Original subtitles

NARRATOR: On an early morning takeoff in Kentucky...

CAPTAIN JEFF CLAY: A hundred knots.

FIRST OFFICER JAMES POLEHINKE: Checks.

NARRATOR: ...two experienced pilots struggle

to get their regional jet off the ground...

CAPTAIN CLAY: V-1. Rotate. Whoa!

NARRATOR: ...and crash into a nearby field.

EVAN BYRNE: This was a catastrophic accident.

NARRATOR: Investigators try to piece together what went wrong...

JOE SEDOR: Get those to Washington.

NARRATOR: ...and end up with more questions than answers.

BYRNE: Why the heck would they stop there?

NARRATOR: Only by retracing the taxi route...

BYRNE: All the cues are right there in plain sight.

NARRATOR: And listening to the cockpit discussions...

FIRST OFFICER POLEHINKE: That is weird with no lights.

CAPTAIN CLAY: Yeah.

NARRATOR: ...do investigators discover the grim truth.

SEDOR: They finally realize something’s wrong.

But it’s already too late.

PILOT: Mayday! Mayday!

GPWS: Pull up!

(indistinct radio chatter)

NARRATOR: It’s almost six in the morning in Lexington, Kentucky.

The pilots of Comair flight 5191

prepare for their pre-flight briefing.

In command is Captain Jeff Clay,

an experienced pilot with more than 4700 flying hours.

CAPTAIN CLAY: Man, I always feel like I could eat a little more

when I get a seatbelt like this.

NARRATOR: First officer James Polehinke is also a seasoned pilot,

with more than 6500 hours.

CAPTAIN CLAY: Are you up for flying this leg?

FIRST OFFICER POLEHINKE: Yeah, I'll take us to Atlanta.

SHAWN PRUCHNICKI: Both the captain and the first officer

were very highly regarded.

They had an outstanding professional reputation,

and individuals that had flown with them had nothing

but high marks and uh very, very favorable comments,

as far as their qualities.

NARRATOR: The crew is flying a Bombardier CRJ-100,

a small, twin-engine jet

designed for short commuter flights.

Shawn Pruchnicki flew that aircraft for Comair for ten years.

PRUCHNICKI: The CRJ is an aircraft

that’s built for short haul flights.

For example, the Lexington to Atlanta less than an hour type flight,

is really what these airplanes are designed to do.

CAPTAIN CLAY: Ladies and gentlemen,

we'd like to take this time to welcome you onboard

Comair flight 5191 direct to Atlanta.

We'll try to keep it as quiet as possible.

Hopefully you can catch a nap on the way there.

It’s our pleasure having you on board today.

NARRATOR: There are 47 passengers

and one flight attendant on today’s flight.

The pilots begin their briefing.

FIRST OFFICER POLEHINKE: Right flex takeoff procedures

off of... he said what runway? Two-four?

CAPTAIN CLAY: It’s two-two.

PRUCHNICKI: Something that we do prior to take off

is we do a flight briefing between the two crew members.

And the primary reason we do this is to make sure

that everyone has the same amount of information

and knowledge to safely depart the airport.

FIRST OFFICER POLEHINKE: Huh. On two-two the ILS is out.

Came in the other night.

The runway identifier lights were out all over the place.

CAPTAIN CLAY: All right.

FIRST OFFICER POLEHINKE: Two-two's a short taxi.

Any questions?

CAPTAIN CLAY: No questions before starting.

Your leisure.

NARRATOR: In the cabin, passengers prepare for takeoff.

FLIGHT ATTENDANT: Seatbelt, please.

NARRATOR: Today they are bound for Atlanta, Georgia,

just a 67-minute flight straight south

from Lexington’s Blue Grass Airport.

FIRST OFFICER POLEHINKE: Comair 1-91 is ready to taxi.

CONTROLLER: Comair 1-91,

taxi to runway two-two.

Altimeter three-zero-zero-zero.

Winds are two-zero-zero at eight.

