AIR TRAFFIC CONTROLLER FATIGUE AND HUMAN ERROR
by
Anthony Nicholas Dionisio
ADIONISIO@LIVE.COM
http://www.anthonydionisio.com/research.html
Embry-Riddle Aeronautical University
August 2010
i
AIR TRAFFIC CONTROLLER FATIGUE AND HUMAN ERROR
by
Anthony Nicholas Dionisio
This Graduate Capstone Project
was prepared under the direction of the candidate’s Project Review Committee Member,
William M. Villegas II, M.A.S.,
and the candidate’s Project Review Committee Chair,
Dr. Philip R. Jacobs,
and has been approved by the Project Review Committee. It was submitted to the
Worldwide Campus in partial fulfillment of the requirements for the degree of
Master of Aeronautical Science
ii
ACKNOWLEDGEMENTS
The researcher would first and foremost like to personally thank all of the
NATCA controllers who took the time to complete the fatigue survey. The researcher
greatly appreciates the time that the members and proprietor from stuckmic.com spent
contributing to this research. Thanks to the following FAA air traffic controllers and
managers who provided time and specific research support Rob Anderson, Doug Church,
Paul Cox, Jonathan Stewart, Mike Dowd, Mike Flanagan, Jose Ruiz and Dustin
Halvorson. Thanks to the following organizations for helping recruit survey respondents
faafollies.com, NATCA National Office, NATCA BBS, NATCA New England Region,
ROA ATCT/TRACON, DAB ATCT, JAX ATCT/TRACON, ZBW ARTCC and ZJX
ARTCC. Thanks to the following DOD air traffic controllers for helping shape the data
collection device and other research support Victor Deleon, Victor Gonzalez, Patrick
Harrison, Paul Margeson, Bryan Park and Steven Ramirez. Lastly the researcher would
like to thank his family for supporting him throughout his educational career.
iii
ABSTRACT
Researcher:
Anthony Nicholas Dionisio
Title:
Air Traffic Controller Fatigue and Human Error
Institution:
Embry-Riddle Aeronautical University
Degree:
Master of Aeronautical Science
Year:
2010
The National Transportation Safety Board (NTSB) has been concerned about the effects
of fatigue on air traffic controllers since the 1980s and has made numerous
recommendations to the Federal Aviation Administration (FAA) regarding controller
fatigue. The FAA has disregarded many of the NTSB’s recommendations and continues
to schedule controllers in a manner that contributes to fatigue. This paper will first
discuss the work environment experienced by controllers and its effect on fatigue and
aviation safety. A survey completed by 88 FAA air traffic controllers and its results
regarding scheduling practices and fatigue will then be explored. The remainder of the
paper will present a direct correlation between fatigue and human error through research
and lastly provide recommendations to combat controller fatigue.
iv
TABLE OF CONTENTS
Page
PROJECT REVIEW COMMITTEE
ii
ACKNOWLEGDEMENTS
iii
ABSTRACT
iv
LIST OF TABLES
viii
Chapter
I
II
INTRODUCTION
1
Background of the Problem
1
Researcher’s Work Setting and Role
4
Statement of the Problem
5
Problem Significance
6
Limitations
7
Assumptions
8
Acronyms
8
REVIEW OF RELEVANT INFORMATION
10
Overview
10
Causes of Controller Fatigue
10
Shift Work
11
Staffing and Funding Issues
12
Air Traffic Controller Shortages
12
Current Training Issues
13
Funding Issues
15
v
Air Traffic Control Privatization
III
IV
Workload and Traffic Complexity
17
Position Rotation
18
Reporting Programs and Safety Training
19
National Transportation Safety Board Recommendations
20
Conclusions
20
Statement of the Hypothesis
21
RESEARCH METHODOLOGY
22
Research Model
22
Survey Population
22
Sources of Data
22
The Data Collection Device
23
Pilot Study
23
Distribution Method
24
Instrument Reliability and Validity
24
Procedures
25
Treatment of Data
25
RESULTS
26
Survey Responses
V
15
26
DISCUSSION
41
Rotating Shifts
41
Sleep Deficits
42
Position Rotation
44
vi
Fatigue and Human Error
45
VI
CONCLUSIONS
47
VII
RECOMMENDATIONS
50
REFERENCES
52
APPENDIXES
A
BIBLIOGRAPHY
55
B
DATA COLLECTION DEVICE
56
vii
LIST OF TABLES
Table
Page
1
Question One Results
26
2
Question Two Results
29
3
Question Three Results
31
4
Question Four Results
33
5
Question Five Results
34
6
Question Six Results
35
7
Question Seven Results
37
8
Question Eight Results
38
viii
1
CHAPTER I
INTRODUCTION
Background of the Problem
Fatigue, sleepiness and stress all contribute greatly to both the amount of human
errors in the aviation system and the severity. The current safety culture and staffing
crisis at the Federal Aviation Administration (FAA) has created a situation where
controllers are fatigued on a daily basis. The FAA has been given numerous
recommendations by both the National Transportation Safety Board (NTSB) and the
Office of the Inspector General (OIG) regarding the fatigue experienced by air traffic
controllers but has not implemented any changes to error reporting procedures or
scheduling procedures known to cause fatigue. A discussion of fatigue issues such as
work schedule, overtime and on-the-job training (OJT) will be provided next to give the
reader an in depth understanding of how fatigue can affect air traffic control services.
Controllers work in an environment where their daily work schedule is constantly
changing, couple this with overtime, consistent training and combined positions and
fatigue becomes a serious issue. Imagine working on first shift for two days, second shift
for two days and then having to work first shift again the last day of the week. This
rotating type shift schedule is not easy to adjust to and even veteran controllers report
having issues getting adequate sleep. The schedule often only allows 8 hours off between
shifts and this usually occurs at least once a week before the last shift. If a controller is
working at a facility and has to drive 45 minutes each way to work, eat a meal and
shower before the next shift, 8 hours between shifts might only allow them to get 4-5
hours of sleep. Coupling this grueling work schedule with other staffing factors only
2
makes the problem worse. Imagine the same controller who only had 4-5 hours sleep now
having to work a 10 hour shift. Take the same tired controller and have them train a new
controller all day, where they are not actively controlling aircraft only monitoring a
trainee; this inactive type of work can make it very hard to stay focused, especially after
10 hours. Combining fatigue factors such as rotating shifts, overtime and on-the-job
training, a controller on the last hour of their last shift could easily become complacent on
position and forget to issue an instruction or miss a problem. In an industry where
mistakes mean lives, why would the FAA not complete more research and actually
implement changes to the above mentioned issues? Why would the FAA not require
collection of fatigue data regarding rotating shifts, overtime and on-the-job training in the
report following an accident or near accident in the FAA? There are just no simple
answers to these questions, what is painfully apparent is that the FAA has not followed
numerous recommendations from the NTSB and OIG regarding how fatigue can
contribute to operational errors and has not implemented any solutions to these issues
(Office of the Inspector General [OIG], 2009).
The staffing crisis being experienced in the FAA directly correlates to the massive
influx of controllers hired after the strike of 1981. Being the mandatory retirement age for
controllers is 56, it would be expected that the FAA would have began hiring controllers
to replace its aging workforce prior to them retiring; but the FAA did not begin hiring
large numbers of new controllers until 2006. Due to the compressed hiring schedule a
massive number of trainees are now in the system causing many controllers to provide
extended hours of OJT, work overtime and often work combined positions (Wethe,
2007).
3
FAA facilities are staffed to traffic, so a busy facility such as Atlanta Hartsfield
International needs more controllers than a slower facility such as Orlando International
to allow for breaks, time-off, training, etc. When nearly every facility in the system is low
on qualified workers, where can busy or slow facilities find more qualified workers if the
facility’s management deems they do not have enough? Again, there is no simple answer
because there are no spare qualified controllers in the system. The FAA’s solution to this
shortage was to hire a massive number of trainees, but this solution was too little, too late
as massive numbers of qualified controllers exited the system. Facilities that had been
staffed around 100% for decades now had a shortage of qualified workers. Chicago
O’Hare and Chicago TRACON for example, both have 30% or more of their personnel in
training and this is the case for more than 40% of all FAA facilities. Although the FAA
can say both the facilities are fully staffed with controllers, for example they are allowed
100 controllers and have 105, both facilities have at least 10% fewer fully qualified
controllers than authorized. Currently the FAA shows that the majority of its facilities are
overstaffed but this does not consider that nearly 27% of controllers nationwide are not
fully certified (OIG, 2009). These low staffing levels can have a threefold effect on air
traffic controllers including increased overtime, combined positions and increased
training, all of which can lead to fatigue and cause stress on the qualified portion of the
workforce.
How the FAA records operational errors and deviations is also an issue. Currently
the FAA records errors with an operational error (OE) or an operational deviation (OD)
report. The OE/OD reports only require controllers to list facts surrounding the event
itself and do not require controllers to report human factors issues. A study conducted by
4
the OIG found that controllers were not required to list work schedule, overtime, OJT or
staffing as a contributing cause of an OE (OIG, 2009). It would be suspected that the
form have a mandatory requirement for controllers to list these human factors issues,
especially after the NTSB and OIG have recommended that the FAA have portions on the
reporting forms where controllers can list this information. Even though the FAA has
long known about human factors issues and that they are known to cause fatigue, what
seems as easy and obvious as adding a box on a form for human factors issues has again
been ignored by the FAA. The FAA has long know about these human factors issues,
that they are known to cause fatigue and their effect on the safety of the travel public, yet
to date no changes have been implemented to the OE/OD reporting system which would
require controllers to report them.
