Feds Say Air Controller Slept 2 Hours

August 31, 2006, 4:57 AM EDT

LEXINGTON, Ky. -- In the day leading up to the crash of Comair Flight 5191, a federal investigator says the air traffic controller on duty had worked for almost 15 hours and slept for two.

National Transportation Safety Board member Debbie Hersman, the lead investigator in the crash that killed 49 people, said in her final briefing before leaving Lexington Thursday that the controller had only nine hours off between work shifts Saturday.

That was just enough to meet federal rules, which require a minimum of eight hours off between shifts, Hersman said.

"He advised our team that he got approximately two hours of sleep," Hersman said.

http://www.newsday.com/news/nationworld/nation/wire/sns-ap-kentucky-crash,0,3774054.story?coll=sns-ap-nation-headlines

The Pilot in Command WAS..

the families of the people who died on the plane care.

The runway was too short, The pilots eyes would have told them that, IF he was looking. No lights on the runway.

It was not the controller that was flying that plane!!!!!!

We'll just depend on pilots to use their senses sensibly and everyone will be safe

pilots that FU.

FYI, my inactive license reads "Airplane Single & Multiengine Land"

I learned to fly on a 3200 foot runway.

On a multiengine commercial plane on takeoffs BOTH pilots have their hands on the throttles. If ANYTHING goes wrong the FIRST THING that must be done is pulling the throttles back.

There were lights on the taxiway and on the longer runway just not on the short one, that should have been a major clue that something was wrong.

That much is a given certainty in NTSB reports on airline emergencies. There are a series of events that line up in just the right way and at the right time to have a fatal accident. While it may not seem that important, the controller having only 2 hours of sleep may have in some way have been a contributing factor to the aircraft accident

And of course, it's safety that NTSB is worried about, that's why they do these intensive reports. I'm sure you've read many of them, they're quite long and quite detailed. Perhaps the 2 hours sleep of the controller was the last click on the sequence of events. Perhaps he could have noticed that the aircraft was lined up on the wrong runaway. The chances of his noticing this and his cognitive abilities go downhill with only 2 hours of sleep.

Yes, it seems that errors in judgment by the captain and the first officer were the major reason for this accident, but it's not the only reason.

I'm sure you know there is no such thing as "Pilot Error." From my extensive research on aviation accidents, I can think of no incident during the last 30-40 years in the US that that can be solely attributed to pilot error. The only incident that comes to mind was the AeroFlot flight where the captain let his teenage kid fly the plane and he drove it into a stall/uncontrollable spin, killing everyone.

During my 30+ years with TWA I attended annual federally required recurrent (refresher) training.
One of the most fascinating classes I experienced was called "Breaking the Chain".
Examination of the significant events leading up to every aircraft incident or accident shows the final mishap to be the result of a series of errors of omission or comission.

Several cases were studied, and in every one there were opportunities (usually more than one) to avoid the unfortunate outcome.

Many were the result of just a distraction in the cockpit.
A flight attendant coming up to ask a question during the reading of a checklist.
Or a radio call from ground control.
When the checklist is continued, an item is missed, with sometimes deadly results.
TWA came to institute a couple of new rules.
If a flight attendant came into the cockpit while a checklist was being read, they remianed silent until they heard "Checklist complete".
If the reading of a checklist was interrupted for ANY reason, you started all over again at the very top.

The captain might "guard" the throttles during a co-pilot take off.
Woe be to the co-pilot who would do that on the captain's take off.

a slight rise that cuts off the view of the end, so if they didn't realize they were on the wrong runway, the visual would have not given the appropriate clue.

was the pilot's fault.

It is theoretically possible for there to occur an accident in which the air traffic controller is not at fault. Or vice versa.

....THEN didn't get on the right runway...sounds like they were drunk or something if that's true. :shrug:

AND one person on duty in an air traffic control tower is the FAA's FAULT...that shouldn't have ever been allowed either. :grr:

...fatigue. ComAir (and most of the feeder airlines) pay amazingly low wages to their pilots and co-pilots.

Would you believe $15,000.00 to $25,000.00 per year? That's after paying for their own training and uniform costs, so he might have been tired from his second job.

The pre-flight briefing says your aircraft is at gate 21, so you walk out to the gate and there's the airplane. Many times, from close-up on the ground, it's difficult to see the tail number.
More than once I've gotten on the wrong aircraft because a last minute change had put ours at another gate. I was pretty sober most of those times.

The big tip-off is usually no cabin crew and no passengers.
;-)

The FAA has been abusing its controller workforce lately. They've been trying to "cut expenses & run it like a bidness" but at the same time they've increased the supervisory ranks & spent money flying every manager to STL for briefings on a new "non tract" that will make all controllers wear spiffy new clothes because dressing up has something to do with directing traffic. Someone fire Marion Blakey NOW!

as an almost 30 year Flight Attendant with a major carrier many times pilots and/or flight attendants will get on the wrong airplane due to numerous reasons, it has nothing to do with the crash. That is the msm trying to make more headlines. Let's be responsible and not make a horrible situation worse by suggesting something we know nothing about.

