Comair Flight 5191
Encyclopedia
Comair Flight 191, marketed as Delta Connection Flight 5191, was a scheduled United States (US) domestic passenger flight from Lexington, Kentucky
Lexington, Kentucky
Lexington is the second-largest city in Kentucky and the 63rd largest in the US. Known as the "Thoroughbred City" and the "Horse Capital of the World", it is located in the heart of Kentucky's Bluegrass region...

, to Atlanta, Georgia, operated on behalf of Delta Connection
Delta Connection
Delta Connection is the name under which a number of individually owned regional airlines and one wholly owned regional carrier operate short and medium haul routes in association with Delta Air Lines Inc...

 by Comair
Comair
Comair is a wholly owned subsidiary of Delta Air Lines headquartered on the grounds of Cincinnati-Northern Kentucky International Airport in unincorporated Boone County, Kentucky, United States, west of Erlanger, and south of Cincinnati, Ohio...

. On the morning of August 27, 2006, the Bombardier Canadair Regional Jet 100ER
Bombardier CRJ200
The Bombardier CRJ100 and CRJ200 are a family of regional airliner manufactured by Bombardier, and based on the Canadair Challenger business jet.-Development:...

 that was being used for the flight crashed while attempting to take off from Blue Grass Airport
Blue Grass Airport
Blue Grass Airport is a public airport located in Fayette County, Kentucky, United States, 4 miles west of the central business district of the city of Lexington. The main terminal building was opened in 1977. The airport covers an area of and has two runways. It is also home to the Aviation...

 in Fayette County, Kentucky
Fayette County, Kentucky
Fayette County is a county located in the U.S. state of Kentucky. The population was 295,083 in the 2010 Census. Its territory, population and government are coextensive with the city of Lexington, which also serves as county seat....

, four miles (6 kilometers) west of the central business district of the City of Lexington.

The aircraft was assigned the airport's Runway 22 for the takeoff, but used Runway 26 instead. Runway 26 was too short for a safe takeoff, causing the aircraft to overrun the end of the runway before it could become airborne. It crashed just past the end of the runway, killing all 47 passengers and two of the three crew. The flight's first officer was the only survivor. Although not the pilot in command
Pilot in command
The pilot in command of an aircraft is the person aboard the aircraft who is ultimately responsible for its operation and safety during flight. This would be the "captain" in a typical two- or three-pilot flight crew, or "pilot" if there is only one certified and qualified pilot at the controls of...

, according to the cockpit voice recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...

 transcript, the first officer was the pilot flying at the time of the accident.

Flight details

The flight was sold under the Delta Air Lines
Delta Air Lines
Delta Air Lines, Inc. is a major airline based in the United States and headquartered in Atlanta, Georgia. The airline operates an extensive domestic and international network serving all continents except Antarctica. Delta and its subsidiaries operate over 4,000 flights every day...

 brand as Delta Flight 5191 (DL5191) and was operated by Comair
Comair
Comair is a wholly owned subsidiary of Delta Air Lines headquartered on the grounds of Cincinnati-Northern Kentucky International Airport in unincorporated Boone County, Kentucky, United States, west of Erlanger, and south of Cincinnati, Ohio...

 as Comair Flight 191 (OH191). It is usually identified as Comair Flight 5191.

The flight had been scheduled to land at Hartsfield-Jackson Atlanta International Airport
Hartsfield-Jackson Atlanta International Airport
Hartsfield–Jackson Atlanta International Airport , known locally as Atlanta Airport, Hartsfield Airport, and Hartsfield–Jackson, is located seven miles south of the central business district of Atlanta, Georgia, United States...

 at 7:18 a.m.

The aircraft involved was a 50-seat Bombardier Canadair Regional Jet CRJ-100ER, serial number 7472. Manufactured in Canada in January 2001, it was delivered to the airline on January 30, 2001.

Crash

Analysis of the cockpit voice recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...

 (CVR) indicated the aircraft was cleared to take off from Runway 22, a 7003 feet (2,134.5 m) strip used by most airline traffic at Lexington. Instead, after confirming "Runway two-two", Captain Jeffrey Clay taxied onto Runway 26, an unlit secondary runway only 3500 feet (1,066.8 m) long, and turned the controls over to First Officer James Polehinke for takeoff. The air traffic control
Air traffic control
Air traffic control is a service provided by ground-based controllers who direct aircraft on the ground and in the air. The primary purpose of ATC systems worldwide is to separate aircraft to prevent collisions, to organize and expedite the flow of traffic, and to provide information and other...

ler was not required to maintain visual contact with the aircraft; after clearing the aircraft for takeoff, he turned to perform administrative duties and did not see the aircraft taxi to the runway.

