aviation

Attempted Takeoff From Wrong Runway

Comair Flight 5191

Bombardier CL-600-2B19, N431CA

Lexington, Kentucky

August 27, 2006

ACCIDENT REPORT

NTSB/AAR-07/05

PB2007-910406

National

Transportation

Safety Board

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

Aircraft Accident Report

Attempted Takeoff From Wrong Runway

Comair Flight 5191

Bombardier CL-600-2B19, N431CA

Lexington, Kentucky

August 27, 2006 

NTSB/AAR-07/05

PB2007-910406

Notation 7838E

Adopted July 26, 2007
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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.
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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
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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 Administration Oversight .................................................................. 42

1.18 Additional Information.............................................................................................................. 43

1.18.1 Witness Information........................................................................................................... 43

1.18.2 Related Federal Aviation Administration Guidance .................................................... 43

1.18.2.1 Advisory Circular 120-74A.......................................................................................... 43

1.18.2.2 Safety Alert for Operators 06013 ................................................................................ 44

1.18.2.3 Certalert 07-01 ............................................................................................................... 44

1.18.2.4 Takeoff Clearance Notice............................................................................................. 44

1.18.3 Previous Related Safety Recommendations ................................................................... 45

1.18.3.1 Flight Crew Operations ............................................................................................... 45

1.18.3.2 Air Traffic Control ........................................................................................................ 47

1.18.4 Related Accident and Incidents........................................................................................ 50

1.18.5 Aviation Safety Reporting System Reports .................................................................... 53

1.18.6 Local Notices to Airmen Information.............................................................................. 53

1.18.7 Enhanced Taxiway Centerline Markings and Surface Painted

Holding Position Signs ......................................................................................................................... 54

1.18.8 Department of Transportation Inspector General Report............................................ 55

2. Analysis.......................................................................................................................57

2.1 General ........................................................................................................................................... 57

2.2 Taxi and Attempted Takeoff Sequence...................................................................................... 57

2.2.1 Wrong Runway Departure ................................................................................................. 57

2.2.1.1 Before Taxi Activities ..................................................................................................... 57

2.2.1.2 Taxi to Runway ............................................................................................................... 59

2.2.1.3 Takeoff Roll...................................................................................................................... 60

2.2.1.4 Runway Incursions......................................................................................................... 61

2.2.2 Pilot Human Factors ............................................................................................................ 61

2.2.2.1 Available Cues and Aids for Wayfinding................................................................... 62

2.2.2.2 Preflight Activities and Actions During the Taxi....................................................... 63

2.2.2.3 Cues to Indicate a Takeoff From Runway 22.............................................................. 65

2.2.2.4 Fatigue .............................................................................................................................. 69

2.2.2.5 Cockpit Discipline........................................................................................................... 72

2.2.2.6 Summary of Pilot Human Factors................................................................................ 73

2.2.3 Air Traffic Controller Human Factors............................................................................... 77

2.2.3.1 Window of Opportunity During Which the Airplane Was Stopped Short of the 

Wrong Runway.................................................................................................................................... 79

2.2.3.2 Critical Window During Which an Administrative Task Was Performed ............ 81

2.2.3.3 Fatigue .............................................................................................................................. 83

2.2.3.4 Summary of Air Traffic Controller Human Factors .................................................. 85

2.3 Survival Factors............................................................................................................................. 86

2.3.1 Impact Sequence and Injury Information......................................................................... 86

2.3.2 Emergency Response ........................................................................................................... 88

2.3.3 Summary of Survival Factors ............................................................................................. 90

2.4 Efforts to Mitigate Airport Surface Operation Errors.............................................................. 90

2.4.1 Flight Deck Procedures........................................................................................................ 91

2.4.2 Technological Initiatives...................................................................................................... 93

2.4.3 Airport Surface Marking Standards .................................................................................. 95
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2.4.4 Taxi and Takeoff Clearances............................................................................................... 96

2.4.5 Controller Monitoring Responsibility ............................................................................... 97

2.5 Air Traffic Control Staffing.......................................................................................................... 98

2.6 Other Related Issues..................................................................................................................... 99

2.6.1 Airport Charts....................................................................................................................... 99

2.6.2 Automatic Terminal Information Service Broadcasts................................................... 100

2.6.3 Local Notice to Airmen...................................................................................................... 101

2.6.4 Presence of Extended Taxiway Centerline .................................................................... 101

3. Conclusions ..............................................................................................................103

3.1 Findings........................................................................................................................................ 103

3.2 Probable Cause............................................................................................................................ 105

4. Recommendations...................................................................................................106

4.1 New Recommendations............................................................................................................. 106

4.2 Previously Issued Recommendations Reiterated in This Report ........................................ 107

4.3 Previously Issued Recommendations Resulting From This Accident Investigation........ 107

4.4 Previously Issued Recommendations Classified in This Report ......................................... 108

Board Member Statements.........................................................................................110

5. Appendixes...............................................................................................................120

A: Investigation and Hearing ................................................................................................................. 120

B: Cockpit Voice Recorder...................................................................................................................... 121

C: Blue Grass Airport Charts.................................................................................................................. 158
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Figures

1. Groundpath Before Flight 5191 Aligned With Runway 26 ........................................................ 5

1a. Groundpath as Flight 5191 Aligned With Runway 26.............................................................. 6

2. Blue Grass Airport.......................................................................................................................... 16

3. Taxiways Leading to Runways 4/22 and 8/26.......................................................................... 18

4. Injury Information According to Seat Assignment ................................................................... 33

5. Enhanced Taxiway Centerline Markings and Surface Painted Holding Position Signs...... 55

6. Multifunction Display ................................................................................................................... 67

6a. Primary Flight Display................................................................................................................. 68

7. Air Traffic Control Event Timeline .............................................................................................. 78

8. Approximate Tree Strike Areas and Injury Informatio............................................................. 87
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Abbreviations and Acronyms

AC advisory circular

ACOB air carrier operations bulletin

AFSS automated flight service station

agl above ground level

APU auxiliary power unit

ARFF airport rescue and firefighting

ARTCC air route traffic control center

ASAP aviation safety action program

ASOS automated surface observing system

ASR-7 airport surveillance radar-7

ASRS aviation safety reporting system

ATC air traffic control

ATCT air traffic control tower

ATIS automatic terminal information service

ATL Hartsfield-Jackson Atlanta International Airport

ATOS air transportation oversight system

BDL Bradley International Airport

BNA Nashville International Airport

C Celsius

CAMI Civil Aeromedical Institute

CFR Code of Federal Regulations

cg center of gravity

CRJ Canadair regional jet

CRM crew resource management

CVG Cincinnati/Northern Kentucky International Airport
Abbreviations and Acronyms

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CVR cockpit voice recorder

DBRITE digital bright radar indicator tower equipment

DOT/IG Department of Transportation/Inspector General

EFB electronic flight bag

EFIS electronic flight information system

EGPWS enhanced ground proximity warning system

EICAS engine indicating and crew alerting system

FAA Federal Aviation Administration

FDR flight data recorder

FLL Fort Lauderdale/Hollywood International Airport

FMC flight management computer

FMS flight management system

FOQA flight operations quality assurance

GRR Gerald R. Ford International Airport

Hg mercury

HOU Houston Hobby Airport

HSI horizontal situation indicator

ICAO International Civil Aviation Organization

InFO information for operators

JFK John F. Kennedy International Airport

LEX Blue Grass Airport

LOSA line operations safety audit

MAC mean aerodynamic chord

METAR meteorological aerodrome report

MFD multifunction display

MIA Miami International Airport

msl mean sea level
Abbreviations and Acronyms

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MSP Minneapolis-St. Paul International Airport

NACO National Aeronautical Charting Office

NAS National Airspace System

NATCA National Air Traffic Controllers Association

NFDC National Flight Data Center

nm nautical mile

NOTAM notice to airmen

PFD primary flight display

PIC pilot-in-command

POI principal operations inspector

RAAS runway alert and advisory system

RDU Raleigh-Durham International Airport

ROC Greater Rochester International Airport

SAFO safety alert for operators

SEA Seattle-Tacoma International Airport

SMS safety management system

S/N serial number

TCAS traffic alert and collision avoidance system

TRACON terminal radar approach control 

V1 takeoff decision speed

VFR visual flight rules

VMC visual meteorological conditions

VR rotation speed
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Executive Summary

On August 27, 2006, about 0606:35 eastern daylight time, Comair flight 5191, a 

Bombardier CL-600-2B19, N431CA, crashed during takeoff from Blue Grass Airport, 

Lexington, Kentucky. The flight crew was instructed to take off from runway 22 but 

instead lined up the airplane on runway 26 and began the takeoff roll. The airplane ran 

off the end of the runway and impacted the airport perimeter fence, trees, and terrain. 

The captain, flight attendant, and 47 passengers were killed, and the first officer received 

serious injuries. The airplane was destroyed by impact forces and postcrash fire. The flight 

was operating under the provisions of 14 Code of Federal Regulations Part 121 and was en 

route to Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. Night visual 

meteorological conditions prevailed at the time of the accident. 

The National Transportation Safety Board determines that the probable cause of 

this accident was the flight crewmembers’ 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 the 

accident were the flight crew’s nonpertinent conversation during taxi, which resulted in a 

loss of positional awareness, and the Federal Aviation Administration’s (FAA) failure to 

require that all runway crossings be authorized only by specific air traffic control (ATC) 

clearances.

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) ATC 

policy changes in the areas of taxi and takeoff clearances and task prioritization. Safety 

recommendations concerning these issues are addressed to the FAA. 
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1. Factual Information

1.1 History of Flight

On August 27, 2006, about 0606:35 eastern daylight time,1 Comair flight 5191, 

a Bombardier CL-600-2B19,2 N431CA, crashed during takeoff from Blue Grass Airport 

(LEX), Lexington, Kentucky. The flight crew was instructed to take off from runway 22 

but instead lined up the airplane on runway 26 and began the takeoff roll. The airplane 

ran off the end of the runway and impacted the airport perimeter fence, trees, and terrain. 

The captain, flight attendant, and 47 passengers were killed,3 and the first officer received 

serious injuries. The airplane was destroyed by impact forces and postcrash fire. The flight 

was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 and 

was en route to Hartsfield-Jackson Atlanta International Airport (ATL), Atlanta, Georgia. 

Night visual meteorological conditions (VMC) prevailed at the time of the accident. 

According to a customer service agent working in the Comair operations area, the 

flight crew checked in for the flight at 0515.4

 The agent indicated that the crewmembers 

were casually conversing and were not yawning or rubbing their eyes. 

The flight crew collected the flight release paperwork, which included weather 

information, safety-of-flight notices to airmen (NOTAM), the tail number of the airplane 

to be used for the flight, and the flight plan. The flight crew then proceeded to an area 

on the air carrier ramp where two Comair Canadair regional jet (CRJ) airplanes were 

parked. A Comair ramp agent, who was performing the security check of the accident 

airplane, noticed that the accident flight crew had boarded the wrong airplane and 

started its auxiliary power unit (APU). Another company ramp agent notified the flight 

crewmembers that they had boarded the wrong airplane. The flight crew then shut down 

the APU and proceeded to the correct airplane. 

The LEX air traffic control tower (ATCT) was staffed with one controller at the time 

of the accident airplane’s preflight activities, taxi, and attempted takeoff. The controller 

was responsible for all tower and radar positions.

The cockpit voice recorder (CVR) recording began about 0536:08. At that time, 

the flight crew was conducting standard preflight preparations. About 0548:24, the CVR 

1 All times in this report are eastern daylight time based on a 24-hour clock.

2 The accident airplane was a Canadair regional jet (CRJ)-100 model, which is one of three models in 

the CL-600-2B19 series (the other two models are the CRJ-200 and CRJ-440). Bombardier acquired Canadair 

in December 1986.

3 A pilot for another air carrier was deadheading (that is, traveling on a flight as a nonrevenue passenger) 

to the destination airport. He was seated in the cabin instead of on the jumpseat in the cockpit.

4 The van driver who transported the flight crewmembers from the hotel where they stayed overnight to 

LEX stated that they did not appear tired and that he did not observe them yawning or stretching.
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recorded automatic terminal information service (ATIS) information “alpha,”5 which 

indicated that runway 22 was in use. About 1 minute afterward, the first officer told the 

controller that he had received the ATIS information.6

About 0549:49, the controller stated, “cleared to Atlanta Airport via Bowling Green, 

ERLIN TWO arrival.[7] Maintain six thousand [feet mean sea level (msl)] .... Departure’s 

[departure control radio frequency] one two zero point seven five. Squawk [transponder 

code] six six four one.” The first officer replied, “okay, got uh, Bowling Green uh, missed 

the other part. Six thousand, twenty point seven five. Six six four one.” The controller 

then repeated, “it’s ERLIN TWO. Echo Romeo Lima India November Two arrival,” and 

the first officer acknowledged the arrival information. 

About 0552:04, the captain began a discussion with the first officer about which of 

them should be the flying pilot to ATL. The captain offered the flight to the first officer, 

and the first officer accepted. About 0556:14, the captain stated, “Comair standard,” 

which is part of the taxi briefing,8

 and “run the checklist at your leisure.”9

About 0556:34, the first officer began the takeoff briefing, which is part of the 

before starting engines checklist. During the briefing, he stated, “he said what runway 

... two four,” to which the captain replied, “it’s two two.” The first officer continued the 

takeoff briefing, which included three additional references to runway 22. After briefing 

that the runway end identifier lights were out, the first officer commented, “came in the 

other night it was like ... lights are out all over the place.” The first officer also stated, 

“let’s take it out and ... take ... [taxiway] Alpha. Two two’s a short taxi.” The captain 

called the takeoff briefing complete about 0557:40.10

Starting about 0558:15, the first officer called for the first two items on the before 

starting engines checklist. When the captain pointed out that the before starting engines 

checklist had already been completed, the first officer questioned, “we did”?11 Afterward, 

5 An ATIS is a continuous broadcast of recorded noncontrol information in selected terminal areas. 

6 About 0556:28, the controller advised the flight crew that ATIS information “bravo” was now current; this 

ATIS also stated that runway 22 was in use.

7 ERLIN2 is a standard terminal arrival route. The flight paperwork included a different standard terminal 

arrival route.

8 For information about Comair’s taxi procedures and briefing, see section 1.17.1.1.

9 The CVR showed that the captain stated, “at your leisure,” several more times while giving instructions 

to the first officer.

10 The first item in the before starting engines checklist is the additional crewmember briefing, which the 

captain called complete 1 second earlier. The takeoff briefing is the second item in the checklist.

11 When the first officer called for the first item on the checklist, the additional crewmember briefing, 

the captain responded automatically and indicated that the item was complete. When the first officer called 

for the second item on the checklist, the takeoff briefing, the captain pointed out that the checklist had been 

completed.
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the first officer briefed the takeoff decision speed (V1) as 137 knots and the rotation speed 

(VR) as 142 knots.12

Flight data recorder (FDR) data for the accident flight started about 0558:50. The 

FDR showed that, at some point before the start of the accident flight recording, the 

pilots’ heading bugs13 had been set to 227o, which corresponded to the magnetic heading 

for runway 22. 

About 0559:14, the captain stated that the airplane was ready to push back from 

the gate. FDR data showed that, about 0600:08 and 0600:55, the left and right engines, 

respectively, were started. 

About 0602:01, the first officer notified the controller that the airplane was ready 

to taxi. The controller then instructed the flight crew to taxi the airplane to runway 22. 

This instruction authorized the airplane to cross runway 26 (the intersecting runway) 

without stopping. The first officer responded, “taxi two two.” FDR data showed that the 

captain began to taxi the airplane about 0602:17. About the same time, SkyWest flight 6819 

departed from runway 22. 

About 0602:19, the captain called for the taxi checklist. Beginning about 0603:02, 

the first officer made two consecutive statements, “radar terrain displays” and “taxi 

check’s complete,” that were spoken in a yawning voice. About 0603:38, American Eagle 

flight 882 departed from runway 22. 

From about 0603:16 to about 0603:56, the flight crew engaged in conversation that 

was not pertinent to the operation of the flight.14 About 0604:01, the first officer began 

the before takeoff checklist and indicated again that the flight would be departing from 

runway 22. 

FDR data showed that, about 0604:33, the captain stopped the airplane at the 

holding position, commonly referred to as the hold short line,15 for runway 26. Afterward, 

the first officer made an announcement over the public address system to welcome 

the passengers and completed the before takeoff checklist. About 0605:15, while the 

airplane was still at the hold short line for runway 26, the first officer told the controller 

that “Comair one twenty one” was ready to depart at his leisure; about 3 seconds later, 

the controller responded, “Comair one ninety one ... fly runway heading. Cleared for 

12 V1

 is the maximum speed during the takeoff at which a pilot must take the first action to stop the 

airplane within the accelerate-stop distance (that is, the runway length required to accelerate to a specified 

speed and bring the airplane to a complete stop). VR is the speed at which the rotation of an airplane is initiated 

to a takeoff attitude. FDR data showed that these airspeeds had been entered into the airplane’s electronic 

flight information system.

13 A heading bug is an indicator that is positioned around a compass rose on the primary flight and 

multifunction displays. It can be rotated to a specific heading for reference purposes or for commanding an 

autopilot to fly that heading. 

14 This conversation concerned job opportunities and was a continuation of a previous discussion that 

took place while the airplane was parked at the gate and the crew was conducting preflight activities. 

15 A hold short line is a painted marking on a taxiway at a runway intersection that indicates where an 

airplane is to stop if so instructed by air traffic control. 
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takeoff.” Neither the first officer nor the controller stated the runway number during the 

request and clearance for takeoff. FDR data showed that, about 0605:24, the captain began 

to taxi the airplane across the runway 26 hold short line. The CVR recording showed that 

the captain called for the lineup checklist at the same time. 

About 0605:40, the controller transferred responsibility for American Eagle 

flight 882 to the Indianapolis Air Route Traffic Control Center (ARTCC). FDR data 

showed that, about 1 second later, Comair flight 5191 began turning onto runway 26. 

About 0605:46, the first officer called the lineup checklist complete.

About 0605:58, the captain told the first officer, “all yours,” and the first officer 

acknowledged, “my brakes, my controls.” FDR data showed that the magnetic heading 

of the airplane at that time was about 266o, which corresponded to the magnetic heading 

for runway 26. About 0606:05, the CVR recorded a sound similar to an increase in 

engine rpm. Afterward, the first officer stated, “set thrust please,” to which the captain 

responded, “thrust set.” About 0606:16, the first officer stated, “[that] is weird with no 

lights,” and the captain responded, “yeah,” 2 seconds later. 

About 0606:24, the captain called “one hundred knots,” to which the first officer 

replied, “checks.”16 At 0606:31.2, the captain called, “V one, rotate,” and stated, “whoa,” 

at 0606:31.8. FDR data showed that the callout for V1

 occurred 6 knots early and that the 

callout for VR occurred 11 knots early; both callouts took place when the airplane was at 

an airspeed of 131 knots. FDR data also showed that the control columns reached their 

full aft position17 about 0606:32 and that the airplane rotated at a rate of about 10o per 

second. 

The airplane impacted an earthen berm18 located about 265 feet from the end of 

runway 26, and the CVR recorded the sound of impact at 0606:33.0. FDR airspeed and 

altitude data showed that the airplane became temporarily airborne after impacting the 

berm but climbed less than 20 feet off the ground. 

The CVR recorded an unintelligible exclamation by a flight crewmember at 

0606:33.3. FDR data showed that the airplane reached its maximum airspeed of 137 knots 

about 0606:35. The aircraft performance study for this accident showed that, at that time, 

the airplane impacted a tree located about 900 feet from the end of runway 26. The CVR 

recorded an unintelligible exclamation by the captain at 0606:35.7, and the recording 

ended at 0606:36.2. 

Figures 1 and 1a show key events in the airplane’s taxi to and attempted takeoff 

from runway 26.

16 The first officer’s statement indicated that the airspeed displayed on his indicator was the same as that 

displayed on the captain’s indicator.

17 FDR data showed that the right control column position reached 10.9o and that the left control column 

position reached 10.6o. According to the Bombardier CRJ maintenance manual, the control column aft travel 

limit is 11.1o ± 1.5o. FDR data for the accident airplane’s previous 12 takeoffs showed that the nominal control 

column input for rotation was between 4o and 5o.

18 The height of the berm, relative to the immediate terrain, was about 4 feet.
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Figure 1. Groundpath Before Flight 5191 Aligned With Runway 26

Note: The runway configuration shown in this figure reflects the configuration that was in place at LEX before 

August 20, 2006. The runway and taxiway configurations at the time of the accident are shown in figures 2 

and 3 of this report. 

0605:24 Capt: “line-up check.”

 FDR: airplane resumes taxi

0605:18 ATC: “Comair one ninety one

cleared for takeoff.”

0605:15 F/O: “Comair one twenty one

ready to go.”

0605:06 CVR: takeoff checklist completed

0604:33 FDR: airplane stops

0603:04 CVR: taxi checklist completed

0602:19 CVR: taxi checklist begins

0603:56 CVR: nonpertinent conversation

0603:16 CVR: between Capt and F/O 

0604:01 CVR: takeoff checklist begins 

0605:46 F/O: “line-up check's complete.”

0605:41 FDR: airplane begins turning

onto runway 26

Start
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Figure 1a. Groundpath as Flight 5191 Aligned With Runway 26

Note: The runway configuration shown in this figure reflects the configuration that was in place at LEX before 

August 20, 2006. The runway and taxiway configurations at the time of the accident are shown in figures 2 

and 3 of this report. 

0606:18 Capt: “yeah.”

0606:12 Capt: “thrust set.”

0606:08 F/O: “set thrust please.”

0606:05 CVR: sound similar to increase

in engine rpm

0605:58 Capt: “all yours.”

0606:16 F/O: “[that] is weird with no lights.”

0606:24 Capt: “one hundred knots.”

0606:25 F/O: “checks.”

0606:36 CVR: end of recording

0606:33 CVR: sound of impact

0606:32 FDR: control column reaches

full aft position

0606:32 Capt: “whoa.”

0606:31 FDR: airspeed is 131 knots

0606:31 Capt: “V one, rotate.”

0606:00 FDR: airplane aligns with 

runway 26 centerline

0605:59 F/O: “my brakes, my controls.”

0606:24 FDR: airspeed is 103 knots

Continue
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In a postaccident interview, the controller stated that he did not see the airplane 

take off.19 The controller also stated that, after hearing a sound, he saw a fire west of 

the airport and activated the crash phone (the direct communication to the airport’s 

operations center and fire station) in response. The air traffic control (ATC) transcript 

showed that the crash phone was activated about 0607:17 and that the airport operations 

center dispatcher responded to the crash phone about 0607:22. According to the ATC 

transcript, the controller announced an “alert three”20 and indicated that a Comair jet 

taking off from runway 22 was located at the west side of the airport just off the approach 

end of runway 8 (which is also the departure end of runway 26). Section 1.15.1 discusses 

the emergency response.

1.2 Injuries to Persons

Table 1. Injury chart.

Injuries Flight Crew Cabin Crew Passengers Other Total

Fatal 1 1 47 0 49 

Serious 1 0 0 0 1

Minor 0 0 0 0 0

None 0 0 0 0 0

Total 2 1 47 0 50

Note: Title 49 CFR 830.2 defines a serious injury as any injury that (1) requires hospitalization for more than 48 hours, 

starting within 7 days from the date that the injury was received; (2) results in a fracture of any bone, except simple fractures 

of fingers, toes, or the nose; (3) causes severe hemorrhages or nerve, muscle, or tendon damage; (4) involves any internal 

organ; or (5) involves second- or third-degree burns or any burns affecting more than 5 percent of the body surface.

1.3 Damage to Airplane

The airplane was destroyed by impact forces and a postcrash fire.

1.4 Other Damage

A perimeter fence gate on the airport property and numerous trees beyond the 

airport property received damage from the airplane’s impact.

19 The controller’s actions at this time are further discussed in section 1.10.2.

20 As indicated in the airport’s emergency plan and the letter of agreement between the airport board and 

the ATCT, an alert 3 indicates that an aircraft has been involved in an accident on or near the airport. 
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1.5 Personnel Information

1.5.1 The Captain

The captain, age 35, held an airline transport pilot certificate and a Federal 

Aviation Administration (FAA) first-class medical certificate dated August 21, 2006, with 

a limitation that required him to wear corrective lenses while exercising the privileges of 

this certificate.21 The captain received a type rating on the CL-65 on January 14, 2004. (The 

CL‐600-2B19 airplane is included in the CL-65 type rating.)

The captain attended the professional pilot program at Comair Aviation 

Academy, Sanford, Florida, from July 1997 to August 1998. After graduation, the captain 

was employed as a flight instructor at the academy.22 The captain was hired by Comair 

in November 1999 and upgraded from first officer to captain in January 2004. At the time 

of the accident, he was based at Cincinnati/Northern Kentucky International Airport 

(CVG), Covington, Kentucky, as a reserve captain. The captain’s aviation résumé before 

his employment with Comair indicated that he had experience flying various general 

aviation airplanes. 

Comair employment and flight records indicated that the captain had accumulated 

4,710 hours of total flying time, including 3,082 hours on the CL-65 and 1,567 hours as a 

CL-65 pilot-in-command (PIC). He had flown 571, 159, 56, and 8 hours in the 12 months, 

90 days, 30 days, and 7 days,23 respectively, before the accident. The captain’s last PIC 

line check occurred on May 12, 2006; his last recurrent ground training occurred on 

November 16, 2005; and his last recurrent proficiency check occurred on July 31, 2006. 

FAA records indicated no accident or incident history or enforcement action, and a search 

of records at the National Driver Register found no history of driver’s license revocation 

or suspension.

Comair records indicated that the captain had landed at or taken off from LEX 

six times (not including the accident flight) since September 2004. Three of the arrivals 

occurred during night conditions, and two of the departures (not including the accident 

flight) occurred during night conditions. His last flights to and from LEX before the 

accident trip sequence were on June 16, 2006 (during the day), and June 17, 2006 (at 

night), respectively.

21 The captain’s medical records showed that his distant and near vision measurements were corrected 

to 20/20 in each eye and combined (with no measurements listed for uncorrected vision). A medical application 

dated February 3, 2004, showed that the captain’s uncorrected distant vision measurement was 20/100 and 

that his uncorrected near vision measurement was 20/20. The captain’s medical records also indicated that 

he passed his color vision examination and that he had a normal field of vision.

22 The captain’s flight instructor certificate (airplane single- and multiengine–instruments) was issued in 

August 1998.

23 According to Comair’s Operations Manual, chapter 3, section 3.8.3, page 3-20, “Flight Time Limitations 

and Rest Requirements,” dated June 10, 2005, flight time limits must not exceed 1,000 hours in any calendar 

year, 100 hours in any calendar month, or 30 hours in any 7 consecutive days. 
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The check airman who flew with the captain for his line check in May 2006 stated 

that he received standard scores (three out of a possible four). The first officer who flew 

with the captain on a six-leg trip on August 25 and 26, 2006, described him as someone 

who was “by the book” but easy to talk to and get along with. This first officer stated that 

the captain established a good atmosphere in the cockpit and demonstrated good crew 

resource management (CRM).24 This first officer further stated that the captain was in 

a good mood during the trip and that he did not recall the captain making any specific 

mistakes. A first officer who flew with the captain on August 20, 2006, stated that he 

would have had no problem speaking up to the captain if it had been necessary. A first 

officer who flew with the captain in early August 2006 stated that the captain followed 

standard operating procedures and called for checklists at the appropriate time. All of 

the interviewed Comair pilots who had flown with the captain reported that he had no 

difficulties navigating airports. In addition, instructors and check airmen stated that they 

had not heard anything negative about the captain. 

According to his wife, the captain was in good health and exercised regularly. 

She stated that he was a nonsmoker who did not drink alcohol often and did not take 

any medications.25 The captain’s wife also stated that his finances were stable and that he 

had not experienced any financial, health, or major life changes, besides the birth of their 

second child in May 2006, during the year that preceded the accident. She further stated 

that he did not take any sleep aids, had fairly normal sleep patterns, was “cheery” in the 

morning, and drank a cup of coffee each morning. She indicated that he wore contact 

lenses all of the time and that his night vision was fine. In addition, the captain’s wife 

stated that there was nothing remarkable or unusual about his activities or schedule in 

the days that preceded the accident. 

During the 4 days that preceded the accident, the captain’s activities were as 

follows: 

• On Wednesday, August 23, 2006, the captain was off duty. He awoke that day 

at 0800 and drove with his family during the afternoon from eastern Kentucky 

(where his relatives lived) to his home near the CVG area. After he arrived 

home, the captain ate dinner, performed routine activities around the house, 

and watched television. 

• On Thursday, August 24, 2006, the captain awoke about 0630 and spent the 

day running errands and performing routine activities around the house. 

• On Friday, August 25, 2006, the captain awoke about 0615. He drove 40 minutes 

to CVG and checked in for his “ready reserve”26 assignment about 0752. The 

captain was notified of a 2-day, six-leg trip assignment about 1225. The first 

24 This first officer stated that a newly trained first officer was occupying the cockpit jumpseat during 

one of the flight legs on August 25, 2006, and that the captain briefed the newly trained first officer about the 

importance of adhering to the company’s sterile cockpit procedures (also known as sterile cockpit discipline). 

Section 1.17.1.3 discusses the FAA’s and the company’s sterile cockpit procedures. 

25 The captain’s August 21, 2006, FAA medical application indicated that he did not use any prescription 

or nonprescription medications. 

26 Ready reserve is standby duty at an airport while waiting for a flight assignment.
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leg departed CVG about 1432 and arrived at Gerald R. Ford International 

Airport (GRR), Grand Rapids, Michigan, about 1548. The second leg departed 

GRR about 1603 and arrived at CVG about 1710. The third leg departed CVG 

about 1809 and arrived at Minneapolis-St. Paul International Airport (MSP), 

Minneapolis, Minnesota, about 2006.27 The captain and the first officer for 

this trip went to a hotel in the MSP area. Telephone records showed that the 

captain called his home telephone number about 2149 and that the call lasted 

for about 4 minutes.

• On Saturday, August 26, 2006, the captain met the first officer for the second day 

of the trip about 0630 for a 0640 scheduled report time at MSP. The fourth leg of 

the trip departed MSP about 0740 and arrived at CVG about 0935, after which 

the captain was informed about a modification to his trip. In addition to the 

planned fifth and sixth legs of the trip, the captain would also be deadheading 

from CVG to LEX, flying three legs on August 27, and deadheading from ATL 

to CVG afterward.28

The fifth leg of the trip departed CVG about 1039 and arrived at Nashville 

International Airport (BNA), Nashville, Tennessee, about 1145. The sixth leg 

of the trip departed BNA about 1210 and arrived at CVG about 1306. The flight 

from CVG to LEX departed about 1429 and arrived about 1526, and the captain 

was released from duty about 1546.29

The captain arrived at a hotel in the LEX area.30 Because of the length of his 

layover, the captain’s family picked him up for dinner outside of the hotel 

about 1630. The captain returned to the hotel alone,31 where, according to his 

wife, he spent the evening watching television. Telephone records showed 

that the captain called his home telephone number about 2123 and that the call 

lasted for about 4 minutes. The captain’s wife stated that he was planning to 

go to sleep after the call had ended. 

• On Sunday, August 27, 2006, the captain received a wakeup call about 0415. 

He reported for duty at LEX at 0515.32 The captain’s wife did not speak with 

him that day. 

The accident flight was the first one that paired the captain and the first officer.

27 Comair records showed that the captain’s duty day was 12 hours 26 minutes.

28 The first officer for the six-leg trip stated that the captain was disappointed about the extension of the 

trip but took it in stride and was not distracted during the remaining flight legs. 

29 Comair records showed that the captain’s duty day was 9 hours 6 minutes.

30 The hotel computer system indicated front desk activity associated with the captain’s assigned room 

about 1554. The hotel’s general manager stated that this activity might not correspond to the actual time 

that the captain checked in. Hotel key card records showed activity for the captain’s room at 1458 and 1511; 

however, after the accident, hotel personnel tested the lock on the captain’s room and determined that the 

actual time of key card activity was 1 hour later than indicated in the records (that is, 1558 and 1611). 

31 Hotel key card records showed activity for the captain’s room at 1813 (1913 with the 1-hour correction 

indicated in the previous footnote). No further key card activity occurred after this time. 

32 Comair required that pilots report for duty at field locations away from the pilots’ home base 45 minutes 

before a flight’s departure. The accident flight was scheduled for departure at 0600.
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1.5.2 The First Officer

The first officer, age 44, held an airline transport pilot certificate and an FAA 

first-class medical certificate dated July 18, 2006, with a limitation that required him to 

wear corrective lenses while exercising the privileges of this certificate.33 The first officer 

received a type rating on the CL-65 (second-in-command privileges only) on November 3, 

2005.34

In 1995, the first officer began the American Flyers flight school pilot training 

program. In March 1997, he began working for Gulfstream International Airlines; during 

his employment there, he was a captain on the Beech 1900 and a simulator instructor. 

The first officer was hired by Comair in March 2002 and was based at John F. Kennedy 

International Airport (JFK), Jamaica, New York. 

Comair employment and flight records indicated that the first officer had 

accumulated 6,564 hours of total flying time, including 940 hours as PIC and 3,564 hours 

on the CL-65. He had flown 876, 245, 64, and 18 hours in the 12 months, 90 days, 30 days, 

and 7 days, respectively, before the accident. The first officer’s last recurrent proficiency 

check occurred on April 6, 2006, and his last recurrent ground training occurred on April 4, 

2006. FAA records indicated no accident or incident history or enforcement action, and 

a search of records at the National Driver Register found no history of driver’s license 

revocation or suspension.

Comair records indicated that the first officer had landed at or taken off from 

LEX 12 times (not including the accident flight) since September 2004. Six of the arrivals 

occurred during night conditions, and one of the departures (not including the accident 

flight) occurred during night conditions. His last flights to and from LEX before the 

accident flight were on August 26, 2006 (at night), and May 19, 2006 (during the day), 

respectively.

The check airman who gave the first officer his April 2006 line-oriented evaluation 

in the simulator stated that the first officer met standards and that nothing stood out 

regarding his performance during the evaluation. The captain who flew with the first 

officer on August 25, 2006, stated that the first officer was involved with decision-making 

and had good situational awareness. This captain further stated that, during their flights 

together, the first officer consistently had his taxi charts out without prompting. The 

captain who flew with the first officer on a 3-day trip from August 20 to 22, 2006, stated 

that the first officer was articulate while performing the checklist and that he ensured 

that the captain was “with him” before going forward to the next item. The captain who 

flew with the first officer during a 5-day trip from August 9 to 13, 2006, described the first 

officer as a “thorough by-the-book pilot” who met standards and demonstrated good 

CRM. This captain, who was also a check airman, stated that the first officer used standard 

33 The first officer’s medical records indicated that his distant vision measurement was 20/30 corrected 

to 20/20 in each eye and combined and that his near vision measurement was 20/20 (with no measurement 

listed for corrected vision in each eye and combined). The first officer’s medical records also indicated that he 

passed his color vision examination and that he had a normal field of vision.

34 The first officer also received a flight instructor certificate (airplane single engine) in November 1996 

and a type rating on the Beech 1900 in November 2000.
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phraseology when performing checklists and demonstrated situational awareness and 

good sterile cockpit discipline. Finally, pilots, instructors, and check airmen stated that 

they had not heard anything negative about the first officer, and pilots who had flown 

with the first officer stated that he was looking forward to upgrading to captain.35

National Transportation Safety Board investigators were unable to interview the 

first officer as part of this accident investigation. His attending physician stated that the 

first officer was “medically unfit” to be interviewed. The first officer’s wife stated that he 

did not remember the accident. 

According to his wife, the first officer was in good health and exercised regularly. 

She stated that he drank alcohol occasionally and took a prescription medication to lower 

cholesterol.36 The first officer’s wife also stated that he had not experienced any major life 

changes during the year that preceded the accident but that he was affected by Comair’s 

pay cuts.37 She further stated that the first officer was generally a morning person who 

sometimes drank a cup of coffee in the morning. A captain and friend of the first officer 

described him as an evening person and recalled conversations they had regarding the 

difficulty of going to bed on nights that preceded an early report time.38 The first officer’s 

wife indicated that he did not have any sleep disorders. She also indicated that he wore 

contact lenses for a short time and had excellent night vision.39 In addition, the first 

officer’s wife indicated that there was nothing remarkable or unusual about his activities 

or schedule in the days that preceded the accident. 

The first officer was not on duty on August 23 and 24, 2006. The Safety Board 

attempted to determine the first officer’s activities during the 72 hours that preceded the 

accident but was only able to determine some of the first officer’s activities during the 

2 preceding days,40 which were as follows: 

• On Friday, August 25, 2006, the first officer commuted from his home near 

Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, 

Florida, to JFK to report at 1150 for a 3-day trip. (His flight departed from 

35 A progress report in the first officer’s file showed the highest rating (superior) for all performance 

elements, and the captain who submitted the progress report indicated on the form that the first officer was 

captain material. Other pilots who had recently flown with the first officer stated that they knew he was 

preparing to upgrade to captain and that he would make a good captain because of his adherence to standard 

operating procedures, experience, maturity, and good CRM. 

36 The first officer’s July 18, 2006, FAA medical application indicated that he did not use any prescription 

or nonprescription medications. 

37 A captain who had recently flown with the first officer stated that the company’s pay cuts affected first 

officers more than captains because first officers are at the lower end of the pay scale. This captain also stated 

that the pay cut was not necessarily a concern for this first officer.

38 According to this captain, he and the first officer discussed the difficulty of going to bed at 2100 on 

nights that preceded an early report time but that going to bed at 2300 resulted in less but better-quality 

sleep. 

