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I-Team: Trouble in the Tower

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The voice recordings from the air traffic control tower in Lexington, Kentucky are unmistakable.

“ComAir one ninety-one ready to go,” said the pilot of ComAir flight 5191, a Bombardier CL-600-2b19, tail number N431CA, bound for Atlanta, Georgia, around 6:35am on August 27, 2006.

“ComAir 191 Lexington tower… cleared for takeoff…” replied the air traffic controller to the ComAir pilot.

Air traffic controllers and pilots point to that radio call as a turning point in public aviation safety.

“…cleared for takeoff one ninety-one,” went the command from the tower.

But instead of taking off, ComAir 5191 crashed into heavy woods off the end of runway 26 in Lexington, Kentucky.

The accident killed all on board except for the first officer, 49 people in all.

The next radio recording showed the air traffic controller called fire rescue to respond to the end of the runway where a fireball had just erupted.

“Off the approach end of the runway eight…” said the air traffic controller.

An official National Transportation Safety Board investigation later determined fatigue in the control tower was a contributing factor in the crash.

The NTSB found that only one controller was in the airport control tower at the time of the accident. The controller had had only a couple of hours of sleep.

The NTSB found that the air traffic controller had been fatigued and distracted by other work and failed to warn ComAir 5191 that it was on the wrong runway, runway 26, instead of runway 22. Runway 26 was half as long as runway 22, half as long as needed to safely take off.

Click here to read the entire NTSB into the ComAir 5191 crash

“If that was not a wake-up call back in 2006 and the FAA did not heed it there probably is no hope for the FAA,” said former air traffic controller Robert “Rob” Misick.

The accident in Kentucky and the contributing causes later determined by the NTSB, convinced pilots, controllers, even some regulators that the system is being pushed to the limit and that fatigue in the control tower is a more serious threat to safety than many realize.

“Someone has definitely been asleep at the switch,” said Misick. “(And) it’s not the air traffic controllers. They’re working the shifts that are assigned to them by the FAA.”

Misick worked as an air traffic controller in South Florida for years. He left the control tower about five years ago. In the years since he left, Misick has been an outspoken critic of the FAA, its scheduling and its safety culture.

Misick has written a book, due out this spring, which is critical of the FAA and its treatment of air traffic controllers.

“It (fatigue) has happened before,” said Misick. “This (problem) has been going on for many, many years.”

But until very recently, the FAA failed to act until more incidents got national attention, such as a controller supervisor working alone found asleep in the tower at Reagan National Airport in Washington D.C. in March.

“United 628, just so you’re aware we just had one aircraft go into DCA (Reagan National Airport in Washington, D.C.) and the tower is apparently unmanned,” said one pilot to another. The conversation was captured on a recording of a radio conversation from that day, March 22, 2011, when two planes landed at the airport with no assistance from the Reagan National tower.

“Ah, tried to call a couple of times and there was no answer,” said one pilot on the recording.

After that incident, there have been at least six other sleeping incidents in places such as the air traffic control tower in Knoxville, TN, in Miami International’s radar room and in the tower at Reno, Nevada.

In the Reno case, an air ambulance could not get through to the tower to land and was forced to circle the airport.

“Were you able to get through to the tower?” asked one pilot “No,” replied the air ambulance’s pilot. “Tower? Tower? We’ll keep circling around.”

The CBS4 I-Team Investigative Reporter Stephen Stock has obtained a confidential internal white paper produced by the FAA and the National Air Traffic Controllers Association which dates back more than 2 years.

Click here to read a full copy of the internal white paper

One page of the white paper shows “14 accidents with 263 fatalities since 1993 with fatigue as a casual or contributing factor…”

And “Acute fatigue occurs on a daily basis” in control towers across the country.

The I-Team also uncovered three different scientific studies dating back to the 1990’s which warn of daily fatigue in the control tower.

Click here to read NASA Ames Research

Click here to read the Construct of Fatigue: A Model for Aviation

Click here to read Sleep Deprivation in  Air Traffic Control Communities

“Certainly no one in the FAA can say they didn’t know that this was a problem and that they’re surprised at what’s going on,” said Rob Misick.

The CBS4 I-Team dug even further and, for the first time in the country, uncovered Aviation Safety Reporting System (ASRS) data.

ASRS is a system where pilots, controllers and others anonymously report aviation safety issues.

The I-Team found 125 different reports where fatigue in the control tower caused a safety concern.

The I-Team also found 290 other cases where a controller’s workload caused a safety concern.

Mike Frier is one of a half-dozen pilots who spoke to CBS4’s I-Team about this issue.

Frier has flown commercial airplanes for a dozen years.

“It does raise a flag and it should,” said Frier. “I think if a controller is fatigued he or she should be able to say look I’m too tired to function properly (and not have any repercussions from FAA management.)”

I-Team investigator Stephen Stock asked Frier, “So what happens when you call the tower and no one answers?”

“That’s a good question,” Frier said, noting he had landed without anyone in the control tower before but only when he knew that was going to happen ahead of time.

“They (air traffic controllers) are providing another layer of safety,” said Frier. “And when you expect that layer to be there and it’s not, all of a sudden throws a crink into your entire plan there. And (this happens) at the most critical moment during a flight, the landing.”

Herb Hunter has flown commercially for 32 years, the last seven years as captain of a 747.

“It concerns me of course,” said Hunter. “But I’m on the other side. Fatigue is an issue with pilots too. So of course you don’t want anybody asleep at the wheel up there in the tower.”

“In a world where every dollar counts, where you’re cutting pay you’re cutting benefits, you’re having fewer people working longer hours, the job’s getting harder and you’re forcing good people out (by these FAA work rules and schedules),” said Hunter.

Perhaps most troubling, the I-Team learned that the number of operational errors by air traffic controllers nearly doubled from 947 operational errors (OE’s) in 2009 to 1889 OE’s in 2010.

That, experts told CBS4, further calls into question, the issue of safety from the control tower.

Yet it wasn’t until just two weeks ago that the FAA added a second person on the midnight shift in twenty-seven air traffic control towers across the country, including those at Fort Lauderdale\Hollywood International Airport and Fort Lauderdale Executive Airport.

The CBS4 I-Team caught up with FAA administrator Randy Babbitt when he was in Miami Beach recently, to ask about this threat to public safety.

“We had a team that did some very important work looking at fatigue in other parts, mechanics, pilots and so forth,” said Administrator Babbitt. “We’re investigating all of these incidents (of controllers falling asleep.) We may have to change some of our scheduling practices and work with the controllers to make sure that this never happens again.”

That’s not good enough for former controller Rob Misick who said the FAA should have acted a lot sooner by changing schedules and revising rules to reduce fatigue in the control tower, before these recent stories hit the national news.

“The buck’s got to stop somewhere and it’s got to stop with the FAA itself,” said Misick.

In fact, the I-Team has learned that, for years the NTSB has pushed the FAA to ease the burden of fatigue on air traffic controllers.

In fact, the NTSB put out a brochure calling for the FAA to address fatigue in both pilots and controllers immediately!

The brochure came out in 1990!

Click here to read the brochure

The CBS4 I-Team did obtain this memo of agreement between the FAA and the air traffic controllers’ union which increases the REQUIRED sleep/rest time between shifts to 9 hours.

Pilots and air traffic controllers who talked with the I-Team in exchange for anonymity told Stock, that may not completely solve this problem but they said it’s a step in the right direction.

Click here to read Fatigue Mitigation Implementation Plan Memo

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