FIRST OFFICER POLEHINKE (on radio): Three triple zero

and taxi two-two, Comair 1-91.

NARRATOR: Lexington’s air traffic controller clears flight 5191

to the runway and then turns his attention to another plane.

CONTROLLER: Eagle flight runway two-two, cleared for takeoff.

NARRATOR: With few planes at this small airport,

in near perfect weather,

this flight is far from challenging

for these seasoned pilots.

PRUCHNICKI: During the taxi out,

the captain is responsible primarily

for navigating the aircraft on the airport surface.

The first officer is running numerous checklists

and verifying that the aircraft is safe for departure.

FIRST OFFICER POLEHINKE (over PA): Folks, we're gonna be underway momentarily.

So sit back, relax, and enjoy the flight.

FLIGHT ATTENDANT: We’re all ready in the cabin, sir.

FIRST OFFICER POLEHINKE: Thank you.

Cabin report is received. Before takeoff checks complete.

Ready.

CAPTAIN CLAY: All set.

FIRST OFFICER POLEHINKE: At your leisure,

Comair 1-21 ready to go.

CONTROLLER: Comair 1-91, Lexington tower.

Fly runway heading. Cleared for takeoff.

FIRST OFFICER POLEHINKE: Ugh.

CAPTAIN CLAY: Runway heading, cleared for takeoff, 1-91.

FIRST OFFICER POLEHINKE: Anti-ice off, lights set,

takeoff config's okay, lineup checks completed.

CAPTAIN CLAY: All yours, Jim.

NARRATOR: Captain Clay hands control of the aircraft

to First Officer Polehinke for takeoff.

FIRST OFFICER POLEHINKE: My brakes, my controls.

Set thrust, please.

CAPTAIN CLAY (off screen): Thrust set.

FIRST OFFICER POLEHINKE: That is weird with no lights.

CAPTAIN CLAY: Yeah.

A hundred knots.

FIRST OFFICER POLEHINKE: Checks.

NARRATOR: Something’s not right...

CAPTAIN CLAY: V-1. Rotate.

NARRATOR: ...as 5191 prepares to lift off.

CAPTAIN CLAY: Whoa!

FIRST OFFICER POLEHINKE: Damn it!

(passengers screaming)

(screaming continues)

NARRATOR: Comair Flight 5191 hurtles into a field,

less than half a mile from the runway.

CONTROLLER: This is Lexington.

Alert 3, west side of the runway

with a Comair Regional Jet taking off.

PETE MAUPIN: We knew something was wrong.

We never get an alert three. We never get one.

NARRATOR: Public Safety Officer Pete Maupin rushes to the scene.

MAUPIN: It’s hot. I mean it’s very hot.

There were explosions.

Can we save anybody?

That was what I was thinking when I saw this ball of fire.

NARRATOR: Forty-nine people are dead after the tragic takeoff

of Comair Flight 5191.

First Officer Polehinke is the only survivor.

PRUCHNICKI: The first responders’

quick actions were the reason that First Officer Polehinke

survived this accident.

He was so traumatically injured

that they recognized that time was of the essence

and transported him to the hospital

rather than waiting for an ambulance.

MAUPIN: And he thanked me for saving his life.

I told him that was my job.

But I was glad that I was there to do what I did.

And I told him that.

NARRATOR: The question NTSB investigators now need to answer

is why Comair Flight 5191 couldn’t get off the ground.

As soon as the fires are put out and the crash site is safe,

NTSB investigators begin looking for clues to discover

why Comair Flight 5191 crashed less than half a mile

from Lexington's Blue Grass airport.

SEDOR: Make sure every scrap is documented.

We need a clear picture of the path

this plane took before impact.

NARRATOR: Lead investigator Joe Sedor

is among the first to arrive at the crash site.

SEDOR: In this case, it was quite interesting because initially we didn't,

we didn't have much.

An airplane had crashed.

We didn't know if it was on the airport, off the airport.

