WASHINGTON (AP) – One obvious, overriding cause. Numerous safeguards that weren’t followed or didn’t work.
The federal investigation into last summer’s Kentucky plane crash that killed 49 people ended Thursday with a chilling yet expected conclusion by the National Transportation Safety Board that the fatal errors were human, not machine.
Board members determined the primary cause was a failure by pilots to notice clues that they were steering the Comair plane to the wrong runway in the predawn darkness – an unlit, general aviation strip too short to make a proper takeoff.
That’s the reason it crashed, but the board found plenty of blame to go around for failing to avert disaster.
“Rather than pointing to a mechanical or design flaw in the aircraft that could be fixed or a maintenance problem that could be corrected, this accident has led us into the briar patch of human behavior,” said Deborah Hersman, the board member who led the investigation in Lexington.
The NTSB deliberated all day to determine causes of the Aug. 27, 2006, crash and offer proposals to improve air safety.
Although the findings of the five-member board largely concurred with staff proposals, the fiercest debate came when determining whether to assign blame to the air traffic controller on duty.
Ultimately, the board decided against that, pinning most culpability on the pilots, along with a lesser role for the Federal Aviation Administration for failing to enforce earlier recommendations on runway checks.
Hersman was one of two board members who voted to list the controller’s action as a contributing cause, but she was overruled.
“That’s the frustration of this accident – no single cause, no single solution and no ‘aha’ moment,” Hersman said.
The NTSB also proposed several changes to aviation procedure as a result of the accident, including calls for clearer signs at regional airports and installation of an automated moving map system in which pilots can check in real time whether they’re on the right runway.
In a statement, Comair President Don Bornhorst said he would work with the NTSB and the FAA to address the proposed changes.
The board’s findings were perhaps more notable for the things they decided weren’t factors than the ones they determined were.
Among the non-factors, according to the board, were the flight crew’s lack of updated maps and notices alerting them to construction that had changed the taxiway route a week earlier. Although the board found the controller was fatigued, that also probably didn’t play a role, the board said.
Pilot Jeffrey Clay and first officer James Polehinke were most culpable for ignoring clear signs they were going the wrong way, such as the lack of lights on the shorter runway, the NTSB found. “Weird, no lights,” Polehinke was quoted as saying in the cockpit transcript.
NTSB chairman Mark Rosenker said afterward there were clear differences between the right strip and the wrong one.
“One was lit up like a Christmas tree,” he said. “The other was like a black hole.”
Polehinke was pulled from the charred cockpit as the only survivor, but he sustained brain damage, lost a leg and broke numerous bones. His attorney, Bruce Brandon, declined to comment Thursday.
A secondary cause, NTSB said, was non-pertinent chatter between the crew members as they prepared to taxi and take off. Comair has acknowledged some culpability as a result of the talk, which violated FAA rules calling for a “sterile cockpit.”
NTSB staff concluded the talk “greatly affected the crew’s performance.” Hersman agreed but suggested the disaster couldn’t be pinned on that alone.
“It’s clear this crew made a mistake,” Hersman said. “Their heads just weren’t in the game here. The issue is, what enabled them to make this mistake?”
Hersman pointed to the paperwork the crew never got detailing the taxiway change. Not only was it not in their packet from Comair, but the air traffic controller didn’t broadcast the announcement that morning, even though it had been doing so the rest of the week.
“We deal in redundancies in this business,” Rosenker said. “That’s what enables us to look after each other in the cockpit, and if one of the crewmen fails to do something, the other is there to help fill in the gap.”
No witnesses were called at the board meeting.
Investigators said a lone air traffic controller on duty used poor judgment by turning his back before takeoff, but they debated whether a required second controller could have prevented the accident.
NTSB staff concluded controller Christopher Damron should never have turned away to do an administrative task “not critical to flight safety” as the jet was preparing to take off.
However, the staff dismissed as a non-factor the violation of an FAA directive calling for two controllers to work overnight shifts in airports like Lexington – one to keep an eye on the ground, the other to monitor radar.
Patrick R. Forrey, president of the National Air Traffic Controllers Association, said there was nothing Damron should have done differently. He said the error that happened in the tower was due to staffing.
“He would have had the opportunity to possibly catch that aircraft from going down the wrong runway,” Forrey said.
Among the family members who attended the proceedings was Lexington resident Kathy Ryan, who lost her husband Michael in the accident. She said that she agreed with most of the findings but that the meeting was difficult to endure.
“You relive the accident and you also relive the week of briefings,” Ryan said. “It was like being back there again today.”
About 25 relatives of crash victims gathered at a hotel in downtown Lexington on Thursday to watch a video link to the hearing.
“You just think that if one precaution had been observed, then this tragedy wouldn’t have happened, and we would still have our loved ones,” said Lois Turner, whose husband was a passenger. “And that, I think, is the sad part and the hard part, to know that there were so many missed opportunities.”