39 LEX security camera video showed that the first officer was not wearing glasses when he passed 

through the operations area on the day of the accident. The captain who flew with the first officer from 

August 20 to 22, 2006, stated that he did not wear glasses during the flights.

40 The first officer’s wife did not remember his activities from August 23 to 25, 2006.
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FLL about 0559 and arrived at JFK at 0832.) The first leg of the trip departed 

JFK about 1305 and arrived at Greater Rochester International Airport (ROC), 

Rochester, New York, about 1435. The next leg of the trip departed ROC about 

1600 for JFK but diverted to Bradley International Airport (BDL), Windsor 

Locks, Connecticut, for fuel,41 arriving about 1815. The flight departed BDL 

about 1839 and arrived at JFK about 1955. Because of the airplane’s late arrival, 

Comair asked the pilots to reposition the airplane to LEX. According to the 

captain of this flight, the airplane pushed back from the gate about 2130 but 

did not take off until about 2300. 

• On Saturday, August 26, 2006, the repositioning flight landed on runway 22 

at LEX42 about 0140.43 According to the captain of this flight, the first officer 

checked into his hotel room about 0210.44

Telephone records showed that the first officer made a call about 1443. Hotel key 

card records showed activity for the first officer’s room about 1530.45 A receipt 

from the hotel restaurant showed that the first officer purchased something to 

eat and two bottles of beer about 1826. Telephone records indicated that the 

first officer called the Comair System Operations Control Center about 1836 

and 1844.46 The records also indicated that the first officer called his wife about 

2049 and that the call lasted about 13 minutes. According to his wife, the first 

officer stated that he had been able to sleep in that morning and was going to 

bed early. She stated that he sounded “good as usual.”

• On Sunday, August 27, 2006, mobile phone records showed that the first officer 

received a 24-second call about 0103 followed immediately by a 37-second call 

that went to voicemail.47 The originating telephone number was identified 

41 While en route to JFK, the flight crew received delaying vectors and holds from ATC and, as a result, 

decided to divert.

42 The captain of this flight reported that the left runway edge lights were illuminated but that only 

one-eighth of the right runway edge lights were illuminated. (The right runway edge lights were out after the 

intersection of runway 22 with runway 26.) A NOTAM that was in effect at the time indicated that numerous 

right runway edge lights were out of service.

43 The first officer’s duty time for August 25 and 26, 2006, was 14 hours 10 minutes, including 9 hours 

11 minutes of flight time. The captain of the flights stated that neither he nor the first officer took a nap when 

they were not flying. 

44 The hotel computer system indicated front desk activity associated with the first officer’s assigned 

room about 0158. The hotel’s general manager stated that this activity might not correspond to the actual time 

that the first officer checked in. Hotel key card records showed activity for the first officer’s room at 2257 on 

August 25, 2006; however, after the accident, hotel personnel tested the lock on the first officer’s room and 

determined that the actual time of key card activity was 2 hours later than indicated in the records (that is, 0057 

on August 26). Section 2.2.2.4 further discusses the time of the key card activity for the first officer’s room.

45 The time of the key card activity, with the 2-hour correction stated in the previous footnote, was 1730. 

46 These conversations were regarding the first officer’s report time for the next day. His report time was 

originally scheduled for 0530 but was changed to 0515. 

47 The Safety Board could not determine whether the first officer attempted to answer these calls. 
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as that of the first officer’s brother.48 Telephone records showed that the first 

officer called the Comair System Operations Control Center about 0510 and 

that the call lasted 2 minutes 17 seconds.49 The first officer reported for duty at 

LEX at 0515. 

1.6 Airplane Information

The accident airplane, a Bombardier CL-600-2B19, serial number 7472, was 

manufactured in January 2001 and was delivered new to Comair. At the time of the 

accident, the airplane had accumulated 14,536 total flight hours and 12,048 total flight 

cycles.50

The airplane was equipped with two General Electric CF34-3A1 turbofan engines. 

The left (No. 1) engine was delivered new to Bombardier in December 1998 and was 

installed on the accident airplane on August 3, 2006. The left engine had accumulated 

17,265 total flight hours and 14,850 total flight cycles since new. The right (No. 2) engine 

was delivered new to Bombardier in September 1994 and was installed on the accident 

airplane in November 2005. The right engine had accumulated 27,327 total flight hours 

and 25,373 total flight cycles since new.

The airplane’s electronic flight information system (EFIS) was manufactured by 

Rockwell Collins and contained six electronic flight display positions. The captain’s and 

the first officer’s stations each contained multifunction display (MFD) and primary flight 

display (PFD) positions; the MFDs were located inboard of the PFDs. The panel between 

the captain’s and the first officer’s stations contained the engine indicating and crew 

alerting system (EICAS) positions. The MFDs included a present position map mode 

with which range settings of 5, 10, 20, 40, 80, 160, and 320 nautical miles (nm) could be 

selected and autopilot heading select information and weather and terrain information 

(on radar overlays) could be displayed.51 The PFDs displayed airspeed, altitude, attitude, 

and heading information. 

The airplane was configured with two cockpit flight crew seats; one cockpit 

observer’s seat; one retractable, aft-facing flight attendant jumpseat, which was mounted 

on the forward bulkhead; and 50 coach-class passenger seats. 

A review of the airplane’s maintenance logbooks from February 1 to August 7, 

2006, showed that the maintenance records were up to date and complete with no 

48 During a postaccident interview, the first officer’s brother did not remember placing the calls. 

49 This conversation was concerning the first officer’s desire to deadhead to another base (at the end of 

his duty day) rather than the one originally assigned. The Safety Board listened to a tape of this telephone call. 

The first officer spoke clearly and was conversational throughout the call.

50 A cycle is one complete takeoff and landing sequence.

51 FDR data showed that the captain’s and the first officer’s MFDs were set to the present position map 

mode. The captain’s MFD range was set to 80 nm, and the first officer’s MFD range was initially set to 10 nm 

but was switched to 40 nm about 4 minutes before the takeoff roll. The captain’s and the first officer’s autopilot 

headings were set to 227o, and the MFD radar overlays were active. 
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discrepancies noted. The airplane’s last maintenance check (a line check) occurred on the 

day of the accident. 

The load manifest showed that the airplane’s takeoff weight was 49,087 pounds 

with a forward center of gravity (cg) of 12 percent mean aerodynamic chord (MAC), 

which was within the airplane’s maximum allowable takeoff weight for the accident 

flight of 50,178 pounds and its forward cg range of 9 to 12 percent MAC. 

1.7 Meteorological Information

LEX has an automated surface observing system (ASOS), which is maintained by 

the National Weather Service. Augmentation and backup of the ASOS are provided by 

FAA personnel in the LEX ATCT. The ASOS records continuous information on wind 

speed and direction, cloud cover, temperature, precipitation, and visibility.52 The ASOS 

transmits an official meteorological aerodrome report (known as a METAR) each hour. 

The 0554 METAR indicated the following: winds from 200o at 7 knots, visibility 8 miles, 

few clouds at 9,000 feet, scattered clouds at 12,000 feet, temperature 24o Celsius (C), 

dew point 19o C, and altimeter setting 30.00 inches of mercury (Hg). The 0654 METAR 

indicated the following: winds from 220o at 8 knots, visibility 8 miles, few clouds at 

4,700 feet, ceiling 6,000 feet broken and 9,000 feet overcast, temperature 23o C, dew point 

20o C, altimeter setting 30.02 inches of Hg, rain began at 0612 and ended at 0651, 0.01 inch 

of precipitation measured.53

Sunrise at LEX on August 27, 2006, was at 0703, which was about 1 hour after the 

accident occurred. At the time of the accident, the moon was below the horizon.

1.8 Aids to Navigation

No problems with any navigational aids were reported.

1.9 Communications

No communications problems were reported.

1.10 Airport Information

LEX is located about 4 miles west of the city of Lexington at an elevation of 970 feet 

msl. The airport has two runways, 4/22 and 8/26, as shown in figure 2.

52 Cloud cover is expressed in feet above ground level. Visibility is expressed in statute miles.

53 LEX security camera video from 0600 to 0607 showed no evidence of rain or restrictions to visibility at 

the time of the accident airplane’s taxi and attempted takeoff. 
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Figure 2. Blue Grass Airport

Source: Lexington, Kentucky, Police Department

Runway 4/22, the air carrier runway, was 7,003 feet long and 150 feet wide. It 

had high intensity runway lights.54 Runway 4/22 also had centerline lights and runway 

end identifier lights, but they were out of service at the time of the accident because of a 

construction project (as discussed in this section). Runway 4/22 conformed with the FAA 

airport certification requirements specified in 14 CFR 139.55

Runway 8/26, the general aviation runway, was used for about 2 percent of 

the airport’s total operations. It was not subject to the requirements of 14 CFR 139.56

Runway 8/26 was 3,501 feet long and 150 feet wide, but the paint markings limited the 

usable runway width to 75 feet.57 Runway 8/26 was used only for flights conducted 

when daytime visual flight rules (VFR) prevailed and for aircraft that weighed less than 

12,500 pounds. Although the runway was equipped with runway edge lights when the 

54 High intensity runway lights have five settings, step 1 through step 5, with step 5 being the brightest 

setting. At the time of the accident, the lights were on step 3.

55 Title 14 CFR 139 established minimum standards for airports that conduct U.S. air carrier operations. 

These standards include runway and runway safety area dimensions, airport lighting and markings, airport 

signage, and emergency response capabilities. Taxiways A and C (and their associated connectors) were also 

required to conform with 14 CFR Part 139. 

56 Runway 8/26 was not used by scheduled passenger-carrying aircraft with more than 9 passenger 

seats or unscheduled passenger-carrying aircraft with at least 31 passenger seats. 

57 According to the LEX director of operations, the 150-foot runway width was narrowed to 75 feet in 2001 

because of pavement deterioration on the runway edges. 
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width was 150 feet, these lights had been disconnected since 2001 when the runway 

was designated for daytime VFR use only.58 Runway 8/26 crossed runway 4/22 about 

700 feet south of the runway 4/22 threshold. A 2,000-foot distance-remaining marker and 

a 1,000-foot distance-remaining marker appeared on the north side of runway 8/26 after 

the intersection with runway 4/22.59 The hold short line for runway 26 was about 560 feet 

from the hold short line for runway 22.

At the time of the accident, LEX was nearing the completion of a multiyear 

construction project. The project included shifting runway 4/22 325 feet to the southwest 

to accommodate a longer runway safety area at the approach end of runway 22, 

relabeling the existing taxiway connectors, demolishing taxiway A5 and taxiway A north 

of runway 8/26,60 and creating a new taxiway (labeled A7) at the end of runway 22. 

From August 18 to 20, 2006, LEX was closed to resurface and paint new markings 

on runway 4/22 and change taxiway connector signage. On August 20, the airport was 

reopened at 1800, a local NOTAM was issued to announce the closure of taxiway A north 

of runway 8/26,61 and low-profile barricades with flashing red lights were placed on that 

part of the taxiway. Former taxiway A5 was redesignated as taxiway A and was used by 

airplanes to access runway 22 before the construction of the new taxiway A7, which was 

planned to be completed about 30 to 45 days after the completion date of the repaving 

project (August 20). Figure 3 shows the locations of the existing (A), planned (A7), and 

former (A5 and A north of runway 8/26) taxiways. 

On August 27, 2006, as a result of the accident, a NOTAM was issued to announce 

the closure of runway 8/26, and lighted “X” markings were placed at the end of each 

runway 2 days later. Runway 8/26 remained closed until November 1, 2006, when new 

taxiway A7 was opened. 

58 The disconnected runway edge lights could only be turned on by maintenance personnel. 

59 These distance-remaining markers were unlighted. The marker lights were on the same circuit as the 

runway edge lights, which had been disconnected when the runway was designated for daytime VFR use 

only.

60 According to the program manager of the LEX construction project at the FAA’s Memphis, Tennessee, 

Airports District Office, it would not have been possible to continue to use taxiway A north of runway 8/26 to taxi 

airplanes to the new runway 22 threshold because that would have violated terminal instrument procedures 

criteria.

61 This information was not included in the ATIS information recordings on the day of the accident but 

was included in a sampling of ATIS broadcasts recorded each day between 0530 and 0630 from August 20 

to 26, 2006. 
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Figure 3. Taxiways Leading to Runways 4/22 and 8/26

1.10.1 Airport Charts

The two main sources of airport charts that are available to the pilot community 

are produced by the FAA’s National Aeronautical Charting Office (NACO) and Jeppesen 

Sanderson, Inc. Both organizations receive the information for their publications from 

the National Flight Data Center (NFDC),62 which is within the FAA’s Aeronautical 

Information Services Division. 

62 According to the FAA’s Web site, the NFDC is the principal element within the FAA responsible for 

collecting, collating, validating, storing, and disseminating aeronautical information and detailing the physical 

description and operational status of all components of the National Airspace System (NAS). The NFDC 

maintains the national aeronautical information database and provides aeronautical information to government, 

military, and private producers of aeronautical charts, publications, and flight management systems. The 

NFDC receives information regarding changes to the NAS from other FAA offices.
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The NACO chart for LEX that was current at the time of the accident was dated 

August 3, 2006. The chart showed the taxiway configuration at the completion of the 

construction project; that is, future taxiway A7 was shown on the chart, and taxiway A5 

(which had been redesignated as taxiway A at the time of the accident) and taxiway A 

north of runway 8/26 were not shown. According to the LEX airport manager, LEX 

airport officials proposed that the August 3 airport chart revision show an interim 

airport configuration (including closed taxiway A north of runway 8/26 and former 

taxiway A5 redesignated as taxiway A) before the construction of taxiway A7. Because 

the construction schedule planned for the completion of taxiway A7 within 30 to 45 days 

after the repaving project was completed (August 20, 2006), airport officials expected that 

the NACO chart revision that followed63 (September 28, 2006) would show the airport’s 

final configuration. The program manager of the LEX construction project at the FAA’s 

Memphis Airports District Office stated that he recommended against publishing an 

interim chart because the chart would have been inaccurate during the time both before 

and after the construction project.64 

The Jeppesen chart for LEX that was current at the time of the accident was 

dated January 27, 2006. This chart, which was issued to the accident flight crew, showed 

taxiway A5 and taxiway A north of runway 8/26.65 Jeppesen issued a revised chart for 

LEX on September 8, 2006.66 As with the NACO chart for LEX, the revised Jeppesen 

chart showed future taxiway A7 and did not show taxiway A5 and taxiway A north of 

runway 8/26.67 Appendix C shows the NACO and Jeppesen airport charts.

After the accident, Comair published a notice, dated September 8, 2006, that 

was appended to each dispatch release for operations to and from LEX. The notice 

warned, “published airport diagrams may not accurately reflect actual airport signage 

and markings. Exercise extreme caution during all ground operations. Utilize high threat 

taxi procedures.[68] If unsure of position or taxi clearance clarify with ATC or request 

progressive taxi instructions.” The notice also specified the parts of the September 8, 2006, 

Jeppesen chart that were not accurate regarding the airport configuration at the time. The 

notice was removed from dispatch releases on November 3, 2006 (after new taxiway A7 

was opened and the Jeppesen chart accurately reflected the airport configuration).

63 All NACO airport charts are published on a 56-day revision cycle.

64 An FAA official who was involved with the decision not to publish an interim airport chart stated that 

it was “a practice in circumstances” to recommend the publishing of an airport chart that depicts the ultimate 

airport configuration and that NOTAMs were to be used to advise pilots of any differences to the published 

charts.

65 According to the Jeppesen flight safety manager, the Jeppesen chart did not reflect information about 

the LEX construction project that was received on June 23, 2006, because of a software error. (Specifically, the 

information was received after normal work hours on a Friday, and the software recognized only those changes 

that were received during the regular business week. Jeppesen has since fixed this software problem.) On 

August 29, 2006, Jeppesen published a corrected chart on its Web site and sent this chart electronically to its 

customer airlines. 

66 Even though the chart had been corrected on August 29, 2006, the official date of the revised LEX 

chart was September 8, 2006.

67 Although Jeppesen publishes airport charts on a 14-day cycle, the company revises only those charts 

for airports where there has been a modification from the information shown on a previous chart.

68 Section 1.17.1.1 describes these procedures.
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1.10.2 Air Traffic Control

The LEX ATCT and terminal radar approach control (TRACON) provide ATC 

services from the surface to 10,000 feet msl within 35 nm of Lexington. ATC radar data 

are obtained from an airport surveillance radar-7 (ASR-7) radar at the airport.69 The ASR-7 

radar received two transponder returns (about 0606:31 and 0606:35) from the accident 

airplane.

About 0047 on the day of the accident, all LEX tower and radar positions70

were combined and were being worked by one controller at the local control position. 

In addition, the controller was responsible for obtaining releases from the Indianapolis 

ARTCC’s traffic management unit,71 recording the ATIS broadcasts,72 and performing all 

other required operational and administrative duties. 

The controller began his employment with the FAA in October 1988 and was 

assigned to LEX in January 1989. He had been working at the full-performance level since 

the mid-1990s. The controller was required to wear glasses to correct for nearsightedness 

while working air traffic, and he reported that he was wearing his glasses at the time of 

the accident. The controller also reported that he had not experienced any operational 

errors during the 2 years that preceded the accident.73

The controller reported that his activities during the 3 days that preceded the 

accident were as follows:74 

• On Thursday, August 24, 2006, at 0100, the controller finished a work shift that 

had started the previous day at 1700. He went to sleep between 0130 and 0145 

and awoke about 0915. Afterward, he performed routine activities around the 

house and ran errands. He worked from 1500 to 2100,75 returned home, and 

went to sleep about 2230. 

69 LEX was not equipped with ground radar systems such as the airport movement area safety system 

and the airport surface detection equipment – model X.

70 The tower positions were clearance delivery, flight data, local control, and ground control, and the 

radar positions were radar departure/approach control and radar data. During his shift, the controller was also 

responsible for the duties of the controller-in-charge.

71 Controllers at the LEX ATCT were required to obtain a release from the Indianapolis ARTCC’s traffic 

management unit for all flights destined for Chicago-O’Hare International Airport, Detroit Metropolitan Wayne 

County Airport, and ATL.

72 ATC recordings indicated that the controller announced a new ATIS recording every hour, approximately 

on the hour, during his shift.

73 According to FAA Order 7210.56, “Air Traffic Quality Assurance,” all references to a specific operational 

error are removed from a controller’s records 2 1/2 years after the event. Also, all references to a specific 

operational error classified as low severity and all references to a specific operational deviation are removed 

from a controller’s record 1 year after the event.

74 The controller was working a “2-2-1” schedule, that is, two evening shifts, two day shifts, and one 

midnight shift. During a postaccident interview, the FAA’s vice president for terminal services stated that the 

2-2-1 schedule was the most common shift rotation used by ATC facilities. 

75 The controller was scheduled to work until 2200 but used 1 hour of annual leave at the end of 

his shift.
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• On Friday, August 25, 2006, the controller awoke about 0715. He reported 

feeling good that morning. He worked from 0815 to 1615 and arrived home 

from work about 1630. He performed routine activities around the house, had 

dinner, and went to sleep about 2230.

• On Saturday, August 26, 2006, the controller awoke about 0540. He stated that 

he slept “very well” and that he did not feel tired. He worked from 0630 to 1430, 

returned home about 1445, went to sleep about 1530, and awoke between 1730 

and 1800. The controller described the quality of his sleep during the afternoon 

as “not real good.” Between 1800 and 2230, the controller’s activities included 

eating dinner; running; visiting with friends at his home; and preparing for his 

next work shift, which was scheduled for 0000 to 0800 on Sunday, August 27 

(the day of the accident). The controller arrived at the ATCT at 2325, signed in 

at 2330,76 and relieved another controller at 2337. 

The controller was the only one on duty in the ATCT from 0000 to 0640 on 

the day of the accident.77 The LEX traffic count log (LEX form 7230-10) for August 27, 

2006, showed that, between 0000 and 0300, 14 air traffic operations were conducted in 

LEX airspace. There were no aircraft operations between 0300 and 0545. The controller 

stated that he stayed awake during the time with no air traffic by walking inside the 

tower cab and listening to an AM/FM radio.78 He recalled that, about 0545, a pilot of 

SkyWest flight 6819 had requested a clearance to its destination airport, which he issued. 

Afterward, pilots of American Eagle flight 882 and Comair flight 5191 had requested and 

received clearances to their destination airports. 

The controller stated that, after a Comair pilot had requested and received taxi 

instructions, the airplane proceeded to taxiway A, which is parallel to runway 22. (By 

that time, both the SkyWest and American Eagle flights had departed from runway 22.) 

The controller indicated that he saw the lights and the tail of the Comair airplane when 

it was across from the parking garage.79 Afterward, a Comair pilot told the controller 

that the flight was ready to depart, and the controller issued the takeoff clearance. The 

controller stated that he scanned runway 22 from the departure to approach ends to make 

sure that the runway was clear and that he scanned the digital bright radar indicator 

tower equipment (DBRITE) to see if there was any traffic. 

The controller stated that he communicated with a pilot of the American Eagle 

flight and then handed off the flight to the Indianapolis ARTCC. The controller also 

76 The controller arrived 30 minutes early for his shift to earn credit time.

77 Another controller was scheduled to begin the day shift at 0630 but was 10 minutes late reportedly 

because of traffic. An additional controller working the day shift was scheduled to report for work at 0700. 

78 A review of ATC tapes indicated that a radio was on during the controller’s shift. According to the FAA, 

at the time of the accident, the use of AM/FM radios, televisions, and electronic devices were authorized 

in specific locations in an ATC facility, such as a break room and lounges, but facility managers had some 

discretion with regard to this policy. The LEX facility manager permitted the use of AM/FM radios in the tower 

as long as the volume level did not create a distraction that would interfere with operations. According to the 

latest labor contract between the FAA and the National Air Traffic Controllers Association, AM/FM radios, 

televisions, and similar equipment are prohibited in all operating areas.

79 The controller stated that he noticed both the SkyWest and American Eagle airplanes at about the 

same point and that he also saw the American Eagle airplane at the hold short line for runway 22.
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stated that he then saw the Comair airplane make a turn toward what he “presumed to 

be [runway] 22,” which was the last time he observed the airplane. Further, the controller 

stated that, after he saw the airplane make this turn, he turned away from the tower cab 

windows (which overlooked the runway) and faced the tower cab’s center console so 

that he could begin the traffic count (that is, a count of the hourly air traffic operations, 

as recorded on flight progress strips, during his shift). The controller stated that it 

was his common practice to place all of the flight progress strips that he accumulated 

throughout the night into a pile and do the traffic count all at once instead of hourly, 

and he estimated that the traffic count would have taken between 2 and 5 minutes to 

complete.80 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 (ARFF). Afterward, he made additional accident notifications and completed 

the accident checklist paperwork.

The controller stated that there was nothing unusual about the Comair flight or 

the clearance and that the pilots did not seem to be rushed. The controller also stated that 

he learned that the accident airplane had taken off from runway 26 between 1030 and 

1100 after the radar data were reviewed and that he “couldn’t believe it.” The controller 

further stated that it might have been possible for him to detect that the accident airplane 

was on the wrong runway if he had been looking out the tower cab window. In addition, 

the controller stated that, in his 17 years working at LEX, an air carrier airplane had never 

departed from runway 26.

The controller stated that he was not experiencing any health or personal issues 

that would have affected his performance on the day of the accident. He stated that he 

did not take prescription medications or use tobacco products and that he drank alcohol 

occasionally. He indicated that he had not consumed alcohol during the 24 hours that 

preceded the accident or taken any nonprescription medication during the 72 hours 

before the accident. The controller also stated that during his shift he was tired but felt 

“fine” and “alert.”81

The controller did not report monitoring the location and movement of the 

Comair airplane on the airport surface during the scans of runway 22 and the DBRITE. 

The controller stated that his normal work practice was to monitor airplanes during taxi 

and takeoff if another airplane was on final approach and he needed to ensure separation 

between the departing and arriving airplanes. The controller also stated that, when aircraft 

separation was not a factor, his decision to watch airplanes taxi and take off depended on 

whether he had other tasks to perform. 

80 The traffic count was accomplished by examining each flight progress strip, counting the number 

of strips for each category, and marking the numbers on a standardized form. The controller was required 

to count a total of 17 flight progress strips for this shift; 14 of the strips were for the air traffic operations 

conducted between 0000 and 0300, and the remaining 3 strips (for the SkyWest, American Eagle, and Comair 

flights) were to be counted as part of the 0600 to 0700 traffic count.

81 The controller further stated that he “always managed to deal with” the lack of sleep during the midnight 

shift and that he felt “a little more tired on the mid[night] shift” compared with other shifts.
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1.10.2.1 Lexington Air Traffic Control Scheduling 

The LEX air traffic manager82 stated that the LEX ATCT became a 24-hour facility 

in 1992 after an incident in which an airplane was cleared for a direct approach to LEX, 

but the pilots conducted the approach to and landed at a nearby airport.83 In 2005, the 

air traffic manager prepared two studies to support closing the LEX ATCT during the 

midnight shift.84

At LEX, work hours for the day shifts were 0630 to 1430, 0700 to 1500, or 0800 to 

1600; work hours for the swing shifts were 1500 to 2300 or 1600 to 0000; and work hours 

for the midnight shift were 0000 to 0800. The LEX air traffic manager stated that there 

were typically four controllers on duty during the day shifts, one controller on duty from 

1000 to 1800 (in addition to the day and swing shift controllers), and five controllers on 

duty during the swing shifts. The midnight shift had been staffed with one controller. 

On November 16, 2005, the LEX air traffic manager notified LEX ATC personnel 

by e-mail that, according to verbal guidance from the FAA’s vice president of terminal 

services, facilities with radar and tower responsibilities were to be staffed with two 

controllers on the midnight shift so that the functions could be split, although both 

controllers could be colocated in the tower. According to the LEX air traffic manager, 

this directive was precipitated by an August 17, 2005, incident at Raleigh-Durham 

International Airport (RDU), Raleigh, North Carolina, which involved a loss of aircraft 

separation while a controller was working both the radar and tower functions.85

The LEX position logs for January 1 through March 31, 2006, showed that the 

midnight shift was staffed with two controllers for 36 of the 90 days covered by the logs. 

82 The air traffic manager had worked at the LEX ATCT since 1992 and had been the air traffic manager 

for 4 years at the time of the accident. Supervisors at the ATCT reported directly to him, and he reported to 

the hub manager located at CVG.

83 In July 1987, a Delta Air Lines Boeing 737 flight crew was cleared direct to LEX for an approach to 

the airport. At that time, the LEX tower and radar approach control were closed. After receiving the approach 

clearance, the flight crew located an airport with runway lights on, entered the traffic pattern, and landed. 

However, that airport was Capital City Airport, Frankfort, Kentucky, with a 5,000-foot runway instead of 

LEX, the destination airport, with a 7,000-foot runway. (Capital City Airport is located 17 nm from LEX.) The 

unavailability of ATC services at LEX was included as a contributing factor to the incident. For more information, 

see ATL87IA201 at the Safety Board’s Web site at <http://www.ntsb.gov>.

84 The first study was an airspace reclassification study, performed during winter 2005, to support closing 

the LEX ATCT from 0000 to 0630 and having the Indianapolis ARTCC be responsible for the airspace during 

that time. In April 2006, the FAA’s eastern terminal service unit indicated that additional information was needed 

before the airspace reclassification study could be forwarded to FAA headquarters. In July 2007, the FAA 

indicated that there was not a pending airspace reclassification study regarding LEX. The second study was 

a staff study, prepared in March 2005. This study, which was based on operational data from February 2004 

to February 2005, showed that LEX did not have a sufficient traffic count (that is, 1.4 operations per hour) 

from 0000 to 0545 to justify ATC services during that time. As a result, the air traffic manager requested that 

the ATCT be closed during the midnight shift and that the Indianapolis ARTCC be responsible for the airspace 

during that time. The FAA’s eastern terminal service unit supported this request and forwarded the study to 

FAA headquarters in April 2005. In July 2007, the FAA stated that the staff study, “neither constitutes a request 

for reclassification of the airspace at LEX, nor meets the requirements of an airspace staff study that is needed 

for airspace change actions.”

85 This loss of separation was resolved when the departing airplane responded to a traffic alert and 

collision avoidance system resolution alert.
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In April 2006, the midnight shift was again staffed with one controller because traffic had 

increased during the day and swing shifts and the second midnight controller was needed 

on those shifts, according to the air traffic manager. After the accident, the midnight shift 

was consistently staffed with two controllers.86 Also, on November 17, 2006, the FAA 

issued Notice N JO 7210.639, “Consolidating Control Functions,” which modified FAA 

Order 7210.3, “Facility Operation and Administration,” to formalize the verbal guidance 

from the FAA’s vice president of terminal services regarding midnight shift staffing for 

facilities with radar and tower responsibilities.87

In addition, in January 2006, when the LEX ATCT was staffed with 19 controllers, 

the air traffic manager sent an e-mail to his hub manager, requesting that the tower be 

staffed with 21 controllers. At the time of the accident, the tower was still staffed with 

19 controllers. In July 2007, the FAA stated that four additional controllers were hired at 

the LEX ATCT after the accident (two in November 2006 and two in May 2007).

1.10.2.2 Amended Takeoff Clearance Procedure

On January 4, 2007, LEX ATCT Notice N7220.124, “Runway 22 Takeoff Clearance 

Procedure,” was issued to all LEX ATC personnel. The notice stated the following: 

“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.” 

1.10.3 Taxi Demonstrations

Members of the Operations/Human Performance and Survival Factors 

investigative teams conducted two taxi demonstrations—one during daytime conditions 

and one during nighttime conditions—on the day after the accident. The purpose of these 

demonstrations was to observe airport features, including runways 22 and 26, taxiway A, 

runway and taxiway markings, lighting, and signage. The ATC investigative team 

observed the nighttime demonstration from the tower. 

For the daytime observation, the Operations/Human Performance and Survival 

Factors investigative teams traveled around the airport by 15-passenger van. At the 

time, the weather conditions were overcast and rainy. For the nighttime observation, 

the Survival Factors investigative team traveled around the airport by 15-passenger van, 

86 According to the FAA, at the time of the accident, the Duluth, Minnesota, and Fargo, North Dakota, 

ATCTs also did not consistently comply with the midnight shift staffing policy and were combining radar and 

tower functions. Further, four ATCTs—located at Tulsa, Oklahoma; Kansas City, Missouri; Springfield, Missouri; 

and Little Rock, Arkansas—were staffed with two controllers on the midnight shift but combined the radar and 

tower functions. All of the facilities are now in compliance with FAA guidance. 

87 All FAA notices expire 1 year after issuance. Because the notices are temporary by nature, they are 

rarely renewed. According to Notice N JO 7210.639, the notice is to be in effect for 1 year or until changes 

are published in FAA Order 7210.3, change 3, whichever occurs first. The publication schedule in FAA 

Order 7210.3 indicated that submissions for change 3 were due on March 15, 2007, and that the effective 

date of the publication would be August 30, 2007.
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and the Operations/Human Performance investigative team traveled aboard a Comair 

CRJ‐100 airplane. At the time, weather conditions were broken to overcast clouds with no 

precipitation and good visibility, and the ramp, taxiway, and runway surfaces were dry. 

Also, the taxiway lights were on step 2,88 and the runway 22 high intensity runway lights 

were on step 3, as they were at the time of the accident. (As previously stated, runway 26 

had no lighting.)

The CRJ-100 demonstration airplane was positioned on the ramp near the gate 

from which the accident flight departed. The airplane taxied along the accident taxi route 

and down runway 26 to a point just past the intersection of runway 26 with runway 22; 

afterward, the airplane turned around and taxied down runway 26 to taxiway C and then 

to the ramp.89 Next, the airplane taxied from the ramp to runway 22 using the former 

taxiway A5 (which had been redesignated as taxiway A at the time of the accident). After 

reaching runway 22, the airplane taxied down the runway to taxiway C.

During the taxi demonstration, the runway edge lights south of the intersection 

of runway 22 with runway 26 were dimmer on the right side than on the left side. These 

lights were repaired so that their intensity was returned to normal on both sides of 

runway 22.

Section 1.10.3.1 describes the observations made by the Operations/Human 

Performance investigative team from the CRJ-100 demonstration airplane, and 

section 1.10.3.2 describes the observations made by the ATC investigative team from the 

tower. 

1.10.3.1 Operations/Human Performance Observations

The following observations90 were made by the Operations/Human Performance 

investigative team from a CRJ-100 airplane during the nighttime taxi demonstration:91

At the hold short line for runway 26:

• The black and yellow taxiway location sign for taxiway A and the red and 

white runway holding position sign for runway 26 were visible to the left of 

the airplane. The signs were illuminated.

• The taxiway A yellow centerline split into three lines after the hold short 

position for runway 26.92 The left centerline (referred to as a lead-on/off line) 

arced to the left onto the centerline of runway 26; this path was to the left 

of the white runway 26 numbers. The middle centerline arced slightly to the 

88 The taxiway lights had three settings, steps 1 through 3, with step 3 being the brightest. 

89 Taxiway C is shown on the airport charts in appendix C.

90 The Survival Factors investigative team made similar observations from the 15-passenger van as it 

traveled around the airport.

91 Figures 2 and 3 show the locations referenced in this section.

92 These lines were not outlined in black, as strongly recommended, but not required, by Advisory 

Circular 150/5340-1J, “Standards for Airport Markings,” dated April 29, 2005.
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left across runway 26 to the new taxiway A (designated as taxiway A5 on the 

Jeppesen chart that was current at the time of the accident). The right centerline 

led to former taxiway A (north of runway 8/26), which was blocked by lowprofile barricades with flashing red lights. 93

• The red and white runway holding position sign for runway 22 (which was 

located on taxiway A on the north side of runway 26) was visible. The sign 

was illuminated.

• With the airplane’s taxi lighting configuration (which used lights located in 

the wing root), the white runway 26 numbers were visible to the right of the 

airplane’s nose. The concrete in the area around the numbers was light in color 

and provided relatively low contrast to the numbers. 

• With the airplane’s taxi lighting configuration, the taxiway A yellow centerline 

markings were visible but appeared darker than the surrounding area. With 

the airplane’s takeoff lighting configuration (which included landing lights 

in the airplane’s nose and wing root lights), the markings were visible and 

appeared brighter than the surrounding area.

In position on runway 26:

• White side stripes (edge markings) on runway 26 were illuminated with the 

airplane’s takeoff lighting configuration. The markings appeared bright and 

reflective. With the airplane’s taxi lighting configuration, the markings were 

visible but not as bright.

• The white centerline striping on runway 26 was visible.

• The white runway 26 numbers were positioned behind the airplane and were 

not visible.

• A red and white runway holding position sign for runway 4/22 was visible to 

the left of the airplane’s nose. The sign was illuminated. 

• White edge lights for runway 22 were visible.

• The 2,000-foot black and white distance-remaining marker on the right side of 

runway 26 was not visible.

• The end of runway 26 was not visible with the dark horizon that existed at the 

time.94

• The runway 26 surface was brighter near the airplane than it was farther down 

the runway.

• Blue taxiway lights were visible to the left and the right of the airplane. More 

lights were present on the left than on the right sides.

93 Advisory Circular 150/5340-1J indicates that pavement markings that are no longer needed should be 

physically removed.

94 Operations/Human Performance investigative team members described the view as a “black hole” 

except for red obstruction lights on a shack to the right of runway 26 and on radio towers on the northwest 

side of the airport.
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In position on runway 22 at taxiway A (former taxiway A5):

• White precision runway markings were visible and illuminated with the 

airplane’s takeoff lighting configuration. The white runway 22 numbers were 

visible in front of the airplane.

• White centerline striping for runway 22 was visible and illuminated with the 

airplane’s takeoff lighting configuration.

• White edge lights for runway 22 were visible, and the brightness was balanced 

on the left and right sides of the runway. About 10 pairs of runway edge lights 

were visible. No red runway threshold lights were visible.

• White side stripes for runway 22 were visible, but their appearance was less 

distinct compared with the appearance of the runway 26 side stripes.

• The end of runway 22 was not visible.

• Ramp floodlights and terminal lighting were visible.

1.10.3.2 Air Traffic Control Tower Observations

During the nighttime demonstration, the airplane was clearly visible while on 

taxiway A between taxiway A6 and runway 22.95 The airplane was also clearly visible 

when it taxied from taxiway A to runway 26, although it was difficult to determine whether 

the airplane was actually on runway 26 or was on runway 22 because the approach ends 

of both runways appeared close together.96 As the airplane continued down runway 26 

past its intersection with runway 22, the airplane’s position on runway 26 became more 

discernible because of the lighting on runway 22. As the airplane continued farther along 

runway 26, it became difficult to determine whether the airplane was on runway 26 or 

was located on an adjacent taxiway.

When the airplane taxied from taxiway A to runway 22, it was easy to determine 

that the airplane was on that runway because the runway lights illuminated the airplane. 

Also, as the airplane proceeded down runway 22, the airplane’s location became even 

more discernible because of the additional illumination from its landing lights, which 

appeared brighter than they did when the airplane was on runway 26. 

The flashing red lights on the low-profile barricades located on taxiway A north 

of runway 8/26 were clearly visible from the tower. 

95 Taxiway A6 is shown on the August 3, 2006, NACO chart and the September 8, 2006, Jeppesen chart 

in appendix C.

96 The parking garage lights provided ambient lighting, but it was not enough to distinguish the 

runway surface.
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1.10.4 Postaccident Events

Piper PA-2 Lance Event

On November 9, 2006, a Piper PA-32 Lance was on a Part 91 flight from Shelby 

Municipal Airport, Shelby, North Carolina, to Logan/Cass County Airport, Logansport, 

Indiana, when the pilot decided to land for fuel at LEX.97 The pilot reported that night 

VMC prevailed at the time. 

After his airplane was refueled, the pilot began to taxi to runway 22 for takeoff. 

