- vor 10 Stunden
On 27 August 2006, Comair Flight 5191, operating for Delta Connection, crashes into a wooded area while taking off from Blue Grass Airport in Kentucky, killing all but the first officer on board. The pilots lost situational awareness and inadvertently taxied onto the wrong runway.
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00:00on an early morning takeoff in Kentucky under knots checked two experienced pilots struggle
00:11to get their regional jet off the ground B1 rotate whoa
00:16and crash into a nearby field this was a catastrophic accident investigators try
00:27to piece together what went wrong get those to Washington and end up with more questions than
00:33answers why the heck would they stop there only by retracing the taxi route all the queues are
00:40right there in plain sight and listening to the cockpit discussions that is weird but no light
00:46do investigators discover the grim truth they finally realize something's wrong but it's already
00:55too late
01:04it's almost six in the morning in Lexington Kentucky
01:24the pilots of Comair flight 5191 prepare for their pre-flight briefing
01:32in command is captain Jeff clay an experienced pilot with more than 4,700 flying hours
01:41man I always feel like I could eat a little more when I get a seatbelt like this
01:47first officer James pole hinkey is also a seasoned pilot with more than 6,500 hours
01:55you up for flying this leg yeah I'll take us to Atlanta both the captain in their first officer were
02:02very highly regarded right seat flex take I had an outstanding professional reputation and individuals
02:08that had to flow with them had nothing but high marks and very very favorable comments as far as their
02:12qualities the crew is flying a Bombardier CRJ 100 a small twin-engine jet designed for short commuter flights
02:23Sean Pruch Nicky flew that aircraft for Comair for 10 years
02:30the CRJ is an aircraft that's built for short-haul flights for example the Lexington to Atlanta less than an hour type flight
02:37is really what these airplanes are designed to do ladies and gentlemen we'd like to take
02:47this time to welcome you on board Comair flight 5191 direct to Atlanta we'll try to keep it as quiet as
02:53possible hopefully we can catch a nap on the way there it's our pleasure having you on board today
02:57there are 47 passengers and one flight attendant on today's flight
03:09the pilots begin their briefing right flex takeoff procedures off of he said what runway 24 it's 22
03:19something that we do prior to takeoff is we do a flight briefing between the two crew members
03:23the primary reason we do this is to make sure that everyone has the same amount of information
03:28and knowledge to safely depart the airport well 22 the ILS is out you mean the other night the runway
03:35identifier lights were out all over the place all right 22 is your short taxi any questions no questions
03:42before starting your leisure
03:53in the cabin passengers prepare for takeoff seatbelt please
04:03today they are bound for Atlanta Georgia just a 67-minute flight straight south from Lexington's
04:10bluegrass airport
04:13Comair 191 is ready to taxi Comair 191 taxi to runway 22 altimeter 3000 winds are 2000 at 8.
04:31Lexington's air traffic controller clears flight 5191 to the runway and then turns his attention to another plane
04:38Eagle flight runway 22 cleared for takeoff
04:45with few planes at this small airport in near perfect weather this flight is far from challenging
04:51for these seasoned pilots
04:55during the taxi out the captain is responsible primarily for navigating the aircraft on the airport surface
05:01the first officer is running numerous checklists and verifying that the aircraft is safe for departure
05:15folks we're going to be underway momentarily so sit back relax and enjoy the flight
05:19we're all ready in the cabin sir thank you
05:29cabin reports received before takeoff checks complete ready all set
05:35at your leisure Comair 121 ready to go
05:38calm air 191 lexington tower
05:42fly runway heading clear for takeoff runway heading clear for takeoff 191
06:00and the ice off lights set takeoff configs okay line up checks completed
06:14all yours jim captain clay hands control of the aircraft to first officer pole hinkey for takeoff
06:21off my brakes my controls
06:36set thrust please
06:39thrust set
06:51that is weird with no lights yeah
07:03under knots checks
07:08something's not right v1 rotate this 5191 prepares to lift off
07:17whoa
07:21damn it
07:42com air flight 5191 hurtles into a field less than half a mile from the runway
07:51this is lexington alert 3 west side of the runway to the com air regional jet taking off
08:07we knew something was wrong we never get an alert 3 we never get one
08:16public safety officer pete moppin rushes to the scene
08:22it's hot
08:22it's hot i mean it's very hot
08:27there were explosions
08:33can we save anybody that was what i was thinking when i saw this ball of fire
08:49fire
09:01but i think it was like uh...
