Board members criticized the FAA's reliance on nonbinding recommendations to prevent similar pilot errors in the future, rather than new safety requirements. They also asked whether a decline in attention to safety was eroding the impact of the agency's recommendations and regulations.
In preliminary investigations, the NTSB found that human errors contributed to the Comair pilot's attempt to take off on the wrong runway and the plane's crash shortly after it became airborne. Mistakes included the failure by the pilot and first officer to complete a briefing on the taxi route, their conduct of an unrelated conversation during the time when they ought to have been silent to avoid distractions and their failure to notice multiple visual cues.
Construction at the Lexington airport added more complications. One taxiway to the runway the plane should have used was shut, charts reflected what the airport would look like after construction rather than during it, and lights along the runways were down.
But the panel seemed unconvinced Thursday that these factors were entirely to blame for the disaster, which killed 49 people.
"This crew, when they were taxiing out, missed all the cues," NTSB member Steven R. Chealander said. "At any point, they might have prevented this themselves if they'd registered that they were going onto the wrong runway."
The board issued five recommendations in response to the crash -- two in December calling on the FAA to require airplane crews to confirm and cross-check their location prior to takeoff and to clarify lighting requirements for night takeoffs, and three in April related to air traffic controller staffing.
The FAA moved quickly to address the sources of pilot error identified by the NTSB, but stopped short of issuing new rules. The agency issued a safety alert on Sept. 1, 2006, in advance of the board's recommendations, reminding flight crews of proper steps to confirm their location before taxi and takeoff. Another alert followed on April 16, 2007, recommending that pilots use horizontal system indicators in cockpits to provide better visual images of takeoff positions, make verbal announcements to confirm correct runway positions, and call on air traffic controllers for help in confirming their position. On May 11, the FAA issued a notice reminding pilots that they should not take off at night if runway lights are out.
Those actions were not enough to satisfy some members of the panel, who questioned whether they simply replicated ineffective old recommendations.
Board member Kitty Higgins noted that as early as 1989, the NTSB asked the FAA to require that all air carriers make their crews verify their locations before taxiing and taking off. The agency's response then was strikingly similar to the response in the wake of the Comair crash.
"The FAA came back and said that they were giving guidance, which is not mandatory, and we closed it [as] acceptable based on the fact that they assured us that all carriers were doing this anyway," Higgins said. "Here we are almost 20 years later; we issued this similar recommendation again in September. We have a response from the FAA in March, which says 'we will issue a [Safety Alert for Operators].' Our recommendation was to require. A SAFO does not require operators [to cross-check their locations] . . . . I think this is very, very troubling."
Other board members questioned whether the problems, particularly the crew's failure to stop nonrelevant conversations, were due more to a culture of noncompliance than to a lack of strong regulations.
"What is it that makes people do the right thing when nobody's watching, when they're supposed to zip it and it's a sterile cockpit?" asked board member Debbie Hersman, who led the on-the-ground investigation of the crash. "What makes them adhere to the procedures that are laid out for them? Is it a bigger issue? Is it something we need to address in our industry?"