Researcher’s Work Setting and Role
The researcher has an extensive background in the air traffic control field as a
Federal Aviation Administration-certified air traffic control specialist (ATCS), with
ratings as a Carrier Control Center Supervisor by the United States Navy. He has
personally controlled thousands of military aircraft sorties on various radar positions
including marshal, approach and final radar control. He has worldwide operational and
managerial experience working with the United States Department of Defense (DOD) in
conjunction with piloting experience and extensive training in various aviation fields. He
holds a Bachelor of Science degree in Professional Aeronautics from Embry-Riddle
Aeronautical University with a Minor in Aviation Safety. He is currently employed as a
Senior Systems Engineer at Hanscom Air Force Base, Massachusetts with oversight of
the development and installation of the Iraqi Air Defense System. During his time at
5
Hanscom, he has also overseen the development of the training and manning packages
for three Iraqi military radar facilities specifically dealing with issues such as fatigue and
human error.
Statement of the Problem
Air traffic controllers employed by the FAA are fatigued as a result of shift-work
and staffing levels throughout the National Airspace System (NAS). In conjunction with
fatigue, mismanagement and poor planning, the FAA has been increasing the rate of
experienced controller attrition thereby decreasing the average experience of the air
traffic controller workforce. Controller attrition has increased the time that remaining
qualified controllers must work and in some cases mandatory overtime has been
implemented. Currently the FAA is conducting a mass hiring effort to make up for the
current deficit of qualified air traffic controllers. Unfortunately a greater number of
qualified controllers are being forced to work longer shifts often without breaks to help
train the influx of new controllers creating an environment where fatigue is nearly
inevitable (Wethe, 2007).
Fatigue can be experienced by controllers at any time of day, it can be mental or
physical in nature and causes a general decrease in attention. The job of an air traffic
controller requires their constant attention and being in any way fatigued on position is
unacceptable. Any fatigue naturally experienced by air traffic controllers is only
exacerbated by the shift work and long hours currently experienced by controllers. The
current scheduling practices only add to the problem causing controllers to work at times
they would normally be asleep and sleep at times they would normally be awake. The
NTSB noted that in the August 2006 crash of Comair Flight 5191, the lone controller on
6
duty had only 2 hours of sleep before his shift. Due to this accident and resulting
investigations the NTSB has specifically expressed concerns to the FAA regarding
fatigue and working rotational shifts since April 2007 (OIG, 2009).
Problem Significance
Effectively managing fatigue in the FAA is a complex issue which requires a
balancing act of running 24 hour facilities, considering all human factors issues and doing
so with low staffing levels and limited funds. The immediate reaction by management to
the current staffing shortages was to have qualified controllers work longer hours often
with shorter breaks, this solution is not the answer and only worsens the fatigue
experienced by controllers. There have been multiple studies ordered by National Air
Traffic Controller Association (NATCA), Civil Aerospace Medical Institute (CAMI) and
the Office of the Inspector General to research the effects of fatigue on air traffic
controllers and implement changes to provide safer FAA air traffic control services; but
the FAA has yet to change its policies regarding shift work or breaks since these
recommendations were issued (OIG, 2009).
FAA management has not aggressively attempted to resolve any of the
systemic fatigue or staffing problems facing the air traffic controller workforce. The FAA
has not changed its policies regarding shift work or breaks when it would make the NAS
safer. Not all facilities provide their controllers with breaks every two hours while on
position, but most facilities do provide the required breaks without issue. Some facilities
have straight day or night schedules like most industries and operate without issue, yet
others do not. These statements leave an open door as to why the FAA does not provide
fixes for these issues, many solutions seem like common sense but the FAA has
7
continued to turn a blind eye. Being that the FAA’s number one concern is the safety of
the traveling public it seems the difficulty of staffing a 24 hour facility is not an excuse to
continue putting countless lives at risk.
The FAA needs to fix the scheduling problem; there is no reasonable cost or
scheduling basis for them to continue to refuse to change. With an ever increasing
number of new trainees flooding the system and years of experience leaving the FAA as
each qualified controller retires, new hires are coming to work with less sleep, less
training and are responsible for more aircraft than their predecessors (Wallace, 2008).
Fatigue is a known issue throughout the aviation community and has been cited as a
contributing cause in incidents such as the crash of Comair Flight 5191 and as such the
significance of fatigue in a workforce responsible for the safety of the flying public can
no longer be ignored.
Limitations
The most important limitation in this study of air traffic controller fatigue is
the researcher’s ability to obtain a sample from a large enough population to represent the
thousands of controllers at different locations throughout the United States. Air traffic
control services are provided at hundreds of locations around the country and each
location has unique issues regarding management style, equipment and safety. Although
the researched attempted to have either NATCA or the FAA sponsor the study to obtain a
larger sample size, neither organization would assist in the research study making mass
dissemination to controllers impossible.
8
Assumptions
The researcher will use prior data and recommendations provided by a
number of government agencies and other researchers to establish survey data to be
posed to a sample of FAA air traffic controllers. The data was gathered from a random
sample of FAA air traffic controllers. It is assumed that the participants answered the
questions honestly and without regard for contract or management issues. It is also
assumed that each participant only took the survey once.
Acronyms
AMAFCS - Aerospace Medical Association Fatigue Countermeasures Subcommittee
ATCS - Air Traffic Control Specialist
BBS - NATCA Bulletin Board System
CAMI - Civil Aerospace Medical Institute
DOD - Department of Defense
FAA - Federal Aviation Administration
FSDO - Flight Standards District Office
GAO - General Accounting Office
NAS - National Airspace System
NATCA - National Air Traffic Controller Association
NATS - National Air Traffic Service
NTSB - National Transportation Safety Board
OD - Operational Deviation
OE - Operational Error
OIG - Office of the Inspector General
9
OJT - On-the-job training
OMB - U.S. Office of Management and Budget
TRACON - Terminal Radar Approach Control
10
CHAPTER II
REVIEW OF RELEVANT INFORMATION
Overview
The FAA is charged with providing a safe and effective air transportation system
and is responsible for the oversight of all air traffic control services. Unfortunately the
FAA currently has a workforce that is consistently exposed to an environment that leads
to fatigue and has expressed little concern and no plan to fix the situation. The Aerospace
Medical Association Fatigue Countermeasures Subcommittee (AMAFCS) has stated that
“. . .fatigue represents a significant risk in aviation when left unaddressed, there are
currently numerous countermeasures and strategies that can be employed to increase
safety” (Caldwell, Caldwell, Mallis, Miller, Neri, & Paul, 2009, p. 53). The AMAFCS
and FAA have known about the direct risks involved with controller fatigue for years, but
the FAA continues to create a work environment and use scheduling practices known to
cause fatigue. This chapter will discuss the causes of controller fatigue, the reasons
behind the current work environment and NTSB recommendations on how to improve
the work conditions experienced by air traffic controllers.
Causes of Controller Fatigue
The current scheduling practices used by the FAA add to the fatigue experienced
by the controller workforce. Factors such as shift work, staffing levels and position
rotation all have an effect on the fatigue experienced by controllers. Currently many FAA
facilities are understaffed and controllers often find that they are working rotating shifts
and many hours of overtime, which is compounded by the lack of qualified controllers
11
and the amount of training qualified controllers must conduct. This section will focus on
the factors currently contributing to controller fatigue and their associated issues.
Shift Work
Shift work is known to have adverse consequences on circadian rhythms of
workers increasing fatigue and stress, and in turn affecting the health and safety of those
involved (Macpherson & Tvaryanas, 2009). Most FAA facilities are staffed 24 hours and
it has been determined by the FAA that rotating shifts are the most effective way to staff
these facilities. Aviation managers must be aware of the effects of rotating shifts and take
measures to mitigate those effects to the maximum extent possible.
The FAA requires that managers give controllers at least 8 hours rest between
shifts, but considering travel time to and from home and the time to fall asleep, many
controllers will not get adequate sleep with such a schedule. A study conducted by the
U.S. Department of Transportation Office of the Inspector General found that in all three
facilities it researched, controllers were scheduled with less than 10 hours of rest between
shifts, and many times controllers worked “quickturn” shifts with only 8 hours between
shifts (OIG, 2009). An example work week could be 7 a.m.-3 p.m., 9 a.m.-5 p.m., 12
p.m.-8 p.m., 2 p.m.-10 p.m. and 6 a.m.-2 p.m., this example shows an ever changing shift
and the last shift is only 8 hours after the previous shift.
