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  • 6/19/2025

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00:00On an early morning take-off in Kentucky...
00:04100 knots. Checks.
00:06...two experienced pilots struggle to get their regional jet off the ground...
00:11B-1. Rotate.
00:13Whoa!
00:19...and crash into a nearby field.
00:21This was a catastrophic accident.
00:24Investigators try to piece together what went wrong...
00:27Get those to Washington.
00:28...and end up with more questions than answers.
00:31Why the heck would they stop there?
00:33Only by retracing the taxi route...
00:36All the queues are right there, in plain sight.
00:39...and listening to the cockpit discussions...
00:42That is weird with no lights.
00:43Yeah.
00:44...do investigators discover the grim truth.
00:47They finally realize something's wrong.
00:51But it's already too late.
00:53It's almost six in the morning in Lexington, Kentucky.
00:57It's almost six in the morning in Lexington, Kentucky.
01:04The pilots of Comair flight 5191 prepare for their pre-flight briefing.
01:19In command is Captain Jeff Clay, an experienced pilot with more than 4,700 flying hours.
01:38Man, I always feel like I could eat a little more when I get a seatbelt like this.
01:45First officer James Polhincke is also a seasoned pilot with more than 6,500 hours.
01:53You up for flying this leg?
01:55Yeah, I'll take us to Atlanta.
01:57Both the captain and their first officer were very highly regarded.
02:01Right seat flex, take off.
02:02They had an outstanding professional reputation...
02:04...and individuals that had flown with them had nothing but high marks...
02:07...and very, very favorable comments as far as their qualities.
02:10The crew is flying a Bombardier CRJ-100, a small twin-engine jet designed for short commuter flights.
02:24Sean Pruchnicki flew that aircraft for Comair for 10 years.
02:29The CRJ is an aircraft that's built for short-haul flights.
02:33For example, the Lexington to Atlanta, less than an hour-type flight...
02:36...is really what these airplanes are designed to do.
02:39Ladies and gentlemen, we'd like to take this time to welcome you onboard Comair flight 5191, direct to Atlanta.
02:49We'll try to keep it as quiet as possible, hopefully we can catch a nap on the way there.
02:53It's our pleasure having you onboard today.
02:56There are 47 passengers and one flight attendant on today's flight.
03:02The pilots begin their briefing.
03:08Bright Flex takeoff procedures off of...
03:11He said what runway? 2-4?
03:13It's 2-2.
03:15Something that we do prior to takeoff is we do a flight briefing between the two crew members.
03:20The primary reason we do this is to make sure that everyone has the same amount of information...
03:25...and knowledge to safely depart the airport.
03:27Well, 2-2, the ILS is out.
03:31You mean the other night?
03:32The runway identifier lights were out all over the place.
03:34All right.
03:362-2 is your short taxi.
03:38Any questions?
03:39No questions.
03:40Before starting, your leisure.
03:42No questions.
03:43No questions.
03:50In the cabin, passengers prepare for takeoff.
03:53See you, pal, please.
03:58Today, they are bound for Atlanta, Georgia, just a 67-minute flight straight south from
04:07Lexington's Bluegrass Airport.
04:11Comair 191 is ready to taxi.
04:14Comair 191, taxi to runway 22. Altimeter 3-0-0-0. Winds are 2-0-0 at 8.
04:243-0-0, taxi 2-2. Altimeter 191.
04:28Lexington's air traffic controller clears flight 5191 to the runway, and then turns his attention to another plane.
04:36Eagle flight runway 22, cleared for takeoff.
04:43With few planes at this small airport, in near-perfect weather, this flight is far from challenging for these seasoned pilots.
04:51During the taxi out, the captain is responsible primarily for navigating the aircraft on the airport surface.
05:03The first officer is running numerous checklists and verifying that the aircraft is safe for departure.
05:09Folks, we're going to be underway momentarily, so sit back, relax, and enjoy the flight.
05:20We're all ready in the cabin, sir.
05:22Cabinet reports received. Before takeoff check's complete, ready.
05:31All set.
05:33At your leisure, Comair 121, ready to go.
05:37Comair 191.
05:39Lexington Tower. Fly runway heading, clear for takeoff.
05:42Ugh.
05:44Runway heading, clear for takeoff.
05:45191.
05:46Let's see more.
06:06Anti-ice off. Lights set. Takeoff config's okay. Line up check's complete.
