Comair 5191 Crash Led to Air Traffic Control Changes

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

Fifteen years ago today, on August 27, 2006, Comair flight 5191, a Bombardier CL-600-2B19, lined up on the wrong runway and crashed during takeoff from Blue Grass Airport, Lexington, Kentucky (LEX), killing 49 people, including the captain and flight attendant. The first officer, who was seriously injured, was the only survivor. This investigation led to several improvements that furthered safety for all air travelers.

What Happened

The flight crew was instructed to take off from runway 22, a 7,000-foot-long air carrier runway. Instead, they lined up the airplane on runway 26, a 3,500-foot-long general aviation runway, and began the takeoff roll without cross-checking and verifying that the airplane was on the correct runway before takeoff.

Because runway 26 was too short for the takeoff, the airplane ran off the end of the runway, became momentarily airborne, and crashed into the airport perimeter fence, trees, and terrain. The airplane was destroyed by impact forces and postcrash fire.

What We Found

The NTSB investigation determined that there were adequate cues on the airport surface and resources were available in the cockpit to allow the flight crew to successfully navigate from the air carrier ramp to the runway 22 threshold. The flight crew believed that they were taking off on runway 22, even though it was dark when flight 5191 tried to take off and runway 26 was unlighted. We determined the crash was due to:

• the flight crewmembers’ failure to use available cues and aids to identify the airplane’s location on the airport surface during taxi, and
• their failure to cross-check and verify that the airplane was on the correct runway before takeoff.

We also found that the flight crew was engaged in nonpertinent conversation during taxi, resulting in a loss of positional awareness, contributing to the accident. This is a violation of the FAA’s sterile cockpit rule, which bans nonpertinent conversation in critical phases of flight. (As awareness of distraction spread to other modes of transportation—and to distraction by other means—the sterile cockpit rule began to be seen as a forerunner of later anti-distraction measures.)

Our Recommendations

Although, the probable cause pointed to flight crew actions, our recommended changes covered all aspects of the aviation industry. We not only recommended improving flight crew procedures, but also recommended that moving map displays be required in cockpits to improve situational awareness to help prevent similar accidents in the future.

In addition, we saw other aspects of the aviation industry that could be improved to help prevent similar accidents: improving air traffic control practices and procedures.

Also contributing to the crash was the Federal Aviation Administration’s (FAA) failure to require that all runway crossings be authorized only by specific air traffic control clearances. In this case, the air traffic controller on duty, like the pilots, had the ability to head off the accident, if he was alert and aware of the flight’s surface movements.

But the tower controller who could see the airplane on the airport surface did not detect the flight crew’s lining up to take off on the wrong runway. Instead of monitoring the airplane’s departure, he was not looking inside the control tower while he performed a lower-priority administrative task that could have waited until after transferring responsibility for the airplane.

The controller’s duty times, and sleep patterns indicated that he was most likely experiencing fatigue at the time of the accident. However, his routine practices did not consistently include the monitoring of takeoff. What’s more, the FAA’s policies and procedures at the time were not optimized to prioritize controller monitoring of aircraft surface operations over administrative tasks.

Lessons Learned

Followers of aviation safety know that the loss of Comair flight 5191 was an accident that brought a focus on preventing fatigue in air traffic controllers. The NTSB recommended, and the FAA implemented, numerous measures improving air traffic control practices and procedures. These included fatigue management programs, training, and, together with the National Air Traffic Controllers Association, working to improve scheduling practices.

Many other recommendations which came out of the tragedy were implemented, advancing crew resource management and airport surface painting and markings, and prohibiting the issuance of a takeoff clearance during an airplane’s taxi to its departure runway until after the airplane has crossed all intersecting runways.

Because the NTSB’s mission is to improve safety, not to punish, finding a human error was by no means the end of the investigation. Instead, the actions of the flight crew were only the beginning. What conditions led to the human error? Was there anything that could have been done to capture the error? Were there other errors in other parts of the transportation system that allowed the crash to transpire? What could prevent the next crash?

The result is that revisions have been made to ensure that the same set of circumstances at play in LEX during the early morning of August 27, 2006, will not lead to another fatal accident.