The pilot mentioned that runway 22 was lit up very well and that runway 26 was dark. He 

stated that, when approaching runway 22, he stopped the airplane before the runway 22 

hold short line because he had to do the runup (preflight checks for airplanes with piston 

engines). The pilot stated that, after the runup was completed, he called the controller to 

report that he was ready to take off. The controller informed the pilot that the airplane 

was on runway 26 and instructed him to taxi the airplane onto runway 22. 

The pilot stated that his airplane was on the taxiway to runway 22 at all times 

and that the airplane had not aligned with runway 26. The pilot also stated that, when he 

stopped the airplane before the runway 22 hold short line, the airplane was apparently 

on runway 26, which likely gave the controller the mistaken impression that the airplane 

would be taking off from runway 26.

Learjet 45 Event

On January 1, 2007, a Learjet 45 (Flexjet flight 428) was on a Part 91 flight from 

LEX to Spirit of St. Louis Airport, St. Louis, Missouri. Night VMC prevailed at the time. 

The airplane was instructed to taxi to runway 22 and then was cleared for takeoff 

while the airplane was still on taxiway A but before it arrived at runway 26. According to 

the captain, he taxied the airplane across the runway 26 hold short line and made a slight 

left turn but did not see the taxiway to runway 22 where he expected to find it.98 The 

captain stated that he then saw the taxiway to his right and that, about the same time, the 

first officer saw the taxiway and pointed it out. Also about the same time, the controller 

informed the flight crew that it looked as if the airplane were lining up on runway 26 

instead of runway 22. The captain stated that the first officer told the controller that they 

saw the taxiway for runway 22. The captain further stated that he turned the airplane 

toward the right and proceeded on taxiway A to runway 22. 

The captain stated that, although the airplane was on runway 26, the airplane 

was never lined up to take off from that runway.99 The first officer stated that he and 

97 Before the time of this event and the next event described in this section, the construction project 

at LEX had been completed, so taxiway A north of runway 8/26 and former taxiway A5 (redesignated as 

taxiway A) no longer existed, and taxiway A7 was in use.

98 The taxiway to runway 22 required a wider left turn and then a straight-ahead path to the runway.

99 The captain added that it was not legal for him to take off from runway 26 because his company’s 

policy did not allow any takeoffs from runways that were less than 4,000 feet. 
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the captain were not confused about the correct runway for takeoff. In addition, the 

first officer stated that he could not see the runway 22 approach lights, and the captain 

stated that he could not see the taxiway A lights, until the airplane had taxied up to the 

centerline of runway 26.

1.11 Flight Recorders

1.11.1 Cockpit Voice Recorder

The airplane was equipped with a Fairchild model A100S solid-state CVR, serial 

number (S/N) 03035. The exterior case of the CVR sustained heat and structural damage, 

but the interior case did not appear to have any heat or structural damage. The audio 

information was extracted normally and without difficulty. 

The CVR was sent to the Safety Board’s laboratory for readout. The CVR recording 

contained four channels100 of good-quality audio data.101 A transcript was prepared of the 

entire 30-minute 29-second digital recording (see appendix B).

1.11.2 Flight Data Recorder

The airplane was equipped with an L-3 Communications Fairchild Model F1000 

FDR, S/N 102368. The FDR recorded flight information in a digital format using solidstate memory as the recording medium.

The FDR was sent to the Safety Board’s laboratory for readout and evaluation. 

The FDR showed evidence of external damage as a result of the postcrash fire, but the 

internal components were in good condition, and the data were extracted normally. 

About 51 hours of data were recorded on the FDR, including about 7 minutes 46 seconds 

of data from the accident flight (from 0558:50 to 0606:36). Because of the damage to the 

airplane during the accident sequence, data recorded during the last second of data were 

invalid, and data for some parameters were invalid beginning 3 seconds before the end 

of the recording.

The accident airplane’s FDR was not in compliance with the carriage requirements 

in 14 CFR 121.344, Appendix M. Specifically, the source of the vertical acceleration 

parameter was not updated at a rate that met the required recording intervals. Also, 

the pitch attitude parameter was recorded at a higher sample rate than the source was 

100 The first through fourth channels were the captain’s station, the first officer’s station, the cockpit area 

microphone, and the frequency shift keying timing signal, respectively.

101 The Safety Board rates the audio quality of CVR recordings according to a five-category scale: excellent, 

good, fair, poor, and unusable. The Board considers a good-quality audio recording to be characterized by 

the following traits: most of the crew conversations could be accurately and easily understood. The transcript 

that was developed might indicate several words or phrases that were not intelligible. Any loss in the transcript 

could be attributed to minor technical deficiencies or momentary dropouts in the recording system or to a large 

number of simultaneous cockpit/radio transmissions that obscured each other. 
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updated. On May 16, 2003, the Safety Board issued Safety Recommendation A-03-15 to 

the FAA because of problems with the quality of FDR data recorded by several regional 

jet airplanes, including the CRJ. Safety Recommendation A-03-15 asked the FAA to do 

the following: 

Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, Canadair 

Challenger CL-600, and Fairchild Dornier 328-300 airplanes be modified 

with a digital flight data recorder system that meets the sampling rate, 

range, and accuracy requirements specified in 14 Code of Federal Regulations

Part 121.344, Appendix M.

The FDR installed on the Pinnacle Airlines CRJ-200 airplane that was involved in 

the October 2004 accident in Jefferson City, Missouri, had the same parameter problem 

as the FDR installed on the Comair airplane. In its final report on the Pinnacle Airlines 

accident,102 the Safety Board stated that, since the time of that accident, the Board had 

downloaded FDR data from seven events involving CL-600-2B19 airplanes (including 

the Comair accident). All of these downloads showed that the FDRs recorded the 

vertical acceleration and pitch parameters from sources that did not meet the recording 

intervals required by 14 CFR 121.344, Appendix M. The Board concluded, in part, that 

the parameter quality problems with the FDR systems installed on CL-600-2B19 airplanes 

needed to be corrected so that future investigations involving these airplane models 

would not be hindered by inaccurate or incomplete data. As a result, on January 23, 2007, 

the Board reiterated Safety Recommendation A-03-15 and classified the recommendation 

“Open—Unacceptable Response.”

1.12 Wreckage and Impact Information

1.12.1 Wreckage Site

No obvious tire marks or skid marks were found on the last 2,000 feet of the 

departure end of runway 26, but tire marks from the left and right main landing gear and 

the nose landing gear were found in the grass immediately off the end of the runway. 

About 130 feet off the end of the runway, the nose landing gear tire marks disappeared, 

but tire marks from the left and right main landing gear were still present. The left and 

right main landing gear tire marks continued for an additional 135 feet. Also, two ground 

rubs that were canted inward were found outboard of the main landing gear tire marks. 

These ground rubs appeared to be consistent with the main landing gear doors. A berm 

was located in this area. 

One of the main landing gear doors was found before the berm, and a few small 

pieces of debris were found beyond the berm. No significant pieces of wreckage were 

102 National Transportation Safety Board, Crash of Pinnacle Airlines Flight 3701, Bombardier CL‐6002B19, N8396, Jefferson City, Missouri, October 14, 2004, Aircraft Accident Report NTSB/AAR-07/01 

(Washington, DC: NTSB, 2007).
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found until the airport perimeter fence, which was located about 380 feet off the departure 

end of runway 26. A perimeter fence gate that was in line with the extended centerline of 

runway 26 was torn from its hinges, and tire marks were found on the top of the gate.

A ground rub and two tire marks, all of which were close to the extended 

runway centerline, were located about 585 and 620 feet, respectively, beyond the end of 

the runway. One of the tire marks appeared to be made by the nose landing gear, and 

the other appeared to be made by a main landing gear, with about 6 feet separating the 

tire marks. The first sizable piece of airplane wreckage, a segment of the wing flap, was 

located about 750 feet beyond the end of the runway and about 70 feet to the left of the 

extended runway centerline.

About 900 feet beyond the departure end of the runway was the first tree strike 

with marks at 6 feet above ground level (agl). The tree had blue paint markings and 

small pieces of wreckage in the bark. A winglet tip was found forward and to the left 

of this tree, and the left winglet was found beyond the tree. The second and third tree 

strikes, with marks at 7 feet agl, were consistent with contact by the airplane at a 20o 

left-wing-down attitude. A section of the outboard wing was found beyond the two 

trees. Along the airplane’s groundpath and about 35 feet beyond the three trees were 10 

additional trees that were sheared off at about the same level but at an increasing height 

(12 feet agl) because the ground sloped downward after the first tree. Minor fire damage 

was observed on the third through ninth trees. Ground scars appeared about 400 feet 

beyond the first tree strike. Fire damage to the ground and four trees in this area was 

observed. The main wreckage was found about 900 feet beyond the first tree strike and 

about 1,800 feet west of the departure end of runway 26. 

1.12.2 Airplane Wreckage

The fuselage had separated into two main sections, and both wings had separated 

from the fuselage. The left and right engines remained attached to the aft fuselage. The 

empennage had separated from the aft fuselage. The left and right main landing gears 

had separated at their respective airframe attachment points, but part of the nose landing 

gear remained attached to the airframe.

Impact forces and postcrash fire damaged the main avionics compartment and the 

components that were installed in the compartment. All of the primary and secondary 

flight control systems were identified in the wreckage, but the impact damage to the 

systems prevented an examination of flight control cable continuity. 

The main cabin door was closed and intact in the door frame. The exterior of the 

door was blackened by heat, and the interior of the door and the interior door handle 

were consumed by fire. The four latch pins were engaged in the door frame in the closed 

position. The forward service door was closed, and the unburned portion was intact 

in the door frame. The exterior door handle was in the closed position, and the interior 

door handle, which was partially consumed by fire, was also in the closed position. The 
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left overwing exit103 was found within the main cabin debris area on the right side of the 

main wreckage area. The exit release handle was in its closed position. The spring-loaded 

securing pins were extended. Portions of the right overwing exit frame and window exit 

were found in a pile of wreckage near their approximate position in the fuselage. The 

spring-loaded securing pins were found extended.

A portion of the captain’s seat frame was found fragmented and burnt about 

15 feet to the left of the cockpit area. The first officer’s seat was found in the cockpit 

separated into two pieces. The flight attendant jumpseat and the passenger seats and 

restraint systems were severely damaged or destroyed by impact forces and postcrash 

fire. 

1.13 Medical and Pathological Information

The Fayette County Coroner’s office examined the remains of the captain, flight 

attendant, and passengers. Their cause of death was “multiple injuries sustained in a 

commercial aviation crash with subsequent fire.” The major pathologic findings for 

these airplane occupants are shown in figure 4 along with injury information for the first 

officer.

Toxicology tests were performed by the FAA’s Civil Aeromedical Institute 

(CAMI) on specimens from the captain and the first officer. Tissue specimens from the 

captain tested negative for ethanol and a wide range of drugs, including major drugs of 

abuse. In addition, the captain’s postmortem examination identified a contact lens over 

the left eye. Blood from the first officer104 tested negative for ethanol and a wide range 

of drugs, including major drugs of abuse, except that a low amount of pseudoephedrine 

was detected.105

The controller took a drug and alcohol test106 at 1330 on the day of the accident in 

accordance with 14 CFR 65.46, “Use of Prohibited Drugs.”107 The results were negative.

103 The overwing exits are located at row 8 (see figure 4 in section 1.13).

104 The specimen from the first officer was collected at 0656 on the day of the accident.

105 Pseudoephedrine is a decongestant that is available without a prescription in various preparations 

that are marketed for the treatment of cold or allergy symptoms. The captain who flew with the first officer on 

August 25 and 26, 2006, stated that the first officer showed no indication of a cold or an allergy during their 

flights.

106 A urine specimen was tested for the presence of alcohol and five drugs: marijuana, cocaine, 

phencyclidine, amphetamines, and opiates.

107 According to the FAA drug testing project manager, drug and alcohol testing is mandatory after any 

fatal accident, and the testing should be complete within 8 hours of the accident. 
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Figure 4. Injury Information According to Seat Assignment

Note: Seat positions showing more than one color indicate more than one reported major pathologic finding 

in the autopsy reports. 

Note: The nonrevenue passenger (who was deadheading to ATL) is not depicted in the cabin because he 

was not assigned a seat.

1.14 Fire

The airplane wreckage showed no evidence of a preimpact fire. The wreckage 

showed postcrash fire damage. 
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1.15 Survival Aspects

The first officer, the only survivor of the accident, received serious, life-threatening 

blunt force injuries. He was rescued from the cockpit wreckage and was immediately 

transported to the University of Kentucky Hospital in Lexington. The first officer was 

discharged to a rehabilitation facility on October 13, 2006, where he remained until 

December 15, 2006.

1.15.1 Emergency Response

A LEX public safety officer108 and a city of Lexington police officer109 were the first 

to arrive at the accident site. According to radio transmission audio recordings from the 

LEX operations center, the LEX public safety officer arrived on scene about 5 1/2 minutes 

after receiving alert 3 notification and located the fuselage about 3 1/2 minutes later. He 

and the police officer from the city of Lexington were able to free the first officer from 

the cockpit wreckage. Another LEX public safety officer arrived on scene while the first 

officer was being extricated. This LEX public safety officer used his sport‐utility vehicle 

to transport the first officer to the hospital rather than wait for an ambulance.110 This LEX 

public safety officer estimated that they arrived at the hospital (located about 7 miles 

from the accident site) before 0630. 

Two 3,000-gallon ARFF vehicles responded to the accident. To reach the accident 

site, the ARFF vehicles traveled about 2 1/2 miles from the ARFF station by way of 

public roads, a dirt road with a significant incline, and off-road terrain. The first ARFF 

vehicle to arrive on scene arrived about 11 minutes after the alert 3 notification and began 

fire suppression immediately using its high-flow turret to knock down most of the fire 

followed by the bumper turret and handlines for additional fire suppression. This ARFF 

vehicle had been directed to the location of the accident by a LEX public safety officer. 

The second ARFF vehicle to arrive on scene began additional fire suppression using its 

high-reach extendable turret.111 The LEX operations center incident report showed that 

the fire was controlled within about 3 minutes. 

108 LEX public safety officers are cross-trained as police officers, firefighters, and emergency medical 

technicians.

109 City of Lexington police officers were notified of the accident by the police department’s dispatcher, 

who had received emergency calls from citizens. 

110 The city of Lexington police officer traveled in the back of the sport-utility vehicle with the first officer.

111 The high-reach extendable turret was equipped with a forward-looking infrared camera. The operator 

of this ARFF vehicle did not activate the camera during the emergency response. After the accident, the 

camera system was modified so that it would activate at the time of engine start. 
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1.16 Tests and Research

1.16.1 Aircraft Performance Study

The Safety Board performed an aircraft performance study for this accident. FDR 

and CVR data were time correlated. The latitude and longitude data recorded on the FDR, 

however, were not sufficient to determine the airplane’s exact position. As a result, the 

Board developed a time history of the accident airplane’s motion to identify the position 

of the airplane in the context of the transmissions recorded on the CVR. To develop 

the time history, the Board integrated acceleration and attitude data from the FDR and 

combined the results with wind and atmospheric data at the time of the accident, airport 

information, and wreckage documentation.

FDR data showed that the airplane began to taxi about 0602:17, about 

2 1/2 minutes after the flight crew initiated the pushback from the gate. FDR data also 

showed that the airplane was stopped at the hold short line for runway 26 from about 

0604:33 to about 0605:23 and that the airplane had taxied across the runway 26 hold short 

line about 0605:24.112 In addition, FDR data showed that the airplane aligned with the 

runway 26 centerline about 0606:00 and began the takeoff roll about 0606:06. The aircraft 

performance data (V1, VR, and V2)113 referenced in the flight paperwork and recorded on 

the CVR assumed a takeoff on runway 22. 

The airplane impacted a berm (located about 265 feet from the end of runway 26) 

about 0606:32. FDR airspeed and altitude data showed that the airplane became 

temporarily airborne after impacting the berm but climbed less than 20 feet off the ground. 

Less than 1 second after impacting the berm, the airplane impacted the airport perimeter 

fence (located 380 feet from the end of runway 26) and experienced a vertical load factor 

of at least 2.5 Gs at that time.114 FDR airspeed and altitude data showed that the airplane 

accelerated about 4.3 knots per second from the time of the takeoff roll to the time that the 

airplane impacted the airport perimeter fence. About 0606:35, the airplane impacted the 

first tree (located about 920 feet from the end of the runway) and experienced a vertical 

load factor of at least 4.0 Gs. 

1.16.2 Takeoff Distance and Accelerate-Stop Calculations

Bombardier provided the Safety Board with accelerate-stop performance 

calculations for runway 26. These calculations showed the point beyond which a CRJ‐100 

could not be stopped on the available runway, even with maximum braking applied. For 

the airplane to stop before the end of runway 26, maximum braking would have had to 

start when the airplane was at an airspeed of 103 knots. This speed would be reached 

112 The airplane did not stop again along the remaining taxiway or the runway.

113 V2

 is the takeoff safety speed. 

114 G is a unit of measurement that is equivalent to the acceleration caused by the earth’s gravity 

(32.174 feet/second2

).
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when the airplane was 1,834 feet down runway 26, leaving 1,667 feet for stopping on the 

runway.

In addition, Bombardier calculated that a CRJ-100 would need 3,593 feet to reach 

a V1

 speed of 135 knots115 and 3,744 feet to start rotation.

1.17 Organizational and Management Information

Comair, Inc., was founded in 1977 and provided service initially to and from 

Cincinnati, Cleveland, and Akron-Canton, Ohio. In 1984 Comair became a Delta 

Connection air carrier. In 1993 the company began to transition from turboprop116 to 

turbojet airplanes with the addition of 40- and 50-passenger seat CRJs to its fleet. In January 

2002 Comair became a wholly owned subsidiary of Delta Air Lines. In 2002 Comair added 

the 70‐passenger-seat CRJ to its fleet and became an all-turbojet operation. 

Comair has its headquarters in Erlanger, Kentucky. At the time of the accident, the 

company served 97 cities in the United States, Canada, and the Bahamas, with an average 

of 772 flights per day, and employed more than 6,400 personnel, including 1,631 pilots 

(825 captains and 806 first officers).

1.17.1 Flight Manuals

1.17.1.1 Taxi Procedures and Briefing

The Comair Operations Manual, chapter 4, section 4.4.1, page 4-23, “General 

Taxi Procedures,” dated September 1, 2005,117 stated that, before taxi, the captain should 

perform the taxi briefing and that, during taxi, the captain should verbalize the essential 

elements of taxi clearances received, emphasizing runway crossings. This section also 

stated that both flight crewmembers should monitor the progress of the taxi by utilizing 

the horizontal situation indicators (HSI), airport diagrams, and airport signage to confirm 

positions. Further, this section stated that, in the event that a taxi clearance would take 

the airplane into a part of the airport that was not briefed or if either flight crewmember 

lacked complete understanding of the taxi clearance, the crew should stop the taxi, refer 

to the airport diagram, and query ATC if required.

Section 4.4.2, page 4-23, “Taxi Briefing,” stated that the captain’s taxi briefing was 

to include Comair standard taxi information. This information was to be briefed in its 

115 As previously stated, the V1

 speed according to Comair was 137 knots. A difference existed between 

Comair’s and Bombardier’s V1

 speeds because Comair computed V speeds using interpolations for airplane 

weight and atmospheric conditions (altitude and temperature), whereas Bombardier computed V speeds using 

the exact airplane weight and atmospheric conditions.

116 The company had operated the Piper Navajo, Piper Chieftain, Embraer EMB-110, Shorts 330, Fairchild 

SA-227, Saab 340, and Embraer EMB-120 turboprop airplanes.

117 All of the taxi procedures in this section were dated September 1, 2005.
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entirety for the first flight as a crew and could be abbreviated to “Comair standard” for 

subsequent flights. The Comair standard taxi information included the following:

• Both flight deck crewmembers will have appropriate airport diagrams out and 

available.

• Complicated or unexpected clearances shall be written down.

• Traversing runways ... requires extra vigilance.

• If unsure of position or instructions ... clear any runways, stop, and call ATC.

Section 4.4.4, page 4-25, “Airport/Field Taxi,” stated that, when clear of the ramp, 

the captain should verbalize the essential elements of the taxi clearance, placing special 

emphasis on runway crossings. 

Section 4.5.5, pages 4-27 and 4-28, “High Threat Taxi Procedures,” stated that flight 

crews were to use high threat taxi procedures when the operating environment presented 

“exceptional” hazards to safe taxi and that these procedures were to be used “when the 

captain deems the operation requires exceptional vigilance.” The section also stated that, 

during these operations, both pilots were to be heads-up during airplane movement and 

that they should monitor the taxi and hold short locations. In addition, the section stated, 

“both pilots must be familiar with the assigned taxi route before aircraft movement. If in 

doubt, remain clear of all runways and contact ATC.”118

1.17.1.2 Checklist Usage

The Comair CRJ Flight Standards Manual, volume I, chapter 3, sections 3.7.3 and 

3.7.6 through 3.7.8, pages 3-60, 3-74, 3-76, and 3-78, dated November 30, 2005, stated that 

the first officer was to perform the before starting engines, taxi, before takeoff, and lineup 

checklists. These checklists contained challenge and response items, which were read by 

the first officer and responded to by the captain, and verbal response items, which were 

verbalized by the first officer. 

The manual also stated that the captain was to call for the taxi, before takeoff, and 

lineup checklists but did not specifically mention which crewmember was to call for the 

before starting engines checklist. According to Comair, although either pilot can call for 

the before starting engines checklist, the captain typically calls for it.

118 Comair used “pink sheets” to supplement airport information shown on Jeppesen charts. The 

pink sheets contained operational procedures and recommendations, including the use of high threat taxi 

procedures when appropriate, for a specific airport. A pink sheet had not been issued for LEX at the time of 

the accident. 
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1.17.1.3 Sterile Cockpit Procedures

The Comair Operations Manual, chapter 5, section 5.13.2, pages 5-61 and 

5-62, “Critical Phases of Flight/Sterile Cockpit,” dated December 1, 2005, stated the 

following:119 

Critical phase of flight includes all ground operations involving taxi, takeoff 

and landing, and all other flight operations conducted below 10,000 ft, 

except cruise flight. Taxi is defined as ‘movement of an aircraft under its 

own power on the surface of an airport.’

No flight crewmember shall perform any duties during a critical phase of 

flight except those duties required for the safe operation of the aircraft.

No flight crewmember may engage in, nor may any pilot-in-command 

permit, any activity during a critical phase of flight which could distract 

any flight crewmember from the performance of his duties or which could 

interfere in any way with the proper conduct of those duties ... such as ... 

engaging in nonessential conversations within the flight deck.

1.17.1.4 Heading Bugs

The Comair CRJ Flight Standards Manual, volume I, chapter 3, section 3.7.3, 

page 3-63, “Before Starting Engines,” dated November 30, 2005, stated that flight 

crewmembers should set course selectors and heading bugs. Volume II of the manual, 

chapter 7, section 7.3.4, “Heading Bug,” dated November 30, 2005, stated that, on 

departure, if a turn is required at or below 400 feet agl, the heading bugs should be set 

to the heading required by ATC, the departure procedure, or the runway heading. This 

section also stated that, if a straight-out departure is planned or a turn is required by 

departure procedures above 400 feet agl, the heading bugs should be set to the runway 

heading.

1.17.1.5 Normal Takeoff

The Comair CRJ Flight Standards Manual, volume II, chapter 7, section 7.4.4, 

pages 7-14 and 7-15, “Normal Takeoff,” dated November 30, 2005, stated that the 

nonflying pilot was to call “V1

” and “rotate” as appropriate. The section also stated that 

the V1 callout should be made so that, upon reaching V1, the callout would be completed. 

In addition, the section stated that, at VR, the flying pilot should rotate the airplane 

smoothly toward the target pitch attitude in one continuous motion at a rate of about 

3o per second.

1.17.1.6 Use of Alcohol

The Comair Operations Manual, chapter 3, section 3.11, page 3-26, “Intoxicants 

and Illicit Drugs,” dated June 10, 2005, stated that a certificated airman would be subject to 

119 These procedures were in accordance with 14 CFR 121.542, “Flight Crewmember Duties.”
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termination if the airman consumed any alcohol within 12 hours of scheduled departure. 

(Title 14 CFR 121.458(d)(1) states that pilots may not perform flight crewmember duties 

within 8 hours of consuming alcohol.)

1.17.1.7 Flight Crew Rest Periods

The Comair Operations Manual, chapter 3, section 3.8.3, page 3-18, “Flight Time 

Limitations and Rest Requirements,” dated June 10, 2005, stated that a pilot’s rest period 

begins 20 minutes either after actual block in or the last scheduled airplane movement or 

when actually released, whichever is later. This section also stated that the rest period 

at a field location ends when the crewmember reports to the gate or operations center 

(45 minutes before departure or 30 minutes before departure if necessary because of 

transportation). Further, the section stated that transportation to and from a local hotel is 

considered to be part of the rest period.

Page 3-20 described the following rest requirements for pilots, which were 

based on the number of scheduled flight hours in the preceding 24 hours of the planned 

completion of each flight segment:120

• For a scheduled flight time of less than 8 hours, the required rest in between 

flights is 9 hours.

• For a scheduled flight time of between 8 and 9 hours, the required rest in 

between flights is 10 hours.

• For a scheduled flight time of 9 or more hours, the required rest in between 

flights is 11 hours.

1.17.1.8 Crew Resource Management

The Comair Operations Manual, chapter 5, section 5.6.1.2, page 5-20, “Crew 

Resource Management,” dated May 15, 2005, stated that the captain was responsible 

for the CRM concept of “authority with participation.” This section also stated that the 

captain was responsible for providing leadership but would also elicit and welcome 

participation from other crewmembers during the conduct of a flight. 

This section further stated that the first officer was responsible for the CRM 

concept of “assertiveness with respect.” In addition, this section stated that the first officer 

would be an integral participant in the safe conduct of a flight and that the first officer 

would interact with the captain in a positive, consistent manner while still honoring the 

captain’s position. 

120 These requirements were in accordance with 14 CFR 121.471(b).
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1.17.2 Crew Resource Management Training

As part of their initial training at Comair, the flight crewmembers received two 

8-hour classes in basic CRM training, a 4-hour class in command leadership, and a 

2-hour class in CRM in automation. At the time of the accident, new captains received an 

additional 3-hour class in command leadership and an additional 2-hour class in CRM 

in automation during their upgrade training. Also, Comair provided a 2-hour “common 

day” class with pilots, dispatchers, and flight attendants in the same class.

In addition, Comair provided CRM training during 2-hour modules in each 

recurrent training cycle. The topics presented during recurrent CRM training included 

teamwork, communication, decision-making, situational awareness, and workload 

management. The course referenced industry CRM guidance, accidents and incidents 

that occurred at Comair and other air carriers, and Safety Board reports and studies. The 

information was presented through lectures and interactive discussions based on event 

scenarios. 

Each CRM recurrent training module contained specific areas of emphasis. For 

example, the 2006 CRM module focused on managing errors and understanding how 

selective attention and selective noncompliance could increase the likelihood of an error. 

Also, the 2005 CRM module focused on understanding and managing the risks associated 

with daily operations and mitigating these risks by applying good decision-making and 

team-building skills. In addition to the CRM training modules, CRM skills were evaluated 

during simulator training, line-oriented evaluations, and checkrides. 

During a postaccident interview, a CRM facilitator instructor (who was also a 

check airman) stated that the CRM training at Comair was excellent. The instructor also 

stated that Comair’s culture encouraged first officers to speak up if a captain has made 

an error and that this aspect of CRM was reinforced during flight training. The instructor 

further stated that, when first officers have not spoken up during line checks after a 

captain has made an error, it was because of a lack of situational awareness rather than a 

hesitancy to speak up. 

Comair captains described CRM training as good. Comair first officers stated that 

they had no difficulties speaking up if they felt rushed or had concerns with the conduct 

of the flight. Also, the principal operations inspector (POI) for Comair stated that there 

had not been a crew interaction problem during the 5 years that preceded the accident.

1.17.3 Safety Program Personnel Initiatives

At the time of the accident, Comair’s corporate compliance committee (which 

comprised the officers and the president of the company) met at least quarterly to review 

safety performance metrics and progress in achieving the company’s safety initiatives. 
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The director of corporate safety reported to the corporate compliance committee. A flight 

safety specialist, an aviation safety action program (ASAP)121 coordinator, and two ASAP 

analysts reported to the director of corporate safety. 

Comair initiated action before the accident to create the position of manager of 

flight safety, but the change to the organizational structure did not occur until the week 

after the accident. The manager of flight safety reports to the director of corporate safety, 

and the flight safety specialist, ASAP coordinator, and two ASAP analysts now report 

to the manager of flight safety. The director of corporate safety stated that flight safety 

department staff provided briefings during initial and recurrent ground schools and 

worked closely with the training department to ensure that flight safety trends, such as 

navigation or altitude deviations, were addressed.

Comair’s written safety policy is published in multiple locations, including the 

employee Web page and the corporate program safety manual. Pilots receive flight‐specific 

safety information through the dispatch release. Pilots receive other relevant flight safety 

information through communications on bulletin boards; the quarterly safety newsletter; 

and “Ops Notes,” which are one-page safety reports.

One way Comair pilots can communicate flight safety concerns is through 

irregular operations reports, which are transmitted to flight operations managers; the 

corporate safety department; and the flight safety department, which tracks and evaluates 

them. Another way that pilots can communicate such concerns is through Comair 

communications logs, which are sent to and reviewed by the flight safety department. 

In addition, another way that pilots can communicate flight safety concerns is 

through the company’s ASAP. From May 2004 to July 2006, the company received more 

than 2,400 ASAP reports.122 The company’s ASAP event review committee meets weekly 

to review ASAP reports. According to Comair, no reports had been received describing 

circumstances related to those of the accident. In addition, the flight safety department 

reviews ASAP and irregular operations reports to monitor trends, and the information 

learned from these reviews is presented at quarterly flight safety committee meetings. 

Deviations that are identified through this process are evaluated so that recommendations 

can be proposed to reduce the deviations. 

The director of corporate safety stated that the company was working toward 

implementation of a flight operations quality assurance (FOQA) program123 by the end of 

2008. The director also stated that the company was examining FAA Advisory Circular 

121 An ASAP is an FAA-approved, voluntary safety program that encourages pilots to report safety 

concerns in a nonpunitive environment, which allows the air carrier and the FAA to act on this information 

before an accident or an incident occurs. An ASAP depends on the willingness of pilots to voluntarily submit 

reports about other pilots or themselves. Comair’s ASAP for pilots began in May 2004.

122 Comair’s ASAP included dispatchers, and the company was working to add maintenance personnel 

to the program. An ASAP can also include flight attendants.

123 A FOQA program is an FAA-approved, voluntary program for the routine collection and analysis of 

FDR data gathered during aircraft operations. 
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(AC) 120-92, “Introduction to Safety Management Systems [SMS] for Air Operators”124

(issued in June 2006), and was moving toward implementing an SMS program.125

In addition, the director stated that Comair was working on a Line Operations Safety 

Audit (LOSA) program;126 had contracted with the University of Texas at Austin, which 

developed the program in 1994 through FAA-sponsored research known as the Human 

Factors Research Project; and was awaiting the support of the company’s local pilot 

union. 

Comair’s corporate safety and compliance departments prepare monthly safety 

performance and compliance reports, which include monthly data showing the number 

of runway incursions reported during the previous 12 months and brief statements 

describing those incursions that occurred during the previous month. For the 12-month 

period ending July 2006, Comair reported 21 runway incursions. None of these incursions 

involved a takeoff from the wrong runway. 

1.17.4 Federal Aviation Administration Oversight

The FAA certificate management office for the Comair certificate is located in 

Atlanta, and the certificate management unit (which handles oversight) is located in 

Louisville, Kentucky. The POI and assistant POI for Comair had been in their positions 

for about 3 1/2 and 2 years, respectively, at the time of the accident. The certificate 

management unit also included two aircrew program managers and a cabin safety 

inspector.

At the time of the accident, the FAA conducted its oversight of Comair through 

the air transportation oversight system (ATOS).127 The Safety Board’s review of ATOS 

records showed that the FAA had conducted more than 120 inspections at Comair 

124 An SMS program incorporates proactive safety methods for air carriers to identify hazards, mitigate 

risks, and monitor the extent that air carriers are meeting their objectives. Program components include safety 

policy, safety risk management, safety assurance, and safety promotion. 

125 On January 23, 2007, as a result of its investigation of the Pinnacle Airlines flight 3701 accident, 

the Safety Board issued Safety Recommendation A-07-10, which asked the FAA to “require that all 14 Code 

of Federal Regulations Part 121 operators establish Safety Management System programs.” On April 13, 

2007, the FAA stated that it began a rulemaking project to meet the International Civil Aviation Organization’s 

deadline of January 1, 2009, for SMS requirements. The FAA also stated that pilot project trials had been 

scheduled to better address issues related to SMS implementation.

126 The LOSA program is an observational process that assesses CRM practices, the management of 

threats to safety, and human error during flight operations. Trained personnel associated with the project 

conduct line observations under conditions of confidentiality so that the operator is provided only with details of 

the observations and no information about the pilots who were involved. As a result, in contrast to a company 

line check, LOSA observations do not result in adverse actions against pilots who did not perform well during 

their observation. Also, LOSA observations have identified rule violations and deviations from procedures, 

which suggested that the pilots being observed did not view the LOSA observers as a threat and would be 

likely to perform in the same manner as they would without an observer present. 

127 In 1998, the FAA established ATOS, which employs a systems safety approach to air carrier oversight. 

The benefits of the ATOS program’s system safety approach to air carrier oversight include a more integrated 

approach to oversight that better identifies risks to system safety and a more effective allocation of oversight 

resources to problem areas. Comair became an ATOS carrier in June 2006; before that time, the FAA conducted 

its oversight of the company under the National Program Guidelines. The guidelines, which have been in effect 

since 1985, are part of a traditional inspection program to ensure that airlines comply with safety regulations.
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between June 2006 and the time of the accident and that the results of these inspections 

were satisfactory. The POI stated that Comair anticipated the oversight system changeover 

and, as a result, had reviewed its processes to determine how they would align with 

ATOS inspection checklists. 

1.18 Additional Information

1.18.1 Witness Information

The two eyewitnesses to this accident were interviewed by the Safety Board. One 

eyewitness was an American Eagle station agent who was on a ramp by a gate when the 

accident airplane taxied past his location at a normal taxi speed. The station agent stated 

that he saw the airplane make a sharp, instead of a slight, turn to the left. He thought the 

flight crew might have made this turn so that the airplane could return to the gate. The 

station agent was not paying attention to the airplane when its engine power increased, 

but he then realized that the airplane was taking off from runway 26. He saw the airplane 

continue down the runway but did not notice if the nose of the airplane rose. The station 

agent then saw and heard an explosion followed by some “pops” and three or four 

smaller explosions. Also, he stated that the runway 22 lights and taxiway lights were 

illuminated. 

The other eyewitness to the accident was a resident of the living quarters portion 

of a horse trailer located on property near the airport. He was at home when he heard a 

“freight train” sound. He then looked outside and saw the accident airplane’s landing 

lights coming toward him. He saw the airplane strike the ground once or twice before 

becoming airborne and striking a group of trees on the property. He estimated that the 

airplane was about 10 feet in the air when it struck the first trees. He stated that he was 

not able to see the airplane after it struck the trees because horse barns on the property 

obstructed his view but that he was able to see fire and smoke at that point. 

1.18.2 Related Federal Aviation Administration Guidance

1.18.2.1 Advisory Circular 120-74A

AC 120-74A, “Parts 91, 121, 125, and 135 Flightcrew Procedures During Taxi 

Operations,” dated September 26, 2003, contained guidelines for establishing standard 

operating procedures to promote safe aircraft ground operations. In a section addressing 

crew verbal coordination on the flight deck, AC 120-74A states, “before entering a runway 

for takeoff, the flightcrew should verbally coordinate to ensure correct identification 

of the runway and receipt of the proper ATC clearance to use it.” Appendix 2 of AC 

120-74A contained information about runway incursion prevention and recommended 

that flight crews “verify that the compass heading approximately matches the runway 

heading and taxiway orientation” to confirm proper runway or taxiway selection. 

Appendix 4 of AC 120-74A contains recommended normal procedures for surface 
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operations and departure and states that, after being cleared onto the active runway, the 

flight crew should “verbally confirm ATC clearance onto [the] active runway with other 

crewmembers and confirm proper runway selection using airport signs and markings 

and the airport diagram.” Appendix 4 also states that, when the airplane is at the takeoff 

end of the runway, the flight crew should “confirm proper runway selection using [the] 

HSI.”

1.18.2.2 Safety Alert for Operators 06013

On September 1, 2006, the FAA issued Safety Alert for Operators (SAFO)128 06013, 

“Flight Crew Techniques and Procedures That Enhance Pre-takeoff and Takeoff Safety,” 

which discussed techniques, procedures, and items for consideration for training 

programs that emphasize safe operations in the pretakeoff and takeoff phases of flight. 

The SAFO provided reminders of existing FAA guidance on ground operations, such 

as AC 20‐74A, and stated that flight crews should “confirm, using the challenge and 

response technique, that the aircraft is actually positioned on the assigned runway by 

reference to the heading indicator.” Also, the SAFO recommended that pilots “use all 

available resources to ensure that the aircraft is positioned on the proper runway” and 

that flight crews of flight management system (FMS)-equipped airplanes “verbally 

announce that the proper runway and departure procedure are selected in the FMS and 

that the aircraft heading agrees with the assigned runway for takeoff.”

