COMAIR FLIGHT 5191 CRASH DURING TAKE-OFF FROM WRONG

RUNWAY AT LEXINGTON, KENTUCKY

Gaurav Shukla (2012CE10351) & Rajat Jain (2012CE10385)
ABSTRACT:
This report explains the accident which involved a Bombardier CL-600-2B19, N431CA,
operated by Comair, Inc., which crashed during the take-off from Blue Grass Airport,
Lexington, Kentucky on august 27, 2006. The aircraft was assigned the airport's runway 22,
but instead it used runway 26 for take-off. Runway 26 was too short for a safe take-off, which
caused aircraft to overrun the end of the runway before it could become airborne. It crashed
just past the end of the runway. All 47 passengers and two of the three crew members were
killed in the incident.
THE INCIDENT:
Comair Flight 5191, was a scheduled
United States (US) domestic passenger
flight from Lexington, Kentucky, to
Atlanta, Georgia. On August 27, 2006, at
around 06:07 EDT, the Bombardier
Canadair Regional Jet 100ER that was
being used for the flight crashed in attempt
to take off from Blue Grass Airport in
Fayette County, Kentucky, four miles (6
kilometres) west of the district of the City
of Lexington. The aircraft was supposed to
take-off from the airport's runway 22, but
used runway 26 instead. Based upon an
estimated take-off weight of 22,265 kg, the
manufacturer calculated a speed of 138
knots and a distance of 1,141 m would have
been needed for rotation (increasing noseup pitch), with more runway needed to
achieve lift-off. But the overall length of
runway 26 was just 1100m as compared to
runway 22 whose length was 2135m.
Hence, Runway 26 was too short for a safe
take-off which caused the aircraft to
overrun the end of the runway before it
could lift off. At a speed approaching 100
knots, the pilots understood that its weird
for runway to have no lights, but the flight
data recorder gave no indication that either
pilot ever tried to abort the take-off as the
aircraft accelerated to 137 knots.
Pilots called for rotation but the aircraft
sped off the end of the runway before it

could lift off. It then struck a low earthen

wall which was adjacent to a ditch, and then
became momentarily airborne. It then
clipped the airport perimeter fence with its
landing gear, and got smashed into trees,
which separated the fuselage and flight
deck from the tail. Aircraft hit the ground
about 300 m from the end of the runway.
Forty-nine of the 50 people on board died
in the accident; most of them died instantly
in the initial impact. The resulting fire
destroyed the aircraft. All 47 passengers
and two of the three crew members were
killed in the incident. The flight's first
officer was the only survivor. Among the
deceased, were 42 US nationals, 3
Canadians and 2 Japanese citizens. James
Polehinke, who the first officer was the
only survivor and suffered serious injuries
including multiple broken bones, a
collapsed lung, and severe bleeding.
CAUSE OF ACCIDENT:
In the National Transportation Safety Board
(NTSB) report on the crash, the
investigators found that most likely cause
of the accident was pilots error. The board
stated that the two pilots Clay and
Polehinke ignored clues that they were on
the wrong runway. They also failed to
confirm their position on the runway and
talked too much, in violation of "sterile
cockpit" procedures. The air traffic
controller was required to maintain visual

contact with the aircraft but after aircraft

cleared for the take-off, he got back to
perform administrative duties and did not
see the aircraft taxi to the runway. Comair
accepted the responsibility for the crash but
also put the blame on the airport authorities
for poor runway signs and marking.

Figure 1: Approximate paths at Blue Grass

Airport with blue indicating desired path
via Runway 22 & red indicating actual path
via Runway 26, ending at approximate
crash site with X marking the closed
taxiway.
During the investigation of the case, the
Federal
Aviation
Administration
discovered that tower staffing levels at Blue
Grass Airport violated an internal policy as
mentioned in a November 16, 2005,
memorandum that stated the requirement of
two controllers during the overnight shift.
One required for the tower working
clearance, ground, and tower frequencies,
and the other one, either in the tower or
remotely at Indianapolis Centre, working
TRACON (radar). At the time of the
accident, there was a single controller in the
tower who was performing both the radar
and the tower duties. On August 30, 2006,
the FAA announced that Lexington and the
other airports with similar traffic levels,
must be staffed with two controllers in the
tower around the clock effective