Learn More

Aviation Accident Report: Attempted Takeoff from Wrong Runway Comair Flight 5191, Lexington, KY, August 27, 2006

Aviation Investigation Docket: Attempted Takeoff from Wrong Runway Comair Flight 5191, Lexington, KY, August 2006

Episode 42: TWA Flight 800

In this episode of Behind-the-Scene @NTSB, NTSB Managing Director, Sharon Bryson and Frank Hilldrup, Chief Technical Advisor for International Affairs, NTSB Office of Aviation Safety, talk about the July 17, 1996, TWA flight 800 accident.  We discuss what happened, the findings and safety recommendations that came out of the investigation, its tremendous impact on aviation safety, how the Aviation Disaster Family Assistance Act of 1996 led to the establishment of NTSB’s disaster assistance program, and the decommissioning of the TWA flight 800 reconstruction.

The NTSB final report for the TWA flight 800 in-flight breakup mentioned in this episode and the NTSB docket for investigation is also available on our website.

To learn more about the NTSB Transportation Disaster Assistance (TDA) Program, visit our TDA web page.     

To learn more about the NTSB Most Wanted List (MWL), visit our MWL web page. You can also access the MWL archive  on our website.

Information about upcoming NTSB virtual training courses are available on our Training Center web page.                                                               

Get the latest episode on Apple Podcasts , on Google Play, Stitcher, or your favorite podcast platform.

And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/

It’s Time to Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles

By Member Michael Graham

Motor vehicle crashes are a leading cause of death and injuries in the United States. Early estimates for 2020 show that more than 38,000 people lost their lives in traffic crashes on our nation’s roads. These preventable tragedies are often due to driver mistakes and poor decisions—speeding or driving while impaired, distracted, or fatigued. Collision-avoidance technologies have the potential to mitigate the impact of these mistakes by alerting a driver to impending danger or actively reducing the vehicle’s speed if the driver does not act.

“Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles” is on the NTSB’s 2021–2022 Most Wanted List of Safety Improvements to increase public awareness about collision-avoidance systems as a lifesaving technology. The National Highway Traffic Safety Administration (NHTSA) should develop comprehensive performance standards and mandates for collision-avoidance systems and connected-vehicle technology, and we urge NHTSA to incorporate collision-avoidance system ratings into its New Car Assessment Program (NCAP).

Collision-Avoidance Systems

The primary goal of any collision-avoidance technology is to prevent and mitigate the severity of crashes by detecting a conflict, alerting the driver and, when necessary, automatically braking. A standard collision-avoidance system is comprised of two separate technologies that work together to prevent and mitigate crashes: forward collision warning and automatic emergency braking. Forward collision warning assists a driver by presenting an auditory, visual, or haptic warning to the driver before a collision. Typically, once a warning occurs and a driver does not respond, automatic emergency braking autonomously applies the brakes to prevent or mitigate a crash.

According to the Insurance Institute for Highway Safety (IIHS), an estimated 56 precent of rear‑end crashes that result in injuries could be prevented if passenger vehicles were equipped with a combination of forward collision warning and automatic emergency braking. These technologies can also improve the safety of commercial trucks. The IIHS found that equipping large trucks with both of these systems could eliminate more than 40 percent of crashes in which a large truck rear-ends another vehicle.

Despite the proven safety benefit of collision-avoidance systems, these lifesaving technologies are not required as standard options on passenger vehicles or commercial trucks. NHTSA’s regulatory inaction has delayed the broad deployment of these systems for too long. NHTSA must require forward collision warning and automatic emergency braking on all passenger vehicles and commercial trucks.

Performance Standards

Although more collision-avoidance technologies have been deployed into new vehicles recently, forward collision warning and automatic emergency braking performance and reliability vary significantly among vehicle manufacturers and models. Performance standards specify the minimum level of performance for these technologies, and NHTSA has been slow to adopt comprehensive performance standards and criteria to assess these systems. Testing protocols to assess the performance of forward collision-avoidance systems should be expanded to include common obstacles, such as traffic safety hardware, cross-traffic vehicle profiles, and other applicable vehicle shapes or objects found in the highway operating environment.  Further, testing protocols should also assess their performance at various speeds that represent the wide range of speed conditions seen in crashes, including high speeds. NHTSA should set robust minimum performance standards for both systems to provide consumers with confidence and certainty of the safety benefits of these technologies.

