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Attempted Takeoff from Wrong Runway Comair Flight 5191 Bombardier CL-600-2B19, N431CA Lexington, Kentucky August 27, 2006

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Attempted Takeoff from Wrong Runway Comair Flight 5191 Bombardier CL-600-2B19, N431CA Lexington, Kentucky August 27, 2006 Attempted Takeoff From Wrong Runway Comair Flight 5191 Bombardier CL-600-2B19, N431CA Lexington, Kentucky August 27, 2006 aviationACCIDENT REPORT NTSB/AAR-07/05 PB2007-910406 NTSB/AAR-07/05 PB2007-910406 Notation 7838E Adopted July 26, 2007 Aircraft Accident Report Attempted Takeoff From Wrong Runway Comair Flight 5191 Bombardier CL-600-2B19, N431CA Lexington, Kentucky August 27, 2006 National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 National Transportation Safety Board. 2007. Attempted Takeoff From Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, N431CA, Lexington, Kentucky, August 27, 2006. Aircraft Accident Report NTSB/AAR-07/05. Washington, DC. Abstract: This report explains the accident involving a Bombardier CL-600-2B19, N431CA, operated by Comair, Inc., which crashed during takeoff from Blue Grass Airport, Lexington, Kentucky. The safety issues discussed in this report focus on 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) air traffic control policy changes in the areas of taxi and takeoff clearances and task prioritization. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also may be obtained from the Web site or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2007-910406 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. AIRCRAFT Accident Report CONTENTS Abbreviations and Acronyms .....................................................................................vii Executive Summary .........................................................................................................x 1. Factual Information.....................................................................................................1 1.1 History of Flight .............................................................................................................................. 1 1.2 Injuries to Persons ........................................................................................................................... 7 1.3 Damage to Airplane ....................................................................................................................... 7 1.4 Other Damage ................................................................................................................................. 7 1.5 Personnel Information ................................................................................................................... 8 1.5.1 The Captain ............................................................................................................................. 8 1.5.2 The First Officer .................................................................................................................... 11 1.6 Airplane Information ................................................................................................................... 14 1.7 Meteorological Information ........................................................................................................ 15 1.8 Aids to Navigation ....................................................................................................................... 15 1.9 Communications ........................................................................................................................... 15 1.10 Airport Information .................................................................................................................... 15 1.10.1 Airport Charts ..................................................................................................................... 18 1.10.2 Air Traffic Control .............................................................................................................. 20 1.10.2.1 Lexington Air Traffic Control Scheduling ............................................................... 23 1.10.2.2 Amended Takeoff Clearance Procedure ................................................................... 24 1.10.3 Taxi Demonstrations .......................................................................................................... 24 1.10.3.1 Operations/Human Performance Observations ..................................................... 25 1.10.3.2 Air Traffic Control Tower Observations ................................................................... 27 1.10.4 Postaccident Events ............................................................................................................ 28 1.11 Flight Recorders .......................................................................................................................... 29 1.11.1 Cockpit Voice Recorder ..................................................................................................... 29 1.11.2 Flight Data Recorder .......................................................................................................... 29 1.12 Wreckage and Impact Information .......................................................................................... 30 1.12.1 Wreckage Site ...................................................................................................................... 30 1.12.2 Airplane Wreckage ............................................................................................................. 31 1.13 Medical and Pathological Information .................................................................................... 32 1.14 Fire ................................................................................................................................................ 33 1.15 Survival Aspects ......................................................................................................................... 34 1.15.1 Emergency Response ......................................................................................................... 34 1.16 Tests and Research ...................................................................................................................... 35 1.16.1 Aircraft Performance Study .............................................................................................. 35 1.16.2 Takeoff Distance and Accelerate-Stop Calculations ...................................................... 35 1.17 Organizational and Management Information ...................................................................... 36 1.17.1 Flight Manuals .................................................................................................................... 36 1.17.1.1 Taxi Procedures and Briefing ...................................................................................... 36 1.17.1.2 Checklist Usage ............................................................................................................. 37 1.17.1.3 Sterile Cockpit Procedures .......................................................................................... 38 1.17.1.4 Heading Bugs ................................................................................................................ 38 1.17.1.5 Normal Takeoff ............................................................................................................. 38 1.17.1.6 Use of Alcohol ............................................................................................................... 38 National Transportation Safety Board iii AIRCRAFT Contents Accident Report 1.17.1.7 Flight Crew Rest Periods ............................................................................................. 39 1.17.1.8 Crew Resource Management ...................................................................................... 39 1.17.2 Crew Resource Management Training ............................................................................ 40 1.17.3 Safety Program Personnel Initiatives .............................................................................. 40 1.17.4 Federal Aviation
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