Why Did Comair 5191 Takeoff from the Wrong Runway?
In the early morning hours of August 27, 2006, Comair Flight 5191 crashes at the end of a runway at Lexington’s Bluegrass Airport. NTSB Investigators soon discover the plane tried to takeoff from the wrong runway. The investigation into the crash reveals the pilot error as the probable cause. The pilots shockingly missed important cues that would have told them they were lined up with the wrong runway. Ultimately, the legacy of this complex crash teaches us about the complexities – and dangers – of confirmation bias.
Comair 5191 Tries to Takeoff from the Wrong Runway
At around 5:15 AM on the morning of August 27, 2006, Captain Jeffrey Clay and First Officer James Polehinke arrive at Blue Grass Airport in Lexington, KY. After checking in, they begin their pre-flight tasks, which include reading and reviewing information about the day’s weather, important safety-of-flight notices, and the flight plan. So far, their day is going right according to plan as they make their way toward the aircraft they will be flying today, which will be known as Comair Flight 5191, headed for Atlanta.
There is already much about this day that is very familiar and routine for these experienced pilots. Captain Clay has been with Comair since 1999, and in total, he has accumulated 4,710 hours of total flying time, including 3,082 hours on the Bombardier CRJ-100 aircraft and 1,567 hours as a pilot-in-command (PIC). The First Officer was hired by Comair in 2002 and is also highly experienced, having accumulated 6,564 hours of total flying time, including 940 hours as pilot-in-command (PIC) and 3,564 hours on the aircraft.
The plane they would be flying was a Canadian-made Bombardier CRJ-100, a popular short-range jet with two tail-mounted engines and room for 50 passengers. And with a full flight today, the captain and first officer focus on being prepared for an on-time departure for Atlanta at 6:05 AM. As passengers board the plane, the pilots are busy completing important pre-flight checklists.
At this time in August 2006, Blue Grass Airport was nearing the completion of a multiyear construction project, which included shifting one runway 325 feet to make room for a longer runway safety area. The airport at the time had one runway for smaller aircraft and a longer runway for commercial carriers. About one week before this flight, the airport had closed to resurface and paint new markings on one of the runways and change taxiway connector signage.
Finally, on August 20, a week before the flight, the airport reopened, and a safety-of-flight notice was issued to announce the ongoing closures of certain taxiways marked by low-profile barricades with flashing red lights. And, of course, while this construction work was perhaps a nuisance, it should not impact on departing flights like 5191, which is about to takeoff.
In the tower at Blue Grass Airport is a single air traffic controller at the helm who will be responsible for all tower and radar positions. And so, a little before 6:00 AM, the controller informs the crew of Flight 5191 that they are cleared for takeoff to Atlanta and should maintain 6,000 feet.
Soon after, Captain Clay and First Officer Polehinke prepare to taxi and discuss which of them will be flying the leg to Atlanta. Captain Clay graciously offers the flight to the first officer, and the first officer accepts.
About one minute later, during the takeoff briefing in the cockpit, First Officer Polehinke makes a statement that sounds like he is seeking clarification: “he said what runway … two four” to which Captain Clay corrects him by saying, “it’s two two.”
And then First Officer Polehinke continues with the takeoff briefing. And one of the final things the pilots do is to adjust their heading bugs to correspond to the magnetic heading for runway 22. Again, all of this is customary for takeoff.
At 6 AM, the pilots start the plane’s engines and notify ATC that Flight 5191 is ready to taxi from the gate, to which the controller responds by directing them to the runway. To get there, Flight 5191 will cross the very beginning of runway 26 (the intersecting runway reserved for smaller aircraft) without stopping to make their way to a stop position for runway 22. First Officer Polehinke responds with a confirmation, “Taxi two two”, indicating the runway from which they will takeoff.