1.18.2.3 Certalert 07-01

On January 9, 2007, the FAA issued Certalert 07-01,129 which suggested that airport 

operators supply detailed information about runway and taxiway closures and airport 

construction to air carriers and fixed-base operators on the airport. The certalert indicated 

that this information should be provided both textually and visually. To provide this 

information visually, the certalert suggested that airport operators create diagrams 

that pinpoint the exact location of any runway or taxiway closures and disseminate the 

diagrams by e-mail, through a Web site, or by hand delivery. 

1.18.2.4 Takeoff Clearance Notice

On June 1, 2007, the FAA issued Notice N JO 7110.468, “Takeoff Clearance,” to 

amend the required phraseology for issuing aircraft departure instructions. The notice 

included the following procedures: “when issuing a clearance for takeoff, first state the 

‘runway number followed by the takeoff clearance’” and “if the takeoff clearance is issued 

prior to the aircraft crossing all intervening runways, restate the runway to be crossed in 

conjunction with the takeoff clearance.” The notice indicated that this information would 

be incorporated into FAA Order 7110.65 on February 14, 2008. 

128 FAA Order 8000.87, dated August 29, 2005, established SAFOs and stated, in part, that SAFOs 

conveyed “new important safety information” directly to operators as that information became available but 

that SAFOs were not mandatory. 

129 Certalerts are advisory and cautionary in nature.
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1.18.3 Previous Related Safety Recommendations

1.18.3.1 Flight Crew Operations

Safety Recommendation A-89-15

On March 24, 1989, the Safety Board issued Safety Recommendation A-89-15 

(urgent) as a result of two incidents of pilot deviation that involved departures of U.S. air 

carrier airplanes from the wrong runway at Houston Hobby Airport (HOU), Houston, 

Texas.130 Safety Recommendation A-89-15 asked the FAA to do the following:

Take immediate corrective action, in conjunction with the airport 

authority, to prevent inadvertent takeoffs by air carrier airplanes on 

runway 17 at the Houston Hobby Airport.

On May 1, 1989, the FAA stated that it and the HOU airport authority had posted 

additional guidance signs and issued NOTAMs regarding the closing of runway 17 and 

instructions for taxiing to runway 12R (which intersected runway 17 near the approach 

end of the runway). On the basis of these actions, the Safety Board classified Safety 

Recommendation A-89-15 “Closed—Acceptable Action” on July 12, 1989.

Safety Recommendation A-89-74

Although the Safety Board believed that the actions taken by the FAA and the 

HOU airport authority were responsive toward eliminating additional inadvertent 

departures from runway 17 at HOU, the Board was concerned about preventing similar 

incidents at other airports. The Board thought that the incidents at HOU could have been 

prevented if the flight crews had compared their heading indicators with the runway 

heading as the crews aligned their airplanes with the runway centerline. Also, in its 

final report on the December 23, 1983, accident involving Korean Air Lines flight 84 and 

South Central Air flight 59, the Board found that the Korean Air Lines airplane was on 

the wrong runway and that the flight crewmembers could have made this determination 

if they had compared their heading indicator with the runway heading.131 As a result, on 

July 17, 1989, the Safety Board issued Safety Recommendation A-89-74, which asked the 

FAA to do the following: 

Assure that the ‘Normal Procedures’ section of the operations manuals 

of all air carriers operating under Title 14 Code of Federal Regulations

Parts 121 and 135 requires flightcrews to cross-check the heading 

130 The first incident occurred on January 10, 1989, when Eastern Airlines flight 536, a McDonnell Douglas 

DC-9, struck barricades on rotation during the takeoff roll from runway 17 (which had been closed because 

of construction) and overflew workers and equipment. The flight continued to its destination without further 

incident. The second incident occurred on March 23, 1989, when American Airlines flight 508, a McDonnell 

Douglas MD-82, struck a barricade on rotation during the takeoff roll from runway 17 (which was still closed). 

The flight continued to its destination without further incident. 

131 For more information, see National Transportation Safety Board, Korean Air Lines, McDonnell Douglas 

DC-10-30, HL 7339, South Central Air Piper PA-31-350, N35206, Anchorage, Alaska, December 23, 1983, 

Aircraft Accident Report NTSB/AAR-84/10 (Washington, DC: NTSB, 1984).
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indicator to the runway heading when the airplane is aligned with the 

runway for takeoff. 

On September 28, 1989, the FAA stated that almost every Part 121 and 135 air 

carrier had incorporated the recommended procedure into their before takeoff checklist. 

Nevertheless, the FAA stated that it planned to revise Air Carrier Operations Bulletin 

(ACOB) 8-85-1, “Crewmember Procedures and Responsibilities During Ground Operation 

in Restricted Visibility Conditions,”132 to address this procedure. On August 22, 1990, 

the FAA stated that it revised ACOB 8-85-1, to address the cross-check of the heading 

indicator to the runway heading when an airplane is aligned with the runway for takeoff. 

As a result of this action, the Safety Board classified Safety Recommendation A‐89-74 

“Closed—Acceptable Action” on December 11, 1990.

Safety Recommendations A-06-83 and -84

On December 12, 2006, the Safety Board issued Safety Recommendations A-06-83 

and -84 after identifying that multiple Part 121 operators (including Comair) did not have 

procedures for positively verifying that an airplane is aligned on the correct departure 

runway133 and learning that some Part 121 operators (including Comair) did not provide 

guidance to their pilots about conducting takeoffs at night on unlighted runways.134 Safety 

Recommendations A-06-83 and -84 asked the FAA to do the following: 

Require that all 14 Code of Federal Regulations Part 121 operators 

establish procedures requiring all crewmembers on the flight deck 

to positively confirm and cross-check the airplane’s location at the 

assigned departure runway before crossing the hold short line for 

takeoff. (A-06-83)

Require that all 14 Code of Federal Regulations Part 121 operators provide 

specific guidance to pilots on the runway lighting requirements for 

takeoff operations at night. (A-06-84)

The FAA responded to these recommendations on March 13, 2007. With regard 

to Safety Recommendation A-06-83, the FAA stated that it intended to issue a SAFO 

132 As part of its investigation into the accident, the Safety Board issued Safety Recommendation 

A‐84‐102, which asked the FAA to “require that air carriers incorporate in training of their crewmembers 

procedures and responsibilities during ground operations in restricted visibility conditions to enable them 

to operate safely in such conditions.” In response, the FAA issued ACOB 8-85-1 in May 1985. The Board 

classified Safety Recommendation A‐84‐102 “Closed—Acceptable Action” on September 12, 1985.

133 On March 23, 2007, Comair revised its operations manual to include a section titled, “Departure 

Runway Check.” This section states the following: “when taxiing onto the runway for departure, both flight 

crewmembers must check airplane heading to ensure that the heading corresponds to the assigned departure 

runway. The heading check must be used in conjunction with external cues to confirm the correct runway.” 

This procedure was added to the company’s lineup checklist. 

134 The Safety Board’s postaccident survey of Part 121 operators revealed inconsistencies among those 

operators with rules governing or prohibiting takeoff operations from an unlighted runway at night. For example, 

one operator prohibited such takeoffs unless the flight crew was given permission from the company’s director 

of operations, who evaluated the risks involved. Another operator authorized takeoffs on unlighted runways 

as long as the visibility was adequate and enough ambient light was available for the flight crew to identify the 

runway surface and maintain directional control during the takeoff roll. 
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recommending that “directors of safety, directors of operations, trainers, and pilots 

develop and implement explicit standard operating procedures to be contained in pilots’ 

operating manuals, supported in their training, and practiced in daily operations.” The 

FAA also stated that the SAFO would “emphasize the importance of making a final 

confirmation that the airplane is on the assigned runway once it has crossed the hold short 

line onto the runway.” (SAFO 07003, “Confirming the Takeoff Runway,” was issued on 

April 16, 2007.) The FAA further stated that it would also consider addressing this issue 

in Part 121 training requirements. 

With regard to Safety Recommendation A-06-84, the FAA stated that it planned to 

issue an Information for Operators (InFO) message135 that would reach directors of safety, 

directors of operations, trainers, and pilots in Parts 121, 125, 135, and 91. The InFO was 

expected to make two points: “no runway lights, no takeoff at night” and “no takeoff on 

a closed runway.” The FAA stated that the InFO would also recommend that directors of 

safety, directors of operations, trainers, and pilots of air carriers operating under Part 121

collaborate to include these key points in their pilots’ manuals and training programs 

and to have pilots apply the key points during flight operations. (InFO 07009, “Runway 

Lights Required for Night Takeoffs in Part 121, was issued on May 11, 2007.) 

The Safety Board’s analysis of the FAA’s actions in response to Safety 

Recommendations A-06-83 and -84 and the Board’s classifications for the recommendations 

are discussed in section 2.4.1.

1.18.3.2 Air Traffic Control

Safety Recommendation A-00-67

On July 6, 2000, the Safety Board issued Safety Recommendations A-00-67 and ‐68 

to address safety issues related to runway incursions and other airport surface events. 

Safety Recommendations A-00-67 and -68 asked the FAA to do the following:

Amend 14 Code of Federal Regulations (CFR) Section 91.129(i) to require 

that all runway crossings be authorized only by specific air traffic 

control clearance, and ensure that U.S. pilots, U.S. personnel assigned 

to move aircraft, and pilots operating under 14 CFR Part 129 receive 

adequate notification of the change. (A-00-67)

Amend Federal Aviation Administration Order 7110.65, “Air Traffic 

Control,” to require that, when aircraft need to cross multiple runways, 

air traffic controllers issue an explicit crossing instruction for each 

runway after the previous runway has been crossed. (A-00-68)

135 On October 20, 2006, the FAA issued Order N8000.91 to establish a method of sending information 

to operators in a timely manner. According to the order, an InFO message contains “valuable information for 

operators that should help them meet administrative requirements or certain regulatory requirements with 

relatively low urgency or impact in safety.” InFO messages are not mandatory. 
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In an April 11, 2006, letter to the FAA, the Safety Board stated that it met with the 

FAA on June 30, 2005, to discuss safety recommendations related to runway incursions. 

During the meeting, the FAA cited its study of 1,300 runway incursion events involving 

pilot deviations and controller operational errors. The FAA found that only 28 of the 

1,300 events included the use of 14 CFR 91.129(i) as a causal factor. The Board expressed 

concern with the FAA’s findings and noted that, during the first 6 months of 2005, the 

Board identified six cases that were relevant to Safety Recommendations A‐00‐67 and ‐68. 

Because the Board found six cases in a 6-month period using a more limited set of data 

than the FAA, the Board questioned whether the FAA considered the most appropriate 

data source for its study and whether the FAA might have applied criteria in the study 

that were too restrictive. 

During the June 2005 meeting, the FAA also stated its belief that no safety 

problem existed when proper procedures were followed and that pilots should never 

cross a runway unless authorized to do so. The Safety Board’s April 2006 letter expressed 

concern about situations in which pilots might be lost or pilots might believe that they 

had received permission to move to a position that was different than the one that the 

controller intended. Thus, because 14 CFR 91.129(i) allows pilots to cross a runway 

without requesting a specific clearance to do so, the regulation may not provide adequate 

protection against simple, individual mistakes that can have catastrophic consequences. 

Accordingly, the Board classified Safety Recommendations A-00-67 and -68 “Open—

Unacceptable Response.”

Safety Recommendations A-07-30 through -32

On April 10, 2007, the Safety Board issued Safety Recommendations A-07-30 and 

‐31 to the FAA and A-07-32 to the National Air Traffic Controllers Association (NATCA) 

as a result of the Board’s concern about the effects of fatigue on air traffic controllers’ 

performance. Safety Recommendations A-07-30 and -31 asked the FAA to do the 

following:

Work with the National Air Traffic Controllers Association to reduce the 

potential for controller fatigue by revising controller work-scheduling 

policies and practices to provide rest periods that are long enough for 

controllers to obtain sufficient restorative sleep and by modifying shift 

rotations to minimize disrupted sleep patterns, accumulation of sleep 

debt, and decreased cognitive performance. (A-07-30)

Develop a fatigue awareness and countermeasures training program 

for controllers and for personnel who are involved in the scheduling 

of controllers for operational duty that will address the incidence 

of fatigue in the controller workforce, causes of fatigue, effects of 

fatigue on controller performance and safety, and the importance of 

using personal strategies to minimize fatigue. This training should be 

provided in a format that promotes retention, and recurrent training 

should be provided at regular intervals. (A-07-31)
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Safety Recommendation A-07-32 asked NATCA to do the following:

Work with the Federal Aviation Administration to reduce the 

potential for controller fatigue by revising controller work-scheduling 

policies and practices to provide rest periods that are long enough for 

controllers to obtain sufficient restorative sleep and by modifying shift 

rotations to minimize disrupted sleep patterns, accumulation of sleep 

debt, and decreased cognitive performance. (A‐07-32)

On July 5, 2007, the FAA responded to Safety Recommendations A-07-30 and ‐31. 

Regarding Safety Recommendation A-07-30, the FAA stated that it had convened a 

working group to develop shift rotation and scheduling guidelines. According to the 

FAA, this working group would be chaired by an FAA quality assurance safety manager 

and a CAMI human factors fatigue expert, and the group would consist of members of 

the FAA’s Air Traffic Organization operational service units and operations planning 

service unit. The FAA stated that NATCA would be invited to participate by providing 

subject matter expertise.

Regarding Safety Recommendation A-07-31, the FAA stated that it would develop 

and implement a fatigue awareness and countermeasures training program to be used 

by all Air Traffic Organization operational service units. The FAA also stated that its 

director of technical training would be the lead for the development and implementation 

of the curriculum and that CAMI fatigue experts would be providing technical support. 

In addition, the FAA stated that the modules being developed for initial training of 

TRACON, tower, and en route ATC specialists would incorporate fatigue awareness 

information and that initial curriculum content would be developed within 12 months.

The Safety Board’s analysis of the FAA’s actions in response to Safety 

Recommendations A-07-30 and -31 and the Board’s classifications for the recommendations 

are discussed in section 2.2.3.3. Safety Recommendation A-07-32 is currently classified 

“Open—Await Response.” 

Safety Recommendation A-07-34

On April 10, 2007, the Safety Board issued Safety Recommendation A-07-34 to 

the FAA as a result of the Board’s concern about issues related to controller vigilance, 

judgment, and safety awareness. Safety Recommendation A-07-34 asked the FAA to do 

the following: 

Require all air traffic controllers to complete instructor-led initial and 

recurrent training in resource management skills that will improve 

controller judgment, vigilance, and safety awareness.

On July 13, 2007, the FAA stated that it had delivered CRM workshops, posters, 

and follow-up support to the Phoenix, Chicago, Boston, and Los Angeles ATCTs and the 

Las Vegas, Philadelphia, and Miami ATCTs and TRACONs. The FAA also stated that 

the CRM implementation plan for fiscal years 2007 through 2009 included instructor‐led 
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training at “a percentage of” the highest-error-rate terminal and en route facilities 

and CRM training for initial hires in the FAA Academy and college training initiative 

programs. The FAA further stated that it would develop plans to train additional 

controllers on an initial and a recurrent basis.

The Safety Board’s analysis of the FAA’s actions in response to Safety 

Recommendation A-07-34 and classification for the recommendation are discussed in 

section 2.2.3.2. 

1.18.4 Related Accident and Incidents

In addition to the 1989 Eastern Airlines flight 536 and American Airlines flight 508 

incidents at HOU and the 1983 Korean Air Lines flight 84/South Central Air flight 59 

accident in Anchorage (see section 1.18.3.1), the Safety Board has identified the following 

related accident and incidents:

Singapore Airlines Flight 006 Accident

On October 31, 2000, Singapore Airlines flight 006, a Boeing 747, crashed during 

an attempted takeoff from a partially closed runway at Chiang Kai-Shek International 

Airport, Taoyuan, Taiwan.136 Of the 179 occupants aboard the airplane, 83 were killed. 

The report by Taiwan’s Aviation Safety Council found that the pilots did not adequately 

review the taxi route to ensure that they understood that the route to runway 5L (the 

correct departure runway) required passing runway 5R (a parallel runway that was 

under construction and open only for taxi operations). The report also stated that the 

pilots did not verify the airplane’s position with the taxi route as they were turning onto 

the runway and that the company’s operations manual did not include a procedure to 

confirm an airplane’s position on the active runway before initiating takeoff. The report 

concluded that the flight crew lost situational awareness and took off from the wrong 

runway despite numerous available cues that provided information about the airplane’s 

position on the airport.137 The Aviation Safety Council recommended that Singapore 

Airlines “include in all company pre-takeoff checklists an item formally requiring positive 

visual identification and confirmation of the correct takeoff runway.”

China Airlines Flight 011 Incident

On January 25, 2002, China Airlines flight 011, an Airbus A340, departed from a 

taxiway at Ted Stevens Anchorage International Airport, Anchorage, Alaska, instead of the 

assigned runway. The available distance on the taxiway was 6,800 feet, but the airplane’s 

calculated takeoff distance was 7,746 feet. The airplane took off, but its main landing gear 

left impressions in a snow berm at the end of the taxiway. The airplane proceeded to 

136 In accordance with the provisions of Annex 13 to the Convention on International Civil Aviation, the Safety 

Board participated in the investigation of this accident as a representative of the State of Manufacture.

137 Aviation Safety Council, Crashed on a Partially Closed Runway During Takeoff, Singapore Airlines 

Flight 006, Boeing 747-400, 9V-SPK, CKS Airport, Taoyuan, Taiwan, October 31, 2000, Aircraft Accident 

Report (Taiwan, Republic of China: Aviation Safety Council, 2002).
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its destination and landed without further incident. The Safety Board determined that 

the probable cause of this incident was the captain’s selection of a taxiway instead of a 

runway for takeoff and the flight crew’s inadequate coordination of the departure, which 

resulted in a departure from a taxiway. The Board determined that a contributing factor 

to the incident was the lack of an operator requirement for the flight crew to verbalize 

and verify the runway in use before takeoff.138 As a result of this incident, China Airlines 

modified its Airbus A340 operating manual to include verbalization and verification of 

the runway in use.

Alaska Airlines Flight 61 Incident

On October 30, 2006, Alaska Airlines flight 61, a Boeing 737, took off from 

runway 34R instead of runway 34C (center), which was the assigned runway, at 

Seattle‐Tacoma International Airport (SEA), Seattle, Washington. The airplane continued 

uneventfully to its destination of Juneau International Airport, Juneau, Alaska.139

According to the captain of the flight, the ATIS that was current at the time 

indicated that departing aircraft were taking off either with the full length of runway 34R 

or at the point where the runway intersected taxiway Q. The first officer of the flight 

stated that the takeoff briefing included a departure from runway 34R. 

The captain stated that the controller instructed the flight crew to follow a 

Boeing 757 to runway 34R and that the 757 departed from runway 34R where the runway 

intersected taxiway Q. The captain also stated that the controller instructed the crew to 

taxi the airplane into position and hold on runway 34C. Further, even though he repeated 

this information to the controller, the captain was still thinking that the airplane would 

be taking off from runway 34R. During this time, the first officer was completing flight 

paperwork and conducting other preflight activities. 

After receiving takeoff clearance from runway 34C from the controller, the captain 

stated that he lined up the airplane on runway 34R and transferred control of the airplane 

to the first officer. The airplane departed uneventfully from runway 34R. 

According to the controller, he was scanning the runways and noticed that the 

airplane was rolling on runway 34R abeam the tower instead of runway 34C. Because 

there were no potential air traffic conflicts at the time, the controller thought that it would 

be safer to let the airplane depart from runway 34R than to have the pilots abort the 

takeoff. After the airplane had taken off, the controller informed the flight crew that the 

airplane had departed from the wrong runway.

138 More information about this accident, ANC02IA011, is available at the Safety Board’s Web site at 

<http://www.ntsb.gov>.

139 More information about this accident, DCA07IA008, is available at the Safety Board’s Web site at 

<http://www.ntsb.gov>.
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United Airlines Flight 1404 Incident

On April 18, 2007, about 0625, United Airlines flight 1404, an Airbus A320, taxied 

onto a closed runway at Miami International Airport (MIA), Miami, Florida, and began 

its takeoff roll. Night VMC prevailed at the time. A NOTAM indicated that runway 9/27 

was closed from 2300 on April 17 to 1000 on April 18; the NOTAM was included in the 

flight release paperwork. The runway closure was also included in the ATIS information 

broadcast. 

The flight crewmembers reported that they had the airport charts out and 

available. The controller told the flight crew to taxi the airplane to runway 30. The captain 

stated that he observed taxiway S almost directly opposite from the airplane’s position 

and chose to make a left turn from taxiway S onto taxiway Q. This parallel taxi route 

placed the airplane adjacent to runway 30, the assigned runway for takeoff. The captain 

stated that, as the airplane passed the intersection with taxiway T, he verified that the 

runway sign was for runway 30. The first officer stated that, during this time, he was 

busy with flight paperwork and was accomplishing flight control checks.

Taxiway Q made a slight bend to the left after the intersection with taxiway T so 

that the taxiway was parallel with runway 27. The captain stated that he saw a runway, 

which he believed to be runway 30, when he looked to the right.

The first officer called the tower and advised that the airplane was ready to depart 

on runway 30. The controller cleared the airplane for takeoff from runway 30 while the 

airplane was still on taxiway Q. The first officer acknowledged the clearance for takeoff 

but did not state the runway number for the departure. The captain stated that, as the 

airplane neared the end of taxiway Q, he observed the hold short line and that, because 

the airplane was cleared for takeoff, he chose to turn directly onto the runway without 

stopping and transfer control of the airplane to the first officer. The first officer stated that 

his heading display was rotating to the right and in the correct direction to line up with 

the runway, which was still located to the right. 

The first officer stated that he advanced the throttles, and, just before they reached 

the cruise thrust position, the airplane’s nose wheel light illuminated a truck flashing its 

lights on the right side of the runway. The captain and the first officer stated that they 

observed the truck at the same time. Simultaneously, the controller was querying the 

flight crew to determine whether the airplane was on runway 30. The first officer rejected 

the takeoff, and the captain assumed control of the airplane. 

Ramp personnel called the tower to advise that an airplane was on a closed runway, 

and the controller acknowledged this information. The controller subsequently advised 

the crew to use caution for workers and equipment on runway 27 and instructed the 

flight crew to taxi the airplane to runway 30. The airplane then took off to its destination 

airport—Dulles International Airport, Chantilly, Virginia—without further incident. 
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The pilots reported that the runway 27 edge lights were on. However, an airport 

engineer who witnessed the incident stated that he immediately scanned runway 27 after 

the event and noted that the runway edge lights were off.

1.18.5 Aviation Safety Reporting System Reports

The National Aeronautics and Space Administration’s aviation safety reporting 

system (ASRS) showed 114 reports of incidents from March 1988 to September 2005 in 

which flight crews of turbojet airplanes lined up on the wrong runway for takeoff. The 

ASRS reports indicated that wrong runway takeoff events involved both intersecting and 

parallel runways.The ASRS reports also indicated that the pilots involved in these events, 

pilots of other aircraft in the area at the time, or air traffic controllers detected the mistake 

either before or after takeoff. 

An ASRS report submitted in 1993 by an air carrier pilot operating out of LEX 

stated that the flight had been cleared for an immediate takeoff on runway 22 but that, 

because of the weather, the flight crewmembers told the controller that they “needed 

a moment to check departure routing with weather radar.” The report further stated 

that the flight crew realized that the airplane’s heading was not correct for the assigned 

runway and that “at that moment [the] tower called ... to cancel takeoff clearance because 

[the airplane was] lined up on runway 26.” The pilot who submitted the report cited poor 

visibility and rain as factors in this event along with a “confusing” runway intersection in 

which multiple runway ends were in the same general location. 

1.18.6 Local Notices to Airmen Information

FAA Order 8400.10, “Aviation Safety Inspectors Handbook,” volume 3, chapter 6, 

states the following in paragraph 1151, “Flight Information”:

NOTAM (L) or local information includes such information as airport 

and taxiway construction and certain airport lighting. This information is 

directly relevant to surface movement guidance and control. NOTAM (L) s 

can also contain information that is expected to be in effect for less than 

1 hour concerning NAVAIDS [navigational aids], lighting, and runways. 

NOTAM (L)s are not normally transmitted beyond the area of coverage for 

the local FSS [flight service station] or automated flight service station.[140]

LEX sends local NOTAMs via fax to its airport tenants. At Comair, the 

local NOTAMs are received by the System Operations Control Center at company 

headquarters. The local NOTAMs are then taken to the System Operations Control 

Center’s performance analyst, who reviews the local NOTAM. If the analyst determines 

140 The other NOTAM categories are distant NOTAMs, which include information such as navigational 

aids, landing areas, and airport lighting facilities, and flight data center NOTAMs, which are regulatory in nature. All 

distant and flight data center NOTAMs are disseminated globally by the FAA and are included in flight dispatch 

paperwork.
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that the information might have an impact on a flight’s schedule, then the analyst 

forwards the local NOTAM to Comair’s planning performance group, which might 

make an adjustment to the schedule. If the analyst determines that the information in the 

local NOTAM might have an operational impact on the flight, then the analyst sends the 

information to the flight standards department for review. The department might decide 

to issue the local NOTAM as a company NOTAM. All company NOTAMs are included 

in the flight planning system and the flight dispatch paperwork. 

In a July 2007 meeting, the FAA told the Safety Board that it was planning to 

align the U.S. NOTAM system with that of the International Civil Aviation Organization 

(ICAO)141 in October 2007, at which time local NOTAMs would be converted to distant 

NOTAMs (because ICAO does not have local NOTAMs). According to the FAA, aligning 

with ICAO’s standard NOTAM procedures will help U.S. NOTAM information be 

processed in a more timely, accurate, complete, and traceable manner. The FAA indicated 

that training on new NOTAM policies and procedures would begin in August 2007. 

Also, the FAA has other planned actions to modernize the current NOTAM system; 

these actions include having digital NOTAM data displayed in the cockpit in textual and 

graphical formats.142 

1.18.7 Enhanced Taxiway Centerline Markings and Surface Painted 

Holding Position Signs

In 2002, the FAA’s Office of Runway Safety and Operation Services sponsored 

a study to determine whether it was feasible to use paint markings to improve the 

situational awareness of pilots taxiing on the airfield. The study, which was undertaken 

by the Mitre Corporation, comprised an aviation industry team and a human factors 

team. 

A January 2005 Mitre Corporation report found that enhanced taxiway centerline 

markings (that is, parallel yellow dashed lines on a black background that appear on 

either side of a taxiway centerline for 150 feet before a runway holding position marking) 

provided “beneficial redundancy” to pilots and increased awareness that the pilots 

were entering the runway environment.143 The report also found that surface painted 

holding position signs (that is, white runway numbers on a red background that appear 

just before a runway holding position marking) were effective in increasing runway 

awareness among transport-category pilots. In spring 2005, authors of this report stated 

the following:144

141 The ICAO Council, among other things, adopts standards and recommended practices concerning 

air navigation.

142 This information was discussed at the FAA’s May 2007 “NOTAM Industry Day” briefing.

143 Cheryl R. Andrews, Steven L. Estes, Dr. Peter M. Moertl, and B. Oscar Olmos, Summary of Airport 

Surface Marking Project, Product No. 05W0000005, McLean, Virginia: Mitre Corporation, 2005.

144 Steven Estes, Oscar Olmos, Cheryl Andrews, Anthony D. Andre, Susan Chrysler, and Dan Hannon, 

“Better Taxiway Surface Markings: Safer Airports,” Ergonomics in Design, Spring 2005.
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Surface painted holding position signs meet several design goals. The 

orientation of the text supports directional information ... they are also easy 

to understand because they mirror existing vertical signage and airport 

marking standards ... they are easier to find because they are collocated 

with the hold line. 

Figure 5 shows an example of enhanced taxiway centerline markings and surface 

painted holding position signs. Enhanced taxiway centerline markings are not currently 

required, but, by June 30, 2008, all Part 139 airports with 1.5 million or more annual 

passenger enplanements will be required to have these markings before each runway 

holding position. Surface painted holding position signs are currently required only 

where the width of the holding position on the taxiway is greater than 200 feet.

Figure 5. Enhanced Taxiway Centerline Markings and Surface Painted Holding 

Position Signs

1.18.8 Department of Transportation Inspector General Report

The Department of Transportation Inspector General’s (DOT/IG) office issued a 

report, dated March 16, 2007, that presented the results of the office’s review of staffing 

at combined radar approach control and tower with radar facilities.145 The report stated 

that the FAA’s vice president of terminal services issued verbal guidance in August 2005 

indicating that two controllers should normally be on duty at those facilities that have 

145 U.S. Department of Transportation, Review of Staffing at FAA’s Combined Radar Approach Control 

and Tower With Radar Facilities, Report Number AV-2007-038 (Washington, DC: DOT, 2007).

16 - 34 16 - 34

Hold short line

Surface painted

holding position sign

Surface painted

holding position sign

Enhanced taxiway

centerline markings
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radar and tower functions. The report also stated that the vice president expected his 

area directors to disseminate this guidance to their hub managers who, in turn, would 

disseminate the guidance to facility managers. The DOT/IG found that, because the 

guidance was verbal, it was misinterpreted and inconsistently applied. 

The DOT/IG reviewed a statistical sample of 20 randomly selected weeks of 

staffing data (between August 28, 2005, and September 2, 2006) for the midnight shift 

at 15 of 62 facilities (a total of 2,100 shifts). The review identified 234 midnight shifts 

during which only one controller was scheduled. On the basis of this finding, the 

DOT/IG statistically projected (with a 95-percent confidence level) that about 2,563, or 

11.1 percent of the 23,002 total midnight shifts at the 62 facilities were staffed with one 

controller between August 28, 2005, and September 2, 2006. The report noted that the 

number of noncompliant facilities was higher at the beginning of the sample period than 

toward the end.

The DOT/IG also found evidence suggesting that, even when two controllers 

were on duty during the midnight shift, the radar and tower duties were combined for 

substantial periods instead of being staffed separately. The report stated that position logs 

at several facilities showed that the two controllers on duty alternated between working 

the combined position and taking breaks. 

In addition, the DOT/IG found that, before the Comair accident, the FAA had no 

controls in place to ensure that facilities had consistently implemented the verbal staffing 

policy guidance and were uniformly complying with it. The report noted that, after the 

accident, the FAA formalized the verbal guidance into Notice N JO 7210.639.

The DOT/IG recommended that the FAA communicate in writing all future 

guidance changing or reiterating existing air traffic policies and procedures to ensure 

uniform implementation and compliance. The DOT/IG also recommended that the FAA 

develop and implement appropriate policies and procedures to ensure that facilities are 

complying with the provisions of FAA Notice N JO 7210.639. 
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2. Analysis

2.1 General

The captain and the first officer were properly certificated and qualified under 

Federal regulations. There was no evidence of any medical or behavioral conditions 

that might have adversely affected their performance during the accident flight. Before 

reporting for the accident flight, the flight crewmembers had rest periods that were longer 

than those required by Federal regulations and company policy. 

The accident airplane was properly certified, equipped, and maintained in 

accordance with Federal regulations. The recovered components showed no evidence of 

any structural, engine, or system failures.

Weather was not a factor in this accident. No restrictions to visibility occurred 

during the airplane’s taxi to the runway and the attempted takeoff. The taxi and the 

attempted takeoff occurred about 1 hour before sunrise during night VMC and with no 

illumination from the moon.

This analysis discusses the taxi and attempted takeoff sequence and the associated 

human factor issues, survival factors, efforts to mitigate surface navigation errors, ATC 

staffing, and other issues related to the accident flight. 

2.2 Taxi and Attempted Takeoff Sequence

The pilots attempted to take off from a different runway than the airplane had 

been cleared to use. Section 2.2.1 details the events leading to the attempted takeoff, 

section 2.2.2 considers the pilot human factors that might have played a role in this 

surface navigation error, and section 2.2.3 explains the ATC human factors that might 

have played a role. 

2.2.1 Wrong Runway Departure

2.2.1.1 Before Taxi Activities

The Comair Operations Manual indicated that the captain was to conduct the taxi 

briefing. The briefing was 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 flight as a crew and could be abbreviated to 

“Comair standard” for subsequent flights. The accident flight was the pilots’ first flight 
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as a crew, but, about 0556:14, the captain stated “Comair standard” instead of all of the 

information in that portion of the taxi briefing, including that runway 26 was to be crossed 

while navigating to runway 22. The abbreviated briefing was contrary to company policy, 

and the Safety Board notes that it is prudent for pilots to fully conduct taxi briefings 

according to standard operating procedures. However, despite this abbreviated briefing 

(which occurred about 10 minutes before the accident), multiple and more salient cues 

existed to aid the flight crew while navigating to the runway, and the airport navigation 

task was relatively simple,146 as discussed in this analysis. 

The first officer was the flying pilot for the accident flight. About 0557:23, he 

briefed the taxi route as part of the takeoff briefing,147 stating, “let’s take it out and ... take 

... [taxiway] Alpha. Two two’s a short taxi.” Although the CVR did not record either 

pilot explicitly referencing the airport chart, this statement is consistent with the first 

officer examining the chart because no specific taxi instructions had been provided to 

the flight crew. Also, the number of times that each crewmember had previously arrived 

at or departed from LEX was likely not sufficient to allow either one to have memorized 

taxiway identifiers and routes. 

During the takeoff briefing, the first officer stated that the runway end identifier 

lights were out and then commented, “came in the other night it was like ... lights are 

out all over the place.” The first officer was referring to observations he made on a 

repositioning flight that landed on runway 22 about 0140 on the day before the accident. 

(The right runway edge lights after the intersection of runway 22 with runway 26 were 

out at that time.)

The first officer did not brief that the taxi to runway 22 required crossing runway 26. 

The Safety Board was unable to determine why this information was not included in the 

first officer’s briefing. It is possible that the simplicity of the taxi and the use of only one 

taxiway might have led him to assume that it was unnecessary to include this additional 

information in his briefing. During postaccident interviews, other pilots indicated that 

they would brief this “short taxi”148 in a similar manner. No evidence indicated that the 

pilots were unaware of the need to cross runway 26 to arrive at runway 22. 

About 0602:01, the first officer notified the controller that the airplane was ready 

to taxi. The controller then instructed the flight crew to taxi the airplane to runway 22. 

Title 14 CFR 91.129(i), “Takeoff, Landing, Taxi Clearance,” permits pilots instructed to 

taxi to a point on the airport surface to cross all intersecting runways along the taxi route 

(without stopping) except for the assigned departure runway.149 Thus, the controller’s 

clearance for the airplane to taxi to runway 22 complied with 14 CFR 91.129(i), and the 

first officer’s response of “taxi two two” was an appropriate acknowledgment of the taxi 

146 Comair’s high threat taxi procedures are used at those airports with an operating environment that 

presented “exceptional” hazards to safe taxi. However, these procedures were not in place for operations at 

LEX at the time of the accident. 

147 As stated in section 1.1, the takeoff briefing is part of the before starting engines checklist.

148 Taxiway A is used for the taxi to both runways 4 and 22, but the taxi to runway 22 is significantly 

shorter than the taxi to runway 4, as shown on airport charts (see appendix C).

149 This regulation is discussed further in section 2.4.4.
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instruction. Because two airplanes, SkyWest flight 6819 and American Eagle flight 882, 

were given the same taxi clearance and had already correctly taxied to and held short 

of runway 22 without any special instructions, there was no apparent reason for the 

controller to have suspected that the pilots would have had difficulty navigating to the 

departure runway.150

2.2.1.2 Taxi to Runway

From about 0603:16 to 0603:56, while the captain was taxiing the airplane and 

performing navigational checking activities, both pilots resumed the nonpertinent 

discussion that was started while the airplane was parked at the gate. (Figure 1 shows the 

location of the airplane along the taxi route while this conversation was occurring.) The 

nonpertinent conversation was not in compliance with the sterile cockpit rule required 

by company procedures and 14 CFR 121.542 (see section 1.17.1.3). The primary reason 

for the sterile cockpit rule is to ensure that the pilots’ attention is directed to operational 

concerns during critical phases of flight (including taxi) and is not redirected or degraded 

because of nonessential activities or discussion. 

FDR data showed that, about 0604:33, the airplane stopped on taxiway A at the 

hold short line for runway 26, which was about 560 feet from the intended destination—

the hold short line for runway 22. During this time, the first officer was completing the 

before takeoff checklist. About 0605:15, the first officer advised the controller that the 

airplane was ready to depart, and the controller told the flight crew that the airplane 

should fly the runway heading and was cleared for takeoff. Neither the first officer nor 

the controller stated the runway number during the request and clearance for takeoff, but 

ATC procedures did not require them to do so. Because the flight crew believed that the 

airplane was at the hold short line for runway 22 at the time of the takeoff clearance (see 

section 2.2.2.3), the absence of a reference to runway 22 in the request and clearance for 

takeoff was not a factor in this accident. 

The 50-second timeframe during which the airplane was stopped at the runway 26 

hold short line should have provided the flight crew with ample time to look outside the 

cockpit and determine the airplane’s position on the airport. 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.151

FDR data showed that, about 0605:24, the captain began to taxi the airplane across 

the runway 26 hold short line. FDR data also showed that, about 0605:41, the airplane 

began to turn onto runway 26, and the CVR showed that, about 0605:46, the first officer 

completed the lineup checklist.

150 In accordance with FAA Order 7110.65, “Air Traffic Control,” paragraph 3-7-2, the controller would have 

been required to provide turn-by-turn directions to the departure runway if the flight crew had so requested.

151 During the 50-second timeframe, the controller did not query the flight crew regarding why the airplane 

was stopped at the hold short line for runway 26. The controller’s actions during the taxi and attempted takeoff 

sequence are discussed in section 2.2.3.
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2.2.1.3 Takeoff Roll

About 0605:58, the captain transferred control of the airplane to the first officer, 

stating, “all yours,” to which the first officer acknowledged, “my brakes, my controls.” At 

this time, the captain would have switched his attention from outside to inside the cockpit, 

and the first officer would have switched his attention from inside to outside the cockpit. 

