NTSB: Air controller fatigue contributed to 4 mishaps

Story Highlights

• Investigators want FAA to revise schedules so air traffic controllers get more sleep
• Fatigued air traffic controllers contributed to four recent mishaps, investigators say
• FAA will look at scheduling practices in light of NTSB recommendation
• Fatigue may have played a role in last year's Comair crash that killed 49

From Mike M. Ahlers
CNN

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WASHINGTON (CNN) -- Fatigued air traffic controllers contributed to four aviation mishaps in recent years, and may have been a factor in last year's Comair crash that killed 49 people, according to federal accident investigators.

The investigators are calling on the Federal Aviation Administration to revise work schedules and take other actions to prevent controllers from becoming tired on the job.

"Controllers are absolutely more tired now than they have ever been, and it's because they are forced to work overtime. This is an understaffed system, and the FAA is lying when they say it's not," said Doug Church, spokesman for the National Air Traffic Controllers Association.

In a letter to the FAA, Mark Rosenker, chairman of the National Transportation Safety Board, said it's still unclear what role fatigue played in the crash of Comair Flight 5191, but four other incidents "provide clear and compelling evidence" that controllers are sometimes operating while fatigued because of their work schedules and poor use of rest periods.

"That fatigue has contributed to controller errors," Rosenker wrote.

Union: 'This is a wonderful gift'

The air traffic controller's union jumped on the report as validation of its long-held claims that the system is severely understaffed and that controllers are being forced to work overtime against their wishes.

"This is a wonderful gift from the NTSB, to finally tell the FAA that their controllers need more rest," Church said.

FAA spokeswoman Laura Brown said the FAA has between 14,500 and 14,600 controllers, about 1,000 fewer than it had in late 2003. But, Brown pointed out, the peak number was based on a contract with controllers that anticipated growing air traffic, not the drop that followed the September 11 terrorist attacks.

Brown said the FAA will look at scheduling practices in light of the NTSB recommendation, but "many of the schedules we have in place are at the request of employees." She noted that the NTSB said it is also incumbent upon controllers to "use personal strategies" to maximize sleep and minimize fatigue.

The FAA determines rest requirements, but it negotiates with unions on how employees are rotated through shifts, Brown said.

"The (NTSB) recommendations don't say anything about understaffing," Brown noted. "There is mandatory overtime at a very small number of facilities."

In many cases, the FAA is able use controllers who request overtime -- or are on a volunteer list -- before seeking others to work overtime, she said.

Controller working on just 2 hours of sleep when plane crashed

In the August 27 Comair crash in Lexington, Kentucky, the lone air-traffic controller was working on just two hours of sleep, according to the NTSB.

The controller cleared the CRJ-100 to take off from the correct runway, which was 7,003 feet long, but the airplane mistakenly turned onto a shorter runway that was just half that length. The plane crashed into a fence and trees at the airport perimeter, killing 49 of the 50 people onboard.

While the NTSB is focusing on the crew's actions, and aviation experts say the controller was not required to observe the plane's departure, the NTSB is evaluating to what extent, if any, the controller's fatigue may have influenced events.

The controller in the tower had worked a 6:30 a.m.-to-2:30 p.m. shift the day before the accident, then returned nine hours later and worked from 11:30 p.m. until the 6:07 a.m. accident, the NTSB says. He told investigators his only sleep between shifts was a two-hour nap.

"Such limited sleep can degrade alertness, vigilance and judgment," Rosenker wrote.

A history of incidents

The four aviation mishaps that allegedly involved tired controllers all involved what are termed runway incursions -- instances in which aircraft or other vehicles improperly intruded onto operating runways.

The four incidents are:

Chicago, Illinois, March 23, 2006: The NTSB letter says a controller cleared an Airbus A320 passenger plane to cross a runway and then, less than 15 seconds later, cleared a Boeing 737 to take off on the same runway. The pilot of the Boeing saw the Airbus and stopped before reaching the taxiway intersection. The controller told investigators he had slept only four hours during a nine-hour break between shifts.

Los Angeles, California, August 19, 2004: A controller cleared a Boeing 737 passenger plane to taxi onto and take off from a runway at the same time that another plane, a Boeing 747, had been cleared to land on the same runway. The pilot of the landing plane saw the 737 and pulled up 12 seconds before a collision would have occurred, passing about 200 feet above the runway. The controller had slept five or six hours before returning to work, the NTSB letter says.

Denver, Colorado, September 25, 2001: A controller approved a request from a Boeing 757 cargo plane crew to depart from a runway, even though the runway had been closed for construction. The aircraft passed within 32 feet of lights that had been erected in the construction zone. Investigators determined that the controller had slept less than two hours during a nine-hour period between work days.

Seattle, Washington, July 8, 2001: A controller cleared a Boeing MD-80 passenger airplane to cross a runway at the same time a Boeing 767 passenger airplane was about to land on the runway. The pilots in the landing airplane hit their brakes to avoid a collision, stopping only 810 feet short of the MD-80. The controller was working his third shift in two days, with eight-hour rest periods between shifts.

The NTSB recommended the FAA and controllers' union revise work schedule policies and practices and modify shift rotations to minimize sleep disruptions. The FAA should also develop fatigue awareness programs, which should be taught at regular intervals, the NTSB said.

It commended the FAA for a new "resource management program" to help controllers detect controller and pilot mistakes.

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