09:06were the reason that First Officer Pohenke survived this accident.
09:10He was so traumatically injured that they recognized that time was of the essence
09:15and transported him to the hospital rather than waiting for an ambulance.
09:20When he thanked me for saving his life, I told him that was my job,
09:25but I was glad that I was there to do what I did, and I told him that.
09:32The question NTSB investigators now need to answer
09:35is why Comair Flight 5191 couldn't get off the ground.
09:46As soon as the fires are put out and the crash site is safe,
09:51NTSB investigators begin looking for clues to discover why Comair Flight 5191
09:56crashed less than half a mile from Lexington's Bluegrass Airport.
10:02Make sure every scrap is documented.
10:04We need a clear picture of the path this plane took before impact.
10:10Lead investigator Joe Cedar is among the first to arrive at the crash site.
10:15In this case, it was quite interesting because initially we didn't have much.
10:20An airplane had crashed.
10:21We didn't know if it was on the airport, off the airport.
10:26We actually started at the final resting place for the wreckage,
10:29and then we walked back towards the airport.
10:33First impact point is there.
10:34And the plane hit those trees over there.
10:55Those impact marks aren't more than 20 feet up those trunks.
10:59We were looking at the trajectory of the airplane.
11:05It clearly looked like it took off just about the end of the runway
11:09and immediately started contacting trees into the wreckage site.
11:14The wreckage path tells investigators that the plane was struggling to get off the ground.
11:27Was it engine trouble or something else?
11:30Looks like they took off from runway 26.
11:32Oh, hang on.
11:4226 wasn't in use last night.
11:48Lexington Airport has two runways, runway 26 and runway 22.
11:56According to the flight plan, they were supposed to take off from runway 22.
11:59So how the heck did they end up over here?
12:06Investigators are surprised to discover that flight 5191 took off from the wrong runway.
12:12Well, at that point in time, because we knew that it was a wrong runway takeoff,
12:15the question is, is why, right?
12:17And it's one that doesn't make sense.
12:20Did they misunderstand their instructions
12:23or deliberately change their plans to take off from a different runway?
12:27There's got to be something on that CVR about why they were on runway 26.
12:33Get those to Washington.
12:36The flight recorder and the cockpit voice recorder
12:38were retrieved and flown back here to Washington, D.C.
12:43But being on the wrong runway doesn't explain
12:46why the plane barely made it off the ground.
12:48Let's take a closer look at those engines.
12:57When the engines are examined,
12:59what the investigator is looking for is damage.
13:04The more damage that there is and the type of damage tells us
13:07that if it was turning at high speed or turning at a lower speed.
13:10Hey, they were spinning all right.
13:15Evidence of deformed blades suggests the engines were running on impact.
13:20All the indications were that both engines were operating at high power
13:24when the break-up sequence started.
13:26There was no problem with the engines.
13:27Something else must have kept them from getting airborne.
13:39Maybe they were too heavy?
13:42With engine failure ruled out,
13:45the team wonders if the plane was loaded with too much weight to take off.
13:49There's a certain maximum weight that the aircraft can take off safely with.
13:53So what we do is we calculate the load that's on the aircraft
13:57at the time of the accident.
14:02Hmm.
14:04Oh, here it is.
14:06CRJ's max takeoff weight is 50,178 pounds.
14:17And the load manifested, the plane weighed 49,087 pounds
14:23on that day.
14:26It's close, but it's within their limit.
14:29The aircraft wasn't too heavy to take off.
14:32In that aircraft on that day,
14:35with that weight,
14:36how much runway would be needed to take off safely?
14:39Using the actual weight of the aircraft
14:41and the CRJ-100 specifications,
14:45investigators calculate how much runway the plane needed to lift off.
