New documents released yesterday show disagreement among Blue Grass Airport, Comair, and unions representing pilots and air traffic controllers over who bears blame for the crash of Comair Flight 5191.
All agree that Comair Flight 5191 crashed because the pilots attempted to take off from the wrong runway, but they differ over what factors contributed to that mistake.
The National Transportation Safety Board on April 4, 2007, released documents from parties involved in the investigation of the Aug. 27 crash in Lexington that killed the pilot, flight attendant and 47 passengers. Only the co-pilot survived, though he was badly injured.
The plane attempted to take off from Runway 26, which was too short, and crashed into a farm field.
The submissions are the one chance the various groups get to give the NTSB their opinions about what went wrong -- and to make recommendations about how to prevent future crashes. This is one of the last steps before the safety board begins preparing its final report, which will indicate probable cause. The board is expected to issue its decision this summer.
In its submission, Blue Grass Airport laid the blame squarely on the two Comair pilots.
“The probable cause of the crash of 5191 are (sic) directly related to the performance of the Captain and First Officer,” the airport states. This includes “the loss of situational and location awareness” which led Capt. Jeffrey Clay to mistakenly taxi the airplane onto the shorter Runway 26 instead of main Runway 22.
According to the airport, this was “due to the unprofessional manner in which the flight crew performed their required duties after starting the airplane and during taxi for takeoff” as well as “the engagement in continuous non-essential and distracting conversation ... .”
Transcripts of the cockpit voice recorder, previously released by the NTSB, showed that Clay and co-pilot James Polehinke at various times discussed jobs, dogs and children while waiting to take off.
In the airport’s view, taxiways, markings, lights and signage “were proper and in compliance” with FAA regulations.
The Air Line Pilots Association disputed that, stating that the pilots confronted “misleading taxiway signage and lighting cues that led them to believe that they were approaching runway 22; their intended runway.” About a week before the crash, Blue Grass Airport had done major construction on the runways, repaving the main runway and changing part of the taxiway route used to reach the runway.
ALPA also cited inaccurate airport diagrams and inadequate air traffic control tower staffing, as well as significant fatigue issues with both the pilots and the lone controller on duty that morning.
“During the course of this investigation, numerous system and safety deficiencies were identified as well as a significant number of human performance issues on the part of both the flight crew and the controller on duty at the time; all of which played a major role in this accident,” the union said.
ALPA said that confusion and poor coordination between the controller and rescuers also kept first responders from getting to the crash site sooner. The pilots’ union said it took five minutes for the first public safety officers to reach the scene, and eight minutes for airport fire trucks to arrive.
In its filing, the National Air Traffic Controllers Association blamed the FAA for not having two controllers on duty, a violation of the FAA’s own tower staffing policy. “Had there been two controllers in the tower, as required, NATCA’s position is that this accident would not have happened,” according to the union’s submission.
Comair’s filing was more circumspect but said the safety board should look carefully at the FAA and “systemic failures.” It highlighted the problems of inaccurate airport diagrams and information, as well as tower staffing.
“Comair believes and suggests the Board investigate the FAA’s approach to runway airport surveillance. Had the controller on duty been required to devote all his attention to the airport environment while aircraft were departing, this accident may have been prevented,” according to the air carrier’s statement.
Comair also points out that runway diagrams given to pilots before the crash did not accurately reflect changes that had been made because of the recent construction.
“Comair further believes and suggests that the Board investigate the way in which the aviation system can provide more timely, useful, and accurate information to flight crews,” the statement continued. “The LEX (Lexington airport) information available to all flight crews on August 26 & 27, 2006, was inaccurate, incomplete and of limited utility.”
Comair has previously said that the cockpit discussions between Clay and Polehinke violated company policy designed to eliminate distractions. The airline has been sued by families of the victims; it has in turn sued the FAA.
In the submission, the airline said its intent was not “to lay blame or place fault,” but stated, “Comair understands and accepts that the conduct of one of its flight crews is one of numerous factors which contributed to this accident.”
“Comair has consistently acknowledged a degree of responsibility for the accident, but we also believe it would be inaccurate to conclude it was solely a mistake by our experienced flight crew,” airline spokeswoman Kate Marx said yesterday.
The FAA, which is also a party to the investigation, usually does not submit a statement, according to Laura Brown, FAA spokeswoman. “The FAA expects the NTSB will rely on fact finding and not speculation as it moves forward in determining a probable cause,” Brown said.
Former NTSB managing director Peter Goelz, who has been hired as a consultant by Blue Grass Airport, said yesterday that the submissions raise some important issues, such as the inaccurate maps, but that the crash still boils down to pilot error.
“This is a painful accident because it is so heavily focused on human performance failures. ... It’s a terrible thing to have to say that,” Goelz said.
But he contended the facts and the cockpit transcript indicated the pilots were completely unaware of their mistakes even when they should have been. “You cannot underestimate the amount of distraction ... They were not paying attention,” Goelz said.
The NTSB hopes to have a final report before the August anniversary of the crash. The board will vote on probable cause and any recommendations at a meeting that has yet to be scheduled.
Goelz said he was surprised the board would not be holding a public hearing on the crash as it has previously on major accidents. “I think they didn’t have a hearing because there had been criticism of the board that they were taking too long to issue accident reports,” he said.