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Fri, Jul 27, 2007

NTSB Releases Probable Cause Report on Comair Flight 5191

Agency Says Accident Caused By Numerous Errors

After offering the families of those who perished in the Comair Flight 5191 accident last year, the National Transportation Safety Board announced its findings on the 11-month investigating into what went wrong in the early morning hours of August 27, 2006.

Comair Flight 5191 mistakenly took off from a too-short runway at Blue Grass Airport in Lexington, KY in an accident that killed 49 of 50 people on board.

The Louisville Courier-Journal reported the final draft focused on the behaviors of the pilot, first officer and controller.

"This accident has led us into the briar patch of human behavior," said NTSB board member Debbie Hersman. "No simple cause. No single solution. No 'aha' moment."

From what the NTSB has made public, several issues figure in to the final outcome.
 
"I don't see one overriding factor," said John Nance, author and aviation analyst for ABC World News. "There are always probable causes."

Among several reported errors made by pilot Capt. Jeffrey Clay and First Officer James Polehinke (the sole survivor) was 40 seconds of conversation that was said to be in violation of FAA regulations, according to USA Today.

NTSB transcripts of that conversation between Clay and Polehinke were about schedules, families, a pet and another pilot just before takeoff.

According to the carrier, this kind of conversation is in violation of the "sterile cockpit" rule. The federal regulation requires pilots to focus on the aircraft only, said Nance.

But, "would they have caught (their wrong location) if they had been quiet and professionally focused? You can't say that," he said.

The Air Line Pilots Association recently submitted statements to the NTSB claiming airport signage did not match given diagrams and charts and proper recorded notice to airmen information did not include critical information such as the normal taxiway to the main runway was closed due to construction, that the distance-remaining lights on the main runway were out of service or that the runway they were about to take off from was for daytime use only, as ANN reported.

The carrier agreed and added LEX had mismanaged a construction project caused confusion that contributed to the crash.

LEX countered that line of reasoning saying the NTSB found in December 2006 that appropriate signs were in place and the air crew's inattention when they violated the "sterile cockpit" rule caused the crash.

"This accident was caused by poor human performance," said NTSB Chairman Mark V. Rosenker.  "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."

Another factor presented was the fact there was only on controller on duty at LEX that morning. The FAA admitted there was, indeed, one controller instead of the required two.

That sole controller, Christopher Damron, initially told investigators he watched the aircraft taxi to the correct runway then changed his statement to say he had, in actuality, turned away to do other job-related duties.

Some analysts have speculated the outcome of this situation might have been very different had there been the required controllers on duty that day, a claim FAA administrator has been reported to Marion Blakey dispute.

"I want to emphasize, in case there is any doubt: This Lexington controller did nothing wrong. He cleared the aircraft to the correct runway and performed his duties by the book. Our bottom line is this: We believe this terrible tragedy might well have been prevented had there been a second controller in this facility on this shift," said National Air Traffic Controllers Association President Patrick Forrey.

"(The) NATCA's long-held position is there should NEVER be one controller working by themselves. Ever. It is not safe, for the controller or for the flying public."

"Really, the main thing we would like to see happen is that (NTSB) recommendations are enforced," said Connie Fahey, mother of Thomas Fahey, 26, who died in the accident. "Somebody needs to make sure they follow through and do what needs to be done."

The probable cause reads: "The National Transportation Safety Board today determined the probable cause of the Comair flight 5191 accident in Lexington, Kentucky was the flight crew's 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 this accident were the flight crew's nonpertinent conversation during taxi, which resulted in 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."

FMI: www.ntsb.gov, www.natca.org, www.alpa.org, www.comair.com

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