UPDATE ON NTSB INVESTIGATION INTO THE CRASH OF COMAIR FLIGHT 5191

[NTSB Press Releases <NTSBPressReleases@xxxxxxxx>]

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                       NTSB ADVISORY
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National Transportation Safety Board
Washington, DC 20594

September 25, 2006

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UPDATE ON NTSB INVESTIGATION INTO THE CRASH 
OF COMAIR FLIGHT 5191

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        On August 27, 2006, about 6:07 a.m., Comair flight 
5191, a Bombardier CRJ-100, (N431CA) crashed upon takeoff 
from Blue Grass Airport in Lexington, Kentucky. Of the 47 
passengers and 3 crewmembers onboard, 49 were fatally 
injured and one (the first officer) survived in critical 
condition. The following is an update of factual information 
developed during the Safety Board's investigation.

Washington, DC --The Safety Board has completed the on-scene 
portion of the investigation.  All of the investigative 
groups will be completing factual reports, which will be 
released to the public when the public docket is opened in 
the next several months.

Accident Sequence
Flight 5191, from Lexington, Kentucky to Atlanta, Georgia, 
was the third of three airplanes scheduled to take off in 
the early morning.  The previous two departures took off 
without incident from runway 22.  Flight 5191 was also 
cleared to taxi to runway 22 and subsequently cleared for 
takeoff; however, the airplane attempted to take off from 
runway 26.  According to recorded information, the aircraft 
began its takeoff roll, accelerated to a maximum of about 
137 knots, ran off the end of the runway through the airport 
perimeter fence, and impacted trees on an adjacent horse 
farm.  The entire sequence took about 36 seconds.  The 
airplane was destroyed by impact forces and a post-crash 
fire.  

Aircraft Wreckage 
Witness marks on scene indicate that all three landing gear 
were on the ground as the airplane exited the runway.  The 
main wreckage was located approximately 1,800 feet from the 
end of the runway.  Both engines were examined at the 
accident site and no evidence of pre-impact failure was 
noted and the thrust reversers were stowed.  The flaps were 
found in the takeoff position and no problems were noted 
with any other airplane system or structure.   The wreckage 
from flight 5191 has been moved to a storage facility in 
Georgia.  

Recorders 
The flight data recorder (FDR) and the cockpit voice 
recorder (CVR) were recovered immediately and have provided 
valuable information.  Investigators are continuing to 
extract data from the flight recorders, the air traffic 
control tape recordings and airport video surveillance 
cameras.  FDR data indicate that the airplane stopped near 
the end of runway 26 for about 45 seconds before the flight 
was cleared for takeoff.  The airplane was cleared for 
takeoff and 6 seconds later started to taxi onto runway 26. 
It took about 36 seconds for the airplane to taxi onto runway 26 
and complete the turn before power was increased to initiate 
the takeoff.  FDR vertical accelerometer data indicate that 
the airplane departed the end of the runway about 32 seconds 
after the takeoff was initiated.  The FDR recording ended 
about 4 seconds later.  Time correlation of those data 
continues.  

Operations/Human Performance
Operations/Human Performance group has completed initial 
follow-up interviews at Comair headquarters in Covington, 
KY.  The group conducted airport observations under day and 
night conditions; a simulator observation of Comair taxi and 
takeoff procedures; and interviews with multiple persons 
including: ramp personnel, flight instructors, check airmen, 
and several pilots who had flown with the accident flight 
crew.  These interviews provided investigators with 
information about procedures and techniques used by pilots 
for taxi and takeoff runway identification and information 
about the accident flightcrew.  Additionally, the Director 
of Corporate Safety for Comair and FAA personnel responsible 
for oversight of the Comair certificate were interviewed.  
The group gathered relevant documents pertaining to the 
accident flight, flight crew training and evaluation, 
operations of the CRJ100, and oversight of the airline.  
Investigators are now reviewing interview summaries and 
documentation to identify areas for further investigation 
and evaluation.   The group continues to evaluate the pilot 
actions that led to the attempted takeoff on runway 26.

Airport Information/Survival Factors
Runway 22 is 7003 feet long, 150 feet wide, and is lighted 
for nighttime use.  Runway 26 is 3500 feet long, 150 feet 
wide but marked to 75 feet wide, and is not lighted and is 
restricted to daytime use only.  In order to take off from 
runway 22 it is necessary to taxi across the end of runway 
26.  An airport construction project, begun in 2004, was 
still underway at LEX at the time of the accident.  The 
project was intended to mill and repave runway 4-22 and 
upgrade the safety areas at both ends of runway 4-22, the 
main runway.  This project necessitated changes to some of 
the taxiways and signage.  The group continues to evaluate 
the airport taxiway and runway markings, lighting and 
signage as well as additional information that was available 
to pilots.  The Airport/Survival Factors Group will also be 
documenting the factors that may have contributed to the 
loss of lives in this accident.

Air Traffic Control
At the time of the accident, there was one air traffic 
controller in the tower.  After handling several aircraft at 
the beginning of his shift, there were several hours without 
aircraft movements.  In the 20 minutes leading up to the 
accident, there were three departures, including Comair 
5191, from LEX under his control.  The ATC group has 
interviewed several Lexington control tower personnel and 
FAA air traffic personnel.  The controller on duty at the 
time of the accident relayed the following information to 
investigators: he cleared the accident flight crew to take 
off (from runway 22) and to fly runway heading (220 
degrees); after providing takeoff clearance for flight 5191, 
he turned away from the window to perform an administrative 
task (traffic count); he did not witness the accident, but 
heard the crash, turned around and saw fire, and immediately 
activated the emergency response.  As in all investigations, 
the group will review the controller's workload and duty 
schedule and the tower staffing level.  

Toxicological Test
Toxicology testing performed on specimens from both pilots 
did not detect any illicit substances or alcohol.  An over 
the counter decongestant, pseudoephedrine, was detected at a 
low level in the first officer's blood. 
     
Post Accident FAA Action
On September 1, 2006, the FAA issued a Safety Alert for 
Operators (SAFO), titled, "Flight Crew Techniques and 
Procedures that Enhance Pre-takeoff and Takeoff Safety."  
This alert highlights existing FAA aircraft ground operation 
guidance and reminds flightcrews that maximum attention 
should be placed upon maintaining situational awareness 
during taxi operations.  

   
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NTSB Media Contact:     	

Terry N. Williams
(202) 314-6100
williat@xxxxxxxx


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