The OIG found that “The NTSB has expressed concern regarding this type of
work schedule because it limits the amount of time for rest between shifts” (OIG, 2009,
p. 5). Still the controller is responsible for attaining adequate sleep, and although some
controllers like the above mentioned schedule because it offers a 3-day weekend, others
find this schedule disrupts their sleep and family life and causes an undue amount of
12
stress. The FAA needs to continue considering the advice of the NTSB, OIG and others
and continue its own studies into the effects of shift work and what can be done system
wide to mitigate safety concerns caused by shift work (Kirwan, Rodgers and Schaffer,
2005).
Staffing and Funding Issues
There are many safety and funding issues currently affecting the FAA and its air
traffic controllers. Many spawn from the air traffic controllers’ strike of 1981 and
government funding issues. The discussion of these topics will consist of the following:
air traffic controller shortages, current training issues, funding issues and air traffic
control privatization; these topics all have safety implications on the NAS and this will be
the main focus of the following sections (Kjelgaard, 2002).
Air Traffic Controller Shortages
In 1981 almost three-fourths of air traffic controllers went on strike. Ronald
Reagan proceeded to fire every striking controller and banned them from ever being
rehired by the FAA. This created a need for over ten thousand new controllers who were
hired and trained within two to three years of the strike (Kjelgaard, 2002).
Due to the strike of 1981, almost fourteen thousand controllers will be eligible for
retirement by the year 2011 (Kjelgaard, 2002). This will place a large demand on the
FAA and its facilities to hire and train new controllers. Future increases in air travel will
also create a need for additional new hires throughout the United States.
With the requirements for new controllers, existing shortages at many facilities
and the need for extended workweeks and overtime, new demands will be placed on
current air traffic controllers. The FAA’s training and financial plans do not take these
13
needs into account (Kjelgaard, 2002). Overwork and stress will create a hoard of safety
issues that the FAA must keep in mind during the next decade.
Current Training Issues
Many of the FAA’s training issues are caused by the air traffic controller
shortages mentioned above. These shortages are warranting the need for an increase in
the number of new air traffic controllers. This section will discuss the need for more
efficient training programs and how the lack of qualified controllers will affect training.
The FAA’s increase of new hires will place added demand on the FAA Academy
in Oklahoma and air traffic facilities. In 2004, the FAA conducted a study on reducing
the amount of time required to train new hires and discovered several ways to reduce
training time and costs. One of the primary efficiencies the FAA found was hiring college
graduates with specific aviation degrees that would eliminate the need for the 5-week Air
Traffic Basics course provided at the FAA’s training academy. By increasing new hire
education requirements the FAA could streamline the training process by five weeks or
more and reduce costs by approximately $20 million over 9 years (FAA, 2005). If the
FAA does not streamline the training process and take into account new and existing
controller attrition there will no doubt be controller shortages throughout the United
States in the future.
Controller attrition is a broad topic and deserves some discussion as it relates to
fatigue. Attrition in the FAA consists of both new controllers washing out of the training
program and qualified controllers leaving the FAA due to retirements, promotions,
resignations, removals and deaths as specified by the FAA (FAA, 2009). The latter is a
very important training issue as new trainees require vast amounts of OJT from
14
experienced controllers and without an ample amount of experienced controllers a
training bottleneck will arise. There are multiple contractual issues that have lead to the
increase in qualified controller attrition, primarily the fact that all NATCA controllers
have been working under imposed pay rules for five years prior to the publishing of this
paper. Imagine working for a company for 20 or more years and finally, without regard to
fair collective bargaining agreements that have been established for years, the company
cuts all of its blue collar workers’ pay. Many of these controllers were eligible for
retirement and they did what would be expected, they retired rather than deal with forced
pay cuts and working rules that their Union could do nothing about. The following is an
excerpt from a NATCA press release on August 3, 2010, the 29th anniversary of the 1981
PATCO strike regarding the current contract negotiations being pursued by NATCA:
“NATCA is now pushing for final passage, before the Sept. 30 deadline of the
current reauthorization extension, of a compromise FAA reauthorization bill that
includes language that would provide a permanent fair process for collective
bargaining. This would ensure a stabilized workforce, leading to increased safety
margins as the most experienced controllers elect to stay on the job longer. They
would also continue to teach the more than 25 percent of the workforce now in
training, passing along their experiences and wisdom” (Church, 2010).
Without passage of an FAA reauthorization bill, mandatory pay cuts imposed by the FAA
in 2006 will continue to stay in place. If nothing changes moving forward, new
controllers will continue to become under-trained and experienced controllers over
worked as the number of fully qualified controllers continues to decrease (Wallace,
2008).
15
Current and future FAA training plans are very important to the safety of the
traveling public and the ability of its controllers. The following statement made by the
General Accounting Office (GAO) shows how important this topic really is, “… FAA
has not addressed the resources that may be needed at its training academy and for
providing OJT at its control facilities in order to handle the large influx of new
controllers and ensure that FAA’s controller workforce will continue to have the
knowledge, skills and abilities necessary to perform its critical mission” (Kjelgaard,
2002, ¶ 5).
Funding Issues
Recently the United States Government has had many funding issues. These
issues are affecting the FAA and its need for new hires and increased training. The
NATCA’s president, John Carr, has said the following, “Unless the funds for hiring are
appropriated, staff shortages will inevitably lead to serious delays, congestion and, yes,
safety concerns” (Huey, 2004, ¶ 8). These funding issues must be addressed immediately
by the FAA. An already struggling workforce will eventually be forced to compromise
safety without new controllers; the required funding would prevent this and help keep the
air traffic control system functioning as it should.
Air Traffic Control Privatization
America’s air traffic controllers are a vital part of its aviation safety and security.
Recently the government has been showing signs that air traffic control could move to the
private sector. After the tragedies of 2001, President Bush moved many functions and
departments around in the United States government. This included the creation of the
Department of Homeland Security; however, it did not include the FAA. John Carr of the
16
NATCA commented on this topic, “If this nation’s air traffic controllers didn’t prove
their mettle on that fateful morning, then I suppose there’s nothing we can do to prove
ourselves critical to this nation’s safety and security” (Kjelgaard, 2002a, ¶ 5). Air traffic
controllers play a very important role in the nation’s safety and security, and like the
military should continue to be managed by the government sector.
Many countries around the world such as Canada and England have already
moved air traffic control to the private sector. When the U.S. government mentions
privatization, NATCA points to England and its privatized National Air Traffic Service
(NATS). The NATS was given over forty-three million dollars in 2002 by the English
government, and still faced bankruptcy (Kjelgaard, 2002a). Considering what has
happened to the NATS the U.S. government should continue researching privatization
and ensure that any U.S. company taking on the project can truly handle the entire system
cost effectively.
The argument that the private sector would be more efficient than a government
agency at running the nation’s air traffic control system is likely a true one. Government
organizations typically are not focused on profit margins and lower costs, while this is the
primary driver for the private sector. Although the private sector may be able to lower the
costs associated with the air traffic control services, they would likely do so in a way
already attempted by the FAA which would increase controller attrition or compromise
safety through combining positions, lowering pay or not provide adequate breaks. Air
traffic control is not a field that should be in the private sector as its main focus is on
safety, just the opposite of the private sector whose focus is on profits (Murray, 1975).
The government should continue controlling, regulating and employing air traffic
17
controllers if it wishes to keep the air traffic system as safe and secure as it has proven to
be; in the words of the U.S. Office of Management and Budget (OMB) the FAA is “so
intrinsically linked with the public interest as to mandate their performance by federal
employees” (Kjelgaard, 2002a, ¶ 11).
Workload and Traffic Complexity
The amount of workload or traffic complexity that a controller is experiencing
will have a definite effect on the amount of stress and fatigue experienced by the
controller. Managing controller workload is an important task considering that stress and
fatigue have a direct relation to controller error and accidents. Since experienced air
traffic controllers can only control about 30-40 aircraft at any one time (Hah & Willems,
2008), management must ensure that their controllers are not being presented with more
traffic then they can handle.
With all the issues currently contributing to controller fatigue, the relationship
between workload and stress must be closely monitored to ensure controllers are not
become too fatigued on position. An experiment conducted on eight air traffic controllers
in a simulation environment showed a direct correlation between the amount of fatigue
experienced by controllers and their workload (Bourgeois-Bougrine, Cabon, David, &
Mollard, 2000). The same study found a link between sleepiness and fatigue, showing
that sleepiness from shift work coupled with stress from workload could compound the
fatigue experienced by controllers. Another study also found a direct link between the
decision making abilities of controllers and workload. Using 16 qualified air traffic
controllers it was determined that during high workload situations controllers used less
efficient procedures and did not apply the most effective solutions to conflicting aircraft
18
(Fothergill & Neal, 2008). This experiment showed that controllers working under high
workload conditions will tend to make decisions more quickly and in turn create a less
efficient use of airspace. Considering that controllers need to use their airspace
effectively to route many aircraft in the most efficient manner, this lack of efficiency will
likely compound into more problems and more stress later for the controller.
It is important that during high workload or complex traffic situations that both
controllers and supervisors understand their limitations and do not let stress and fatigue
cause controllers to make a catastrophic error. Low staffing levels, shift work and long
hours will only compound the problems presented by the high workload environment for
controllers. While many high workload situations are inevitable, many of the other
fatigue factors can be mitigated.
