Accidents

COMAIR Flight 5191

Inaccurate (out of date) aerodrome charts led to take-off being attempted from the wrong runway. Aircraft overran the runway; 49 fatalities.

On 27th August 2006, Comair flight 5191 crashed during take-off from Blue Grass Airport, Lexington,  Kentucky. The flight crew was instructed to take-off from runway 22, but instead lined up on runway 26  and began the take-off roll. The airplane ran off the end of the runway and impacted the airport perimeter  fence, trees, and terrain. The captain, flight attendant and 47 passengers were killed.

The National Transportation Safety Board determined that the probable cause of the accident was the  flight crews’ failure to use available cues and aids to identify the airplane’s location on the airport surface  during taxi and their failure to cross-check and verify that the airplane was on the correct runway before  take-off.

The Airport Charts used by the crew were inaccurate. The airport was under construction, and the charts  were not kept current with the rapid changes that were taking place during the construction work. The  chart did not accurately reflect either the taxiway identifiers or a taxiway that was closed on the day of the  accident.

Due to a previously unrecognised software problem, any information the chart provider received after  normal work hours on Fridays was not included in their regular updates. Furthermore, the chart provider  modified the Blue Grass Airport chart after the accident to include a note that Runway 8/26 is “daytime  VMC use only”, even though this information had been published since 2001. Additionally there was a local  NOTAM issued advising of taxiway closures due to construction work. However the crew was not provided  with this information in their dispatch paperwork.

This incident highlights the importance of the timeliness Data Property, specifically with regards to the  charts. The completeness Data Property is also relevant, given that neither the “after hours” changes on  Fridays nor the local NOTAM were communicated appropriately.

Links 

• http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR07-05.pdf
  (accessed 29 November 2017).
• http://en.wikipedia.org/wiki/Comair_Flight_5191
  (accessed 29 November 2017).