Crash of Flight 5191

Recommendations to the Federal Aviation Administration

Recommendations from the National Transportation Safety Board to the Federal Aviation Administration after the investigation into the crash of Comair 5191:

Require airlines to establish procedures that ensure crew members confirm and cross-check the airplane’s location at the assigned runway before takeoff.

Require that airlines install in aircraft cockpits “moving map” displays or an automatic system that alerts pilots when a takeoff is attempted on a taxiway or a runway other than the one intended.

Require that airports implement enhanced taxiway centerline markings and painted holding position signs at all runway entrances.

Prohibit air traffic controllers from issuing takeoff clearance during an airplane’s taxi to its departure runway until after the airplane has crossed all intersecting runways.

Change FAA guidelines to indicate that controllers should refrain from performing administrative tasks, such as the traffic count, when moving aircraft are in the controller’s area of responsibility.

The NTSB reiterated two previously issued recommendations:

Require specific air traffic control clearance when an aircraft crosses a runway.

Require that when aircraft need to cross multiple runways, air traffic controllers issue an explicit crossing instruction for each runway after the previous one has been crossed.

The NTSB has previously issued recommendations to the FAA because of the Comair crash. They include:

Require airlines to provide guidance to pilots on the runway lighting requirements for takeoff operations at night.

Ask the National Air Traffic Controllers Association and FAA to work to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide longer rest periods, and developing a training program on controller fatigue.

Require all air traffic controllers to complete training to improve “controller judgment, vigilance, and safety awareness.”

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