We actually started at the,

the final resting place for the wreckage,

and then we walked back towards the airport.

The first impact point is there.

Then the plane hit those trees over there.

Those impact marks aren't more than 20 feet up those trunks.

BYRNE: We were looking at the trajectory of the airplane.

It clearly looked like it took off

just about the end of the runway and immediately started

contacting trees into the wreckage site.

NARRATOR: The wreckage path tells investigators

that the plane was struggling to get off the ground.

Was it engine trouble or something else?

SEDOR: It looks like they took off from runway 26.

Hang on.

26 wasn't in use last night.

NARRATOR: Lexington airport has two runways: runway 2-6 and runway 2-2.

SEDOR: According to the flight plan,

they were supposed to take off from Runway 22.

So how the heck did they end up over here?

NARRATOR: Investigators are surprised to discover that Flight 5191

took off from the wrong runway.

SEDOR: Well, at that point in time,

because we knew that it was a wrong runway takeoff,

the question is, is why, right?

And that's, and it’s one that, that doesn't make sense.

NARRATOR: Did they misunderstand their instructions

or deliberately change their plans to take off

from a different runway?

SEDOR: There's gotta be something on that CVR

about why they were on runway 26.

Get those to Washington.

The flight recorder and the cockpit voice recorder were retrieved

and flown back here to Washington, DC.

NARRATOR: But being on the wrong runway doesn't explain

why the plane barely made it off the ground.

SEDOR: Let’s take a closer look at those engines.

When the engines are examined,

what the investigator is looking for is damage.

The more damage that there is, and the type of damage,

tells us that if it was turning at high speed

or turning at a lower speed.

Yeah, they were spinning all right.

NARRATOR: Evidence of deformed blades

suggests the engines were running on impact.

SEDOR: All the indications were that

both engines were operating at high power

when the breakup sequence started.

There was no, no problem with the engines.

Something else must have kept them from getting airborne.

Maybe they were too heavy?

NARRATOR: With engine failure ruled out,

the team wonders if the plane was loaded with too much weight to take off.

SEDOR: There's a certain maximum weight that the aircraft can take off safely with

so what we do is we calculate the load

that's on the aircraft at the time of the accident.

BYRNE: Hmm. Ah, here it is.

The CRJ's max takeoff weight is 50,178 pounds.

SEDOR: And the load manifest said

the plane weighed 49,087 pounds on that day.

It's close, but its within their limit.

NARRATOR: The aircraft wasn’t too heavy to take off.

SEDOR (off screen): In that aircraft on that day at that weight,

how much runway would be needed to take off safely?

NARRATOR: Using the actual weight of the aircraft

and the CRJ 100 specifications,

investigators calculate how much runway

the plane needed to lift off.

PRUCHNICKI: The weight of the aircraft

affects how fast they have to be going to be able to lift off,

and that is directly correlated to how much runway it takes

to be able to achieve that speed.

BYRNE: 3,744 feet.

SEDOR: 3,744 feet.

And Runway 2-6 is...?

BYRNE: 3,501 feet.

NARRATOR: Investigators reach an astonishing conclusion.

SEDOR: Runway 2-6 is 243 feet too short.

They ran out of runway.

NARRATOR: They now understand why the plane couldn't get airborne.

But they’re still mystified.

Why didn’t flight 5191 take off from the longer runway?

BYRNE: I hate to say this,

but you’re not gonna get any answers

from the First Officer either.

His injuries are very severe.

NARRATOR: The First Officer is medically unfit to be interviewed.

It’s a big loss to the investigation.

BYRNE: It can be frustrating

when you’re not able to speak with people

that you'd like to speak with,

but as investigators, we need to work with the data that we have.

NARRATOR: Investigators look for other clues that might reveal why

Flight 5191 ended up on a runway they were not cleared to use.

SEDOR: All right, they left the gate here.

They taxi along here.

They’re supposed to leave from runway 2-2 here.

But they end up here.

The question is: Why?

