Why did Comair 5191 Crash at Lexington?

Before dawn on Sunday, August 27th past, Comair Flight 5191 carrying fifty passengers and crew crashed during takeoff, while attempting to depart on a runway one—half the length of the one it was cleared to use. The accident killed all aboard with the exception of the copilot, whose condition was recently upgraded to serious from critical.

There is no question that the pilot of the Bombardier CRJ—100/200 (depending on the source) lined—up on the 3,500 ft. runway 26 rather than the 7,000 ft. runway 22. The CRJ—100/200 would normally require about a 5,000 ft takeoff roll. Evidence of tire marks in the sod past the end of the runway and impact evidence on an earthen berm farther on, indicate that the aircraft never rotated for takeoff, but did temporarily become airborne after hitting the berm.

This may very well mean that the crew never even knew what had happened. Though the copilot should survive, his first words upon regaining consciousness were, "Why did God do this to me?" Crash victims often have no recollection of the moments just prior to the traumatic event. Mr. Polehinke will probably not be of much help to the NTSB.

Also not very helpful is all the speculating, questioning, posturing, politicking and silly emailing that has been going in the media and cyberspace regarding what is and is not important regarding this accident. What happened is and will forever be about as pure a case of pilot error as you will ever hear about. There has been no assertion of any mechanical failure. And how many controllers were or were not in the tower is of little or no importance in this instance.

Even if there had been two controllers in the tower, and one was watching what, given the time of day and location, would have probably been an empty radar screen, and the other was doing his paperwork, as the controller actually present at the time was engaged in doing, neither would have seen the plane line up on the wrong runway. Whatever FAA policy is regarding whatever number of controllers are to be present in a control tower under a given set of circumstances, it has no bearing on this accident.

The two—controller policy was the result of a near—miss between two airborne planes at another location and has absolutely nothing to do with takeoff instructions or monitoring. Taking off on the runway for which one has received takeoff clearance is solely the pilot's responsibility. Period. And don't forget, two other flights had taken off earlier without incident.

What is interesting, is that if you look at the airport diagram for Lexington Blue Grass International, the departure end of both runway 22 and 26 are nearly inline when viewed from the tower. The two runway headings differ by only 40 degrees. With conditions as they were the morning of the crash —  a light rain falling a little before dawn — it's very possible that even if a controller in the tower had been watching Flight 5191 as it lined up and started its takeoff roll, he may not have immediately realized that the aircraft was moving down the wrong runway. After all, in either case it would have been moving laterally to his field of view. With visibility and lighting conditions as they were, depth of field and perception would have been reduced.

At major airports with high volumes of traffic, radar is used for aircraft separation and control both on the ground as well as in the air. Some very large facilities, such as Chicago's O'Hare, even have more than one ground control frequency depending on where you are while taxiing. This is to reduce the level of 'chatter' to avoid confusion and reduce the chance of error and accident. The ground control radar is used to track aircraft independent of visibility.

You will never find this level of control and supervision of ground traffic at an airport such as Lexington. It is just too expensive and would be wasteful. The controller at a small airport, especially during periods of light traffic, would merely give the pilot the takeoff runway, surface winds, barometer setting for the altimeter and the ATC frequency to contact after takeoff, if that hadn't been given with the IFR (Instrument Flight Rules) clearance.

If there wasn't any other traffic operating in the area, this information could include the magic words, 'Comair 5191 you are cleared for takeoff runway...' Prior to taking off those exact words must be received from the controlling authority at an airport with an operating control tower— 'You are cleared for takeoff.'

If you takeoff without that clearance, you can be cited for a violation of FAA rules. For landing the magic words are 'You are cleared to land runway...' This is true, believe it or not, world—wide for international traffic. Part of the pilots' bible. If Comair 5191 had been so cleared, no further communication is required or necessary between the tower controller and the aircraft. It's strictly up to the pilot to find the right runway. Sure, the tower would alert the pilot if they noticed that something was amiss. But it is not in any way the controller's responsibility to place the pilot on the correct runway for takeoff. After all, he's not operating the aircraft. The pilot is.