Position Rotation
Controllers on position in high workload environments for extended periods, like
those mentioned in the previous section, will cause a great amount of stress leading to
fatigue in controllers. The FAA has had a longstanding policy of rotating positions every
two hours to ensure that controllers do not become too fatigued while on position (OIG,
2009). Considering the high workload environment or a low workload environment,
where boredom may occur, providing breaks and changing positions is an effective way
to prevent controller fatigue and errors. Unfortunately as mentioned above, low staffing
levels are providing fully qualified controllers with less breaks and rotations and more
time on the same position (OIG, 2009).
19
Reporting Programs and Safety Training
The FAA implements many reporting programs both mandatory and voluntary.
This section will discuss the following: the aviation safety reporting program, near midair
collision reporting and training arising from these programs. By using these programs
the FAA ensures safety data gathering, processing, and hazard avoidance.
The Aviation Safety Reporting Program was implemented to gather information
concerning problems with the aviation system. It is designed as a voluntary program in
which pilots, controllers, and other aviation personnel can anonymously report safety
hazards. Reports that are filed and processed through the National Aeronautics and
Space Administration who acts as a third-party to the FAA. The system ensures that
certain disciplinary actions are not taken against airmen who file reports in a timely
manner. (FAA, 2004, ¶ 7-6-1)
Air traffic controllers and control facilities are required to submit a near midair
collision report when the possibility of collision existed in a controller’s airspace. The
Aeronautical Information Manual defines this as a possible collision between two aircraft
within 500 feet of each other (FAA, 2004, ¶ 7-6-3). When these types of incidents occur
the facility will forward the report to the nearest Flight Standards District Office (FSDO).
The FSDO will conduct an investigation of radar, communications, and possibly the
flight crews involved. Enforcement actions can be taken if the investigation shows any
violations of FAA regulation (FAA, 2004, ¶ 7-6-3).
Safety training is an important part of an air traffic control facility. FAA
publications are constantly being updated and are changed to reflect new regulations and
methods, creating an ever safer air traffic system. Facilities also receive hazard reports
20
that either apply to their airspace or the NAS. These reports will identify safety issues
and corrective measures that must be taken by facilities. Controllers must know what
these hazard reports and all updated publications contain. Air traffic controllers must
continue their safety training throughout their careers to maintain a safe airspace system
(FAA, 2004).
National Transportation Safety Board Recommendations
The NTSB has made numerous safety recommendations to the FAA regarding
controller fatigue. In response to recommendations provided by the NTSB in 2007
following a catastrophic accident, the FAA formed a workgroup to address the
recommendations but has yet to implement any changes (National Transportation Safety
Board [NTSB], 2007). The FAA has increased controller training on fatigue awareness
but has not implemented changes to its scheduling practices or rest periods between
shifts, which have a direct impact on fatigue and decreased cognitive performance from
controllers (OIG, 2009). Currently the FAA has plans to implement changes to many of
the fatigue factors listed above, but controllers continue to work under fatigue conditions
and every day they do the risk for a catastrophic human error in the air traffic control
system looms.
Conclusions
The FAA has ignored recommendations by the NTSB to change the rotational
shift schedule currently used and ignored an impending staffing crisis that has been
lingering for over 20 years. The FAA continues to place overworked and overstressed
controllers in positions that directly affect the safety of the flying public despite knowing
that these conditions exist. Considering the FAA’s mission is to provide a safe and
21
effective air transportation system, continuing to ignore issues that cause controller
fatigue directly counters the mission of the FAA.
Statement of the Hypothesis
It is hypothesized that shift-work and fatigue directly correlate to the number of
operational errors and deviations experienced by the air traffic controller workforce. The
current safety culture in the FAA is not focused on known human factors issues such as
those caused by shift-work and fatigue as they continue to schedule controllers in a
manner that contributes to fatigue. The hypothesis is designed not to answer the question
of if FAA air traffic controllers are fatigued but if these situations are causing unsafe
operations and if so to what effect.
22
CHAPTER III
RESEARCH METHODOLOGY
Research Model
The research model for this study was a mix of both qualitative and quantitative
comparisons. The objective of the study was to identify if FAA air traffic controllers
believe that shift-work and other work related conditions are contributing to the amount
of fatigue they are experiencing while on position and if fatigue had contributed to any
operational errors at their facilities. The survey allowed respondents to provide feedback
and comments about each question which will be qualitatively analyzed to see if they
verify or reject the hypothesis. The number based data collection device will be
quantitatively analyzed and also used to test the hypothesis, primarily through the use of
Microsoft Excel 2007 and SPSS version 15.0.
Survey Population
The population of the survey was comprised entirely of FAA air traffic controllers
located at Approach Control, Terminal and En Route FAA facilities nationwide. Data
was gathered without regard to demographics, type of facility, union status, training
status or other indentifying factors in order to provide information that is more likely
linked to the experience of the broader FAA air traffic controller workforce. Results were
not categorized by facility name, location or type in an effort to protect the respondents
from any actions from facility management or the FAA.
Sources of Data
The qualitative portion of this project analyzed data received in the form of
comments by those surveyed and also a mix of research regarding various government
23
studies and other relevant information regarding fatigue and the FAA. The quantitative
portion of the study was derived solely from analysis of responses to the number based
data collection device.
The Data Collection Device
The data collection device is comprised of a survey designed by the researcher
that will was completed online using the online service at http://www.formsite.com. A
copy of the survey can be found at http://www.anthonydionisio.com/atcsurvey.htm. The
questions posed in the survey were designed to discern whether there is a statistical
significance in responses from FAA air traffic controllers that would indicate there is a
problem with fatigue in the FAA. Primary answers to the questions are provided in
number format coordinated to the five-point Likert scale which consists of strongly
disagree, disagree, neutral, agree and strongly agree, answers will then be used to
determine trends regarding fatigue at FAA facilities. The survey also allows respondents
to make comments about each question so that the researcher can make qualitative
analysis regarding these statements and fatigue.
Pilot Study
A pilot study was distributed via email to 20 air traffic controller contacts
personally known by the researcher. The study was not designed to derive responses
relevant to FAA air traffic controller fatigue, but to receive feedback from various
Department of Defense and private sector air traffic controllers about the data collection
device. Relevant to the working conditions in both the DOD and the private sector, the
respondents answered the questions in an expected range and provided feedback relevant
to the survey questions and their wording to help increase the reliability of the study.
24
Distribution Method
The survey was distributed in a variety of methods to provide the most
comprehensive representation of FAA air traffic controllers for this study. The researcher
provided a link to the survey so that FAA air traffic controllers known directly and
through various air traffic control networking groups could provide responses. The
researcher used contacts on http://www.stuckmic.com and http://www.linkedin.com to
recruit controllers for the survey. In addition to the researcher’s efforts, a current member
of NATCA posted a link to the survey on the NATCA bulletin board system (BBS). The
BBS by far resulted in the most responses generating about 50 responses within two days
of posting the link. The survey was active between 02/10/2010 and 03/01/2010 and a
total of 88 responses were received from current FAA air traffic controllers for the study.
Instrument Reliability and Validity
The instrument was deemed reliable by the researcher during the pilot study as all
respondents understood and responded to the questions in the expected method. Using
http://www.formsite.com to record the results of the survey was also deemed reliable by
the researcher. The researcher personally tested the form ensuring proper data collection
at least once a week during the study; there were no problems with the use of the form or
in the presentation of the results to the researcher.
The validity of the survey was supported by the research data and feedback
collected through the pilot study. The questions were designed to be valid as related to
the hypothesis and determinations about the hypothesis could be made specifically from
the data collection device. The validity of the individual questions was determined from
the researcher’s prior experience in air traffic control and also through consultation with
25
various air traffic controllers. Surveys with partial answers were not submitted in the
study thereby reducing the possibility of any data skewing.
Procedures
The link to the survey was distributed to FAA air traffic controllers via the
methods mentioned previously. The posts used to recruit respondents to the study
instructed users to respond to the survey at a specific link provided by the
http://www.formsite.com service and that there results would be kept confidential. The
following instructions preceded the survey on the online form:
The following are general questions about shift-work and other working
conditions you might experience in the FAA. Please answer each question with a
corresponding answer. You are encouraged to make comments regarding each
question whether positive or negative.
Treatment of Data
Data was collected in a manner as to keep all respondent facility and demographic
information confidential. Survey respondents answering no to the question “I am
currently an FAA Air Traffic Controller” were removed from the study as to only collect
data from controllers currently employed by the FAA; a total of 4 results were removed
from the study due to this reason, no other results were removed or edited by the
researcher. Upon receipt of survey results the researcher input the numbered answers and
any feedback immediately into Microsoft Word or Excel 2007. Raw data from Microsoft
Excel 2007 was then input into SPSS version 15.0. Using tools from both programs the
researcher analyzed the raw data.
26
CHAPTER IV
RESULTS
Survey Responses
There were a total of nine questions answered by 92 respondents, four of these
responses were provided by personnel whom were not currently FAA Air Traffic
Controllers and were therefore removed from the study. The first question “I am currently
an FAA Air Traffic Controller” was answered yes by the remaining 88 respondents. The
following will provide tables indicating the responses to the remaining 8 questions
regarding controller fatigue. Selected responses, with the permission of the GCP
Committee, have been edited for readability without undermining the respondent’s intent.