About 2 seconds later, the airplane was aligned with the centerline for runway 26. 

The CVR recording showed that the flight crew had referred to runway 22 as the 

departure runway multiple times before takeoff, and FDR data showed that the pilots’ 

heading bugs were set to 227o, which was consistent with the magnetic heading for 

runway 22. The Safety Board concludes that the captain and the first officer believed that 

the airplane was on runway 22 when they taxied onto runway 26 and initiated the takeoff 

roll.

About 0606:16, the first officer stated, “[that] is weird with no lights,” to which the 

captain responded, “yeah.” At that time, the airplane was passing through the intersection 

of runway 26 with runway 22. About 0606:24, the captain called the 100-knot airspeed 

check. About the same time, the airplane accelerated beyond the maximum airspeed that 

would have allowed the airplane to remain on the available runway if the flight crew had 

rejected the takeoff and used maximum braking.152

At 0606:31.2, the captain called, “V one, rotate,” followed immediately by his 

exclamation, “whoa.” The aircraft performance study for this accident showed that, at 

the time of the VR callout, the airplane was 236 feet from the end of the runway. The 

appearance of the runway end environment would have provided a salient cue to the 

flight crew that the airplane was in an extremely hazardous situation and could not 

remain on the ground. The airplane’s airspeed at the time of the captain’s VR callout 

was 131 knots, which was 11 knots below the planned VR airspeed of 142 knots (which 

the flight crew had briefed and entered into the airplane’s EFIS).153 Thus, the captain’s 

early VR callout and subsequent “whoa” exclamation indicated that he recognized that 

something was wrong with the takeoff. 

FDR data showed that, in response, the first officer pulled the control column full 

aft154 and that the airplane rotated at a rate of about 10o per second, which is three times 

the normal rotation rate. This abnormal column input showed that the first officer also 

recognized that something was wrong with the takeoff.

Although numerous cues, including the lack of runway lighting, were available to 

indicate that the airplane was not on the assigned runway (see sections 2.2.2.1 and 2.2.2.3), 

152 According to calculations by Bombardier, for the airplane to have stopped before the end of runway 26, 

maximum braking would have had to start when the airplane was at an airspeed of about 103 knots. 

153 FDR data for the accident airplane’s 12 previous takeoffs indicated that rotation occurred at or after 

reaching the VR airspeed.

154 FDR data showed that the left and right control column inputs during the accident rotation reached 

10.6o and 10.9o, respectively, and that the nominal control column input for rotation during the accident 

airplane’s 12 previous takeoffs was between 4o and 5o.
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the flight crew had not correctly interpreted these cues or noticed them until after it was 

too late to successfully abort the takeoff. The Safety Board concludes that the flight crew 

recognized that something was wrong with the takeoff beyond the point from which the 

airplane could be stopped on the remaining available runway.

2.2.1.4 Runway Incursions

The FAA currently defines a runway incursion as “any occurrence in the airport 

runway environment involving an aircraft, vehicle, person, or object on the ground that 

creates a collision hazard or results in a loss of required separation with an aircraft taking 

off, intending to take off, landing, or intending to land.” ICAO defines a runway incursion 

as “any occurrence at an aerodrome involving the incorrect presence of an aircraft vehicle 

or person on the protected area of a surface designated for the landing and take-off of 

aircraft.” According to these definitions, ICAO would classify this accident as a runway 

incursion, but the FAA would not consider this accident to be a runway incursion because 

no other airplane impeded the accident airplane’s ability to take off. The Safety Board 

notes that the presence of another airplane on a runway should not be a consideration 

in determining whether a runway incursion has occurred; rather, criteria for making this 

determination should consider, among other things, whether an airplane’s movement 

is consistent with the clearances provided to the flight crew. As a result, the Safety 

Board concludes that, because the accident airplane had taxied onto and taken off from 

runway 26 without a clearance to do so, this accident was a runway incursion.155

At the Safety Board’s runway incursion forum in March 2007, the FAA announced 

that it planned to revise its definition of a runway incursion to align with ICAO’s definition 

by the end of fiscal year 2007 and that it would begin reporting runway incursions 

according to the revised definition in fiscal year 2008. The Board is encouraged by the 

FAA’s plan to adopt and apply the ICAO definition because wrong runway takeoffs 

should be reflected in runway incursion statistics so that runway safety trends can be 

accurately monitored and appropriate countermeasures can be taken.

2.2.2 Pilot Human Factors

The flight crew’s performance on the day of the accident seemed to be 

uncharacteristic with past reports. The captain and the first officer were described 

favorably by company personnel, and pilots who had flown with them described both 

as competent pilots who had not previously demonstrated difficulty with airport surface 

operations. The captain was described as someone who managed the cockpit well, 

adhered to standard operating procedures, and demonstrated good CRM. The first officer 

was preparing for an opportunity to upgrade to captain and was described as someone 

who would have made a good captain because of his adherence to standard operating 

procedures. 

155 Even though the FAA does not consider the SEA and MIA incidents (discussed in section 1.18.4) to be 

runway incursions, the Safety Board does consider these incidents to be runway incursions. 
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The Safety Board examined possible reasons why the flight crew stopped at the 

incorrect hold short line and attempted to take off from the incorrect runway, as discussed 

in sections 2.2.2.1 through 2.2.2.4. 

2.2.2.1 Available Cues and Aids for Wayfinding

Pilots integrate many sources of wayfinding information, either alone or in 

combination, to establish their position and navigate to their intended destination on 

the airport. Wayfinding information sources include geographic knowledge of standard 

airport surface features that are common to all airports (such as terminal buildings, ramp 

areas, taxiways, and runways), knowledge of standard conventions for marking and 

identifying airport surface features, airport charts, and taxi instructions from ATC. 

Because both pilots were experienced, they should have been knowledgeable 

about basic airport geographic features and signage and surface marking standards 

(the Safety Board did not note any signage or surface markings at LEX that were not 

in compliance with FAA regulations), and they should have been skilled at interpreting 

airport charts. In addition to their knowledge about the specific route (taxiway A to 

runway 22), multiple external cues and features were available to the pilots to support their 

navigation to runway 22, and no evidence indicated that their view from the windscreen 

was obstructed. Observations from a CRJ-100 airplane after the accident demonstrated 

that, during nighttime conditions, taxiway location signs were visible along the full length 

of the taxi route, a runway 26 holding position sign adjacent to the runway 26 hold short 

line was visible, and the runway 26 numbers were visible. Also, evidence indicated that, 

at the time of the accident, the signs identifying the critical features along the taxi route 

(that is, the runway 26 holding position sign, the taxiway A extension across runway 26, 

and the runway 22 holding position sign) were illuminated and would have been visible 

to both pilots.156

The flight crewmembers had resources available to them within the cockpit to 

support their navigation to runway 22, including the Jeppesen airport chart. Even though 

discrepancies existed between the airport chart and the external cues available to the 

pilots because of an ongoing construction project at the airport,157 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 227o to correspond to the magnetic heading 

for runway 22. This heading information, which was clearly presented on both flight 

crewmembers’ MFDs and PFDs, would have provided the pilots with a real-time cue of 

their orientation relative to runway 22. 

156 Although the first officer’s attention was focused inside the cockpit while the airplane was taxiing to 

the departure runway, he would have had multiple opportunities to look outside the cockpit and monitor the 

airplane’s progress along the taxi route. Such monitoring would have helped the first officer gauge and pace 

his activities with the available time left for taxi.

157 Taxiway A north of runway 26 had been closed (as indicated by a local NOTAM) and barricaded, and 

taxiway A5 had been redesignated as taxiway A. Neither of these changes was depicted on the airport chart. 

However, no evidence indicated that either pilot was confused by the discrepancies. In addition, the pilots of 

SkyWest flight 6819 and American Eagle flight 882 used the same chart to navigate to runway 22.
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In addition, the flight crewmembers could have communicated with the controller 

if they became unsure of their position at any time.158 However, the CVR did not record 

any statement by either flight crewmember about being unsure of the airplane’s position 

on the airport surface at any time during the taxi and takeoff roll. The CVR also did not 

record any indication that the crewmembers had attempted to confirm the airplane’s 

position on the runway before beginning the takeoff roll. 

The taxi routing and cues available to the accident pilots were identical to 

those that were available to the pilots of the two regional jets (SkyWest flight 6819 and 

American Eagle flight 882) that departed before Comair flight 5191. The SkyWest and 

American Eagle pilots had no difficulty identifying, and successfully navigating to, 

runway 22 using the available cues,159 even with the differences in taxiway signage and 

chart labeling.160 In addition, even though the airport configuration at the time of the 

accident had been in place for 1 week, the Safety Board did not identify any reports about 

surface navigation problems at LEX during that time.161 The Safety Board concludes that 

adequate cues existed on the airport surface and available resources were present in the 

cockpit to allow the flight crew to successfully navigate from the air carrier ramp to the 

runway 22 threshold. 

2.2.2.2 Preflight Activities and Actions During the Taxi

Because the availability of cues and aids for the pilots’ wayfinding task was not a 

factor in this accident, the Safety Board examined the crew’s actions during the preflight 

and taxi phases of the flight’s operation to identify possible reasons for the error.

The flight crew proceeded from the Comair operations center to the air carrier 

ramp area, where two Comair CRJ airplanes were located. The crew initially boarded the 

wrong airplane,162 even though the tail number of the airplane to be used for the flight 

158 Such communications would have been consistent with good CRM (while at towered airports) 

and company policy. In addition, this behavior would have been consistent with reports of the pilots’ past 

performance. 

159 The SkyWest first officer stated that he became “momentarily confused” about the airplane’s orientation 

when he looked up while crossing runway 26 but that he was able to reorient himself after identifying the 

holding position sign for runway 22.

160 The SkyWest and American Eagle pilots did not recall seeing the low-profile barriers on taxiway A 

north of runway 26. The pilots’ lack of recall in this area indicates that the barriers were not significant elements 

in the pilots’ wayfinding and that the taxiway A closure did not encumber their navigation to runway 22. The 

pilots’ lack of recall does not indicate that the barriers were inconspicuous or difficult to see when approaching 

or crossing runway 26. In fact, observations in a CRJ-100 airplane after the accident indicated that the barriers 

would have been clearly visible to the pilots during the taxi. The pilots’ failure to recall these barriers is not 

unusual because people can have difficulty remembering things in their environment with which they did not 

interact. 

161 After runway 26 was reopened (November 2006), two events occurred in which air traffic controllers 

informed pilots that their airplanes were on that runway instead of runway 22 (see section 1.10.4). However, 

an interview with the pilot involved in the first event indicated that he had stopped for preflight activities, was 

aware of the airplane’s position, and did not intend to depart on runway 26. An interview with the captain of 

the flight involved in the second event indicated that he became temporarily confused about the location of 

runway 22 but that the airplane was never lined up to take off from runway 26. An interview with the first officer 

of this flight indicated that he and the captain were never confused about the correct runway for takeoff.

162 The Safety Board does not know which pilot was the first one to board the wrong airplane.
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was included in the flight release paperwork, and started its APU. Although these actions 

likely consumed a portion of the crew’s available time at the gate, CVR evidence and 

interviews with ground personnel indicated that neither pilot appeared to be rushed or 

hurried as he completed required tasks. For example, as stated in section 2.2.1.2, the CVR 

recorded both crewmembers involved in a detailed nonpertinent discussion before and 

during pushback from the gate, which indicated that both crewmembers were relaxed. 

In addition, FDR data showed that the navigation to the runway was conducted at a 

normal pace, and the controller stated that the pilots did not seem to be rushed. Thus, the 

available evidence indicated that the flight crew was not under time pressure.

The Safety Board reviewed the CVR recording to evaluate the flight crew’s 

workload and focus of attention during the taxi to the runway. While the captain was 

maneuvering the airplane along the taxi route, the first officer was performing preflight 

checklists, including some additional items that were necessary because the flight was 

the airplane’s first flight of the day. Although FDR data showed that the taxi lasted only 

about 2 1/2 minutes, the first officer had adequate time to complete the preflight activities. 

It is important to note that the first officer was experienced in his position and that these 

activities, including the first-flight-of-the-day items, would have been well learned and 

would not have presented him with a high workload condition. 

In addition to navigating the airplane along its taxi route, the captain would have 

been overseeing the first officer’s performance and providing cross-checking as necessary. 

The captain was also experienced in his position and would have been skilled at dividing 

his attention between controlling the airplane, navigating the airport, and monitoring the 

first officer’s performance. Moreover, with the captain’s level of experience, the control 

inputs associated with controlling an airplane on an airport surface would have required 

very little cognitive effort.

The nonpertinent conversation occurred during 40 seconds of the 150-second 

taxi time (from about 0603:16 to about 0603:56). The timing of this discussion and its 

duration are the most salient evidence 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, people 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.163

More than 20 years of research using the ASRS database has shown that pilots 

cite social conversation with other crewmembers as an activity that can distract the 

pilots from tasks that must be performed.164 Also, human factors research on aviation 

wayfinding indicated that any breakdown in a pilot’s assessment of position “can result 

163 R.K. Dismukes, “Concurrent Task Management and Prospective Memory: Pilot Error as a Model 

for the Vulnerability of Experts.” Proceedings of the Human Factors and Ergonomics Society 50th Annual 

Meeting, 2006.

164 R.K. Dismukes, G.E. Young, and R.L. Sumwalt, Cockpit Interruptions and Distractions: Effective 

Management Requires a Careful Balancing Act. ASRS Directline, vol. 10, pages 4-9, 1998.
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in either a slight deviation from an intended path, or becoming totally lost.”165 In addition, 

active attention is thought to be necessary for maintaining situational awareness, and the 

allocation of attention to irrelevant stimuli can degrade awareness.166 Finally, research on 

distractions while driving found that drivers are less likely to detect changes that have 

occurred in the environment when they are involved in casual conversation because 

being engaged in a conversation may degrade the encoding of visual information.167 

The first officer initiated the nonpertinent conversation as the captain was 

navigating along the taxi route. The captain had the responsibility to assert both his 

leadership role and command authority to stop the discussion. Rather, the captain 

allowed the conversation to continue and participated in it. Also, instead of initiating 

the nonpertinent conversation, the first officer should have been monitoring the captain’s 

actions and independently assessing the airplane’s location along the taxi route. The 

Safety Board concludes that the flight crewmembers’ nonpertinent 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. 

2.2.2.3 Cues to Indicate a Takeoff From Runway 22

The presence of runway markings—a white centerline and side stripes—ahead of 

the airplane would have facilitated the captain’s perception that the airplane had arrived 

at the hold short line for runway 22, even though the airplane was actually at the hold 

short line for runway 26. In addition, the angle from the runway 26 hold short line on 

taxiway A to runway 26 was the same as the angle from the runway 22 hold short line on 

former taxiway A (north of runway 8/26) to runway 22. 

Also, the taxiway A centerline split into three lines after the runway 26 hold short 

line. These extended taxiway centerlines led onto the closed portion of taxiway A, across 

runway 26 to runway 22, and onto the runway 26 centerline (a lead-on/off line). The 

presence of a lead-on/off line from a taxiway directly to a runway could have supported 

the captain’s perception that the airplane had arrived at the departure runway. 

In addition, as stated in section 2.2.1.1, the first officer told the captain during his 

takeoff briefing, “lights are out all over the place,” in reference to observations he made 

while landing on runway 22 about 0140 on the day before the accident. The first officer’s 

statement might have contributed to the captain’s perception that the airplane was taxiing 

onto runway 22 because he might have anticipated a dark runway environment. At the 

165 R. Conejo and C.D. Wickens, The Effects of Highlighting Validity and Feature Type on Air‐to‐Ground 

Target Acquisition Performance, Technical Report ARL-97-11, Savoy, Illinois: University of Illinois Aviation 

Research Lab, 1997.

166 C.D. Wickens and J.S. McCarley, Attention-Situation Awareness (A-SA) Model of Pilot Error, Technical 

Report ARL-01-13/NASA-01/06, Savoy, Illinois: University of Illinois Aviation Research Lab, 2001.

167 Jason S. McCarley, Margaret J. Vais, Heather Pringle, Arthur F. Kramer, David E. Irwin, and David L. 

Strayer, “Conversation Disrupts Change Detection in Complex Traffic Scenes,” Human Factors, vol. 46, no. 3, 

pages 424-436, 2004.
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least, this statement reduced the significance of the first officer’s subsequent statement, 

“[that] is weird with no lights” (to which the captain responded “yeah”), as the airplane 

rolled down runway 26. 

There are well-known psychological concepts associated with perception and 

decision-making that can allow a person’s mistaken assessment to persist. For example, 

confirmation bias occurs when people seek out or observe elements in their environment 

that support their perception. Specifically, confirmation bias results 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.168 Confirmation bias can cause 

a person to persist in holding an incorrect belief despite the availability of contradictory 

evidence. For the flight crew, 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. 

There were cues available to the flight crew that were not consistent with a taxi 

onto runway 22. These cues included the runway holding position sign for runway 26, 

the 75-foot painted width of runway 26 (versus the 150-foot width of runway 22),169 and 

the absence of runway edge lights and precision runway markings (such as threshold 

markings and touchdown zone 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. 

On July 17, 1989, the Safety Board issued Safety Recommendation A-89-74, which 

asked the FAA to ensure that the operations manuals of all Part 121 and 135 air carriers 

require flight crews to cross-check the heading indicator with the runway heading 

when the airplane is aligned with the runway for takeoff. The Board classified Safety 

Recommendation A-89-74 “Closed—Acceptable Action” on December 11, 1990, after 

the FAA revised ACOB 8-85-1 to address the need for pilots to cross-check the heading 

indicator with the runway heading before takeoff. These bulletins, however, are not 

mandatory, and, during this investigation, the Board determined that Comair and other 

Part 121 operators did not have procedures for positively verifying that an airplane was 

aligned on the correct departure runway.170

FDR data showed that, at some point before the start of the recording, the pilots’ 

heading bugs had been set to 227o to correspond to the magnetic heading for runway 22. 

168 The Safety Board notes that confirmation bias has multiple definitions. This report refers to confirmation 

bias as a phenomenon that occurs automatically (that is, without conscious intervention or intent) at the 

perceptual level. 

169 Postaccident observations from a CRJ-100 airplane indicated that the reduced available width of 

runway 26 was clearly visible at night because the side stripes were brightly illuminated by the airplane’s 

external lighting system. 

170 As a result of this finding and the finding that that some Part 121 operators (including Comair) did 

not provide guidance to their pilots about conducting takeoffs at night on unlighted runways, the Safety Board 

issued Safety Recommendations A-06-83 and -84 on December 12, 2006 (see sections 1.18.3.1 and 2.4.1). 
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At the time that the first officer began to increase thrust for takeoff, FDR data showed 

that the magnetic heading of the airplane was about 266o, which corresponded to the 

magnetic heading for runway 26. Figures 6 and 6a show the approximate configuration 

of the captain’s MFD and PFD, including the heading bug setting and magnetic heading 

indication, when the airplane was lined up on the runway 26 centerline. As shown in the 

figures, the heading bug was offset by 40o, providing a salient cue that the airplane was 

not lined up on the correct departure runway. The CVR did not record any awareness by 

the flight crewmembers about this offset. 

Figure 6. Multifunction Display 

Source: Rockwell Collins. The display was configured as requested by the Safety Board.
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Figure 6a. Primary Flight Display

Source: Rockwell Collins. The display was configured as requested by the Safety Board.

The wayfinding task includes an ongoing cross-check between an airplane’s 

expected and actual position using available cues in the environment and aids in the 

cockpit. The CVR did not record any discussion by the flight crew about the need to 

cross-check the airplane’s position on the runway.171 The Safety Board concludes that the 

flight crewmembers failed to recognize that they were initiating a takeoff on the wrong 

runway because they did not cross-check and confirm the airplane’s position on the 

runway before takeoff and they were likely influenced by confirmation bias. 

171 On March 23, 2007, Comair revised its operations manual to include a departure runway 

checklist item.
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2.2.2.4 Fatigue

The Safety Board examined whether pilot fatigue could have been a factor in this 

accident by assessing the preconditions that could allow for the development of a fatigued 

state and examining the nature of the pilots’ demonstrated performance deficiencies. 

Potential conditions that can lead to the development of a fatigued state include chronic 

sleep restriction, acute sleep loss, circadian disruption (work during times when one 

would normally be asleep), and time since awakening.

The captain and the first officer received more than the minimum required rest 

periods during their respective trips in the days before the accident, and their flight and 

duty times in the week and month before the accident would not have precluded them 

from obtaining adequate sleep. Also, both pilots had only been awake for about 2 hours 

at the time of the accident.172

Two factors in the pilots’ schedules just before the accident could have been 

associated with the potential development of a fatigued state: acute sleep loss and 

circadian disruption. Evidence indicated that both flight crewmembers likely went 

to sleep between 2100 and 2200 on the night before the accident (as discussed later in 

this section) and awoke the next morning about 0415,173 which would have afforded 

each pilot about 6 to 7 hours of available sleep time (which is 1 to 2 hours less than the 

nominal 8-hour sleep period). Restricting sleep by 2 hours has been shown to result in 

slight decreases in the performance of simple cognitive tasks, but there are individual 

differences on whether such effects are realized.174 

The captain and the first officer also awakened on the day of the accident at a time 

when they would normally be asleep. The pilots’ time of awakening occurred during 

the period known as the “circadian trough” (0300 to 0500), which is a time of decreased 

alertness and cognitive performance among people who are adapted to sleeping at night. 

However, at the time of the accident, the pilots had been awake for 2 hours, at which time 

circadian factors would have increased their alertness.

More importantly, from a circadian disruption standpoint, the first officer likely 

went to sleep about 0230 on August 26, 2006.175 According to his wife, the first officer 

172 A review of the flight and duty times for the pilots of SkyWest flight 6819 and American Eagle flight 882 

showed that these times were similar to those of the accident pilots. 

173 Hotel records indicated that the captain received a wake-up call at this time. The Safety Board 

estimated a similar wake-up time for the first officer. 

174 H.P.A. Van Dongen, G. Maislin, et al., “The Cumulative Cost of Additional Wakefulness: Dose‐Response 

Effects on Neurobehavioral Functions and Sleep Physiology From Chronic Sleep Restriction and Total Sleep 

Deprivation,” Sleep, vol. 26, no. 2, pages 117-126, 2003. 

175 Hotel key card records showed activity for the first officer’s room at 2257 on August 25, 2006. After 

the accident, hotel personnel tested the lock on the first officer’s room and determined that the actual time of 

key card activity was 2 hours later than shown in the records (that is, 0057 on August 26). However, the first 

officer’s repositioning flight arrived at LEX about 0140, and the captain of the flight estimated that the first 

officer checked into his hotel room about 0210. As a result, the Safety Board determined that the actual time 

of key card activity was 3 hours later than shown in the records, indicating that the first officer arrived in his 

room about 0157.
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was able to sleep in that morning. The Safety Board was unable to determine how many 

hours the first officer slept, but, if he had received 8 hours of sleep, the first officer would 

have awakened about 1030. With this awakening time, it could have been difficult for the 

first officer to fall asleep after the call to his wife (which ended at 2102) because he would 

have been awake for only about 11 hours. However, it is unknown whether this time 

since awakening would have affected the first officer’s ability to obtain restful sleep on 

the night before the accident because it is unknown whether he actually obtained 8 hours 

of sleep on the morning of August 26 and whether his estimated bedtime was close to his 

normal sleep time. 

Although there was evidence of some preconditions that were conducive to the 

development of fatigue in both flight crewmembers, the uncertainty associated with the 

pilots’ actual recent sleep times made it difficult to assess the degree of fatigue that they 

might have been experiencing on the morning of the accident. If the captain and first officer 

were able to maximize their available sleep time, they might have been experiencing only 

mild fatigue resulting from a slightly restricted sleep period (about 7 hours) the night 

before the accident. In addition, any use of caffeine by the crewmembers could have 

served as an effective countermeasure for mild fatigue impairment.176

The absence, or the presence, of preconditions that are conducive to the 

development of fatigue is not sufficient by itself to determine whether fatigue was a factor 

in an accident. For fatigue to be considered a factor, performance deficiencies need to be 

clearly discernible and consistent with the known effects of fatigue, and any evidence 

supporting alternative explanations for such deficiencies needs to be considered. 

In this accident, the surface navigation error and the attempted takeoff from the 

wrong runway were the most significant errors made by the flight crew. Other errors 

included the flight crew boarding the wrong airplane, the first officer asking during his 

takeoff briefing about the runway in use and offering up “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 beginning 

about 0603:02. 

The CVR recording also indicated that the captain corrected some of the first 

officer’s errors.177 For example, the captain stated “its two two” when queried about 

the runway in use and pointed out that the before starting engines checklist had been 

completed. Such corrections are inconsistent with a fatigue impairment.

176 The wives of the captain and the first officer reported that their husbands drank coffee, and the CVR 

recorded the captain (about 0553:04) asking the flight attendant for a cola.

177 About 0549:49, the controller provided the flight crew with a modified clearance to ATL. The first officer 

told the controller that he “missed” the arrival route part of the clearance, but he acknowledged the rest of the 

clearance. The controller repeated the arrival information, which the first officer acknowledged. Because the 

arrival route information provided by the controller was different than that in the flight release paperwork, the 

first officer’s request for the controller to repeat the arrival information cannot be considered an error but rather 

a request for clarification, which is a normal event.
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This investigation was constrained by a lack of available information to establish 

the pilots’ sleep activities before the accident flight. For example, the Safety Board 

was unable to determine how much sleep the first officer obtained on the morning of 

August 26, 2006, whether either pilot received supplemental sleep (in the form of naps) 

during the afternoon of August 26, or whether the pilots’ sleep time was uninterrupted.178

Also, the Board was unable to obtain reliable information about the nominal sleep needs 

for the pilots or their normal sleep and wake patterns. 

It is important to note, however, that both crewmembers seemed to be aware of 

the need to obtain adequate rest for the next day.179 Specifically, each pilot called his wife 

on the evening of August 26, 2006. The telephone call from the captain to his wife ended 

about 2127. The captain told his wife that he was planning on going to sleep afterward. 

The telephone call from the first officer to his wife ended about 2102. The first officer told 

his wife that he was going to bed early. Also, the Safety Board listened to a taped telephone 

conversation made by the first officer to the Comair System Operations Control Center at 

0510 on the day of the accident; he was clear and conversational at that time. Further, 

witnesses reported that the pilots did not demonstrate behaviors consistent with being 

tired, such as yawning, stretching, and rubbing their eyes. In addition, CVR evidence 

showed that (1) neither pilot acted withdrawn or irritable or made any statements about 

receiving an inadequate amount of sleep and (2) both pilots were sociable.

The Safety Board concludes that, even though the flight crewmembers made some 

errors during their preflight activities and the taxi to the runway, there was insufficient 

evidence to determine whether fatigue affected their performance.

Previous Fatigue-Related Accidents

Even though there was insufficient evidence for the Safety Board to determine 

whether fatigue affected the Comair flight crew’s performance, the Board has previously 

cited fatigue impairment as a causal or a contributing factor for those accidents in which 

documented performance deficiencies were consistent with the effects of fatigue and clear 

evidence showed that the pilots’ recent activities were conducive to fatigue. For example, 

in its report on the June 1, 1999, American Airlines flight 1420 accident, the Board found 

that the flight crewmembers failed to discontinue the approach to the airport when severe 

thunderstorms had moved into the area and failed to ensure that the flight spoilers had 

extended after touchdown. The Board also found that the flight crewmembers were 

nearing the end of a long duty day and that, although the pilots had slept more than 

9 hours the night before, they had been continuously awake for at least 16 hours by the 

178 As stated in section 1.5.2, the Safety Board was unable to determine whether the first officer attempted 

to answer the two consecutive incoming calls to his cell phone about 0103 on the day of the accident. 

179 The Safety Board has previously identified the need to improve fatigue awareness among pilots. 

Most recently, on February 7, 2006, the Safety Board issued Safety Recommendation A-06-11, which asked 

the FAA to “require 14 Code of Federal Regulations Part 121 and 135 operators to incorporate fatiguerelated information similar to that being developed by the Department of Transportation Operator Fatigue 

Management Program into their initial and recurrent pilot training programs; such training should address the 

detrimental effects of fatigue and include strategies for avoiding fatigue and countering its effects.” Safety 

Recommendation A-06-11 was classified “Open—Acceptable Response” on November 9, 2006.
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time of the accident.180 According to the report, contributing to the accident was the flight 

crew’s “impaired performance resulting from fatigue.”181

Also, in its report on the October 19, 2004, Corporate Airlines flight 5966 accident, 

the Safety Board found that the flight crew did not follow established procedures and 

properly conduct a nonprecision approach at night in instrument meteorological 

conditions and did not adhere to the established division of duties between the flying 

and nonflying pilot. The Board also found that the pilots’ work schedule required them 

to go to bed and wake up much earlier than normal and that they had only a 9-hour rest 

period before having to report for duty. Before the accident flight, the captain told family 

members that he slept poorly, and other pilots saw him trying to take a brief nap in a 

meeting area. By the time of the accident, the flight crew had been awake for 15 hours and 

on duty for 14 1/2 hours and was performing the sixth flight leg of the day. According to 

the report, the pilots’ fatigue “likely contributed to their degraded performance.”182

In contrast to the Little Rock and Kirksville flight crews, the Comair captain and 

first officer had rest periods of more than 13 and 27 hours, respectively, before reporting 

for the accident flight. Also, the Comair pilots had only been awake for 2 hours and on 

duty for less than 1 hour at the time of the accident. 

2.2.2.5 Cockpit Discipline

The captain was responsible for establishing the tone in the cockpit so that 

disciplined adherence to standard operating procedures would be maintained and crew 

vigilance would not be reduced. However, as recorded on the CVR, the captain told the 

first officer several times, “at your leisure,” with regard to his performance of checklists, 

which was indicative of a casual cockpit atmosphere. The first officer apparently adopted 

this casual attitude when he told the controller that the flight was ready to depart at his 

leisure. 

According to Comair procedures, the captain was responsible for calling for the 

taxi, before takeoff, and lineup checklists, but the CVR did not record the captain formally 

call for the before takeoff checklist. Instead, after the first officer finished the taxi checklist, 

the captain stated about 1 minute later, “finish it up your leisure,” referring indirectly to 

the need to conduct the before takeoff checklist. Also, as previously stated, the captain 

performed an abbreviated taxi briefing, which was contrary to company guidance, and 

the flight crew engaged in a nonpertinent conversation while the airplane was in a critical 

phase of flight, which was not in compliance with the sterile cockpit regulation and 

180 Research has indicated that lapses in cognitive performance occur when the waking day is extended 

beyond a normal length of 14 to 16 hours. For more information, see G.P. Kruger, “Sustained Work, Fatigue, 

Sleep Loss, and Performance: A Review of the Issues,” Work and Stress, vol. 3, pages 129-141, 1989.

181 National Transportation Safety Board, Runway Overrun During Landing, American Airlines Flight 1420, 

McDonnell Douglas MD-82, N215AA, Little Rock, Arkansas, June 1, 1999, Aircraft Accident Report NTSB/

AAR-01/02 (Washington, DC: NTSB, 2001).

182 National Transportation Safety Board, Collision with Trees and Crash Short of the Runway, Corporate 

Airlines Flight 5966, BAE Systems BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004, Aircraft 

Accident Report NTSB/AAR-06/01 (Washington, DC: NTSB, 2006).
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company procedures. The abbreviated briefing and the nonpertinent conversation were 

also examples of the flight crew’s casual cockpit atmosphere.

The Safety Board has discussed the role of reduced cockpit discipline in other 

flight crew-involved air carrier accidents. For example, in its report on the August 16, 

1987, Northwest Airlines flight 255 accident, the Board found that checklists (except 

for the before start checklist) were not being called for or accomplished according to 

company procedures and that, after pushback, the flight crew initiated conversations that 

were not related to duty requirements and diverted the crew’s attention from task-related 

activities. Regarding the role of cockpit discipline in these errors, the report stated, “it is 

the captain’s responsibility to structure the manner in which his crew will accomplish 

its duties ... he must set the tone for how this information will be proffered.” The report 

further stated that a well-defined role structure in the cockpit reduces ambiguity about 

each crewmember’s responsibilities and when those responsibilities will be performed.183

In addition, data from the LOSA Collaborative184 showed that flight crewmembers who 

intentionally deviated from standard operating procedures were three times more likely 

to commit other types of errors, mismanage more errors, and find themselves in more 

undesired aircraft situations compared with those flight crewmembers who did not 

intentionally deviate from procedures. 

The Safety Board concludes that the flight crew’s noncompliance with standard 

operating procedures, including the captain’s abbreviated taxi briefing and both pilots’ 

nonpertinent conversation, most likely created an atmosphere in the cockpit that enabled 

the crew’s errors.

2.2.2.6 Summary of Pilot Human Factors

Even with the discrepancies that existed between airport charts and signage, 

the navigational task that the pilots of Comair flight 5191 faced—taxi to runway 22 

via taxiway A—was straightforward and inherently simple. The primary cues for this 

navigational task—the airport markings and signage at hold short positions—were 

accurate and available to the flight crew.

Flight crews are responsible for maintaining positive control of an airplane 

during all phases of flight, including surface operations. An essential component to 

positive control is knowing the position of the airplane at all times. It was the accident 

pilots’ responsibility, once they were cleared to taxi, to safely maneuver the airplane to 

runway 22. Each pilot had experience and expertise to allow the successful completion 

of this task using only the standard airport marking conventions; that is, once the pilots 

detected and recognized signs off the air carrier ramp that identified taxiway A, they 

183 National Transportation Safety Board, Northwest Airlines, Inc., McDonnell Douglas DC-9-82, N312RC, 

Detroit Metropolitan Wayne County Airport, Romulus, Michigan, August 16, 1987, Aircraft Accident Report 

NTSB/AAR-88/05 (Washington, DC: NTSB, 1988).

184 According to its Web site, the LOSA Collaborative is a network of researchers, safety professionals, 

pilots, and airline representatives collaborating to provide, among other things, oversight and implementation 

of LOSA and a forum for information exchange regarding LOSA. The referenced data were provided to the 

Safety Board in January 2007. 
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had only to follow those signs and the taxiway centerline to the runway holding position 

sign for runway 22. Although this task is more difficult during night conditions, when 

surrounding features in the environment and horizon as well as other cues are not easily 

detectable, the critical features along the navigation route were internally lit or were 

illuminated by the airplane’s external lighting system. 

Both pilots were described to be in good health in the days before the accident.185

Postaccident toxicological testing for both pilots did not detect the presence of alcohol186

or any substances known to affect performance. 

Both pilots were required to wear corrective lenses during flight operations. 

Evidence indicated that the captain was wearing contact lenses during the accident 

flight, but the Safety Board could not determine whether the first officer was wearing 

corrective lenses during the flight. Even if the first officer had not been wearing corrective 

lenses, his ability to verify the airplane’s position during the taxi to runway 22 would 

most likely not have been affected.187 Evidence indicated that both pilots were able to 

read and interpret features inside the cockpit at intermediate distances and detect objects 

outside the cockpit at greater distances, and the pilots were described to have normal 

night vision. Observations in a CRJ-100 airplane after the accident demonstrated that no 

objects along the taxi route would have produced temporary flash blindness188 that could 

have impeded the pilots’ ability to detect signage and surface markings.189

As previously stated, numerous cues were available to the flight crew to indicate 

that the airplane was not at the position on the airport surface that it was supposed to 

be. For example, when the airplane stopped at the runway 26 hold short line instead of 

the runway 22 hold short line, the flight crew would have been able to see the runway 26 

holding position sign and painted runway numbers, the continuation of taxiway A across 

runway 26, and the runway 22 holding position sign. Also, when the airplane was in 

185 The first officer tested positive for a low level of pseudoephedrine. This drug, at low levels, is not 

considered to cause impairment. Performance-based side effects of pseudoephedrine are similar to those of 

caffeine. CAMI does not quantify this substance unless it is above therapeutic levels. The Safety Board was 

not able to determine why and when the medication was taken. 

186 On August 26, 2006, at 1826, the first officer purchased food and two bottles of beer at the hotel 

restaurant. (Section 1.17.1.6 describes the FAA’s and Comair’s alcohol use policy.) According to the CAMI 

toxicology report, the first officer tested negative for ethanol. On the basis of known information about the 

first officer’s height, weight, and normal alcohol consumption, it is likely that the two beers would have been 

metabolized within a few hours of consumption. Research has shown that low blood alcohol concentrations 

do not appear to be associated with significant sleep disruption or reduced feelings of well being the next 

morning for normal, healthy people and that a low blood alcohol concentration is unlikely to have a significant 

impact on performance the next day. For more information, see B. Feige, H. Gann, R. Brueck, M. Hornyak, S. 

Litsch, F. Hohagen, and D. Riemann, “Effects of Alcohol on Polysomnographically Recorded Sleep in Healthy 

Subjects,” Alcoholism: Clinical and Experimental Research, vol. 30, pages 1527-1537, 2006. 

187 At his July 18, 2006, FAA medical examination, the first officer’s uncorrected distance vision 

measurement was 20/30. 

188 Temporary flash blindness results when an observer adapted to darkness is exposed to a very bright 

light and is then returned to conditions of darkness. Such high-intensity light exposures can dramatically 

reduce an observer’s visual acuity in low-light conditions for several minutes.

189 No aircraft were operating near the accident airplane during taxi. The CVR contained no mention of 

lightning, and ground personnel interviewed after the accident did not report the presence of lightning near 

the airport. 
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position at runway 26 instead of runway 22, the crew would have been able to see the 

holding position sign for runway 22 and the 75-foot width of the runway (versus the 

150‐foot width of runway 22). 