Regarding all the chatter about airport construction, new taxiways, barriers, lighting not being on or not working, the situation is similar. In the wonderful world of aviation we have what's acronymically called 'NOTAMS.' That is, 'Notices to Airmen.' Anything that can affect operations at an airport, be it repairs, closures, openings, or modifications of runways, taxiways, lighting, et cetera, will be in the NOTAMS for that airfield both prior to (if possible) and subsequent to any such changes or restorations. The same is true for instrument approach procedures, changes to the traffic pattern, runway markings, navigational aids, communication frequencies, new or modified significant structures in the vicinity of the field or along approach or departure paths, and so forth. Just about anything and everything that could possibly impact operations will be in the NOTAMS. Fail to read and heed these at your own peril. You might even takeoff on the wrong runway. Sorry, fellas. Such things may contribute to an error but they are no excuse or justification for not paying attention.

One item that troubles me greatly is the fact that runway 26 had no lights. And yet they took—off on that runway. Was the visibility so bad that neither the captain nor first officer saw the lights on runway 22 as they went through the intersection? You'd think that would be one helluva clue that something wasn't quite right. With it being not yet light with a light rain, I'd think you'd be looking for runway lights. Right? There's the blue taxiway lights. The white runway lights. The green runway threshold lights.

The runway 22 centerline lights were not working at the time. But no lights on the runway for takeoff? The cockpit voice recorder showed that they even commented to one another about the absence of lights! Duh! Just line up on the centerline stripe with the aircraft lights, throttle up and press off into the abyss? I don't get it. Not at all.

Not that you have to see the runway to takeoff. Not at all. At the time I went through Air Force pilot training, and that was more moons ago than I care to admit to, when you started advanced training in the T—38 Talon supersonic trainer, the six weeks after your one 'gee—whiz' ride in the front seat were spent in back, under the hood, doing instrument flying training. With two tandem, that is front—to—back seats, the rear seat could be completely sealed off visually with a 'hood' that could be pulled forward to block all outside attitude reference. The instructor, in the front seat, would line the aircraft up on the centerline of the runway, turn it over to the 'blind' student in the rear and away you'd go.

Take off, fly an instrument departure, navigate a route, do practice approach procedures and go—arounds then, at the end of the flight, fly an ILS (Instrument Landing System) approach to a bit before touchdown, whereupon the instructor would take over and have you pull the hood back to see how well you flew the ILS. All without ever looking outside until just before touchdown. No, you don't have to see the runway to takeoff. Nowadays there are some systems that don't require that you see it even to land. You'd just better be on the right runway!

There have been some major aircraft takeoff  accidents directly attributable to pilot error. The worst aircraft accident ever, in terms of total fatalities, occurred on Tenerife in the Canary Islands on March 27, 1977, a ground/air collision of two loaded 747s and took 583 lives. It was the direct result of a pilot taking off without clearance. He had not heard the magic words 'you are cleared for takeoff' but proceeded to do so anyway. He had assumed his IFR flight plan approval was his clearance to takeoff. It wasn't.

A little over ten years later, on August 16, 1987, Northwest Flight 255 crashed shortly after takeoff killing 154 souls but sparing, incredibly, a four—year—old girl. Cause: the crew had failed to complete the pre—flight checklist and lower the flaps to takeoff position. Without the leading and trailing edge flaps deployed for takeoff, that aircraft lost lift when it climbed out of the 'ground effect' and settled back down. A contributing mechanical factor was that there was no electrical power to the flap warning system.

According to the NTSB database, there have been four accidents caused by pilots taking off on the wrong runway worldwide since 1982. According to the NASA flight incident database, there have been two other instances at Lexington, one in 1993, one in 1995, in which the pilot had taxied onto the wrong runway for takeoff. In one instance the pilot caught the error, in the other the tower did. In 2006, neither did.

