Comair Flight 191

Comair Flight 191

A CRJ-100ER in Comair livery at the gate in Jacksonville, Florida, USA.
Accident summary
Date	August 27, 2006 (2006-08-27)
Type	Runway confusion due to pilot error
Site	Blue Grass Airport, Lexington, Kentucky, USA
Passengers	47
Crew	3
Injuries	1
Fatalities	49
Survivors	1
Aircraft type	Bombardier Canadair Regional Jet (CRJ) CRJ-100ER
Operator	Comair (d/b/a Delta Connection)
Tail number	N431CA
Flight origin	Blue Grass Airport
Destination	Hartsfield-Jackson Atlanta International Airport

Comair Flight 191, marketed as Delta Connection Flight 5191, was a scheduled United States (US) domestic passenger flight from Lexington, Kentucky, to Atlanta, Georgia, operated on behalf of Delta Connection by Comair. On the morning of August 27, 2006, the Bombardier Canadair Regional Jet 100ER that was being used for the flight crashed while attempting to take off from Blue Grass Airport in Fayette County, Kentucky, four miles (6 kilometers) 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 two of the three crew. The flight's first officer was the only survivor.^[1][2] Although not the pilot in command, according to the cockpit voice recorder transcript, the first officer was the pilot flying at the time of the accident.^[3]

Flight details

The flight was sold under the Delta Air Lines brand as Delta Flight 5191 (DL5191) and was operated by Comair as Comair Flight 191 (OH191). It is usually identified as Comair Flight 5191.

The flight had been scheduled to land at Hartsfield-Jackson Atlanta International Airport at 7:18 a.m.

The aircraft involved was a 50-seat Bombardier Canadair Regional Jet CRJ-100ER, serial number 7472.^[4] Manufactured in Canada in January 2001, it was delivered to the airline on January 30, 2001.

Crash

Approximate paths at Blue Grass Airport (picture before airport construction done weeks before the crash):

  Desired path via Runway 22

  Actual path via Runway 26, ending at approximate crash site.

X marks the closed taxiway

Analysis of the cockpit voice recorder (CVR) indicated the aircraft was cleared to take off from Runway 22, a 7,003 feet (2,135 m) strip used by most airline traffic at Lexington.^[5] Instead, after confirming "Runway two-two", Captain Jeffrey Clay taxied onto Runway 26, an unlit secondary runway only 3,500 feet (1,100 m) long,^[6] and turned the controls over to First Officer James Polehinke for takeoff.^[7] The air traffic controller was not required to maintain visual contact with the aircraft; after clearing the aircraft for takeoff, he turned to perform administrative duties and did not see the aircraft taxi to the runway.

Based upon an estimated takeoff weight of 49,087 pounds (22,265 kg),^[8] the manufacturer calculated a speed of 138 knots (159 miles per hour or 256 kilometers per hour) and a distance of 3,744 feet (1,141 m) would have been needed for rotation (increasing nose-up pitch), with more runway needed to achieve lift-off.^[9] At a speed approaching 100 knots (120 mph), Polehinke remarked, "There is no lights" referring to the lack of lighting on Runway 26.^[10] "Yeah", confirmed Clay, but the flight data recorder gave no indication either pilot tried to abort the takeoff as the aircraft accelerated to 137 knots (158 mph).

Clay called for rotation but the aircraft sped off the end of the runway before it could lift off. It then struck a low earthen wall adjacent to a ditch, becoming momentarily airborne,^[10] clipped the airport perimeter fence with its landing gear, and collided with trees, separating the fuselage and flight deck from the tail. The aircraft struck the ground about 1,000 feet (300 m) from the end of the runway.^[8] Forty-nine of the 50 people on board perished in the accident; most of them were killed instantly in the initial impact.^[11] The resulting fire destroyed the aircraft.

Victims

Nationality	Passengers		Crew		Total
	Total	Killed	Total	Killed	Total	Killed
United States	42	42	3	2	45	44
Canada	3	3	0	0	3	3
Japan	2	2	0	0	2	2
Total	47	47	3	2	50	49
Note: the two Japanese citizens were residents of Lexington, Kentucky.

