July 27, 2007 | Mark Paradies

Comair Crash in Kentucky – Was the NTSB Investigation a Good Root Cause Analysis?

 Cnn 2007 Us 07 26 Comair.Crash.Ap Art.Comair.Ap

An AP Story at the CNN web site said the following:

Comair pilots’ failure to notice clues that they were heading to the wrong runway was the primary cause of last summer’s deadly Kentucky plane crash that killed 49 people, safety investigators concluded Thursday.

Pilot error caused the August 2006 crash of a Comair commuter plane in Kentucky, investigators have ruled.

The National Transportation Safety Board deliberated all day on possible causes of the August 27, 2006, crash of Comair Flight 5191, which tried to depart from the wrong runway — a general aviation strip too short for a proper takeoff.

Board members originally had considered listing errors by the air traffic controller as a contributing cause but ultimately pinned most of the blame on the pilots and the Federal Aviation Administration’s failure to enforce earlier recommendations on runway checks.

NTSB board member Deborah Hersman suggested during the meeting that there were numerous causes — nearly all of them human.

“That’s the frustration of this accident — no single cause, no single solution and no ‘aha’ moment,” Hersman said. “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.”

Is “pilot error” really a root cause? Should there be only one “root cause” for a major accident?

More from the article:

NTSB staff member Joe Sedor identified one possible overriding factor — unnecessary chatter between pilot Jeffrey Clay and first officer James Polehinke 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.”

Sedor said 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?”

Did the 40 seconds of conversation really cause the accident?

Ken Turnbull, a TapRooT® Instructor and experienced investigator of accidents (but not aviation accidents) will present his analysis of the crash at the 2008 Summit. If you would like to see how TapRooT® can be used to find the real root causes of a major accident, attend Ken’s talk.

Here is the link to the NTSB’s press release:


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