So when we are looking into trying to understand

why this flight crew thought they were on runway 2-2,

we looked at anything that was different,

anything that the flight crew may have misunderstood

with regard to both the, the airport and the charts

or any of their training.

BYRNE: Hey, look at this.

Our guys got some shots of the runway.

Hey, check this out.

The taxiway to runway 2-2 was blocked off by construction.

PRUCHNICKI: There were numerous construction projects

that were in place at the Lexington Airport

the day of the accident.

SEDOR: Okay, sure, but wasn't that in their chart?

NARRATOR: Normally when a taxiway is closed,

pilots receive an interim airport chart

with an alternate route.

BYRNE: Nope. Nothing on the chart.

NARRATOR: Investigators are amazed to learn

that the crew’s airport chart

only showed the taxi route before construction,

not the updated taxi route.

SEDOR: It is a surprise to see that the airport construction

had not been updated in the charts

that the flight crew had.

NARRATOR: It’s a disturbing find.

Could out-of-date taxi charts

have misled the pilots into taking off from a runway

that was too short for their plane?

SEDOR (off screen): So they get out there

and they find their taxiways blocked

and they don't have anything to tell them

how to get to runway 2-2.

BYRNE: That could trip you up.

NARRATOR: But something doesn’t add up.

Comair Flight 5191 wasn’t the only plane

departing Lexington that morning.

SEDOR: Other planes left before them

and none of them ended up on runway 2-6.

CONTROLLER: Eagle flight runway two-two,

cleared for takeoff.

SEDOR: The other two flights took off prior to 5191,

received the same information

that the flight crew from 5191 received

and did not have any difficulties

in navigating to the runway.

BYRNE: The fact that two other aircraft were able to depart successfully

that morning caused us to look deeper.

Maybe there’s something on the security footage.

NARRATOR: Investigators turn their attention to CCTV footage

in the hopes that it will explain

why Comair 5191 took off from the wrong runway.

PRUCHNICKI: We were able to retrieve

security footage from cameras on the parking garage

that showed our aircraft taxiing out that morning.

BYRNE: All right. Let’s see what they were actually up to.

NARRATOR: Investigators quickly confirm

how straightforward the taxi route was.

SEDOR: The taxi is short

and there’s not another aircraft in sight.

BYRNE: Our assessment based on examination of surveillance video

showed that it was a nominal taxi.

The taxi route from the ramp

to runway two-two was straightforward

and only required one runway crossing, two-six.

SEDOR: Wait. Stop it right there.

It looks like they’ve stopped at the hold short line for runway 26.

NARRATOR: Before takeoff, planes stop, or hold short of the runway

until they’re cleared to proceed by air traffic control.

BYRNE: Well they were on their way to runway 22.

Why the heck would they stop there?

NARRATOR: Investigators are startled by the discovery.

SEDOR: We noticed, at that time,

that the aircraft had stopped prior to runway 2-6,

for over fifty seconds.

This is unusual,

because there was no real reason for them to stop there.

(sighs)

We need to see the taxi route.

BYRNE: All right.

NARRATOR: Were there clues telling the pilots

they were in the wrong place?

BYRNE: One of our main questions

when we realized that they stopped for 50 seconds

at the hold short line for runway two-six was:

What could they have been seeing?

NARRATOR: To better understand why the pilots of Comair flight 5191

stopped at the hold short line for the wrong runway...

BYRNE: All right, let's get started.

NARRATOR: ...investigators retrace their taxi route.

SEDOR: We wanted to understand what the flight crew was seeing.

In order to do that, we had to do a taxi demonstration

to identify all the signage, the markings,

and the cues available to the flight crew.

BYRNE: There on the left there’s a sign for Runway 26.

Straight ahead, I can see the hold short line

for Runway 26. I mean it’s as clear as day.

Things that we’re looking for during that taxi demo

were things like the quality of the markings on the taxiway,

the signage, whether it was illuminated or not.

The taxi lines splits three ways.