All 47 passengers and two of the three crew members on board the flight were killed. Comair released the passenger manifest on August 29, 2006.^[12]

Most of the passengers were US 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.^[13]

A memorial service for the victims was held on August 31, 2006, at the Lexington Opera House.^[14] A second public memorial service was held on September 10, 2006, at Rupp Arena in Lexington.^{[citation needed]} The Lexington Herald-Leader published a list of the victims with short biographies.^[15]

The Flight 5191 Memorial Commission was established shortly after the crash to create an appropriate memorial to the victims, first responders, and community that supported them. The Commission chose the University of Kentucky Arboretum as its memorial site.^{[citation needed]}

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 pulled Polehinke out of the wreckage. Polehinke underwent surgery for his injuries, including an amputation of his left leg. Doctors later determined that Polehinke had suffered brain damage and has no memory of the crash or the events leading up to it.^[16] As of August 2007^[update], Polehinke was a wheelchair user.^[17] During the same month, Polehinke filed a lawsuit against the airport and the company that designed the runway and taxi lights.^[18]

Polehinke said through his attorney, William Johnson, that "should have been aware of the dangerous conditions that existed in that there had been considerable media coverage about the necessity of improving runway conditions at the airport."^[19] Johnson later withdrew the argument. David Royse, an attorney for the plaintiffs, criticized Polehinke's statement.

Aftermath

During the course of its investigation, the Federal Aviation Administration (FAA) discovered that tower staffing levels at Blue Grass Airport violated an internal policy as reflected in a November 16, 2005, memorandum requiring two controllers during the overnight shift: one in the tower working clearance, ground, and tower frequencies, and another, either in the tower or remotely at Indianapolis Center, working TRACON (radar).^[20] 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 Lexington, as well as other airports with similar traffic levels, would be staffed with two controllers in the tower around the clock effective immediately.^[21]

On September 12, 2006, Comair announced that all of its pilots had been using an airport map with outdated information at the time of the crash. A new diagram was received by the airline on Friday, September 8, two weeks after the crash. At the same time, the airline issued a warning to pilots to exercise "extreme caution" when taxiing to the appropriate runway. Despite the existence of the outdated chart, an airport spokesman stated that the updated taxi route was available to pilots via a Notice To Airmen (NOTAM) released when the construction began.^[7]

On September 14, 2006, Fayette Circuit Judge Pamela Goodwine issued a restraining order to prevent Blue Grass Airport from continuing any construction to preserve evidence in the crash pending the inspection by safety experts and attorneys for the families of the victims.^[22]

On December 12, 2006, the National Transportation Safety Board (NTSB) recommended that the FAA should take steps to ensure that pilots cross-check their position before crossing the hold-short line^[23] and initiating takeoff. The NTSB also recommended that pilots be given specific guidance on runway lighting requirements for take-off at night.^[24]

The NTSB released several factual reports on January 17, 2007, including transcripts and recordings of the CVR and an engineering report.^[25]

In April 2007, the NTSB made four further recommendations, three measures to avoid fatigue affecting the performance of air traffic controllers,^[26] and one to prevent controllers from carrying out non-essential administrative tasks while aircraft are taxiing under their control.^[27] Although these recommendations were published during the course of the NTSB's investigation into the accident to Comair Flight 191, they were in part prompted by four earlier accidents, and the Board was unable to determine whether fatigue contributed to the Comair accident.

In July 2007, a flying instructor for Comair testified that he would have failed both pilots for violating Sterile Cockpit Rules.^[28] Later the same month, the NTSB released its final report into the accident, citing this "non-pertinent conversation" as a contributing factor in the accident.

On July 8, 2008, United States District Judge Karl Forester ruled Delta will not be held liable for the crash, because while Comair is a wholly owned subsidiary of the Atlanta-based airline, Comair maintains its own management and policies, and employs its own pilots.^[29]

On December 17, 2009, Judge 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.^[30]

Families of 45 of the 47 passengers sued Comair for negligence. (Families of the other two victims settled with the airline before filing litigation.) Three sample cases were due to be heard on August 4, 2008; but the trial was indefinitely postponed after Comair reached a settlement with the majority of the families. Cases brought by Comair against the airport authority and the FAA, arguing each should share in the compensation payments, are now resolved. The case against the airport authority was dismissed on sovereign immunity grounds, and this ruling was upheld by the Kentucky Supreme Court on October 1, 2009.^[31] In Comair's case against the United States a settlement was reached with the United States agreeing to pay 22% of the liability for the crash, while Comair agreed to pay the remaining 78%.^[32]

All but one of the passengers' families settled their cases. After a four day jury trial in Lexington, Kentucky, that ended on December 7, 2009, the estate and daughters of 39 year old Bryan Woodward were awarded compensatory damages in the amount of $7.1 million.^[32] While Comair challenged this verdict as excessive, on April 2, 2010, Judge Forester overruled Comair's objections and upheld the verdict.^[33]

The Woodward case, formally known as Hebert v. Comair, was set for a punitive damages jury trial July 19, 2010.^[34] In that trial a different jury was to decide whether Comair was guilty of gross negligence that was a substantial factor causing the crash and, if so, the amount of any punitive damages the jury deemed appropriate.^[35] However in a later hearing the decision to allow a jury trial was reversed with the judge ruling that the company couldn't be punished for the "reprehensible conduct" of its pilot.^[36]

