LEXINGTON, Ky. — To fly safely, pilots need to know vital information, including changes to runways, taxiways and airspace restrictions. That information is issued to pilots through a complex system of written notices.
But the crash of Comair Flight 5191 in Lexington exposed holes in the Federal Aviation Administration's oftentimes confusing pilot-notification system.
On the day of the crash last year, the Comair pilots were missing four such notices, including one detailing the closing of a taxiway at Blue Grass Airport. The missing notice could have alerted the pilots that the usual route to the main runway had changed because of recent construction. The plane mistakenly took off from the airport's shorter, general aviation runway, crashing and killing 49 of the 50 people aboard.
Spotty distribution of such notices is just one of the system's problems, pilots say. The notices use a hard-to-understand code system developed in the days of teletype machines, and there's no system to help pilots filter out which notices are urgent and which are routine.
"The system is broken," said Heidi Williams, director of air traffic services for the Aircraft Owners and Pilots Association. AOPA represents more than 411,000 general aviation pilots in the United States. "It doesn't mean that it doesn't function at all, but it certainly limps along," Williams said.
Problems with the pilot-notification system are likely to be a topic Thursday when the National Transportation Safety Board meets in Washington to release its findings and state a probable cause in the Lexington crash. The board is also expected to make safety recommendations.
In May, Mark V. Rosenker, chairman of the NTSB, said the board is examining the notification system as part of its investigation.
FAA officials say they are aware of pilot criticisms about the notification system - also referred to as Notices to Airmen, or NOTAMs - and are working to address some concerns.
"We're running the safest air traffic control system in the country and certainly the world," said Nancy Kalinowski, the FAA's director of system operations, air space and aeronautical information management. "We also believe there is a lot of room for us to do continuous improvement in the NOTAM system."
NOTAMs are the primary way for the nation's commercial and general aviation pilots to receive critical flight safety information.
They are used to notify pilots about changes to arrival and departure procedures, runway closings, construction at airports or other issues that affect the progress of a flight. Each day, anywhere from 300 to more than 1,000 notices are issued, and thousands of airplanes take off and land in the United States without incident.
But when a breakdown occurs, it can be disastrous.
Between 1991 and 2006, NTSB investigators cited NOTAMS as a cause or a contributing factor in 30 accidents and incidents, according to NTSB documents. In its reports, the NTSB cited inadequately worded NOTAMs, failures to issue NOTAMs and failures by pilots to obtain, read and follow them.
A recent study conducted for the FAA highlighted numerous problems in the NOTAM system.
"Because of the complexity of the system, it is inherently error-prone. A breakdown can occur at any step in the process, or in multiple steps, leading to possibly serious consequences," according to the report published in the April 2004 Flight Safety Digest. The study was conducted by the University of Central Florida.
The study found that the archaic language of abbreviation used in NOTAMs can lead to confusion and difficulty in interpreting the notices. A survey the researchers conducted found that pilots "agreed that the current NOTAMs system is clumsy to use and that it is easy to make mistakes using it," according to the report.
Pilots say the most critical problem is in the distribution of NOTAMs, like those missing in the Comair crash.
AOPA has been telling the FAA for years that local airport notices need to be available electronically, Williams said.
Local NOTAMs, which deal with airfield operations such as lawn mowing and taxiway closings, are not distributed nationally. Pilots can get local notices by calling one of the FAA's 16 regional flight-service stations or in a message on the Automatic Terminal Information System, a radio frequency pilots use to access pre-recorded messages from the air traffic control tower. Pilots can also ask air traffic controllers for local notices. Many pilots mistakenly think that local notices are available online.
Other types of NOTAMs - those that deal with runway or regulatory issues - are available online, in addition to the other methods.
The distribution problem affects all pilots, but it's even more pronounced for general aviation pilots who typically gather the notice information themselves. Commercial pilots typically receive NOTAM information as part of the preflight paperwork from their airlines.
On the day of the Comair crash, Capt. Jeffrey Clay and First Officer James Polehinke had many, but not all, of the notices that should have been available to them that day.
Comair's pilots had 15 notices available through the airline's flight dispatch paperwork. But four notices - including the one detailing the closing of the taxiway that pilots typically used to reach the main runway - were missing, the Air Line Pilots Association said in a submission to the NTSB.
In addition to the taxiway NOTAM, Clay and Polehinke were missing others that would have told them that the distance-remaining signs on the airport's main runway were out of service and that the general aviation runway (which they mistakenly used when they took off in the dark) was for daytime-use only, ALPA said.
"This clearly indicates a deficiency in the NOTAM dissemination system," ALPA said in NTSB filings.
Clay and Polehinke did not have the taxiway notice because Comair does not have a system to pick up local NOTAMs either from its gate agents in Lexington, from the company that provides Comair with all of its notice information or from a regional flight service station. The FAA operates the flight service stations, which pilots can call to obtain NOTAMs, weather briefings and en route communications.