Based upon an estimated takeoff weight of 49,087 pounds (22,265 kg), the manufacturer calculated a speed of 138 knots (159 miles per hour or 256 kilometers per hour) and a distance of 3744 feet (1,141.2 m) would have been needed for rotation (increasing nose-up pitch
Flight dynamics
Flight dynamics is the science of air vehicle orientation and control in three dimensions. The three critical flight dynamics parameters are the angles of rotation in three dimensions about the vehicle's center of mass, known as pitch, roll and yaw .Aerospace engineers develop control systems for...

), with more runway needed to achieve lift-off. At a speed approaching 100 knots (121.8 mph), Polehinke remarked, "There is no lights" referring to the lack of lighting on Runway 26. "Yeah", confirmed Clay, but the flight data recorder
Flight data recorder
A flight data recorder is an electronic device employed to record any instructions sent to any electronic systems on an aircraft. It is a device used to record specific aircraft performance parameters...

 gave no indication either pilot tried to abort the takeoff as the aircraft accelerated to 137 knots (166.8 mph).

Clay called for rotation but the aircraft sped off the end of the runway before it could lift off. It then struck a low earthen wall adjacent to a ditch, becoming momentarily airborne, clipped the airport perimeter fence with its landing gear, and collided with trees, separating the fuselage
Fuselage
The fuselage is an aircraft's main body section that holds crew and passengers or cargo. In single-engine aircraft it will usually contain an engine, although in some amphibious aircraft the single engine is mounted on a pylon attached to the fuselage which in turn is used as a floating hull...

 and flight deck
Flight deck
The flight deck of an aircraft carrier is the surface from which its aircraft take off and land, essentially a miniature airfield at sea. On smaller naval ships which do not have aviation as a primary mission, the landing area for helicopters and other VTOL aircraft is also referred to as the...

 from the tail. The aircraft struck the ground about 1000 feet (304.8 m) from the end of the runway. Forty-nine of the 50 people on board perished in the accident; most of them were killed instantly in the initial impact. The resulting fire destroyed the aircraft.

Victims

Nationality Passengers Crew Total
Total Killed Total Killed Total Killed
42 42 3 2 45 44
3 3 0 0 3 3
2 2 0 0 2 2
Total 47 47 3 2 50 49
Note: the two Japanese citizens were residents of Lexington, Kentucky.

All 47 passengers and two of the three crew members on board the flight were killed. Comair released the passenger manifest on August 29, 2006.

Most of the passengers were US citizens from the Lexington area, ranging in age from 16 to 72. They included a young couple who had been married the previous day and were traveling to California on their honeymoon.

A memorial service for the victims was held on August 31, 2006, at the Lexington Opera House
Lexington Center
The Lexington Center is located on a site in Lexington, Kentucky. It features a convention center, a shopping mall, the Hyatt Regency Hotel, and Rupp Arena...

. A second public memorial service was held on September 10, 2006, at Rupp Arena
Rupp Arena
Rupp Arena is an arena located in downtown Lexington, Kentucky, U.S. Since its opening in 1976, it has been the centerpiece of Lexington Center, a convention and shopping facility owned by an arm of the Lexington-Fayette Urban County Government, and serves as home court to the University of...

 in Lexington. The Lexington Herald-Leader
Lexington Herald-Leader
The Lexington Herald-Leader is a newspaper owned by The McClatchy Company and based in the U.S. city of Lexington, Kentucky. According to the 1999 Editor & Publisher International Yearbook, the Herald-Leaders paid circulation is the second largest in the Commonwealth of Kentucky...

published a list of the victims with short biographies.

The Flight 5191 Memorial Commission was established shortly after the crash to create an appropriate memorial to the victims, first responders, and community that supported them. The Commission chose the University of Kentucky Arboretum
University of Kentucky Arboretum
The University of Kentucky Arboretum , 40 hectares or , is located at the University of Kentucky in Lexington, Kentucky, USA...

 as its memorial site.

Survivor

James Polehinke, the first officer, suffered serious injuries, including multiple broken bone
Bone fracture
A bone fracture is a medical condition in which there is a break in the continuity of the bone...

s, a collapsed lung
Pneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...

, and severe bleeding
Bleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...

. Lexington-Fayette and airport police officers pulled Polehinke out of the wreckage. Polehinke underwent surgery for his injuries, including an amputation
Amputation
Amputation is the removal of a body extremity by trauma, prolonged constriction, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for...

 of his left leg. Doctors later determined that Polehinke had suffered brain damage
Brain damage
"Brain damage" or "brain injury" is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors...

 and has no memory of the crash or the events leading up to it. , Polehinke was a wheelchair user. During the same month, Polehinke filed a lawsuit against the airport and the company that designed the runway and taxi lights.