immediately. After the accident Comair

announced that all of its pilots had been
using an airport map with outdated
information at the time of the crash.
CONCLUSIONS:
The captain and the first officer were
properly certificated and qualified under
Federal regulations. The first officer and the
captain believed that the airplane was on
runway 22 when they taxied onto runway
26 and under this confirmation bias they
initiated the take-off roll. The flight crew
did recognize that something was wrong
with the take-off but it was well beyond the
point from which the airplane could be
stopped on the remaining available runway.
The airplane was properly certified,
equipped, and maintained in accordance
with Federal regulations. There was no
evidence of any structural, engine, or
system
failures
from
recovered
components.
The flight crewmembers did not crosscheck and confirm the airplanes position
on the runway before take-off and thus
failed to recognize that they were on the
wrong runway. The flight crews
noncompliance with standard operating
procedures which included the captains
abbreviated taxi briefing and also both
pilots non-pertinent conversation, most
likely created an atmosphere in the cockpit
that caused the crews errors. It was also
observed that weather was not a primary
factor in the cause of the accident.
Moreover, fatigue was also ruled out from
being the primary cause of accident as the
pilots were sufficiently rested. There was
no visibility issue during the airplanes taxi
to the runway and the attempted take-off.
The controller also failed to detect the flight
crews attempt to take off on the wrong
runway because he preferred to perform a
lower-priority administrative task instead
of monitoring the airplanes departure that

could have waited until he transferred

responsibility for the airplane to the next air
traffic control facility. He didnt notice that
flight crew has stopped the plane just before
the wrong runway as he didnt anticipate
any issues with the airplanes taxiing to the
correct runway. Due to the construction
project taking place at Blue Grass Airport,
the taxiway identifiers represented in the
airport chart available to the flight crew
were inaccurate also the crew were not
informed about the closure of taxiway A.
This information could have been made
available to them via automatic terminal
information service broadcast or the flight
release paperwork. A standard procedure
requires Code of Federal Regulations Part
91K, 121, and 135 pilots to confirm and
cross-check that the airplane is positioned
at the correct runway before crossing the
hold short line and initiating a take-off
would help to improve the pilots positional
awareness during surface operations. The
installation of cockpit moving map displays
and cockpit runway alerting systems aboard
the aircraft would enhance flight safety by
providing pilots with improved positional
awareness during surface navigation.
Moreover, there should be enhanced
taxiway centreline markings with surface
painted holding position signs to provide
pilots with additional awareness about the
runway and taxiway environment. After the
occurrence of the accident, runway 26 was
replaced by a new runway which was not
crossing runway 22, hence making the risk
of confusion less likely.

REFERENCES:

NTSB Final Report (2007).

Attempted Take-off from Wrong
Runway Comair Flight 5191
Bombardier
CL-600-2B19,
N431CA Lexington, Kentucky on
August
27,
2006
<http://www.ntsb.gov/investigation
s/AccidentReports/Reports/AAR07
05.pdf> (25-10-2015).
FAA RegistryAircraft No.
<http://registry.faa.gov/aircraftinqu
iry/NNum_Results.aspx?NNumber
txt=N431CA> (25-10-2015).
Ortiz,
Brandon
(2007-0828). "Polehinke Files Suit in Crash:
Remembering
flight
5191".
<http://www.accessmylibrary.com/
coms2/summary_028632739321_ITM> (25-10-2015).
Jeffrey McMurray (August 27,
2006).
"Comair plane took off
from
wrong
runway".
<http://web.archive.org/web/20060
907044841/> (25-10-2015).
Brandon
Ortiz
(2008-0125). "Lawyer claimed 5191 victims
shared blame Defense by Co-Pilot
to
Be
Withdrawn".
<http://theairlinewebsite.com/topic/
385030-lawyer-claimed-crashvictims-shared-blame/>
(25-102015).