Why did Comair 5191 Crash at Lexington?

Before dawn on Sunday, August 27th past, Comair Flight 5191 carrying fifty passengers and crew crashed during takeoff, while attempting to depart on a runway one-half the length of the one it was cleared to use. The accident killed all aboard with the exception of the copilot, whose condition was recently upgraded to serious from critical.

There is no question that the pilot of the Bombardier CRJ-100/200 (depending on the source) lined-up on the 3,500 ft. runway 26 rather than the 7,000 ft. runway 22. The CRJ-100/200 would normally require about a 5,000 ft takeoff roll. Evidence of tire marks in the sod past the end of the runway and impact evidence on an earthen berm farther on, indicate that the aircraft never rotated for takeoff, but did temporarily become airborne after hitting the berm.

This may very well mean that the crew never even knew what had happened. Though the copilot should survive, his first words upon regaining consciousness were, “Why did God do this to me?” Crash victims often have no recollection of the moments just prior to the traumatic event. Mr. Polehinke will probably not be of much help to the NTSB.

Also not very helpful is all the speculating, questioning, posturing, politicking and silly emailing that has been going in the media and cyberspace regarding what is and is not important regarding this accident. What happened is and will forever be about as pure a case of pilot error as you will ever hear about. There has been no assertion of any mechanical failure. And how many controllers were or were not in the tower is of little or no importance in this instance.

Even if there had been two controllers in the tower, and one was watching what, given the time of day and location, would have probably been an empty radar screen, and the other was doing his paperwork, as the controller actually present at the time was engaged in doing, neither would have seen the plane line up on the wrong runway. Whatever FAA policy is regarding whatever number of controllers are to be present in a control tower under a given set of circumstances, it has no bearing on this accident.

The two-controller policy was the result of a near-miss between two airborne planes at another location and has absolutely nothing to do with takeoff instructions or monitoring. Taking off on the runway for which one has received takeoff clearance is solely the pilot’s responsibility. Period. And don’t forget, two other flights had taken off earlier without incident.

What is interesting, is that if you look at the airport diagram for Lexington Blue Grass International, the departure end of both runway 22 and 26 are nearly inline when viewed from the tower. The two runway headings differ by only 40 degrees. With conditions as they were the morning of the crash – a light rain falling a little before dawn – it’s very possible that even if a controller in the tower had been watching Flight 5191 as it lined up and started its takeoff roll, he may not have immediately realized that the aircraft was moving down the wrong runway. After all, in either case it would have been moving laterally to his field of view. With visibility and lighting conditions as they were, depth of field and perception would have been reduced.

At major airports with high volumes of traffic, radar is used for aircraft separation and control both on the ground as well as in the air. Some very large facilities, such as Chicago’s O’Hare, even have more than one ground control frequency depending on where you are while taxiing. This is to reduce the level of “chatter” to avoid confusion and reduce the chance of error and accident. The ground control radar is used to track aircraft independent of visibility.

You will never find this level of control and supervision of ground traffic at an airport such as Lexington. It is just too expensive and would be wasteful. The controller at a small airport, especially during periods of light traffic, would merely give the pilot the takeoff runway, surface winds, barometer setting for the altimeter and the ATC frequency to contact after takeoff, if that hadn’t been given with the IFR (Instrument Flight Rules) clearance.

If there wasn’t any other traffic operating in the area, this information could include the magic words, “Comair 5191 you are cleared for takeoff runway…” Prior to taking off those exact words must be received from the controlling authority at an airport with an operating control tower- “You are cleared for takeoff.”

If you takeoff without that clearance, you can be cited for a violation of FAA rules. For landing the magic words are “You are cleared to land runway…” This is true, believe it or not, world-wide for international traffic. Part of the pilots’ bible. If Comair 5191 had been so cleared, no further communication is required or necessary between the tower controller and the aircraft. It’s strictly up to the pilot to find the right runway. Sure, the tower would alert the pilot if they noticed that something was amiss. But it is not in any way the controller’s responsibility to place the pilot on the correct runway for takeoff. After all, he’s not operating the aircraft. The pilot is.

