Comair Flight 5191 was a scheduled United States domestic passenger flight from Lexington, Kentucky, to Atlanta, Georgia. On the morning of August 27, 2006, at around 06:07 EDT (10:07 UTC), the Bombardier CRJ100 crashed while attempting to take off from Blue Grass Airport in Fayette County, Kentucky, west of the central business district of the city of Lexington.
The aircraft was assigned the airport's Runway 22 for the takeoff but used Runway 26 instead. Runway 26 was too short for a safe takeoff, causing the aircraft to overrun the end of the runway before it could become airborne. It crashed just past the end of the runway, killing all 47 passengers and 2 of the 3 crew members. It was the second-deadliest accident involving the CRJ100/200 after China Eastern Airlines Flight 5210, which had crashed two years earlier and claimed 55 lives.
The first officer, James Polehinke, was the pilot flying at the time of the accident and was the sole survivor. Captain Jeffrey Clay was the one who had primary responsibility for taxiing to the wrong runway. In the National Transportation Safety Board's report on the crash, investigators concluded that the likely cause of the crash was pilot error.
Flight details
The aircraft was a 50-seat Bombardier Canadair Regional Jet CRJ100ER, serial number 7472.N431CA FAA registration certificate. Retrieved June 19, 2008. (Note: CL600-2B19 is the official designation of the CRJ100). It was manufactured in January 2001 and was delivered new to the airline.
The captain was 35-year old Jeffrey Clay. He had 4,710 flight hours, including 3,082 hours on the CRJ100.
The first officer was 44-year-old James Polehinke. Prior to his employment by Comair, Polehinke worked for Gulfstream International Airlines as a captain on the Beechcraft 1900. He had 6,564 flight hours, including 940 hours as a pilot in command and 3,564 hours on the CRJ100.
Accident
Analysis of the cockpit voice recorder (CVR) indicated that the aircraft was cleared for takeoff from Runway 22, a runway used by most airline traffic at Lexington. However, after confirming the takeoff clearance for Runway 22, Clay taxied onto Runway 26, which was only 3,501 feet (1,067 m) long, unlit and unauthorized for commercial use. Clay then relinquished flight control to Polehinke for takeoff.
Based upon an estimated takeoff weight of , the aircraft's manufacturer calculated that a speed of and a distance of would have been needed for rotation (increasing nose-up pitch), with more runway needed to achieve liftoff. At about an hour before daybreak and at a speed approaching , Polehinke remarked, "That is weird with no lights," referring to the lack of lighting on Runway 26. Clay replied in agreement, but the flight data recorder offered no indication that either pilot had tried to abort the takeoff as the aircraft accelerated to .
Clay called for rotation, but the aircraft reached the end of the runway before it could become airborne. It then struck a low earthen wall adjacent to a ditch, briefly leaving the ground, clipped the airport perimeter fence with its landing gear and smashed into trees, separating the fuselage and flight deck from the tail. The aircraft crashed about from the end of the runway, and it was destroyed in the resulting fire.
CVR transcript Transcript of Comair flight 5191's CVR (Times are expressed in CST) * = Unintelligible word; () = Questionable text; (()) = Commentary; — = Break in continuity; Shading = Radio communication; ## = Expletive TimeSourceContent06:04:38First Officer (Over PA)And folks one * time from the flight deck, we'd like to welcome you aboard. We're going to be underway momentarily.... sit back, relax and enjoy the flight. Kelly, when you have a chance, please prepare the cabin.06:04:48 ((Sound of hi-lo chime of cabin/cockpit intercom))06:04:49First OfficerPre-takeoff * complete cabin report received CAS.06:04:53CaptainChecked and clear.06:04:54*Unclear***, Six or seven ** (Whispered) 06:04:49CaptainOh.06:04:58First OfficerOh Yeah.06:04:59First OfficerI'm looking at it 'cause like, okay I see seven but it's06:05:01CaptainYeah there's a green extra one there but...06:05:06First OfficerUuuh, cabin report's received, CAS clear ** before takeoff check's complete, ready. 06:05:12CaptainAll set06:05:15Captain 5191 (to LEX Tower)At your leisure Comair one-twenty-one ready to go.06:05:17LEX (to 5191)Comair one-ninety-one, Lexington, uh, Tower, fly runway heading, cleared for takeoff.06:05:19*Unclear***06:05:21Captain 5191 (to LEX Tower)Runway heading, cleared for takeoff one-ninety-one.06:05:23CaptainAnd line-up check06:05:34CaptainThrow that bad boy on06:05:41First OfficerTransponder's on, packs on, bleeds closed, cleared for take-off, runway heading. Six grand.06:05:45CaptainAll right06:05:46First OfficerAnti-ice off, lights set, takeoff config's okay, line-up check's complete.06:05:51 ((Sound of clicks similar to pilot adjusting his seat))06:05:57CaptainAll yours, Jim06:05:58First OfficerMy brakes, my controls 06:06:05 ((Sound of increasing RPM))06:06:07First OfficerSet thrust, please06:06:11CaptainThrust set06:06:16First OfficerThat is weird with no lights.06:06:18CaptainYeah06:06:24CaptainOne hundred knots.06:06:25First OfficerChecks.06:06:31CaptainV-one, rotate-06:06:31CaptainWhoa!06:06:32 ((Unknown ambient noise))06:06:32CaptainFuck.06:06:33.0((Sound of impact))06:06:33.3Voice unidentified((Unintelligible exclamation))06:06:33.8((Sound similar to stick shaker))06:06:34.7((Sound of chime))06:06:34.7((Sound similar to stall warning starts and continues to end of recording))06:06:35.1Voice unidentified#06:06:35.7Captain((Unintelligible exclamation))End of recording
Passengers NationalityPassengersCrewTotalTotalDiedTotalDiedTotalDiedUnited States4242324544Canada3333Japan2222Total4747325049
Of the 50 people on board, 49 were killed (all 47 passengers and 2 of the 3 crew members). The victims died from thermal injuries, smoke inhalation, and traumatic injuries caused by the impact and subsequent fire. Comair released the passenger manifest on August 29, 2006.
