Comair Flight 5191: What Went Wrong? A Comprehensive Analysis of Aviation’s Critical Safety Lessons

On August 14, 2006, Comair Flight 5191 crashed shortly after takeoff from Blue Grass Airport in Lexington, Kentucky, claiming 49 of the 50 people aboard. This tragic accident remains one of the most significant aviation disasters in recent American history, serving as a sobering reminder of how multiple failures in communication, procedure, and airport infrastructure can converge catastrophically. Understanding what happened that morning requires examining the complex chain of events that led to the aircraft attempting to depart from an incorrect runway.

The Bombardier CRJ-100 regional jet was scheduled to operate a flight to Atlanta when the crew made a fateful decision that would change aviation safety protocols forever. This analysis explores the technical, human, and systemic factors that contributed to this preventable tragedy, examining how even experienced crews can become vulnerable to error when standard procedures break down.

The Flight and Initial Circumstances

Comair Flight 5191 was a Delta Connection flight operated by Comair, a regional carrier that provided service to smaller markets across the United States. The aircraft, a Bombardier CRJ-100, was a 50-seat regional jet that had been in service since 1992. The captain, Jeffrey Clay, had over 20 years of flying experience and approximately 3,100 hours in the CRJ aircraft. The first officer, James Polehinke, was less experienced but still held a valid commercial pilot license with approximately 3,500 total flight hours.

On that fateful morning, the crew arrived at Blue Grass Airport in Lexington to operate what would be a routine regional flight to Hartsfield-Jackson Atlanta International Airport. Blue Grass Airport, also known as Lexington Blue Grass Airport (LEX), is a medium-sized regional airport that serves the Lexington, Kentucky area. The airport has two parallel runways: Runway 22L (the longer runway at 10,000 feet) and Runway 22R (a shorter runway at 8,000 feet). Both runways were available for departure that morning, and the crew would need to determine which runway to use based on weather conditions and air traffic control clearances.

Before departure, the crew conducted standard preflight checks and briefings. They reviewed weather conditions, fuel requirements, and flight plan details. The weather at Lexington that morning was relatively clear with good visibility, so neither runway presented significant weather-related challenges. However, the airport’s layout would prove to be the critical factor in the tragedy that followed.

Runway Confusion: The Critical Error

The fundamental error that led to the crash was the crew’s decision to use Runway 22R instead of the assigned Runway 22L. This mistake, while seemingly simple, had catastrophic consequences because Runway 22R was significantly shorter and was not suitable for a loaded regional jet attempting to depart. The crew never received explicit clearance to use Runway 22R from air traffic control, yet they proceeded with their departure from this runway.

What makes this error particularly significant is that it occurred despite multiple opportunities for correction. The crew should have noticed during their approach to the runway that they were on the shorter runway. Standard operating procedures require pilots to verify runway length and confirm that the runway is appropriate for their aircraft type and weight. In this case, Runway 22R was only 8,000 feet long, while a fully loaded CRJ-100 typically requires closer to 8,500 to 9,000 feet for safe departure, depending on weather conditions and aircraft weight.

The NTSB investigation revealed that the crew likely became confused about which runway they were approaching due to poor signage and the parallel nature of the runways. Blue Grass Airport’s runway identification signs and markings, while meeting FAA standards, were not as prominent or clear as they could have been. The two parallel runways were close enough together that from certain angles and distances, it could be challenging to distinguish which runway was which, especially under low-light conditions or when attention was divided.

The captain, who was the pilot in command, made the decision to proceed with takeoff from Runway 22R. This decision appears to have been influenced by several factors: potential fatigue, time pressure to depart, and the lack of a clear recognition that they were on the wrong runway. The first officer, despite his less experienced status, did not effectively challenge this decision, which represents a failure in crew resource management (CRM)—a critical safety concept that emphasizes the importance of all crew members speaking up when they notice potential problems.

Communication Breakdowns in the Cockpit

Effective communication within the cockpit is one of the most fundamental safety principles in aviation. The Comair Flight 5191 accident highlighted significant failures in this critical area. While the crew was in communication with air traffic control, there appears to have been inadequate internal communication and verification between the captain and first officer regarding runway assignment.

The captain did not explicitly confirm the runway assignment with the first officer, nor did the first officer verify the runway selection with the captain. This lack of verification is contrary to standard operating procedures that require cross-checks of critical flight parameters. In many airlines, procedures call for both pilots to independently verify runway information and then confirm it with each other before proceeding.

Additionally, the crew did not request a progressive taxi from air traffic control, which would have provided step-by-step guidance to the correct runway. This is a common procedure at airports with multiple parallel runways, particularly when visibility is reduced or when crews are unfamiliar with the airport. The crew’s failure to request this assistance represents a missed opportunity for ground-based intervention.

