Air traffic controllers made record number of mistakes in 2010, data show

By Ashley Halsey III
Washington Post Staff Writer
Friday, December 31, 2010; 12:00 AM

The air traffic controllers in the Washington region, who direct more than 1.5 million flights, have made a record number of mistakes this year, triggering cockpit collision warning systems dozens of times.

Errors recorded by air traffic controllers have increased by 51 percent nationwide, and the Federal Aviation Administration this week cautioned that warning systems aboard more than 9,000 planes may not be keeping track of all the nearby planes in busy airspace. The FAA wants to require software upgrades to ensure that the emergency units don't make mistakes that "could compromise separation of air traffic and lead to subsequent midair collisions."

Washington's regional control facility recorded its 52nd error of the year on Christmas Eve when a controller mistakenly put two Southwest Airlines 737s approaching Baltimore-Washington International Marshall Airport on converging courses. The facility, known as the Potomac Terminal Radar Approach Control center, recorded 21 errors in 2009. The increase corresponds with what the acting director of the center described in an internal document as "a definite increase in sloppy or poor adherence to SOP and handbook procedures."

The record number of errors - locally and nationally - reflects many instances in which planes came too close but without risk of collision and some in which fatal consequences were narrowly averted.

This month in Cincinnati, a 50-seat regional jet was instructed to land on the same runway from which a Delta 737 was taking off. And in September, two planes, one carrying 95 people, flew blindly by each other about 50 feet apart in a cloud bank because of controller errors in Minneapolis.

FAA Administrator Randy Babbitt is confident that his agency runs an "incredibly safe system," and he notes that crash fatalities involving commercial airliners are at an all-time low.

"I think that we have all come a very long way in terms of making our system as safe as it as it can be . . . and our record proves it," Babbitt said in a speech in October. "And given the collaborative approach we're now using, I expect even greater gains."

Training methods criticized

Babbitt has sought to smooth a generational transition, with the retirement of air traffic controllers who were hired in the 1980s after then-President Ronald Reagan responded to a strike by firing the entire workforce. Critics contend that mistakes have increased as less-experienced controllers have been prematurely placed in challenging situations, often receiving on-the-job training from colleagues.

A pitfall of the on-the-job approach at busy facilities was outlined last month in an all-hands memo written by Roderick Harrison, acting director of the Potomac facility. Harrison said veteran controllers were teaching inappropriate shortcuts to new hires, so "our newer controllers are developing the bad habits of some of our older . . . controllers."

"Regardless of what has happened in the past with a procedure, historical practice does not allow for deviation from the rules," Harrison wrote.

One of Babbitt's innovations is a system of self-reporting by which controllers can alert supervisors to their mistakes without fear they will be punished for them. Babbitt reasoned that the more his supervisors knew about mistakes, the better they could catch trends and find ways to strengthen the system.

As Babbitt's new Air Traffic Safety Action Program (ATSAP) was rolled out during fiscal 2010, the number of reported errors nationwide jumped by 51 percent, to 1,869.

FAA officials said the program had encouraged greater honesty, which they said explained why the number of errors reported had spiked up.

"This cultural change in safety reporting has produced a wealth of information to help the FAA identify potential risks in the system and take swift action to address them," the FAA reiterated in a statement issued Thursday in response to an inquiry from The WashingtonPost. "The new system has resulted in a higher number of reports of incidents involving the loss of the required separation between aircraft than in previous years."

But it does not explain why the official error count locally and nationally has increased so dramatically.

The FAA and the controllers union, which worked with the agency to create the new program, later acknowledged that self-reported errors are not included in the official count.

Harrison's memo to Potomac controllers warned that increased errors had drawn attention to the facility and said: "The fact that ATSAP is here is not a reason to ignore or cheat, just a little, on directives and procedures. Directives and Order are exactly that. . . . They do not give individuals the latitude to follow the ones they like and ignore the ones they don't like."

Investigating mistakes

The complex business of coordinating air traffic is easily defined: Keep the planes at a safe distance - generally three miles or 1,000 feet of altitude apart - and get them up and down in orderly fashion.

This year, the National Transportation Safety Board (NTSB) took an unprecedented step by beginning to investigate the most serious mistakes by air traffic controllers.

Among the cases under NTSB review are near-collisions between a Boeing 737 and a helicopter in Houston; a Boeing 777 and a small plane in San Francisco; an Airbus 319 and a Boeing 747 in Anchorage; and an incident near Reagan National Airport that involved an airliner carrying a congressman.

Earlier in the year, Rep. F. James Sensenbrenner Jr. (R-Wis.) demanded an explanation from the FAA after his United Airlines flight bound for National swerved to avoid another jet after the encounter activated the onboard collision avoidance system.

Efforts to modernize the nation's air traffic control system - upgrading from radar developed during World War II to modern Global Positioning System technology - have faced cost overruns and delays, according to an inspector general's report issued this month.

Problems with the onboard warning systems provided the FAA with an unexpected technological twist. The systems, which sense the proximity of other aircraft and issue commands that help the pilots steer clear, have been a major advancement in air safety. Although they sometimes trigger when no collision is imminent, there have been several times this year when they probably averted a major disaster.

The FAA became concerned when tests showed a system installed in more than 9,000 planes was losing track of nearby aircraft for 40 seconds or more. Under the mandate proposed by the FAA, airlines could take up to four years to make the repair.

A close encounter

One of the year's worst near-collisions - the cloud bank encounter over Minneapolis - was even closer than first reports indicated, according to records, recordings and transcripts obtained by The Post under the federal Freedom of Information Act.

The Sept. 16 incident involved a US Airways Airbus 320 taking off for Philadelphia with 95 passengers and crew members onboard. A twin-engine turboprop cargo plane was taking off from a parallel runway, 3,380 feet to the left, en route to LaCrosse, Wis. The cloud ceiling had dropped to 900 feet above the Minneapolis-St. Paul Airport.

It was just before 7 a.m., and inside the control center additional controllers were coming on duty to handle the heavier volume of morning traffic. Responsibility for the left and right runways, which is combined overnight, was being divided between two controllers. The controller in charge of the facility was briefing his morning replacement.

Both planes were cleared for takeoff, each by a different controller, and both pilots were instructed to turn left. Then one controller was distracted by a third plane that needed guidance.

In a written statement to the FAA, the cargo plane's controller said: "Soon thereafter I heard the [collision avoidance] alarm and observed the two targets merging [on radar] at the departure end of runway 30L. I determined that the [cargo plane] had not taken the [left] turn."

By then, the planes were disappearing into the clouds, neither pilot aware of the other.

The statement of US Airways pilot Joey Hemphill describes what happened next.

"We were in a normal takeoff climb rate when the [onboard collision system] commanded a much greater climb to clear the conflicting traffic. The first officer responded with a swift pull-up," Hemphill wrote. "We were in the clouds . . . and could not see the aircraft. Within just a few seconds I heard the whine of turboprops go under our aircraft from left to right."

Hemphill radioed the controllers:

"What's this guy doin' off the left side?" he's heard saying on an FAA recording. A minute or two later, he added: "Yeah, advise me that that controller's been relieved of duty at the moment."

The control center radioed back: "Yeah, we're working on that now."

FAA investigators, in their detailed internal report, concluded that the responsibility to maintain separation between the flights was that of the cargo plane's controller.

Although radar showed that the planes came within 100 feet of each other, the investigators concluded that the US Airways flight probably passed above the cargo plane within 50 feet, less than the distance between the pitcher's mound and home plate.

© 2010 The Washington Post Company