WASHINGTON (AP) - Pilots' failure to notice clues that they were
heading to the wrong runway was the primary cause of last summer's
deadly Kentucky plane crash that killed 49 people, safety
investigators concluded Thursday.
The National Transportation Safety Board deliberated all day on
possible causes of the Aug. 27, 2006, crash of Comair Flight 5191,
which tried to depart in the pre-dawn darkness from an unlit
general aviation strip too short for a proper takeoff.
Board members originally had considered listing errors by the
air traffic controller as contributing causes but ultimately pinned
most of the blame on the pilots, along with the Federal Aviation
Administration for failing to enforce earlier recommendations on
NTSB board member Deborah Hersman suggested during the meeting
that there were numerous causes - nearly all of them human.
"That's the frustration of this accident - no single cause, no
single solution and no 'aha' moment," Hersman said. "Rather than
pointing to a mechanical or design flaw in the aircraft that could
be fixed or a maintenance problem that could be corrected, this
accident has led us into the briar patch of human behavior."
Hersman was one of two board members who voted to list the
controller's action as a contributing cause, but she was overruled.
The NTSB also proposed several changes to aviation procedure as
a result of the accident, including calls for clearer signs at
regional airports and installation of an automated moving map
system in which pilots can check in real time whether they're on
the right runway.
In a statement, Comair President Don Bornhorst said he would
work with the NTSB and the FAA to address the proposed changes.
The board's findings were perhaps more notable for the things
they decided weren't factors than the ones they determined were.
Among the non-factors, according to the board, were the flight
crew's lack of updated maps and notices alerting them to
construction that had changed the taxiway route a week earlier.
Although the board found the controller was fatigued, that also
likely didn't play a role, the board said.
Pilot Jeffrey Clay and first officer James Polehinke were most
culpable for ignoring clear signs they were going the wrong way,
such as the lack of lights on the shorter runway, NTSB found.
"Weird, no lights," Polehinke was quoted as saying in the cockpit
NTSB chairman Mark Rosenker said afterward there were clear
differences between the right strip and the wrong one.
"One was lit up like a Christmas tree," he said. "The other
was like a black hole."
Polehinke was pulled from the charred cockpit as the only
survivor, but he sustained brain damage, lost a leg and broke
numerous bones. His attorney, Bruce Brandon, declined comment
A secondary cause, NTSB said, was non-pertinent chatter between
the crew members as they prepared to taxi and take off. Comair has
acknowledged some culpability as a result of the talk, which
violated FAA rules calling for a "sterile cockpit."
NTSB staff concluded the talk "greatly affected the crew's
performance." Hersman agreed but suggested the disaster couldn't
be pinned on that alone.
"It's clear this crew made a mistake," Hersman said. "Their
heads just weren't in the game here. The issue is, what enabled
them to make this mistake?"
Hersman pointed to the paperwork the crew never got detailing
the taxiway change. Not only was it not in their packet from
Comair, but the air traffic controller didn't broadcast the
announcement that morning, even though it had been doing so the
rest of the week.
"We deal in redundancies in this business," Rosenker said.
"That's what enables us to look after each other in the cockpit,
and if one of the crewmen fails to do something, the other is there
to help fill in the gap."
No witnesses were called at the board meeting.
Investigators said a lone air traffic controller on duty used
poor judgment by turning his back before takeoff, but they debated
whether a required second controller could have prevented the
NTSB staff concluded controller Christopher Damron should never
have turned away to do an administrative task "not critical to
flight safety" as the jet was preparing to depart.
However, the staff dismissed as a non-factor the violation of an
FAA directive calling for two controllers to work overnight shifts
in airports like Lexington - one to keep an eye on the ground, the
other to monitor radar.
Patrick R. Forrey, president of the National Air Traffic
Controllers Association, said there was nothing Damron should have
done differently. He said the error that happened in the tower was
due to staffing.
"He would have had the opportunity to possibly catch that
aircraft from going down the wrong runway," Forrey said.
Among the family members who attended the proceedings was
Lexington resident Kathy Ryan, who lost her husband Michael in the
accident. She said she agreed with most of the findings but that
the meeting was difficult to endure.
"You relive the accident and you also relive the week of
briefings," Ryan said. "It was like being back there again
About 25 relatives of crash victims gathered at a hotel in
downtown Lexington on Thursday to watch a video link to the
"You just think that if one precaution had been observed, then
this tragedy wouldn't have happened, and we would still have our
loved ones," said Lois Turner, whose husband was a passenger.
"And that, I think, is the sad part and the hard part, to know
that there were so many missed opportunities."
Associated Press writers Ann Sanner in Washington and Joe Biesk
in Lexington contributed to this report.
On the Net:
NTSB report: http://www.ntsb.gov/Publictn/2007/AAR-07-05.htm
(Copyright 2007 by The Associated Press. All Rights Reserved.)