Original subtitles

[Airplane Roaring]

[Narrator] On an early morning takeoff in Kentucky.

Hundred knots.

[James] Checks.

[Narrator] Two experienced pilots struggled to get

their regional jet off the ground.

V-1.

Rotate.

Whoa!

[Airplane Roaring]

[Narrator] And crash into a nearby field.

This was a catastrophic accident.

[Narrator] Investigators try to piece together

what went wrong.

Get those to Washington.

[Narrator] And end up with more questions than answers.

Why the heck would they stop there?

[Narrator] Only by retracing the taxi route.

All the cues are right there in plain sight.

[Narrator] And listening to the cockpit discussions.

-That is weird with no lights. -Yeah.

[Narrator] Do investigators discover the grim truth.

They finally realize something's wrong,

but it's already too late.

[Dramatic Music]

[Attendant] Ladies and gentlemen,

we are starting our approach.

[Pilot] We lost both engines.

[Attendant] Put the mask over your nose.

Emergency detect.

[Attendant] Brace for impact!

[Dramatic Music]

[Man] It's gonna crash!

[Dramatic Music]

[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,

and experienced pilot with more than 4,700 flying hours.

[Jeff Chuckling]

Man, I always feel like I could eat a little more

when I get a seatbelt like this. [Chuckling]

[Narrator] First Officer James Polehinke

is also a seasoned pilot, with more than 6,500 hours.

You up for flying this leg?

Yeah, I'll take us to Atlanta.

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 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.

[Shawn] 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.

Ladies and gentlemen, we'd like to take this time

to welcome you on board Comair flight 5191,

direct to Atlanta.

We'll try to keep it as quiet 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.

Right flex takeoff procedures off of?

He said what runway? 2-4?

It's 2-2.

[Shawn] Something that we do prior to takeoff 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.

Huh, on 2-2 the ILS is out.

Came in the other night,

the runway identifier lights were out all over the place.

All right.

2-2's your short taxi. Any questions?

No questions before starting. Your leisure.

[Narrator] In the cabin, passengers prepare for takeoff.

Seatbelt, please.

[Narrator] Today they are bound for Atlanta, Georgia,

just a 67-minute flight straight south

from Lexington's Blue Grass Airport.

Comair 1-91 is ready to taxi.

Comair 1-91, taxi to runway 2-2.

Altimeter 3-0-0-0.

Winds are 2-0-0 at eight.

[James] Three triple zero and taxi 2-2.

Comair 1-91.

[Narrator] Lexington's air traffic controller

clears flight 5191 to the runway,

and then turns his attention to another plane.

Eagle flight runway 2-2, 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.

[Shawn] During the taxi out,

the captain is responsible primarily for navigating

the aircraft on the airport surface.

[Airplane Humming]

The first officer is running numerous checklists

and verifying that the aircraft is safe for departure.

[James] Folks, we're gonna be underway momentarily.

So sit back, relax and enjoy the flight.

We're all ready in the cabin, sir.

Thank you.

Cabin reports received.

Before takeoff checks complete.

Ready.

All set.

At your leisure, Comair 1-21,

ready to go.

Comair 1-91, Lexington tower.

Fly runway heading.

Cleared for takeoff.

[James] Ugh.

Runway heading, cleared for takeoff, 1-91.

[Airplane Humming]

Anti-ice off, lights set, takeoff config's okay,

lineup checks completed.

All yours, Jim.

[Narrator] Captain Clay hands control of the aircraft

to First Officer Polehinke for takeoff.

My brakes, my controls.

[Airplane Whirring]

Set thrust, please.

[Jeff] Thrust set.

[Airplane Roaring]

[Dramatic Music]

That is weird with no lights.

Yeah.

[Airplane Roaring]

[Dramatic Music]

100 knots.

[James] Checks.

[Narrator] Something's not right.

V-1.

Rotate.

[Narrator] As 5191 prepares to lift off.

-[Airplane Rattling] -Whoa.

-[Dramatic Music] -[Airplane Roaring]

[James] Dammit!

[Airplane Roaring]

[Passengers Screaming]

[Airplane Roaring]

[Passengers Screaming]

[Narrator] Comair flight 5191 hurtles into a field

less than half a mile from the runway.

This is Lexington.

Alert three.

West side of the runway

with a Comair regional jet taking off.