Responses to the survey questions were as follows:
Question One. I feel that rotating shifts cause me to feel tired and less alert while
at work. Answers are listed in Table 1.
Table 1
Question 1 Responses
51.1%
60%
50%
40%
25.0%
30%
14.7%
20%
5.6%
3.4%
10%
0%
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
27
Out of the respondents for question one 22 strongly agreed, 45 agreed, 13 were neutral, 5
disagreed and 3 strongly disagreed.
Comments were as follows: (1) “I tend to be tired only after one shift, that being a
day shift following the two evening shifts.” (2) “Working a 3-11 then a 7-3 (quick turn),
is by far when I am the most tired at work. On a typical day shift there are at least 5-6
controllers who were on the night shift the day before. Proof of fatigue...we average 3
coffee runs per day shift!” (3) “My shift schedule: Sat 11-9 p.m., Sun 11-9 p.m., Mon 117 p.m., Tue 7-3 p.m., Wed 6-2 p.m. The Mon and Tue shift are Flex shifts so I can come
in 30 min later if I want. This schedule also allows for 72 hours off. Rotating shifts makes
it more interesting because you're able to see the different traffic at different times of the
day.” (4) “What you will find is that the longer you work rotating shifts the more adjusted
you become. At 49 years of age I am good with 6 hours sleep a night. No matter the shift,
I can do it. When I was in my twenties it was certainly an issue. You learn and adjust
mostly but the last day midshift still poses problems. I still have not figured that out yet.”
(5) “Especially the day/mid with only 8 1/2 hours between shifts.” (6) “Tired virtually all
the time.” (7) “At age 25 you can do it, now at age 50 plus there is no way.” (8) “The
only time there is a problem for me is some "quick turns" if I can't get settled right away
at home.” (9) “as I get older” (10) “I currently work a week of day shifts(not all the same
hours)then a week of night shifts(not all the same hours). It is better than the previous
schedule of a week of night/night/night/day/day. Still hard on the body though.” (11) “I
actually end up feeling less alert on my days off and by the time I start work again the
next week I have recovered.” (12) “What is known as the "quick turn" is where I feel
tired. This is where a controller switches from the night to a day, or a day to a midnight
28
shift with minimal hours between (8 hrs).” (13) “It is not so much the rotation of shifts, or
days off, it is the way they schedule shifts that is a problem. The combination of shifts
that only allow 8 hours between shifts are not going to allow 8 hours of sleep when you
exclude commute time between work and home.” (14) “Been controlling and rotating
shifts for 27 years - I never ever have gotten "used to it"...always tired, never sleep well oh well that's life.” (15) “For over 1 year now I've been working straight evening. What a
world of difference! I am alert, rested and able to deal with the regular stresses from
home and work in much better fashion than I was able to when working rotating shifts.”
(16) “one year, about 3 years ago I counted approx 25 days where I went to work on 1/2
hour of sleep or less! Yes, shift work is a killer.” (17) “Not having a regular sleep
schedule is a killer. Also, having a family with small children causes one to be even more
tired when working rotating shifts. Your body, and your family cannot get used to the
way that our shifts work, as they are constantly changing.” (18) “Some facilities try and
schedule your last day for you to come to work late and your last day of work to early for
you to maximize your time off. What you do to maximize your time off whether sleeping
to catch up or spend time with your family is all on the individual.” (19) “"Quick turns"
are the worst. It's difficult to tell you body to turn off to get rest prior to going right back
to work; most of times you have exactly 8-9 hours between the turn-arounds.” (20) “The
worst is rotating from a night shift to a day shift.” (21) “I believe the body adjusts to the
abnormal shifts.” (22) “It depends on the shift work schedule, for example, a week of
days followed by a week of nights causes your body to be out of sync. With a rattler
schedule it is not as bad, unless you are doing quick turns with only 8 hours off between
the shifts. When working a month or two of nights then a month or two of days, your
29
body seems to adjust better.” (23) “The morning after my work turn I am usually tired,
but that is the only time.” (24) “I feel fatigue is cumulative, so I usually nap more when I
have a quick turn. Power naps at work really do help me through these days.” (25)
“Problem is with quick turns or when you have to do multiple quick turns” (26) “I
appreciate the longer weekends, but the shift schedule is tiring.” (27) “It's almost
impossible to sleep after my second shift, which happens to mean getting off at 10pm and
being back the next morning no later than 7 a.m.”
Question Two .I would perform better at work if I worked the same hours each
day. Answers are listed in Table 2.
Table 2
Question 2 Responses
39.7%
40%
28.4%
30%
20.4%
20%
9.0%
2.5%
10%
0%
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Out of the respondents for question two 35 strongly agreed, 25 agreed, 18 were neutral, 8
disagreed and 2 strongly disagreed.
30
Comments were as follows: (1) “My sleep schedule could then get into a normal
routine” (2) “fatigue in breed by shift work as well” (3) “I don't know because I haven't
done it. But I think it would get monotonous (lacking in variety).” (4) “At a min, change
weekly” (5) “Unfortunately, planes fly 24/7” (6) “This seems like such an obviously true
statement that it shouldn't even need to be asked, none the less the FAA has prohibited
working straight shifts.” (7) “See comment above it is a need for more than 8 hours plus
commute time between shifts.” (8) “I think that working the same shifts every day would
cause the controllers to become complacent - working the same traffic all of the time.
Also, some shifts tend to be busier than others, and on controller may always work traffic
while their sector is in the red if they worked the same shift all of the time.” (9) “I would
perform better at work if I worked the same shift(s) all week long. i.e. a week of nights,
then a week of mids” (10) “I think that shift work is something you get use to, just like
when you train at a sector your train your body to do the shift work” (11) “As long as you
have adequate rest rotating shifts are workable.” (12) “To say I would perform "better" is
hard to say. I would be less tired on the 3rd and 5th days of the week for sure.”
Question Three. I have worked shifts or mandatory overtime that did not allow me
to get 8 hours of sleep between shifts. Answers are listed in Table 3.
31
Table 3
Question 3 Responses
63.6%
70%
60%
50%
40%
20.4%
30%
20%
1.3%
7.9%
6.8%
10%
0%
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Out of the respondents for question three 56 strongly agreed, 18 agreed, 1 was neutral, 7
disagreed and 6 strongly disagreed.
Comments were as follows: (1) “I have a shift where from the time I leave from
work till the time I have to be at work is right at 8 hours. It's usually recommended for
me to not sleep while driving” (2) “I believe that would be illegal” (3) “My typical end of
the week schedule is 3 p.m. - 11 p.m., 7 a.m. - 3 p.m., 11 p.m. - 7 a.m., I get about 10
hours of sleep total until 7 a.m. after the midnight shift.” (4) “At my facility it is difficult
to get overtime. There is overtime sheet, if you want overtime you can put your name on
it, if you do not request overtime you will not get it.” (5) “If you only have 8 hours
between shifts you obviously can't get 8 hours sleep.” (6) “See above comment. My
commute is 20 minutes each way with 8 1/2 hours between a shift.” (7) “We do this to
ourselves to get a longer weekend break. This has always been the way in my 25 years in
air traffic control. I almost feel like any change will require imposition against our will.”
32
(8) “We regularly have shifts that start a mere 8 hours after signing off. That leaves only
8 hours to drive home, eat, sleep, prepare for work, and drive back. Sometimes there are
two occurrences of these shift combinations in one week.” (9) “It is impossible to get
eight hours of sleep between shifts when you only have eight hour between shifts. At best
a person gets home ten minutes after work, and then they spend the next hour to two
trying to spool down and get ready to sleep. In the morning, one must get up, shower, and
get ready for work before heading in. I would say that on my quick turn nights I average
about 5 hours of sleep, and my commute is only five minutes from work.” (10) “As a
civilian controller the FAA mandates that a controller has to have at least 8 hours off duty
prior to assuming the next watch. In the military the same rules apply except in war time
when forward deployed.” (11) “This is illegal.” (12) “If I have a quickturn shift, (from
night to day or day to mid), I rarely receive more than 3-4 hours sleep between the two
shifts.” (13) “At least once a week I have 8 hours between shifts..so it's impossible to get
8 hours of sleep” (14) “Eight hours between shifts does not allow for eight hours of
sleep.” (15) “Almost weekly. Get off at 10pm and usually back at 7 a.m., but sometimes
6 a.m. That gives me 8-9 hours between leaving work and being back at work. You have
to add in commute time, eating time, getting ready for work time, talking to the wife
time, etc.”
Question Four. I get on average 8 hours of sleep a night. Answers are listed in
Table 4.
33
Table 4
Question 4 Responses
43.1%
50%
42.0%
40%
30%
10.2%
20%
10%
3.4%
1.3%
0%
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Out of the respondents for question four 1 strongly agreed, 9 agreed, 3 were neutral, 38
disagreed and 37 strongly disagreed.