Polehinke said through his attorney
Lawyer
A lawyer, according to Black's Law Dictionary, is "a person learned in the law; as an attorney, counsel or solicitor; a person who is practicing law." Law is the system of rules of conduct established by the sovereign government of a society to correct wrongs, maintain the stability of political...

, William Johnson, that "should have been aware of the dangerous conditions that existed in that there had been considerable media coverage about the necessity of improving runway conditions at the airport." Johnson later withdrew the argument. David Royse, an attorney for the plaintiff
Plaintiff
A plaintiff , also known as a claimant or complainant, is the term used in some jurisdictions for the party who initiates a lawsuit before a court...

s, criticized Polehinke's statement.

Aftermath

During the course of its investigation, the Federal Aviation Administration
Federal Aviation Administration
The Federal Aviation Administration is the national aviation authority of the United States. An agency of the United States Department of Transportation, it has authority to regulate and oversee all aspects of civil aviation in the U.S...

 (FAA) discovered that tower staffing levels at Blue Grass Airport
Blue Grass Airport
Blue Grass Airport is a public airport located in Fayette County, Kentucky, United States, 4 miles west of the central business district of the city of Lexington. The main terminal building was opened in 1977. The airport covers an area of and has two runways. It is also home to the Aviation...

 violated an internal policy as reflected in a November 16, 2005, memorandum requiring two controllers during the overnight shift: one in the tower working clearance, ground, and tower frequencies, and another, either in the tower or remotely at Indianapolis Center
Area Control Center
In air traffic control, an Area Control Center , also known as a Center, is a facility responsible for controlling instrument flight rules aircraft en route in a particular volume of airspace at high altitudes between airport approaches and departures...

, working TRACON (radar). At the time of the accident, the single controller in the tower was performing both tower and radar duties. On August 30, 2006, the FAA announced that Lexington, as well as other airports with similar traffic levels, would be staffed with two controllers in the tower around the clock effective immediately.
On September 12, 2006, Comair announced that all of its pilots had been using an airport map with outdated information at the time of the crash. A new diagram was received by the airline on Friday, September 8, two weeks after the crash. At the same time, the airline issued a warning to pilots to exercise "extreme caution" when taxiing to the appropriate runway. Despite the existence of the outdated chart, an airport spokesman stated that the updated taxi route was available to pilots via a Notice To Airmen
NOTAM
NOTAM or NoTAM is the quasi-acronym for a "Notice To Airmen". NOTAMs are created and transmitted by government agencies and airport operators under guidelines specified by Annex 15: Aeronautical Information Services of the Convention on International Civil Aviation...

 (NOTAM) released when the construction began.

On September 14, 2006, Fayette Circuit Judge Pamela Goodwine issued a restraining order to prevent Blue Grass Airport from continuing any construction to preserve evidence in the crash pending the inspection by safety experts and attorneys for the families of the victims.

On December 12, 2006, the National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...

 (NTSB) recommended that the FAA should take steps to ensure that pilots cross-check their position before crossing the hold-short line and initiating takeoff. The NTSB also recommended that pilots be given specific guidance on runway lighting requirements for take-off at night.

The NTSB released several factual reports on January 17, 2007, including transcripts and recordings of the CVR and an engineering report.

In April 2007, the NTSB made four further recommendations, three measures to avoid fatigue affecting the performance of air traffic controllers, and one to prevent controllers from carrying out non-essential administrative tasks while aircraft are taxiing under their control. Although these recommendations were published during the course of the NTSB's investigation into the accident to Comair Flight 191, they were in part prompted by four earlier accidents, and the Board was unable to determine whether fatigue contributed to the Comair accident.

In July 2007, a flying instructor for Comair testified that he would have failed both pilots for violating Sterile Cockpit Rule
Sterile Cockpit Rule
The Sterile Cockpit Rule is an FAA regulation requiring pilots to refrain from non-essential activities during critical phases of flight, normally below 10,000 feet...

s. Later the same month, the NTSB released its final report into the accident, citing this "non-pertinent conversation" as a contributing factor in the accident.

On July 8, 2008, United States District Judge Karl Forester ruled Delta will not be held liable for the crash, because while Comair is a wholly owned subsidiary of the Atlanta-based airline, Comair maintains its own management and policies, and employs its own pilots.

On December 17, 2009, Judge Forester granted a passenger family's motion for "partial summary judgment" determining, as a matter of law, that Comair's flight crew was negligent, and that this negligence was a substantial factor causing the crash of Flight 5191.

