Comair Flight 191
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Comair Flight 5191 (marketed as Delta Connection Flight 5191 under a codeshare agreement with
Delta Air Lines Delta Air Lines, Inc., typically referred to as Delta, is one of the major airlines of the United States and a legacy carrier. One of the List of airlines by foundation date, world's oldest airlines in operation, Delta is headquartered in Atla ...
) was a scheduled United States domestic passenger flight from
Lexington, Kentucky Lexington is a city in Kentucky, United States that is the county seat of Fayette County, Kentucky, Fayette County. By population, it is the List of cities in Kentucky, second-largest city in Kentucky and List of United States cities by popul ...
, to
Atlanta, Georgia Atlanta ( ) is the capital and most populous city of the U.S. state of Georgia. It is the seat of Fulton County, the most populous county in Georgia, but its territory falls in both Fulton and DeKalb counties. With a population of 498,715 ...
. On the morning of August 27, 2006, at around 06:07 EDT (10:07 UTC), the Bombardier Canadair Regional Jet 100ER crashed while attempting to take off from Blue Grass Airport in
Fayette County, Kentucky Fayette County is located in the central part of the U.S. state of Kentucky. As of the 2020 census, the population was 322,570, making it the second-most populous county in the commonwealth. Its territory, population and government are coextens ...
, 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. It was the second-deadliest accident involving the CRJ-100/-200; two years earlier,
China Eastern Airlines Flight 5210 China Eastern Airlines Flight 5210 (CES5210/MU5210), also known as the Baotou Air Disaster, was a flight from Baotou Erliban Airport in Inner Mongolia, China, to Shanghai Hongqiao International Airport, with a planned stopover at Beijing Capital ...
claimed 55 lives. The flight's first officer, James Polehinke, was the pilot flying at the time of the accident and was the sole survivor. In the
National Transportation Safety Board The National Transportation Safety Board (NTSB) 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 incid ...
's report on the crash, investigators concluded that the likely cause of the crash was pilot error.


Flight details

The flight was marketed under the
Delta Air Lines Delta Air Lines, Inc., typically referred to as Delta, is one of the major airlines of the United States and a legacy carrier. One of the List of airlines by foundation date, world's oldest airlines in operation, Delta is headquartered in Atla ...
brand as Delta Connection Flight 5191 (DL5191) and was operated by Comair as Flight 5191. It was identified for air-traffic control and flight-tracking purposes as Comair 191 (OH5191/COM5191). The flight had been scheduled to land at Hartsfield-Jackson Atlanta International Airport at 7:18 a.m. The aircraft involved was a 50-seat Bombardier Canadair Regional Jet CRJ-100ER, serial number 7472.N431CA FAA registration certificate. Retrieved June 19, 2008. (Note: CL600-2B19 is the official designation of the
CRJ100 The Bombardier CRJ100 and CRJ200 (previously Canadair CRJ100 and CRJ200) is a regional jet designed and manufactured by Bombardier Aerospace between 1991 and 2006, the first of the Bombardier CRJ family. The ''Canadair Regional Jet'' (CRJ) pro ...
).
It was manufactured in Canada and was delivered to the airline on January 30, 2001. The captain was 35-year old Jeffrey Clay. He had 4,710 flight hours, including 3,082 hours on the CRJ-100. The first officer was 44-year-old James Polehinke. Prior to his employment by Comair, Polehinke worked for
Gulfstream International Silver Airways LLC. is a United States regional airline with its headquarters in Fort Lauderdale–Hollywood International Airport in Broward County, Florida, near Fort Lauderdale. It was founded in 2011 with assets from the former Gulfstream ...
as a captain. He had 6,564 flight hours, including 940 hours as a captain and 3,564 hours on the CRJ-100.


