Crash of Flight 5191

NTSB makes safety recommendations

Spurred by the Comair Flight 5191 crash, the National Transportation Safety Board yesterday recommended that the federal government order commercial airlines to require pilots to cross-check their instruments to ensure they’re taking off from the correct runway.

The NTSB, which is investigating the Aug. 27 accident, also recommended that the Federal Aviation Administration require airlines with scheduled commercial service to provide specific guidance to pilots for runway lighting requirements at night.

The recommendations are the first the NTSB has made since the crash at Blue Grass Airport that killed 49 people. The Comair pilots took off at 6 a.m. from an unlit general aviation runway that was half as long as the lighted, recently repaved 7,000-foot runway from which they were supposed to depart. The plane crashed into trees on a nearby farm and burned. Only the first officer survived.

Although the NTSB has not concluded its investigation, it said that the airport had appropriate runway and taxiway signs. The NTSB’s nine-page report focuses mainly on Comair, the pilots and the FAA.

The report says the Comair 5191 pilots stopped near the end of Runway 26 for 45 seconds before requesting clearance for takeoff. According to cockpit recordings, the pilots didn’t sound confused, but they also didn’t confirm their position on the runway. The pilots noticed the lack of lights on the short runway, but continued the takeoff.

The first statements acknowledging their mistake came after they reached their “V1” speed, the “commit speed” at which a pilot must take off because he doesn’t have enough runway left to stop. In essence, said aviation expert Paul Czysz, that means by the time the pilots realized they were on the wrong runway, it was too late. Marks on the ground show that the plane’s nose wheel was still on the ground at the end of the runway.

In the report to FAA Administrator Marion Blakey, the NTSB recommended “requiring all crew members on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold-short line for takeoff.”

The NTSB made a similar recommendation in 1989 after a plane took off from the wrong runway at Hobby Airport in Houston. But, rather than issuing a mandate to airlines, the FAA advised them to establish procedures for double checking runways.

At the time, the NTSB considered the FAA’s response acceptable. But yesterday the board questioned that decision.

Comair did not have such operating procedures, the NTSB said.

“... (T)he FAA must move beyond providing advisory information to operators and become more aggressive in effecting change in this area,” the board wrote.

FAA spokeswoman Laura Brown said last night that the agency has 90 days to respond to the NTSB’s recommendations. The FAA is not required to enact them, but it follows such recommendations 90 percent of the time, she said.

Blue Grass Airport Executive Director Mike Gobb was traveling early last night and not immediately available. Airport spokesman Brian Ellestad said only that airport officials “are glad that the investigation is moving forward and are looking forward to the next step in the process.”

Czysz, a retired aeronautics professor at St. Louis University, says the FAA has been reluctant to take any steps that might slow flight operations and therefore anger passengers. Czysz says that explains the FAA’s response in 1989.

He noted that the FAA has a dual responsibility of regulating air operation and encouraging passenger traffic.

“They have to make sure the flights are safe. But anything that takes 10 seconds to delay the flight they look at with a jaundiced eye” for fear of upsetting impatient passengers, he said. “I just hope the FAA will listen to them for the 54th time. ... This happens often enough that it should be stopped.”

National data from the Aviation Safety Reporting System, which is maintained by the National Aeronautics and Space Administration, found 114 reports of pilots lining up on the wrong runway from March 1988 to September 2005, according to the NTSB. A board member wrote that there are probably many more incidents than that because the reporting system is voluntary.

In 1993, for example, a pilot realized he was about to take off from the wrong runway at Blue Grass. The pilot blamed poor weather and the confusing layout of the runways.

The report also pointed to confusion among pilots about rules for night takeoffs on unlighted runways

NTSB interviews with Comair pilots showed that they were unsure whether the airline had rules on whether they could take off from unlighted runways at night, according to the report.

“The Board is concerned that, in the case of the Comair flight 5191 accident, both pilots recognized the unlighted runway during the takeoff roll but did not use that information to re-evaluate whether they were on the correct runway for takeoff,” the board wrote. The main runway had lights on each side, but its center-line lights were out because of recent construction.

An NTSB survey found airlines have inconsistent rules about runway lighting. One requires pilots to call the company’s director of operations, who evaluates the risks involved. Another allowed takeoffs if visibility is adequate and there is enough ambient light for the crew to identify the runway surface and maintain directional control.

Comair spokeswoman Kate Marx said the airline currently complies with all FAA regulations and guidelines, “but we will continue to review our policies and procedures in accordance with additional guidance from the FAA.”

The airline’s current policy on taking off in low visibility, including fog or darkness, directs pilots to use runway markings or runway lighting to provide “adequate visual reference.”

Before taking off, Marx said, pilots are required to review all pertinent flight information -- including airport diagrams, heading indicators and cockpit instruments -- that would show their position.

An attorney representing the estate of a crash victim said the NTSB’s report is a public relations blow to Comair’s effort to shift some responsibility for the crash to the FAA and airport. Comair has sued both.

“Because these findings are so public, it will put a lot of pressure on Comair,” said Chad Wadlington, who represents the family of Rebecca Adams in a lawsuit against Comair. “They’ve been trying to spread the blame around, but this is largely a Comair incident.”

Marx said she could not comment on pending litigation.

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