Given the numerous cues that were available to the flight crew and the simplicity 

of the navigation task, the Safety Board could not determine why the flight crew stopped 

the airplane at the incorrect hold short line and then attempted to take off from the 

incorrect runway. However, as previously stated, the Board believes that these events 

occurred because the flight crew did not use the available cues on the airport surface 

during taxi and did not cross-check and confirm the airplane’s position on the runway 

before departure. Also, the flight crewmembers engaged in a nonpertinent conversation 

during a critical phase of flight (taxi operations), which caused them to lose positional 

awareness. In addition, before the airplane arrived at the dark runway, the first officer 

briefed the outage of the runway end identifier lights, he recounted that lights were out 

during his arrival at LEX early on the morning that preceded the accident flight, and the 

flight crew most likely read the NOTAM in the flight release paperwork that indicated 

that the runway 4/22 centerline lights were out of service.

This accident is not the first one involving a wrong runway takeoff in which 

pilots did not use existing cues to identify the airplane’s location on the airport surface 

or cross-check and verify the airplane’s position before takeoff. For example, the final 

report on the October 31, 2000, Singapore Airlines flight 006 accident (see section 1.18.4) 

stated that the pilots did not verify the airplane’s position on the taxi route as the airplane 

was turning onto the wrong runway and concluded that the flight crew lost situational 

awareness and took off from the wrong runway despite numerous available cues that 

provided information about the airplane’s position on the airport. However, the final 

report for that accident cited a possible reason for the flight crew’s actions: the pilots did 

not adequately review the taxi route to ensure that they understood that the route to the 

correct departure runway required passing a parallel runway that was under construction 

and was open only for taxi operations. 

Numerous other wrong runway events have occurred. The ASRS database 

showed 114 reports of incidents from March 1988 to September 2005 in which flight 

crews of turbojet airplanes lined up on the wrong runway for takeoff. The ASRS reports 

indicated that the pilots involved in these events, pilots of other aircraft in the area at 

the time, or air traffic controllers detected the mistake either before or after takeoff. Also, 

on October 30, 2006, an Alaska Airlines 737 departed from the wrong runway at SEA. 

According to postincident interviews, the controller instructed the flight crew to taxi the 

airplane into position and hold on runway 34C, but the captain assumed that the airplane 

would be taking off from runway 34R. After the airplane departed uneventfully from 

runway 34R, the controller informed the flight crew that the airplane had departed from 

the wrong runway. 

Most recently, on April 18, 2007, a United Airlines Airbus A320 taxied onto 

runway 27, which was closed, instead of runway 30, the assigned departure runway, at 

MIA and began the takeoff roll. A NOTAM, which was included in the flight release 

paperwork, and the ATIS information broadcast, which the flight crew received, indicated 
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that runway 27 was closed. Also, the flight crew reported that the airport charts were out 

and available. As the airplane proceeded down runway 27, the airplane’s nose wheel 

light illuminated a truck flashing its lights. The captain and the first officer stated that 

they observed the truck at the same time. Simultaneously, the controller queried the flight 

crew to determine whether the airplane was on runway 30. The flight crew rejected the 

takeoff, and the airplane continued uneventfully to its destination.

The Comair flight 5191 accident and other wrong runway takeoff events 

demonstrate that all pilots are vulnerable to this and other types of surface navigation 

errors. Even when navigation tasks are straightforward and simple, there is a potential for 

a catastrophic outcome resulting from human error if available cues are not observed and 

considered during taxi and the airplane’s position is not cross-checked at the intended 

runway. Systemwide interventions, such as improved airport standard markings and 

technologies to improve pilots’ positional awareness while navigating airport surfaces, 

can help protect against human error during airport surface operations by providing a 

redundant display of critical information. Such interventions are further discussed in 

section 2.4.

In addition, the Safety Board is concerned about the breakdown in sterile cockpit 

discipline in the sequence of events leading to this accident. The pilots’ actions with 

regard to sterile cockpit procedures, specifically, their nonpertinent conversation while 

the captain was taxiing the airplane, were uncharacteristic with past reports. A first 

officer who flew with the captain 2 days before the accident described the captain’s sterile 

cockpit discipline as very good and stated that, when a newly trained first officer was 

occupying the cockpit jumpseat during one of the flight legs, the captain briefed him 

about sterile cockpit discipline. The first officer was also described as having good sterile 

cockpit discipline. 

On February 7, 2006, the Safety Board issued Safety Recommendation A-06-7, 

which was the result of the Board’s investigation of the Corporate Airlines flight 

5966 accident. Safety Recommendation A-06-7 asked the FAA to direct the POIs of all 

14 CFR Part 121 and 135 operators to reemphasize the importance of strict compliance with 

the sterile cockpit rule.190 Also, the Board notes that sterile cockpit violations are among 

the types of intentional noncompliance that can be detected through LOSA observations 

(see section 1.17.3). On January 23, 2007, as a result of its investigation of the October 

14, 2004, Pinnacle Airlines flight 3701 accident, the Board issued Safety Recommendation 

A-07-9, which asked the FAA to require that all 14 CFR Part 121 operators incorporate 

into their oversight programs periodic LOSA observations and methods to address and 

correct findings resulting from these observations.191

190 On April 28, 2006, the FAA issued SAFO 06004, “Approach and Landing Accident Reduction: 

Sterile Cockpit, Fatigue,” to emphasize the importance of sterile cockpit discipline. As a result, Safety 

Recommendation A-06-7 was classified “Closed—Acceptable Action” on November 9, 2006.

191 On April 13, 2007, the FAA stated that LOSA was not necessarily the only way in which an operator 

could accomplish oversight of the safety of its operations and that no-notice line checks, for example, offered 

many of the same advantages as LOSA with regard to the information gained. The FAA also stated its belief 

that the most effective approach to the underlying safety issues discussed in this recommendation was the 

effective implementation of SMS, for which a rulemaking project has begun.
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2.2.3 Air Traffic Controller Human Factors

Indications of the flight crew’s surface navigation error were visible from the 

tower during two distinct time periods. The first time period occurred when the airplane 

was stopped at the runway 26 hold short line for 50 seconds, from 0604:33 to 0605:23,192

during which time the first officer announced that the airplane was ready to depart 

and the controller issued a takeoff clearance. The airplane had been cleared to taxi to 

runway 22, and the flight crew was not required to stop the airplane short of runway 26. 

If the controller had noticed that the airplane had stopped in that location before issuing 

the takeoff clearance, the controller could have queried the flight crew, issued additional 

taxi instructions, or closely monitored the airplane’s subsequent progress. The controller’s 

postaccident statements indicated that he did not notice that the airplane had stopped 

short of runway 26. As a result, he missed an opportunity to prevent the flight crew’s 

surface navigation error and subsequent wrong runway takeoff attempt.

The second time period lasted 28 seconds. It began about 0605:56, when the airplane 

began to align with runway 26, and ended about 0606:24, when the airplane accelerated 

beyond the maximum airspeed that would have allowed the airplane to remain on the 

available runway if the flight crew rejected the takeoff and used maximum braking. The 

airplane’s movements during this time were not consistent with the clearance provided 

by the controller and were a clear sign of a lack of positional awareness on the part of the 

flight crew. If the controller had been looking out the tower cab window and monitoring 

the flight, he could have addressed this situation by alerting the flight crewmembers that 

the airplane was on the wrong runway or, later, by instructing them to reject the takeoff. 

The controller did not take any such actions. The controller indicated that he did not see 

the airplane align with runway 26 or begin its takeoff roll because he had turned around 

to perform the traffic count, which is an administrative record-keeping task.

The Safety Board examined possible reasons why the controller did not notice 

indications of the flight crew’s surface navigation error either during the 50-second 

window of opportunity, which began about 2 minutes before the accident, or during the 

28-second critical window, which began about 39 seconds before the accident. Figure 7 

shows a detailed timeline of communications and events that occurred in the 2 minutes 

before the accident. 

192 Flight crews stop along a taxi route for various reasons, including a perception of potential traffic 

conflicts, passenger movements in the cabin, and uncertainty about the taxi clearance or the taxi routes. Some 

stops during taxi are accompanied by radio transmissions to ATC to explain the delay or seek clarification. 

Some controllers have a heightened sense of awareness when stops are made during taxi depending on the 

circumstances and the duration. 
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Figure 7. Air Traffic Control Event Timeline

Note: COM, Comair; EGF, American Eagle; SKW, SkyWest; ZID, Indianapolis Air Route Traffic Control 

Center; TMU, traffic management unit. 
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2.2.3.1 Window of Opportunity During Which the Airplane Was Stopped 

Short of the Wrong Runway

On the day of the accident, all LEX tower and radar positions were combined 

and were being worked by one controller.193 As a result, the controller had to switch his 

attention between tower and radar tasks. The controller’s tower responsibilities included 

controlling aircraft operations on the airport surface and during takeoffs and landings,194

and his primary source of visual information was the view of the airport surface.195 The 

controller’s radar responsibilities included controlling airplanes in the airspace around 

the airport,196 and his primary source of visual information was the DBRITE, which was 

mounted below the tower cab windows at the local control position. Despite the need to 

divide his attention between these tasks, the controller’s workload at this time was not 

excessive.

When Comair flight 5191 stopped at the hold short line for runway 26, the 

controller had just finished obtaining that flight’s departure release from the Indianapolis 

ARTCC’s traffic management unit (a tower task) and coordinating a heading change 

for SkyWest flight 6819 with the ARTCC’s LEX sector controller (a radar task). After 

the Comair flight had stopped, the controller spent 8 seconds vectoring American Eagle 

flight 882 (a radar task). No ATC communications took place during the next 34 seconds. 

The first officer of the Comair flight then requested takeoff clearance. The controller 

immediately issued this takeoff clearance (a tower task), and the first officer repeated the 

clearance. About 2 seconds later, as the Comair airplane began to roll, the controller asked 

the flight crewmembers of the American Eagle flight whether they were satisfied with the 

airplane’s present heading or would like a new one to avoid weather (a radar task).

Performance of concurrent tasks requires a division of attention. Some concurrent 

tasks can be performed simultaneously, but when concurrent tasks draw on different 

sources of visual information, they require a person to engage in selective attention, 

which involves the switching of attention back and forth between sources of information 

associated with each task to update information about the tasks in working memory.197

The timeline shown in figure 7 indicates the controller’s tower and radar tasks during the 

50-second window of opportunity, and the controller’s communications during this time 

can be analyzed, along with task requirements, to draw conclusions regarding how the 

controller was focusing his attention during various time periods.

The controller was facing certain considerations in performing radar-related 

tasks. For example, because the SkyWest and American Eagle flights were going to be 

193 The decision to staff the LEX ATCT with one controller during the midnight shift is discussed in 

section 2.5.

194 The controller’s tower responsibilities also included monitoring in-flight aircraft operations within a 

radius of 4.3 nm and 2,500 feet agl.

195 Other sources of information that were used by the controller for his tower responsibilities included 

the DBRITE and flight progress strips.

196 This airspace was within 35 nm from the surface to 10,000 feet msl and included surrounding 

airports. 

197 C.D. Wickens, Engineering Psychology and Human Performance, New York: HarperCollins, 1992.
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using the same route and airspace as they left the local area, the controller needed to 

ensure a separation of at least 10 miles in between these airplanes (in accordance with an 

agreement between the LEX ATCT and the Indianapolis ARTCC). Also, the SkyWest flight 

crew had requested a deviation around an area of precipitation that was located about 

10 miles west of LEX, and the controller’s communications indicated his anticipation that 

the American Eagle flight crew might request a similar course deviation. The controller 

knew that, if this request were made, he would have to coordinate another heading 

change with the Indianapolis ARTCC’s LEX sector controller. These considerations 

increased the controller’s expectation that he would need information from the DBRITE 

to manage these aspects of his radar responsibilities, which increased the likelihood that 

he was frequently examining the DBRITE during the 50-second window of opportunity. 

However, the workload associated with the controller’s radar tasks would not have 

prevented him from periodically looking out the tower cab window.

 In contrast, the controller’s tower responsibilities at that time had become relatively 

simple. Because the controller had already obtained the Comair flight’s departure release 

and provided the flight crew with the clearance to taxi to runway 22 (which the first 

officer acknowledged), the only tower task he had to perform was to clear the airplane 

for takeoff. The controller did not have to frequently look at the runway environment to 

perform this task because he would have expected that the flight crew would inform him 

when the airplane was ready to depart, and he would be able to scan the runway at that 

time. Because no other traffic was on the airport surface to pose a conflict to the airplane 

during its taxi, the controller would not have expected much useful information to be 

obtained by frequently scanning the runway environment, which would have decreased 

the likelihood that he was frequently looking out the tower cab windows at the runway 

environment during the 50-second window of opportunity. The Safety Board concludes 

that the controller did not notice that the flight crew had stopped the airplane short of the 

wrong runway because he did not anticipate any problems with the airplane’s taxi to the 

correct runway and thus was paying more attention to his radar responsibilities than his 

tower responsibilities. 

Postaccident observations from the LEX ATCT revealed that, from the controller’s 

work station at night, it was somewhat difficult to see whether the CRJ-100 demonstration 

airplane was located at the hold short line for runway 26, on taxiway A, or at the hold 

short line for runway 22 because of (1) the proximity of these locations in the controller’s 

visual field as a result of the new taxiway configuration198 and (2) the reduced visibility 

of ground texture, linear perspective, and other monocular depth cues that are useful for 

judging distances beyond 15 to 20 feet. Although the controller had been working at the 

tower for 17 years and had presumably become an expert at recognizing aircraft positions 

on the airport surface, the use of former taxiway A5 (redesignated as taxiway A) to reach 

the runway 22 threshold was new to him because the runway had been shifted and the 

redesignated taxiway had been in place for only 1 week (four of the controller’s shifts) 

198 From the tower cab, the hold short lines for runways 22 and 26 appeared close to each other because 

they were separated by less than 5o of visual angle.
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at the time of the accident.199 These factors would have made it more difficult for the 

controller to determine the airplane’s exact location. 

In addition, the controller was not required to determine that the airplane had 

reached the departure runway before he cleared the airplane for takeoff; he was only 

expected to determine that the airplane was at a location that was consistent with its taxi 

clearance. When the flight crew had stopped the airplane at the runway 26 hold short line, 

the airplane was in a location that was consistent with its taxi clearance. The controller 

reported that he did not see the airplane stop in this position. Even if the controller had 

seen the airplane at that time and noticed that it was not moving, a brief scan of the 

runway environment would not have informed him of whether the airplane had been 

stopped only briefly or for a longer period of time. Nevertheless, the controller could 

have detected that the airplane had stopped short of the wrong runway if he had been 

monitoring the airplane’s progress along the taxi route. 

2.2.3.2 Critical Window During Which an Administrative Task Was Performed

After the LEX controller cleared Comair flight 5191 for takeoff, he told American 

Eagle flight 882 to contact the Indianapolis ARTCC. According to the ATC transcript, 

the handoff of the American Eagle flight to the Indianapolis ARTCC occurred about 

0605:40. About that time, Comair flight 5191, the only airplane for which the controller 

had responsibility, was turning onto runway 26 and had not yet deviated from the issued 

taxi clearance. The controller’s next active task would be to establish contact with the 

Comair flight and provide departure services (radar tasks), but he would likely not have 

expected to perform this task for about 1 minute.200 This 1-minute pause in active control 

tasks afforded the controller greater flexibility in terms of his allocation of attention. 

The controller stated that, after the handoff of the American Eagle flight to the 

Indianapolis ARTCC, he began the combined traffic count, which was an administrative 

record-keeping task.201 The standard operating procedure at LEX was to perform 

the traffic count on an hourly basis. However, the controller stated that he normally 

accumulated flight progress strips throughout the night and performed the traffic count 

once toward the end of his shift. The controller estimated that the traffic count would 

take 2 to 5 minutes to complete.202 

The controller was expecting to be relieved by the incoming day shift controller 

at 0630, so he most likely wanted to complete the traffic count by that time. However, 

199 When taxiway A north of runway 8/26 was used to reach the runway 22 threshold, the hold short lines 

for runways 22 and 26 were farther apart in the controller’s visual field. 

200 The time between flight crew acknowledgment of the takeoff clearance and the controller’s 

acknowledgment of radar contact was 41 and 78 seconds for the SkyWest and American Eagle departures, 

respectively.

201 When the tower was staffed with more than one controller, the controller at the radar data position 

recorded the radar traffic count, and the controller at the clearance delivery position recorded the tower traffic 

count. When the midnight shift was staffed with one controller, that controller performed a combined radar and 

tower traffic count.

202 As a result, the controller must have expected that he would have to interrupt this administrative task 

to provide radar services to the Comair flight. 
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because this task was not urgent or critical to flight safety and the day shift controller 

was not expected to arrive for more than 20 minutes, the accident controller could have 

delayed performing the traffic count until after he handed off the Comair flight to the 

Indianapolis ARTCC. If the controller had monitored the Comair flight during its takeoff, 

he most likely would have detected, during the 28-second critical window, the flight 

crew’s deviation from the taxi and takeoff clearances, and he could have then warned the 

flight crewmembers about their mistake and have possibly prevented the accident. 

Similar to air traffic controllers, pilots must also prioritize overlapping tasks, and 

inappropriate prioritization of tasks has often been documented as a factor in aircraft 

accidents and incidents.203 Task prioritization can break down under high workload 

conditions, but the controller’s workload was relatively light 1 minute before the 

accident. As a result, the Safety Board considered other factors that could influence task 

prioritization to understand the controller’s decision to perform an administrative task 

instead of monitoring the airplane. Research indicated that prioritization of concurrent 

tasks was strongly affected by procedural requirements and that tasks to be performed 

at a particular time tended to receive higher priority than nonrequired tasks.204 The 

controller was not required to monitor the Comair flight’s takeoff or perform the traffic 

count at that particular time. Because of the lack of a procedural requirement, the 

controller’s prioritization of attention would have been based on other factors. Research 

indicated that other factors that can affect task prioritization included a task’s perceived 

importance, the acceptability of its present status, and its ease of completion.205

The controller assumed that the likelihood of a surface navigation error was small. 

Before the accident, no air carrier airplane had attempted to take off on runway 26,206 and 

the controller had no reason to suspect that a flight crew would attempt to do so. No other 

traffic was on the airport surface to pose a conflict, so the potential for a ground collision 

was extremely low. As a result, the controller most likely considered the importance 

of monitoring the takeoff as low. In addition, the controller’s postaccident statements 

indicated that he had not adopted a practice of consistently monitoring takeoffs whenever 

possible. 

Because the controller performed the traffic count at the end of his shift instead 

of hourly, the status of this task had become an issue. The controller was nearing the 

203 Research found that 23 percent of major aircraft accidents between 1960 and 1989 involved cockpit 

task management errors and that 32 percent of the accidents in this category involved pilot deficiencies 

in task prioritization. For more information, see C. Chou, D. Madhavan, and K. Funk, “Studies of Cockpit 

Task Management Errors,” International Journal of Aviation Psychology, vol. 6, pages 307-320, 1996. These 

researchers also studied aircraft incidents reported through ASRS and found that 35 percent of cockpit task 

management errors involved task prioritization.

204 Research on pilot prioritization of in-flight tasks indicated that significant individual differences existed 

in prioritizing tasks but that the primary factor might be procedural consistency or operating procedures that 

require a certain task to be performed at a certain time. For more information, see K. Colvin, K. Funk, and 

R. Braune, “Task Prioritization Factors: Two Part-Task Simulator Studies,” International Journal of Aviation 

Psychology, vol. 15, pages 321-338, 2005.

205 K. Colvin, K. Funk, and R. Braune, 2005.

206 A 1993 ASRS report indicated a near takeoff on runway 26 by an air carrier airplane (see 

section 1.18.5). 
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end of his shift and needed to complete the task, which he viewed as quick and easy, 

before he could be relieved of his duties. Although the controller decided that the traffic 

count needed to be performed at that time, the performance of that administrative task 

was not directly related to safety. Unexpected hazardous events can occur during airport 

operations, as demonstrated by this accident, and controller monitoring can provide an 

important redundant safety protection against such events.

The Safety Board 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.

On April 10, 2007, the Safety Board issued Safety Recommendation A-07-34, 

which asked the FAA to require all air traffic controllers to complete instructor-led initial 

and recurrent training in resource management skills to improve controller judgment, 

vigilance, and safety awareness (see section 1.18.3.2). On July 13, 2007, the FAA stated that 

it had delivered CRM workshops, posters, and follow-up support to several ATCTs and 

TRACONs. The FAA also stated that the CRM implementation plan for fiscal years 2007 

through 2009 included instructor-led training at “a percentage of” the highest-error-rate 

terminal and en route facilities and CRM training for initial hires in the FAA Academy 

and college training initiative programs. The FAA further stated that it would develop 

plans to train additional controllers on an initial and a recurrent basis.

The Safety Board is encouraged that the FAA has provided CRM training to some 

ATC facilities but is concerned that such training may not be provided to all controllers, 

including those at smaller facilities (such as LEX). The Board is also concerned about 

the FAA’s plans for recurrent CRM training at only a percentage of the terminal and en 

route facilities with the highest error rates. The FAA needs to ensure that all controllers 

(and not just those at highest-error-rate facilities) receive this training on an initial and 

a recurrent basis. Pending this action, Safety Recommendation A-07-34 is classified 

“Open—Acceptable Response.” 

2.2.3.3 Fatigue

As stated in section 2.2.2.4, potential conditions that can lead to the development 

of a fatigued state include chronic sleep restriction, acute sleep loss, circadian disruption, 

and time since awakening. The controller’s reported duty times and sleep patterns from 

August 24 to 26, 2006, were not indicative of a chronic sleep restriction, but they were 

indicative of acute sleep loss, circadian disruption, and a long time since awakening.

The controller reported that, on August 26, 2006, he awoke at 0540, worked 

from 0630 to 1430, and took a nap between about 1530 and 1730 (the quality of his sleep 

during the nap was described as “not real good”). As a result, the controller had slept 

about 2 hours in the 24 hours that preceded the accident (which is much less than the 

nominal sleep period of about 8 hours), and he had been continuously awake for more 

than 12 hours since his nap. In addition, the controller was adapted to sleeping at night, 

and the accident occurred at a time when he would have normally been asleep and when 
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circadian factors would tend to diminish alertness. Thus, the controller’s recent duty 

times and sleep patterns indicated that he would have been experiencing some fatigue 

at the time of the accident. However, a review of ATC tapes found that the controller’s 

communications throughout his shift (including those involving the SkyWest, American 

Eagle, and Comair flights) were prompt and professional. The review also found that 

the controller did not yawn during his transmissions or make any phraseology errors 

(except for not advising the flight crew that taxiway A north of runway 8/26 was closed, 

as discussed in section 2.6.2).

Nevertheless, reducing daily sleep periods by as little as 2 hours can produce 

slight decreases in cognitive performance, and greater sleep restrictions can produce 

more pronounced effects.207 Fatigue tends to increase preoccupation with single tasks 

or elements, reduce scanning, increase vigilance errors, impair decision-making, and 

diminish awareness of one’s own degraded performance. These effects tend to have a 

negative effect on the performance of concurrent tasks. 

As discussed in section 2.4.4, the FAA’s existing procedures for issuing takeoff 

clearances allowed the controller to issue the takeoff clearance and scan the runway 

environment before the airplane crossed the intersecting runway. Also, as discussed 

in section 2.4.5, the FAA did not have a policy that explicitly required the controller to 

monitor airplanes during takeoff or a policy that explicitly stated that the controller was 

required to give higher priority to the monitoring of takeoffs rather than the performance 

of an administrative task. FAA Order 7110.65, “Air Traffic Control,” states that actions 

that are most critical to safety should be performed first, but this policy leaves a great 

deal of interpretation to the individual controller. 

The controller was not in the habit of monitoring takeoffs. The controller stated 

that his decision to monitor an airplane during takeoff depended on traffic spacing and 

the other tasks he had to perform. On the basis of this statement, the controller’s decision 

to perform the traffic count when Comair flight 5191 was taking off could have been 

consistent with his normal practice for monitoring departing airplanes.

The Safety Board concludes that the controller was most likely fatigued at the 

time of the accident, but the extent that fatigue affected his decision not to monitor the 

airplane’s departure could not be determined in part because his routine practices did not 

consistently include the monitoring of takeoffs. The Safety Board further concludes that 

FAA operational policies and procedures at the time of the accident were deficient because 

they did not promote optimal controller monitoring of aircraft surface operations. 

On April 10, 2007, the Safety Board issued Safety Recommendations A-07-30 

and -31 to the FAA to address its concerns about the potential impact of fatigue on air 

traffic controller performance.208 Safety Recommendation A-07-30 asked the FAA to 

work with NATCA to reduce the potential for controller fatigue by (1) revising controller 

207 H.P.A. Van Dongen, G. Maislin, et al., 2003. 

208 Also on April 10, 2007, the Safety Board issued Safety Recommendation A-07-32 to NATCA to address 

this issue (see section 1.18.3.2). The recommendation is currently classified “Open—Await Response.”
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work scheduling policies and practices to provide rest periods that are long enough for 

controllers to obtain sufficient restorative sleep and by (2) modifying shift rotations to 

minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive 

performance. Safety Recommendation A-07-31 asked the FAA to develop a fatigue 

awareness and countermeasures training program for controllers and personnel who are 

involved in the scheduling of controllers for operational duty that addresses the incidence 

of fatigue in the controller workforce, causes of fatigue, effects of fatigue on controller 

performance and safety, and the importance of using personal strategies to minimize 

fatigue. 

On July 5, 2007, the FAA responded to Safety Recommendations A-07-30 and ‐31. 

The FAA stated that it had convened a working group to develop shift rotation and 

scheduling guidelines and that NATCA would be invited to participate in the group. 

The FAA also stated that it would develop, within 12 months, and implement a fatigue 

awareness and countermeasures training program to be used by all FAA Air Traffic 

Organization operational service units. Pending (1) the development of guidance for 

controller work scheduling policies and practices to provide rest periods that are long 

enough for controllers to obtain sufficient restorative sleep and (2) the modification of 

shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and 

decreased cognitive performance, Safety Recommendation A-07-30 is classified “Open—

Acceptable Response.” Pending the development and implementation of a fatigue 

awareness and countermeasures training program for controllers and personnel involved 

in the scheduling of controllers for operational duty, Safety Recommendation A-07-31 is 

classified “Open—Acceptable Response.”

2.2.3.4 Summary of Air Traffic Controller Human Factors

The concurrent radar and tower tasks that required the controller to divide his 

attention occurred during the window of opportunity when the controller could have, 

but did not, notice that the airplane was stopped short of runway 26. After the controller 

transferred control of American Eagle flight 882 to the Indianapolis ARTCC, he did not 

have any further active radar duties. However, after the transfer, the controller performed 

an administrative task—the traffic count—instead of monitoring the departure of Comair 

flight 5191. The controller had turned around in the tower cab to perform this task before 

the start of the critical window. At that time, the airplane had not yet deviated from the 

issued clearances. However, at the end of the critical window, the airplane had accelerated 

beyond the maximum airspeed that would have allowed the airplane to remain on the 

available runway if the flight crew rejected the takeoff and used maximum braking. Thus, 

at that point, the controller missed his final opportunity to notice the flight crew’s error in 

enough time to take action to prevent the accident. 

The controller most likely considered the importance of monitoring the Comair 

flight’s takeoff as low because he assumed that there was little opportunity for a surface 

navigation error and no other traffic was on the airport surface to pose a conflict. On the 

other hand, the controller most likely considered that the traffic count was a higher priority 

at that time because he was nearing the end of his shift and needed to complete the task 

before he could be relieved of his duties. The controller did not appropriately prioritize 
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his tasks because the traffic count was not directly related to safety, but monitoring the 

takeoff would have provided an important safety protection. 

Because of the nature of their responsibilities, controllers are expected to be able 

to appropriately prioritize and perform concurrent tasks. Some controllers may not 

recognize the critical importance of their monitoring efforts in providing a redundant 

safety protection against unexpected flight crew errors and other threats to flight safety.

This issue is further discussed in section 2.4.4. 

The controller’s recent duty times and sleep patterns indicated that he was most 

likely experiencing fatigue at the time of the accident. Also, the circumstances of this 

accident suggested that task prioritization could be improved by modifying existing FAA 

guidelines on duty priority so that they explicitly state that active control tasks with a 

direct flight safety benefit, such as monitoring departing and arriving aircraft, are a higher 

priority than administrative record-keeping tasks, such as a traffic count. This issue is 

further discussed in section 2.4.5. 

2.3 Survival Factors

2.3.1 Impact Sequence and Injury Information

The airplane’s impact with a berm located about 265 feet from the departure end 

of runway 26 caused the airplane to become momentarily airborne. No airplane debris 

(except for a main landing gear door) was found before the berm, indicating the airplane 

structure was intact before this point. Ground scars from the left main and nose landing 

gears were found about 620 feet from the end of the runway. The airplane then became 

airborne again, and the cockpit and the left wing impacted an initial group of trees located 

about 900 feet from the end of the runway. This impact caused the cockpit to break open 

and the left wing fuel tank to rupture, allowing a fuel-air mixture to ignite. The airplane 

then impacted the ground about 1,250 feet from the end of the runway, as evidenced by 

ground scars from the entire lower surface of the airplane. 

The airplane then slid 400 feet and struck two large diameter trees. The impacts 

breached the passenger cabin, separating it into two sections and allowing a large amount 

of fuel, fuel vapor, and fire to enter the cabin. The fuselage traveled another 150 feet 

before coming to a stop. The airplane structure continued to burn, and the fire eventually 

consumed the entire fuselage and cabin interior.

The simultaneous impacts with two large diameter trees caused numerous blunt 

force fatal injuries to passengers. One of these tree strikes occurred on the left side of the 

fuselage several rows aft of the main cabin door.209 The other tree strike occurred in the 

area where the left inboard wing attached to the fuselage. This tree breached the left wing 

fuel tank and the cabin in the area of the left overwing exit, cut through the cabin as the 

airplane continued to slide, and exited the right side of the aft cabin. Figure 8 shows the 

approximate tree strike areas in the cabin. 

209 This tree was uprooted and carried with the airplane to its final location. 
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Figure 8. Approximate Tree Strike Areas and Injury Information

Note: On the basis of body location information and autopsy results, the Safety Board determined that, 

before the attempted takeoff, the passengers assigned to seats 2A and 2B most likely switched seats, the 

passenger assigned to seat 10D most likely moved to seat 7B, and the nonrevenue passenger most likely 

took seat 12B. 

Note: Seat positions showing more than one color indicate more than one reported major pathologic finding 

in the autopsy reports.
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The captain’s body was found in the forward area of the passenger cabin. The 

seriousness of the captain’s blunt force injuries would have precluded him from initiating 

any postaccident movement. Thus, the captain (and his seat) must have been separated 

from the cockpit during the impact sequence. 

The first officer was found in the remnants of his seat secured by the seat’s restraint 

system. He was extricated from the cockpit wreckage by first responders to the accident 

scene and transported to the hospital, as discussed in section 2.3.2.

The flight attendant’s body was found close to his jumpseat. His autopsy report 

and those of several passengers in the forward area of the cabin showed a relative lack of 

blunt force injuries and evidence of smoke inhalation. These findings indicated that these 

occupants survived the impact but succumbed to the effects of the postcrash fire and 

smoke. It was not possible to determine the length of time that these occupants survived, 

but it is important to note that all of these occupants were found close to their seats. 

Several passengers who were seated in the forward left part of the cabin were 

found near each other in the aft right part of the cabin. It is likely that the forward tree 

strike caused these passengers and their seats to be displaced. Most of these passengers 

sustained fatal blunt force injuries. 

Most of the passengers seated in rows 7 through 9 (the overwing exit row and the 

rows immediately in front of and in back of it) were killed immediately by the flash fire 

that occurred after the left wing fuel tank was breached by the aft tree strike and fuel, fuel 

vapor, and fire entered the cabin. 

Two passengers were found outside of the cabin on the left side of the fuselage. 

These passengers sustained fatal thermal injuries, and neither sustained serious blunt 

force injuries. Evidence indicated that the passengers were likely thrown outside (through 

the break in the fuselage caused by the aft tree strike) when the airplane came to a stop. 

Several passengers who were seated in the aft cabin sustained some blunt force 

injuries, and most showed evidence of smoke inhalation. It was not possible to determine 

the length of time that these passengers survived, but it is important to note that all of the 

passengers were found close to their seats. 

2.3.2 Emergency Response

According to the aircraft performance study for this accident, the airplane struck 

trees and terrain west of the airport about 0606:35. The sounds of the accident took about 

5 seconds to reach the tower. The controller stated that, after hearing these sounds, he 

saw a fire west of the airport. The ATC transcript showed that the controller activated 

the crash phone about 0607:17. Thus, about 37 seconds had elapsed between the time that 

the accident sounds could be heard in the tower and the time that the controller activated 

the crash phone. During this time, the controller had to turn around and look outside 

the tower cab window; assess the situation; and recognize that, even though the airplane 
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had been cleared to take off from runway 22, the airplane was actually located off the 

departure end of runway 26. The ATC transcript showed that the airport fire department 

responded to the crash phone about 0607:22. According to the ATC transcript, the 

controller announced an “alert three” and indicated that a Comair jet was located at the 

west side of the airport just off the approach end of runway 8. By providing clear and 

accurate information about the airplane’s status and location, the controller’s actions 

complied with the LEX ATCT’s standard operating procedures and letter of agreement 

with the airport board regarding emergency notifications.

The first emergency responders to arrive on scene were a LEX public safety officer 

and a police officer from the city of Lexington. They arrived (independently of each other) 

in the general vicinity of the accident about 5 1/2 minutes after receiving notification of 

the accident and reached the fuselage within 3 1/2 minutes despite restricted visibility 

caused by tall vegetation near the accident site. The first ARFF vehicle arrived on scene 

about 11 minutes after alert 3 notification using route information provided by another 

LEX public safety officer (who was in the general vicinity of the accident site but was not 

yet on scene). This route was the most effective direct route available to the accident site. 

This ARFF vehicle immediately began fire suppression and knocked down most of the 

fire. The second ARFF vehicle arrived on scene shortly afterward and began additional 

fire suppression. The LEX operations center incident report showed that the fire was 

controlled about 3 minutes after the first ARFF vehicle arrived on scene. The assistant 

ARFF chief (who arrived on scene in the first ARFF vehicle) stated that, upon reaching 

the airplane, its top was gone, and its sides were mostly gone. Other first responders 

reported that the cabin interior was completely involved (that is, completely on fire) at 

the time of their arrival on scene. 

The LEX public safety officer and the police officer from the city of Lexington were 

able to free the first officer from the cockpit wreckage. Another LEX public safety officer 

and the city of Lexington police officer transported the first officer to the hospital in a 

sport-utility vehicle instead of waiting for an ambulance. This LEX public safety officer 

estimated that they arrived at the hospital (located about 7 miles from the accident site) 

before 0630. Because of the serious traumatic injuries that the first officer sustained from 

the accident, it was imperative that he be quickly transported to and receive immediate 

treatment from a trauma center. The Safety Board concludes that the first officer’s survival 

was directly attributable to the prompt arrival of the first responders; their ability to 

extricate him from the cockpit wreckage; and his rapid transport to the hospital, where 

he received immediate treatment. The Safety Board further concludes that the emergency 

response for this accident was timely and well coordinated.
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2.3.3 Summary of Survival Factors

The Safety Board’s definition of a survivable accident is as follows:210

An accident in which the forces transmitted to the occupant(s) through the 

seat and restraint system do not exceed the limits of human tolerance to 

abrupt accelerations and in which the structure in the occupants’ immediate 

environment remains substantially intact to the extent that a livable volume 

is provided for the occupants through the crash sequence.

The captain and the passengers who received fatal blunt force injuries as a 

result of the simultaneous tree strikes were clearly in areas of the airplane in which the 

forces transmitted to the occupants exceeded the limits of human tolerance. Most of the 

passengers in the overwing area of the cabin did not experience similar forces; however, 

the large amount of fuel, fuel vapor, and fire forced into the cabin by the aft tree strike 

made the cabin environment immediately unsurvivable for those passengers. The flight 

attendant and most of the passengers in the forward and aft areas of the cabin also did 

not experience forces that exceeded the limits of human tolerance and maintained a 

livable volume of occupiable space for an undetermined amount of time. As stated in 

section 2.3.1, the flight attendant and these passengers were found close to their assigned 

seats.

Because the impact forces did not exceed the limits of human tolerance and 

occupiable space was maintained for some of the airplane occupants, this accident was 

partially survivable. However, the environment inside the airplane deteriorated quickly 

as a result of the postcrash fire and smoke, which did not allow sufficient time or means 

for those occupants to evacuate.

2.4 Efforts to Mitigate Airport Surface Operation Errors

Surface operation errors, including those that lead to wrong runway takeoff 

events, can be mitigated in several ways, such as improved flight deck procedures, the 

implementation of cockpit moving map displays or cockpit runway alerting systems, 

improved airport surface marking standards, and ATC policy changes. These systemwide 

interventions, which are discussed in sections 2.4.1 through 2.4.5, can provide the necessary 

redundancy to reduce the opportunity for human error during surface operations and, if 

an error were to occur, to stop it before it becomes catastrophic. These interventions can 

also help prevent runway incursions, which is an issue on the Safety Board’s list of Most 

Wanted Transportation Safety Improvements. 