Crash

Analysis of the cockpit voice recorder (CVR) indicated that the aircraft was cleared to take off from Runway 22, a runway used by most airline traffic at Lexington. However, after confirming the takeoff clearance for Runway 22, Captain Clay taxied onto Runway 26, a much smaller and unlit runway that was not authorized for commercial use, and turned the controls over to First Officer Polehinke for takeoff. The air traffic controller 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 , the manufacturer calculated that a speed of and a distance of would have been needed for
rotation Rotation, or spin, is the circular movement of an object around a '' central axis''. A two-dimensional rotating object has only one possible central axis and can rotate in either a clockwise or counterclockwise direction. A three-dimensional ...
(increasing nose-up pitch), with more runway needed to achieve liftoff. At a speed approaching , Polehinke remarked, "That is weird with no lights" referring to the lack of lighting on Runway 26 – it was about an hour before daybreak. "Yeah", confirmed Clay, but the flight data recorder (FDR) gave no indication that either pilot had tried to abort the takeoff as the aircraft accelerated to . 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 smashed into trees, separating the
fuselage The fuselage (; from the French ''fuselé'' "spindle-shaped") is an aircraft's main body section. It holds crew, passengers, or cargo. In single-engine aircraft, it will usually contain an engine as well, although in some amphibious aircraft t ...
and flight deck from the tail. The aircraft struck the ground about from the end of the runway. The resulting fire destroyed the aircraft.


Passengers

Forty-nine of the 50 people on board perished in the accident (all 47 passengers and two of the three crew members); most of the victims died instantly, in the initial crash impact. Comair released the passenger manifest on August 29, 2006. Most of the passengers were American 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.


Sole survivor

James Polehinke, the first officer, suffered serious injuries, including multiple
broken bone A bone fracture (abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a '' ...
s, a
collapsed lung A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve is ...
and severe bleeding. Lexington-Fayette and airport police officers pulled Polehinke out of the wreckage. He underwent surgery for his injuries, including an
amputation Amputation is the removal of a limb by trauma, medical illness, 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 indi ...
of his left leg that confined him to a wheelchair. Doctors later determined that Polehinke had suffered
brain damage Neurotrauma, brain damage or brain injury (BI) is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors. In general, brain damage refers to significant, undiscriminating t ...
and had no memory of the crash or the events leading up to it.


Investigation

During the investigation, the
Federal Aviation Administration The Federal Aviation Administration (FAA) is the largest transportation agency of the U.S. government and regulates all aspects of civil aviation in the country as well as over surrounding international waters. Its powers include air traffic m ...
(FAA) discovered that tower-staffing levels at Blue Grass Airport 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, 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. Comair discovered after the accident that all of its pilots had been using an airport map that did not accurately reflect changes made to the airport layout during ongoing construction work. The
National Transportation Safety Board The National Transportation Safety Board (NTSB) 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 incid ...
(NTSB) later determined that this did not contribute to the accident. Construction work was halted after the accident on the orders of Fayette Circuit judge Pamela Goodwine in order to preserve evidence in the crash pending the inspection by safety experts and attorneys for the families of the victims. The NTSB released several reports on January 17, 2007, including transcripts of the CVR and an engineering report. In April 2007, acting on a recommendation made by the NTSB during its investigation of Comair 5191, the FAA issued a safety notice that reiterated advice to pilots to positively confirm their position before crossing the hold-short line onto the takeoff runway, and again when initiating takeoff. 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 5191, they were in part prompted by four earlier accidents, and the board was unable to determine whether fatigue contributed to the Comair accident. In May, acting on another NTSB recommendation, the FAA advised that pilot training should include specific guidance on runway lighting requirements for takeoff at night. In July 2007, a Comair flying instructor testified that he would have failed both pilots for violating
Sterile Cockpit Rule In aviation, the sterile flight deck rule or sterile cockpit rule is a procedural requirement that during critical phases of flight (normally below ), only activities required for the safe operation of the aircraft may be carried out by the fligh ...
s. Later that month, the NTSB released its final report, citing this "non-pertinent conversation" as a contributing factor in the accident.


Probable cause

During a public meeting on July 26, 2007, the NTSB announced the probable cause of the accident:
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.
NTSB investigators concluded that the likely cause of the crash was that Clay and Polehinke ignored clues that they were on the wrong runway, failed to confirm their position on the runway and engaged in too much conversation not pertinent to the flight, in violation of sterile cockpit procedures. Captain Clay's widow strongly disputes laying primary blame on the pilots, stating that other factors contributed, "including an under-staffed control tower and an inaccurate runway map."