Regarding all the chatter about airport construction, new taxiways, barriers, lighting not being on or not working, the situation is similar. In the wonderful world of aviation we have what’s acronymically called “NOTAMS.” That is, “Notices to Airmen.” Anything that can affect operations at an airport, be it repairs, closures, openings, or modifications of runways, taxiways, lighting, et cetera, will be in the NOTAMS for that airfield both prior to (if possible) and subsequent to any such changes or restorations. The same is true for instrument approach procedures, changes to the traffic pattern, runway markings, navigational aids, communication frequencies, new or modified significant structures in the vicinity of the field or along approach or departure paths, and so forth. Just about anything and everything that could possibly impact operations will be in the NOTAMS. Fail to read and heed these at your own peril. You might even takeoff on the wrong runway. Sorry, fellas. Such things may contribute to an error but they are no excuse or justification for not paying attention.

One item that troubles me greatly is the fact that runway 26 had no lights. And yet they took-off on that runway. Was the visibility so bad that neither the captain nor first officer saw the lights on runway 22 as they went through the intersection? You’d think that would be one helluva clue that something wasn’t quite right. With it being not yet light with a light rain, I’d think you’d be looking for runway lights. Right? There’s the blue taxiway lights. The white runway lights. The green runway threshold lights.

The runway 22 centerline lights were not working at the time. But no lights on the runway for takeoff? The cockpit voice recorder showed that they even commented to one another about the absence of lights! Duh! Just line up on the centerline stripe with the aircraft lights, throttle up and press off into the abyss? I don’t get it. Not at all.

Not that you have to see the runway to takeoff. Not at all. At the time I went through Air Force pilot training, and that was more moons ago than I care to admit to, when you started advanced training in the T-38 Talon supersonic trainer, the six weeks after your one “gee-whiz” ride in the front seat were spent in back, under the hood, doing instrument flying training. With two tandem, that is front-to-back seats, the rear seat could be completely sealed off visually with a “hood” that could be pulled forward to block all outside attitude reference. The instructor, in the front seat, would line the aircraft up on the centerline of the runway, turn it over to the “blind” student in the rear and away you’d go.

Take off, fly an instrument departure, navigate a route, do practice approach procedures and go-arounds then, at the end of the flight, fly an ILS (Instrument Landing System) approach to a bit before touchdown, whereupon the instructor would take over and have you pull the hood back to see how well you flew the ILS. All without ever looking outside until just before touchdown. No, you don’t have to see the runway to takeoff. Nowadays there are some systems that don’t require that you see it even to land. You’d just better be on the right runway!

There have been some major aircraft takeoff accidents directly attributable to pilot error. The worst aircraft accident ever, in terms of total fatalities, occurred on Tenerife in the Canary Islands on March 27, 1977, a ground/air collision of two loaded 747s and took 583 lives. It was the direct result of a pilot taking off without clearance. He had not heard the magic words “you are cleared for takeoff” but proceeded to do so anyway. He had assumed his IFR flight plan approval was his clearance to takeoff. It wasn’t.

A little over ten years later, on August 16, 1987, Northwest Flight 255 crashed shortly after takeoff killing 154 souls but sparing, incredibly, a four-year-old girl. Cause: the crew had failed to complete the pre-flight checklist and lower the flaps to takeoff position. Without the leading and trailing edge flaps deployed for takeoff, that aircraft lost lift when it climbed out of the “ground effect” and settled back down. A contributing mechanical factor was that there was no electrical power to the flap warning system.

According to the NTSB database, there have been four accidents caused by pilots taking off on the wrong runway worldwide since 1982. According to the NASA flight incident database, there have been two other instances at Lexington, one in 1993, one in 1995, in which the pilot had taxied onto the wrong runway for takeoff. In one instance the pilot caught the error, in the other the tower did. In 2006, neither did.

I would be very surprised if the NTSB found other than “Pilot Error” as the primary cause.

My uncle suspects that the pilots of 5191 were boozing it up the night before

The investigation will include blood tox work on the aircrew as a matter of procedure. Not that this is always foolproof. One accident investigation in the '50's initially showed the pilot and co-pilot to be sauced. It was later demonstrated that, after the crash, their bodies adsorbed alcohol from the plane's de-icing system. The plane had crashed in the water, and the deice fluid was dumped into the cockpit.