06:12All yours, Jim.
06:14Captain Clay hands control of the aircraft to First Officer Pol Hincky for takeoff.
06:20My brakes, my controls.
06:33Set thrust, please.
06:36Thrust set.
06:44That is weird with no lights.
06:53Yeah.
07:00100 knots.
07:02Checks.
07:05Something's not right.
07:07V1.
07:09Rotate.
07:10As 5191 prepares to lift off.
07:14Whoa.
07:19Damn it!
07:20Comair flight 5191 hurtles into a field less than half a mile from the runway.
07:45This is Lexington, alert 3, west side of the runway to the Comair regional jet taking off.
08:05We knew something was wrong, we never get an alert 3, we never get one.
08:14Black Safety Officer Pete Moppin rushes to the scene.
08:20It's hot, I mean it's very hot.
08:25There were explosions.
08:30Can we save anybody?
08:31That was what I was thinking when I saw this ball of fire.
08:3749 people are dead after the tragic take off of Comair flight 5191.
08:57First Officer Paul Hincky is the only survivor.
09:02The first responders quick actions were the reason that First Officer Paul Hincky survived
09:06this accident.
09:07He was so traumatically injured that they recognized that time was of the essence and transported
09:13him to the hospital rather than waiting for an ambulance.
09:16He thanked me for saving his life.
09:20I told him that was my job, but I was glad that I was there to do what I did and I told
09:25him that.
09:29The question NTSB investigators now need to answer is why Comair flight 5191 couldn't
09:36get off the ground.
09:44As soon as the fires are put out and the crash site is safe, NTSB investigators begin looking
09:50for clues to discover why Comair flight 5191 crashed less than half a mile from Lexington's
09:56Bluegrass Airport.
09:58Make sure every scrap is documented.
10:01We need a clear picture of the path this plane took before impact.
10:07Lead investigator Joe Seador is among the first to arrive at the crash site.
10:11In this case it was quite interesting because initially we didn't have much.
10:16An airplane had crashed, we didn't know if it was on the airport, off the airport.
10:23We actually started at the final resting place for the wreckage and then we walked back towards
10:27the airport.
10:30First impact point is there.
10:35And the plane hit those trees over there.
10:49Those impact marks aren't more than 20 feet up those trunks.
10:59We were looking at the trajectory of the airplane, clearly looked like it took off just about
11:05the end of the runway and immediately started contacting trees into the wreckage site.
11:19The wreckage path tells investigators that the plane was struggling to get off the ground.
11:24Was it engine trouble?
11:25Or something else?
11:26Looks like they took off from runway 26.
11:31Hang on.
11:3526 wasn't in use last night.
11:45Lexington Airport has two runways, runway 26 and runway 22.
11:51According to the flight plan they were supposed to take off from runway 22.
11:58So how the heck did they end up over here?
12:03Investigators are surprised to discover that flight 5191 took off from the wrong runway.
12:08Well at that point in time, because we knew that it was a wrong runway takeoff, the question
12:13is why, right?
12:14And it's one that doesn't make sense.
12:17Did they misunderstand their instructions?
12:20Or deliberately change their plans to take off from a different runway?
12:24There's got to be something on that CVR about why they were on runway 26.
12:29Get those to Washington.
12:30The flight recorder and the cockpit voice recorder were retrieved and flown back here
12:36to Washington DC.
12:38But being on the wrong runway doesn't explain why the plane barely made it off the ground.
12:44Let's take a closer look at those engines.
12:53When the engines are examined, what the investigator is looking for is damage.
13:00The more damage that there is and the type of damage tells us that if it was turning at
13:04high speed or turning at a lower speed.
13:07Hey, they were spinning all right.
13:11Evidence of deformed blades suggests the engines were running on impact.
13:16All the indications were that both engines were operating at high power when the break-up sequence
13:21started.
13:22There was no problem with the engines.
13:31Something else must have kept them from getting airborne.
13:33Maybe they were too heavy.
13:38With engine failure ruled out, the team wonders if the plane was loaded with too much weight
13:44to take off.
13:45There's a certain maximum weight that the aircraft can take off safely with.
13:50So what we do is we calculate the load that's on the aircraft at the time of the accident.
13:54Hmm.
13:55Oh, here it is.
13:56CRJ's max takeoff weight is 50,178 pounds.