Aftermath

A memorial service for the victims was held on August 31, 2006, at the
Lexington Opera House The Lexington Opera House is a theatre located at 401 West Short Street in downtown Lexington, Kentucky. Built in 1886, the Opera House replaced the former theatre, located on the corner of Main and Broadway, after fire destroyed it in January 1 ...
. A second public memorial service was held on September 10, 2006 at Rupp Arena in Lexington. The ''
Lexington Herald-Leader The ''Lexington Herald-Leader'' is a newspaper owned by the McClatchy Company and based in Lexington, Kentucky. According to the ''1999 Editor & Publisher International Yearbook'', the paid circulation of the ''Herald-Leader'' is the second large ...
'' 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 for the victims, first responders and community that supported them. The commission chose the
University of Kentucky Arboretum The Arboretum, State Botanical Garden of Kentucky (Also known as University of Kentucky Arboretum or Lexington Arboretum), 40 hectares or , is located at the University of Kentucky in Lexington, Kentucky, United States. It is open to the public fr ...
as its memorial site. The Flight 5191 Memorial, created by Douwe Blumberg, consists of a sculpture of 49 stainless steel birds in flight over a base of black granite. In July 2008, U.S. district judge
Karl Forester Karl Spillman Forester (May 2, 1940 – March 29, 2014) was a United States district judge of the United States District Court for the Eastern District of Kentucky. Education and career Born on May 2, 1940, in Harlan, Kentucky, Forester receiv ...
ruled that Delta Air Lines could not be held liable for the crash, because although Comair is a wholly owned subsidiary of Delta, Comair maintains its own management and policies, and employs its own pilots. In December of the following year, 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.IN RE: Air Crash at Lexington, Kentucky, August 27, 2006
justia.com
Runway 8/26 at Blue Grass Airport was closed in March 2009, and the new Runway 9/27 opened on August 4, 2010. The new runway has been built on a separate location not connected to Runway 22.


Lawsuits

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 to be heard on August 4, 2008, but the trial was indefinitely postponed after Comair reached a settlement with the majority of the families. Comair sued the airport authority over its runway signs and markings as well as the FAA, which had only one air traffic controller on duty, contrary to a memo that it had previously issued requiring two workers on overnight shifts. The case against the airport authority was dismissed on sovereign immunity grounds, and this ruling was upheld by the Kentucky Supreme Court on October 1, 2009. In Comair's case against the United States, a settlement was reached with the government 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 that ended on December 7, 2009, the estate and daughters of 39‑year‑old victim Bryan Woodward were awarded
compensatory damages At common law, damages are a remedy in the form of a monetary award to be paid to a claimant as compensation for loss or injury. To warrant the award, the claimant must show that a breach of duty has caused foreseeable loss. To be recognised at ...
in the amount of $7.1 million. Though Comair challenged this verdict as excessive, on April 2, 2010, Judge Forester overruled Comair's objections and upheld the verdict. The case, formally known as ''Hebert v. Comair'', was set for a punitive damages jury trial on 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 punitive damages to assess. The decision to allow a jury trial was reversed in a later hearing, with the judge ruling that the company could not be punished for the "reprehensible conduct" of its pilots. In May 2012, Polehinke filed a lawsuit against the airport and the company that designed the runway and taxi lights. The estates or families of 21 of the 47 passengers filed lawsuits against Polehinke. In response, Polehinke's
attorney Attorney may refer to: * Lawyer ** Attorney at law, in some jurisdictions * Attorney, one who has power of attorney * ''The Attorney'', a 2013 South Korean film See also * Attorney general, the principal legal officer of (or advisor to) a gove ...
, William E. Johnson, raised the possibility of contributory negligence on the part of the passengers. When asked by the plaintiffs' attorney David Royse, who criticized the statements, to explain what that meant, Johnson replied that the passengers "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." At the time when Johnson submitted the contributory negligence defense, he had not yet been able to speak to Polehinke. By the time that newspapers reported on the court documents, Johnson said that he had already informed Royse that he would withdraw the argument.


