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... - Special Reports - The crash of Comair Flight 5191 - NTSB Hearing on Flight 5191

Friday, Jul. 27, 2007

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Conclusions of the NTSB report

1. The captain and the first officer were properly certified 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 crew members 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 crew members' non-pertinent 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 crew members 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 crew members 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' non-pertinent 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.

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