Pilot error blamed in plane crash that killed 49

Official cites 'briar patch of human behavior'

By Brandon Ortiz, Janet Patton and Michelle Ku - MKU@HERALD-LEADER.COM

WASHINGTON -- After putting in 13,000 man hours of investigation over 11 months and reviewing more than 1,000 pages of evidence, federal investigators concluded that Comair Flight 5191 crashed because of mistakes made by the pilots.

But investigators still could not answer the question that has frustrated them since Aug. 27, the day of the crash: How did two experienced pilots, navigating a simple, "straightforward" airport, take off from the wrong runway?

And why did they take off from an unlit runway -- a black hole -- asked National Transportation Safety Board chairman Mark V. Rosenker.

"To try to get into the minds of operators, of pilots -- you can't do it," Rosenker said after the hearing.

The NTSB attempted to delve into the minds of pilots Jeffrey Clay and James Polehinke to find answers in the crash that killed 49 people near Blue Grass Airport. Polehinke was the only survivor.

After a daylong hearing that looked at everything from air traffic control to taxiway markings, the NTSB cited two major errors by the plane's pilot and co-pilot as the causes of the crash: their failure to use cues and aids to identify the aircraft's location, and their failure to verify that the commuter plane was on the correct runway before takeoff.

The five-member board identified two contributing factors to the crash: the crew's distracting cockpit conversation about work, family and other topics; and the Federal Aviation Administration's failure to require that all pilots be cleared by air traffic controllers before they cross a runway.

At 6:05 a.m. on Aug. 27, in dark but clear conditions, the 50-seat regional jet weighing 50,000 pounds took off from the shorter of Blue Grass's two runways, Runway 26, which was far too short for a plane that size. It was supposed to take off from Runway 22, which is 7,000 feet long.

Many questions remained yesterday as the board delved into what NTSB member Debbie Hersman described as "the briar patch of human behavior." Hersman was the NTSB member on the scene of the Lexington crash.

"It did not take long for all of us to realize that, no matter how many people we interviewed, no matter how many documents we reviewed, no matter how much evidence we collected, the accident would offer up no easy explanations for us," Hersman said. "No simple solutions. There would be no moment where we could point to one thing and say, 'Aha, that is what caused this accident.'"

Hersman described the Comair crash as the "most searing" she's been involved in -- because of the loss of life and because there was no single, clear cause, such as a mechanical problem.

The board also considered a staff recommendation to include a third contributing factor: the air traffic controller's performance of an administrative task not directly related to flight safety. However, the board voted, 3-2, to remove that factor from the official listing of causes.

Hersman and member Kitty Higgins, who voted to keep the controller as a contributing factor, said they will file concurring opinions.

After ruling on the cause, the NTSB made several safety recommendations to the Federal Aviation Administration. Those included requiring pilots and co-pilots to cross-check and confirm that they are on the correct runway; requiring that cockpits be fitted with electronic maps or displays that would alert pilots if they are on the wrong taxiway or runway; enhancing taxiway markings; and telling air traffic controllers to refrain from performing administrative functions while they are supposed to be monitoring the safety of aircraft.

The board reiterated some earlier recommendations, including additional guidance for using unlit runways and urging the FAA to deal with issues related to fatigue among air traffic controllers.

Board members expressed frustration at the FAA's failure to enact prior recommendations, particularly those dealing with runway issues.

Throughout the hearing, board members discussed the several cues that the pilots missed that should have warned them they were on the wrong, too-short runway, and how they chatted about irrelevancies.