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 departed safely from Runway 22. An identical occurrence took place in January 2007 when a Learjet lined up on Runway 26, but again the error was noticed and corrected before the flight took off. On October 31, 2000, the crew of
Singapore Airlines Flight 006 Singapore Airlines Flight 006 (SQ006/SIA006) was a scheduled Singapore Airlines passenger flight from Singapore Changi Airport to Los Angeles International Airport via Chiang Kai-shek International Airport (now Taiwan Taoyuan International Airp ...
mistakenly used a closed runway for departure from Chiang Kai-shek International Airport in
Taipei, Taiwan Taipei (), officially Taipei City, is the capital and a special municipality of the Republic of China (Taiwan). Located in Northern Taiwan, Taipei City is an enclave of the municipality of New Taipei City that sits about southwest of the ...
. The
Boeing 747-400 The Boeing 747-400 is a large, long-range wide-body airliner produced by Boeing Commercial Airplanes, an advanced variant of the initial Boeing 747. The "Advanced Series 300" was announced at the September 1984 Farnborough Airshow, targeting ...
collided with construction equipment during the takeoff roll, resulting in the deaths of 83 of the 179 passengers and crew on board. On October 31, 1979, at 5:42 a.m. CST (UTC−06:00),
Western Airlines Flight 2605 Western Airlines Flight 2605, nicknamed the "Night Owl", was an international scheduled passenger flight from Los Angeles, California, to Mexico City, Mexico. On October 31, 1979, at 5:42 a.m. CST ( UTC−06:00), the McDonnell Douglas DC-10 o ...
, a McDonnell Douglas DC-10, crashed at Mexico City International Airport in fog, after landing on a runway closed for maintenance. Flight 2605 remains the deadliest aviation disaster in Mexico City.


In popular culture

The crash was featured in the third episode of Season 21 of ''
Mayday Mayday is an emergency procedure word used internationally as a distress signal in voice-procedure radio communications. It is used to signal a life-threatening emergency primarily by aviators and mariners, but in some countries local organiza ...
,'' also known as ''Air Crash Investigation.'' The episode is titled "Tragic Takeoff". The flight's first officer, the crash's only survivor, was later featured in a film about sole survivors of plane crashes. The opening skit of the 2006 Emmy Awards featured host
Conan O'Brien Conan Christopher O'Brien (born April 18, 1963) is an American television host, comedian, writer, and producer. He is best known for having hosted late-night talk shows for almost 28 years, beginning with ''Late Night with Conan O'Brien'' (19 ...
getting into a plane crash similar to the TV show Lost. The Emmy's were airing the same night as the plane crash. The skit was criticized and called called "tasteless."


See also

* Aviation safety * List of accidents and incidents involving commercial aircraft * List of sole survivors of airline accidents or incidents *
Western Airlines Flight 2605 Western Airlines Flight 2605, nicknamed the "Night Owl", was an international scheduled passenger flight from Los Angeles, California, to Mexico City, Mexico. On October 31, 1979, at 5:42 a.m. CST ( UTC−06:00), the McDonnell Douglas DC-10 o ...
*
Singapore Airlines Flight 006 Singapore Airlines Flight 006 (SQ006/SIA006) was a scheduled Singapore Airlines passenger flight from Singapore Changi Airport to Los Angeles International Airport via Chiang Kai-shek International Airport (now Taiwan Taoyuan International Airp ...
* China Airlines Flight 204


Notes


References


External links


NTSB Final ReportComair Press ReleasesArchive



Cockpit Voice Recorder transcript and accident summary
* {{Good article 2006 in Kentucky Airliner accidents and incidents caused by pilot error Accidents and incidents involving the Bombardier CRJ200 Airliner accidents and incidents in Kentucky Airliner accidents and incidents involving runway overruns Aviation accidents and incidents in the United States in 2006 5191 History of Lexington, Kentucky August 2006 events in the United States