14:07And the load manifested the plane weighed 49,087 pounds on that day.
14:21It's close, but it's within their limit.
14:25The aircraft wasn't too heavy to take off.
14:28In that aircraft on that day, with that weight, how much runway would be needed to take off safely?
14:35Using the actual weight of the aircraft and the CRJ-100 specifications, investigators calculate
14:42how much runway the plane needed to lift off.
14:45The weight of the aircraft affects how fast they have to be going to be able to lift off.
14:50And that is directly correlated to how much runway it takes to be able to achieve that speed.
14:543,744 feet.
14:593,744 feet.
15:02And runway 26 is...
15:043,501 feet.
15:08Investigators reach an astonishing conclusion.
15:15Runway 26 is 243 feet too short.
15:19They ran out of runway.
15:21They now understand why the plane couldn't get airborne.
15:27But they're still mystified.
15:30Why didn't Flight 5191 take off from the longer runway?
15:34Hate to say this, but you're not going to get any answers from the first officer either.
15:48His injuries are very severe.
15:50The first officer is medically unfit to be interviewed.
15:56It's a big loss to the investigation.
15:59It can be frustrating when you're not able to speak with people that you'd like to speak with,
16:04but as investigators we need to work with the data that we have.
16:09Investigators look for other clues that might reveal why Flight 5191 ended up on a runway they were not cleared to use.
16:18All right, they left the gate here.
16:23They taxi along here.
16:27They're supposed to leave from runway 22 here.
16:34But they end up here.
16:37The question is, why?
16:39So when we were looking into trying to understand why this flight crew thought they are on runway 22,
16:44we looked at anything that was different, anything that the flight crew may have misunderstood
16:49with regard to both the airport and the charts or any of their training.
16:54Hey, look at this.
16:56Our guy's got some shots at the runway.
16:59Taxiway to runway 22 was blocked off by construction.
17:16There were numerous construction projects that were in place at the Lexington Airport through the day of the accident.
17:22Okay, sure, but wasn't that in their chart?
17:25Normally, when a taxiway is closed, pilots receive an interim airport chart with an alternate route.
17:34Nope, nothing on the chart.
17:37Investigators are amazed to learn that the cruise airport chart only showed the taxi route before construction,
17:45not the updated taxi route.
17:52It is a surprise to see that the airport construction had not been updated in the charts that the flight crew had.
18:00It's a disturbing find.
18:04Could out-of-date taxi charts have misled the pilots into taking off from a runway that was too short for their plane?
18:16So they get out there and they find their taxiways blocked,
18:19and they don't have anything to tell them how to get to runway 22.
18:22That could trip you up.
18:25But something doesn't add up.
18:29Comair flight 5191 wasn't the only plane departing Lexington that morning.
18:36Other planes left before them and none of them ended up on runway 26.
18:40Eagle flight runway 22 cleared for takeoff.
18:46The other two flights took off prior to 5191.
18:52I received the same information that the flight crew from 5191 received
18:57and did not have any difficulties in navigating to the runway.
19:01The fact that two other aircraft were able to park successfully that morning caused us to look deeper.
19:15Maybe there's something on the security footage.
19:17Investigators turned their attention to CCTV footage.
19:21In the hopes that it will explain why Comair 5191 took off from the wrong runway.
19:28We were able to retrieve security footage from cameras on the parking garage that showed our aircraft taxiing out that morning.
19:48All right, let's see what they were actually up to.
19:52Investigators quickly confirm how straightforward the taxi route was.
19:57Taxi's short and there's no other aircraft in sight.
20:00Our assessment based on examination of surveillance video showed that it was a nominal taxi.
20:07The taxi route from the ramp to runway 22 was straightforward and only required one runway crossing 26.
20:19Wait, stop it right there.
20:23It looks like they've stopped at the hold short line for runway 26.
20:38Before takeoff planes stop or hold short of the runway until they're cleared to proceed by air traffic control.
20:45Well, they were on their way to runway 22. Why the heck would they stop there?
20:50Investigators are startled by the discovery.
20:53We noticed at that time that the aircraft had stopped prior to runway 26 for over 50 seconds.
21:01This is unusual because there was no real reason for them to stop there.
21:04We need to see the taxi route.
21:08All right.
21:10Were there clues telling the pilots they were in the wrong place?
21:14One of our main questions when we realized that they stopped for 50 seconds at the hold short line for runway 26 was what could they have been seen?
