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Comair 5191

Accident Case Study

Other crews have suffered similar loss of Situational Awareness and have taken off on the wrong runway. One of the advantages of airline operations, airport familiarization, can also be a detriment. The crew was used to a certain pattern at this airport and when the pattern was changed, they failed to adapt.


 

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Figure: Ground path Before Flight 5191 Aligned With Runway 26, from NTSB Report, Figure 1.

Accident Report

  • Date: 27 AUG 2006
  • Time: 06:07
  • Type: Canadair CL-600-2B19 Regional Jet CRJ-100ER
  • Operator: Comair for Delta Connection
  • Registration: N431CA
  • Fatalities:2 of 3 crew, 47 of 47 passengers
  • Aircraft Fate: Destroyed
  • Phase: Takeoff
  • Airports: (Departure) Lexington-Blue Grass Airport, KY (LEX) (LEX/KLEX), United States of America; (Destination ) Atlanta Hartsfield-Jackson International Airport, GA (ATL) (ATL/KATL), United States of America

Narrative

Weather at Lexington (LEX) was fine on the morning of August 27 (METAR for 05:54 local: KLEX 270954Z 20007KT 8SM FEW090 SCT120 24/19 A3000) with a small shower approaching from the West. It was still dark just after 06:00 as Comair flight 5191 taxied out for takeoff. The crew were cleared for a runway 22 departure, which is Lexington's main runway. Because the runway was repaved just recently with an added safety area at the approach end of runway 22, one taxiway was no longer in use. Since August 20 the taxi route to runway 22 was changed. The crew lined up on the shorter (3500 x 75 feet) and unlit runway 26. The first officer commenced the takeoff roll. One of the pilots made a remark about the lack of runway light illumination, but the takeoff was continued. The fully laden CRJ was not able to rotate within the 3500 feet runway distance and continued past the runway end. It knocked down a metal fence and continued onto a field. The airplane struck several trees and burst into flames on a working farm. NASA ASRS records show a possible similar scenario when some 13 years ago a twin engine passenger jet inadvertently taxied into position on runway 26 at LEX while being cleared for an immediate runway 22 takeoff. The tower controller noticed this and cancelled the takeoff clearance. According to the report "Possible contributing factors were poor visibility and wx (rain), confusing rwy intxn and twr's request for an immediate tkof." In the meantime work had been performed on the runways at LEX. Since October 2003 for instance a runway resurfacing project was started. The project also added 600 feet of safety area at each runway end.

Probable Cause

The flight crew's failure to use available cues and aids to identify the airplane's location on the airport surface during taxi and their failure to cross check and verify that the airplane was on the correct runway before takeoff. Contributing to this accident were the flight crew's non pertinent conversation during taxi, which resulted in loss of positional awareness and the Federal Aviation Administration's failure to require that all runway crossings be authorized only by specific air traffic control clearances.

See Also:

Call Outs

Situational Awareness

References

Aviation Safety Network

NTSB Aircraft Accident Report, AAR-07/05, Attempted Takeoff From Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, N431CA, Lexington, Kentucky, August 27, 2006

Revision: 20120314
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