NTSB releases cockpit voice recording transcripts in Comair 5191 investigation
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NTSB releases cockpit voice recording transcripts in Comair 5191 investigation
January 18, 2007
On Wednesday, the National Transportation Safety Board released transcripts of cockpit voice recordings that indicate the pilots of Comair Flight 5191, which crashed in Lexington, Ky. last August 27, knew something was unusual about their early-morning takeoff from Blue Grass Airport.
Tragically, they didn't realize the mistake in time to prevent the deaths of 49 of the 50 people onboard.
The NTSB report said there was laughing, yawning and general ease in the cockpit as Capt. Jeffrey Clay of Burlington, Ky., and First Officer James M. Polehinke of Margate, Fla., chatted about kids, dogs and fellow pilots while running through checklists.
According to cockpit voice recordings, 17 seconds before impact copilot Polehinke noted it was "weird" that the runway they were on had no lights. The captain, Clay, responded "Yeah."
The Comair jet attempted takeoff from Runway 26 at Blue Grass Airport, instead of Runway 22 as instructed by the tower. At 3,500 feet in length, Runway 26 is half the length of Runway 22, and was too short for the fully-loaded regional jet.
Runway 26 is used only by smaller planes at Blue Grass Airport and is not approved for night operations.
In the transcript, Polehinke asked Clay to verify the correct runway minutes before 5191 started its takeoff roll, as part of preflight checks.
"Right seat flex takeoff procedures off of ummmm ... he said what runway? One of 'em. Two four," Polehinke said.
"It's two-two," Clay responded, indicating Runway 22, which was the correct runway.
The transcripts also showed that Clay and Polehinke failed to maintain a sterile cockpit during taxi for takeoff, discussing topics including their work conditions and families.
"Both kids were sick though, they, well they all got colds," Clay told Polehinke while he taxied the aircraft for takeoff. "It was an interesting dinner last night."
Clay lined up the Bombardier CRJ-100 on Runway 22, then turned the controls over to Polehinke for take off.
According to the transcript, the last understandable words came from Clay just one second before the crash, when he called out V-1 rotation speed, followed by a single word: "Whoa."
The subsequent crash killed Clay, 47 passengers and one flight attendant, Kelly Heyer, from Cincinnati. Polehinke, the sole survivor, suffered brain damage and his left leg was amputated following injuries sustained in the accident. He reportedly does not remember any details related to the crash.
Comair spokeswoman Kate Marx said the transcript does not by itself indict the plane's pilots, and noted the NTSB has not issued its analysis of the accident.
"The transcript does make it clear the crew did not follow Comair's sterile cockpit policy," said airline spokeswoman Kate Marx. "It is unclear what role, if any, this played in the accident, so it would be premature to determine that."
Other documents released by the NTSB show the tower controller on duty at the time of the accident initially had told investigators he watched the plane taxi to the correct runway, but later changed his statement to say he had not watched the plane taxi to Runway 26.
"After the review of my original personnel statement, I did not watch Com191 take Runway 22," wrote controller Christopher Damron. "I saw Com191's position on Taxiway A, heading for Runway 22. I then cleared Com191 for takeoff. I saw Com191's lights turning toward Rwy 22. I turned around to do the traffic count, heard a crash and saw a fireball west of the airport."
The documents do not state what prompted Damron to change his statement.
While the safety board likely will take several months to determine a probable cause, the report revealed that the pilots committed errors.
Most notably, they failed to conduct a taxi briefing. During this briefing, pilots review any trouble spots on the airport grounds to ensure they reach the correct runway. This error occurred in spite of the airport's alert through a radio recording that construction could make the airport's taxiways tricky to navigate.
In addition, the Comair pilots failed to verify that their compass reading coincided with the direction of the runway. They were assigned take off on the 7,000-foot Runway 22, so compass readings should have been about 220 degrees. Instead, they lined up on Runway 26, which has a reading of about 260 degrees.
The pilots' conversations about matters nonessential to the flight also violated procedures.
In 1981, the Federal Aviation Administration approved the "sterile cockpit rule" that forbids extraneous conversation during taxi, takeoff and landing.
NTSB investigators also examined whether the two pilots might have been tired. Fatigue is a factor in many accidents. A transcript of the cockpit conversation indicated that Polehinke was yawning.
Yet several witnesses have said the two pilots appeared wide awake when they checked into the Comair's flight operations office at 5:15 a.m.
However, there were hints that Clay and Polehinke were distracted. The two initially boarded the wrong plane and started up its auxiliary power unit before ramp agents alerted them to the mistake.
After the accident, toxicology reports showed that the pilots did not have alcohol or "major drugs of abuse" in their systems.
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