Ten Years Later: FAA’s Pattern of Concealment After the Comair 5191 Crash

Among the greatest lessons learned from this year’s democratic party primary debacle was the complicity of the mainstream media in aiding corrupt party officials. Those leaked DNC Emails – nearly 20,000 emails total! – showed an incredible level of collusion between DNC officials (unapologetically hell-bent on defeating Bernie Sanders and nominating Hillary Clinton) and the mainstream media players (also corrupted, hell-bent in their lust for campaign advertising dollars).

Just to be clear, this was NOT a lesson about solely the democratic party; no, this was a lesson about the troubling reality of U.S. politics today… that We The People are being manipulated by the two dominant parties, using tools of propaganda. This is being called ‘engineered consent’ and, yes, this manipulation is being done by both oppressing political parties. In the process, the reigning duopoly that serves up ‘lesser-of-two-evil’ choices each cycle, has all but destroyed our so-called Democracy.

One critical tool of this manipulation is in the repetitive framing and reframing of so-called facts to crystallize acceptance of a historical perspective that fits the needs of the established political powers. We see this in politics, and we see it outside politics in retrospective news stories, for example. One of those retrospectives just happened again: the ten year anniversary of the horrific crash in Lexington, of Comair 5191. Here is a PDF copy:

Click on the image below for a scrollable view; the PDF file may be downloaded; or click here to view original source article.

If you read the article and research other U.S. aviation disasters, a clear pattern emerges: FAA’s response consistently is to hide disclosable information, obscure employee/management accountability, obstruct any proposal that would cost money, and delay-delay-delay on what few reforms are eventually emplaced. See for example the 10-year restrospective on the ValuJet Everglades crash in 1996, opined by FAA Whistleblower Gabe Bruno.

A few analysis points about the Comair/Lexington accident:

  1. FAA’s failures surrounding the Lexington crash were many. Not just the chain of seemingly tiny failures that led to the fatalities, but also the many, MANY efforts since to distort facts and reject long overdue safety and culture reforms.
  2. the principle cause of this accident was fatigue, for both the flight crew and the air traffic controller. This was perhaps the most important fact revealed by the extensive NTSB investigation. Cost-cutting by both the airlines and the FAA contributed to a combination of fatigued personnel that led to a chain-reaction of inattention, costing 49 lives.
  3. this accident should never have happened. The same combination of fatigue (in both the control tower and on the flight deck) had occurred over and over again, and continues to occur even today. BUT, the fact that aviation professionals can and will become bored/inattentive/fatigued is a given, and a key part of why so many redundancies are built into the aviation safety system. When simple redundancies – like, re-scanning the runway – are skipped, the system can and will break down.
  4. the controller, Chris Damron, simply failed to look out the window, not even once during the critical 2-minutes between when he issued a takeoff clearance and when he called out the emergency crews, nearly 45-seconds AFTER the crashed jet exploded in flames.
  5. just one look, during the critical 50-second window prior to start of takeoff (the time it took to move forward, turn onto and line up on the runway, finish the checklist and open the throttles), would have produced a quick transmission, cancelling the takeoff clearance.
  6. the transcript at the back of the 174-page NTSB investigative report shows the abrupt end of audio and data recording a half-second after the last audible exclamation by the pilots; thus, it appears that the explosion happened immediately, yet the controller did not make the crash phone call until another 44-seconds passed. It was a quiet Sunday morning, and there were no other airplanes. When he did make the call, his voice was markedly different, with a clear panic (the call was initiated at time 6:28 in the Crash Phone ATC recording, and the airport emergency crews picked up the call almost immediately).
  7. was the controller inattentive? Absolutely. He did not actually watch what played out, or he would have spoken up. He was either focused on nothing at all – resting while on position – or focused on another activity (distracted).
  8. was he possibly resting on position? Yes, quite possibly. It was the end of his workweek and the final hour of an overnight shift, so he was certainly tired. When fatigued while on position, nearly all seasoned FAA controllers do this: they physically rest, even shutting their eyes, while vigilantly listening to audible cues such as the power-up sequence. In this situation, with no other traffic, fatigued controllers are conditioned to apply an internal timer, reflexively waiting another half-minute or so after the last audible jet-noise cue, to then perform the next task for that flight – establishing radar contact on the digital radar display. While waiting, a common physical posture would have him reclined in his controller chair, eyes shut, but otherwise attentive and listening, much like a reliable watchdog. This is a strategy of fatigue management; it is practiced by both controllers and pilots. The pattern is repeated ad nauseum; it commonly creates a workplace boredom that can potentially become a lethal complacency, as happened at Lexington.
  9. how might he have been distracted? Three possibilities: he may have been doing other controller duties, he may have been doing administrative duties, or he may have been distracted with non-ATC activities.
    1. controller duties? not possible. He had no other controller duties to perform, since all his other traffic was gone.
    2. administrative duties? not plausible. The only excuse offered to investigators comes nowhere close to explaining nearly two minutes of inattention. The only cited administrative task was counting fourteen (14) 1″ by 8″ computer-printed paper strips, representing the entirety of his work the previous six hours. Any truthful controller will note this task I a quick finger-shuffling and recording a half dozen figures, thus would require less than 10-seconds. Any competent controller would perform this task quickly, only when traffic allowed, and then immediately scan the runway and airspace.
    3. non-ATC activities? very possible, and indeed likely, if he was not resting on position. He may have been reading, watching a movie or a TV show, playing a game on his laptop, online and surfing the internet, or texting with his cellphone device. In my FAA ATC career, I saw all of these activities routinely happening, and all were accepted by most on-duty supervisors as helpful strategies to manage fatigue.
  10. was the controller’s fatigue excessive and noticeable on the audio? No. Listen to the official Tower ATC recording and, frankly, Mr. Damron sounds professional, alert, and competent. His speech is quick and focused; he is clearly doing tasks that have been done many times before. He efficiently handles a departure push, with three flights to hubs at Chicago, DFW and Atlanta. There is no slurring and no hesitation. Based on this, his momentary inattention would logically happen ONLY if he was distracted into another activity such as using a digital device.
  11. were there larger national-level issues between FAA and NATCA? Absolutely. At the time this happened, controller morale was extremely low and FAA management was imposing draconian work rules onto all air traffic controllers. It was nearly three years later that a mediation panel ordered FAA management to abandon these imposed work rules (aka ‘The WhiteBook’).
  12. would a second controller have helped? Probably not. A few years after Lexington, in 2013, a fatigued controller lost two fatigued pilots when a UPS flight crashed at 4:49am on approach at Birmingham [KBHM]. One of his first actions was to use the tower phone system to call the other controller back to the tower. On overnight shifts, as another fatigue-management strategy, it is very common for paired controllers to alternate; one controller works the combined positions (which is generally easy, since traffic levels are very low), while the other controller can relax, catch a nap, or stay alert with other non-ATC activities (internet, DVD movies, music, studying, etc.)
  13. caused a near-midair collision in March 1989