Next, Captain Clay calls for the taxi checklist, which they complete. As Captain Clay is currently still controlling the plane, he stops the airplane at a holding position, commonly referred to as the hold short line. A hold short line is a painted marking on a taxiway at a runway intersection that indicates where an airplane is to stop if instructed to do so by air traffic control. As they wait for other flights to takeoff from the runway, the captain and first officer make small talk about opportunities for advancement at Comair. First Officer Polehinke also begins the before takeoff checklist and indicates the runway they’ll be taking off from. While they stop here at this hold short line, First Officer Polehinke addresses the passengers in the cabin and welcomes everyone onboard.
Then, ATC finally clears them for takeoff.
Captain Clay taxis the plane across the runway short hold line and calls for the lineup checklist at the same time. He also makes a sharp left turn onto the runway, and that is when the Captain gives control over to the First Officer, who will now be the pilot flying.
Soon, Flight 5191 is accelerating down the runway. It is still early morning at this time, a little after 6 AM, and it is very dark outside the cockpit windshield. So dark in fact that, that as they are accelerating near a pace of 120 mph, First Officer Polehinke remarks, "There is no lights" referring to a lack of lighting on the runway. And Captain Clay notices the same lack of lighting and remarks back to the first officer with a "Yeah”.
This is right before it becomes evident to both pilots that something is wrong with the runway they are now– it should not be this dark. In fact, it was hard to see the end of the runway – there was simply no lighting. And then, most likely very suddenly, things come into focus for Captain Clay. He realizes they are about to run out of runway surface area; he calls for rotation well before reaching the speed at which they would normally start to lift off. Captain Clay exclaims, “Whoa!” while First Officer Polehinke immediately pulls his control column all the way back in a desperate attempt to climb. But it is no use. The aircraft speeds off the end of the runway without lifting off. Traveling at almost 200 mph, Flight 5191 bounces across the grass overrun area at the very end of the runway.
A split second later, the main landing gear smashes into an earthen berm 260 feet past the end of the runway, and the plane momentarily becomes airborne.
Inside the cockpit, stall warnings blare as the pilots shouts out various unintelligible words and expletives in surprise and terror. The tail section of the plane next clips the airport perimeter fence with its landing gear, then the plane briefly touches down in a field before bouncing back into the air. It next collides with trees, the impact of which causes the plane’s fuel tanks to erupt into a massive ball of flames and causes the fuselage and cockpit to be torn away from the tail. The aircraft finally comes to a stop in separate pieces on the ground about 1,000 feet (300 m) from the end of the runway, all but one of the sections submerged in a raging fire.
Everyone Onboard Comair 5191 Perishes – Except for the First Officer
The impact with the berm and the trees instantly kills many of the 50 people on board, including Captain Clay, who is ripped out of the cockpit from underneath and thrown into the passenger cabin. Most of the remaining passengers and crew survive the trauma of the initial impacts with the berm and the trees, but never had any chance of escaping the burning inferno of the fuselage. Within a very short period, likely 30 seconds or less, the rest of the passengers perish in the smoke and flames, some from thermal injuries (i.e., the scientific way to say they burned to death) or from smoke inhalation. During the subsequent recovery of the wreckage, many of the passengers’ bodies are found close to their seats, indicating that there simply was not enough time for them to escape the plane before they succumbed to the smoke and fire.
But there is a sole survivor. When the first emergency rescuers arrive at the scene, the only part of the plane they did not find on fire was the cockpit, and this is where they discover an unconscious First Officer Polehinke still strapped into the shattered remains of his seat. Rescuers work quickly to extract him from the cockpit, and it is immediately evident that the First Officer has grave injuries. Fearing he will die, one of the police officers drive the First Officer to the hospital right away in the police SUV instead of waiting for an ambulance.
Meanwhile, firefighters arrive at the crash site and work quickly to bring the fire under control. Amid the smoldering wreckage, they come to the grim conclusion that the First Officer is indeed the only one to survive: the remaining 47 passengers and 2 crew have all perished.
NTSB Investigation into Comair 5191 Crash Focuses on Performance of Pilots
Immediately, investigators from the National Transportation Safety Board (NTSB) arrive at the crash site and examine the wreckage for answers as to why the plane crashed. After studying the engines and flaps, investigators find that the engines are all working properly, and the flaps were extended in the correct positions. And after reviewing all the flight data about aircraft performance, investigators conclude that the plane was performing effectively all the way up to the very end– the recovered components show no evidence of any structural, mechanical, engine, or system failures. Investigators also quickly rule out weather as a contributor to the crash. No restrictions to visibility occurred during the airplane’s taxi to the runway and the attempted takeoff.