I would be very surprised if the NTSB found other than 'Pilot Error' as the primary cause.

Update:

The number on a runway is the magnetic compass direction of that runway rounded to the nearest ten degrees. However, if you check the airport diagram for Lexington Blue Grass, you'll see that though the actual direction is 225.3, it's still designated runway 22 and not runway 23. You can also see a visual representation for the magnetic variation on the airport diagram. Note that magnetic variation "varies" over time as shown on the diagram. So the number on the runway will have to be changed at some time in the future. But the important thing to remember is that the runway number's purpose is to distinguish it from other runways. If you have parallel runways, as does Detroit's Metro Airport which has three parallel runways, they end up with the same number but with the suffices L, C, & R for "Left", "Center", and "Right"
 
When you line up an a runway, your "whiskey" compass — so—called because the bowl is filled with alcohol as a dampening fluid for this purely magnetic compass — and your heading indicator, which is a gyroscopic instrument, should both read approximately the same magnetic direction as the runway. If not, you have one of two problems. First, you're lined up on the wrong runway or, second, one or both of your directional reference is malfunctioning. Before taking off, one would be well advised to find out which it is!
 
You may wonder why with today's modern instruments we even bother with "Magnetic" headings and not just use "True" north as a reference. The reason is very simple. If you're faced with a total electrical failure and all your fancy instruments are inoperative, the earth's magnetic field is still there. The whiskey compass will still work. You can still tell in which direction you're going. The reason for magnetic variation is that the earth's magnetic north pole is not located at the rotational axis north pole. So "Variation" varies depending on where you are. When operating an aircraft one actually does have to keep these things in mind. Flying is about 20% physical skill and 80% knowledge and procedural skills. Hence, the above illustration of why a straightforward question such as yours — and a good one, I might add — takes a bit more than a simple answer if you're to get a fairly decent idea of the issues involved with the crash of Comair 5191

Dennis Sevakis is a former USAF fighter pilot.

Before dawn on Sunday, August 27th past, Comair Flight 5191 carrying fifty passengers and crew crashed during takeoff, while attempting to depart on a runway one—half the length of the one it was cleared to use. The accident killed all aboard with the exception of the copilot, whose condition was recently upgraded to serious from critical.

There is no question that the pilot of the Bombardier CRJ—100/200 (depending on the source) lined—up on the 3,500 ft. runway 26 rather than the 7,000 ft. runway 22. The CRJ—100/200 would normally require about a 5,000 ft takeoff roll. Evidence of tire marks in the sod past the end of the runway and impact evidence on an earthen berm farther on, indicate that the aircraft never rotated for takeoff, but did temporarily become airborne after hitting the berm.

This may very well mean that the crew never even knew what had happened. Though the copilot should survive, his first words upon regaining consciousness were, "Why did God do this to me?" Crash victims often have no recollection of the moments just prior to the traumatic event. Mr. Polehinke will probably not be of much help to the NTSB.

Also not very helpful is all the speculating, questioning, posturing, politicking and silly emailing that has been going in the media and cyberspace regarding what is and is not important regarding this accident. What happened is and will forever be about as pure a case of pilot error as you will ever hear about. There has been no assertion of any mechanical failure. And how many controllers were or were not in the tower is of little or no importance in this instance.

Even if there had been two controllers in the tower, and one was watching what, given the time of day and location, would have probably been an empty radar screen, and the other was doing his paperwork, as the controller actually present at the time was engaged in doing, neither would have seen the plane line up on the wrong runway. Whatever FAA policy is regarding whatever number of controllers are to be present in a control tower under a given set of circumstances, it has no bearing on this accident.

The two—controller policy was the result of a near—miss between two airborne planes at another location and has absolutely nothing to do with takeoff instructions or monitoring. Taking off on the runway for which one has received takeoff clearance is solely the pilot's responsibility. Period. And don't forget, two other flights had taken off earlier without incident.

