Incapacitation of an Air Traffic Controller at McCarran, Las Vegas Tower
Bernard Gonsalves
On a Global Mission to 'Optimize the Sky'. Director-Founder at fliteX, Director IFALDA
A perfect cocktail of staffing, night shifts and professional integrity..... gone sour
"Incapacitated" says the FAA.
The Oxford Dictionary describes it as ... "Prevent from functioning in a normal way". e.g. ‘she was incapacitated by a heart attack’
Or…. in the case of the solo Air Traffic Tower Cab Controller, late Wednesday, November 7 at McCarran, Las Vegas who clearly failed her walk & speech test.
“Is there somebody up there that knows what they’re doing”?
There were reportedly five inbound aircraft and several taxiing when the ‘incapacitation’ occurred. For an estimated 30 minutes, Pilots landing, taxing and taking off remained completely befuddled. The controller’s slurred words and slow speech was quite obviously a bad enough condition to be walking out of a late-night bar at closing time, let alone Controlling airplanes out of the 7th busiest airport in the US.
Several pilots first sounded surprised and eventually took to making their own decisions when it became quite obvious she had ‘lost it’. They talked among themselves about the issues in the tower; to question the Controller’s basic abilities to actively control. One Spirit pilot suggests that they all “call their respective companies to get an update for what’s going on”. Others still airborne, just opted to get into a hold to avoid obvious disaster from simply following the incomprehensible clearances. American 2785 on a hold-short clearance struggled to get back their call-sign after 4 incorrect tries.
Take a listen to the tapes from LiveATC.net showing a rapid degradation in the controller’s performance as it started to go berserk at about 11:09 p.m. local time. The Controller started coughing and slurring words. By about 11:30 p.m. she was mixing up call signs and taxi instructions. The pilots are heard – confused for call-sign read-back, frequency assignments and taxi instructions. Her speech rapidly grew more irrational and incoherent and at one point a United pilot wonders “is there somebody up there that knows what they’re doing.” Other pilots start asking if there are any other controllers in the Cab. Another broadcasts to all traffic on the tower frequency that “something’s wrong.” The controller then comes in to say she’s “choking a little bit” and fails to respond to several calls, including one from Frontier on a visual approach to Runway 26L. The controller keys her mic briefly while coughing and choking on a ‘hot mike’ ... that finally goes silent. At about 11:47 the second controller returns about 30 minutes later and informs all the traffic to “standby one… I have taken over… will be right back with you”.
Fixing Sleeping Lapses
Earlier in 2011, a slew of at least 4 successive incidents involving air traffic controllers falling asleep on duty sparked widespread calls for reform and increased oversight. There was a wave of unanswered nighttime calls by concerned pilots to control towers. Hank Krakowski, who headed the FAA's ATO at that time resigned in April that year. These incidents caused the FAA to increase midnight shift staffing at 27 key facilities.
A medical flight with an ill patient on board was forced to land in the wee morning hours in Reno without receiving a landing clearance. The sole controller on duty appears to have been sleeping. A similar incident occurred at Reagan Washington National. Later in the same month, on the midnight shift again at Reagan, controllers failed to hand off control of a departing aircraft to the Fort Worth ARTCC. In April 2011 a controller fell asleep in the tower at Boeing Field/King County Airport in Seattle.
The FAA Staffs to Traffic
The FAA has done fairly well as it has over the many years as it “staffs to traffic,” matching the number of air traffic controllers at its facilities with traffic volume and workload. A primary driver affecting controller workload is the demand created by air traffic, covering both commercial and non-commercial activity. With the rash of “sleeping at the console” incidents however, a national debate on Air traffic controller staffing quickly heated up in Congress and in 2016 culminated in a string of critical reports, one such from the Transportation Department's inspection general. The report however centered on the FAA’s funding ability rather than Controller performance. The FAA and rightly so, promptly ruled to increase midnight shift staffing at these 27 key facilities. This includes McCarran, Las Vegas.
The Hagelian Dialectic – 'One Controller working alone is bound to make mistakes'.
NATCA- the US Union rightfully acclaims …. "We are proud of our safety record both there and at every facility and will continue to work to keep our airspace system the world's safest."
Established in 1982, the FAA launched a Contract Tower program overseeing 250 contract towers providing ATC to airports nationwide. In 1994 NATCA filed a lawsuit against the FAA challenging not only the value of contracting, but the agency’s ability to launch the program in the first place.
Evaluations from a sample of 30 contract towers conducted between May 2006 and September 2010 identified a total of 156 deficiencies at the 30 contract towers and 338 deficiencies at the 30 FAA towers. Anecdotally and in the ensuing debate NATCA aggressively questioned the quality of service at contract towers. It claimed that solo Controller staffing “is dangerously inadequate” and that controllers at contract towers were not afforded the same quality and quantity of training as FAA controllers.