"The investigation will include blood tox work on the aircrew as a matter of procedure. Not that this is always foolproof."

One other complication is that decomposition produces alcohol. I believe the Civil Aeromedical Institute (CAMI)makes note of this in their reports when minute amounts of alcohol are found.

It was reported in the Cincy papers yesterday that the surviving pilot came to and asked the question: "Why did God do this to me?"

LEXINGTON, Ky. (AP) — The co-pilot who survived the crash of Comair Flight 5191 has asked family members from his hospital bed, “Why did God do this to me?” but hasn’t mentioned the crash.

Found at: http://www.herald-dispatch.com/apps/pbcs.dll/article?AID=/20060906/NEWS01/60906014

But why should that stop this writer?

What happened is and will forever be about as pure a case of pilot error as you will ever hear about. There has been no assertion of any mechanical failure. And how many controllers were or were not in the tower is of little or no importance in this instance.

We can all speculate, but we don't know. Ultimately pilot error can usually be blamed for non-mechanical accidents. HOWEVER, the point of the NTSB is to find out WHY that error occurred and to try to make it less likely to occur next time.

Over here...
http://www.freerepublic.com/focus/news/1697688/posts?page=24
... they're blaming Satan.

Well, they're clearly wrong. The sole survivor is blaming God, and his firsthand account is the only one we have.

The immediate cause was that they took off on the wrong runway. If you are asking why they did that, it is because of crew fatigue.

The crew in question arrived in Lexington at 10pm. This would put them in their hotel room at around 11:30 or so. They reported back at 4:30 in the morning. Which means that they probably woke up between 3:30 and 4.

Comair 5191 crashed because the crew was likely trying to fly on 3 hours of sleep.

As for the rules that supposedly demand crew rest? The crew was on a stand up overnight. Normally what happens is that if a pilot is called in to work, the airline has to pay a minimum amount. This makes sense, and keeps a dispatcher from parking a crew at an airport for 14 hours and paying them for 1 or 2.

The consequence of this is that if you want to cover two days of flying, you pay for two days of crew time. The stand up overnight is a mechanism by which disreputable airlines schedule a 16 hour duty day over the middle of the night to try and cover two days of flying and only incur one pay period. It saves management money, but the minor detail is that the crew gets little or no sleep.

This time, there were consequences to such poor scheduling practices.

> The sole survivor is blaming God,

Well, one coudl argue that if God did create the universe and free will and predestinantion and Satan and all the rest, then *ultimately* he's responsible.

> and his firsthand account is the only one we have.

I'm sure some psychics will show up to proclaim that the Ascended Masters From Atlantis shot the plane down with their Oooo-ray.

Were there any problems with the signs? I'm not a pilot, but whenever I've paid attention to what's outside the plane it seems there are signs all over the place showing the directions to each runway. Unless the signs were missing or vastly less clear at Lexington than anywhere else, there is no way to accidentally get on the wrong runway except through gross pilot error. The only other explanations are the controller giving the pilot the wrong runway or radio interference so the pilot thought he should take off on runway "two < crackle >". The voice recorders will prove or eliminate those possibilities.

Right now I'm betting on major pilot error.

The amazing part of that story is that the KLM pilot at fault, Capt. VanZanten, was a senior training pilot and had even been featured in KLM print ads.

"The sole survivor is blaming God, "

What makes anyone believe that he is blaming God for the crash? Why couldn't he be saying why did God let me live and the others die? People too often jump to conclusions too fast and try to write their own feeling into a story.

The first thing the pilot should have done after he was lined up on the runway was check his compass heading. It would have shown he was at 260 degrees and not the 220 degress he should have been at. That would have immediately tipped him off that he was on the wrong runway.

"As a Civil Air Patrol mission pilot (Search and Rescue pilot) it bewilders me why that commercial craft crossed a lighted runway and selected the dark runway. Makes no logic."

They never even reached that runway, so there is no way they could cross it. Sounds like you would have made a mistake yourself! They were clearly confused by the new taxi pattern which place them first at the end of the short runway. In the past they taxied directly to the end of the long runway. If they had been paying more attention, they would have realized the recent changes required them to pass the short runway to reach the long runway.

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