New Car Assessment Program

The NCAP is a government resource, developed by NHTSA, that evaluates and rates the crashworthiness of all passenger vehicles. Consumers rely on NHTSA’s vehicle safety ratings to make informed purchasing decisions for their safety and that of their loved ones. The NCAP has been an effective tool for informing the public about a vehicle’s crashworthiness; however, the current NCAP does not rate collision-avoidance technologies such as forward collision warning and automatic emergency braking. This allows a vehicle without collision-avoidance technology to achieve the same safety rating as a vehicle equipped with a highly effective collision‑avoidance system.

The NTSB recommends that NHTSA expand the NCAP to rate collision-avoidance technology performance. Such a rating can inform the public about a vehicle’s capacity to prevent and mitigate crashes, as well as differentiate collision-avoidance systems based on their performance. Incorporating collision-avoidance system ratings into the NCAP also provides an incentive for vehicle manufacturers to equip new vehicles with forward collision-avoidance systems, which can speed up deployment of such systems into all vehicles.

Connected-Vehicle Technologies

One of the most promising lifesaving collision-avoidance technologies being researched and developed for nearly three decades is connected-vehicle technology. This technology does not rely on radar or cameras but on direct communication between vehicles, called vehicle-to-vehicle (V2V) communications. This technology also allows vehicles to communicate with infrastructure and vulnerable road users such as pedestrians—collectively known as vehicle-to-everything communications (V2X).         

The NTSB’s investigations have found that V2X communications-based technology could address many crash scenarios, including many intersection crashes. Additionally, connected-vehicle technology increases the safety and visibility of vulnerable road users by alerting drivers to the presence of pedestrians, bicyclists, and motorcyclists that may be outside a driver’s or vehicle‑based sensor’s field of observation.  

However, connected-vehicle technology depends on an available communications spectrum. Currently, the entire program is at risk due to a recent decision by the Federal Communications Commission (FCC) to allow shared use of a wireless communications band previously dedicated solely for transportation safety. We are concerned that sharing this spectrum could compromise successful connected-vehicle technology deployment. The NTSB urges the FCC and others to overcome this communications challenge so connected-vehicle technology can be deployed widely and securely.

Bottom Line

Every day we lose more than 100 lives in preventable traffic crashes on our nation’s roads. Humans make mistakes that lead to crashes, but technology can mitigate those mistakes, avoiding death and serious injuries. Collision-avoidance technologies assist drivers by alerting a driver to an impending crash and automatically stopping the vehicle if the driver does not act. This proven, lifesaving technology is available today.

Tragically, regulatory inaction has slowed both deployment and broad availability of these technologies. The NTSB calls on the NHTSA to:

• require forward collision warning and automatic emergency braking on all passenger vehicles and commercial trucks,
• adopt comprehensive performance standards and criteria to assess these systems, and
• expand the NCAP to rate the performance of collision-avoidance technologies.

Any further delay will cost more lives.

Back-to-School Transportation Safety

By Stephanie Shaw, NTSB Safety Advocate

As parents, caregivers, teachers, school administrators, and school transportation safety professionals prepare for the return to school the health and safety of our children is the highest priority. 

This school year, back to school preparation for our children looks very different and it’s easy to forget about transportation safety amidst these other thoughts and concerns. But it’s so important that in addition to ensuring children are safe in the classroom, we also dedicate the time to discuss with our kids the safest way for them to get to and from school.

Over the past 50 years, we’ve made school transportation safety a priority. Many of the most pressing back-to-school transportation issues (including speeding, impaired driving, distracted driving, and pedestrian and bicycle safety) are currently items on our Most Wanted List (MWL) of transportation safety improvements. Our MWL contains what we believe to be the safety improvements that can prevent crashes and save lives, and these issues are among our highest priorities in our advocacy work.