Families of 45 of the 47 passengers sued Comair for negligence. (Families of the other two victims settled with the airline before filing litigation.) Three sample cases were due to be heard on August 4, 2008; but the trial was indefinitely postponed after Comair reached a settlement with the majority of the families. Cases brought by Comair against the airport authority and the FAA, arguing each should share in the compensation payments, are now resolved. The case against the airport authority was dismissed on sovereign immunity
Sovereign immunity in the United States
Sovereign immunity in the United States is the legal privilege by which the American federal, state, and tribal governments cannot be sued. Local governments in most jurisdictions enjoy immunity from some forms of suit, particularly in tort...

 grounds, and this ruling was upheld by the Kentucky Supreme Court
Kentucky Supreme Court
The Kentucky Supreme Court was created by a 1975 constitutional amendment and is the state supreme court of the commonwealth of Kentucky. Prior to that the Kentucky Court of Appeals was the only appellate court in Kentucky...

 on October 1, 2009. In Comair's case against the United States a settlement was reached with the United States agreeing to pay 22% of the liability for the crash, while Comair agreed to pay the remaining 78%.

All but one of the passengers' families settled their cases. After a four day jury trial in Lexington, Kentucky, that ended on December 7, 2009, the estate and daughters of 39 year old Bryan Woodward were awarded compensatory damages in the amount of $7.1 million. While Comair challenged this verdict as excessive, on April 2, 2010, Judge Forester overruled Comair's objections and upheld the verdict.

The Woodward case, formally known as Hebert v. Comair, was set for a punitive damages jury trial July 19, 2010. In that trial a different jury was to decide whether Comair was guilty of gross negligence that was a substantial factor causing the crash and, if so, the amount of any punitive damages the jury deemed appropriate. However in a later hearing the decision to allow a jury trial was reversed with the judge ruling that the company couldn't be punished for the "reprehensible conduct" of its pilot.

Probable cause

During a public meeting on July 26, 2007, the NTSB announced the probable cause of the accident, as follows:


The National Transportation Safety Board determines that the probable cause of this accident was the flight crew members’ 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 conversations 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.

Captain Clay's wife strongly disputes laying primary blame on the pilots, stating that other factors contributed, "including an under-staffed control tower and an inaccurate runway map".

Similar accidents and incidents

  • In 1993, a commercial jet at Blue Grass Airport was cleared for takeoff on Runway 22 but mistakenly took Runway 26 instead. Tower personnel noticed the mistake and canceled the aircraft's takeoff clearance just as the crew realized their error. The aircraft subsequently made a safe departure from Runway 22.
  • In January 2007, a Learjet was cleared to take off at Blue Grass Airport on runway 22, but mistakenly turned onto runway 26. Takeoff clearance was canceled by the local controller prior to the start of the takeoff roll.
  • On October 31, 2000, the crew of Singapore Airlines Flight 006
    Singapore Airlines Flight 006
    Singapore Airlines Flight 006 was a scheduled passenger flight from Singapore Changi Airport to Los Angeles International Airport via Chiang Kai-shek Airport in Taiwan...

     mistakenly used a closed runway for departure from Chiang Kai-shek International Airport, Taipei
    Taipei
    Taipei City is the capital of the Republic of China and the central city of the largest metropolitan area of Taiwan. Situated at the northern tip of the island, Taipei is located on the Tamsui River, and is about 25 km southwest of Keelung, its port on the Pacific Ocean...

    . The Boeing 747-400
    Boeing 747-400
    The Boeing 747-400 is a major development and the best-selling model of the Boeing 747 family of jet airliners. While retaining the four-engine wide-body layout of its predecessors, the 747-400 embodies numerous technological and structural changes to produce a more efficient airframe...

     collided with construction equipment during the takeoff roll, resulting in the deaths of 83 of the 179 passengers and crew on board.

See also

  • Singapore Airlines Flight 006
    Singapore Airlines Flight 006
    Singapore Airlines Flight 006 was a scheduled passenger flight from Singapore Changi Airport to Los Angeles International Airport via Chiang Kai-shek Airport in Taiwan...

  • Western Airlines Flight 2605
    Western Airlines Flight 2605
    On October 31, 1979, Western Airlines Flight 2605, a McDonnell Douglas DC-10-10 flying from Los Angeles to Mexico City, landed on a closed runway at Benito Juarez International Airport in early morning fog and burst into flames after striking a parked truck...

  • Air safety
    Air safety
    Air safety is a term encompassing the theory, investigation and categorization of flight failures, and the prevention of such failures through regulation, education and training. It can also be applied in the context of campaigns that inform the public as to the safety of air travel.-United...

  • Lexington, Kentucky
    Lexington, Kentucky
    Lexington is the second-largest city in Kentucky and the 63rd largest in the US. Known as the "Thoroughbred City" and the "Horse Capital of the World", it is located in the heart of Kentucky's Bluegrass region...

  • List of accidents and incidents on commercial airliners
  • List of sole survivors of aviation accidents or incidents
  • National Transportation Safety Board
    National Transportation Safety Board
    The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...



External links

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