The relationship between the captain and first officer also appears to have played a role. The first officer may have been hesitant to challenge the captain’s decisions due to the traditional hierarchical structure of cockpit authority. Modern aviation training emphasizes that all crew members have a responsibility to speak up when they identify safety concerns, regardless of rank. However, this cultural change takes time to implement fully across the industry, and in 2006, some crews may not have fully embraced this principle.

Airport Infrastructure and Design Flaws

While the crew’s errors were the immediate cause of the accident, the NTSB investigation also identified significant deficiencies in the airport’s infrastructure and design that contributed to the confusion. Blue Grass Airport’s runway identification system, while meeting minimum FAA standards, was inadequate for preventing this type of error.

The runway designation signs at Blue Grass were not as large, bright, or clearly visible as they could have been. The parallel runways were positioned close enough together that pilots approaching them could easily become confused about which runway they were approaching. The airport lacked some of the visual aids that larger airports use, such as enhanced lighting systems or prominent runway edge markings that would make runway selection unmistakable.

Furthermore, the airport’s taxiway system was configured in a way that made it possible for the crew to reach Runway 22R without receiving a specific clearance from air traffic control. In many modern airports, taxiway design prevents aircraft from accessing runways without explicit clearance, but this level of design sophistication was not present at Blue Grass Airport.

The NTSB recommendations following this accident included improvements to runway identification systems at airports with parallel runways. These recommendations have led to enhanced signage, improved lighting, and better markings at many regional airports across the United States. The accident demonstrated that airport infrastructure plays a crucial role in preventing runway confusion accidents, and that minimum standards are not always sufficient to ensure safety.

The Crash and Immediate Aftermath

As the Comair Flight 5191 crew advanced the throttles for takeoff on Runway 22R, they began their takeoff roll at approximately 6:07 AM local time. The crew did not immediately recognize that they were on the shorter runway, and by the time they realized the critical situation, it was too late to abort the takeoff safely.

The aircraft accelerated down the 8,000-foot runway, consuming runway length at an alarming rate. As the crew attempted to rotate the aircraft for flight, they realized they were running out of runway. The aircraft became airborne briefly but could not gain sufficient altitude to clear the terrain beyond the runway. Just after 6:07 AM, the CRJ-100 struck a stand of trees at the end of Runway 22R and crashed, coming to rest approximately 1,000 feet beyond the runway threshold.

The impact was catastrophic. The aircraft broke apart on impact, and a post-crash fire ensued. Of the 50 people aboard—47 passengers and 3 crew members—49 perished in the accident. The sole survivor was the first officer, James Polehinke, who suffered severe injuries but was rescued from the wreckage. The loss of life made this one of the deadliest aviation accidents in recent U.S. history and the deadliest aviation accident in Kentucky.

Emergency responders arrived at the scene within minutes, and rescue efforts continued throughout the morning. The severity of the impact and resulting fire limited the possibility of additional survivors. The crash site was immediately secured, and investigation of the wreckage began under the direction of the National Transportation Safety Board (NTSB).

Investigation Findings and Contributing Factors

The NTSB investigation into Comair Flight 5191 was comprehensive and thorough, involving hundreds of investigators, engineers, and specialists. The investigation examined the aircraft, cockpit voice recordings, flight data, weather conditions, crew training records, and airport operations. The findings identified multiple contributing factors to the accident.

Primary Cause: The fundamental cause was the crew’s decision to attempt takeoff from Runway 22R instead of the assigned Runway 22L. The crew failed to verify that they were on the correct runway before advancing the throttles for takeoff.

Contributing Factors:

• Inadequate runway identification systems at Blue Grass Airport, including insufficient signage and lighting
• Failure of the crew to request progressive taxi instructions from air traffic control
• Lack of effective crew resource management and communication between the captain and first officer
• Possible fatigue or distraction affecting the crew’s situational awareness
• The proximity and similarity of the two parallel runways, which made confusion possible
• Inadequate training on runway identification procedures specific to airports with parallel runways

The NTSB determined that this was a preventable accident. Every one of the contributing factors represented an opportunity for intervention that was missed. If any one of these factors had been addressed differently, the accident likely would not have occurred.

Safety Improvements and Industry Response

The Comair Flight 5191 accident prompted significant safety improvements across the aviation industry. The NTSB issued multiple recommendations directed at the FAA, airlines, and airport operators. These recommendations have been largely implemented and have contributed to preventing similar accidents.

FAA Regulations and Guidance: The FAA issued new guidance requiring enhanced runway identification systems at airports with parallel runways. This included requirements for larger, more visible runway designation signs, improved lighting, and better taxiway markings. The FAA also strengthened requirements for progressive taxi instructions at airports where runway confusion is a known risk.

