the aviation community -- we were glued to the television most of the day on Sunday, and also spent quite a bit of time visiting various aviation message boards trying to learn who was aboard the flight, and what might have happened to cause the accident.

By now it seems clear that the aircraft did indeed attempt to take off from the wrong runway. What is less clear, so far, is what chain of events combined to result in the ultimate error. It is tempting to speculate, but we will refrain from doing that. We hope that the NTSB will be able to piece together all of the varied bits of evidence that they collect to determine the reasons for the accident.

The NTSB findings for this accident, and for all others, will not be able to undo the damage, nor restore the lives that were lost. The best that can be hoped for is that a better understanding will emerge that may lead to changes in procedures -- on the flight deck, at airports, at ATC towers -- that will serve to prevent similar accidents in the future.

A blog post written by Ralph Hood, a columnist for Airport Business, recounts several prior accidents that resulted in new safety procedures or regulations. He says:

Accident investigation is something we do well in this country. The truth will out, changes will be made, and airline travel -- already the safest means of transportation in the history of the world -- will become even safer.

That may be true, but it is little comfort to the families and colleagues of those who perished in the aircraft accidents that demonstrated the need for changes.

We cannot count how many times we have heard pilots say that "the FARs are written in pilots' blood." Yes. And in the blood of cabin crew and passengers as well.

Source: Black Sunday - Airport Business

Technorati Tags: air travel, airlines, aircraft accidents, aviation, aviation safety, Comair