14:49The weight of the aircraft affects how fast they have to be going
14:52to be able to lift off,
14:54and that is directly correlated to how much runway it takes
14:57to be able to achieve that speed.
15:003,744 feet.
15:043,744 feet.
15:07And runway 26 is...
15:103,501 feet.
15:12Investigators reach an astonishing conclusion.
15:20Runway 26 is 243 feet too short.
15:24They ran out of runway.
15:28They now understand why the plane couldn't get airborne.
15:32But they're still mystified.
15:34Why didn't flight 5191 take off from the longer runway?
15:38I hate to say this,
15:48but you're not going to get any answers from the first officer either.
15:52His injuries are very severe.
15:56The first officer is medically unfit to be interviewed.
16:00It's a big loss to the investigation.
16:02It can be frustrating when you're not able to speak with people
16:07that you'd like to speak with,
16:08but as investigators we need to work with the data that we have.
16:14Investigators look for other clues
16:16that might reveal why flight 5191 ended up on a runway
16:20they were not cleared to use.
16:21All right, they left the gate here.
16:27They taxi along here.
16:31They're supposed to leave from runway 22 here.
16:37But they end up here.
16:41The question is, why?
16:43So when we were looking into trying to understand
16:45why this flight crew thought they are on runway 22,
16:48we looked at anything that was different,
16:50anything that the flight crew may have misunderstood
16:53with regard to both the airport and the charts
16:56or any of their training.
16:59Hey, look at this.
17:00Our guy's got some shots at the runway.
17:11Hey, check this out.
17:16Taxiway to runway 22.
17:18It was blocked off by construction.
17:20There were numerous construction projects
17:22that were in place at the Lexington airport
17:24through the day of the accident.
17:27Okay, sure.
17:27Wasn't that in their chart?
17:31Normally, when a taxiway is closed,
17:34pilots receive an interim airport chart
17:36with an alternate route.
17:39Nope, nothing on the chart.
17:44Investigators are amazed to learn
17:46that the crew's airport chart
17:48only showed the taxi route before construction,
17:50not the updated taxi route.
17:57It is a surprise to see that the airport construction
18:01had not been updated in the charts
18:03that the flight crew had.
18:06It's a disturbing find.
18:08Could out-of-date taxi charts
18:10have misled the pilots into taking off
18:13from a runway that was too short for their plane.
18:20So they get out there
18:21and they find their taxiways blocked,
18:23and they don't have anything to tell them
18:24how to get to runway 22.
18:26That could trip you up.
18:31But something doesn't add up.
18:35Comair flight 5191
18:37wasn't the only plane
18:38departing Lexington that morning.
18:40Other planes left before them,
18:42and none of them ended up on runway 26.
18:47Eagle flight runway 22,
18:49cleared for takeoff.
18:50The other two flights
18:55took off prior to 5191.
18:57I received the same information
18:58that the flight crew from 5191 received
19:01and did not have any difficulties
19:03in navigating to the runway.
19:05The fact that two other aircraft
19:07were able to depart successfully that morning
19:10caused us to look deeper.
19:11Maybe there's something
19:21on the security footage.
19:23Investigators turned their attention
19:24to CCTV footage
19:26in the hopes that it will explain
19:28why Comair 5191
19:30took off from the wrong runway.
19:41We were able to retrieve security footage
19:48from cameras on the parking garage
19:49that showed our aircraft
19:51taxing out that morning.
19:53All right.
19:54Let's see what they were actually up to.
19:57Investigators quickly confirm
19:58how straightforward the taxi route was.
20:03Taxi's short,
20:04there's no other aircraft in sight.
20:07Our assessment based on examination
20:09of surveillance video showed
20:11that it was a nominal taxi.
20:15The taxi route from the ramp
20:18to runway 22
20:20was straightforward
20:21and only required
20:23one runway crossing, 26.
20:26Wait, stop it right there.
20:33It looks like they've stopped
20:35at the whole short line
20:36for runway 26.
20:41Before takeoff,
20:43planes stop or hold short
20:45of the runway
20:46until they're cleared
20:47to proceed by air traffic control.
