Bombardier, Inc. CRJ-100COMAIR INC
Lexington, KY, USA · 2006-08-27·N431CA
What happened
NTSB summary, verbatimThe Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-07/05. On August 27, 2006, about 0606:35 eastern daylight time, Comair flight 5191, a Bombardier CL-600-2B19, N431CA, crashed during takeoff from Blue Grass Airport, Lexington, Kentucky. The flight crew was instructed to take off from runway 22 but instead lined up the airplane on runway 26 and began the takeoff roll. The airplane ran off the end of the runway and impacted the airport perimeter fence, trees, and terrain. The captain, flight attendant, and 47 passengers were killed, and the first officer received serious injuries. The airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 and was en route to Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. Night visual meteorological conditions prevailed at the time of the accident.
Photographs
69the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationthe flight crewmembers's 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 conversation 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.
Safety recommendations
11 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Require that all 14 Code of Federal Regulations Part 121 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold-short line for take off. (Superseded by A-07-44 through A-07-48)
TO THE FEDERAL AVIATION ADMINISTRATION: Require that all 14 Code of Federal Regulations Part 121 operators provide specific guidance to pilots on the runway lighting requirements for takeoff operations at night.
TO THE FEDERAL AVIATION ADMINISTRATION: Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop a fatigue awareness and countermeasures training program for controllers and for personnel who are involved in the scheduling of controllers for operational duty that will address the incidence of fatigue in the controller workforce, causes of fatigue, effects of fatigue on controller performance and safety, and the importance of using personal strategies to minimize fatigue. This training should be provided in a format that promotes retention, and recurrent training should be provided at regular intervals.
TO THE NATIONAL AIR TRAFFIC CONTROLLERS ASSOCIATION: Work with the Federal Aviation Administration to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance.
TO THE FEDERAL AVIATION ADMINISTRATION: Require all air traffic controllers to complete instructor-led initial and recurrent training in resource management skills that will improve controller judgment, vigilance, and safety awareness.
TO THE FEDERAL AVIATION ADMINISTRATION: Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold short line for takeoff. This required guidance should be consistent with the guidance in Advisory Circular 120-74A and Safety Alert for Operators 06013 and 07003. (Supersedes Safety Recommendation A-06-083)
TO THE FEDERAL AVIATION ADMINISTRATION: Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 operators install on their aircraft cockpit moving map displays or an automatic system that alerts pilots when a takeoff is attempted on a taxiway or a runway other than the one intended. (Supersedes Safety Recommendation A-06-083)
TO THE FEDERAL AVIATION ADMINISTRATION: Require that all airports certificated under 14 Code of Federal Regulations Part 139 implement enhanced taxiway centerline markings and surface painted holding position signs at all runway entrances. (Supersedes Safety Recommendation A-06-083)
TO THE FEDERAL AVIATION ADMINISTRATION: Prohibit the issuance of a takeoff clearance during an airplane’s taxi to its departure runway until after the airplane has crossed all intersecting runways. (Supersedes Safety Recommendation A-06-083)
TO THE FEDERAL AVIATION ADMINISTRATION: Revise Federal Aviation Administration Order 7110.65, Air Traffic Control, to indicate that controllers should refrain from performing administrative tasks, such as the traffic count, when moving aircraft are in the controller’s area of responsibility. (Supersedes Safety Recommendation A-06-083)
Sequence of events
12 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)- 05:59:37-06:00:48 EDTtaxip.5Left turn from about 130 degrees magnetic heading to 46.3 (left) / 48.9 (right) degrees
- 06:00:14-06:01:26 EDTtaxip.5Engine 1 N1 increased from 0% to 26% (06:00:44); Engine 2 N1 from 0% to 25% (06:01:26) - engine start
- 06:02:18 EDTtaxip.5Control checks began, ending about 31 seconds later; right MFD range changed 10 nm to 40 nm at 06:02:24 and radar overlay became active four seconds later
- 06:02:15-06:04:20 EDTtaxip.5Several heading changes, finally reaching 40.3 (left) and 41.6 (right) degrees; left MFD range 40 nm to 80 nm at 06:04:34
- 06:04:36-06:05:22 EDTtaxip.5Longitudinal acceleration indicates the airplane was not moving (holding short)
- 06:05:39-06:06:00 EDTline-upp.5Left turn to 266.5 (left) / 265.8 (right) degrees - lined up on runway 26 rather than runway 22; both autopilot lateral takeoff modes engaged as of 06:05:50
- 06:06:00-06:06:13 EDTtakeoff rollp.5Engine 1 and 2 N1 increased, reaching 91% at 06:06:12 and 06:06:13; computed airspeed began increasing at 06:06:05
- 06:06:30 EDTrotationp.6At 127 knots right computed airspeed the control columns began moving aft; elevators trailing edge up the following second; maximum aft column 10.9 degrees (right) at 06:06:33 at 135 knots; maximum elevator 22.6 degrees TEU (right) at 06:06:32
- 06:06:32 EDTrotation/impactp.6Right pitch reached 4.7 deg ANU, dropped to 0 the following second, then left pitch 6.7 deg ANU rising to a maximum 15.9 deg ANU (right) over the next two seconds; vertical acceleration 1.199 g, 0.766 g, then 2.742 g; gear WOW indicated air (left briefly ground then air); radio altitudes began increasing; engine N1 began decreasing
- 06:06:33-06:06:34 EDTimpact sequencep.6Right stick shaker active at 06:06:33, then left stick shaker and both stick pushers active; left aileron to 24.9 deg right wing down, left flight spoiler to 42 deg; roll to 17.4 deg left wing down (06:06:35); right rudder pedal 5.7 deg and rudder 10.1 deg TER; nose gear WOW air at 06:06:33
- 06:06:35 EDTimpact sequencep.6Left computed airspeed 136.75 knots; left angle of attack 13.3 deg (maximum); final vertical acceleration 3.113 g; longitudinal acceleration 0.736 g; final pitch 12.7 deg ANU; Engine N1 final values 80% (06:06:35) and 74% (06:06:34); lateral acceleration 0.135 g then -0.096 g
- 06:06:36 EDTimpactp.6Nose and right gear WOW returned to ground; end of valid data
NTSB analysis
from the final reportThe Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-07/05. On August 27, 2006, about 0606:35 eastern daylight time, Comair flight 5191, a Bombardier CL-600-2B19, N431CA, crashed during takeoff from Blue Grass Airport, Lexington, Kentucky. The flight crew was instructed to take off from runway 22 but instead lined up the airplane on runway 26 and began the takeoff roll. The airplane ran off the end of the runway and impacted the airport perimeter fence, trees, and terrain. The captain, flight attendant, and 47 passengers were killed, and the first officer received serious injuries. The airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121 and was en route to Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. Night visual meteorological conditions prevailed at the time of the accident.