210 This definition was cited in the Safety Board’s 1981 special study on cabin safety in large transport 

aircraft. According to the study, the definition (1) was developed using aviation crash injury research by Cornell 

University and aviation safety engineering and research by the Flight Safety Foundation and (2) was used in 

the Aircraft Crash Survival Design Guide, which was prepared by the U.S. Army Research and Technology 

Laboratories along with other Federal agencies. The definition has been used by the Board since that time to 

determine the survivability of accidents. In addition, the definition appeared in the Board’s 2001 safety report 

on the survivability of accidents involving Part 121 U.S. air carrier operations from 1983 to 2000. 
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2.4.1 Flight Deck Procedures

Well-designed flight deck procedures can be an effective countermeasure against 

surface operation errors. After this accident, the Safety Board recognized the need to 

improve industry standards for confirming an airplane’s position at the departure runway 

before takeoff and, on December 12, 2006, issued Safety Recommendation A-06-83. This 

recommendation asked that the FAA require all Part 121 operators to establish procedures 

requiring all crewmembers on the flight deck to positively confirm and cross-check the 

airplane’s location at the assigned departure runway before crossing the hold short line 

for takeoff. 

On April 16, 2007, the FAA issued SAFO 07003, “Confirming the Takeoff Runway,” 

in response to Safety Recommendation A-06-83. According to the SAFO, its purpose is to 

emphasize the importance of implementing standard operating procedures and training 

for flight crews to ensure that an airplane is at the intended runway. 

SAFO 07003 was aimed at directors of safety, directors of operations, fractional 

ownership program managers, trainers, and pilots. The SAFO stated that pilots should 

positively confirm and cross-check the takeoff runway and the airplane’s location at the 

assigned departure runway before crossing the hold short line and while in the takeoff 

position. The SAFO further stated that airplane-specific standard operating procedures 

should be established, implemented, and supported by pilot training that uses all available 

resources to confirm and cross-check an airplane’s position. The SAFO mentioned that 

these resources included the HSIs, which can confirm that an airplane’s position is where 

the flight crew intended, and air traffic controllers, who can help confirm an airplane’s 

position during taxi or at a hold short line.

The Safety Board is encouraged that the FAA is providing renewed emphasis 

about the importance of cross-checking and confirming an airplane’s position on a 

runway. The Board also notes that SAFO 06013, “Flight Crew Techniques and Procedures 

That Enhance Pre-takeoff and Takeoff Safety” (see section 1.18.2.2), addressed the issue 

of training and procedures for improving safety during taxi operations. This SAFO 

referenced AC 120‐74A, “Parts 91, 121, 125, and 135 Flightcrew Procedures During Taxi 

Operations,” which outlined best practices for surface operations. The AC indicated 

that these best practices include sterile cockpit procedures to protect against human 

error and procedures to maximize “heads-out” time for both pilots to provide necessary 

redundancy. 

The FAA’s issuance of SAFO 07003 addressed the intent of Safety 

Recommendation A-06-83. However, SAFOs are, by definition, advisory only, and the 

recommendation asked the FAA to require all Part 121 operators to establish procedures 

requiring flight crewmembers to positively confirm and cross-check an airplane’s location 

at the assigned departure runway before crossing the hold short line for takeoff. Also, the 

Board’s survey of Part 121 operators found that many did not include the procedures 

recommended in SAFO 06013, which had been issued in September 2006. SAFO guidance 

may be an acceptable alternate response to a Board recommendation if an FAA survey 

finds that all Part 121 operators have implemented the recommended procedures.
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Because the decision to implement a SAFO rests with an operator and because of the 

importance to flight safety that the information in SAFO 07003 (as well as SAFO 06013) be 

required and extended to Part 91K211 and 135 operators, Safety Recommendation A-06-83 

is classified “Closed—Acceptable Alternate Action/Superseded.” In addition, the Safety 

Board concludes that a standard procedure requiring Part 91K, 121, and 135 pilots to 

confirm and cross-check that their airplane is positioned at the correct runway before 

crossing the hold short line and initiating a takeoff would help to improve the pilots’ 

positional awareness during surface operations. Therefore, the Safety Board believes 

that the FAA should require that all 14 CFR Part 91K, 121, and 135 operators establish 

procedures requiring all crewmembers on the flight deck to positively confirm and crosscheck the airplane’s location at the assigned departure runway before crossing the hold 

short line for takeoff. This required guidance should be consistent with the guidance in 

AC 120-74A and SAFOs 06013 and 07003. 

In addition, after the accident, the Safety Board also recognized the need to 

improve industry standards regarding takeoffs at night on unlighted runways. As a 

result, on December 12, 2006, the Board issued Safety Recommendation A-06-84, which 

asked the FAA to require all Part 121 operators to provide specific guidance to pilots on 

the runway lighting requirements for takeoff operations at night. 

On May 11, 2007, the FAA issued InFO 07009, “Runway Lights Required for 

Night Takeoffs in Part 121.” This InFO recognized that, even though runway lighting 

varied among airports and runways, every pilot operating under Part 121 needed to 

understand the following: (1) pilots should not take off at night on a runway without 

lights; (2) pilots must check NOTAMs for runway light outages and taxiway and runway 

closures, and takeoffs are not permitted on closed runways; and (3) a pilot must think 

beyond pertinent NOTAMs because inoperative runway lights do not necessarily cause 

a runway to be closed by the airport authority, or a runway may be unusable even if its 

runway lights are fully operational. The InFO recommended that Part 121 directors of 

safety, directors of operations, trainers, and pilots collaborate to make these three points 

clearly understood by their flight crews and include these points in their pilot operating 

manuals, training programs, and plans for any night takeoff.

Even though the information in InFO 07009 is responsive to Safety 

Recommendation A-06-84, InFOs are advisory only, and the recommendation asked 

the FAA to require Part 121 operators to provide pilot guidance on runway lighting 

requirements for night takeoff operations. However, if the FAA can determine, by 

surveying all Part 121 operators, that the guidance in the InFO has been adopted, then 

the Safety Board could consider the InFO to be an acceptable alternative action to the 

recommendation. Pending the results of an FAA survey of all Part 121 operators to 

determine whether they have adopted the guidance in InFO 07009, Safety Recommendation 

A-06-84 is classified “Open—Acceptable Alternate Response.”

Finally, in its report on the February 16, 2005, crash of a Cessna Citation 560 in 

Pueblo, Colorado, the Safety Board discussed the need for pilots to receive training in 

211 Title 14 CFR 91 Subpart K applies to fractional ownership operations. 
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monitoring skills and have opportunities to practice these skills.212 On February 27, 2007, 

the Board issued Safety Recommendation A-07-13, which asked the FAA to “require that 

all pilot training programs be modified to contain modules that teach and emphasize 

monitoring skills and workload management and include opportunities to practice and 

demonstrate proficiency in these areas.”213 If this recommendation were implemented, 

pilots would receive training that would not only benefit in-flight operations but also 

airport surface operations.

2.4.2 Technological Initiatives

Advances in technology can provide pilots with improved positional awareness 

while navigating airport surfaces. Such technologies were discussed and illustrated at the 

Safety Board’s Runway Incursion Forum in March 2007. Cockpit moving map displays in 

which the aircraft’s position is superimposed on a map of the airport surface, including 

all runways, taxiways, and terminal areas, would help pilots orient themselves during 

navigation if they were to become lost, thus mitigating surface navigation errors. A 

cockpit moving map display could be an effective countermeasure against the type of 

perceptual error and confirmation bias that occurred with this accident. Efforts to establish 

digital maps of airports were included as part of the FAA’s Safe Flight 21 program, and 

cockpit-based tools for surface navigation were addressed in the FAA’s 2002 Blueprint 

for Runway Safety. In addition, research showed that, if airborne electronic map 

displays were extended to airport surface navigation, they could significantly decrease 

navigational errors, such as wrong turns in low visibility conditions.214

On March 23, 2007, the FAA announced that it was accelerating the certification 

process to facilitate the installation in air carrier cockpits of class 2 electronic flight bags 

(EFB), which are portable devices that can display various textual and graphical data, 

including moving maps.215 The FAA’s decision to accelerate the certification process 

and allow class 2 EFBs to be used for ground operations was the result of the agency’s 

recognition that the requirements for the ground use of these devices could be relaxed 

compared with the more stringent class C standards for the airborne use of the devices. 

The FAA’s decision to relax the standards for the ground use of class 2 EFBs was partly 

the result of the agency’s review of human factors research on the safety benefits of these 

systems. According to the FAA, the research showed that pilots had better awareness of 

their position on the airport’s surface using an “own ship” position display, and recent 

212 National Transportation Safety Board, Crash During Approach to Landing, Circuit City Stores, Inc., 

Cessna Citation 560, N500AT, Pueblo, Colorado, February 16, 2005, Aircraft Accident Report NTSB/AAR-07/02 

(Washington, DC: NTSB, 2007). The report includes a discussion of the Safety Board’s previous work in the 

area of pilot monitoring.

213 On May 17, 2007, the FAA stated that 14 CFR Part 61 and the Aircraft Type Rating Practical Test 

Standard specifically addressed the CRM requirement for airman certification and checking. The FAA also 

stated that it would consider identifying in its work program a list of required inspections that would reemphasize 

to regional and flight standards district office managers the need to validate the training that is already required 

and verify its effectiveness. 

214 V. Battiste, M. Downs, and R.S. McCann, “Advanced Taxi Map Display Design for Low-Visibility 

Operations,” Proceedings of the Human Factors and Ergonomics Society, pages 997-1001, 1996.

215 Class 2 EFBs operate using the airplane’s power system.
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tests demonstrated that pilots typically glanced at such displays and then quickly looked 

out their windows to verify that information visually, thus eliminating the concern that 

pilots would be “heads down” too long for safe operations.

The FAA expected to have guidance on its streamlined certification process for 

the ground use of class 2 EFB moving map displays by the end of April 2007. (As of 

July 3, 2007, this guidance had not been issued.) The class C certification standards, which 

were established in 2003, will remain the same for these devices, but the new certification 

process is expected to lower the cost for their deployment and implementation.

In addition to cockpit moving map displays, the Safety Board reviewed other 

available technologies that might have alerted the accident flight crewmembers about 

their surface navigation error. For example, after the Singapore Airlines flight 006 

accident, Boeing developed a wrong runway alert that compares the runway selected 

in the flight management computer (FMC) with the airplane’s position or heading at the 

time of takeoff. This optional upgrade to EICAS software annunciates a cautionary EICAS 

alert when a takeoff is attempted on a runway that is not the FMC-selected runway.216

Also, Honeywell developed the runway alert and advisory system (RAAS), 

which is a software addition to the company’s enhanced ground proximity warning 

system (EGPWS). RAAS does not require the installation of additional hardware but 

does require an airplane to be equipped with a global positioning system. RAAS uses 

the same runway database as EGPWS to provide an aural advisory to pilots when their 

airplane is approaching or is on a runway during taxi operations. The RAAS system also 

provides pilots with an aural advisory when their airplane is on a runway of an operatordefined insufficient length or if the airplane is positioned for an intersection departure of 

insufficient length. In addition, RAAS provides an aural advisory to pilots if a takeoff is 

attempted on a taxiway. Research conducted by Honeywell indicated that RAAS could 

mitigate flight crew surface navigation errors that could lead to wrong runway takeoffs. 

Currently, eight CRJ airplanes have RAAS installed.

The Safety Board is encouraged by the FAA’s actions with regard to cockpit moving 

map displays for surface navigation and cockpit runway alerting systems. However, 

these technologies have not been mandated despite their demonstrated safety benefits. 

These technologies need to be considered in the same category as existing technological 

interventions such as the traffic alert and collision avoidance system (commonly referred 

to as TCAS) and EGPWS. The Safety Board concludes that the implementation of cockpit 

moving map displays or cockpit runway alerting systems on air carrier aircraft would 

enhance flight safety by providing pilots with improved positional awareness during 

surface navigation. Therefore, the Safety Board believes that the FAA should require 

that all 14 CFR Part 91K, 121, and 135 operators install on their aircraft cockpit moving 

map displays or an automatic system that alerts pilots when a takeoff is attempted on a 

taxiway or a runway other than the one intended. 

216 According to Boeing, 14 air carriers currently have airplanes equipped with this alert.
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2.4.3 Airport Surface Marking Standards

In 2002, the FAA sponsored a study to determine whether paint markings would 

improve the situational awareness of pilots taxiing on an airfield. The study, which was 

undertaken by the Mitre Corporation, found that enhanced taxiway centerline markings 

and surface painted holding position signs (see figure 5) were effective in increasing 

runway awareness among transport-category pilots. 

The FAA is expected to modify its airport marking standards according to the 

enhanced taxiway centerline marking recommendations from the Mitre Corporation’s 

January 2005 report. Specifically, the FAA is requiring that, by June 30, 2008, all Part 139 

airports with 1.5 million or more annual passenger enplanements have enhanced taxiway 

centerline markings before each runway holding position.217 

According to AC 150/5340-1J, “Standards for Airport Markings,” the enhanced 

taxiway centerline markings were designed to make hold short lines more conspicuous to 

pilots and help prevent a loss of situational awareness. The markings were also intended 

to alert pilots that they were approaching a runway holding position and that they 

“should go into a ‘heads-up’ mode of operation until they determine the exact location of 

the holding position.”218

Even though the FAA-sponsored study found that surface painted holding 

position signs were effective in increasing positional awareness for pilots, the FAA did 

not modify its requirement for these holding position signs. Currently, the signs are only 

required where the width of the holding position on the taxiway is greater than 200 feet. 

From a human factors standpoint, surface painted holding position signs provide pilots 

with an unambiguous cue of their position on the airport surface. The central location 

of these position signs (adjacent to the taxiway centerline) increases their conspicuity, 

providing a critical redundancy to existing signage. 

The Safety Board is encouraged by the FAA’s plan to incorporate enhanced 

taxiway centerline markings at airports with 1.5 million or more annual passenger 

enplanements. However, the Board is concerned that other Part 139 airports will not be 

required to implement these markings and that surface painted holding position signs will 

still only be required where the width of the holding position on the taxiway is greater 

than 200 feet. The Safety Board concludes that enhanced taxiway centerline markings and 

surface painted holding position signs provide pilots with additional awareness about 

the runway and taxiway environment. Therefore, the Safety Board believes that the FAA 

should require that all airports certificated under 14 CFR Part 139 implement enhanced 

taxiway centerline markings and surface painted holding position signs at all runway 

entrances. 

217 According to the FAA’s passenger enplanement data for 2005 (the most recent data available), these 

markings will be required at 75 airports. LEX is not one of those airports; during 2005, it had about 0.5 million 

passenger enplanements.

218 AC 150/5340-1J also stated, “installation at other airports is at the option of the airport operator. If 

an airport operator decides to exercise this option, the enhanced markings must be installed at all holding 

positions on the airport.”
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2.4.4 Taxi and Takeoff Clearances

As stated in section 2.2.1.1, 14 CFR 91.129(i) permits pilots, after receiving taxi 

clearance, to cross all intersecting runways along the taxi route (without stopping) 

except for the assigned departure runway. On July 6, 2000, the Safety Board issued 

Safety Recommendations A-00-67 and -68, which asked, in part, that the FAA (1) amend 

14 CFR 91.129(i) to require that all runway crossings be authorized only by specific ATC 

clearance and (2) amend FAA Order 7110.65 to require that, for aircraft that need to cross 

multiple runways, air traffic controllers issue an explicit crossing instruction for each 

runway after the previous runway has been crossed. The Board classified these safety 

recommendations “Open—Unacceptable Response” on April 11, 2006. 

If these safety recommendations had been implemented before this accident, the 

controller would have been required to issue a specific taxi clearance for the airplane 

to cross runway 26 and then issue a specific taxi clearance for the airplane to continue 

taxiing to runway 22. These procedures would have provided the flight crew with better 

awareness of the airplane’s position along the taxi route and would have required the 

controller to visually observe the airplane’s position and monitor the taxi as the airplane 

progressed toward the departure runway. Thus, the flight crew’s surface navigation error 

might have been prevented. In addition, Mitre reports cited pilot and controller concerns 

about the adequacy of runway crossing requirements, and most of these pilots and 

controllers thought that it would be beneficial to safety to modify 14 CFR 91.129(i) so that 

it required a specific clearance for each runway crossing.219 The Safety Board concludes 

that this accident demonstrates that 14 CFR 91.129(i) might result in mistakes that have 

catastrophic consequences because the regulation allows an airplane to cross a runway 

during taxi without a pilot request for a specific clearance to do so. Therefore, the Safety 

Board reiterates Safety Recommendations A-00-67 and -68. 

In addition, no FAA guidance specifically prohibits issuing a takeoff clearance 

until all intersecting runways to the departure runway have been crossed. On January 4, 

2007, the LEX air traffic manager issued a notice that stated that controllers at the tower 

were not to issue takeoff clearances for runway 22 until the departing airplanes were 

observed to have completely crossed runway 26.220 Such guidance would benefit other 

airports with intersecting runways. On June 1, 2007, the FAA issued Notice N JO 7110.468 

to amend the required phraseology for issuing departure instructions. According to this 

notice, a controller has to specifically clear an airplane across all intervening runways 

before issuing a takeoff clearance. However, this guidance does not instruct controllers to 

wait until an airplane has crossed the runways before issuing the takeoff clearance. 

219 (a) Reports by Airline Pilots on Airport Surface Operations: Part 2. Identified Problems and 

Proposed Solutions for Surface Operational Procedures and Factors Affecting Pilot Performance, Technical 

Report No. MTR94W0000060.v2, McLean, Virginia: Mitre Corporation, 1994; and (b) Reports by Air Traffic 

Control Tower Controllers on Airport Surface Operations: The Causes and Prevention of Runway Incursions, 

Technical Report No. MTR98W0000033, McLean, Virginia: Mitre Corporation, 1998.

220 In addition, in its July 17, 1989, letter transmitting Safety Recommendation A-89-74 (see 

section 1.18.3.1), the Safety Board noted that the controllers at HOU were required to observe airplanes cross 

the approach end of runway 17 before issuing a clearance for takeoff for runway 12. This requirement was 

the result of two pilot deviation events in early 1989 that involved departures of U.S. air carrier airplanes from 

the wrong runway at the airport. 
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The Safety Board concludes that, if controllers were required to delay a takeoff 

clearance until confirming that an airplane has crossed all intersecting runways to a 

departure runway, the increased monitoring of the flight crew’s surface navigation 

would reduce the likelihood of wrong runway takeoff events. Therefore, the Safety 

Board believes that the FAA should prohibit the issuance of a takeoff clearance during an 

airplane’s taxi to its departure runway until after the airplane has crossed all intersecting 

runways. 

2.4.5 Controller Monitoring Responsibility

FAA Order 7110.65, paragraph 2-1-2, “Duty Priority,” states that controllers 

should “give first priority to separating aircraft and issuing safety alerts” and that “good 

judgment shall be used in prioritizing all other provisions of this order based on the 

requirements of the situation at hand.” Visual monitoring of takeoffs and landings is not 

specifically required by the order, so a controller’s decision whether to monitor a takeoff 

or landing is thus left to his or her judgment.

Unless other active, flight safety-related control tasks demand attention, controllers 

should visually monitor departing and arriving airplanes because such monitoring can 

allow the detection of unexpected threats to flight safety, including surface navigation 

errors. Thus, the monitoring of takeoffs and landings should have a higher priority than 

performing administrative tasks because such tasks, although required, do not directly 

affect flight safety, whereas visual monitoring of takeoffs and landings provides a safety 

protection. 

The Safety Board recognizes that controllers may not be able to continuously 

monitor all takeoffs and landings in their area of operations. Research on performance 

criteria for ATC specialists indicated that local (tower) controllers spent about 38 percent 

of their time looking out of tower cab windows.221 These controllers were looking at the 

DBRITE and flight progress strips during most of their other time, which was necessary 

because these sources of information were routinely changing and thus required visual 

attention. Even though controllers cannot continuously monitor departing and arriving 

airplanes, controllers can prioritize their duties so that they give priority to monitoring 

tasks over the performance of administrative tasks. 

The LEX controller stated that he monitored the takeoff of departing airplanes 

when arriving airplanes were on final approach so that he could ensure that the departing 

airplanes took off in time to maintain adequate separation. The controller stated that he 

might decide to watch other airplanes take off but that this decision depended on whether 

he needed to attend to other duties. The controller’s decision to perform the traffic count 

instead of monitoring the Comair flight’s departure, in addition to his description of his 

normal monitoring practices for departing airplanes, suggested that he did not regard the 

visual monitoring of takeoffs and landings as a necessary flight safety activity. However, 

221 K. Cardosi and A. Yost, Controller and Pilot Error in Airport Operations: A Review of Previous Research 

and Analysis of Safety Data, Technical Report No. DOT/FAA/AR-00/51 (Washington, DC: Department of 

Transportation, 2001). 
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after the accident, the controller acknowledged that it might have been possible for him 

to detect that the accident airplane was on the wrong runway if he had been looking out 

the tower cab windows.

Administrative tasks should not have priority over radar and tower monitoring 

tasks. The Safety Board concludes that, if controllers were to focus on monitoring tasks 

instead of administrative tasks when aircraft are in the controller’s area of operations, 

the additional monitoring would increase the probability of detecting flight crew errors. 

Therefore, the Safety Board believes that the FAA should revise FAA Order 7110.65, 

“Air Traffic Control,” to indicate that controllers should refrain from performing 

administrative tasks, such as the traffic count, when moving aircraft are in the controller’s 

area of responsibility. 

2.5 Air Traffic Control Staffing

In August 2005, an operational error occurred during the midnight shift at RDU, 

which resulted in a loss of separation between a departing and an arriving airplane. At the 

time, one controller was performing radar and tower functions in the tower cab. The FAA 

attributed this incident to “controller situational awareness and actions,” specifically, the 

controller’s “failure to maintain constant surveillance and awareness of [radar] displays 

and traffic situation, failure to comprehend and project the future status of displayed data, 

and failure to provide attention to detail necessary for the safe operation of aircraft under 

control.” The FAA’s final report on the operational error described the traffic situation as 

“moderately difficult” because the controller was handling nine airplanes (one departure, 

six arrival, and two taxiing airplanes) and thunderstorms were in the airspace, which led 

the controller to vector one of the airplanes off of a standard arrival route. 

As a result of this incident, the FAA issued verbal guidance in late August 2005 

indicating that all facilities with radar and tower responsibilities were to be staffed 

with two controllers during the midnight shift so that the functions could be split.222

In November 2005, the LEX air traffic manager notified his staff by e-mail about this 

guidance. 

Staffing during the midnight shift at LEX (0000 to 0800) was frequently not in 

compliance with this guidance. The midnight shift at LEX was staffed with one controller 

until January 2006. Between January and March 2006, the midnight shift was staffed with 

two controllers 40 percent of the time. In April 2006, the shift was again staffed with one 

controller because traffic had increased during the day and swing shifts and the second 

222 As stated in section 1.10.2.1, in November 2006 the FAA issued Notice N JO 7210.639 to formalize 

this verbal guidance.
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midnight controller was needed on those shifts.223 As a result of this staffing change, 

only one controller was performing both radar and tower functions at the time of the 

accident.

As discussed in section 2.2.3.1, the controller’s combined radar and tower 

responsibilities imposed concurrent tasks, which required him to engage in selective 

attention during the minutes before the accident. However, the controller’s performance 

of concurrent tasks should not have precluded adequate monitoring of Comair 

flight 5191 during its attempted takeoff. As discussed in section 2.2.3.2, after he 

transferred responsibility of American Eagle flight 882 to the Indianapolis ARTCC, the 

controller’s sole operational responsibility was the Comair flight. Thus, no radar duties 

were interfering with the controller’s tower responsibilities during the 28-second critical 

window just before the accident.

The controller’s workload was not excessive, and ample time was available during 

the Comair flight’s taxi and takeoff roll for him to perform all necessary radar tasks 

while also monitoring the flight’s progress on the airport surface. As a result, the Safety 

Board concludes that, even though the air traffic manager’s decision to staff midnight 

shifts at LEX with one controller was contrary to FAA verbal guidance indicating that 

two controllers were needed, it cannot be determined if this decision contributed to the 

circumstances of this accident.

2.6 Other Related Issues

2.6.1 Airport Charts

At the time of the accident, the flight crew had the most recent Jeppesen chart for 

LEX, which was dated January 2006. This chart showed taxiway A5 and taxiway A north 

of runway 8/26. However, at the time of the accident, taxiway A5 had been redesignated 

as taxiway A, and taxiway A north of runway 8/26 had been closed.

The Jeppesen flight safety manager stated that the Jeppesen chart did not reflect 

information about the LEX runway and taxiway configuration (received from NFDC on 

June 23, 2006) because of a software error. After the accident, Jeppesen posted a revised 

chart on its Web site on August 29, 2006, and issued the revised chart on September 8, 

2006. This chart showed future taxiway A7 but not taxiway A5 and taxiway A north 

of runway 8/26 (the taxiway configuration at the completion of the construction 

project). Jeppesen and FAA officials indicated that it was not unusual during long-term 

construction projects for airport charts to differ slightly from what was actually present 

on the airport and for the changes to be included in local NOTAMs.

223 In a postaccident interview, the LEX air traffic manager stated that he understood the midnight shift 

staffing guidance but that he thought he had some flexibility to manage the ATCT and its staff as he deemed 

necessary.
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In addition, the August 3, 2006, NACO chart for LEX had been updated by the 

FAA to show the taxiway configuration at the completion of the construction project 

(future taxiway A7 was shown but not taxiway A5 and taxiway A north of runway 8/26). 

The program manager of the LEX construction project at the FAA’s Memphis Airports 

District Office stated that he did not recommend publishing an interim chart because the 

chart would have been inaccurate during the time both before and after the construction 

project. 

Neither the Jeppesen nor the NACO chart reflected the taxiway identifiers that 

were present on the airport at the time of the accident. However, the CVR did not record 

any discussion between the flight crewmembers indicating confusion about the airport 

taxiways, and the discrepancies between the Jeppesen chart available to the flight crew 

and the taxiway identifiers on the airport at the time would not have misled the pilots 

to runway 26 instead of runway 22. Nevertheless, the Safety Board recognizes that, 

under different circumstances, up-to-date charts might be necessary for a flight crew’s 

successful navigation on an airport and that, for those circumstances, the charts would 

need to be complete, accurate, and timely. The Safety Board concludes that, because of 

an ongoing construction project at LEX, the taxiway identifiers represented in the airport 

chart available to the flight crew were inaccurate, and the information contained in a 

local NOTAM about the closure of taxiway A was not made available to the crew via 

ATIS broadcast or the flight release paperwork.

2.6.2 Automatic Terminal Information Service Broadcasts

The flight crew indicated that it had received ATIS information “alpha,” and the 

controller advised the flight crew when ATIS information “bravo” was current. Neither 

ATIS broadcast indicated that taxiway A north of runway 8/26 had been closed as part of 

the airport construction project. FAA Order 7110.65, paragraph 2-9-3g, “Content,” states 

that taxiway closures that affect the entrance or exit of active runways should be included 

in ATIS broadcasts. After the accident, the Safety Board determined that the taxiway 

closure information had been included in a sampling of ATIS broadcasts recorded 

between 0530 and 0630 each day between August 20 and 26, 2006.

FAA Order 7110.65, paragraph 2-9-2d, “Operating Procedures,” allows controllers 

to supplement ATIS information during their direct communications with pilots. 

The CVR showed that the controller did not advise the flight crew about the status of 

taxiway A north of runway 8/26. Because the construction project affected the entrance 

and exit paths of runway 4/22, either the ATIS broadcasts or the controller’s direct 

communications with the pilots should have included information about the altered 

taxiway A configuration. 

The Safety Board was not able to determine what effect, if any, information about 

the closure of taxiway A north of runway 8/26 (either through the ATIS broadcasts or 

the controller’s direct communications with the flight crew) would have had on the 

circumstances of this accident. However, this possible cue would not have had the same 

salience as the primary cues—the airport markings and signage—that were accurate 
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and available to the flight crew. It is also important to note that the airplane turned 

onto runway 26 before it would have encountered the area on taxiway A that had been 

closed. Thus, the Safety Board concludes that the controller’s failure to ensure that the 

flight crew was aware of the altered taxiway A configuration was likely not a factor in 

the crew’s inability to navigate to the correct runway. Nevertheless, the Board recognizes 

that, under different circumstances, information on an altered taxiway configuration 

might be necessary for a flight crew’s successful navigation on an airport and that, for 

those circumstances, the crew would need to receive complete, accurate, and timely ATIS 

information.

2.6.3 Local Notice to Airmen

The local NOTAM that indicated that taxiway A north of runway 8/26 was closed 

was not included in the Comair flight planning system or the flight release paperwork 

for the accident flight because the company determined that the information in the local 

NOTAM did not affect safety of flight. The Safety Board was not able to determine what 

effect, if any, this information would have had on the circumstances of this accident. 

However, this possible cue would not have had the same salience as the primary cues—

the airport markings and signage—that were accurate and available to the flight crew. 

In addition, the Board’s analysis of the accident determined that the taxi to runway 22 

was relatively simple and could have been successfully conducted by using the cues 

and aids available to the flight crew. Thus, the Safety Board concludes that, because the 

information in the local NOTAM about the altered taxiway A configuration was not 

needed for the pilots’ wayfinding task, the absence of the local NOTAM from the flight 

release paperwork was not a factor in this accident. 

As stated in section 1.18.6, the FAA has planned initiatives to modernize the 

current NOTAM system. These initiatives include aligning the U.S. NOTAM system with 

that of ICAO by October 2007 so that U.S. NOTAM information can be processed and 

provided to flight crews in a more timely, accurate, complete, and traceable manner and 

having digital NOTAM data displayed in the cockpit in textual and graphical formats. 

For this accident, even though the information in the local NOTAM was not necessary for 

the flight crew’s successful navigation to the correct runway, such information might be 

necessary under different circumstances. Thus, the Safety Board is pleased that the FAA 

is taking a proactive role to improve the current NOTAM system.

2.6.4 Presence of Extended Taxiway Centerline 

One of the three centerlines that diverged from the taxiway A hold short position 

for runway 8/26 led to taxiway A north of runway 8/26, which had been closed and 

was blocked by low-profile barricades with flashing red lights. This extended taxiway 

centerline had not been removed at the time of the accident. 
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The LEX construction plan called for the removal of taxiway A north of 

runway 8/26 and the associated extended taxiway centerline within 30 to 45 days of that 

taxiway’s closure. Because proper barricades had been put into place until such time, and 

because the CVR did not record any confusion between the flight crewmembers about the 

taxiway A configuration, the Safety Board concludes that the presence of the extended 

taxiway centerline to taxiway A north of runway 8/26 was not a factor in this accident. 
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3. Conclusions

3.1 Findings

1. The captain and the first officer were properly certificated and qualified under Federal 

regulations. There was no evidence of any medical or behavioral conditions that might 

have adversely affected their performance during the accident flight. Before reporting 

for the accident flight, the flight crewmembers had rest periods that were longer than 

those required by Federal regulations and company policy. 

2. The accident airplane was properly certified, equipped, and maintained in accordance 

with Federal regulations. The recovered components showed no evidence of any 

structural, engine, or system failures.

3. Weather was not a factor in this accident. No restrictions to visibility occurred during 

the airplane’s taxi to the runway and the attempted takeoff. The taxi and the attempted 

takeoff occurred about 1 hour before sunrise during night visual meteorological 

conditions and with no illumination from the moon.

4. The captain and the first officer believed that the airplane was on runway 22 when 

they taxied onto runway 26 and initiated the takeoff roll.

5. The flight crew recognized that something was wrong with the takeoff beyond the 

point from which the airplane could be stopped on the remaining available runway.

6. Because the accident airplane had taxied onto and taken off from runway 26 without 

a clearance to do so, this accident was a runway incursion.

7. Adequate cues existed on the airport surface and available resources were present in 

the cockpit to allow the flight crew to successfully navigate from the air carrier ramp 

to the runway 22 threshold.

8. The flight crewmembers’ nonpertinent conversation during the taxi, which was not in 

compliance with Federal regulations and company policy, likely contributed to their 

loss of positional awareness.

9. The flight crewmembers failed to recognize that they were initiating a takeoff on the 

wrong runway because they did not cross-check and confirm the airplane’s position 

on the runway before takeoff and they were likely influenced by confirmation bias.

10. Even though the flight crewmembers made some errors during their preflight activities 

and the taxi to the runway, there was insufficient evidence to determine whether 

fatigue affected their performance.
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11. The flight crew’s noncompliance with standard operating procedures, including the 

captain’s abbreviated taxi briefing and both pilots’ nonpertinent conversation, most 

likely created an atmosphere in the cockpit that enabled the crew’s errors.

12. The controller did not notice that the flight crew had stopped the airplane short of the 

wrong runway because he did not anticipate any problems with the airplane’s taxi to 

the correct runway and thus was paying more attention to his radar responsibilities 

than his tower responsibilities.

13. 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 air traffic control facility.

14. The controller was most likely fatigued at the time of the accident, but the extent 

that fatigue affected his decision not to monitor the airplane’s departure could not 

be determined in part because his routine practices did not consistently include the 

monitoring of takeoffs.

15. The Federal Aviation Administration’s operational policies and procedures at the 

time of the accident were deficient because they did not promote optimal controller 

monitoring of aircraft surface operations. 

16. The first officer’s survival was directly attributable to the prompt arrival of the first 

responders; their ability to extricate him from the cockpit wreckage; and his rapid 

transport to the hospital, where he received immediate treatment. 

17. The emergency response for this accident was timely and well coordinated.

18. A standard procedure requiring 14 Code of Federal Regulations Part 91K, 121, and 135 

pilots to confirm and cross-check that their airplane is positioned at the correct runway 

before crossing the hold short line and initiating a takeoff would help to improve the 

pilots’ positional awareness during surface operations.

19. The implementation of cockpit moving map displays or cockpit runway alerting 

systems on air carrier aircraft would enhance flight safety by providing pilots with 

improved positional awareness during surface navigation.

20. Enhanced taxiway centerline markings and surface painted holding position 

signs provide pilots with additional awareness about the runway and taxiway 

environment.

21. This accident demonstrates that 14 Code of Federal Regulations 91.129(i) might result 

in mistakes that have catastrophic consequences because the regulation allows an 

airplane to cross a runway during taxi without a pilot request for a specific clearance 

to do so.
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22. If controllers were required to delay a takeoff clearance until confirming that an 

airplane has crossed all intersecting runways to a departure runway, the increased 

monitoring of the flight crew’s surface navigation would reduce the likelihood of 

wrong runway takeoff events. 

23. If controllers were to focus on monitoring tasks instead of administrative tasks when 

aircraft are in the controller’s area of operations, the additional monitoring would 

increase the probability of detecting flight crew errors.

24. Even though the air traffic manager’s decision to staff midnight shifts at Blue Grass 

Airport with one controller was contrary to Federal Aviation Administration verbal 

guidance indicating that two controllers were needed, it cannot be determined if this 

decision contributed to the circumstances of this accident.

25. Because of an ongoing construction project at Blue Grass Airport, the taxiway identifiers 

represented in the airport chart available to the flight crew were inaccurate, and the 

information contained in a local notice to airmen about the closure of taxiway A was 

not made available to the crew via automatic terminal information service broadcast 

or the flight release paperwork.

26. The controller’s failure to ensure that the flight crew was aware of the altered taxiway A 

configuration was likely not a factor in the crew’s inability to navigate to the correct 

runway.

27. Because the information in the local notice to airmen (NOTAM) about the altered 

taxiway A configuration was not needed for the pilots’ wayfinding task, the absence of 

the local NOTAM from the flight release paperwork was not a factor in this accident.

28. The presence of the extended taxiway centerline to taxiway A north of runway 8/26 

was not a factor in this accident.

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of 

this accident was the flight crewmembers’ 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 the 

accident were the flight crew’s nonpertinent conversation during taxi, which resulted in a 

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.
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4. Recommendations

4.1 New Recommendations

As a result of the investigation of this accident, the National Transportation Safety 

Board makes the following recommendations:

—To the Federal Aviation Administration:

Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 

operators establish procedures requiring all crewmembers on the flight 

deck to positively confirm and cross-check the airplane’s location at 

the assigned departure runway before crossing the hold short line for 

takeoff. This required guidance should be consistent with the guidance 

in Advisory Circular 120-74A and Safety Alert for Operators 06013 and 

07003. (A-07-44)

Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 

operators install on their aircraft cockpit moving map displays or an 

automatic system that alerts pilots when a takeoff is attempted on a 

taxiway or a runway other than the one intended. (A-07-45)

Require that all airports certificated under 14 Code of Federal Regulations 

Part 139 implement enhanced taxiway centerline markings and surface 

painted holding position signs at all runway entrances. (A-07-46)

Prohibit the issuance of a takeoff clearance during an airplane’s taxi to 

its departure runway until after the airplane has crossed all intersecting 

runways. (A-07-47)

Revise Federal Aviation Administration Order 7110.65, “Air Traffic 

Control,” to indicate that controllers should refrain from performing 

administrative tasks, such as the traffic count, when moving aircraft 

are in the controller’s area of responsibility. (A-07-48)
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4.2 Previously Issued Recommendations Reiterated in 

This Report

The Safety Board reiterates the following recommendations to the Federal 

Aviation Administration:

Amend 14 Code of Federal Regulations (CFR) Section 91.129(i) to require 

that all runway crossings be authorized only by specific air traffic 

control clearance, and ensure that U.S. pilots, U.S. personnel assigned 

to move aircraft, and pilots operating under 14 CFR Part 129 receive 

adequate notification of the change. (A-00-67)

Amend Federal Aviation Administration Order 7110.65, “Air Traffic 

Control,” to require that, when aircraft need to cross multiple runways, 

air traffic controllers issue an explicit crossing instruction for each 

runway after the previous runway has been crossed. (A-00-68)

4.3 Previously Issued Recommendations Resulting From 

This Accident Investigation

As a result of the investigation into this accident, the Safety Board issued 

the following recommendations to the Federal Aviation Administration (FAA) on 

December 12, 2006:

Require that all 14 Code of Federal Regulations Part 121 operators 

establish procedures requiring all crewmembers on the flight deck 

to positively confirm and cross-check the airplane’s location at the 

assigned departure runway before crossing the hold short line for 

takeoff. (A-06-83)

Require that all 14 Code of Federal Regulations Part 121 operators provide 

specific guidance to pilots on the runway lighting requirements for 

takeoff operations at night. (A-06-84)

For additional information about these recommendations, see sections 1.18.3.1 

and 2.4.1 of this report.

