The NTSB meeting into the crash of Comair Flight 5191 is underway in Washington, D.C. Investigators are presenting their findings to the five member board.
Board Member Kitty Higgins says that the goal of this meeting is to find out exactly what happened the day of the crash, and to ensure that this kind of accident doesn't happen again.
So far, the meeting has mainly focused on the human error that led to the fatal crash. Non-pertinent conversation between the crew members, a lack of information from the Air Traffic Controller, and insufficient ground markings have all been attributed to the cause of the crash.
The investigation into flight view operations indicates that the captain paused at the runway before departing for 57 seconds,
giving them ample time to look outside the plane and verify their location.
However, evidence shows that unnecessary conversation between crew members served as a distraction, and therefore the pilots did not positively cross check and confirm their location.
Vice Chairman Robert Sumwait says that crew issues are to blame for the crash, including the fact that the crews were engaged in non-pertinent conversation at the time of departure, which is a direct violation of procedures. Sumwait says, "Critical items were missed, and vigilance was lost on this flight."
Board Member Hersman says that was the first time that this particular flight crew had flown together, and there was a failure to complete a full taxi briefing. If the briefing had been completed, crew members would have been aware that the taxi route of the plane was intended to cross Runway 26 in navigation to Runway 22. Instead, the pilots took off from Runway 26, which caused the crash.
In review of the conversation that was taking place between the pilots, the co-pilot made the comment, "That's weird, with no lights," referring to Runway 26. Board Member, Captain Steven Chealander, indicated that at the time this comment was made, the pilots could have stopped the plane if they had noticed that something was wrong.
As the discussion turns to system errors that contributed to the crash, Board Members discuss the signage that identifies the runways at the Blue Grass Airport. Board Members say that these signs are very visible and brightly lit, especially at night. Experts concluded that all identifiers on the runway met standards, and say that the pilots had every opportunity to verify their location.
Prior to take off, pilots are supplied with charts and diagrams, which include the diagrams of the runways. Evidence suggests that the charts supplied to the pilots of Flight 5191 were inaccurate. When there are changes in these charts, notifications called NOTAMS are created. At the Blue Grass Airport, there was a NOTAM out regarding the taxiway closure and construction. However, there is no indication that the pilots of 5191 ever received this notification.
Chairman of the Board, Mark Rosenker, asked several people in the room who had aviation background if they had ever taken off from a dark runway. Each pilot responded that he had not. Rosenker went on to say that he could not understand why these pilots, who had logged in thousands of hours of experience, did not question their location prior to take off.
Board Member Captain Steven Chealander says that there are a lot of issues with this accident. However, he says there comes a time when flight crews have to make the right decisions, and this particular crew didn't do their job. "There is human error and system error, [and in this case] the human error far outweighed the system error."
Flight 5191 was the third plane to depart the Blue Grass Airport the morning on the crash. The investigation into the other two flights that took off prior to 5191 show that they took off under similar circumstances. The diagrams supplied to these planes were also incorrect, and those crews had not received any notification of the closed runway. However, when Flight 5191 paused for take off clearance, the plane was on Runway 26, when the two previous planes stopped for taxi clearance, they were on Runway 22, the correct runway.
In a presentation by Dr. Bill Bramble, he indicted that Blue Grass Airport should have had two air traffic controllers on duty. Since the crash, the FAA has made it a mandatory regulation for all airports to have at least two air traffic controllers on duty at all times.
At the time of the accident, the controller on duty failed to provide vital information, including the fact that a taxiway was closed. He also choose to perform an administrative task at the time Flight 5191 began to depart.
In an interview with the air traffic controller held previously to this meeting, when asked what he would have done differently that day of the accident, the air traffic controller said he would have not performed that administrative task. In that same interview, investigators learned that the air traffic controller had only had two hours of sleep the day before, and was suffering from fatigue.
In the third round of questioning, Board Members focus on the system of failures that led to the accident. The Automatic Terminal Information Service, also referred to as ATIS, is administered by the traffic controller, and contains information such as current weather and NOTAM information, such as taxiway closures. The morning of the crash, the ATIS was not recorded, and therefore the NOTAM was omitted from the broadcast.
At this time, the NTSB Board and Staff has passed 28 points of findings regarding the crash. These findings include the following:
- Flight crew members non-pertinent conversation during the taxi, which was in non-compliance with FAA regulations, likely contributed to loss of positional awareness
- The Air Traffic Controller did not notice that the flight crew was stopped short of the wrong runway
- FAA operational policies and procedures at time of accident were not sufficient
- Emergency response to this accident was timely and well coordinated
Probable cause has yet to be determined.
Check back here for the latest updates on the meeting.