Airline Training Programs: Airlines enhanced their training programs to emphasize runway identification procedures, particularly at airports with parallel runways. Training now includes specific emphasis on the importance of verifying runway assignments and the critical nature of crew communication. Many airlines implemented mandatory callouts for runway verification before takeoff.

Cockpit Procedures: Airlines updated standard operating procedures to require explicit verification of runway assignment by both the captain and first officer before takeoff. This includes reading back runway information and confirming that the runway is appropriate for the aircraft type and weight. Enhanced crew resource management training emphasizes that all crew members have a responsibility to speak up about safety concerns.

Airport Infrastructure: Airports across the country upgraded their runway identification systems. Many installed enhanced lighting systems, larger signs, and improved markings. Some airports implemented electronic systems that prevent aircraft from taxiing to the wrong runway without explicit clearance from air traffic control.

These improvements represent a significant investment in aviation safety and demonstrate the industry’s commitment to preventing runway confusion accidents. The tragic loss of life in the Comair Flight 5191 accident has contributed to making commercial aviation safer for millions of passengers.

Lessons for Air Travel Safety

The Comair Flight 5191 accident provides important lessons for aviation safety professionals, pilots, air traffic controllers, and anyone interested in transportation safety. These lessons extend beyond aviation and apply to many safety-critical industries.

The Importance of Verification: Critical decisions, especially those involving safety, must be verified through independent checks. The crew’s failure to verify runway assignment was the immediate cause of the accident. In aviation and other industries, procedures that require verification help prevent human error from cascading into disasters.

Communication is Paramount: Effective communication within teams is essential for safety. The accident highlighted the importance of cockpit resource management and the need for all team members to feel empowered to speak up about concerns. Modern aviation training emphasizes that hierarchy should never prevent a crew member from raising a safety issue.

Infrastructure Matters: Physical design and infrastructure play a critical role in safety. While human error was the immediate cause of this accident, the airport’s infrastructure deficiencies contributed to the confusion. Well-designed systems can prevent errors from occurring in the first place, or can catch errors before they result in accidents.

Continuous Improvement: The aviation industry’s response to this accident demonstrates the importance of learning from accidents and continuously improving safety systems. The recommendations implemented following this accident have made commercial aviation safer for everyone.

If you’re planning Houston to NYC flights or considering flights Phoenix Las Vegas, you can take comfort knowing that the aviation safety improvements implemented since 2006 have made regional airports significantly safer. Similarly, travelers booking Chicago to Houston flights benefit from these enhanced safety protocols. For those interested in best travel destinations for couples or best ski destinations for beginners, commercial aviation has never been safer. Alternatively, some travelers prefer best train journeys in Europe for their transportation needs.

The memory of those lost in the Comair Flight 5191 accident serves as a reminder of why safety must always be the top priority in aviation. The improvements made since 2006 represent a commitment to ensuring that such tragedies do not occur again.

FAQ

What exactly caused Comair Flight 5191 to crash?

The aircraft attempted takeoff from the wrong runway (Runway 22R instead of Runway 22L) at Blue Grass Airport in Lexington, Kentucky. Runway 22R was too short for the loaded aircraft to safely depart. The crew failed to verify the runway assignment before takeoff, and the airport’s inadequate runway identification systems contributed to the confusion. The aircraft ran out of runway, struck trees at the runway’s end, and crashed.

How many people died in the Comair Flight 5191 crash?

Forty-nine of the 50 people aboard the aircraft perished in the crash. This included all 47 passengers and two of the three crew members. The sole survivor was the first officer, James Polehinke, who suffered severe injuries. The crash remains one of the deadliest aviation accidents in recent U.S. history.

What changes were made to prevent similar accidents?

Following the accident, the FAA implemented enhanced runway identification systems at airports with parallel runways, including larger signs, improved lighting, and better markings. Airlines strengthened training programs emphasizing runway verification procedures and crew resource management. Standard operating procedures now require explicit verification of runway assignment by both pilots before takeoff. Many airports also upgraded their taxiway systems to prevent unauthorized runway access.

Was pilot error the sole cause of the accident?

While pilot error was the immediate cause, the NTSB investigation identified multiple contributing factors, including inadequate airport infrastructure, poor runway identification systems, and insufficient crew communication. The accident resulted from a combination of human factors and systemic deficiencies. This demonstrates why modern aviation safety emphasizes not just training pilots, but also designing systems that prevent errors from occurring.

Is commercial aviation safer now than before this accident?

Yes, commercial aviation is significantly safer following the improvements implemented after the Comair Flight 5191 accident. The enhanced runway identification systems, improved training procedures, and better airport infrastructure have prevented numerous potential runway confusion accidents. The aviation industry’s commitment to learning from accidents and continuously improving safety systems has made commercial aviation one of the safest forms of transportation available.