[Suspenseful Music]

[Pete Maupin] We knew something was wrong.

We never get an alert three.

We never get one.

[Dramatic Music]

[Narrator] Public Safety Officer Pete Maupin

rushes to the scene.

It's hot. I mean, it's very hot.

[Dramatic Music]

There were explosions.

-[Saw Buzzing] -[Sirens Wailing]

Can we save anybody?

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

-[Dramatic Music] -[Flames Crackling]

[Sirens Wailing]

[Helicopter Whirring]

[Narrator] 49 people are dead after the tragic takeoff

of Comair flight 5191.

First Officer Polehinke is the only survivor.

[Shawn] 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.

[Pete] 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.

[Helicopters Whirring]

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.

Ensure 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.

In this case it was quite interesting because

initially 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 final resting place

for the wreckage,

and then we walked back towards the airport.

First impact point is there.

[Airplane Roaring]

And the plane hit those trees over there.

[Airplane Roaring]

Those impact marks are more than 20 feet up those trunks.

[Evan Byrne] We were looking at the trajectory of the airplane.

Clearly looked like it took off just about

the end of the runway,

and immediately started contacting trees

into the wreckage site.

[Soft Dramatic Music]

[Narrator] The wreckage path tells investigators

that the plane was struggling to get off the ground.

Was it engine trouble or something else?

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, then runway 2-2.

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.

[Joe] 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 doesn't make sense.

[Narrator] Did they misunderstand their instructions

or deliberately change their plans to take off

from a different runway?

There's gotta be something on that CVR about why

they were on runway 26.

Get those to Washington.

[Joe] The flight recorder and the cockpit voice recorder

were retrieved and flown back here to Washington D.C.

[Airplane Roaring]

[Narrator] But being on the wrong runway

doesn't explain why the plane barely made it off the ground.

[Airplane Roaring]

Let's take a closer look at those engines.

[Joe] 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.

[Joe] All the indications were that both engines

were operating at high power

when the breakup sequence started.

There was no problem with the engines.

[Engine Roaring]

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.

[Joe] 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.

Hmm.

Ah, here it is.

CRJ's max takeoff weight

is 50,178 pounds.

[Suspenseful Music]

And the load manifest said the plane weighed

49,087 pounds on that day.

It's close, but it's within their limit.

[Narrator] The aircraft wasn't too heavy to take off.

In that aircraft on that day with 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.

A 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.

3,744 feet.

3,744 feet.

And runway 2-6 is?

3,501 feet.

[Narrator] Investigators reach an astonishing conclusion.

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?

[Airplane Roaring]

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.

[Evan Sighing]

[Evan] 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.

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?

[Joe] So when we were looking into trying to understand why

this flight crew thought they are on runway 2-2,

we looked at anything that was different,

anything that the flight crew may have misunderstood

with regard to both the airport and the charts

or any of their training.

Hey, look at this.

Our guys got some shots of the runway.

Hey, check this out.

Taxi way to runway 2-2 was blocked off by construction.

[Shawn] There were numerous construction projects

that were in place at the Lexington airport

the day of the accident.

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.

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.

[Joe] 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?

So they get out there and they find

their taxi ways blocked.

And they don't have anything to tell them

how to get to runway 2-2.

That could trip you up.

[Narrator] But something doesn't add up.

Comair flight 5191 wasn't the only plane

departing Lexington that morning.

Other planes left before them

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

Eagle flight runway 2-2, cleared for takeoff.

[Joe] 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.

[Evan] The fact the two other aircraft were able to

depart successfully that morning

caused us to look deeper.

-[Airplane Roaring] -[Dramatic Music]

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 flight 5191 took off from the wrong runway.

[Airplane Roaring]

[Passengers Screaming]

[Suspenseful Music]

We were able to retrieve security footage from cameras

on the parking garage that showed our aircraft

taxiing out that morning.

All right, let's see what they were actually up to.

[Narrator] Investigators quickly confirm

how straightforward the taxi route was.

Taxi is short and there's no other aircraft in sight.

[Evan] Our assessment based on examination

of surveillance video showed that it was a nominal taxi.

The taxi route from the ramp to runway 2-2

was straightforward and only required

one runway crossing, 2-6.

Wait, stop it right there.

[Suspenseful Music]

It looks like they've stopped at the hold short line

for runway 26.

