Guest Post: Sleeping Air Traffic Controllers. Mistake-Proofing Anyone?

Recent headlines have screamed about third shift air traffic controllers who have fallen asleep on the job, causing some inconvenience to inbound aircraft. I use the word inconvenience because there are procedures to follow when landing aircraft lose communication.  The pilots do the actual flying, not the air traffic controllers.

There are a lot of reasons why an air traffic controller may fall asleep on the job, particularly if he/she is the sole person on duty.  Late night air traffic control can be very boring.  Perhaps they haven't had enough rest prior to their shift (another matter, indeed). In certain locations, there may be very few flight arrivals over several hours.  Tower cabs and radar rooms have subdued lighting and playing radios or other electronic devices are not allowed.

So, you have several red flag conditions contributing to an environment that make it easy for a controller to fall asleep. So the reaction from the FAA administration?

  • Suspend/fire the offenders.
  • Hire a second controller for each facility.

So with the additional personnel, you are now going to have an already light work load divided between two workers, making the non-value added situation even worse.

Let's look at it from a mistake-proofing point of view.  What is the source error?  While there are several contributing factors, the source error is the controller falling asleep because there is not enough activity to keep him awake.

Once you have determined the source error to any defect, finding a mistake-proofing device is relatively easy.  We simply need some kind of automatic control to keep the controllers attention. Let's brainstorm for a solution.

  • Take the controllers chairs away, so they must stand.
  • I once heard that in Australia there is a railroad track that runs absolutely straight for hundreds of miles, and because of poor track, the train can only travel at 30 mph.  To keep the engineers from falling asleep, every 3 minutes or so he has to push a button.  If the button is not pushed, the train slows to a stop.  Interlocks are in place to prevent the engineer from bypassing the intent of the button.  Perhaps we could devise a similar device for our sleepy controllers.

Here are a few suggestions taken from readers on a blog at AvWeb:

  • If there is so little traffic the controllers can't stay awake, then I say close the tower during those hours. Spokane/GEG has airlines landing at night with the tower closed. Why double your costs when you can eliminate them? In this time of budget cuts is no time to increase costs unnecessarily. As pilots, we all know that night ops can be safely flown at night with no tower. (Note:  many smaller air traffic control towers in the USA close at night.  After hours, the pilots simply broadcast their intentions on the tower frequency.  We've been doing it that way since day one. Air Traffic Controllers don't land the plane, pilots do.)
  • Anyone suggest a $200 CCTV camera run to the nearest night shift security guard? Too simple to be elegant?
  • What if the feds considered staffing the midnight shift with one controller, and one student in an ATC program. Perhaps offering college credit, a guaranteed interview, and perhaps even meager pay to the college kid would be enough to entice them, and it would be much better experience than they'll get in the classroom. If nothing else, the night shift guys would have someone to play cards with in the off time!

Can you think of some more?

The whole point is, throwing an additional person at an under-tasked job is making a wasteful condition even worse and many companies do it.  Mistake-proof it instead.  Look at your source error, then devise a low cost/no cost method to keep it from happening. Don't just throw more people a the problem.

How do you think we could keep a lone air traffic controller awake? Send in your comments and let's hear your ideas.

This post was written by Sam Hoskins, CSSBB, MS, president of MistakeProofing.Net. Sam is an experienced hands-on mistake-proofing trainer and facilitator, who has conducted dozens of events for a diverse range of industries such as explosives manufacturing, processed food companies, welding and fabricating shops, and healthcare.  He learned lean and mistake-proofing while at the Ensign-Bickford Company and authored the mistake-proofing portion of their successful application for the 2001 Shingo Prize.  In addition to mistake-proofing, he is currently conducting Lean 101 training for a variety of companies through Parkland College in central Illinois. You may reach Sam at

Related Post: Guest Post: Preventing Mistakes – Not Just Chump Change

There are 16 Comments

Suwandi's picture

What about those sensors/devices/systems in automobile?
I copied from a website:

Lexus placed a camera in the dashboard that tracks the driver's face, rather than the vehicle's behavior, and alerts the driver if his or her movements seem to indicate sleep.

Saab uses two cameras in the cockpit to monitor the driver's eye movement and alerts the driver with a text message in the dash, followed by a stern audio message if he or she still seems sleepy.

More like a warning poka-yoke.

Sam Hoskins's picture

Jerry, the lighting would be definitely be a contributing factor. I'm sure when they are working a screen having the light dimmed helps the readability, but you have a good idea, keep the lights bright until there is activity, then dim them and sound an audio alert. Good brainstorming.