21:24To better understand why the pilots of Comair flight 5191 stopped at the hold short line for the wrong runway.
21:31All right, let's get started.
21:34Investigators retrace their taxi route.
21:41We wanted to understand what the flight crew was seeing.
21:44In 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.
21:53Here on the left, there's a sign for runway 26.
22:09Straight ahead, I can see the hold short line for runway 26.
22:13I mean, it's as clear as day.
22:14Things that we were 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.
22:28The taxi line splits three ways.
22:30Investigators can see what the pilots would have seen from the hold short line for runway 26.
22:35The line on the left goes to runway 26.
22:36The line on the left goes to runway 26.
22:43The line in the middle is the route to runway 22.
22:49The line on the right is runway 22's old taxi route.
22:54Blocked by barricades.
22:55I can clearly see the sign that's telling us that we're at the hold short line for runway 26.
23:02I mean, it's hard to miss that.
23:06Investigators discover that the crew had clear cues that they were at the hold short line for runway 26, not 22.
23:16The question remains, how did they miss those cues?
23:19Okay, let's go to 26.
23:28The test plane follows the line on the left to runway 26.
23:32Okay, see?
23:34That's where they should have taken the taxi route and stopped the hold short line for runway 22.
23:41Investigators are surprised to learn that even as flight 5191 was turning onto runway 26,
23:47the crew had a clear view of the sign pointing to the runway they were meant to be on.
23:54There were no features in the environment in terms of the signs, marking, or lighting that showed they were on runway 22.
24:06All the cues are right there.
24:09In plain sight.
24:12Joe Cedar then uncovers one more disturbing fact.
24:15When we taxied from the taxiway onto and turned onto runway 26, all of the lights on runway 26 were out, and there was no lights in the distance.
24:25As an experienced pilot, I look at that and say, why did this flight crew take off from this runway?
24:33We need to know what was going on in that cockpit.
24:36We need to know what was going on in that cockpit.
24:42That is weird with no lights.
24:45Yeah.
24:46Yeah.
24:51The cockpit voice recorder from Comair flight 5191 is finally ready to be reviewed.
24:57OK, let's hear what we've got.
24:59It 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.
25:10In this type of human factors accident, it's very difficult because we have to try to determine what the pilots were thinking.
25:17The main tool that we use in order to determine that is the cockpit voice recorder.
25:24The CVR was very important in understanding what the flight crew was talking about and what they were doing during the taxi and the take-off.
25:31You good for flying this flight?
25:35I'll take us to Atlanta.
25:36OK, so the first officer is going to fly. That's standard stuff.
25:42The flight crew were conducting themselves in a professional manner.
25:46For own briefing, Comair standard, run the checklist, do your leisure, keep me out of trouble. I'll do the same for you.
25:52I'll do the same. Whenever you're ready.
25:56OK, here comes the taxi brief.
25:58Light seat flex, take-off procedures off of...
26:02You said what runway, 2-4?
26:04It's 2-2.
26:052-2. The ILS is out on 2-2.
26:08Came in the other night, the runway identifier lights were out all over the place.
26:12All right.
26:142-2 is your short taxi. Any questions?
26:16No questions before starting at your leisure.
26:19Something in the briefing surprises investigators.
26:22Wait, stop it right there.
26:24Is that not a short brief to you?
26:29They discover that the crew used an abbreviated version of the taxi brief, called Comair standard.
26:35Pull up the Comair standard taxi brief.
26:38There's no mention of crossing runways or stopping to call ATC if they're unsure where they are.
26:52Investigators are baffled to discover that even the shortened taxi brief with eight checklist items, including a very crucial one, wasn't followed.
26:56Yeah, they never briefed on the runway they had to cross to get to runway 22.
27:11The crew's abbreviated briefing that morning was a deviation from standard operating procedures that we identified.
27:16Had the crew done a full taxi briefing, they would have discussed the need to cross runway 26 on the way to 2-2.
27:25They missed an opportunity to review the airport diagram and determine that they needed to cross runway 26 and intervening runway before they reached runway 22.
27:35Okay, let's hear their taxi checklist.
27:40Flight controls. Check left. On the right, trims.
27:46Engage 07.2.
27:49Radar terrain displays. All taxi checks complete.
27:52Finish up the before takeoff checklist. Your leisure.
27:54Yes, at your leisure.