NARRATOR: Investigators can see what the pilots

would have seen from the hold short line for runway 2-6.

The line on the left goes to runway 2-6.

The line in the middle is the route to runway 2-2.

The line on the right is runway 2-2’s old taxi route

blocked by barricades.

BYRNE: I can clearly see the signs

telling us that we’re at the hold short line

for runway 26.

I mean it’s hard to miss that.

NARRATOR: Investigators discover that the crew had clear cues

that they were at the hold short line for runway 2-6, not 2-2.

The question remains, how did they miss those cues?

BYRNE: Okay. Let’s go to 26.

NARRATOR: The test plane follows the line on the left to runway 2-6.

BYRNE: Okay. See?

That’s where they should have taken the taxi route,

stopped at the hold short line for runway 22.

NARRATOR: Investigators are surprised to learn that

even as Flight 5191 was turning onto Runway 2-6,

the crew had a clear view of the sign

pointing to the runway they were meant to be on.

BYRNE: There were no features in the environment

in terms of the signs, marking or lighting

that showed they were on runway 2-2.

All the cues are right there in plain sight.

NARRATOR: Joe Sedor then uncovers one more disturbing fact.

SEDOR: When we taxied

from the taxiway onto... and turned onto runway 2-6,

all of the, the lights on runway 2-6 were out

and there was no lights in the distance.

As an experienced pilot, I look at that and say:

Why did this flight crew take off from this runway?

BYRNE: We need to know what was going on in that cockpit.

FIRST OFFICER POLEHINKE: That is weird with no lights.

CAPTAIN CLAY: Yeah.

NARRATOR: The cockpit voice recorder from Comair flight 5191

is finally ready to be reviewed.

SEDOR: Okay, let’s hear what we've got.

NARRATOR: It may be the only hope of explaining

why the crew ended up on an out-of-service runway

instead of the one they were cleared to use.

SEDOR: In this type of human factors accident,

it’s very difficult because we have to try to determine

what the pilots were thinking.

The main tool that we use in order to determine that

is the cockpit voice recorder.

The CVR was very important in understanding

what the flight crew was talking about

and what they were doing during the taxi and the takeoff.

CAPTAIN CLAY: Are you up for flying this leg?

FIRST OFFICER POLEHINKE: I'll take us to Atlanta.

BYRNE: Okay, so the first officer is gonna fly.

That’s standard stuff.

SEDOR: The flight crew were conducting themselves in a professional manner.

CAPTAIN CLAY: For our own briefing,

Comair standard. Run the checklist, your leisure.

Keep me out of trouble. I'll do the same for you.

FIRST OFFICER POLEHINKE: I'll do the same.

Whenever you’re ready.

SEDOR: Okay, here comes the taxi brief.

FIRST OFFICER POLEHINKE: Right seat flex takeoff

procedures off of... he said what runway? Two-four?

CAPTAIN CLAY: It’s two-two.

FIRST OFFICER POLEHINKE (off screen): Two-two.

The ILS is out on 2-2.

Came in the other night,

the runway identifier lights were out all over the place.

CAPTAIN CLAY: All right.

FIRST OFFICER POLEHINKE: Two-two's a short taxi. Any questions?

CAPTAIN CLAY: No questions before starting.

At your leisure.

NARRATOR: Something in the briefing surprises investigators.

SEDOR: Wait. Stop it right there.

Is that not a short brief to you?

NARRATOR: They discover that the crew used an abbreviated version

of the taxi brief called Comair Standard.

SEDOR: Pull up the Comair Standard Taxi Brief.

There’s no mention of crossing runways

or stopping to call ATC

if they’re unsure of where they are.

NARRATOR: Investigators are baffled to discover

that even the shortened taxi brief with 8 check list items,

including a very crucial one, wasn’t followed.

BYRNE: Yeah, they never briefed

on the runway they had to cross to get to runway 22.

The crew’s abbreviated briefing that morning

was a deviation from standard operating procedures that we identified.