The hour before and after school are the most dangers times for students on the roads.  In fact, more school-age pedestrians were killed between 7-7:59 a.m. and 3-3:39 p.m. than any other hours of the day. 

So, how will your kids get to school this year? Will they take the bus? Do you have a carpool set up with another family? Do they walk or bike to school? Is your teen driving to and from school this year? Regardless of how your child gets there and home, this is a critical time for you, as a parent, to think about ways you can help keep them safe. By talking to your children about steps you can take together this school year to ensure a safe trip to and from school.

Here are a few tips for keeping students safe this school year:

• Students are about 70 times more likely to get to school safely if they take the school bus instead of traveling by car. If your student can ride the bus, make this your first choice.  School buses are the safest vehicle for traveling to- and from- school and school-related activities. If your students school bus is equipped with seat belts ask them to buckle up, every trip, every time.
• If your student will be walking to school, map out the safest route for them before school is back in session and practice it a few times. This will help your child become familiar with the route, including any crosswalks or intersections they may need to negotiate and allows you the opportunity to demonstrate safe walking behaviors.
• If you have a student biking to school, be sure they wear a helmet and reflective gear! Helmets are the most important piece of safety equipment for bicycle riders. Just as with walking, it’s also important to help your child select the safest bicycle route before starting the school year.
• If you’re the parent of a teen driver, talk to them about safe driving behaviors—following posted speed limits, no cell phone use, about always buckling up and getting enough sleep before they get behind the wheel.  Consider signing a parent-teen driving contract with your teen driver with clear guidelines for using the car. 

We all have a shared responsibility to ensure that all children make it to school and return home safely.  Drivers, be on the look out for children in neighborhoods and around schools, and slow down. If you approach a school bus with flashing lights on and stop arm out, STOP!  When you’re behind the wheel, give the driving task your full attention, don’t be distracted by your cell phone —hand’s free doesn’t mean risk free— and never drive impaired by alcohol or other drugs, even over-the-counter medication.

For additional tips check out these valuable resources:

School Bus Safety

NTSB School Bus Safety

School Bus Safety from NHTSA

School Bus Safety from American School Bus Council

School Bus Safety Tips from Safe Kids Worldwide

Pedestrian Safety

Pedestrian Safety Tips from Safe Kids Worldwide

Consejos de Seguridad para los Peatones

Teaching Children to Walk Safely as They Grow and Develop from Safe Routes to School

Bicycle Safety

Bicycle Safety from National Highway Traffic Safety Administration

Bicycle Safety Skills from Safe Routes to School

Teen Drivers

State Graduated Licensing Laws

Safe Vehicles for Teens from IIHS

DriveitHOME from the National Safety Council

Contract for Life from SADD

Teens and Speeding: Breaking the Deadly Cycle from GHSA

Accident Data for Investigations, Routine Flight Data for Prevention

By Acting Chairman Bruce Landsberg

Most people are familiar with the nightly news image of NTSB investigators at the scene of an accident, searching for the “black (orange) box.” The flight data recorder (FDR), which records aircraft control inputs and operational conditions, and the cockpit voice recorder (CVR), which records pilot conversations, are at the heart of modern aviation accident investigations on all airline aircraft. The devices have helped to improve the safety of airline operations tremendously. They are used, of course, in crash investigations but most airlines also use them routinely to monitor pilot and aircraft performance and correct problems before they result in a crash.  

However, these devices designed to help in investigations are not required or used in most air-taxi or charter operations. For example, no recording equipment was installed in 86 percent of the turbine-powered aircraft involved in fatal accidents between 2005 and 2017. As a result, valuable information was missing to fully understand what happened and to prevent a crash from happening in the first place if the operator had used the predictive approach that the systems provide.

We believe recorders and analysis of their data before a crash offer tremendous safety benefits. That’s one reason why Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs is on the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL).  