20:49They were on their way
20:50to runway 22.
20:51Why the heck
20:51would they stop there?
20:54Investigators are startled
20:55by the discovery.
20:57We noticed at that time
20:59that the aircraft had stopped
21:00prior to runway 26
21:02for over 50 seconds.
21:04This is unusual
21:06because there was no real reason
21:08for them to stop there.
21:10We need to see the taxi route.
21:13All right.
21:14Were there clues
21:15telling the pilots
21:16they were in the wrong place?
21:18One of our main questions
21:19when we realized
21:21that they stopped
21:21for 50 seconds
21:22at the whole short line
21:23for runway 26
21:24was what could they
21:25have been seeing?
21:28To better understand
21:29why the pilots
21:30of Comair Flight 5191
21:32stopped at the whole short line
21:34for the wrong runway...
21:35All right.
21:36Let's get started.
21:38Investigators retrace
21:39their taxi route.
21:45We wanted to understand
21:46what the flight crew
21:47was seeing.
21:48In order to do that,
21:49we had to do
21:50a taxi demonstration
21:52to identify
21:53all the signage,
21:55the markings,
21:56and the cues
21:56available to the flight crew.
22:04Here on the left,
22:06there's a sign
22:07for runway 26.
22:13Straight ahead,
22:14I can see the whole
22:15short line for runway 26.
22:17I mean, it's as clear as day.
22:18Things that we were looking
22:22for during that taxi demo
22:23were things like
22:25the quality of the markings
22:27on the taxiway,
22:29the signage,
22:30whether it was illuminated
22:31or not.
22:32The taxi line splits
22:33three ways.
22:35Investigators can see
22:36what the pilots
22:37would have seen
22:37from the whole short line
22:39for runway 26.
22:40The line on the left
22:41goes to runway 26.
22:43The line in the middle
22:48is the route
22:48to runway 22.
22:53The line on the right
22:54is runway 22's
22:55old taxi route,
22:58blocked by barricades.
23:01I can clearly see
23:03the sign is telling us
23:04that we're at the whole
23:04short line for runway 26.
23:07I mean,
23:07it's hard to miss that.
23:12Investigators discover
23:13that the crew
23:13had clear queues
23:15that they were at
23:15the whole short line
23:16for runway 26,
23:18not 22.
23:20The question remains,
23:22how did they miss
23:23those queues?
23:27OK, let's go to 26.
23:32The test plane
23:33follows the line
23:34on the left
23:34to runway 26.
23:36OK, see?
23:38That's where they
23:39should have taken
23:40the taxi route
23:40and stopped
23:41the whole short line
23:42for runway 22.
23:46Investigators
23:46are surprised
23:47to learn
23:48that even as
23:48flight 5191
23:50was turning
23:50on to runway 26,
23:53the crew
23:53had a clear view
23:54of the sign
23:55pointing to the runway
23:56they were meant
23:57to be on.
23:58There were
23:59no features
24:00in the environment
24:01in terms of the signs,
24:02marking,
24:03or lighting
24:03that showed
24:05they were on runway 22.
24:07All the queues
24:12are right there
24:12in plain sight.
24:16Joe Cedar
24:17then uncovers
24:17one more disturbing fact.
24:20When we taxied
24:21from the taxiway
24:22onto and turned
24:23onto runway 26,
24:25all of the lights
24:26on runway 26
24:27were out
24:27and there was
24:28no lights
24:29in the distance.
24:29as an experienced
24:33pilot
24:33I look at that
24:34and say
24:35why did this
24:36flight crew
24:36take off
24:37from this runway?
24:39We need to know
24:40what was going on
24:41in that cockpit.
24:41That is weird
24:48with no lights.
24:50Yeah.
24:55The cockpit
24:56voice recorder
24:57from Comair
24:58Flight 5191
24:59is finally
25:00ready to be reviewed.
25:02Okay,
25:03let's hear
25:03what we've got.
25:06It may be
25:07the only hope
25:08of explaining
25:08why the crew
25:09ended up
25:10on an out-of-service
25:11runway.
25:12Instead of the one
25:13they were cleared
25:14to use.