But statements from eyewitnesses begin to bring the potential cause of the crash into clear view. One eyewitness is an American Eagle station agent who was on a ramp by a gate when Flight 5191 taxied past at a normal taxi speed. The station agent saw Flight 5191 make a sharp turn to the left– instead of a slight, turn to the left. The station agent thought at the time that the flight crew of 5191 must be returning to the gate based on the left turn they made. But then he realized that the airplane was taking off from runway 26, which was the runway reserved for short aircraft, instead of runway 22, the runway reserved by commercial jets.
Investigators have confirmed through this eyewitness statement and the location of the wreckage that Flight 5191 indeed tried to take off from the wrong runway. But how did something like this happen?
Did Air Traffic Control Have a Role to Play in Crash of Comair 5191?
One of the many factors that investigators consider is the accuracy and specificity of the directions the pilots received from air traffic control. Remember, there was a single controller in the tower at the time of the crash. Upon being interviewed after the accident, the controller confirmed there was nothing unusual about the Comair flight or the clearance and the pilots did not seem to be rushed.
The controller said he saw the Comair jet make a turn toward what he “presumed to be [runway] 22,” but this turn toward the runway happened to be the last time he observed the airplane. Why? Because soon after, he turned away from the tower windows (which overlook the runway) and faced the tower’s center console to begin an administrative task that he was required to complete before the end of his shift, which was coming up. This task was to perform the traffic count (that is, a count of the hourly air traffic operations, as recorded on flight progress strips, during his shift).
He recalled that, while performing this task, he heard a noise, saw fire west of the airport, and contacted the airport’s operations center and airport rescue and firefighting teams. The controller conceded that it might have been possible for him to detect that Flight 5191 was on the wrong runway if he had been looking out the tower window. This fact becomes one of the many “what ifs” in this story: what if he had seen the aircraft turn onto runway 26, would he have been able to cancel the takeoff in time and help prevent the disaster? And more importantly, had another controller been in the tower with him, would that individual have noticed, or would that have eased his workload?
When investigators share with the controller that Flight 5191 has taken off from runway 26 instead of runway 22, he simply could not believe it was true. It was just too astonishing, and in his 17 years as an air traffic controller, he had never heard anything like this happening before.
After completing their interviews with the controller, the NTSB concludes that the controller did not detect the flight crew’s attempt to take off on the wrong runway because, instead of monitoring the airplane’s departure, he performed a lower-priority administrative task that could have waited until he transferred responsibility for the airplane to the next ATC facility.
Following the crash, in response to the revelation that the controller had ended his observation of the Flight 5191 to perform administrative tasks, the Lexington air traffic control tower issued a notice to all its personnel stating that “a takeoff clearance for Runway 22 shall not be issued until the aircraft has been physically observed having completed a crossing of Runway 26.” The notice indicated that the amended procedure was “an effort to add a layer of safety … and avoid pilot confusion.”
During the course of the investigation, it was discovered that tower staffing levels at Blue Grass Airport violated an internal policy as reflected in a November 2005 memorandum requiring two controllers during the overnight shift: one performing tower duties, and another, either in the tower or remotely at the nearby Indianapolis Center, working radar. The controller on duty the morning of the accident was performing both tower and radar duties. On August 30, 2006, just three days after the crash of Flight 5191, 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.
Ultimately, and despite the issues uncovered during the interviews with air traffic control, the NTSB did not believe the controller was accountable for the crash of Flight 5191.
Investigators Uncover Pilot Errors Leading Up to Comair 5191 Takeoff
Investigators next seek to retrace all the steps completed and events that happened during the taxi and attempted take off sequence.