What is interesting, is that if you look at the airport diagram for Lexington Blue Grass International, the departure end of both runway 22 and 26 are nearly inline when viewed from the tower. The two runway headings differ by only 40 degrees. With conditions as they were the morning of the crash —  a light rain falling a little before dawn — it's very possible that even if a controller in the tower had been watching Flight 5191 as it lined up and started its takeoff roll, he may not have immediately realized that the aircraft was moving down the wrong runway. After all, in either case it would have been moving laterally to his field of view. With visibility and lighting conditions as they were, depth of field and perception would have been reduced.

At major airports with high volumes of traffic, radar is used for aircraft separation and control both on the ground as well as in the air. Some very large facilities, such as Chicago's O'Hare, even have more than one ground control frequency depending on where you are while taxiing. This is to reduce the level of 'chatter' to avoid confusion and reduce the chance of error and accident. The ground control radar is used to track aircraft independent of visibility.

You will never find this level of control and supervision of ground traffic at an airport such as Lexington. It is just too expensive and would be wasteful. The controller at a small airport, especially during periods of light traffic, would merely give the pilot the takeoff runway, surface winds, barometer setting for the altimeter and the ATC frequency to contact after takeoff, if that hadn't been given with the IFR (Instrument Flight Rules) clearance.

If there wasn't any other traffic operating in the area, this information could include the magic words, 'Comair 5191 you are cleared for takeoff runway...' Prior to taking off those exact words must be received from the controlling authority at an airport with an operating control tower— 'You are cleared for takeoff.'

If you takeoff without that clearance, you can be cited for a violation of FAA rules. For landing the magic words are 'You are cleared to land runway...' This is true, believe it or not, world—wide for international traffic. Part of the pilots' bible. If Comair 5191 had been so cleared, no further communication is required or necessary between the tower controller and the aircraft. It's strictly up to the pilot to find the right runway. Sure, the tower would alert the pilot if they noticed that something was amiss. But it is not in any way the controller's responsibility to place the pilot on the correct runway for takeoff. After all, he's not operating the aircraft. The pilot is.

Regarding all the chatter about airport construction, new taxiways, barriers, lighting not being on or not working, the situation is similar. In the wonderful world of aviation we have what's acronymically called 'NOTAMS.' That is, 'Notices to Airmen.' Anything that can affect operations at an airport, be it repairs, closures, openings, or modifications of runways, taxiways, lighting, et cetera, will be in the NOTAMS for that airfield both prior to (if possible) and subsequent to any such changes or restorations. The same is true for instrument approach procedures, changes to the traffic pattern, runway markings, navigational aids, communication frequencies, new or modified significant structures in the vicinity of the field or along approach or departure paths, and so forth. Just about anything and everything that could possibly impact operations will be in the NOTAMS. Fail to read and heed these at your own peril. You might even takeoff on the wrong runway. Sorry, fellas. Such things may contribute to an error but they are no excuse or justification for not paying attention.

One item that troubles me greatly is the fact that runway 26 had no lights. And yet they took—off on that runway. Was the visibility so bad that neither the captain nor first officer saw the lights on runway 22 as they went through the intersection? You'd think that would be one helluva clue that something wasn't quite right. With it being not yet light with a light rain, I'd think you'd be looking for runway lights. Right? There's the blue taxiway lights. The white runway lights. The green runway threshold lights.

The runway 22 centerline lights were not working at the time. But no lights on the runway for takeoff? The cockpit voice recorder showed that they even commented to one another about the absence of lights! Duh! Just line up on the centerline stripe with the aircraft lights, throttle up and press off into the abyss? I don't get it. Not at all.