<http://www.newsday.com/news/nationworld/nation/wire/chi-0608300167aug30,0,218478.story?coll=sns-ap-nation-headlines>

would have seen that he was on the wrong runway and stopped the pilot before they started rollout.

but ppl should not be trying to blame the controller not eyeballing the plane until it was in the air.

after giving the plane clearance to take off while it was still taxiing to the runway. That is unacceptable. The flying public should not just have to depend on the pilots. The controllers also have a responsibility.

The controllers are much more familiar with an individual airport than the pilots are. Not that the pilot isn't culpable, but controllers guide planes right up until they're ready to blast down the runway.

is this what how you want air traffic controllers working? Solo? Two hours sleep between shifts? I routinely work hours much, much worse than is being described, but no one will die if I make a mistake because I got no sleep or I'm doing my own job and someone else's job too.

...sick or tired to the workplace. Now, some people don't have a choice bcause their finances are a mess and their bosses are jerks. I could easily see that being the case here, in which case it is management's fault for understaffing.

But there are some people who just really need to learn when to call in.

He informed them that he was working off two hours sleep and was already the victim of poor scheduling. Management understaffed thier team and that's what they got.

are dead.

FAA is at fault for not enforcing their own regulations and for not requiring proper safeguards to prevent a plane from taking off on the wrong runway.

The controller is at fault for not making sure the plane was not lining up on the correct runway before giving clearance to take off.

The airport operators were at fault for not marking the runways more clearly.

The pilots were at fault for not checking their heading and for not noticing that there were no lights on the runway before they began to roll.

Human error all around. As with most tragedies, it is not just one mistake that is the cause. That is why there are redundancies and safeguards, and yes - regulation. It costs money. We get what we are willing to pay for.

GOP does not like govt. and they run almost every thing badly. Plus we seem to have crooks into every thing now. The Gilded Age is with us once more.

--

firing the controllers in the 1980's and our current administration's budgeting. Not enough hands and feet to do the jobs needed while we waste lives and treasure on the "Fool's Errand" that is Iraq.

...ALL of them. I mean, that idiot just canned every single one of them for daring to demand shifts that made lives safer.

And yes, this is fallout from that time. The other shoe that's about to drop is that nearly all the ATCs are the same age (having been hired all at once to replace the ones that were fired) --- and they are going to retire in one big wave.

Hekate
:argh:

Next they will be training illegals to do the job.

He has always told me that the government wanted to make it sound like it was about wages, but it was really about the antiquated equipment and unreasonable working conditions. He worked in the Radar Control Center in Fremont, ca. Somethings when they would have a morning shift , after a swing shift, they would go across the street, have a couple of drinks to wind down and then sleep in their cars. He sometimes would have up to 17 aircraft , maybe a half commercial planes, and the old out dated computers would go down. He says getting fired from that job was the best thing that ever happened to him.

Your state. It has to be done by a joint team of locals and the people who are going to build the road. The GOP seem to have a way of running govt. like they do IBM as a top down group. Plus the profits, which they want their friends to have, but then govt. is a service and not a profit making company. I just do not think the GOP understand this at all.

They want some heads to roll, but it won't be the FAA -- we all know they're infallable. And it won't be ConAir -- they're a corportation and therefore first citizens of the US. So they need some patsy and I guess the air traffic controller's turn in the barrel is just going to be longer.

Bastards.

.. that in the vast majority of this kind of accident that there are multiple points of failure.

Yes, the pilot should have found the right runway, but then it's my understanding that in airports where the ATC tower is positioned such that the runways can be seen by the controler, that visual confirmations are generally done.

It seems like there were at least 3 factors contributing:

1) the flight crew - hit the wrong runway, didn't even ask why no lights
2) the controller- did not visually confirm
3) the airport - did not mark the runway as closed in any meaningful way

Hello to all on my Aviation List.
This is a hard hitting report from an unknown pilot who seems to know what he's talking about.
It is not for the faint hearted. I don't know the author.
And, please don't shoot me...I'm only the messenger.
Len
First an intro...



A pretty simple formula here:

* Extraordinarily poor pay, working conditions & benefits at Comair = minimally qualified & inexperienced pilots are hired.

(who else is going to do the job anymore with crappy pay and no pensions...certainly no more incentive for military pilots to leave early to fly for an airline, when you can stay in the military and make similar senior-pilot pay and still get a lifetime pension and medical benefits. Likewise, what pilot students' want to go to Embry-Riddle University and spend $200,000+ getting a degree and learning to fly, only to go get a shitty job after graduation? Pay at the commuters starts at $1,800/month and tops out at $50K-60K/year after 12 years with no pension...you can almost make that at a fast food restaurant. Pilots are quitting in droves for better careers elsewhere...even the senior guys...as you know I quit early because they terminated our pensions and medical benefits...and I wasn't the only one)

* Inadequate scheduled overnight rest = fatigue

* Inexperienced crew + fatigue = accidents

Here's a real good preliminary explanation of the Comair crash...and why it will most likely happen more frequently than in the past.






