Table of Contents I. EXECUTIVE SUMMARY................................................................................................................................1 A. HISTORY OF FLIGHT ........................................................................................................................................1 B. OVERVIEW .......................................................................................................................................................2 C. LEXINGTON AIRPORT.......................................................................................................................................2 D. NOTICES TO AIRMAN (NOTAMS)...................................................................................................................2 E. HUMAN PERFORMANCE CONSIDERATIONS.......................................................................................................3 F. AIR TRAFFIC CONTROL ....................................................................................................................................3 G. SURVIVAL FACTORS.........................................................................................................................................3 H. TECHNOLOGICAL ADVANCES...........................................................................................................................4 II. THE ACCIDENT AIRCRAFT’S TAXI ROUTE ...........................................................................................5 III. LEXINGTON AIRPORT .............................................................................................................................7 A. CONSTRUCTION................................................................................................................................................7 1. June 2006: Changes to Airport Construction Plan ....................................................................................7 2. Jeppesen Chart Production Software Malfunction.....................................................................................8 3. Charting and Signage Discrepancies .........................................................................................................9 4. Positional Uncertainty..............................................................................................................................10 B. NOTAMS......................................................................................................................................................13 C. RECOMMENDATIONS......................................................................................................................................18 IV. HUMAN FACTORS/OPERATIONS........................................................................................................19 A. EXECUTIVE SUMMARY OF HUMAN PERFORMANCE........................................................................................19 B. HUMAN PERFORMANCE CONSIDERATIONS.....................................................................................................20 1. Situational Awareness ..............................................................................................................................20 2. Threat and Error Management.................................................................................................................22 3. The Accident Flight Crew.........................................................................................................................23 a) The Captain .......................................................................................................................................................... 23 b) The First Officer................................................................................................................................................... 24 4. A Time Line Perspective...........................................................................................................................24 a) Arrival in Lexington for each flight crew member:.............................................................................................. 25 b) Arrival at the airport ............................................................................................................................................. 27 c) Arrival at the aircraft ............................................................................................................................................ 28 d) Flight Segment One.............................................................................................................................................. 29 e) Flight Segment Two ............................................................................................................................................. 36 f) Flight Segment Three ........................................................................................................................................... 37 g) Flight Segment Four............................................................................................................................................. 41 h) Flight Segment Five ............................................................................................................................................. 47 i) Flight Segment Six ............................................................................................................................................... 54 j) Flight Segment Seven........................................................................................................................................... 61 k) Summary .............................................................................................................................................................. 66 5. Other flights the morning of the accident at Lexington ............................................................................67 a) Skywest Flight 6819............................................................................................................................................. 67 b) American Eagle Flight 882................................................................................................................................... 68 6. Recommendations.....................................................................................................................................69 V. AIR TRAFFIC CONTROL ............................................................................................................................71 A. ACCIDENT SUMMARY ....................................................................................................................................71 B. TAKEOFF CLEARANCES..................................................................................................................................71 C. NOTICES TO AIRMEN (NOTAMS)..................................................................................................................72 D. ATC STAFFING ..............................................................................................................................................74 E. CONTROLLER FATIGUE ..................................................................................................................................75 F. CONTROLLER DUTIES ....................................................................................................................................76 G. RECOMMENDATIONS......................................................................................................................................77 i VI. SURVIVAL FACTORS..............................................................................................................................79 A. AIRPORT RESCUE AND FIRE FIGHTING (ARFF) RESPONSE.........................................................................79 B. RUNWAY SAFETY AREA.................................................................................................................................85 C. RECOMMENDATIONS......................................................................................................................................86 VII. TECHNOLOGICAL ADVANCES............................................................................................................87 A. RUNWAY AWARENESS ADVISORY SYSTEM (RAAS)......................................................................................87 B. ELECTRONIC FLIGHT BAG..............................................................................................................................89 C. RECOMMENDATIONS:.....................................................................................................................................90 VIII. SIMILAR EVENTS ....................................................................................................................................91 A. LEXINGTON BLUE GRASS AIRPORT................................................................................................................91 1. Part 121 Airline Crew: November 1993...................................................................................................91 2. Learjet: January 1, 2007 ..........................................................................................................................91 3. Other Comair Crews ................................................................................................................................92