Comments were as follows: (1) “more like 5-7” (2) “I average about 4-6.” (3) “As
you can see by my schedule, worst case scenario is 12 hours between shifts.” (4) “Old men don't need 8 hours a night.” (5) “Only cause I sleep 10 hours on my off days and
night shifts to "catch up"” (6) “Almost never.” (7) “That is true when I work nights
because I can sleep in, but when I work days, I can't get to sleep early enough to get 8 hrs
before my 4am wakeup” (8) “I feel like I've had a good night's sleep if I get 6 or 7
uninterrupted sleep.” (9) “Only on nights without a quick turn of 8 hours between shifts.”
(10) “Now that I'm on a straight shift (1+ year) I do. Before when on a rotating shift I
would get an average of 5 hours of sleep.” (11) “At best I average about 6 a night with
my totally disrupted sleep patterns, and those days when I sleep in when I do not have to
work, on enever really "catches up" on sleep” (12) “5-6 is the norm, a little more on my
34
rdo's.” (13) “I have 3 kids so even when I work late in the day I have to get up early to
take care of my kids” (14) “7 to 7.5 is good for me.” (15) “Except on mids.” (16) “Even
on days off I don't get 8 hours of sleep in a night. I'm usually up after 6 hours of sleep,
but I do love my 1-2 hour naps in the afternoon.”
Question Five. I perform better at work when I get 8 hours of sleep. Answers are
listed in Table 5.
Table 5
Question 5 Responses
37.5%
40%
35.2%
30%
19.3%
20%
5.6%
10%
2.4%
0%
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Out of the respondents for question five 31 strongly agreed, 33 agreed, 17 were neutral, 5
disagreed and 2 strongly disagreed.
Comments were as follows: (1) “it can, especially between 3rd and 4th shift ( day
to day )” (2) “If I choose not to go to bed and stay up late before work, I will not perform
well the next day.” (3) “Not sure, I can't remember last time I slept 8 hours in the same
night.” (4) “I prefer 6 hours of sleep per night to feel my best the next day.” (5) “I don't
35
know if I perform better or just feel better. I definitely feel better.” (6) “I perform better
when I get at least 6 hours of sleep.” (7) “I rarely get more than 7 hrs. I learned not to
sleep 30 yrs ago doing port and starboard watches at sea.” (8) “I would strongly agree
that "if" I got 8 hours of sleep I would perform better than if I got 5 hours of sleep (the
norm)."
Question Six. Receiving breaks every 2 hours greatly enhances my job
performance. Answers are listed in Table 6.
Table 6
Question 6 Responses
56.8%
60%
50%
30.6%
40%
30%
9.0%
20%
3.6%
10%
0.0%
0%
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Out of the respondents for question six 50 strongly agreed, 27 agreed, 8 were neutral, and
3 disagreed.
Comments were as follows: (1) “sometimes a quicker break rotation is warranted
based on traffic complexity, however supervisors are locked into a clock watch mode,
sometimes due to complexity, help is better than relief, because you are in the zone and
36
have the picture, explaining a difficult situation to a newly arriving person can be
hazardous.” (2) “breaks should be at intervals of less than two hours.” (3) “We like to call
it "hitting the wall" after about 2 hours you start tripping over your own words and start
missing some things. When it is busy it could happen as quick as 1 hour.” (4) “every hour
is better!” (5) “As someone that had an OE at 1 hour 59 minutes on position I don't
believe that routinely running two hours on position is a safe practice.” (6) “Receiving
break at least every two hours enhances my performance. I find a short break after about
an hour and fifteen minutes on position works best for me.” (7) “Preferably less than two
hours. 2 hrs working busy traffic is very tiring.” (8) “The more breaks the better. We
have to be perfect and vigilant every minute we are working traffic. Try doing that for 25
years working 2 hours on. I think an hour on a half hour off is ideal.” (9) “This strongly
agree statement is based on the presumption that the two hours on position is the
MAXIMUM time that a controller should be on position. Working two hours or LESS on
position is far better than working more than 2 hours on position.” (10) “not sure if this is
a correct statement when you consider workloads. Heavy traffic sessions of 45-60
minutes are just as mentally fatiguing as working 2 hours of light traffic.” (11) “Although
your attention span drastically declines after 55 minutes of continuous activity, I would
prefer shorter times on position.” (12) “The timing of breaks for performance
improvement is highly complex. During times of low traffic and time of high traffic,
breaks more often are helpful. The simple act of sitting at a low traffic position can cause
loss of concentration due to distractions and lack of productive work to perform. At a
high traffic position, one 40 minute rush can totally exhaust you.” (13) “Breaks every
hour to hour and a half work better for job performance.” (14) “Two hours is on the cusp
37
of being too long on position, but it's better than three.” (15) “Receiving breaks in the 1
hour and 20 minute region should be mandatory. Working 2 hours straight if you are
anywhere near the “map number for even half that time is brutal on the mind.”
Question Seven. I receive a break every two hours while on position. Answers are
listed in Table 7.
Table 7
Question 7 Responses
50.0%
50%
40%
25.0%
30%
11.3%
20%
7.9%
5.6%
10%
0%
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Out of the respondents for question seven 22 strongly agreed, 44 agreed, 10 were neutral,
7 disagreed and 5 strongly disagreed.
Comments were as follows: (1) “if left to management and their "productivity
goals', then no. if rotated properly then yes” (2) “There have been plenty of days we have
been so short staffed we have been stuck on position for 2:30+ sometimes 3 hours.” (3)
“At my facility you get breaks almost every hour. There are times when you're on
position for 2 hours, but it's rare.” (4) “Breaks every hour.” (5) “Even though staffing is
38
down, so is traffic. In the summer time we'll be busting our asses. We take the winter to
recharge. I wish management understood that and would just let us take breaks and leave
when we can.” (6) “I receive breaks about every 45 minutes.” (7) “I rarely go over two
hours on position unless it's a midshift.” (8) “It's a rare day to be on position 2 hours
straight. Luckily my facility (L30) has decent manning.”
Question Eight. Someone at my facility has had an operation error/deviation that
could be attributed to fatigue associated with rotating shifts, overtime or lack of breaks.
Answers are listed in Table 8.
Table 8
Question 8 Responses
39.7%
40%
30%
22.7%
15.9%
15.9%
20%
5.6%
10%
0%
Strongly
Agree
Agree
Neutral
Disagree
Strongly
Disagree
Out of the respondents for question eight 20 strongly agreed, 14 agreed, 35 were neutral,
14 disagreed and 5 strongly disagreed.
Comments were as follows: (1) “At CVG, it's been a long time since we were
"busy", and it's hard to remember when someone wasn't bugging you take a break after
39
20 minutes. Honestly the fatigue part comes in trying to keep your mind occupied during
an 8 hour shift where you might be engaged in ATC for all of about 15-20 minutes, it can
be tiring.” (2) “Not to my knowledge although I have lost awareness due to fatigue.” (3)
“There are always multiple reasons for an operational deviation, or error, I am sure if
there was ever an NTSB investigation they could find fatigue to be a contributing factor
in all, but not the main reason.” (4) “Not aware of any. I work at Scottsdale Airport, AZ.
Level 7 facility, Class D, 12-15 controllers, hours of operation 6am-9pm.” (5) “It could
be a contributing factor but who knows.” (6) “Unsure.” (7) “But it was covered up.” (8)
“I would bet that about half of our deals are at least partially caused by fatigue.” (9)
“While there is likely no way to prove this statement, I have no doubts that the rotating
shifts contributes to lower performance.” (10) “We have had very few errors (three in the
last two years).” (11) The idea of “could” be attributed vs. any mention of fatigue in the
report seems to be the issue. Fatigue is not addressed when investigating Operational
Errors and Deviations. The closest that the FAA comes to acknowledging this is
documenting the previous few days of assigned work shifts.” (12) “People will rarely
admit to this because doing so will leave them open for further action by showing up for
work and not fully rested. The FAA expects you to be fully rested and does not take into
account that a person cannot force their own body to immediately go to sleep when they
get home. Plus, if they are a single parent household the ability to do this becomes even
more difficult. I can only recall one accident where controller fatigue came into play and
that was the crash at Los Angeles International Airport. Fatigue was mentioned but the
controller was also busy with other duties and it was never proved that the person was
actually tired. Some people also feel refreshed if they take short cat naps although
40
napping can leave the person open for disciplinary action from the FAA, which can bring
someone up on charges even if they exhibit sleeplike behavior.” (13) “Not that I know
of” (14) “Deviations I've seen were caused by incompetence.” (15) “I don't know.” (16)
“If it did, I haven't had anyone directly say that was the reason for the error.”
41
CHAPTER V
DISCUSSION
Rotating Shifts
As the NTSB is concerned about the rotating shift schedule used by the FAA, this
study found that more than 75% of controllers surveyed either agreed or strongly agreed
that rotating shifts cause them to feel tired and less alert while at work. Less than 10% of
the controllers surveyed disagreed or strongly agreed that rotating shifts caused fatigue,
with most of these responses coming from controllers that enjoyed the 3 day weekend
afforded by this type of schedule.
Numerous comments were made supporting the NTSB’s findings that shift-work
directly contributes to fatigue in the controller workforce. One controller stated that after
working rotating shifts for 27 years they were still not “used to it” and still always felt
tired and never slept well. Another controller reported having had 30 minutes of sleep or
less for approximately 25 days in one year before having a shift. Most of the controllers
comments can be summed by the following response about rotating shifts, “Tired
virtually all the time.”