The discussion was focused largely on cost savings in determining the formulae used by the FAA for the value of contract tower cost savings. The NATCA’s contract tower representative suggested “Safety is certainly an issue from a staffing perspective. Employment standards are different and contract towers are permitted to hire controllers who would not qualify for FAA employment. One controller working alone is bound to make mistakes.”
Working alone approximately 50 percent of the time, NATCA attributed such Contract Controllers as a direct causal factor related to the midair collision that occurred at Chicago Meigs Field in 1997 and Chicago/Waukegan tower. All said and sorely missing the point in this entire debate is the performance of an “incapacitated controller” albeit solo or paired.
Does Incapacitation require a different approach?
Back in July 2015, Police arrested an Arkansas air traffic controller for allegedly being drunk on the job. This Controller was found passed-out in his chair with his shirt off at the Springdale Municipal Airport. A Cab employee was sent up to go check on the 50-year-old man after a pilot's repeated requests for clearance to land were ignored. The Controller denied being drunk and also refused to take a breathalyzer test. As it ended up, press reports state; he was arrested for public intoxication and resigned from his job over that weekend.
Earlier in July 2011, the FAA removed an enroute Denver Controller from his position after he failed an alcohol test. During a routine, random test, the veteran controller was found to have a blood-alcohol level exceeding the allowed limit. The controller was more than six hours into his eight-hour shift.
Performance at the Tower Cab
Controllers working in tower cabs manage traffic within a radius of a few miles of the airport. They instruct pilots during taxiing, takeoff and landing, and they grant clearance for aircraft to fly. As traffic, workload and complexity decrease, positions are combined and minimum staffing kicks in.
The tower cab staffing models were updated in early 2008. The revised tower cab staffing models were developed using regression analysis as the primary method for modeling the relationship between staffing and workload drivers.
The FAA also supports a recurrent training program, administered every six months. It is a combination of classroom and computer-based instruction for all operational personnel. FAA’s staffing models are generally based on the
a. output of mathematical models used to relate controller workload to air traffic activity
b. past productivity of the facility, and
c. productivity of similar facilities.
The question that arises in view of the ‘Incapacitation incident’, November 7 then is if there is room in this model for observational & behavioral metrics to monitor and manage risks of inebriated solo controllers as they go about their on-job tasks?
Is Staffing the solution?
For sometime now, the FAA has required two controllers to be in the tower cab working traffic until a certain time based on shift periods and traffic levels. After the McCarran incident, it reversed its existing policy which allowed the combining of positions - or single staffing in the tower - before midnight. It now rules that facilities will not combine to one position prior to midnight or 90 minutes after the start of the shift, whichever is later.
The incapacitation incident has also been picked up by a House member. “I’ve been briefed on the incident that occurred at the air traffic control tower at McCarran and am awaiting further details, but I find the initial reports deeply disturbing,” U.S. Rep. Dina Titus said in a statement last week. Titus is a member of the House Subcommittee on Aviation.
Bad Apple Theory- Funding, Fatigue or Negligence?- Three 'Hail Marys'
1. Oversight: The FAA Office of Aerospace Medicine (AAM) is responsible for oversight and enforcement to a broad range of medical programs, Drug & Alcohol testing being one of them.
According to AAM, “Drug and alcohol testing of safety-sensitive aviation employees helps protect public safety and keep our skies safe. Testing is required by the Omnibus Transportation Employees Testing Act of 1991 and by DOT and FAA regulations (49 CFR part 40 and 14 CFR part 120)”.
It is certainly enforced on airlines by inspecting each airlines’ in-house testing program. Controllers are included in the list of Employee Categories under this program.
2. Investigation: The recent Air Canada 759- Airbus A320-211incident of July 7, 2017 involving 4 other aircraft in SFO sets the stage for a similar investigation by the NTSB. The outcome included 19 findings and 7 recommendations that the Board hoped would prevent a similar mishap occurring in the future.The NTSB as an independent Federal agency charged by Congress with investigating civil aviation safety could be called on to review this incident. In its Mission statement of making transportation safer by conducting independent investigations and advocating for safety improvements, it could be called upon to render the Board’s rationale for the conclusions, probable cause, and safety recommendations to Controller Incapacitation.
3. Enforcement: With a single controller position being a reality both in FAA Towers and Contract Towers, it still calls for a reinforcement of current FAA policy, whereby controllers are removed from safety sensitive positions if they have a blood alcohol concentration of 0.02% or higher, and formal proceedings are taken if the level is 0.04% or higher.