--------------------------------------------------------------------------------

Aviation disaster --a pilot's view

A pilot/writer posted this at another writing site. He gave permission to repost this here because it is both relevant & important.

Here's his email....FYI

I live in Lexington and have thirty years of airline experience flying inand out of LEX. I was also the Delta station liason for Lexington for ten years .

Here is what I think happened:

The two runways in question share the same common run-up area. The extended taxiway to the correct runway, runway 28 was closed due to construction. It has always been difficult to tell between the two runways when you are taxiing out. The natural thing to do is to take the wrong one. It is just there and you are always tempted to take it. When I flew out of LEX we always checked each other at least three times to make sure we were taking
the correct runway. We checked the chart, we checked to make sure the
correct runway number was at the end and we always double checked the FMS generated moving map.

Most FMS systems will have a warning called "runway dissimularity" pop up in magenta when your position at takeoff doesn't match the runway you programmed into the computer. This would not happen at LEX since you are virtually in the same spot when you take either runway.

It was also raining at the time of takeoff and dark. The control tower opens at 6am (because we are, after all, all about saving money) and only has one controller on duty at that time. He or she has to: run ground control, clearance delivery, approach control and departure control. The one controller also has to program the ATIS and make the coffee. He or she probably cleared comair to take off and then put their head back down to do a chore or work another airplane.

Taking the runway, the comair guy would put the power up and wouldn't realize they were on the wrong runway until they were about 70% down the pike. Too late to safely abort so he probaby decided to try and continue the takeoff.

This is when the eye witnesses heard a series of explosions and though the plane blew up in the air. Didn't happen -- what they heard and saw were compressor stalls of probably both engines. The pilot no doubt pushed the throttles all the way up and that demand to the engines combined with the steep pitch attitude cut off enough air to the intakes to cause the compressor stalls -- which, by the way, made them even more doomed. Less power.

They stalled or simply hit one of the large hills to the west of the airport and came to a stop. Everybody on board was probably injured but alive. Then, a second or two later the post-crash fire began. With the darkness and the fact that most of them had broken legs, pelvises and backs they literally burned alive. Not smoke inhalation. They really actually burned to death.

In my role as station liason I wrote most of the post crash safety procedure for Delta at that field. Too bad there weren't enough survivors to use them.

BTW, comair and the press will tell you what a great plane the RJ is. This is a total lie. The Canadair RJ was designed to be an executive barge, not an airliner. They were designed to fly about ten times a month, not ten times a day. They have a long history of mechanical design shortfalls. I've flown on it and have piloted it. It is a steaming, underpowered piece of shit. It never had enough power to get out of its own way and this situation is exactly what everybody who flies it was afraid of.

The senior member of the crew had about five and a half years of total jet experience. The copilot less. They had minimum training (to save money -- enjoy that discount ticket!) and were flying a minimally equipped p.o.s. on very short rest. The layover gets in about 10pm the night before. They report for pick-up at 4:30am.

I'm sorry if I sound bitter but this is exactly the direction the entire airline industry is going. Expect to see bigger more colorful crashes in the future.

email me if you need an off the record so-called expert. I have 20,000 of

heavy jet flying time and am type rated in the 727, 757, 767, 777, DC-8,

DC-9 and L-1011.

Looks like the probable course of events.

airlines but that the last leg of the trip is usually with some little commuter outfit working for the big guys. The big guys get the cash but they cut their costs by jobbing out the last leg.

The flight crew probably had only about 4 hours of sleep between landing the night before and the morning flight.

I don't ahve a link but I read in the Times the other day that the FO had landed 27 or 37 hours before TO & the captain had landed at least 12 hours vefore.

Not 12 hours.

People I know that are controllers often get off work at 2pm and go back at 11pm where they split a night shift.

Happens everyday.

they're staffing the towers in a business like fashion. Instead of having a minimum number of controllers, they're adding more just during busy times like during peak holiday travel times. Translation: the guys in the tower (and maybe in air traffic control?) are going to be pulling multiple over-time swing shifts just when traffic is busiest.

Felling safe, anyone?

that's what I've heard from a commercial pilot who's familiar with Comair practices. The pilots had a very short turnaround from the flight they'd landed the night before, and were likely not up to par. Also, the re-paved runway must have been confusing in the dark -- and the runway wasn't lit up!!!

And the website it came from:

<http://download.aopa.org/ustprocs/20060803/SE-1/lex_airport_diagram.pdf>

<http://www.lexingtonflyingclub.org/links.html>

More interesting info: <http://flightaware.com/news/story/51>