The next survey question focused on whether controllers believed that they would
perform better at work working the same shift each day. More than 65% of controllers
agreed or strongly agreed that working the same shift would increase their work
performance with only 11% disagreeing or strongly disagreeing. Controllers did make a
range of comments regarding this question. Some controllers discussed the possibility of
controller complacency working straight shifts, others stated rotating shifts were fine as
long as there was adequate rest and some discussed how straight shifts would increase
42
their work performance. There was one interesting comment that leads the researcher to
believe that there is a lack of awareness of fatigue and its resulting effects on the human
body in the workforce, “To say I would perform “better” is hard to say. I would be less
tired on the 3rd and 5th days of the week for sure.” Fatigue and cognitive performance
have a direct correlation; therefore being less fatigued actually increases performance. It
is apparent to the researcher that some controllers in the workforce have been
experiencing fatigue for so long that they do not think being “less tired” would increase
their work performance.
Even though it is painfully obvious that controllers whom only have 8 hours
between shifts will likely not get adequate rest, ultimately controllers are responsible for
ensuring they get sufficient rest between shifts. Even though most all of the surveyed
controllers agree that the current scheduling practices of the FAA lead to fatigue and
more than half or the respondents agree that working straight shifts would increase their
job performance, the FAA still continues to use rotating shifts and has no scheduled
change in this policy in the immediate future.
Sleep Deficits
Many controllers work 6 day work weeks with overtime, this compounded with a
rotating schedule can have devastative effects on controller’s circadian rhythm and also
cause controllers to build a sleep deficit during the week. Sleep deficits built from
controllers lacking adequate rest from multiple nights will cause fatigue in the workforce,
interestingly this study found that nearly all controllers surveyed were not getting 8 hours
of rest between shifts.
43
When asked if having ever worked shifts or mandatory overtime that did not
allow them to get 8 hours of sleep between shifts, 84% of controllers agreed or strongly
agreed with less than 15% disagreeing or strongly disagreeing. Most all comments made
by respondents to this question referenced the impossibility of getting 8 hours of sleep
when they only have the 8 hours mandated by the FAA between shifts. One controller
reported only averaging about 5 hours asleep between shifts which seemed typical for
many of the other controllers considering the factors mentioned including driving to and
from work, eating and family considerations. Interestingly, two controllers mentioned
that working shifts or mandatory overtime that does not allow them to get 8 hours of
sleep between shifts would be “illegal.” The FAA mandates that controllers have 8 hours
between shifts, whether or not the controller sleeps for 8 hours is not mandated by FAA
regulation.
The next question dealt specifically with how much sleep controllers averaged per
night. Approximately 85% of controllers reported not averaging 8 hours of sleep a night.
Considering that most adults do not sleep 8 hours every night this should not be too
concerning, but many controllers reported sleeping much less than 8 hours. Most of the
respondents comments specified receiving between 5 and 7 hours of sleep. Considering
the responses to the next question on the survey, this is very concerning regarding fatigue
in the controller workforce.
When asked if they perform better at work when getting 8 hours of sleep more
than 70% of controllers either agreed or strongly agreed with this statement, with less
than 10% not agreeing. One controllers statement sums up many of the comments made
by controllers regarding sleep between shifts, “I would strongly agree that “if” I got 8
44
hours of sleep I would perform better than if I got 5 hours of sleep (the norm).” The
current status quo in the FAA regarding rotating shifts and the minimum of 8 hours
between shifts is hindering performance and causing fatigue for controllers in the FAA.
Even with only 50 controllers reporting these problems this is more than 50% of the
survey respondents; obviously this is a huge problem when considering the entire
workforce.
Position Rotation
During shifts controllers must receive breaks every 2 hours. The idea behind the
break requirement is that controllers whom are dealing with heavy traffic volumes or
complexities will begin to become fatigued after some time on position. The break also
functions to alleviate complacency experienced by controllers on positions with light
traffic volumes for extended periods. In either case NATCA and the FAA agree that
giving controllers breaks at least every 2 hours is an effective way to curb human error
and minimize operational errors.
When asked if receiving breaks every 2 hours greatly enhanced their job
performance more than 85% of controllers agreed or strongly agreed with this statement
with less than 4% disagreeing. This question received multiple comments alluding to the
fact that sometimes 2 hours on position is too much, example “As someone that had an
OE at 1 hour and 59 minutes on position I don’t believe that routinely running two hours
on position is a safe practice.” The general consensus is that anywhere from 1 hour to 1
hour and thirty minutes would be the ideal time to receive breaks, but as one controller
put it 2 hours is better than 3.
45
Considering that only 4% of controllers don’t believe receiving breaks every 2
hours greatly enhances their job performance one would think all controllers would
receive breaks every 2 hours. Only 75% of controllers reported receiving breaks every 2
hours while on position and sadly more than 13% reported having not received breaks
every 2 hours even though it is required by FAA policy. One controller reported
repeatedly being short staffed and being stuck on position for upward of 3 hours. Another
controller reported only having to work more than 2 hours on position on the midshift, in
reality this is a shift where breaks are the most importance as traffic is minimal and the
risk for complacency is much higher than during busier periods. The FAA itself mandates
that controllers receive breaks ever 2 hours to reduce the chances of human errors, yet
more than 10% of the controller’s surveyed reported being on position for more than 2
hours straight. One can only infer that safety is not the number one concern in every FAA
facility.
Fatigue and Human Error
The last question posed to the survey respondents was meant to infer whether
controllers had encountered a situation where rotating shifts, sleep deficits or lack of
breaks had caused a controller to have an operational error or deviation. This question
was designed to specifically verify or reject the hypothesis as to whether fatigue
correlates with the number of operational errors and deviations experienced by air traffic
controllers. The results from this question are disheartening to say the least as many
controllers convey through their comments management’s apparent lack of concern for
the safety of the traveling public and also attempts to cover up human factors issues at
multiple facilities around the country.
46
When asked if someone at their facility has had an operational error or deviation
that could be attributed to fatigue associated with rotating shifts, overtime or lack of
breaks 39% of controllers agreed or strongly agreed with this statement, 40% of
controllers were neutral and only 21% of controllers disagree or strongly disagreed with
the statement. Controllers made a variety of comments some eluding to the fact that they
didn’t have any knowledge of such incidents or that it was never mentioned that fatigue
was an issue, but the majority of comments eluded to the fact that fatigue causes
operational errors and deviations such as “I have lost awareness due to fatigue” and “I
would bet that about half of our deals are at least partially caused by fatigue.”
Controllers made comments directly related to the fact that the FAA does not
require controllers to address fatigue when reporting operational errors, as one controller
noted the closest the FAA comes to acknowledging fatigue in operational errors is
documenting the previous two days of assigned work shifts. Many controllers feel that by
not considering fatigue when addressing operational errors the FAA is covering up how
their scheduling and management practices cause fatigue and yet it is still the controller’s
responsibility to not be fatigued, example “People will rarely admit to this because doing
so will leave them open for further action by showing up for work not fully rested.” With
less than a quarter of respondents disagreeing that fatigue has been responsible for an
operational error/deviation at their facility it is painfully obvious that fatigue is a
contributing factor for many operational errors/deviations throughout the FAA system
whether or not it is reported or investigated by the FAA.
47
CHAPTER VI
CONCLUSIONS
More than 75% of controllers surveyed agreed that rotating shifts caused them to
feel tired and less alert while at work, even so many controllers enjoy the 3 day weekend
they can be afforded with this schedule and also the differences in traffic to break up the
monotony of sitting on the same position day after day. More than 65% of controllers
agreed that working the same shift would increase their work performance, as one
controller put it “This seems like such an obviously true statement that it shouldn’t need
to be asked, none the less the FAA has prohibited working straight shifts.” Due to the
current staffing crisis and lack of qualified personnel throughout the NAS, management
generally does not have the option to move its workforce to straight shifts and even if
they did it's yet to be seen if NATCA would oppose such a change at certain facilities.
Without a doubt the researcher can conclude that rotating shifts contribute to fatigue in
the workforce, by alternating controllers sleep patterns and not allowing for ample sleep
between shifts, as was reported by the respondents.
More than 80% of controllers agreed that they had worked shifts or mandatory
overtime that did not allow them to get 8 hours of sleep between shifts and 85% reported
not getting an average of 8 hours of sleep a night. The current FAA policy only mandates
8 hours between shifts and many facilities schedule at least one shift a week with only 8
hours off, as one controller commented “If you only have 8 hours between shifts you
obviously can’t get 8 hours of sleep.” More than 70% of controllers agreed that they
perform better at work when they get 8 hours of sleep. It can be concluded that current
48
FAA policy is not providing adequate time between shifts to allow controllers the
possibility to get 8 hours of sleep to minimize the fatigue associated with rotating shifts.