Comair says its policy is for pilots to receive local NOTAMs through pre-recorded radio messages from the air traffic control tower.
On most days, that policy probably works, but it didn't on the morning of the crash.
Although Lexington air traffic controllers typically record all local notices on the radio system, the message about the taxiway closing - which had been on the system for six days leading up to the crash - wasn't on the recording that morning.
Randy Harris, president of the local National Air Traffic Controllers Association, said he didn't know why that notice wasn't recorded that day.
The controllers don't pick and choose which NOTAMs to put on the Automatic Terminal Information System, Harris said. "All the ones that affect Lexington, we put on the ATIS."
Although the message about the taxiway closing should have been recorded on ATIS, the bigger issue is why Comair doesn't have a system to gather and distribute local information to its pilots, said Paul Czysz, a retired aeronautics professor at St. Louis University. "That's really a big hole in the process."
Comair should have provided its pilots with the local notices, Czysz said.
"The real issue is that, if somebody at Comair sees the locals aren't there, he doesn't throw his hands up in the air and say `somebody didn't send them to me.' He gets on the phone and tries to find out where they are. They're too important to just ignore like that," he said.
Comair doesn't give its pilots the local notices because it doesn't receive such notices from Jeppesen, a Colorado-based company that provides aviation services such as weather maps, airport charts and flight planning information. Jeppesen provides flight planning services to about 250 commercial airline customers worldwide, including Comair, Northwest and Southwest airlines in the United States.
Jeppesen provides Comair and its other flight-planning customers with other NOTAMs that deal with runway and regulatory issues, said Eric Anderson, Jeppesen's spokesman. But the company doesn't provide any of the local notices because they "aren't disseminated by the FAA, so we have no way to get them to our customers."
Theoretically, Jeppesen could call the regional flight service stations for the local NOTAMs, but it would be logistically difficult, Anderson said. "We haven't found a way to do that unless the FAA sends them to us."
Although Jeppesen doesn't gather local notices for its customers, at least one company that provides similar services to airlines does. Sabre Airline Solutions, a Texas-based company, provides its customers with all NOTAMs, including local ones, said Nancy St. Pierre, a Sabre spokeswoman.
Sabre enlists the help of its customers in collecting local notices directly from the customers' airport gate agents, St. Pierre said. "The local gate attendant gets the NOTAM information from the airport, and they enter it into our dispatch manager system."
Once the local notices are in the system, they are sent directly to pilots along with weather information and other NOTAMs, St. Pierre said. "It doesn't go out to all of our customers. It only goes to our carriers that fly in and out of that particular airport."
In North America, 39 airlines use the Sabre Dispatch Manager, St. Pierre said.
Comair could have used Sabre's method - utilizing local gate agents - to collect local notices for Blue Grass Airport. Whenever Blue Grass Airport requests a NOTAM, a copy is faxed to many airport tenants, including every airline based at Blue Grass, said Michael Gobb, airport director. Across the country, it's standard practice for airports to let their tenants know about any notices in effect, Gobb said.
Although the FAA requires that airlines pick up all NOTAM information, it doesn't specify how the notices should be received, said Laura Brown, FAA spokeswoman.
"We tell the people we regulate what the intended safety outcome we want is," Brown said. "For instance, you must have the most current flight NOTAM information, but if that's the outcome, then we don't necessarily tell you how to get there. There are various ways you can get this, and it's up to you to make sure you get it."
Kate Marx, a spokeswoman for Comair, said the airline's position is that local notices should be distributed through the ATIS radio system.
But relying on ATIS to receive local NOTAM information isn't foolproof, Brown said. "Some of them are included on the ATIS recording, but not all of them."
If pilots want to be sure they have all of the local NOTAMs, they have to call a regional flight service station, Brown said.
Problems with the notification system are expected to come up at the safety board meeting Thursday, but some changes are already in the works.
Since 2004, the FAA has been working to make the notices easier to understand; those changes are now being tested. The FAA is also considering a system to give priority to the most important notices.
Some steps have also been taken to address distribution problems.
Lockheed Martin, which took over operations of the FAA's flight-service stations in 2005, has upgraded the stations' technology to make it easier for them to share information on local NOTAMs.
That technology will eventually allow the FAA to make all local NOTAMs available on the Web. Once the system is up and running, pilots will have 24-hour access to all notice information online and on wireless devices, said Keith Mordoff, Lockheed's director of external communications.
Testing on Web and wireless access is scheduled to begin in a month or two, Mordoff said.
An NTSB recommendation about the notification system could bring added pressure from Congress to do something about the system, said Chris Dancy, AOPA's media relations director.
"A recommendation to fix the NOTAM system from the NTSB is really just drawing attention to a known problem," Dancy said. "Yes, it certainly wouldn't hurt to have the NTSB raise the profile of the problem, but again, it's something the FAA is already trying to do."