Also, the Board issued the following recommendations to the FAA on 

April 10, 2007: 

Work with the National Air Traffic Controllers Association to reduce the 

potential for controller fatigue by revising controller work-scheduling 

policies and practices to provide rest periods that are long enough for 
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controllers to obtain sufficient restorative sleep and by modifying shift 

rotations to minimize disrupted sleep patterns, accumulation of sleep 

debt, and decreased cognitive performance. (A-07-30)

Develop a fatigue awareness and countermeasures training program 

for controllers and for personnel who are involved in the scheduling 

of controllers for operational duty that will address the incidence 

of fatigue in the controller workforce, causes of fatigue, effects of 

fatigue on controller performance and safety, and the importance of 

using personal strategies to minimize fatigue. This training should be 

provided in a format that promotes retention, and recurrent training 

should be provided at regular intervals. (A-07-31)

Require all air traffic controllers to complete instructor-led initial and 

recurrent training in resource management skills that will improve 

controller judgment, vigilance, and safety awareness. (A-07-34)

For additional information about these recommendations, see section 1.18.3.2 of 

this report.

In addition, the Board issued the following recommendation to the National Air 

Traffic Controllers Association on April 10, 2007:

Work with the Federal Aviation Administration to reduce the 

potential for controller fatigue by revising controller work-scheduling 

policies and practices to provide rest periods that are long enough for 

controllers to obtain sufficient restorative sleep and by modifying shift 

rotations to minimize disrupted sleep patterns, accumulation of sleep 

debt, and decreased cognitive performance. (A‐07-32)

For additional information about this recommendation, see section 1.18.3.2 of 

this report.

4.4 Previously Issued Recommendations Classified in 

This Report

Safety Recommendation A-06-83 is classified “Closed—Acceptable Alternate 

Action/Superseded,” and Safety Recommendation A-06-84 is classified “Open—

Acceptable Alternate Response,” in section 2.4.1 of this report. 

Safety Recommendations A-07-30 and -31 are classified “Open—Acceptable 

Response” in section 2.2.3.3 of this report.
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Safety Recommendation A-07-34 is classified “Open—Acceptable Response” in 

section 2.2.3.2 of this report.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER

Chairman

ROBERT L. SUMWALT

Vice Chairman

Deborah A. P. Hersman

Member

KATHRyn O. HIGGINS

Member

Steven R. chealander

Member

Adopted: July 26, 2007

Members Hersman and Higgins filed the following concurring statements on 

August 2, 2007. 
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Board Member Statements
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5. Appendixes

Appendix A

Investigation and Hearing

Investigation

The National Transportation Safety Board was initially notified of this accident 

on August 27, 2006, about 0645. A go-team departed Washington, D.C., about 

1030 and arrived on scene about 1145. Accompanying the team to Lexington was 

Member Deborah A.P. Hersman.

The following investigative teams were formed: Operations, Human Performance, 

Structures, Systems, Powerplants, Air Traffic Control, Meteorology, Aircraft Performance, 

Maintenance Records, Survival Factors, and Witnesses. While the investigative teams 

were in Lexington, specialists were assigned to conduct the readout of the flight data 

recorder and transcribe the cockpit voice recorder at the Safety Board’s laboratory in 

Washington, D.C.

Parties to the investigation were the Federal Aviation Administration, Comair, Blue 

Grass Airport, Air Line Pilots Association, General Electric Aircraft Engines, International 

Association of Machinists and Aerospace Workers, National Air Traffic Controllers 

Association, and Teamsters Local 513 (Flight Attendants). In accordance with the provisions 

of Annex 13 to the Convention on International Civil Aviation, the Transportation Safety 

Board of Canada (the Safety Board’s counterpart agency in Canada) participated in the 

investigation as the representative of the State of Design and Manufacture. Transport 

Canada and Bombardier Aerospace participated in the investigation as technical advisors 

to the Transportation Safety Board of Canada, as provided in Annex 13.

Public Hearing

No public hearing was held for this accident. 
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Appendix B

Cockpit Voice Recorder

The following is the transcript of the Fairchild model A100S cockpit voice recorder, 

serial number 03035, installed on a Comair CRJ-100, N431CA, which crashed while 

attempting to take off from the wrong runway on August 27, 2006.

 

LEGEND

CAM Cockpit area microphone voice or sound source 

hOT Flight crew audio panel voice or sound source 

RDO Radio transmissions from accident aircraft 

PA Voice transmitted over aircraft public address system 

CLR Radio transmission from the Blue Grass Airport clearance controller 

GND Radio transmission from the Blue Grass Airport ground controller 

TWR Radio transmission from the Blue Grass tower controller 

E882 Radio transmission from Eagle flight eight eighty-two 

S6819 Radio transmission from Skywest flight sixty-eight nineteen 

-1 Voice identified as the Captain 

-2 Voice identified as the First Officer 

-3 Voice identified as the male Flight Attendant 

-4 Voice identified as the aircraft mechanical voice 

-5 Voice identified as ACM (additional crew member pilot) 

-? Voice unidentified 

* Unintelligible word 

# Expletive

@ Non-pertinent word 

( ) Questionable insertion 

 [ ] Editorial insertion

Note 1: Times are expressed in eastern daylight time (EDT). 

Note 2: Generally, only radio transmissions to and from the accident aircraft were transcribed. 

Note 3: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the words 

as spoken. 

Note 4: Radio transmissions from CLR, GND and TWR all appear to be the same controller.
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1 of 36

IN

T

R

A-C

O

C

K

PIT

C

O

M

M

U

NIC

A

TIO

N

AIR-G

R

O

U

N

D

C

O

M

M

U

NIC

A

TIO

N

TIME (EDT) TIME (EDT)& SOU

R

CE CONTENT & SOU

R

CE CONTENT

DCA06MA064

05:36:07.7S

T

A

R

T

of R

E

C

O

R

DIN

G

S

T

A

R

T

of T

R

A

N

S

C

RIP

T

05:36:18.4C

A

M [sound of rustling si

milar to so

meone entering the cockpit]

05:36:50.2C

A

M-3 *** well, I reported at five-thirty *****.

05:37:26.9C

A

M-1 ***.

05:37:50.9C

A

M-1 everything else is good.

05:37:52.7C

A

M [sound si

milar to crew

member testing oxygen mask]

05:38:03.4H

O

T-? [sound si

milar to crew

member conducting hot microphone test]

05:38:04.3C

A

M-1 circuit breakers, checked, nose

wheel steering is off, hydraulic 

pumps, all off, landing gear lever, down, spoiler lever, lever, retracted, flaps lever, set to flaps twenty, radar, off, A

H

R

S, mag,

landing gear manual release, A

D

G

manual release, battery master, on, fire protection, checked, nav lights, on, external ** A/C, no

A

P

U, hydraulic pump 3A is on, nose

wheel door, closed, aircraft/crew docs, on board, flight co

mpartment safety inspection is 

co

mplete.

05:38:28.4C

A

M [sound si

milar to crew

member checking an oxygen mask]
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A-C

O

C

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PIT

C

O

M

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TIO

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AIR-G

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O

U

N

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A

TIO

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TIME (EDT) TIME (EDT)& SOU

R

CE CONTENT & SOU

R

CE CONTENT

DCA06MA064

05:38:40.9H

O

T [three tones si

milar to C

V

R test tone]

05:38:53.0C

A

M-? [sound of person whistling]

05:38:55.7C

A

M [sound of hi-lo chime]

05:39:07.6C

A

M-4 [sound of chimes si

milar to fire protection fire test signal] smoke.

05:39:13.3C

A

M-1 smoke.

05:39:20.8C

A

M-4 [sound of triple chime] bleed air duct.

05:39:24.9C

A

M-1 I was talking to another guy I flew

with yesterday. he was uh, had

put his, bid in for uh, JFK captain. he wasn't real happy about itbut......

05:39:35.4C

A

M-2 First

Officer?

05:39:36.3C

A

M-1 yeah.

05:39:37.9C

A

M-3 would you turn the smoking-seatbelt sign on for me?

05:39:40.2C

A

M [sound of chime]
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05:39:41.0C

A

M-1 you got it. here come the lights.

05:39:43.5C

A

M-2 why wasn't he too happy about it? he can always change it.

05:39:46.8C

A

M-1 yeah, you know he just uh, he's just not really looking forward to

reserves, that's all. but he feels like you know and I think he's right if he wants to get out of here. that's his decision he wants todo but. he's gotta get that PIC....

05:40:01.1C

A

M-2 exactly.

05:40:01.9C

A

M-1 ...you gotta bite the bullet so

metimes but, I mean, nobody wants 

to do reserve there.

05:40:08.5C

A

M-2 nope, not here. not the way they do it. they just they have.....

05:40:11.0C

A

M [sound of chime]

05:40:12.9C

A

M-2 ...no clue. they don't utilize....

05:40:14.3C

A

M-? it's time.

05:40:14.4C

A

M-? all right.
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05:40:16.5C

A

M-2 ... the people effectively.

05:40:17.3C

A

M [sound of chime]

05:40:21.9C

A

M-2 you know, you're on for six days and you might fly eight hours 

'cause they *.

05:40:27.1C

A

M-1 it's amazing though right now, they are using everybody pretty 

efficiently. um, just shows you what they can do. like I mean Idon't have

more than ten hours in a hotel, any of these days that

I've been on....

05:40:38.2C

A

M-2 really.

05:40:38.7C

A

M-1 ...and it's been that way for all month. now

September rolls 

around and I'll guarantee you it'll be a different story.

05:40:47.4C

A

M [sound of chime]

05:40:50.3C

A

M-2 because I know

Cincinnati base, they have a lot of reserves. but I

understand.

05:40:55.8C

A

M-1 *.

05:40:56.0C

A

M-1 then, they send them all to New

York.
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05:40:57.1C

A

M-2 right, exactly.

05:40:58.4C

A

M-1 yeah.

05:40:59.9C

A

M [sound si

milar to stick shaker test]

05:41:04.6C

A

M-4 glideslope whoop whoop, pull up, wind shear, wind shear, wind

shear, terrain, terrain, whoop whoop, pull up. [sound of chime]

05:41:09.4C

A

M-? [sound of person whistling]

05:41:22.6C

A

M-4 [sound of triple chime] gear bay overheat.

05:41:45.7C

A

M-4 T

C

A

S system tests okay.

05:41:50.1IN

T-1 test, test.

05:41:52.4C

A

M [sound of three hi-lo chimes]

05:42:10.8C

A

M-1 funny you were talking about @ I mean, I, I, I flew

with a guy who

was, he said he filled out the application process, he filled out theapplication and went through the background checks. actually Idid my uh, my M

V/LO

E

with him uh, about three or four weeks 

ago and uh, he was telling me all about it.
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05:42:33.3C

A

M-2 well that might do all that stuff prior to actually, giving you, the

interview date.

05:42:38.5C

A

M-1 uh huh.

05:42:39.3C

A

M-2 but you are by no means guaranteed anything....

05:42:42.2C

A

M-1 yeah.

05:42:44.4C

A

M-2 but.

05:42:45.1C

A

M-1 I just talked to my wife about it, we looked at, we looked at it on

line. you know and I was looking at the pay scales and uh, yeah Iknow they provide a place ta, for you to live and things like thatand was at four thousand, I don't know, forty-four hundred dollars.

05:43:01.8C

A

M-2 fifty-two, fifty-two twelve, a month for the first * month tax free.

05:43:07.9C

A

M-? how is it?

05:43:08.4C

A

M-2 yeah.

05:43:09.4C

A

M-1 yeah the last time I looked at it or it was like forty-five or so

mething and but. I talked to a guy who was in the military, he said he

was, he said it's really pretty for a desert, you know it's....
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05:43:22.8C

A

M-2 yeah well there's a guy, a military guy, up uh, a first officer, in

Kennedy, he's like I think you're doing the right thing. he says ifnot to visit, maybe to be an ex-patriot and live there is not a goodthing.

05:43:40.9C

A

M-1 yeah, what I heard, you know you can't buy land uum, they'll let

you buy a condo, like on a high rise or so

mething, thank you, but

you can't buy property.... here they come Kelly.

05:44:04.9C

A

M-2 yeah howdy, like yeah, yeah * and then I kept thinking about it....

I guess,

when I'm, I'm deciding on making a major decision, if it

doesn't feel right in my gut. or if I don't have a little voice, if it's starts talking to me and I'm like I need to re-evaluate.

05:44:29.5C

A

M-1 yeah

05:44:43.2C

A

M-2 you know it'd be nice to go over there and fly heavy 

metal, fly international, but they work you hard over there I've been told.

05:44:50.3C

A

M-1 oh do they?

05:44:51.1C

A

M-2 yeah, they fly you if they can up to a hundred hours ** they have

triple sevens *. like for you with the kids, you'd get a housing allowance at a villa. and for me and my wife with no kids,

we'd get

an apartment. the apartments don't allow any animals and I havefour dogs and I'm not, I'm not about to give up, I've had 'em for awhile. if I fly overseas, I wanna start and finish here in the States.
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05:45:32.4C

A

M-1 yeah.

05:45:32.9C

A

M-2 ***.

05:45:36.1C

A

M-1 you were overseas already. is that what you said?

05:45:36.9C

A

M-2 no, if I, if I did fly overseas.

05:45:38.8C

A

M-1 ah, okay.

05:45:44.8C

A

M-1 emergency equipment, checked, crew oxygen masks, checked

left and right, ** psi, C

V

R, checked, standby instruments,

checked, fire protection, checked, gravity cross-flow, checked,duct

monitor, checked, hydraulics, auto and on, ice detector, has 

been checked, cabin signs are on, emergency lights are armed ,stall protection system, checked, anti-skid, checked and armed,MLG bay overheat, checked, stab/mach trim, engaged, enginecontrols, checked, aileron rudder trims checked ya

w damper engaged, cabin/exterior checks co

mplete gear and safety pins, have

been removed acceptance checklist is co

mplete.

05:46:19.5C

A

M-2 *** it just beca

me ** I started looking at it a little more, there was 

just too many * to get through.

05:46:30.3C

A

M-1 you know I....
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05:46:31.4C

A

M-2 is this First

Officer single?

05:46:34.8C

A

M-1 I don't think so but his, his name is, he's got an Arab uh.

05:46:40.5C

A

M-2 oh.

05:46:42.3C

A

M-1 he got a, he has so

me kind of Arab name. @ or so

mething er.

05:46:50.9C

A

M-1 he might blend in a little bit but I heard it's like sixty or seventy

percent European I mean.

05:46:55.2C

A

M-2 well it's not even owned by United Arab E

mirates. it's owned by a

British co

mpany.

05:47:01.1C

A

M-1 oh really.

05:47:08.9C

A

M-2 yeah but you gotta deal with a lot of Brits and Australians. you

know it so

me of these

Brits are a little up tight.

05:47:34.5C

A

M-2 if circu

mstances were different I, I'd consider it, they are as such.

05:47:46.7C

A

M-2 plus if I have the opportunity to make

Captain.
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05:47:51.0C

A

M-1 yeah.

05:47:55.9C

A

M-2 I'm gonna talk to my dad to see if maybe he can help me out but I

think I'm gonna invest in a seven three type rating. if I make

Captain here. I need like three hundred PIC to be eligible to meet

their requirements and then I'll....

05:48:14.1C

A

M-1 who's that, Southwest? isn't that three thousand PIC?

05:48:16.7C

A

M-2 fifteen hundred.

05:48:18.6C

A

M-1 fifteen hundred?

05:48:18.7C

A

M-2 actually no, thirteen hundred PIC.

05:48:20.8C

A

M-1 oh, okay.

05:48:21.1C

A

M-2 like thirteen hundred, that's a weird number.
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05:48:24.4A

TIS Lexington Bluegrass information Alpha, 0854 automated

weather. wind one niner zero at eight, visibility eight, few clouds six thousand, sky broken niner thousand. temperature two four,dew point one niner, altimeter three zero zero zero. ILS and visual approaches in use. landing and departing runway two two.runway two two glideslope out of service. pilots use caution forconstruction on air carrier ramp. hazardous weather informationavailable on HIW

A

S, Flight Watch or Flight Service frequencies.

all departures contact ground control on one two one point niner.advise you have information Alpha.

05:49:42.2R

D

O-2 clearance good morning. Comair one ninety one's going to Atlanta with ALP

H

A.

05:49:49.3CLR

Comair one ninety one, Lexington clearance. cleared to AtlantaAirport via Bowling Green, E

RLIN

T

W

O arrival. maintain six 

thousand, expect flight level two seven zero one zero minutes after departure. departure's one two zero point seven five. squawk six six four one.

05:50:06.5R

D

O-2 okay, got uh, Bowling Green uh, missed the other part. six thousand, twenty point seven five. six six four one.

05:50:14.1CLR

Comair one ninety one, it's E

RLIN

T

W

O, Echo Romeo Lima, India, Nove

mber T

wo arrival.

05:50:20.4R

D

O-2 'kay E

RLIN

T

wo, 'preciate it, Comair one ninety one.

05:50:38.0C

A

M-2 nothing like **.
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05:50:41.2C

A

M [sound of click]

05:50:44.6C

A

M-? [sound of person whistling]

05:50:53.7C

A

M-1 direct

Bowling Green, Bowling Green the E

RLIN

T

W

O. is that

good?

05:50:58.4C

A

M-2 any easier than that.

05:50:59.9C

A

M-1 [sound of laughter]

05:51:29.3C

A

M-1 Chattanooga looks good for the alternate.

05:51:29.8C

A

M-5 well, how's it going guys?

05:51:30.5C

A

M-2 dude, what's up?

05:51:32.6C

A

M-5 how you doin'?

05:51:33.3C

A

M-1 hey good, how you doin'?

05:51:34.8C

A

M-5 I'm

@

with Air Tran trying to get a lift to work this morning.
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05:51:37.1C

A

M-1 hey, no problem any seat, * you already got one.

05:51:38.8C

A

M-5 there you go.

05:51:40.0C

A

M-1 beauty.

05:51:43.2C

A

M-5 all right sir.

05:51:44.4C

A

M-1 'preciate it.

05:51:45.1C

A

M-5 you bet.

05:51:46.1C

A

M-1 any time.

05:51:47.2C

A

M-5 thanks a lot.

05:51:47.7C

A

M-1 can I get the white sheet from you?

05:51:48.9C

A

M-5 all right.

05:51:51.2C

A

M-1 there you go sir.

05:51:52.5C

A

M-5 thanks a lot.
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05:51:53.8C

A

M-1 any time.

05:52:04.3C

A

M-1 well @ did you bring it in the other day or what's the sequence?

keep on with whatever you're doing.

05:52:09.1C

A

M-2 it don't matter to me.

05:52:11.3C

A

M-1 oh. I'm easy buddy. but, I tell you, I always feel good like I could

eat a little more when I get a seatbelt like this man. [sound oflaughter]

05:52:19.6C

A

M-2 Jesus.

05:52:22.9C

A

M-2 *, I'll take us to Atlanta.

05:52:24.0C

A

M-1 sure.

05:52:24.5C

A

M-2 I looked at, for so

me weird reason, I don't have that. I have the

airport diagram and the arrival and departure plates. I don't havethe San Antonio charts.

05:52:36.3C

A

M-1 uh, okay.
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05:52:42.2C

A

M-2 either I'm just

waiting for the stuff to come up from

Cincinnati or

for now or the secretary there.

05:52:50.6C

A

M-1 [sound of chuckle]

05:52:51.8C

A

M-2 very capable.

05:52:52.8C

A

M [sound of click]

05:52:55.2C

A

M-2 plus we have, we don't have a chief pilot any more.

05:52:57.9C

A

M-1 oh, that's right. I heard @ got promoted or so

mething.

05:53:00.2C

A

M-3 ** passenger!s request for an electric cart in the gatehouse for a

passenger.

05:53:03.7C

A

M-1 @, can I grab another Coke from you?

05:53:05.2C

A

M-3 would you like ice?

05:53:06.1C

A

M-1 no thanks.
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05:53:27.2C

A

M-1 thank you.

05:53:27.7C

A

M-3 can I have the P

A please so I can do my verification?

05:53:29.4C

A

M-1 sure.

05:53:58.3C

A

M-2 ** three *.

05:54:12.5C

A

M-2 sixteen-forty *.

05:54:20.2C

A

M-? [sound of person whistling]

05:55:04.4C

A

M-2 I think I have *** this thing I got. my wife called a little excited

about it but *** yeah you'd be gone like three or four days at atime, which you know

with your wife and kids it might be a little

difficult.

05:55:20.2C

A

M-3 it's all yours.

05:55:21.0C

A

M-1 all right.
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05:55:24.9P

A-1 ladies and gentlemen from the flight deck, like to take this time to

welco

me you also on board Comair flight fifty one ninety one direct flight to Atlanta. we'll be cruising at uh, twenty-seven thousand feet this morning. and once

we do get in the air, it looks like

one hour and seven minutes enroute. distance of travel today,we got we got four hundred and twenty two miles.

weather conditions Atlanta, * so

me light winds out of the east, looks like so

me

broken clouds and current temperature of seventy-two degrees Fahrenheit. we'll try to keep it as quiet as possible. hopefully youcan catch a nap going into Atlanta. it's our pleasure having youall on board.

05:56:14.0C

A

M-1 for our own briefing, Comair standard. run the checklist your leisure. keep me out of trouble. I'll do the sa

me for you. I don't

jump on the brakes on your landing. I'll follow along with you.just let me know

when you want me to take it. that's it.

05:56:23.8C

A

M [sound of two clicks si

milar to pilot seat adjust

ment]

05:56:25.2C

A

M-2 I'll do the sa

me whenever you're ready.

05:56:26.9C

A

M-1 all right.

05:56:27.6G

N

D information Bravo is now current. the altimeter's three zero zero

zero.

05:56:28.0C

A

M-2 * control ***.
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05:56:30.4C

A

M-1 sounds good.

05:56:34.1C

A

M-2 right seat flex takeoff procedures off of um.... he said what runway? one of 'em. * two four.

05:56:43.4C

A

M-1 it's two two.

05:56:45.9C

A

M-2 one ninety at eight

05:56:49.9C

A

M-2 two two up to six,

white data * FM

S, flaps twenty. * smokes or

breaks co

me back here. co

me into four or two two. on two two

the ILS is out. or the glideslope is, the R

EILS are out. the uh,

ca

me in the other night it was like [sound si

milar to audible exhale] lights are out all over the place.

05:57:07.8C

A

M-1 all right.

05:57:08.4C

A

M-2 right. remember this runway predicated, before we just go back 

to Cincinnati.

05:57:12.9C

A

M-1 okay.

05:57:13.7C

A

M-2 uum, no continuous, anti-ice, weather radar, hand fly 'til about ten.

taxi instructions with A

T

C.
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DCA06MA064

05:57:21.7C

A

M-1 all right.

05:57:23.3C

A

M-2 let's take it out and um, take uuuh, Alpha. two two's a short taxi.

05:57:31.1C

A

M-1 yeah.

05:57:35.4C

A

M-2 any questions?

05:57:36.5C

A

M-1 no questions. before starting at your leisure.

05:57:38.4C

A

M-2 A

C

M crew briefing.

05:57:39.3C

A

M-1 co

mplete.

05:57:40.0C

A

M-2 takeoff brief.

05:57:40.4C

A

M-1 co

mplete.

05:57:40.7C

A

M-2 radios,

N

A

V aids.

05:57:42.0C

A

M-1 uh, six thousand, your side, both in white data, confirmed the

flight plan. we got uh, tower, ground twenty one *, is everythingon one? do you know?
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DCA06MA064

05:57:49.7C

A

M-2 no it's not.

05:57:50.7C

A

M-3 do you want to do a brief?

05:57:53.5C

A

M-1 nothing differed back there that I sa

w. weather's good Atlanta,

scattered to broken clouds. seventy degrees uum, standardchimes, standard calls. if we do have an emergency, I like toopen the door and talk face to face.

05:58:04.5C

A

M-3 okay.

05:58:06.0C

A

M-1 that's about it. anything for me?

05:58:07.0C

A

M-3 sounds great.

05:58:07.9C

A

M-1 all right.

05:58:08.4C

A

M-3 see you in Atlanta.

05:58:12.2C

A

M-1 uuh, start engines your leisure.

05:58:14.8C

A

M-2 uuuh, A

C

M crew brief.

05:58:16.7C

A

M-1 co

mplete.
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DCA06MA064

05:58:17.1C

A

M-2 takeoff brief

05:58:18.3C

A

M-1 hey man, we already did that one.

05:58:20.5C

A

M-2 we did?

05:58:21.0C

A

M-1 yeah.

05:58:21.2C

A

M-2 I'm sorry.

05:58:22.2C

A

M-? [sound of laughter]

05:58:23.3C

A

M-2 I'll get it to ya.

05:58:24.1C

A

M-1 [sound of laughter]

05:58:24.6C

A

M-2 papers,

manifest.

05:58:26.0C

A

M-1 it's co

mplete out the door.

05:58:27.2C

A

M-2 fuel quantity.

05:58:27.4C

A

M-1 required to have (seventy), seventy-three.
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DCA06MA064

05:58:30.0C

A

M-? **.

05:58:33.3C

A

M [sound of several clicks si

milar to cockpit door operation]

05:58:35.1C

A

M-2 V speeds, takeoff data fifty temp. V one, V r is thirty-seven fortytwo * forty-five ********. [spoken at a very fast speed] you got

normal thrust ** point two.

05:58:43.5C

A

M-1 set for flaps twenty.

05:58:44.5C

A

M-2 doors.

05:58:44.9C

A

M-1 closed.

05:58:45.3C

A

M-2 beacon.

05:58:45.6C

A

M-1 on.

05:58:46.0C

A

M-2 fuel pumps.

05:58:46.8C

A

M-1 number one's on.

05:58:48.7C

A

M-2 see this is telling me that I really need to do something.
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TIME (EDT) TIME (EDT)& SOURCE CONTENT & SOURCE CONTENT

DCA06MA064

05:58:51.7CAM-1 [sound of laughter]

05:59:05.7RDO-1 and ground, Comair one ninety one, just a heads-up on the push.05:59:11.1GND Comair one ninety one advise ready to taxi.05:59:13.3RDO-1 roger.05:59:14.1INT-1 hey, how you doin'? you ca.... can you hear me? okay, brakes 

released, we're cleared to push sir.

05:59:24.6HOT-2 must be one of us, skinny flight attendant.05:59:26.5HOT-1 [sound of laughter]

05:59:33.0E882 ground, Eagle flight eight eighty two ready to taxi with Alpha.

05:59:42.0HOT-1 he said it's okay to turn one at your leisure.

05:59:43.6GND Eagle flight eight eighty two taxi to runway two two. altimeter

three zero zero zero and the wind's two zero zero seven.

05:59:45.4HOT-2 that's pretty cool the family got to come down.
Appendix B

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DCA06MA064

05:59:47.2H

O

T-2 how long of a ride is that?

05:59:50.9H

O

T-1 uuuuh. maybe, maybe an hour.

05:59:52.9E882 taxi to **, Eagle flight eight eighty two.

05:59:57.5H

O

T-2 that's cool.

06:00:09.4H

O

T-1 both kids were sick though, they,

well they all got colds. it was an

interesting br, dinner last night.

06:00:16.1H

O

T-2 really.

06:00:16.6H

O

T-1 huh, oh gosh.

06:00:19.1H

O

T-2 how old are they?

06:00:20.0H

O

T-1 three months and two years old. who was sneezing, either nose

wiped, diaper change I mean that's all we did all night long.

06:00:31.0H

O

T-2 oh yeah I'm sure.
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TIME (EDT) TIME (EDT)& SOURCE CONTENT & SOURCE CONTENT

DCA06MA064

06:00:32.2GND ** sixteen ninety two thanks, turn right heading two seven zero

runway two two, cleared for takeoff.

06:00:32.4HOT-2 [sound of laughter]06:00:34.9HOT-2 that's a nice range, age range.06:00:37.7HOT-1 yeah, I like two years apart basically and that's the kinda what we

were going for.

06:00:45.3HOT-1 my wife wants four, I, I, I'm, I was good at one.06:00:48.5HOT-2 she wants four.06:00:49.9CAM [sound of chime]06:00:50.1HOT-1 yeah.06:00:50.2HOT-1 [sound of chuckle]06:00:52.7HOT-2 it'd be like honey....06:01:02.7CAM [sound of chime]
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DCA06MA064

06:01:07.1H

O

T-2 yeah, it's especially being on reserve it, it's gotta be tough being

away.

06:01:12.2H

O

T-1 ah, tough on her, oh my God. that's why she ca

me down yesterday. she's like, I just need to get out of this house.

06:01:18.0H

O

T-2 yeah, I bet.

06:01:18.9H

O

T-1 I'm like I understand. I, I told her, why don't you just spend the

night. she said well, if you're gonna get up at oh dark thirty andshe said you'll end up waking up the babies. I'm like yeah, you'reprobably right.

06:01:32.1H

O

T-2 yeah it would just be like being at home.

06:01:35.5H

O

T-1 yeah, she's like you know, I don't know, she's like I'll....

06:01:38.5H

O

T-2 instead of having her rush back and drive....

06:01:40.6H

O

T-1 and we got a dog.

06:01:40.8G

N

D *** Lexington tower roger, hold short.

06:01:42.9H

O

T-2 aah, trust

me the dog *. be on the @ slim-fast diet * for a night.
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DCA06MA064

06:01:47.4H

O

T-1 [sound of laughter]

06:01:48.7H

O

T-2 uh, parking brake.

06:01:49.6H

O

T-1 that's on.

06:01:50.0H

O

T-2 number two, actually, engine.

06:01:51.7H

O

T-1 one and two are started.

06:01:52.5H

O

T-2 starting engines co

mplete.

06:01:54.3H

O

T-1 and before taxi.

06:01:55.6H

O

T-2 anti-iiiiice.

06:01:56.6H

O

T-1 windshields and probes are low and on.

06:01:58.3H

O

T-2 nose

wheel steering.

06:01:59.5H

O

T-1 that's armed.

06:02:00.0H

O

T-2 taxi check co

mplete.
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DCA06MA064

06:02:01.3R

D

O-2 Comair one ninety one is ready to taxi

we have ALP

H

A.

06:02:03.8G

N

D

Comair one ninety one, taxi to runway two two. altimeter threezero zero zero and the winds are two zero zero at eight.

06:02:08.9R

D

O-2 three triple zero and taxi two two, Comair one ninety one.

06:02:12.6G

N

D

Eagle flight runway two two, cleared for takeoff.

06:02:15.1H

O

T-1 clear left.

06:02:17.3H

O

T-2 on the right.

06:02:17.9G

N

D

Skywest six eight nineteen radar contact, say altitude leaving.

06:02:18.9H

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T-1 flaps twenty, taxi check.

06:02:21.0H

O

T-2 full right.

06:02:23.8G

N

D

Skywest sixty eight nineteen, climb and maintain one zero thousand, ten thousand, join Victor one seventy one and resu

me *,

own navigation.

06:02:24.0H

O

T-2 full left.
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DCA06MA064

06:02:25.5H

O

T-1 test your brakes any time.

06:02:31.1H

O

T-2 I want to *** down.

06:02:32.3H

O

T-1 sure.

06:02:41.5H

O

T-2 let's see, comin' back.

06:02:51.6H

O

T-2 brakes.

06:02:52.3H

O

T-1 they're checked.

06:02:53.2H

O

T-2 right, flaps.

06:02:54.4H

O

T-1 set twenty, indicating twenty.

06:02:55.6H

O

T-2 flight controls.

06:02:56.3H

O

T-1 check left.

06:02:58.3H

O

T-2 on the right, trims.

06:02:59.5H

O

T-1 engage zero seven point two.
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DCA06MA064

06:03:02.2HOT-2 radar terrain displays. [spoken in a yawning voice]06:03:04.0HOT-2 all the taxi check's complete. [spoken in a yawning voice]06:03:12.0HOT-1 finish it up your leisure.06:03:16.4HOT-2 yeah, I know three guys at Kennedy. actually two guys uh....

@@ he went but he didn't get past the sim.

06:03:26.7HOT-1 oh, really.06:03:29.1HOT-2 and then um, a First Officer from Cinci....

06:03:34.5GND Eagle flight radar contact, radar contact. say altitude leaving.

06:03:35.1HOT-2 got through the second part....06:03:37.2HOT-2 what do you do the uh, these tests.... and he didn't, and that's as 

far as he got.

06:03:40.8GND Eagle flight eight eighty two, climb and maintain one zero thousand, ten thousand.

06:03:49.3HOT-2 and then @@ he actually got offered the position.
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06:03:54.5HOT-1 did he take it or....06:03:55.5HOT-2 yeah.06:03:56.1HOT-1 ah, okay.06:04:01.2HOT-2 second engine started, anti-ice probes windshield low.

06:04:03.1GND * sixteen ninety one, previous question.

06:04:05.6HOT-2 hydraulics checked, APU's on, FMS we got runway two two out of

Lexington up to six.

06:04:13.3HOT-2 thrust reversers are armed, auto crossflow is manual, ignition is 

off, altimeters three triple zero across the board, crosschecked. I'llbe in the back.

06:04:24.8HOT-1 got one.

06:04:25.7TWR Skywest sixty eight nineteen contact Indy center one two six point

three seven.

06:04:29.6S6819 two six three seven, Skywest sixty eight nineteen.
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TIME (EDT) TIME (EDT)& SOURCE CONTENT & SOURCE CONTENT

DCA06MA064

06:04:32.6TWR Eagle flight eight eighty two, turn right heading two seven zero,

join Victor one seventy-one. resume navigation.

06:04:37.5E882 two seven zero, join victor one seventy one, ****.

06:04:38.2PA-2 and folks one * time from the flight deck, we'd like to welcome you

aboard. we're going to be underway momentarily.... sit back relax enjoy the flight. Kelly, when you have a chance, please preparethe cabin.

06:04:48.2CAM [sound hi-lo chime similar to cabin/cockpit interphone signal]06:04:49.3HOT-2 pre-takeoff * complete cabin report received CAS.06:04:53.4HOT-1 checked and clear.06:04:54.4HOT-? **, six seven, **. [whispered]06:04:56.6HOT-1 oh.06:04:58.1HOT-2 oh yeah.06:04:59.4HOT-2 I'm looking at it 'cause like, okay I see seven but it's....
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06:05:01.9HOT-1 yeah there's a green extra one there but....06:05:06.3HOT-2 uuuh, cabin report's received, CAS clear, ** before takeoff check's 

complete, ready.

06:05:12.6HOT-1 all set.

06:05:15.1RDO-2 "churliser" [at your leisure spoken very fast] Comair one twenty 

one ready to go.

06:05:17.7TWR Comair one ninety one, Lexington uh, tower, fly runway heading,

cleared for takeoff.

06:05:19.2HOT-? *.

06:05:21.0RDO-1 runway heading, cleared for takeoff, one ninety one.

06:05:23.7HOT-1 and line-up check.

06:05:25.1TWR Eagle flight eight eighty two, that heading work for you, do you

wanna go uh, northwest around the uh, weather that's ahead ofyou?

06:05:30.7E882 no that looks fantastic. thank you very much.
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DCA06MA064

06:05:32.7TWR * say again please.06:05:33.8E882 *** eight eighty two.

06:05:34.4HOT-1 throw that bad boy on.

06:05:36.3TWR Eagle flight eight eighty two, contact Indy center one two six point

three seven. good day.

06:05:39.5E882 twenty six, thirty seven, * eight eighty two.

06:05:41.3HOT-2 transponder's on, packs on, bleeds closed, cleared for takeoff,

runway heading. six grand.

06:05:45.4HOT-1 all right.06:05:46.4HOT-2 anti-ice off, lights set, takeoff config's okay, line-up check's complete.06:05:51.2CAM [sound of clicks similar to pilot adjusting his seat]06:05:57.6HOT-1 all yours Jim.06:05:58.9HOT-2 my brakes, my controls.
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06:06:05.0C

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M [sound si

milar to increase in engine R

P

M]

06:06:07.8H

O

T-2 set thrust please.

06:06:11.7H

O

T-1 thrust set.

06:06:16.3H

O

T-2 dat is weird with no lights.

06:06:18.0H

O

T-1 yeah.

06:06:24.2H

O

T-1 one hundred knots.

06:06:25.1H

O

T-2 checks.

06:06:31.2H

O

T-1 V one, rotate.

06:06:31.8H

O

T-1 whoa.

06:06:32.2C

A

M [unknown ambient noise]

06:06:32.6H

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T-1 #.

06:06:33.0C

A

M [sound of impact]
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DCA06MA064

06:06:33.3H

O

T-? [unintelligible exclamation]

06:06:33.8C

A

M [sound si

milar to stick shaker]

06:06:34.7C

A

M [sound of chime]

06:06:34.7C

A

M [sound si

milar to stall warning starts and continues to end of recording]

06:06:35.1H

O

T-? #.

06:06:35.7H

O

T-1 [unintelligible exclamation]

06:06:36.2E

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Appendix C

Blue Grass Airport Charts

National Aeronautical Charting Office chart dated August 3, 2006

SE-1, 03 AUG 2006 to 31 AUG 2006

SE-1, 03 AUG 2006 to 31 AUG 2006

Not For Navigation
Appendix C

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Accident Report

160

Jeppeson chart dated January 27, 2006

Reprinted with permission by Jeppeson
Appendix C

National Transportation Safety Board

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Accident Report

161

Jeppeson chart dated September 8, 2006

Reprinted with permission by Jeppeson