The first thing that investigators notice is how the taxi briefing was conducted. The purpose of the briefing is to incorporate Comair standard taxi information, including that both flight crewmembers should have the appropriate airport diagrams out and available and that traversing runways required extra diligence. Comair standard taxi information was to be briefed in its entirety for the first leg of a flight as a crew and could be abbreviated to “Comair standard” for subsequent flights.
Flight 5191 was the pilots’ first flight as a crew, but, despite that fact, Captain Clay stated they would use the abbreviated taxi briefing on this first flight. This means the captain and first officer did not discuss all the information in that portion of the taxi briefing, including that runway 26 was to be crossed while navigating to runway 22. And, during the first officer’s take off briefing, he did not mention that the taxi to runway 22 required crossing runway 26. However, during post-accident interviews, other pilots indicated that they would brief this “short taxi” briefing in a similar manner, and no evidence indicated that the pilots were unaware of the need to cross runway 26 to arrive at runway 22.
Even though this abbreviated approach was used, the NTSB felt that there were tons of other cues that were missed by the pilots that would have clearly indicated they were on the wrong runway.
The controller had directed the crew of Flight 5191 to proceed to runway 22 without stopping. But the crew did stop – at the hold short line for runway 26, instead of going straight to the next hold line, which was for runway 22. The hold short line for runway 26 was about 560 feet from the hold short line for runway 22. But because two flights right before Comair 5191 were given the same taxi clearance and had already correctly taxied to and held short of runway 22 without any special instructions, the NTSB did not think the controller should have any reason to believe the pilots of the Comair jet would have misunderstood how to effectively navigate to the departure runway.
And while the plane waited at the hold short line for runway 26, the pilots had a 50-second timeframe during which the crew would have had ample time to look outside the cockpit and determine the airplane’s position on the runway. At this position, the flight crew would have been able to see the runway 26 holding position sign, the “26” painted runway number, the taxiway A lights across runway 26, and the runway 22 holding position sign in the distance.
The flight crewmembers also had resources available to them within the cockpit to support their navigation to runway 22, including the airport chart. Even though discrepancies existed between the airport chart and the external cues available to the pilots because of the current, ongoing construction project at the airport, the chart depicted the paved taxiway and runway surfaces at the time of the accident. Another available resource within the cockpit was the instrumentation, including the heading bug, which had been set to correspond to the magnetic heading for runway 22. This heading information, which was clearly presented on the control panel, would have provided the pilots with a real-time cue of their orientation relative to runway 22.
The CVR recording showed that the flight crew had referred to runway 22 as the departure runway multiple times before takeoff, and as they began takeoff roll, First Officer Polehinke made a remark about the lack of runway light illumination, but despite this acknowledgement, the takeoff was continued anyway.
For all these reasons, the NTSB concludes that the captain and the first officer believed that the airplane was in fact on runway 22 when they instead taxied onto runway 26 and initiated the takeoff roll. The NTSB releases the probable cause of the crash of Flight 5191as pilot error. But any time pilot error is the probable cause, the NTSB seeks to understand how the error occurred so that this situation can be used for other pilots’ learning.
NTSB Says Comair 5191 Pilots Violate Sterile Cockpit Rule, Were Distracted
There is no “smoking gun” laid out in the NTSB’s report as to WHY the pilots thought they were on the correct runway when they were, in fact, not.
One dynamic within the cockpit stands out to investigators: the nonessential, non-flight-related conversation that occurred 40 seconds out of the 150-second taxi time. The timing of this discussion and its duration are the most salient evidence from the NTSB’s perspective to demonstrate that neither pilot was experiencing high workload at the time or considered the taxi to runway 22 to be a challenging task. However, as we understand from numerous human performance studies in aviation, we all have limited attention resources, and, when distracted by conversation, both real-time processing of information and prospective memory (that is, remembering to do something at a later time) can suffer.
With this context, investigators consider how non-flight-related conversation might have impacted these pilots’ concentration and task orientation during the flight. The first officer initiated the nonessential conversation as the captain was navigating along the taxi route. The captain had the responsibility to stop the discussion; but instead, the captain allowed the conversation to continue and even participated in it. As we may recall from previous episodes, the sterile cockpit rule is in place to ensure that during critical phases of the flight, only activities required for the safe operation of the plane may be carried out by the flight crew. This would essentially prohibit any nonessential conversation below 10,000 feet.