[Narrator] Before takeoff,

planes stop or hold short the runway

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

No, they were on their way to runway 22.

Why the heck would they stop there?

[Narrator] Investigators are startled by the discovery.

[Joe] We noticed at that time that the aircraft had stopped

prior to runway 2-6 for over 50 seconds.

This is unusual because there was no real reason

for them to stop there.

[Joe Sighing]

We need to see the taxi route.

All right.

[Narrator] Were there clues telling the pilots

they were in the wrong place?

[Evan] One of our main questions when we realized

that they stopped for 50 seconds at the hold short line

for runway 2-6 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.

All right, now let's get started.

[Narrator] Investigators retrace their taxi route.

[Evan Sighing]

We want 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.

[Suspenseful Music]

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 clear as day.

[Evan] Things that we're looking for during that taxi demo

were things like the quality of the markings

on the taxi way,

the signage, whether it was illuminated or not.

The taxi line 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.

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 discovered 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?

[Evan Sighing]

Okay, let's go to 26.

[Narrator] The test plane follows the line

on the left to runway 2-6.

Okay. See?

That's where they should have taken the taxi route

and stopped, 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.

There were no features in the environment

in terms of the signs, marking or lighting

that show they were on runway 2-2.

All the cues are right there in plain sight.

[Narrator] Joe Sedor then uncovers

one more disturbing fact.

When we taxied from the taxi way

and turned onto runway 2-6,

all of 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?"

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

[Dramatic Music]

That is weird with no lights.

Yeah.

[Narrator] The cockpit voice recorder

from Comair flight 5191 is finally ready to be reviewed.

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.

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.

[Jeff] Are you up for flying this leg?

[James] I'll take us to Atlanta.

Okay, so the first officer's gonna fly.

That's standard stuff.

The flight crew were conducting themselves

in a professional manner.

[Jeff] For our own briefing, Comair standard.

Run the checklist, your leisure.

Keep me out of trouble.

I'll do the same for you.

I'll do the same.

Whenever you're ready.

Okay, here comes the taxi brief.

[James] Right seat flex takeoff procedures off of?

He said what runway? 2-4?

That's 2-2.

2-2.

The ILS is out on 2-2.

Came in the other night,

the runway identifier lights were out all over the place.

[Jeff] All right.

2-2's your short taxi. Any questions?

[James] No questions before starting.

At your leisure.

[Narrator] Something in the briefing

surprises investigators.

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.

Pull up the Comair standard taxi brief.

[Suspenseful Music]

There's no mention of crossing runways

or stopping to call ATC if they're unsure where they are.

[Narrator] Investigators are baffled to discover

that even the shortened taxi brief

with eight checklist items,

including a very crucial one, wasn't followed.

Yeah, they never briefed on the runway

they had to cross to get to runway 22.

[Evan] 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.

They missed an opportunity to review the airport diagram

and determined that they needed to cross runway 2-6,

and intervening runway, before they reached runway 2-2.

Okay, let's hear their taxi checklist.

[James] Flight controls.

[Jeff] Check left.

[James] On the right, trims.

Engage 07.2.

Radar terrain displaced.

All taxi checks complete.

[Jeff] Finish up the Before Takeoff checklist,

your leisure.

[Joe] One other thing on the CVR we heard

was the captain using the term "at your leisure."

It was used so many times in the CVR.

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

Maybe they were a little bit too relaxed.

[James] Ah, yeah, I know three guys at Kennedy.

Actually two guys.

One went, but he did get through the Sims.

Oh, really?

[James] Then a first officer from Cincinnati,

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

Stop it right there.

[Narrator] Investigators cannot believe

what they're hearing.

What the heck is he talking about?

[Narrator] Instead of focusing on their checklists,

the crew of 5191 was having a casual conversation

during a critical moment.

It's a major breach of what's called

the sterile cockpit rule.

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.

[James] And that's as far as it got,

and then he actually got offered the position.

Did he take it or?

Yeah, he took it.

[Jeff] Oh, okay.

The captain should be shutting this conversation down,

not encouraging it.

[Evan] Although the first officer

started the conversation,

the captain is responsible for ensuring

that sterile cockpit rule's enforced

and distractions do not enter the cockpit

that could affect the safety of flight.

[Narrator] After 40 seconds of casual conversation.

[James] Second engine started.

Anti-ice probes. Windshield low.