25:15In this type
25:16of human factors
25:17accident
25:17it's very difficult
25:18because we have
25:19to try to determine
25:20what the pilots
25:22were thinking.
25:23The main tool
25:24that we use
25:25in order to determine
25:26that is the
25:27cockpit voice recorder.
25:29The CVR
25:29was very important
25:30in understanding
25:31what the flight crew
25:32was talking about
25:33and what they were
25:33doing during
25:34the taxi
25:35and the take-off.
25:38Good for flying
25:39this lake?
25:39I'll take us
25:40to Atlanta.
25:40Okay,
25:41so the first
25:42officer is going
25:43to fly.
25:43That's standard stuff.
25:46The flight crew
25:47were conducting
25:48themselves
25:48in a professional
25:49manner.
25:51For own briefing,
25:52calm air standard,
25:53run the checklist,
25:54your leisure,
25:54keep me out of trouble,
25:55I'll do the same
25:55for you.
25:57I'll do the same
25:57whenever you're ready.
25:59Okay, here comes
26:02the taxi brief.
26:04Light seat flex,
26:05take-off procedures
26:05off a...
26:07You said what runway,
26:082-4?
26:08That's 2-2.
26:102-2.
26:11The ILS is out
26:12on 2-2.
26:13Came in the other night,
26:14the runway identifier
26:14lights were out
26:15all over the place.
26:16All right.
26:182-2 is a short taxi,
26:19any questions?
26:20No questions
26:21before starting
26:21at your leisure.
26:23Something in the briefing
26:24surprises investigators.
26:26Wait,
26:26stop it right there.
26:27Is that not
26:29a short brief to you?
26:34They discover
26:35that the crew
26:35used an abbreviated
26:37version of the taxi brief
26:38called
26:39calm air standard.
26:41Pull up the calm air
26:43standard taxi brief.
26:55There's no mention
26:56of crossing runways,
26:57or stopping to call
26:59ATC if they're
27:00unsure where they are.
27:01Investigators are
27:02baffled to discover
27:03that even the
27:04shortened taxi brief
27:05with eight checklist items,
27:07including a very
27:08crucial one,
27:09wasn't followed.
27:11Yeah, they never
27:11briefed on the runway
27:12they had to cross
27:13to get to runway 22.
27:15The crew's abbreviated
27:16briefing that morning
27:17was a deviation
27:18from standard
27:19operating procedures
27:19that we identified.
27:20Had the crew done
27:24a full taxi briefing,
27:25they would have
27:25discussed the need
27:26to cross runway 26
27:28on the way
27:28to 22.
27:30They missed an opportunity
27:31to review
27:32the airport diagram
27:34and determine
27:35that they needed
27:35to cross runway 26
27:37and intervening runway
27:38before they reached
27:39runway 22.
27:40Okay, let's hear
27:43their taxi checklist.
27:46Flight controls.
27:48Check left.
27:49On the right,
27:49trims.
27:51Engage 07.2.
27:54Radar terrain displays.
27:56All taxi checks
27:56complete.
27:57Finish up
27:57the before takeoff checklist.
27:59Your leisure.
28:00One other thing
28:01on the CVR
28:01we heard
28:02was the captain
28:03using the term
28:04at your leisure.
28:05It was used
28:06so many times
28:07on the CVR.
28:08What this told us
28:09is that this flight crew
28:10was relaxed.
28:11Maybe they were
28:11a little bit
28:11too relaxed.
28:13Yeah, I know
28:14three guys at Kennedy.
28:15Actually, two guys.
28:16One went,
28:17but he did get
28:18through the same.
28:18Oh, really?
28:19Then a first officer
28:20from Cincinnati,
28:21he got through
28:21the second part
28:22and that's as far
28:23as he got.
28:24Wait, stop it right there.
28:26Investigators cannot believe
28:27what they're hearing.
28:28What the heck
28:28is he talking about?
28:30Instead of focusing
28:31on their checklists,
28:32the crew of 5191
28:34were having
28:35a casual conversation
28:36during a critical moment.