Not that you have to see the runway to takeoff. Not at all. At the time I went through Air Force pilot training, and that was more moons ago than I care to admit to, when you started advanced training in the T—38 Talon supersonic trainer, the six weeks after your one 'gee—whiz' ride in the front seat were spent in back, under the hood, doing instrument flying training. With two tandem, that is front—to—back seats, the rear seat could be completely sealed off visually with a 'hood' that could be pulled forward to block all outside attitude reference. The instructor, in the front seat, would line the aircraft up on the centerline of the runway, turn it over to the 'blind' student in the rear and away you'd go.

Take off, fly an instrument departure, navigate a route, do practice approach procedures and go—arounds then, at the end of the flight, fly an ILS (Instrument Landing System) approach to a bit before touchdown, whereupon the instructor would take over and have you pull the hood back to see how well you flew the ILS. All without ever looking outside until just before touchdown. No, you don't have to see the runway to takeoff. Nowadays there are some systems that don't require that you see it even to land. You'd just better be on the right runway!

There have been some major aircraft takeoff  accidents directly attributable to pilot error. The worst aircraft accident ever, in terms of total fatalities, occurred on Tenerife in the Canary Islands on March 27, 1977, a ground/air collision of two loaded 747s and took 583 lives. It was the direct result of a pilot taking off without clearance. He had not heard the magic words 'you are cleared for takeoff' but proceeded to do so anyway. He had assumed his IFR flight plan approval was his clearance to takeoff. It wasn't.

A little over ten years later, on August 16, 1987, Northwest Flight 255 crashed shortly after takeoff killing 154 souls but sparing, incredibly, a four—year—old girl. Cause: the crew had failed to complete the pre—flight checklist and lower the flaps to takeoff position. Without the leading and trailing edge flaps deployed for takeoff, that aircraft lost lift when it climbed out of the 'ground effect' and settled back down. A contributing mechanical factor was that there was no electrical power to the flap warning system.

According to the NTSB database, there have been four accidents caused by pilots taking off on the wrong runway worldwide since 1982. According to the NASA flight incident database, there have been two other instances at Lexington, one in 1993, one in 1995, in which the pilot had taxied onto the wrong runway for takeoff. In one instance the pilot caught the error, in the other the tower did. In 2006, neither did.

I would be very surprised if the NTSB found other than 'Pilot Error' as the primary cause.

Update:

The number on a runway is the magnetic compass direction of that runway rounded to the nearest ten degrees. However, if you check the airport diagram for Lexington Blue Grass, you'll see that though the actual direction is 225.3, it's still designated runway 22 and not runway 23. You can also see a visual representation for the magnetic variation on the airport diagram. Note that magnetic variation "varies" over time as shown on the diagram. So the number on the runway will have to be changed at some time in the future. But the important thing to remember is that the runway number's purpose is to distinguish it from other runways. If you have parallel runways, as does Detroit's Metro Airport which has three parallel runways, they end up with the same number but with the suffices L, C, & R for "Left", "Center", and "Right"
 
When you line up an a runway, your "whiskey" compass — so—called because the bowl is filled with alcohol as a dampening fluid for this purely magnetic compass — and your heading indicator, which is a gyroscopic instrument, should both read approximately the same magnetic direction as the runway. If not, you have one of two problems. First, you're lined up on the wrong runway or, second, one or both of your directional reference is malfunctioning. Before taking off, one would be well advised to find out which it is!
 
You may wonder why with today's modern instruments we even bother with "Magnetic" headings and not just use "True" north as a reference. The reason is very simple. If you're faced with a total electrical failure and all your fancy instruments are inoperative, the earth's magnetic field is still there. The whiskey compass will still work. You can still tell in which direction you're going. The reason for magnetic variation is that the earth's magnetic north pole is not located at the rotational axis north pole. So "Variation" varies depending on where you are. When operating an aircraft one actually does have to keep these things in mind. Flying is about 20% physical skill and 80% knowledge and procedural skills. Hence, the above illustration of why a straightforward question such as yours — and a good one, I might add — takes a bit more than a simple answer if you're to get a fairly decent idea of the issues involved with the crash of Comair 5191

Dennis Sevakis is a former USAF fighter pilot.