Most of the passengers were American citizens from the Lexington area, ranging in age from 16 to 72. They included a young couple who had been married the previous day and were traveling to California on their honeymoon.
Sole survivor James Polehinke, the first officer, suffered serious injuries, including multiple broken bones, a collapsed lung and severe bleeding. Lexington-Fayette and airport police officers extracted him from the wreckage. He underwent surgery for his injuries, including an amputation of his left leg. Doctors later determined that Polehinke had suffered brain damage and had no memory of the crash or of the events preceding it.
Investigation
During the investigation, the Federal Aviation Administration (FAA) discovered that tower-staffing levels at Blue Grass Airport violated an internal policy as reflected in August 2005 verbal guidance requiring two controllers on duty in facilities that have combined radar approach control and tower with radar functions, with one controller monitoring air traffic on radar, and the other performing other tower functions including communications with taxiing aircraft. At the time of the accident, the single controller in the tower was performing both tower and radar duties. On August 30, 2006, the FAA announced that Blue Grass Airport, as well as additional airports that were understaffing their overnight shifts, would use two controllers on duty, or shift radar responsibilities to Indianapolis Center when only one was available. The FAA stated that a second controller would not have prevented the accident.
Comair discovered after the accident that all of its pilots had been using an airport map that did not accurately reflect changes made to the airport layout during ongoing construction work. The National Transportation Safety Board (NTSB) later determined that this did not contribute to the accident. Construction work was halted after the accident to preserve evidence needed for the investigation.
The NTSB released several reports on January 17, 2007, including transcripts of the CVR and an engineering report.
In April 2007, acting on a recommendation issued by the NTSB during its investigation of the Comair 5191 accident, the FAA issued a safety notice that reiterated advice to pilots to positively confirm their position before crossing the hold-short line onto the takeoff runway, and again when initiating takeoff. The NTSB offered four further recommendations: three measures to avoid fatigue affecting the performance of air traffic controllers and one to prevent controllers from carrying out non-essential administrative tasks while aircraft are taxiing under their control. The recommendations were partly prompted by four earlier accidents; the board was unable to determine whether fatigue contributed to the Comair accident. In May, acting on another NTSB recommendation, the FAA advised that pilot training should include specific guidance on runway-lighting requirements for take-off at night.
In July 2007, a Comair flying instructor testified that he would have failed both pilots for violating sterile flight deck rules. Later that month, the NTSB released its final report, citing the pilots' "non-pertinent conversation" as a contributing factor in the accident.
Probable cause During a public meeting on July 26, 2007, the NTSB announced the probable cause of the accident:
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew members' 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. Contributing to the accident were the flight crew's nonpertinent conversations during taxi, which resulted in a loss of positional awareness and the Federal Aviation Administration's failure to require that all runway crossings be authorized only by specific air traffic control clearances.
NTSB investigators concluded that the likely cause was that Clay and Polehinke ignored clues that indicated that they were on the wrong runway, failed to confirm their position on the runway and violated sterile flight deck rules.
Clay's widow strongly opposes the NTSB's assessment blaming the pilots, stating that other factors contributed, "including an understaffed control tower and an inaccurate runway map."
Aftermath
A memorial service for the victims was held on August 31, 2006, at the Lexington Opera House. A second public memorial service was held on September 10, 2006, at Rupp Arena in Lexington. The Lexington Herald-Leader published a list of the victims with short biographies.
The Flight 5191 Memorial Commission was established shortly after the crash to create an appropriate memorial for the victims, first responders and community. The commission selected the University of Kentucky Arboretum as its memorial site.
The Flight 5191 Memorial, created by Douwe Blumberg, consists of a sculpture of 49 stainless-steel birds in flight over a base of black granite.
In July 2008, US district judge Karl Forester ruled that Delta Air Lines could not be held liable for the crash, because although Comair is a wholly owned subsidiary of Delta, Comair maintains its own management and policies and employs its own pilots. In December 2009, Forester granted a passenger family's motion for "partial summary judgment" determining, as a matter of law, that Comair's flight crew was negligent, and that this negligence was a substantial factor causing the crash of Flight 5191.IN RE: Air Crash at Lexington, Kentucky, August 27, 2006. justia.com