28:39It's a major breach
28:40of what's called
28:41the sterile cockpit rule.
28:43The sterile cockpit rule
28:44requires that pilots
28:45refrain from
28:47non-operational conversation
28:49during significant
28:51portions of flight.
28:52One of the key reasons
28:53for the sterile cockpit rule
28:54is that non-pertinent
28:55conversation can be distracting.
28:58And that's as far
28:59as he got?
29:00And then he actually
29:01got off of the position.
29:03Did he take it?
29:04Yeah, he took it.
29:05Oh, okay.
29:06The captain should be
29:07shutting this conversation down,
29:08not encouraging it.
29:10Although the first officer
29:12started the conversation,
29:14the captain is responsible
29:15for ensuring
29:17that sterile cockpit rules
29:18enforced
29:19and distractions
29:20do not enter the cockpit
29:21that could affect
29:22the safety of flight.
29:23after 40 seconds of casual conversation.
29:27Second engine started,
29:30anti-ice probes,
29:31windshield low.
29:34Investigators hear
29:35the pilots turn
29:36to their take-off checklist.
29:39Now they finally
29:40get back to their jobs.
29:42We're surprised by that.
29:44That non-pertinent conversation
29:45was in a critical area
29:47when the flight crew
29:48is making their taxi
29:50out to the runway
29:50where the flight crew
29:52needs to be
29:53100%
29:54flying the aircraft.
29:59Could that period
30:00of inattention
30:01hold the key
30:02to this tragic accident?
30:04Okay, let's see
30:10what we've got so far.
30:12Investigators wonder
30:13if a casual conversation
30:15is at the heart
30:16of the crash
30:16of Comair flight 5191.
30:20We skipped out
30:20at a briefing
30:21that would have told them
30:23they needed to cross 26
30:24to get to 22.
30:30Then for almost a minute,
30:31they violate the sterile
30:33cockpit rule.
30:37Let's see what happens
30:38when they get here.
30:42Investigators hope
30:43the crew will give
30:44some indication
30:45why they stopped
30:46at the hold short line
30:47for runway 26.
30:49Thrust reversers
30:50are armed.
30:52Autocross flow
30:52is manual.
30:55Ignition is off.
30:56Altimeters are
30:58three triple zero
30:59across the board.
31:01Cross-checked.
31:02I'll check in
31:03with the cabin.
31:06That's it?
31:07It was surprising to us
31:08that there was
31:09no conversation
31:10about their location
31:12on the airfield
31:13or confusion about it
31:15while they were
31:16holding short
31:17on runway 26.
31:18We know they were
31:22distracted
31:23but when they
31:25stopped their chit-chat
31:26they don't seem
31:27to recognize,
31:28know or check
31:28where they are.
31:32We got no information
31:33based on the conversation
31:35of the flight crew
31:36while they were
31:36holding short
31:37that they were
31:38disoriented.
31:39No indications
31:40at all.
31:42Investigators are amazed
31:43by what they hear next.
31:45At your leisure,
31:46Comair 121
31:47ready to go.
31:48Comair 191
31:50Lexington Tower.
31:54Flyer runway heading.
31:55Clear for takeoff.
31:58Hold there.
32:00So they're
32:01completely relaxed
32:02when they ask
32:03for clearance.
32:04In fact,
32:04so relaxed
32:05or distracted
32:06that the first officer
32:07uses the wrong
32:08flight number.
32:10Investigators
32:10realize the grim truth.
32:13These guys
32:13actually thought
32:14they were lined up
32:15for runway 22.
32:17The fact that
32:18they stopped
32:19at runway 26
32:20and subsequently
32:22called for takeoff
32:23indicates that
32:24they lost awareness
32:26that they had not
32:27crossed runway 26.
32:29they turn on to runway 26.
32:33Then what?
32:34Keep going.
32:36Line-up checks completed.
32:39Well, here's Jim.
32:40First officer
32:41takes the controls.
32:42So he's looking ahead
32:44probably for the first time.
32:46At this time,
32:49the captain
32:50taxied the aircraft
32:51out onto the runway
32:52and then transferred
32:54controls
32:54to the first officer.