    The TV set at another FAA tower, that caused a near-midair when a controller became distracted watching the NCAA basketball playoffs on a sunny Saturday in March.

    what does the controller probably want/need to say? As a retired ATC whistleblower, I spent decades working inside the ATC culture. I do know that concealment of facts is a big part of that culture. I also know that concealment is very destructive to those stuck concealing. My first whistleblowing was about a TV set at my first ATC tower, that was connected to a near-midair collision; I spoke up and endured retaliation, and was eventually fired 6-months prior to turning age-50, to force me to voluntarily retire at earliest eligibility. My gut-sense is that when the investigation started, Mr. Damron wanted to tell the whole story and was probably ready to talk, but was shut down. He would have had both FAA management and the union (NATCA) leadership scaring him into silence, with ample help from the attorneys brought in from the start. It is chilling to imagine his having to live today with the knowledge of what really happened, yet not be allowed to talk about it.]

  14. the controller’s identity was protected for four months, even though the identity had to be revealed eventually. A basic purpose of the NTSB investigative process is to give the public some transparency on transportation safety issues. FAA’s initial opacity was a classic knee-jerk reaction: acting from bureaucratic fear, protecting culturally entrenched failures from becoming exposed, and hoping to salvage what they could by over-controlling the flow of information.
  15. an initial effort was made to pin the blame on the Lexington tower manager, Duff Ortman. This failed when emails soon emerged, showing how Mr. Ortman was rebuffed in his many efforts to secure resources needed to cover the staffing: either two additional controllers, or an increase in allowed overtime funding.  The emails included comments by Eastern Terminal Services Director John McCartney, attempting to brand Mr. Ortman as a ‘renegade’.
  16. TVs, DVD movies, and other workplace distractions have been documented elsewhere and in numerous national news stories, including:
    1. There was the controller at Cleveland Center, who took off his shoes while watching a movie DVD on an overnight shift; he accidently had a hot mic when a shoe tipped onto a pedal-switch. A ham radio operator was doing his thing that night and heard a movie soundtrack on an ATC frequency, so he called FAA to report what appeared to be a dangerous situation. The FAA manager on duty  promised to investigate; while walking down to the control floor, he stopped at the technicians’ desk and mentioned the problem, and they noted ‘well, he’s probably watching a movie!’. Sure enough, he was. Made the national news but NOBODY was disciplined because it was a ‘prior working condition’ and had been condoned by supervisors for more than a decade. An aiREFORM FOIA request [F11-8134] eventually yielded hundreds of pages, including a confirmation that nobody was ever disciplined.
    2. There was the case at New York Center (Ronkonkoma, NY) where in 2010 a new supervisor, Evan Seeley, spoke up about common practices of sleeping on the job, early undocumented departures, and use of personal electronic devices while working. He was then subjected to vandalism and harassment, and found a management team that could do nothing to correct the situation. An OSC investigation confirmed Mr. Seeley’s claims.
    3. There were the many cases of sleeping air traffic controllers in 2011. Eventually, the Air Traffic COO, Hank Krakowski, was forced to resign.
    4. There was another news story that broke in 2012, when a controller Whistleblower at White Plains, NY [KHPN] leaked cellphone images and video exposing widespread napping and personal electronics in the control tower.
    5. And, there was the TV wired into a cabinet at Troutdale, OR (the photo above). This was the safety risk that launched my career as an ATC Whistleblower in 1989, and eventually led to a forced-voluntary retirement in 2009; see that Whistleblower case study here.