NARRATOR: Had the crew done a full taxi briefing,

they would have discussed the need

to cross runway 2-6 on the way to 2-2.

BYRNE: They missed an opportunity

to review the airport diagram

and determine that they needed to cross runway two-six,

an intervening runway,

before they reached runway two-two.

SEDOR: Okay. Let’s hear their Taxi Checklist.

FIRST OFFICER POLEHINKE: Flight controls.

CAPTAIN CLAY: Check left.

FIRST OFFICER POLEHINKE: On the right -- trims.

CAPTAIN CLAY: Engage zero-seven-point-two.

FIRST OFFICER POLEHINKE: Radar terrain displays.

All taxi checks complete.

CAPTAIN CLAY: Finish up the Before Takeoff checklist,

your leisure.

SEDOR: One other thing on the CVR we heard was the captain using the term,

at your leisure."

It was used so many times on the CVR.

What this told us is that this flight crew was relaxed.

Maybe they were a little bit too relaxed.

FIRST OFFICER POLEHINKE: Yeah, I know three guys at Kennedy...

or actually two guys.

One went but he didn’t get through the Sims.

CAPTAIN CLAY: Oh, really?

FIRST OFFICER POLEHINKE: And then a first officer from Cincinnati,

he got through the second part, and that’s as far as he got.

SEDOR: Stop it right there.

NARRATOR: Investigators cannot believe what they’re hearing.

SEDOR: What the heck is he talking about?

NARRATOR: Instead of focusing on their checklists,

the crew of 5191 were having a casual conversation

during a critical moment.

It’s a major breach of what’s called the Sterile Cockpit rule.

BYRNE: The sterile cockpit rule

requires that pilots refrain

from non-operational conversation

during significant portions of flight.

One of the key reasons for the sterile cockpit rule

is that non-pertinent conversation can be distracting.

FIRST OFFICER POLEHINKE: And that's as far as he got

and then he actually got offered the position.

CAPTAIN CLAY (off screen): Did he take it or...?

FIRST OFFICER POLEHINKE: Yeah, he took it.

CAPTAIN CLAY: Ah. Okay.

SEDOR: The captain should be shutting

this conversation down, not encouraging it.

BYRNE: Although the first officer started the conversation,

the captain is responsible for ensuring

that the sterile cockpit rule is enforced and distractions

do not enter the cockpit

that could affect the safety of flight.

NARRATOR: After forty seconds of casual conversation...

FIRST OFFICER POLEHINKE: Second engine started.

Anti-ice probes. Windshield low.

NARRATOR: ...investigators hear the pilots

turn to their takeoff checklist.

SEDOR: Now they finally get back to their jobs.

We were surprised by that,

that non-pertinent conversation was in a critical area

when the flight crew was making their taxi

out to the runway where the flight crew

needs to be a hundred percent flying the aircraft.

NARRATOR: Could that period of inattention

hold the key to this tragic accident?

SEDOR: Okay.

Let’s see what we’ve got so far.

NARRATOR: Investigators wonder if a casual conversation

is at the heart of the crash of Comair Flight 5191.

SEDOR: They skipped out of their briefing that would have told them

they needed to cross 26 to get to 22.

Then for almost a minute,

they violate the sterile cockpit rule.

Let’s see what happens when they get here.

NARRATOR: Investigators hope the crew will give some indication

why they stopped at the hold short line for runway 2-6.

FIRST OFFICER POLEHINKE (off screen): Thrust reversers are armed.

Auto crossflow is manual. Ignition is off.

Altimeters are three triple zero across the board.

Crosschecked. I’ll check in with the cabin.

SEDOR: That’s it?

BYRNE: It was surprising to us

that there was no conversation about their location

on the airfield or confusion about it

while they were holding short on runway 2-6.

SEDOR: We know they were distracted

but when they stop their chit chat,

they don't seem to recognize, know or check where they are.