Also, instead of initiating the nonessential conversation, the first officer should have been monitoring the captain’s actions and independently assessing the airplane’s location along the taxi route.
The NTSB claims that the flight crewmembers’ nonessential conversation during the taxi, which was not in compliance with Federal regulations and company policy, likely contributed to their loss of positional awareness. It is important to note that the CVR did not record any statement by either flight crewmember about this loss of positional awareness – this is all based on the investigation and what we know about human performance error.
Confirmation Bias Contributed to the Crash of Comair 5191
Let’s dive deeper into the psychological concepts surrounding human performance error that affect perception and decision-making. Despite many indicators that told them they were on the wrong runway, the pilots of Flight 5191 made a false assumption that turned out to be catastrophic.
One of the well-known psychological concepts that would allow a person’s mistaken assessment to persist is called confirmation bias, which occurs when people seek out or observe elements in their environment that support their perception. Specifically, confirmation bias stems from a tendency for people to primarily seek out confirming evidence of a belief while spending less effort to seek out negative evidence that can disconfirm the belief. Confirmation bias can cause a person to persist in holding an incorrect belief despite the availability of contradictory evidence.
For the flight crew of Comair 5191, confirmation bias was in place not only at the hold short line for runway 26 but also during the initial acceleration down the runway because the crew did not evaluate evidence that would contradict the airplane’s position on the airport surface at the time. Many cues indicated that they were not about to taxi onto runway 22. These cues included the runway holding position sign for runway 26, the fact that they turned onto a runway (runway 26) with a 75-foot painted width versus the 150-foot width of runway 22, and the absence of runway edge lights and precision runway markings on runway 26. However, once the flight crewmembers had navigated to what they believed was the correct runway, they were likely no longer giving strong weight to contradictory information as a result of confirmation bias, according to the NTSB.
At the time that the first officer began to increase thrust for takeoff, FDR data showed that the magnetic heading of the airplane corresponded to the magnetic heading for runway 26. As shown in the figures, the heading bug was offset by 40º, providing a salient visual cue that the airplane was not lined up on the correct departure runway. The magnetic heading indicator, which was on their flight control panel, would have clearly shown the heading for runway 26. The CVR did not record any awareness by the flight crewmembers about this offset, which means we have to assume they did not notice this, or if they did, it had no impact on changing their decision making.
Other errors included the flight crew boarding the wrong airplane when they first arrived at the airport early that morning, the first officer asking during his takeoff briefing about the runway in use and referred to it as “two four,” the first officer repeating some items on the before starting engines checklist after having already completed it, and the first officer misidentifying the flight as “Comair one twenty one” when informing the controller that the flight was ready to depart. In addition, the CVR recorded the first officer using a yawning voice for two consecutive statements.
But here is what makes this complicated. A review of records relating to both men and Comair could find nothing wrong with their performance, their training, the airline, or its federal oversight. The investigation had to look at subtler factors that could have misled the pilots in the critical minutes while they taxied to the runway.
There was, of course, the violation of the sterile cockpit rule — but as investigators and pilots willingly admit, the sterile cockpit rule is violated all the time. Although media reports made much of their non-pertinent conversation, in truth it could hardly be described as a scandal, and it certainly didn’t cause the crash all on its own.
And pilots of other flights had misunderstood where they were on the runways of Blue Grass Airport. In January 2007, just five months after the crash of Comair 5191, a Learjet was cleared to take off at Blue Grass Airport on runway 22, but mistakenly turned onto runway 26. Luckily, takeoff clearance was canceled by the local controller before that plane began its takeoff roll.
And these examples are not the only ones. According to the NTSB, between 1988 and 2006, it had 114 similar cases on record in the US alone. This figure included one case at Lexington Airport: in 1993, a flight cleared to take off from runway 22 instead lined up for runway 26, but an accident was prevented when the crew checked their heading bugs and realized they were facing the wrong way. The pilots of that flight later described that part of the airport as “confusing,” an assessment with which airport employees agreed.
