Crash of Flight 5191

Past incidents may hold clues

Pilots have inadvertently taxied to the wrong runway at Blue Grass Airport at least three times since 1993.

On two occasions, either the pilot or someone in the control tower caught the mistake.

Last Sunday, no one caught the mistake and 49 people died.

Comair Flight 5191 crashed and burst into flames at 6:07 a.m. Sunday, killing 49 of 50 passengers and crew members on board, just seconds after taking off from a runway that was too short for the loaded CRJ-100 jet.

Investigators quickly determined that the plane attempted to take off from Blue Grass Airport's 3,500-foot Runway 26, which is used by light planes, instead of the 7,000-foot Runway 22, which is designed for airliners.

Federal investigators are focusing on why the experienced pilots strayed onto the wrong runway.

"It's not the first time" a pilot has taken off from the wrong runway, said Dana Siewert, director of Aviation Safety at the University of North Dakota. "And it won't be the last."

Nor is he sure it has happened only three times at Lexington's airport.

An analysis of NASA's Air Safety Reporting System data found that 99 voluntary reports were submitted by pilots, controllers, maintenance people and others at or near the airport from 1988 through December 2005.

Of those, two are very similar to the Aug. 27 crash, three others involve planes landing and then taxiing onto the wrong runway, and three more report pilots complaining of confusing or inadequate markings to guide crews in and out safely. Most of the rest of the reports had to do with mechanical problems on the airplane.

"They are classic" examples of what happened Sunday, said Linda J. Connell, director of NASA's reporting system.

The two cases Connell believes are relevant from the database happened in 1993 and again in 1995.

In 1993, an aircraft was cleared for takeoff but stopped when it got onto the runway while the crew checked the weather radar; it was raining. The crew realized their heading was wrong at the same time the tower called to cancel the takeoff because they were on Runway 26 instead of Runway 22.

"Possible contributing factors were poor visibility and WX (rain)," according to the report. The pilot also cited a confusing runway intersection and the tower's "request for an immediate takeoff."

Then in 1995, a flight was two minutes late leaving Blue Grass for Nashville when it taxied to the wrong runway. Confusion in this case came from the flight crew calling it Runway 22 and the tower using a different designation. The same person in the tower was handling both ground control and control tower duties.

In both instances, the planes adjusted and took off from Runway 22.

When pilots make mistakes

The program that lets pilots report errors and problems is voluntary, so it doesn't capture everything.

"Not reported? I would imagine there's just as much as there is reported," said Siewert. Filing a report "is a decision a pilot has to make."

When pilots make mistakes, but no accident results, they can file a report with NASA's system. They report what happened, the consequences and what improvements could be made to ensure it doesn't happen again.

"It's sort of a get-out-of-jail-free card," said Randy Reinhardt, a semi-retired aviation attorney and pilot from Lexington. If the Federal Aviation Administration subsequently finds out about the incident and the pilot has proof he filed the report, they can't take his license, he said.

Siewert said the system does "provide pretty good protection" for pilots, but he also sees value in the data the system captures.

So does Connell.

After Flight 5191 crashed, Connell's team pulled the relevant cases from their database and sent them to the NTSB team investigating the crash.

NTSB spokesman Terry Williams said he wasn't familiar with these specific incidents, but stressed that investigators will be reviewing the reports.

Mike Gobb, executive director of Blue Grass Airport,said he was aware of the 1993 incident, but not the one in 1995 or the reports on the three incoming flights.

"I think those kinds of mistakes happen at lots of airports," said Russ Whitney of Georgetown, a retired Delta captain who last flew in and out of Blue Grass Airport about five years ago. But he doesn't think the problem is worse here than anywhere else.

"It's really not the tower's responsibility to make sure you're on the right runway," Whitney said. "It's really up to the pilot."

Jim Burin, director of technical programs for the Flight Safety Foundation in Alexandria, Va., agreed that while it isn't common for airplanes to wander onto the wrong runways or taxiways, these incidents do happen.

"These are unusual, but they have happened before, particularly at airports where you have runways that are closer together, as these two were," Burin said. "That obviously lends itself to a little bit more risk of this happening than if the runways are built at a 90-degree angle."

NASA's program started in 1976 in response to an accident near Dulles International Airport. During the investigation, Connell said, they discovered a similar set of circumstances had occurred at the airport six weeks before the crash.

They knew something needed to be done to track problems, but no one wanted the Federal Aviation Administration to do it.

"They are the cops," said Connell. NASA was independent and had no accountability mandate, so it was a logical choice.

Since that time, NASA has collected more than 700,000 reports nationally -- or roughly 40,000 per year.

Connell's team analyzes each report within three days. They verify the information and then classify it. Those that represent an immediate danger go out on a national alert. Others are forwarded to the appropriate division at the FAA -- without names and identifying information -- and to every "alphabet group in aviation," she said.

Others, like the two previous wrong runway incidents in Lexington, are kept in the database in case they are needed for a study, or in this case, as a historical record after an accident.

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