BYRNE: We got no information

based on the conversation of the flight crew

while they were holding short

that they were disoriented.

No indications at all.

NARRATOR: Investigators are amazed by what they hear next.

FIRST OFFICER POLEHINKE: At your leisure,

Comair 1-21 ready to go.

CONTROLLER: Comair 1-91, Lexington tower.

Fly runway heading. Cleared for takeoff.

FIRST OFFICER POLEHINKE: Ugh.

BYRNE: Hold there.

So they’re completely relaxed when they ask for clearance.

In fact, so relaxed or distracted

that the first officer uses the wrong flight number.

NARRATOR: Investigators realize the grim truth.

BYRNE: These guys actually thought

they were lined up for runway 22.

The fact that they stopped at runway two-six

and subsequently called for takeoff

indicates that they lost awareness

that they had not crossed runway two-six.

SEDOR: They turn onto runway 26.

Then what? Keep going.

FIRST OFFICER POLEHINKE: Lineup check is completed.

CAPTAIN CLAY: All yours, Jim.

SEDOR: The first officer takes the controls.

So he’s looking ahead, probably for the first time.

At this time,

the captain taxied the aircraft out onto the runway

and then transferred controls to the first officer.

So before this time,

the first officer was heads-down in the cockpit.

FIRST OFFICER POLEHINKE: My brakes. My controls.

BYRNE: When the first officer looked out, he saw a runway.

He may not have perceived that it was a narrower runway

than runway 2-2.

SEDOR: They’re looking down runway 26.

Why don't they see the sign for 22 off to the right?

BYRNE: Neither pilot cross-checked

their location at the time that they took the runway.

FIRST OFFICER POLEHINKE: Set thrust, please.

CAPTAIN CLAY: Thrust set.

FIRST OFFICER POLEHINKE: That is weird with no lights.

CAPTAIN CLAY: Yeah.

SEDOR: Hold on.

Runway 26 is not in use, so it’s not lit.

They see the lights for 22, until they cross it.

They’re looking down a pitch-dark runway

and it doesn’t faze them.

NARRATOR: Investigators wonder if the pilots were confused

about what the runway should have looked like.

BYRNE: When they began the takeoff roll on runway two-six,

they had no centerline lights or edge lights on this runway.

However, based on the first officer’s

previous experience of the night before,

he did not expect to see lights.

FIRST OFFICER POLEHINKE: The ILS is out on 2-2.

Came in the other night,

the runway identifier lights were out all over the place.

BYRNE: And so it would not necessarily

have been an unusual sight picture.

NARRATOR: Such decision making based on a person’s mistaken assessment

is called confirmation bias.

SEDOR: Confirmation bias is where

the flight crew expects something to be there,

even though it might not actually be there.

He noticed that there was no lights on the runway,

but he just accepted the fact.

What happens next?

CAPTAIN CLAY (off screen): 100 knots.

FIRST OFFICER POLEHINKE (off screen): Checks.

NARRATOR: The pilots now see they’re almost out of runway...

CAPTAIN CLAY: V-1. Rotate!

NARRATOR: ...and don’t have the required speed to get airborne.

CAPTAIN CLAY: Whoa!

FIRST OFFICER POLEHINKE: Damn it!

(static)

SEDOR: That’s it?

They finally realize something’s wrong and it’s too late.

BYRNE: Based on our calculations,

the crew needed to recognize

that they were on the wrong runway

and successfully reject the takeoff

about 20 seconds into the takeoff roll.

However, their recognition did not occur until much later

when the captain called rotate at a lower speed

than what was required.

NARRATOR: Investigators have unraveled the mystery

of what happened inside the cockpit of flight 5191.

SEDOR: They started by skipping the full briefing.

And then after a long discussion about their airline,

they lose sight of where they are.

They stop at the wrong place,

and they completely miss all the signage

that they’re at the wrong runway.

By the time they figure out their mistake, it’s too late.

These guys were going through the motions

when they should have been at full attention.