32:56So before this time,
32:58the first officer
32:59was heads down
33:00in the cockpit.
33:01my brakes,
33:03my controls.
33:05When the first officer
33:06looked out,
33:06he saw a runway.
33:08He may not have perceived
33:09that it was
33:10a narrower runway
33:11than runway 22.
33:14They're looking down
33:15runway 26.
33:18Why don't they see
33:19the sign for 22
33:21off to the right?
33:25Neither pilot
33:26cross-checked
33:26their location
33:27at the time
33:28that they took
33:28the runway.
33:29Is that thrust, please?
33:38Thrust set.
33:50That is weird
33:51with no lights.
33:53Yeah.
33:57Hold on.
33:59Runway 26
34:01is not in use,
34:02so it's not lit.
34:05They see the lights
34:06for 22
34:06until they cross it.
34:13They're looking down
34:14a pitch-dark runway
34:15and it doesn't faze them.
34:19Investigators wonder
34:20if the pilots
34:21were confused
34:21about what the runway
34:22should have looked like.
34:23when they began
34:26the takeoff roll
34:27on runway 26,
34:28they had no centerline lights
34:30or edge lights
34:31on this runway.
34:32However,
34:33based on the first officer's
34:34previous experience
34:35the night before,
34:36he did not expect
34:38to see lights.
34:40The ILS is out on 22.
34:42Came in the other night,
34:43the runway identifier lights
34:44were out all over the place.
34:45And so it would not necessarily
34:47have been an unusual
34:48sight picture.
34:49Such decision-making
34:51based on a person's
34:52mistaken assessment
34:53is called confirmation bias.
34:57Confirmation bias
34:57is where the flight crew
34:59expects something
35:00to be there
35:01even though it might
35:02not actually be there.
35:05He noticed
35:07there was no lights
35:08on the runway,
35:09but he just accepted
35:10the fact.
35:10what happens next?
35:20100 knots.
35:21Checks.
35:23The pilots now see
35:24they're almost out of runway.
35:26V1, rotate.
35:29And don't have
35:30the required speed
35:31to get airborne.
35:32Whoa.
35:34Damn it!
35:40That's it.
35:43They finally realize
35:44something's wrong
35:45and it's too late.
35:48Based on our calculations,
35:50the crew needed
35:50to recognize
35:51that they were
35:52on the wrong runway
35:53and successfully reject
35:55the takeoff
35:56about 20 seconds
35:57into the takeoff roll.
35:59However,
36:00their recognition
36:01did not occur
36:02until much later
36:03when the captain
36:04called rotate
36:05at a lower speed
36:06than what was required.
36:10Investigators
36:17have unraveled
36:18the mystery
36:19of what happened
36:20inside the cockpit
36:21of flight 5191.
36:29They start out
36:30by skipping
36:30the full briefing.
36:32And then after
36:33a long discussion
36:33about the airline,
36:34they lose sight
36:35of where they are.
36:37They stop
36:37at the wrong place
36:38and they completely
36:39miss all the signage
36:40if they're
36:41at the wrong runway.
36:42By the time
36:43they figure out
36:43the mistake,
36:44it's too late.
36:46These guys
36:47are going through
36:47the motions
36:48when they should have
36:49been at full attention.
36:52The crew's failure
36:53to use available cues
36:55and aids
36:55to identify
36:56and check
36:57the plane's location
36:58led to the tragedy
37:01of Comair
37:01flight 5191.
37:10But the team
37:11still has one
37:12unanswered question.
37:14Why didn't the controller
37:15tell them
37:16they were at the wrong runway?
37:27Investigators wonder
37:28if the air traffic controller
37:30of Comair flight 5191
37:32could have picked up
37:33the crew's error
37:34and prevented the accident.
37:37Happy to answer
37:38any questions.
37:39With the air traffic controller,
37:41we were trying
37:42to understand
37:42did the controller
37:44have an opportunity
37:44to see this airplane
37:45take the wrong runway
37:47and prevent the accident.
37:50At 605,
37:51they asked
37:51for takeoff clearance.
