Contrary to a Federal Aviation Administration order, there was only one air traffic controller on duty at the time of the crash, and that controller was engaged in an administrative task. But at the meeting, the NTSB narrowly voted that the controller's actions were not a cause of the accident. The panel could not conclude whether the presence of another controller would have prevented the crash.
"The position of the staff is that [another controller] would not have given another set of eyes outside of the control tower," said Hilton Hall, chairman of the NTSB's Air Traffic Control Group, in his presentation to the panel. "They would have been downstairs at the radar screen."
Nine months before the crash, Duff Ortman, then the manager of the Lexington facility, wrote a memo to his staff that concluded that "our staffing rarely allows for a second controller to be assigned to the [midnight shift]." FAA supervisors had complained about understaffing at the facility as early as September 2004.
During their deliberations, NTSB members established a clear link between the accident and a subsequent decision to hire more controllers at the air traffic control facility.
"They got this verbal guidance that they had to have two staff on the midnight shift, and [the manager] did it until he couldn't do it [because he didn't have enough staff]," said Deborah Hersman, the NTSB member who led the on-the-ground investigation of the crash. "After the accident, how many air traffic controllers did they get to hire there in Lexington?"
"They hired four within the first six months, and two after," Hall replied.
"So he couldn't get the staff to do what he needed to do until after the accident?" Hersman asked.
"Yes," Hall told her.
The safety board recommended in April that the FAA adjust scheduling to make sure that air traffic controllers had sufficient sleep, improve awareness of the impact of fatigue on controller performance, and require controllers to undergo resource management skills training.
Hersman said that the schedule of the air traffic controller who was working during the crash "defines everything we know about fatigue. He was flipping days and nights -- he didn't have a lot of opportunity for sleep."
NTSB specifically recommended that the FAA work with the National Air Traffic Controllers Association on scheduling issues, which have become a political hot button since last September when the FAA imposed pay and work rules designed to increase managerial control over the workforce. The FAA is in the process of developing a fatigue awareness curriculum and has delivered resource management training at a number of facilities.
According to FAA documents, as of July 5 the agency was "convening a working group to develop shift rotations and scheduling guidelines," with no timeline for when those guidelines would be released or implemented. In communications last week with Rep. Ben Chandler, D-Ky., the agency cited formation of the working group as proof of its response to NTSB recommendations.
NATCA questioned the FAA's commitment to collaboration in the working group proceedings. The union claims that the panel is stacked with employees from the FAA's Air Traffic Organization division, and isn't giving equal status to the union's views, contrary to the NTSB's instructions.
"It's a sham," said Doug Church, NATCA's communications director. "They said they'd have controller subject matter experts who were invited to participate, but it's a lesser status."