27:56One other thing on the CVR we heard was the captain using the term, at your leisure.
28:01It 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.
28:08Yeah, I know three guys at Kennedy. Actually, two guys. One went, but he did get through the same.
28:14Oh, really?
28:15Then a first officer from Cincinnati, he got through the second part, and that's as far as he got.
28:19Wait, stop it right there.
28:20Investigators cannot believe what they're hearing.
28:23What the heck is he talking about?
28:25Instead of focusing on their checklists, the crew of 5191 were having a casual conversation during a critical moment.
28:34It's a major breach of what's called the sterile cockpit rule.
28:39The sterile cockpit rule requires that pilots refrain from non-operational conversation during significant portions of flight.
28:47One of the key reasons for the sterile cockpit rule is that non-pertinent conversation can be distracting.
28:54And that's as far as he got?
28:56And then he actually got offered the position.
28:58Did he take it, or?
28:59Yeah, he took it.
29:00Oh, okay.
29:02The captain should be shutting this conversation down, not encouraging it.
29:04Although the first officer started the conversation, the captain is responsible for ensuring that sterile cockpit rules enforced and distractions do not enter the cockpit that could affect the safety of flight.
29:18After 40 seconds of casual conversation.
29:23Second engine started, anti-ice probes, windshield low.
29:28Investigators hear the pilots turn to their takeoff checklist.
29:32Now they finally get back to their jobs.
29:37We're surprised by that.
29:39That non-pertinent conversation was in a critical area when the flight crew is making their taxi out to the runway, where the flight crew needs to be 100% flying the aircraft.
29:51Could that period of inattention hold the key to this tragic accident?
29:58Okay, let's see what we've got so far.
30:06Investigators wonder if a casual conversation is at the heart of the crash of Comair flight 5191.
30:14We skipped out at a briefing that would have told them they needed to cross 26 to get to 22.
30:21Then for almost a minute, they violate the sterile cockpit rule.
30:29Let's see what happens when they get here.
30:34Investigators hope the crew will give some indication why they stopped at the hold short line for runway 26.
30:41The thrust reversers are armed.
30:46Auto cross flow is manual.
30:49Ignition is off.
30:52Altimeters are three triple zero across the board.
30:56Cross check.
30:58I'll check in with the cabin.
31:00That's it?
31:01It 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 26.
31:16We know they were distracted, but when they stopped their chit chat, they don't seem to recognize, know, or check where they are.
31:24We got no information based on the conversation of the flight crew while they were holding short that they were disoriented.
31:34No indications at all.
31:36Investigators are amazed by what they hear next.
31:40At your leisure, Comair 121 ready to go.
31:43Comair 191.
31:45Lexington Tower.
31:46With the power.
31:49Fly on runway heading.
31:50Clear for takeoff.
31:52Hold there.
31:55So, they're completely relaxed when they asked for clearance.
31:59In fact, it's so relaxed or distracted that the first officer uses the wrong flight number.
32:05Investigators realize the grim truth.
32:08These guys actually thought they were lined up for runway 22.
32:12The fact that they stopped at Runway 26 and subsequently called for takeoff indicates that they lost awareness that they had not crossed Runway 26.
32:25They turn on to Runway 26, then what?
32:30Keep going.
32:31Lineup checks completed.
32:34All yours, Jim.
32:35First officer takes the controls.
32:37So he's looking ahead probably for the first time.
32:43At this time, the captain taxied the aircraft out onto the runway and then transferred controls to the first officer.
32:52So before this time, the first officer was heads down in the cockpit.
32:58My brakes, my controls.
33:00When the first officer looked out, he saw a runway.
33:03He may not have perceived that it was a narrower runway than Runway 22.
33:08They're looking down Runway 26.
33:14Why don't they see the sign for 22 off to the right?
33:20Neither pilot cross-checked their location at the time that they took the runway.
33:24Is that thrust, please?
33:34Thrust set.
33:46That is weird with no lights.
33:47Yeah.
33:49Hold on.
33:56Runway 26 is not in use, so it's not Lynn.
34:00They see the lights for 22 until they cross it.
34:08They're looking down a pitch-dark runway.
34:11And it doesn't faze them.
34:15Investigators wonder if the pilots were confused about what the runway should have looked like.
34:20When they began the take-off roll on Runway 26, they had no centerline lights or edge lights on this runway.