37:53Runway 22 was free,
37:55so I gave Comair
37:57clearance for takeoff.
38:00At your leisure,
38:01Comair 121,
38:02ready to go.
38:03Comair 191,
38:05Lexington Tower.
38:07Fly runway heading,
38:08clear for takeoff.
38:09Runway heading,
38:10clear for takeoff,
38:11191.
38:15And what did you do next?
38:17I saw the plane
38:18proceed towards runway 26
38:19and then scanned runway 22
38:22to make sure
38:22there were no vehicles on it.
38:24Did you watch
38:25the flight takeoff?
38:27Not if I have other jobs to do.
38:30Investigators make
38:30one final discovery.
38:34And then I turned over here
38:35to count my flight strips.
38:38And why would you start
38:39counting your flight strips then?
38:40I wasn't busy.
38:43It only takes a few minutes.
38:44And there was no reason
38:48to think that they'd
38:49have any problems.
38:50In 17 years,
38:51I've never seen a plane
38:53that size try to take off
38:54from runway 26.
38:57The controller was not
38:58watching the airplane
38:59and assumed that the airplane
39:02was going to take off
39:03on the correct runway
39:04because this is such
39:05a simple airport
39:06and because there was
39:07no other traffic
39:08on the airport
39:09at the time of the accident.
39:10And if you hadn't
39:13turned away,
39:14would you have noticed
39:15that they were
39:15in the wrong place?
39:21I might have.
39:24FAA regulations
39:25do not require controllers
39:27to monitor every takeoff.
39:30But if the controller
39:31had been watching the runway
39:32instead of counting
39:33flight strips,
39:34he might have noticed
39:35Flight 5191's mistake.
39:37He was not actually required,
39:40nor are any controllers
39:41required,
39:41to actually watch
39:42an aircraft
39:43during its takeoff roll.
39:45Had they been required
39:46to do that,
39:47this would have given
39:48an opportunity
39:49to have the takeoff
39:50aboard him.
39:52The NTSB concludes
39:54that several factors
39:55led the pilots
39:56to lose track
39:57of their position
39:57on their way
39:58to the runway.
39:59Contributing to that
40:02was the flight crew's
40:03failure to maintain
40:05sterile cockpit
40:06and to have
40:07a non-pertinent conversation
40:08prior to takeoff.
40:10This crash happened
40:11because of a period
40:14of distraction
40:14during what was perceived
40:17as a relatively
40:18simple taxi.
40:20And it illustrates
40:22the perils
40:23of distraction
40:24in that it can
40:26take you off task.
40:27It can cause you
40:28to lose awareness.
40:30And in this case,
40:31both crew members
40:31lost awareness
40:33of where they were
40:34on that airport surface
40:36and made a mistake
40:37that was extremely
40:39consequential.
40:39among the NTSB's
40:44recommendations
40:45is a basic
40:46technological change
40:47to prevent pilots
40:48from getting lost.
40:50The CRJ-100
40:52at the time
40:53had sophisticated
40:54avionics,
40:55but it lacked
40:56a simple GPS system
40:58available in cars
40:59of the same era.
41:02Install moving map
41:03GPS displays
41:04in CRJ-100 cockpits.
41:07The NTSB
41:09also makes
41:10recommendations
41:11for flight crews.
41:12Require pilots
41:14to check
41:14that they are
41:15at their assigned runway
41:16before crossing
41:19the hold short line.
41:25First officer
41:26James Polhinke,
41:28the lone survivor
41:29of Comair Flight 5191,
41:31suffered severe injuries,
41:33including the loss
41:34of his left leg.
41:35He never returned
41:38to commercial aviation.
41:41This was a catastrophic accident.
41:45It affected scores
41:47and scores of lives.
41:49But the legacy
41:50of this accident
41:51are the safety changes
41:54that have been made
41:55to prevent this type
41:56of accident
41:57from happening
41:57in the future.
42:00This accident shows
42:01that there are threats
42:04in any environment
42:05no matter how docile
42:07they seem
42:08and that flight crews
42:09have to be aware
42:10and have to be looking
42:11for all the threats
42:12at all the time.