H46Bubba
Well-Known Member
Hot off the presses.
NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of July 26, 2007
(Information subject to editing)
Report of Aviation Accident
Attempted Takeoff From Wrong Runway,
Comair Flight 5191, Bombardier CL-600-2B19, N431CA
Lexington, Kentucky, August 27, 2006
NTSB/AAR-07/05
This is a synopsis from the Safety Board’s report and does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.
EXECUTIVE SUMMARY
On August 27, 2006, about 0606:35 eastern daylight time, Comair flight 5191, a Bombardier CL-600-2B19, N431CA, crashed during takeoff from Blue Grass Airport, Lexington, Kentucky. The flight crew was instructed to take off from runway 22 but instead lined up the airplane on runway 26 and began the takeoff roll. The airplane ran off the end of the runway and impacted the airport perimeter fence, trees, and terrain. The captain, flight attendant, and 47 passengers were killed, and the first officer received serious injuries. The airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 and was en route to Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. Night visual meteorological conditions prevailed at the time of the accident.
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 .
The safety issues discussed in this report 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, and (4) ATC policy changes in the areas of taxi and takeoff clearances and task prioritization. Safety recommendations concerning these issues are addressed to the FAA.
CONCLUSIONS
PROBABLE CAUSE
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- The emergency response for this accident was timely and well coordinated.
- 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.
- 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.
- Enhanced taxiway centerline markings and surface painted holding position signs provide pilots with additional awareness about the runway and taxiway environment.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- The presence of the extended taxiway centerline to taxiway A north of runway 8/26 was not a factor in this accident.
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.
SAFETY RECOMMENDATION
As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations:
To the Federal Aviation Administration:
PREVIOUSLY ISSUED RECOMMENDATIONS REITERATED IN THIS REPORT
- 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)
- 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)
- 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)
- 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)
- 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)
To the Federal Aviation Administration:
PREVIOUSLY ISSUED RECOMMENDATIONS RESULTING FROM THIS ACCIDENT INVESTIGATION
- 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)
To the Federal Aviation Administration on December 12, 2006:
To the Federal Aviation Administration on April 10, 2007:
- 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)
To the National Air Traffic Controllers Association on April 10, 2007:
- 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 decreased cognitive performance. (A-07-30)
- 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. (A-07-31).
- 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. (A-07-34)
PREVIOUSLY ISSUED RECOMMENDATIONS CLASSIFIED IN THIS REPORT
- Work with the FAA 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‑07-32)
- Safety Recommendation A-06-83 is classified “Closed—Acceptable Alternate Action/Superseded,” and Safety Recommendation A-06-84 is classified “Open—Acceptable Alternate Response.”
- Safety Recommendations A-07-30 and -31 are classified “Open—Acceptable Response.”
- Safety Recommendation A-07-34 is classified “Open—Acceptable Response.”
