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Printed page 1. PDF page 13.
and proceeded to the correct airplane. The LEX air traffic control tower (ATCT) was staffed with one controller at the time of the accident airplane's preflight activities, taxi, and attempted takeoff. The controller was responsible for all tower and radarOpen official document at PDF page 13Attempted Takeoff From Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, N431CA, Lexington, Kentucky, August 27, 2006
Printed page 23. PDF page 35.
controllers), and five controllers on duty during the swing shifts. The midnight shift had been staffed with one controller. On November 16, 2005, the LEX air traffic manager notified LEX ATC personnel by e-mail that, according to verbal guidance fromOpen official document at PDF page 35Attempted Takeoff From Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, N431CA, Lexington, Kentucky, August 27, 2006
Printed page 24. PDF page 36.
Factual Information AIRCRAFT Accident Report In April 2006, the midnight shift was again staffed with one controller because traffic had increased during the day and swing shifts and the second midnight controller was needed on those shifts, according to theOpen official document at PDF page 36Attempted Takeoff From Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, N431CA, Lexington, Kentucky, August 27, 2006
Printed page 56. PDF page 68.
2,563, or 11.1 percent of the 23,002 total midnight shifts at the 62 facilities were staffed with one controller between August 28, 2005, and September 2, 2006. The report noted that the number of noncompliant facilities was higher at theOpen official document at PDF page 68Attempted Takeoff From Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, N431CA, Lexington, Kentucky, August 27, 2006
Printed page 81. PDF page 93.
clearance delivery position recorded the tower traffic count. When the midnight shift was staffed with one controller, that controller performed a combined radar and tower traffic count. 202 As a result, the controller must have expected that he would haveOpen official document at PDF page 93Attempted Takeoff From Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, N431CA, Lexington, Kentucky, August 27, 2006
Printed page 98. PDF page 110.
0800) was frequently not in compliance with this guidance. The midnight shift at LEX was staffed with one controller until January 2006. Between January and March 2006, the midnight shift was staffed with two controllers 40 percent of the time.Open official document at PDF page 110Attempted Takeoff From Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, N431CA, Lexington, Kentucky, August 27, 2006