Cockpit Image Recorders

Even after an FDR and CVR are analyzed, investigators still don’t know for sure how the flight crew interacted with the aircraft systems or what visibility was like inside or outside the cockpit. Even the most modern flight data recorders leave some questions unanswered. That’s where a cockpit image recorder (CIR) can be useful. For more than 20 years, the NTSB has called for CIRs in addition to FDRs and CVRs. The images CIRs provide could quickly reveal a pilot’s actions without ambiguity. Some in the industry claim that it’s an invasion of privacy or that video will be used by the media for sensationalist purposes. Federal law prevents the release of CVR or CIR data except in transcript form and there has never been a breach of that trust! Please note that most other modes of commercial transportation (trucks, busses, railroads and marine) have already installed this equipment and are reaping the benefits.

A  CIR was vital to our investigation of the in-flight breakup of Scaled Composite’s SpaceShipTwo over California in 2014. Cockpit images show a test pilot inadvertently deploying a feature called the “feather,” (similar to a thrust reverser) which led to the in-flight breakup. Without a CIR, the investigation would have taken months, or years, to evaluate the wreckage and understand if the feather lock mechanism mechanically failed or was deployed as a result of a crew action.  

Too many investigations have been hindered by a lack of CIRs. For example, had the Atlas Air Inc. flight 3591, a Boeing 767-375BCF, that crashed near Houston in 2019 been equipped with a crash-resistant image recording system investigators might have had relevant information about the data available to the flight crew and the flight crew’s actions during the accident flight. This information would have been critical in determining what happened and while there’s a very plausible idea of what happened some uncertainty of precise causal factors remains.

Recorders should be able to survive crash dynamics that include impact, submersion or fire. In the 2019 Sikorsky helicopter crash in Calabasas, California, visual cues associated with the adverse weather and the pilot’s focus of attention could not be conclusively determined because the helicopter wasn’t equipped with a CIR. A crash-resistant flight recorder system with audio and image functions could have provided valuable information to possibly identify additional safety issues and prevent a similar crash in the future.

Flight Data Recorders and Monitoring Programs

As an investigative agency, NTSB has a vested interest in recorders because they yield essential evidence, that can often be used to prevent future crashes. Required flight data monitors (FDMs) and FDM programs like Flight Operations Quality Assurance (FOQA) at the airlines have improved safety through the analysis of data collected by these recorders. Other segments of commercial aviation, like corporate and on-demand charter operations, could similarly benefit from FDMs and FDM programs.

On May 15, 2017, a Learjet 35A departed controlled flight while on a circling approach to Teterboro Airport in New Jersey impacting a commercial building and parking lot. Both pilots died.  The investigation again identified the need for FDM programs (and supporting recording devices) for 14 CFR Part 135 operators. The operator lacked safety programs that would have enabled it to identify and correct poor performance and procedural noncompliance which was the primary cause of the crash. Without an FDM program, the operator couldn’t identify the flight crew’s prior deviations from policy and procedures and had no way to determine if previous operations were conducted properly.

The NTSB has long recognized the value of FDM programs for Part 135 operators, having first issued a safety recommendation for data recording devices and monitoring programs for helicopter air ambulance operators in 2009. FDM programs typically involve the use of an onboard device capable of recording various flight parameters. Periodic routine review of the recorded data enables an operator to identify deviations from procedures and observe potential safety issues. Data reviews help a company take proactive measures and corrective action BEFORE a crash occurs. FDM should be integrated into safety management systems (SMS), another pillar of safety in modern aviation. Read more about SMSs on our MWL webpage.

Flight crews are an asset to every operator, who clearly has a vested interest in the safety and performance of the flight crew. Therefore, an FDM program should never be used in a punitive way, but rather to identify and correct safety issues.

Expanding Aviation Lessons for Safety

Through decades of accident investigations, many of which were aided by key evidence gleaned from recorders, airline travel in the United States has become extraordinarily safe. But to keep this strong safety record going, and to make progress elsewhere in aviation through lessons learned, it is essential to install recorders on an even broader scale appropriate to the activity. Devices built to survive a crash and supplemented with FDM programs, will enable operators to identify deviations and safety concerns prior to an accident.

Operators don’t need to wait for government mandates to install them; they can realize the safety benefits of this technology today and just one crash prevented will be highly cost effective for that operator and certainly for the people involved! The fact that an operator, without an FDM program and an effective SMS, hasn’t had a crash as we’ve seen too many times, doesn’t mean that they were good, merely lucky.