NARRATOR: The crew’s failure to use available cues and aids

to identify and check the plane’s location...

led to the tragedy of Comair Flight 5191.

But the team still has one unanswered question.

SEDOR: Why didn’t the controller

tell them they were at the wrong runway?

NARRATOR: Investigators wonder if the air traffic controller

of Comair Flight 5191

could have picked up the crew’s error

and prevented the accident.

CONTROLLER: I’m happy to answer any questions.

BYRNE: With the air traffic controller, we were trying to understand:

Did the controller have an opportunity

to see this airplane take the wrong runway

and prevent the accident?

CONTROLLER: At 06:05,

they asked for takeoff clearance.

Runway 2-2 was free, so I gave Comair clearance for takeoff.

FIRST OFFICER POLEHINKE: At your leisure, Comair 1-21,

ready to go.

CONTROLLER: Comair 1-91, Lexington tower.

Fly runway heading. Cleared for takeoff.

FIRST OFFICER POLEHINKE: Runway heading.

Cleared for takeoff. 1-91.

NTSB INVESTIGATOR: And what did you do next?

CONTROLLER: I saw the plane proceed towards runway 2-6,

and then scanned runway 2-2

to make sure there were no vehicles on it.

NTSB INVESTIGATOR: Did you watch the flight take off?

CONTROLLER: Not if I have other jobs to do.

NARRATOR: Investigators make one final discovery.

CONTROLLER: And then I turned over here

to count my flight strips.

NTSB INVESTIGATOR: And why would you start counting your strips then?

CONTROLLER: I wasn't busy,

and it only takes a few minutes.

And there was no reason to think that they’d have any problems.

In 17 years, I’ve never seen a plane

that size try to take off from runway 2-6.

SEDOR: The controller was not watching the airplane

and assumed that the airplane was going

to take off on the correct runway,

because this is such a simple airport,

and because there was no other traffic on the airport

at the time of the accident.

NTSB INVESTIGATOR: And if you hadn't turned away,

would you have noticed that they were in the wrong place?

CONTROLLER: I might have.

NARRATOR: FAA regulations do not require controllers to monitor every takeoff.

But if the controller had been watching the runway

instead of counting flight strips,

he might have noticed Flight 5191’s mistake.

PRUCHNICKI: He was not actually required,

nor are any controllers required

to actually watch an aircraft during its takeoff roll.

Had they been required to do that,

this would have given an opportunity

to have the takeoff aborted.

NARRATOR: The NTSB concludes that several factors led the pilots

to lose track of their position on their way to the runway.

SEDOR: Contributing to that, was the flight crew’s,

uh, failure to maintain sterile cockpit

and to have a non-pertinent conversation prior to takeoff.

BYRNE: This crash happened because of a period of distraction

during what was perceived as a relatively simple taxi.

And it illustrates the perils of distraction

in that it can take you off task.

It can cause you to lose awareness.

And in this case, both crew members lost awareness

of where they were on that airport surface

and made a mistake that was extremely consequential.

NARRATOR: Among the NTSB’s recommendations is a basic technological change

to prevent pilots from getting lost.

The CRJ-100 at the time had sophisticated avionics,

but it lacked a simple GPS system available in cars of the same era.

SEDOR: Install moving map GPS displays

in CRJ-100 cockpits.

NARRATOR: The NTSB also makes recommendations for flight crews.

SEDOR: Require pilots to check

that they are at their assigned runway

before crossing the hold short line.

NARRATOR: First Officer James Polehinke,

the lone survivor of Comair Flight 5191,

suffered severe injuries,

including the loss of his left leg.

He never returned to commercial aviation.

BYRNE: This was a catastrophic accident.

It affected scores and scores of lives.

But the legacy of this accident are the safety changes

that have been made to prevent this type of accident

from happening in the future.

SEDOR: This accident shows that there

are threats in any environment, no matter how docile they seem,

and that flight crews have to be aware

and have to be looking for all the threats at all the time.

Captioned by Point.360