Sole survivor show , pilots wife , claiming NTSB only said one thing about probable cause. That is not accurate. Here is their prob cause:
3.2 Probable Cause
The National Transportation Safety Board determines that the probable cause of
this accident was the flight crewmembers’
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 takeoff. Contributing to the
accident were the flight crew’s
nonpertinent conversation during taxi, which resulted in a
loss of positional awareness, and the Federal Aviation Administration’s failure to require
that all r
unway crossings be authorized only by specific air traffic control clearances.
The show gives the impression that NTSB just picks on pilots while failing to point out that THIS is what they stated:
Findings
1. The captain and the first officer were properly certificated and qualified under Federal
regulations. There was no evidence of any medical or behavioral conditions that might
have adversely affected their performance during the accident flight. Before reporting
for the accident flight, the flight crewmembers had rest periods that were longer than
those required by Federal regulations and company policy.
2. The accident airplane was properly certified, equipped, and maintained in accordance
with Federal regulations. The recovered components showed no evidence of any
structural, engine, or system failures.
3. Weather was not a factor in this accident. No restrictions to visibility occurred during
the airplane’s taxi to the runway and the attempted takeoff. The taxi and the attempted
takeoff occurred about 1 hour before sunrise during night visual meteorological
conditions and with no illumination from the moon.
4. The captain and the first officer believed that the airplane was on runway 22 when
they taxied onto runway 26 and initiated the takeoff roll.
5. The flight crew recognized that something was wrong with the takeoff beyond the
point from which the airplane could be stopped on the remaining available runway.
6. Because the accident airplane had taxied onto and taken off from runway 26 without
a clearance to do so, this accident was a runway incursion.
7. Adequate cues existed on the airport surface and available resources were present in
the cockpit to allow the flight crew to successfully navigate from the air carrier ramp
to the runway 22 threshold.
8. The flight crewmembers’ nonpertinent conversation during the taxi, which was not in
compliance with Federal regulations and company policy, likely contributed to their
loss of positional awareness.
9. The flight crewmembers failed to recognize that they were initiating a takeoff on the
wrong runway because they did not cross-check and confirm the airplane’s position
on the runway before takeoff and they were likely influenced by confirmation bias.
10. Even though the flight crewmembers made some errors during their preflight activities
and the taxi to the runway, there was insufficient evidence to determine whether
fatigue affected their performance.
Findings
11. The flight crew’s noncompliance with standard operating procedures, including the
captain’s abbreviated taxi briefing and both pilots’ nonpertinent conversation, most
likely created an atmosphere in the cockpit that enabled the crew’s errors.
12. The controller did not notice that the flight crew had stopped the airplane short of the
wrong runway because he did not anticipate any problems with the airplane’s taxi to
the correct runway and thus was paying more attention to his radar responsibilities
than his tower responsibilities.
13. The controller did not detect the flight crew’s attempt to take off on the wrong runway
because, instead of monitoring the airplane’s departure, he performed a lower-priority
administrative task that could have waited until he transferred responsibility for the
airplane to the next air traffic control facility.
14. The controller was most likely fatigued at the time of the accident, but the extent
that fatigue affected his decision not to monitor the airplane’s departure could not
be determined in part because his routine practices did not consistently include the
monitoring of takeoffs.
15. The Federal Aviation Administration’s operational policies and procedures at the
time of the accident were deficient because they did not promote optimal controller
monitoring of aircraft surface operations.
16. The first officer’s survival was directly attributable to the prompt arrival of the first
responders; their ability to extricate him from the cockpit wreckage; and his rapid
transport to the hospital, where he received immediate treatment.
17. The emergency response for this accident was timely and well coordinated.
18. A standard procedure requiring 14 Code of Federal Regulations Part 91K, 121, and 135
pilots to confirm and cross-check that their airplane is positioned at the correct runway
before crossing the hold short line and initiating a takeoff would help to improve the
pilots’ positional awareness during surface operations.
19. The implementation of cockpit moving map displays or cockpit runway alerting
systems on air carrier aircraft would enhance flight safety by providing pilots with
improved positional awareness during surface navigation.
20. Enhanced taxiway centerline markings and surface painted holding position
signs provide pilots with additional awareness about the runway and taxiway
environment.
21. This accident demonstrates that 14 Code of Federal Regulations 91.129(i) might result
in mistakes that have catastrophic consequences because the regulation allows an
airplane to cross a runway during taxi without a pilot request for a specific clearance
to do so.
22. If controllers were required to delay a takeoff clearance until confirming that an
airplane has crossed all intersecting runways to a departure runway, the increased
monitoring of the flight crew’s surface navigation would reduce the likelihood of
wrong runway takeoff events.
23. If controllers were to focus on monitoring tasks instead of administrative tasks when
aircraft are in the controller’s area of operations, the additional monitoring would
increase the probability of detecting flight crew errors.
24. Even though the air traffic manager’s decision to staff midnight shifts at Blue Grass
Airport with one controller was contrary to Federal Aviation Administration verbal
guidance indicating that two controllers were needed, it cannot be determined if this
decision contributed to the circumstances of this accident.
25. Because of an ongoing construction project at Blue Grass Airport, the taxiway identifiers
represented in the airport chart available to the flight crew were inaccurate, and the
information contained in a local notice to airmen about the closure of taxiway A was
not made available to the crew via automatic terminal information service broadcast
or the flight release paperwork.
26. The controller’s failure to ensure that the flight crew was aware of the altered taxiway A
configuration was likely not a factor in the crew’s inability to navigate to the correct
runway.
27. Because the information in the local notice to airmen (NOTAM) about the altered
taxiway A configuration was not needed for the pilots’ wayfinding task, the absence of
the local NOTAM from the flight release paperwork was not a factor in this accident.
28. The presence of the extended taxiway centerline to taxiway A north of runway 8/26
....and 174 pages of info!
http://www.ntsb.gov/doclib/reports/2007/AAR0705.pdf
