A 21-page report by the U.S. DOT Office of the Inspector General points to air safety threats caused by air traffic controller fatigue in Chicago while recent runway incidents in Cleveland and Boston have resulted from training and operational miscues.

The OIG investigation concluded that controllers who direct planes in and out of Chicago's O'Hare International have too little time off between shifts, a factor that contributes to fatigue and could be a safety threat.

The report criticized the Federal Aviation Administration (FAA) for not acting sooner to alleviate controller fatigue at three Chicago-area air traffic control facilities and recommended immediate changes.

The investigators identified a number of issues at the three facilities that could create potential fatigue conditions for controllers. These include minimal hours between shifts; scheduled overtime; and on–the–job training (OJT), which requires a high level of concentration and focus from the instructing controller. Facility personnel also identified other factors that could cause fatigue, including inadequate staffing levels, increased workload and extended time on position or lack of position rotation.

They found that certified controllers at all three facilities conducted OJT on a regular basis. “The time spent conducting OJT in our samples ranged from one to five days per week, and officials at all three facilities cautioned that OJT is expected to increase significantly over the next several years as more trainees are added to the workforce,” stated the audit.

The report said the FAA has failed to act on longstanding National Transportation Safety Board (NTSB) recommendations on controller fatigue and that the federal aviation agency "does not consistently address human factors issues, such as fatigue and situational awareness" when operational errors are investigated.

The report noted that the FAA has begun actions to address the NTSB recommendations regarding fatigue, such as increasing the time available to controllers for rest between shifts. FAA has also developed a computer–based training module on the effects of fatigue on controller performance. But at the time of the on-site review, none of these actions had been implemented at the three facilities.

The OIG report included recommendations, including increasing rest periods, rotating controllers through less demanding positions during each shift and providing fatigue awareness training.

The audit was conducted between January 2008 and February 2009 at the O’Hare tower, the Chicago Terminal Radar Approach Control Facility and the Chicago Air Route Traffic Control Center.

“While our review focused on only the three Chicago facilities, it is likely that the fatigue factors that we identified exist at other large air traffic control facilities throughout the nation. Our recommendations focus on actions FAA needs to take at the national level to mitigate potential fatigue factors and enhance the level of safety of the National Airspace System,’ the report stated.

The controllers union said the government report confirmed that air safety is threatened by tired controllers.

"We have expressed our concerns about controller fatigue for several years, only to have them fall on deaf ears at the FAA, which has ignored NTSB requests to meet with us and work on fatigue issues in a spirit of collaboration," said Patrick Forrey, president of the National Air Traffic Controllers Association, which represents about 15,000 of the nation’s controllers.

Meanwhile, the Safety Board is investigating two runway incursions in the past month at Cleveland Hopkins International involving the same student controller. Both incidents involved a “developmental” controller working under the supervision of fully-qualified colleagues.

The first incident occurred on June 3, when Southwest Airlines Flight 1080, a Boeing 737, was cleared to taxi onto a runway for takeoff. The controller also had given clearance to Continental Express Flight 2942, an Embraer 145 regional jet, to enter the runway. The Continental Express crew saw the Southwest Boeing 737 and queried the tower controller. The jetliners came within 500 feet of each other, the NTSB said.

Three weeks later, on June 26, Express Jet Flight 2426, an Embraer 145 regional jet, was cleared by the same tower developmental controller to cross Runway 24L at Taxiway S in order to depart from Runway 24R. Approximately 19 seconds later, the same controller cleared CommutAir Flight 8717, a de Havilland DH-8, for takeoff on Runway 24L. The Express Jet flight crew saw the departing airplane and advised the tower controller they would not cross the runway. CommutAir 8717 rotated about 1,500 feet from where Express Jet 2426 was positioned.

On Thursday, June 18, a runway incursion occurred at Boston Logan International (BOS), involving a US Airways Airbus A320 (N662AW) and a construction vehicle. The construction crew crossed Runway 15R at Taxiway M without approval as the Airbus was on departure roll.

According to the FAA, the operator of a Ford Explorer, was not in radio communication with BOS tower air traffic controllers and had not been cleared to cross Runway 15R. The A320 rotated approximately 500 feet from the intersection of Runway 15R and Taxiway M as the vehicle cleared the runway edge southbound on Taxiway M. The FAA said it appeared the tower controller was aware of the vehicle operating on taxiway M, but not its intension to cross. The ground radar alerted the controllers of the event.

Taxiway M is currently under construction and Runway 15R is occasionally closed due to the work. The Airport Authority notifies work crews of the runway closure with warning signs, which were not in place during this event, indicating that the runway was an active runway.

The Airport Authority also indicated that all personnel were briefed that the runway was active. The driver of the vehicle indicated that he had not been briefed to that fact.

The driver was suspended from driving on the airport pending an investigation and the Airport Authority ceased all construction through completion of the investigation into the incident.

USAirways Flight 27 was departing Boston for Phoenix, AZ with 84 passengers and five crewmembers.

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