NTSB Links Controller Fatigue To Comair Crash At LEX
In formal safety recommendations issued yesterday, the National Transportation Safety Board tackled the issue of controller fatigue, suggesting the FAA and the National Air Traffic Controllers Association (NATCA) work together to "to reduce the potential for controller fatigue." The recommendations, numbered A-07-30 through -32, come during the NTSB's investigation into the Aug. 27, 2006, fatal crash of Comair Flight 5191, a Bombardier CRJ-100, which attempted taking off from a too-short runway at the Blue Grass Airport, Lexington, Ky., in pre-dawn hours. Together with earlier recommendations to the FAA, yesterday's action begins to paint a picture of what the NTSB may conclude was the accident's probable cause. According to the NTSB, the single on-duty controller at LEX that morning "had worked a shift from 0630 to 1430 the day before the accident," returning nine hours later to work a shift beginning at 2330. The controller's only sleep in the 24 hours before the accident was a two-hour nap between the two shifts. And, FAA supervisors apparently scheduled the controller to be alone in the tower at LEX, apparently violating the agency's own staffing rules.
In its recommendations, the NTSB suggested the FAA and NATCA work together to revise "controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance." The Comair flight, which had been cleared to depart Runway 22, taxied instead to the much-shorter Runway 26 and began its takeoff roll. The CRJ ran off the end of Runway 26 and was destroyed by impact forces and a post-crash fire. Of the 47 passengers and three crewmembers aboard the airplane, 49 were killed and one -- the first officer -- survived with serious injuries. Yesterday's recommendations join others the NTSB has made to the FAA, including requests for a new Part 121 rule requiring flight crews to positively confirm and cross-check the airplane’s location at the assigned departure runway and for specific guidance to pilots on the runway lighting requirements for takeoff operations at night.