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Lexington crash brings subtle changes in aviation

WASHINGTON — Two years after Comair Flight 5191 took off from Blue Grass Airport down the wrong runway and hurtled into a field, killing 49 people, the accident's reverberations can be found in subtle shifts in federal aviation policy.

The changes have occurred "not because of Lexington, but Lexington was one of the high-profile accidents we took into account," said Laura Brown, a spokeswoman for the Federal Aviation Administration.

Still, the seemingly slow pace of change frustrates some safety board members and other transportation experts.

"If we start worrying why it can't be done we'd issue a lot fewer recommendations," Robert Sumwalt, vice chairman of the National Transportation Safety Board, said in an interview.

It's a common theme for an agency that has long held firm against making all of the NTSB's recommendations compulsory. Last year, the Government Accountability Office, Congress' investigative arm, found that there is "a high risk of a catastrophic runway collision occurring in the United States" because of poorly functioning equipment, fatigued air traffic controllers and spotty leadership at the federal level.

After the smoke cleared on Aug. 27, 2006, the National Transportation Safety Board and, ultimately, the FAA were left to piece together how, if at all, the Comair crash would influence aviation safety.

During a hearing in July 2007, the NTSB made several recommendations to the FAA related to runway safety, including:

■ Requiring airlines to install in aircraft cockpits "moving map" displays or automatic systems to alert pilots when a takeoff is attempted on a taxiway or runway other than the one intended.

■ Requiring enhanced markings on taxiways and runways.

■ Taking added care when an aircraft has to cross multiple runways.

"After the Lexington accident we looked back over 10 years of data at incidents when there was some confusion about the right runway to take off on," Brown said. "We were concerned that people were becoming complacent on some of the safety issues."

Last month, the FAA announced a series of runway safety initiatives designed to avoid the types of conditions that led to the Lexington crash. Those measures include installing more than $400 million worth of runway status lights at major airports that would warn pilots when it is unsafe to cross or enter a runway. The agency expects to award a contract this fall to install the runway light systems at 22 large airports over the next three years. Lexington isn't on the list.

The FAA also hopes to provide up to $5 million to test cockpit displays that would give pilots the most up-to-date information on runway conditions.

The FAA also issued an advisory that by June 2008 large airports should implement enhanced taxiway centerline markings and painted holding position signs at all runway entrances — a move that stemmed from longstanding NTSB concerns that were sparked anew after the Lexington crash. Medium sized airports must follow suit by early 2009 and smaller airport by 2010.

"Lexington is a smaller airport and we challenged all the smaller airports to meet those standards before then," Brown said.

But for the most part, the FAA has stopped short of using the NTSB's recommendations from the Comair crash to draft additional rules and make them mandatory.

According to a letter sent last week by National Transportation Safety Board Chairman Mark Rosenker, the FAA's sluggish response on requiring stricter runway checks is "unacceptable". The NTSB was particularly troubled by wording in an FAA safety notice that instructed air traffic controllers to state the takeoff runway but didn't force controllers to wait until a plane had crossed all runway intersections before issuing clearance.

"Simply restating the takeoff runway, as the notice directs, is therefore not responsive" to the NTSB's recommendations, Rosenker wrote.

Some aviation experts say the FAA's cautious approach to rulemaking has saved both lives and money.

"In the United States we're at risk of overreacting to certain events," said Joseph Schwieterman, an aviation expert and a professor of public service management at DePaul University in Chicago. "The truth is most accidents are caused by factors that are unseen. In this case (the Comair crash), it is hard to regulate human judgment."

After the Lexington crash, the NTSB recommended the FAA change its guidelines to bar controllers from performing administrative tasks, such as the traffic count, when moving aircraft are in the controller's area of responsibility.

"A workgroup is reviewing what would the impact be if we did that," Brown said.

The NTSB recommended asking the National Air Traffic Controllers Association to work with the FAA to reduce the potential for controller fatigue — the controller on duty during the Lexington crash had two hours of sleep. The FAA responded by developing a training program, hosting a fatigue symposium in Washington earlier this year, and asking the air traffic controllers group to make recommendations on changes in work-scheduling policies.

"We've yet to adopt policies that tackle the fatigue problem head on," Schwieterman said. "It remains a weakness overall."

Similarly, the NTSB recommended requiring airlines to provide guidance to pilots on the runway lighting requirements for takeoff operations at night. The FAA responded by asking, but not forcing, directors of safety and operations at airlines and trainers to include those points in their training programs.

The NTSB concluded that the Lexington crash was a case of pilot error. The agency also ruled that the plane's two-man flight crew lost track of where the aircraft was and that the crew failed to cross-check and verify that the plane was on the correct runway before takeoff.

In the meantime, some airlines have changed their own policies regarding verification and confirmation of the correct departure runway and have prohibited operations on unlit runways.

However, aviation experts agree that ultimately human error is beyond the powers of the regulatory process, and there is no foolproof way to guarantee that an accident like Comair 5191 doesn't happen again.

"Something we've seen over the last few years is that some of the most difficult safety issues involve human decision-making," Brown said. "There's technology that adds a layer of safety. But human risk factor is one of the most difficult safety issues to solve."

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