Probable cause

During a public meeting on July 26, 2007, the NTSB announced the probable cause of the accident, as follows:

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.^[7][37]

Captain Clay's wife strongly disputes laying primary blame on the pilots, stating that other factors contributed, "including an under-staffed control tower and an inaccurate runway map".^[38]

Similar accidents and incidents

• In 1993, a commercial jet at Blue Grass Airport was cleared for takeoff on Runway 22 but mistakenly took Runway 26 instead. Tower personnel noticed the mistake and canceled the aircraft's takeoff clearance just as the crew realized their error. The aircraft subsequently made a safe departure from Runway 22.^[39]
• In January 2007, a Learjet was cleared to take off at Blue Grass Airport on runway 22, but mistakenly turned onto runway 26. Takeoff clearance was canceled by the local controller prior to the start of the takeoff roll.^[40]
• On October 31, 2000, the crew of Singapore Airlines Flight 006 mistakenly used a closed runway for departure from Chiang Kai-shek International Airport, Taipei. The Boeing 747-400 collided with construction equipment during the takeoff roll, resulting in the deaths of 83 of the 179 passengers and crew on board.

See also

	Kentucky portal
	Aviation portal
	Disasters portal

• Singapore Airlines Flight 006
• Western Airlines Flight 2605
• Air safety
• Lexington, Kentucky
• List of accidents and incidents on commercial airliners
• List of sole survivors of aviation accidents or incidents
• National Transportation Safety Board