NTSB Chairman Mark Rosenker said of the Comair 5191 investigation, "this was not a simple investigation because we were dealing with complex human performance issues…Accidents involving human performance can present a difficult challenge as investigators strive to understand the factors that explain why an error occurred, such as inattention. In many cases, a probe of human error does not yield a singular cause because available data is often not specific or testable as when examining aircraft component failure.”
Families of Victims File Suit Against Comair
Families of 45 of the 47 passengers sued Comair for negligence. (Families of the other two victims settled with the airline before filing litigation.) But the trial was indefinitely postponed in 2008 after Comair reached a settlement with the majority of the families.
In addition to these legal actions, there is also a memorial established for the victims of Flight 5191. The sculpture is of 49 silver birds taking flight and is located at the arboretum at the University of Kentucky. The only name missing from the memorial is that of the First Officer, the crash’s sole survivor.
Comair 5191 Sole Survivor Learns to Live Again
First Officer James Polehinke’s life will never be the same and he battles both physical and psychological scars. After being pulled from the wreckage, he suffered serious injuries, including multiple broken bones, a collapsed lung, and severe internal bleeding. His brain damage was the reason for why he could not remember the crash – due to the trauma, he could recall nothing after lining up on the runway.
His injuries from the crash also forced the amputation of his left leg, and he lost motor control over his right leg due to spinal cord damage. He will never walk again – he is today confined to a wheelchair. Following the accident, First Officer Polehinke went into a deep depression over not just his life-changing injuries but also the fact that the deaths of 49 people weigh heavily on his shoulders. The guilt at times, according to Polehinke himself and friends interviewed for Comair Flight 5191 anniversary specials, has been unbearable.
And the former first officer doesn’t think he’ll ever forgive himself. He said, “The people that came on board the plane were my responsibility,” admitting that he failed them. But the depression and anger that he faced in the first years after the crash eventually gave way to a frank acceptance that he had survived, and that he had best make use of this second chance at life.
Starting in 2012, Polehinke made it his life goal to ski in the Paralympics. A veteran of the U.S. Navy, he remains naturally competitive and athletic, which, combined with the love of speed he enjoyed as a pilot, help him take a shine to alpine skiing. With Polehinke’s newfound love of skiing, he and his supportive wife Ida moved to Grand Junction, FL, where Polehinke immersed himself in adaptive athletics, eventually becoming the president of Colorado Discover Ability, an adaptive outdoor recreation nonprofit based in Grand Junction.
Aviation Changes Resulting from Comair Flight 5191
Following the crash of Comair Flight 5191, the NTSB called for the need for (1) improved flight deck procedures, (2) the implementation of cockpit moving map displays or cockpit runway alerting systems, (3) improved airport surface marking standards, and (4) ATC policy changes in the areas of taxi and takeoff clearances and task prioritization.
In the heart of where the disaster happened, the most direct change occurred as a result of the crash: Blue Grass Airport implemented a change so that short runways no longer intersect with longer ones.
The FAA Fails to Follow a Key NTSB Recommendation from Comair Flight 5191 Investigation
While many general aviation and business aircraft are now equipped with advanced GPS-based navigation aids, such devices are relatively uncommon in large commercial airliners. With the exception of iPads or other tablets replacing pilots’ paper charts in the cockpit, little has changed. The only primary key recommendation that the FAA still has not adopted is to require that all aircraft be equipped with moveable map technology on GPS devices, similar to navigation aids that give drivers turn-by-turn directions. According to the NTSB, there is no question that technology exists and is available for commercial aircraft.
The FAA declined to make this technology a requirement. Ultimately, the FAA decided to make the technology voluntary. It was the only recommendation the board made from the Kentucky crash that the FAA did not adopt. The reason seems to be related to the costliness of the technology, which because of the cost, the technology is almost only available on the newest model commercial aircraft.
After several years of back-and-forth with regulators, the NTSB closed the recommendation in 2014 and classified it as an “unacceptable action.”
And THAT is the frustrating, complex, and heartbreaking story of Comair Flight 5191.