34:28However, based on my first officer's previous experience the night before, he did not expect to see lights.
34:34The ILS is out on 22.
34:38Came in the other night, the runway identifier lights were out all over the place.
34:41And so it would not necessarily have been an unusual sight picture.
34:45Such decision-making, based on a person's mistaken assessment, is called confirmation bias.
34:52Confirmation bias is where the flight crew expects something to be there, even though it might not actually be there.
34:58He noticed there was no lights on the runway, but he just accepted the fact.
35:07What happens next?
35:15100 knots. Checks.
35:18The pilots now see they're almost out of runway.
35:21V1, rotate.
35:24And don't have the required speed to get airborne.
35:27Whoa.
35:28Damn it!
35:37That's it.
35:39They finally realize something's wrong, and it's too late.
35:44Based on our calculations, the crew needed to recognize that they were on the wrong runway,
35:49and successfully reject the take-off about 20 seconds into the take-off roll.
35:53However, their recognition did not occur until much later, when the captain called rotate at a lower speed than what was required.
36:04Investigators have unraveled the mystery of what happened inside the cockpit of flight 5191.
36:18They started out by skipping their full briefing, and then after a long discussion about the airline, they lose sight of where they are.
36:31They stop at the wrong place, and they completely miss all the signage that they're at the wrong runway.
36:38By the time they figure out the mistake, it's too late.
36:40The 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.
36:58But the team still has one unanswered question.
37:09Why didn't the controller tell them they were at the wrong runway?
37:12Investigators wonder if the air traffic controller of Comair flight 5191 could have picked up the crew's error and prevented the accident.
37:30Happy to answer any questions.
37:33With 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?
37:42At 6.05, they asked for take-off clearance.
37:46Runway 22 was free, so I gave Comair clearance for take-off.
37:52At your leisure, Comair 121, ready to go.
37:57Comair 191, Lexington Tower. Fly runway heading, clear for take-off.
38:02Runway heading, clear for take-off, 191.
38:05And what did you do next?
38:10I saw the plane proceed towards runway 26 and then scanned runway 22 to make sure there were no vehicles on it.
38:17Did you watch the flight take-off?
38:20Not if I have other jobs to do.
38:23Investigators make one final discovery.
38:27And then I turned over here to count my flight strips.
38:31And why would you start counting your flight strips then?
38:34I wasn't busy.
38:37It only takes a few minutes.
38:40And there was no reason to think that they'd have any problems.
38:44In 17 years, I've never seen a plane that size try to take-off from runway 26.
38:49The 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.
39:04And if you hadn't turned away, would you have noticed that they were in the wrong place?
39:11I might have.
39:16FAA regulations do not require controllers to monitor every take-off.
39:23But if the controller had been watching the runway instead of counting flight strips, he might have noticed Flight 5191's mistake.
39:32He was not actually required, nor are any controllers required, to actually watch an aircraft during its take-off roll.
39:38Had they been required to do that, this would have given an opportunity to have the take-off aboard him.
39:45The NTSB concludes that several factors led the pilots to lose track of their position on their way to the runway.
39:53Contributing to that was the flight crew's failure to maintain sterile cockpit and to have a non-pertinent conversation prior to take-off.
40:04This crash happened because of a period of distraction during what was perceived as a relatively simple taxi.
40:15And it illustrates the perils of distraction in that it can take you off task.
40:21It can cause you to lose awareness.
40:23And in this case, both crew members lost awareness of where they were on that airport surface and made a mistake that was extremely consequential.
40:33Among the NTSB's recommendations is a basic technological change to prevent pilots from getting lost.
40:45The CRJ-100 at the time had sophisticated avionics, but it lacked a simple GPS system available in cars of the same era.
40:56Install moving map GPS displays in CRJ-100 cockpits.
41:02The NTSB also makes recommendations for flight crews.
41:06Require pilots to check that they are at their assigned runway before crossing the hold short line.
41:14First officer James Polhinke, the lone survivor of Comair flight 5191, suffered severe injuries, including the loss of his left leg.
41:29He never returned to commercial aviation.
41:33This was a catastrophic accident.
41:38It affected scores and scores of lives.
41:43But the legacy of this accident are the safety changes that have been made to prevent this type of accident from happening in the future.
41:51This 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.
42:09I don't want to hear.
42:10This accident shows.
42:11I'm glad I saw here.
42:12You