More than 85% of controllers agreed that receiving breaks every 2 hours greatly
enhances their job performance and 75% of controllers reported receiving breaks every
two hours. Interestingly 14% of respondents reported not receiving the FAA mandated
breaks while on position, obviously contributing to the fatigue experience by air traffic
controllers. One controller responded to the question of receiving breaks every two hours,
“If left to management and their “productivity goals,” then no, if rotated properly then
yes.” Management must ensure it is enforcing all of its policies especially those focused
on reducing controller fatigue and avoiding human errors. The general consensus among
the respondents regarding the breaks was that 2 hours was too long on position whether
there was heavy or light traffic.
The last question posed to controllers was regarding the correlation between
fatigue and operational errors and deviations experienced by those around them. The
majority of respondents did not disagree that operational errors or deviations could be
attributed to rotating shifts, sleep deficits or lack of breaks; therefore the hypothesis that
shift-work and fatigue directly correlate to the number of operational errors and
deviations experienced by the air traffic controller workforce was supported.
The most significant conclusion drawn from the last question’s responses by the
researcher was multiple mentions of the Federal Aviation Administration management’s
apparent attempts to hide the fact that fatigue is a contributing factor in many operational
errors and accidents. As one controller put it, there was an operational error attributed to
fatigue “but it was covered up”. With an attitude of sweeping fatigue issues under the
49
table and a continuance of the current scheduling practices and reporting procedures, it is
not a question of if the next catastrophic aviation accident will occur due to human error
caused by controller fatigue, but when.
50
CHAPTER VII
RECOMMENDATIONS
Air traffic controllers system wide are scheduled in a manner known to cause
fatigue and are overworked due to the current staffing crisis. Although the effects of
fatigue on controllers has been known for years and the NTSB has made numerous
recommendations to the FAA, their only response has been to convene workgroups
addressing fatigue factors, to date no changes have been implemented (OIG, 2009). The
following are recommendations to combat air traffic control fatigue throughout the air
traffic control system. The recommendations were derived from survey results, survey
comments, the researcher’s personal experience with controller fatigue and consulting
with multiple FAA air traffic controllers.
1. More research needs to be conducted into what shift pattern would be most
beneficial to FAA air traffic controllers to eliminate fatigue caused from rotating
shifts. Straight schedules are of an obvious benefit to the workforce but both the
FAA and NATCA will have to come to an agreement on how these schedules can
be implemented with a benefit to controllers while maintaining adequate manning
throughout the system.
2. Currently scheduling at facilities is focused around pay periods. The FAA should
investigate ways to allow controllers to be scheduled with more regard for
controller fatigue and staffing levels rather than pay rules.
3. Current FAA policy only dictates that controllers be given 8 hours between shifts.
At a minimum this should be increased to 10 hours to allow for travel and
personal time for controllers between shifts.
51
4. The survey respondents overwhelmingly recommended that mandatory breaks
should be given at intervals less than 2 hours, preferentially every 1 to 1 and half
hours. At a minimum the FAA must ensure that all controllers are receiving their
required breaks every 2 hours without regard to traffic complexity or shift.
5. The FAA needs to evaluate its current operational error/deviation reporting and
investigation procedures. Not only does the FAA need to include the areas of
work schedule, overtime and OJT in its reporting procedures but the FAA needs
to actively investigate these areas and make changes to its policies as required
after such incidents.
52
REFERENCES
Bourgeois-Bougrine, S., Cabon, P., David, H., & Mollard, R. (2000). Measurement of
fatigue and sleepiness in ATC simulation. [Electronic version]. Human Factors
and Ergonomics Society Annual Meeting Proceedings, Proceedings 3 –
Psychophysiology in Ergonomics, 208-211.
Caldwell, J., Caldwell, L., Mallis, M., Miller, J., Neri, D., & Paul, M. (2009, January).
Fatigue countermeasures in aviation. [Electronic version]. Aviation, Space, and
Environmental Medicine, 80 (1), 29-59.
Church, D. (2010, August 3). NATCA REMEMBERS PATCO STRIKE OF AUGUST 3,
1981. Retrieved August 3, 2010, from http://www.natca.org/mediacenter/pressrelease-detail.aspx?id=658
Federal Aviation Administration. (2004). Aeronautical Information Manual. Washington,
DC: U.S. Government Printing Office.
Federal Aviation Administration. (2005, December 7). FAA HAS OPPORTUNITIES TO
REDUCE ACADEMY TRAINING TIME AND COSTS BY INCREASING
EDUCATIONAL REQUIREMENTS FOR NEWLY HIRED AIR TRAFFIC
CONTROLLERS. Retrieved December 15, 2009, from http://gns.gannettonline.
com/misc/tigdoc.pdf
Fothergill, S., & Neal, A. (2008). The effect of workload on conflict decision making
strategies in air traffic control. [Electronic version]. Human Factors and
Ergonomics Society Annual Meeting Proceedings, 52(1), 30-43.
53
Hah, S., & Willems, B. (2008). The relationship between aircraft count and controller
workload in different en route workstation systems. [Electronic version]. Human
Factors and Ergonomics Society Annual Meeting Proceedings 52(1),. 44-48.
Huey, E. (2004). Controllers ask US Congress to fund new hires, training. [Electronic
version]. Air Transport Intelligence News.
Kirwan, B., Rodgers, M., Schaffer, D. (2005). Human Factors Impacts in Air Traffic
Management. Burlington, VT: Ashgate Publishing Company.
Kjelgaard, C. (2002). GAO urges FAA to address controller hiring & training
[Electronic version]. Air Transport Intelligence News.
Kjelgaard, C. (2002a). White House actions fuel controllers’ privatization fears.
[Electronic version]. Air Transport Intelligence News.
Macpherson, G., & Tvaryanas, A. (2009, May). Fatigue in pilots of remotely piloted
aircraft before and after shift work adjustment. [Electronic version]. Aviation,
Space, and Environmental Medicine 80(5), 454-461.
Murray, M. (1975). Comparing Public and Private Management: An Exploratory Essay.
[Electronic version]. Public Administration Review, Vol. 35, No. 4, 364-371.
National Transportation Safety Board. (2007, April). National Transportation Safety
Board. A-07-30 through -32. Retrieved September 5, 2009, from
http://www.ntsb.gov/Recs/letters/2007/A07_30_32.pdf
Office of Inspector General. (29 June, 2009). Air traffic control: Potential fatigue factors
Report Number: AV-2009-065. Retrieved July 23, 2009, from http://www.oig.
dot.gov/sites/dot/files/pdfdocs/WEB_FILE2_Controller_Fatigue_
AV2009065.pdf
54
Wallace, Steve. (2008, January). NATCA Press Release. More Than Half of New Hires
at Major Miami Radar Center Have Received No Training at All. Retrieved
March 10, 2010, from http://www.natca.com/mediacenter/press-releasedetail.aspx?id=483
Wethe, D. (2007, April). As Air Traffic Controllers Age, FAA Looks to Hire Many.
Retrieved January 27, 2010, from http://www.airportbusiness.com/online/
article.jsp?siteSection=1&id=11359
55
BIBLIOGRAPHY
American Psychological Association. (2001). Publication manual of the American
Psychological Association (5th ed.). Washington, DC: Author.
Bender, A., Clark, R., Hanrahan, P., Harsha, W., McMasters, B., Murphy, E., et al. (Eds).
(2005). Graduate/technical management capstone project guidelines (6th ed.).
Daytona Beach, FL: Embry-Riddle Aeronautical University, Extended Campus.
Gay, L. R., & Airasian, P. (2009). Educational research: Competencies for analysis and
application (9th ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.
56
DATA COLLECTION DEVICE
This is a printable copy of the data collection device. The survey in its online format as
was used in the study may be found at http://www.anthonydionisio.com/atcsurvey.htm.
The following are general questions about shift-work and other working conditions you
might experience in the FAA. Please answer each question with a corresponding answer.
You are encouraged to make comments regarding each question whether positive or
negative.
A. I feel that rotating shifts cause me to feel tired and less alert while at work.
1-Stongly Disagree 2-Disagree
3- Neutral
4-Agree
5-Strongly Agree
B. I would perform better at work if I worked the same hours each day.
1-Stongly Disagree 2-Disagree
3- Neutral
4-Agree
5-Strongly Agree
C. I have worked shifts or mandatory overtime that did not allow me to get 8
hours of sleep between shifts.
1-Stongly Disagree 2-Disagree
3- Neutral
4-Agree
5-Strongly Agree
4-Agree
5-Strongly Agree
D. I get on average 8 hours of sleep a night.
1-Stongly Disagree 2-Disagree
3- Neutral
E. I perform better at work when I get 8 hours of sleep.
1-Stongly Disagree 2-Disagree
3- Neutral
4-Agree
5-Strongly Agree
F. Receiving breaks every 2 hours greatly enhances my job performance.
1-Stongly Disagree 2-Disagree
3- Neutral
4-Agree
5-Strongly Agree
G. I receive a break every two hours while on position.
1-Stongly Disagree 2-Disagree
3- Neutral
4-Agree
5-Strongly Agree
H. Someone at my facility has had an operation error/deviation that could be
attributed to fatigue associated with rotating shifts, overtime or lack of breaks.
1-Stongly Disagree 2-Disagree
3- Neutral
4-Agree
5-Strongly Agree