References

1. ^ "NTSB: Crashed Jet On Wrong Runway". IBS. http://www.wsbtv.com/news/9743984/detail.html. Retrieved 2006-08-29. 
2. ^ Jeffrey McMurray (August 27, 2006). "Comair plane took off from wrong runway". Associated Press. Archived from the original on 2006-09-07. http://web.archive.org/web/20060907044841/http://news.yahoo.com/s/ap/20060827/ap_on_re_us/kentucky_crash. 
3. ^ "CVR transcript". http://www.tailstrike.com/270806.pdf. Retrieved 2010-03-22. 
4. ^ N431CA FAA registration certificate, retrieved June 19, 2008. (Note: CL600-2B19 is the official designation of the CRJ100).
5. ^ "NTSB Preliminary Report DCA06MA064". National Transportation Safety Board. http://www.ntsb.gov/ntsb/brief.asp?ev_id=20060828X01244. Retrieved 2006-08-27. 
6. ^ "AirNav runway information for KLEX". AirNav. http://www.airnav.com/airport/KLEX#rwys. Retrieved 2006-08-28. 
7. ^ ^{a b c} "Report of Aviation Accident, Comair Flight 5191, NTSB/AAR-07/05". National Transportation Safety Board. http://www.ntsb.gov/doclib/reports/2007/AAR0705.pdf. Retrieved 2007-07-26. 
8. ^ ^{a b} Dave Hirschman. "Comair flight almost made it". Atlanta Journal-Constitution. http://www.airportbusiness.com/web/online/Top-News-Headlines/Comair-Flight-Almost-Made-It-Mystery-Deepens/1$7824. Retrieved 2006-08-31. 
9. ^ "NTSB: LEX Controller Had Two Hours Of Sleep Prior To Accident Shift". Aero-News Network. http://www.aero-news.net/index.cfm?ContentBlockID=e6b42893-a854-45eb-be87-f7fd6731a813. Retrieved 2006-09-01. 
10. ^ ^{a b} Wald, Matthew L. (2007-01-18). "Crew Sensed Trouble Seconds Before Crash". The New York Times. http://www.nytimes.com/2007/01/18/us/18crash.html. Retrieved 2007-01-17. 
11. ^ "Coroner: Most Victims Died on Impact". Associated Press. http://www.wave3.com/Global/story.asp?S=5341096. Retrieved 2006-08-29. 
12. ^ Comair. "Passenger Manifest for Flight 5191". http://www.comair.com/comair/cdc.portal?_nfpb=true&_pageLabel=cdc_pg_0021&newsNodeId=%2FComairDotComRepository%2Fcdc%2Fnews%2F5191+Passenger+Manifest&_nfls=false. ^{[dead link]}
13. ^ "Remembering Flight 5191". Lexington Courier-Journal. August 2007. http://www.courier-journal.com/apps/pbcs.dll/article?AID=/99999999/NEWS01/60828021&theme=COMAIR&template=theme. 
14. ^ Mark Pitsch (August 31, 2006). "Several hundred attend memorial service at Lexington Opera House". The Courier-Journal (Louisville). http://www.courier-journal.com/apps/pbcs.dll/article?AID=2007101240073. 
15. ^ Linda Blackford and Amy Wilson (September 3, 2006). "The Tragedy of Flight 5191". Lexington Herald-Leader. Archived from the original on 2007-11-14. http://web.archive.org/web/20071114164211/http://www.realcities.com/mld/kentucky/news/special_packages/crash/.  (archived from the original on 2007-11-14)
16. ^ "Comair Crash Survivor Leaves Hospital; Co-Pilot, The Lone Survivor Of Kentucky Plane Crash, To Begin Rehabilitation". CBS News. 2006-10-03. http://www.cbsnews.com/stories/2006/10/03/national/main2059120.shtml. Retrieved 2006-10-03. 
17. ^ "'A horrendous, horrendous tragedy all around'". courier-journal.com. http://www.courier-journal.com/apps/pbcs.dll/article?AID=/20070826/NEWS01/70824042. Retrieved 2008-03-05. 
18. ^ Ortiz, Brandon (2007-08-28). "Polehinke Files Suit in Crash: Remembering flight 5191". AccessMyLibrary. http://www.accessmylibrary.com/coms2/summary_0286-32739321_ITM. Retrieved 2009-09-11. 
19. ^ Comair passengers blamed in crash
20. ^ "FAA memorandum concerning staffing levels". http://www.globalaviationlaw.com/pdf/faa_staffing.pdf. ^{[dead link]}
21. ^ "FAA: Tower staffing during plane crash violated rules". CNN. http://www.cnn.com/2006/US/08/29/plane.crash/. Retrieved 2006-09-06. 
22. ^ "Judge orders halt to airport construction". Lexington Herald-Leader. http://www.kentucky.com/425/story/10770.html. Retrieved 2006-09-15. 
23. ^ The hold-short line is the demarcation between the runway and taxiway.
24. ^ "NTSB safety recommendations A-06-83/84". NTSB. http://www.ntsb.gov/recs/letters/2006/a06_83_84.pdf. Retrieved 2008-06-25. 
25. ^ "NTSB Advisory". NTSB. http://www.ntsb.gov/Pressrel/2007/070112.htm. Retrieved 2007-01-17. 
26. ^ "NTSB safety recommendations A-07-30/31/32". NTSB. http://www.ntsb.gov/recs/letters/2007/A07_30_32.pdf. Retrieved 2008-06-26. 
27. ^ "NTSB safety recommendation A-07-34". NTSB. http://www.ntsb.gov/recs/letters/2007/A07_34.pdf. Retrieved 2008-06-26. 
28. ^ Instructors Testify Flight 5191 Crew Erred Before Crash (Associated Press) - wkyt.com - Obtained April 12, 2011, published, July 19, 2007.
29. ^ "Transportation Update July 2008". Business.cch.com. http://business.cch.com/updates/transportation/july2008.htm. Retrieved 2010-07-09. 
30. ^ DE 3706
31. ^ http://opinions.kycourts.net/sc/2007-SC-000602-TG.pdf
32. ^ ^{a b} Voreacos, David (2009-12-23). "U.S. Helped Delta Insurers Pay $264 Million Crash Settlements - Bloomberg". Preview.bloomberg.com. http://preview.bloomberg.com/apps/news?pid=newsarchive_en10&sid=aOkG3OyIq1F0. Retrieved 2010-07-09. 
33. ^ DE 3710^{[dead link]}
34. ^ Hewlett, Jennifer (2010-04-20). "Judge sets July date for Comair trial - Courts". Kentucky.com. http://www.kentucky.com/2010/04/20/1230882/trial-set-to-decide-on-punitive.html. Retrieved 2010-07-09. 
35. ^ DE 3550^{[dead link]}
36. ^ "Judge rejects pursuit of punitive damages in Comair case" Kentucky.com 3 February 2011 Retrieved 24 March 2011
37. ^ "NTSB Press Release, July 7, 2007". National Transportation Safety Board. http://www.ntsb.gov/Pressrel/2007/070726.htm. Retrieved 2007-07-26. 
38. ^ "Comair pilot's widow: His death's a blessing". USA Today. 2007-08-18. http://www.usatoday.com/travel/flights/2007-08-18-comair_N.htm. Retrieved 2010-03-22. 
39. ^ "NASA Aviation Safety Reporting System report #256788". NASA. http://www.37000feet.com/report/256788. Retrieved 2008-06-18. 
40. ^ "NASA Aviation Safety Reporting System report #722668". NASA. http://www.37000feet.com/report/722668. Retrieved 2010-04-02. 

External links

• Comair Press Releases
• Comair's future in doubt after crash
• Pictures of the wreckage
• Timeline for Flight 5191

Coordinates: 38°02′16″N 84°36′55″W / 38.0379°N 84.6154°W / 38.0379; -84.6154