[Narrator] Investigators hear the pilots turn

to their takeoff checklist.

Now they finally get back to their jobs.

[Joe] 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

100% flying the aircraft.

[Dramatic Music]

[Narrator] Could that period of inattention

hold the key to this tragic accident?

[Airplane Roaring]

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.

They skipped out of their briefing.

It 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.

Thrust reversers are armed.

Autocross flow is manual.

Ignition is off.

Altimeters are three triple zero across the board.

[James] Crosschecked.

I'll check in with the cabin.

That's it?

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.

We know they were distracted,

but when they stopped their chit-chat

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

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.

[James] At your leisure,

Comair 1-21 ready to go.

[Controller] Comair 1-91, Lexington tower.

Fly runaway heading. Cleared for takeoff.

Ugh.

Hold there.

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

They're so relaxed or distracted

that the first officer uses the wrong flight number.

[Narrator] Investigators realize the grim truth.

These guys actually thought they were lined up

for runway 22.

[Evan] The fact that they stopped at runway 2-6

and subsequently called for takeoff

indicates that they lost awareness

that they had not crossed runway 2-6.

They turn onto runway 26.

Then what?

Keep going.

[James] Lineup checks completed.

[Jeff] All yours, Jim.

First officer takes the controls.

So he's looking ahead

probably for the first time.

[Joe] 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.

My brakes, my controls.

[Evan] 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.

They're looking down runway 26.

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

[Evan] Neither pilot crosschecked their location

at the time that they took the runway.

[Airplane Whirring]

Set thrust, please.

Thrust set.

-[Airplane Roaring] -[Dramatic Music]

That is weird with no lights.

Yeah.

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 phase them.

[Narrator] Investigators wonder if the pilots

were confused about what the runway should have looked like.

[Evan] When they began the takeoff roll on runway 2-6,

they had no center line lights

or edge lights on this runway.

However, based on the first officer's previous experience

the night before,

he did not expect to see lights.

The ILS is out on 2-2. Came in the other night,

the runway identifier lights were out all over the place.

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.

Confirmation bias is where the flight crew

expects something to be there

even though it might not actually be there.

He noticed there was no lights on the runway,

but he just accepted the fact.

What happens next?

[Dramatic Music]

-[Jeff] 100 knots. -[James] Checks.

[Narrator] Pilots now see they're almost out of runway.

[Jeff] V-1. Rotate.

[Narrator] And don't have the required speed

to get airborne.

Whoa.

[Airplane Roaring]

[James] Dammit!

[Airplane Roaring]

[Transmission Static Crackling]

That's it.

They finally realize something's wrong

and it's too late.

[Evan] 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.

[Airplane Roaring]

[Narrator] Investigators have unraveled the mystery

of what happened inside the cockpit of flight 5191.

[Suspenseful Music]

They started by skipping the full briefing.

And then after a long discussion about the 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 the 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.

[Explosion Booming]

[Flames Crackling]

But the team still has one unanswered question.

Why didn't the controller tell them

they were at the wrong runway?

[Dramatic Music]

[Narrator] Investigators wonder

if the air traffic controller of Comair flight 5191

could have picked up the crew's error

and prevented the accident.

Happy to answer any questions.

[Evan] 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?

At 6:05 they asked for takeoff clearance.

Runway 2-2 was free,

so I gave Comair clearance for takeoff.

[James] At your leisure, Comair 1-21, ready to go.

Comair 1-91, Lexington tower.

Fly runway heading.

Cleared for takeoff.

[James] Runway heading. Cleared for takeoff, 1-91.

And what did you do next?

I saw the plane proceed towards runway 2-6,

and then scanned runway 2-2

to make sure there were no vehicles on it.

Did you watch the flight take off?

Not if I have other jobs to do.

[Narrator] Investigators make one final discovery.

And then I turned over here to count my flight strips.

And why would you start counting your flight strips then?

I wasn't busy.

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.

[Joe] 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.

And if you hadn't turned away,

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

I might've.

[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've noticed by 5191's mistake.

[Shawn] 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.

Contributing to that was the flight crews' failure

to maintain sterile cockpit

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

[Evan] This crashed 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 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.

Install moving map GPS displays in CRJ-100 cockpits.

[Narrator] The NTSB also makes recommendations

for flight crews.

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.

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.

[Joe] 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.

[Airplane Roaring]