Investigation Summary
The accident occurred at Blue Grass Airport during a period of construction that had altered taxiway patterns. The flight crew was cleared for takeoff on Runway 22, which was 7,003 feet long. However, they taxied onto Runway 26, an unlit secondary runway only 3,500 feet long. The crew failed to cross-check their heading and position against available cockpit instruments and airport signage. Despite noticing the lack of lights on the runway, the captain continued the takeoff roll. The aircraft overran the runway end, struck a perimeter fence and trees, and burst into flames. The first officer was the sole survivor.
Final Conclusions
The NTSB determined the probable cause was the flight crew's failure to use available cues to identify the aircraft's location on the airport surface and their failure to cross-check the heading indicator with the runway alignment. Contributing factors included non-pertinent conversation (Sterile Cockpit Rule violation) and the FAA's failure to require all runway crossings to be authorized by specific air traffic control clearances.
Video Analysis
The Wrong Runway: Comair Flight 5191 — An analysis of the human factors and navigational errors that led a CRJ-100 to attempt takeoff from a 3,500ft runway.
Watch on YouTube ↗If playback is blocked, the owner has disabled embedding — use the link above.
Systems & Failure Modes
Heading Indicator (HI)
A flight instrument used to inform the pilot of the aircraft's heading; it would have shown a discrepancy if checked against the assigned runway.
Sterile Cockpit Rule
An FAA regulation (14 CFR 121.542) prohibiting non-essential conversation during critical phases of flight, including taxi.
Airport Lighting
Runway 26 was not equipped with edge lights, a cue the crew noticed but did not act upon.
Interesting Facts
- 01Runway 26 was only 3,500 feet long, while the CRJ-100 required approximately 5,000 feet for takeoff.
- 02The airport was undergoing construction, and the taxiway map provided to the pilots was slightly outdated regarding barricade locations.
- 03Only one air traffic controller was on duty, performing both tower and radar functions, which was against FAA internal policy for that facility.
- 04The First Officer, James Polehinke, was the only survivor but sustained permanent injuries.
- 05The flight crew's heading indicators would have shown 266 degrees, significantly different from the assigned 227 degrees.
Safety Actions & Advisories
Enhanced Taxi Clearances
The FAA changed procedures to require specific 'cleared to cross' instructions for every runway encountered during taxi.
Runway Awareness and Advisory System (RAAS)
Increased adoption of software that provides aural alerts to pilots regarding which runway they are on.
Staffing Requirements
The FAA mandated that at least two controllers be present in the tower during all operational hours at airports of this size.