Comair Flight 5191 Crash Report Reveals System Design Flaws

Comair’s Flight 5191 took off from a runway that was too short in Kentucky last summer and crashed, killing 49 people. The National Transportation Safety Board (NTSB) investigation yielded more details about the August 27 crash, but found no definitive reason for it. Pieced together from transcripts and experts interviewed after the report was released, the details yield a host of ergonomic issues that are likely to be cited as contributing factors in inquiries yet to come.

The jet was supposed to take off from the 7,000-foot main runway, called runway 22, but instead used 3,500-foot runway 26, which is meant only for smaller planes.

Many ergonomics studies highlight the dangers of distractions during operations of any kind, and Comair transcripts revealed several. In particular, the pilots, Jeffrey Clay and James Polehinke, were heard chatting about everyday things as the plane taxied from the gate, just four minutes before the crash. A 1981 “sterile cockpit rule” forbids, among other things, extraneous conversation during taxi, takeoff and landing to prevent distractions.

Peter Goelz, the former managing director for the National Transportation Safety Board, said in a Washington Post article about the report that the chatter prior to Comair Flight 5191 was so excessive it might have contributed to the crash. “I think that when the human factors experts at the NTSB analyze the transcripts, they will identify this extraneous conversation as a contributing factor,” he said.

John Goglia, a professor of aviation science at St. Louis University and a former NTSB member, told the Cincinnati newspaper, The Inquirer, that conversation between the pilots about other pilots’ looking for jobs as they taxied away from the gate was careless. “That’s a real problem – it’s called distraction, more than one accident has been caused by it,” Goglia said.

And it appears the lone air traffic controller on duty in the tower, Christopher Damron, was handling two other flights at the time. The transcript notes that he was distracted from Flight 5191 and looking away from it at the critical moment. According to an account of the report by Associated Press and the television network CBS, investigators said the controller did nothing wrong but his actions eliminated any chance he had to warn the pilots of their fatal mistake.

The investigation also showed Damon had worked for almost 15 hours and slept for two. An operator’s sleep deprivation is often a factor in accidents, and as often the result of shift patterns and employment practices that are designed without any thought to the principles of ergonomics.

The May 2005 issue of The Ergonomics
Report