And speaking of serious waste in labor, here's another, "there is no such thing as a bad idea" brainstorm. How about if we had a trained monkey in the control cab? Every half hour or so, the controller has to feed the monkey. If the controller does not feed the monkey, the monkey throws a toy at the controller, waking him/her up. He would work for peanuts.

Sam Hoskins's picture

Mark - you are spot on with your comment about disciplinary action, or the admonition to just try harder.

Most of the time spent in my class is actually spent on garnering buy-in, not on the devices themselves. We first have to accept the fact that the mistake can happen. Everyone makes mistakes. Think about it, when was your own last mistake-free day?

Ask your self, have we given our employees all the tools required to ensure success, or are we setting them up for failure?

Sam Hoskins's picture

I have not heard of the truck driver sleepy eye sensor. Sounds like a viable idea.

How about some more low cost/no cost solutions that could put in place today?

Jerry Sisk's picture

Since I am not an ATC I have no idea what their job responsibilities entail; however, it seems to me that the lighting in the room is part of the root cause; it is only human to want to fall asleep in these types of conditions. If air traffic is so light during the night hours can't they install a system that keeps the lighting bright and when air traffic is present it sounds an alarm and automatically dims the lights for the ATC to perform his job? It also sounds like there is some serious waste going on in the form of labor. Is there nothing more value added that the employees can do in their off time? How about some continuous improvement and ongoing training with urgent crisis simulations on adjacent computers that randomly generate emergency situations where the ATC is forced to use their skills to avoid tragedy. The simulations must be addressed and documened and could serve not as a means for discipline, but as a means for on the job training and increased skill set. Are we all not involved in various forms of training throughout our carreers?

It's very hard to come up with ideas for mistake proofing without being in the Gemba, but it sure seems to me that somebody should be concentrating on the value-added work concept.

Mark Welch's picture

Nice article. I've been thinking along these same lines for weeks with all the attention the world news has been putting on this issue. Unfortunately, I think the newshounds are on the wrong trail (wrong issue). In terms of numbers of airline accidents and deaths the airlines' record is very good - averaging less than 100 deaths over the past decade according to an airline insurance industry stat. In healthcare around 100,000 people die in American hospitals due to medical error alone. Why aren't the newshounds all over this? It's because people dying in ones and twos in thousands of hospitals across our country each day isn't as spectacular as even a potential airplane crash.

If people need to be concerned, don't be too concerned about getting in a commercial airliner - be more concerned about that minor procedure or even that short stay in an American hospital. You're thousands of times more likely to die from that than your next flight.

Mark Graban's picture

And Tim, I forgot to ditto your comment about having supervisors run ATC for VIPs. Is that proven to be effective? It reminds me of hospital pharmacies having the highly skilled pharmacists serve as inspector for the work done by pharmacy techs. Better to error proof it, since there are many cases where the pharmacist can't detect errors (can you really tell what solution was put into that bag or syringe???)

John Hunter's picture

Yes, naps. Studies show that is what works for keeping night shift workers alert. We allow smoking, eating, bathroom breaks but the administrator has stated nap breaks would not be allowed "on his watch." Failed "leadership" - disregard the science because you want to be seen as tough.

Other countries allow them. Yes I understand it sounds funny to give someone a break to take a 15 minute nap, but it works. Combining that with some sorts of mistake proofing measures - pushing a button, or something, makes sense to me.

Mark's comment is great too.

Sam Hoskins's picture

The news usually gets the priorities wrong, it first started years ago with the old headline "Man bites dog"!

The newest brouhaha is the First Lady's aircraft doing a go-around. This is the aviation equivalent to a driver stopping their car to allow a pedestrian to cross the street, a non-event procedure that pilots train for during their first few hours of flight lessons.

But what about that controller, how are we going to ensure that he/she does not fall asleep?

Let's hear your ideas to mistake-proof it.

Mark Welch's picture

Correction to my post - I meant to say the commercial airline industry is averaging less than 100 deaths PER YEAR over the last decade. Sorry...

A significant contributor to that statistic was the 9/11 tragedy...

Tim McMahon's picture

Nice post. With the news announced today about the need for supervisors oversight on critical flights (by critical I mean VIPs) I'd like to know why they are more qualified. Why not just hire a bunch of supervisors? or maybe train everyone else to do what the supervisor can do.
These solutions by the FAA are the type of solutions you get from managers who manage from the office and have not seen the Gemba.

Mark Graban's picture

Sam, most of the media and general public response is so diametrically opposed to the error proofing and systems view. The general response is "fire anybody who falls asleep" and "come on, be a professional and stay awake!"

The same mindset is ineffective in healthcare, if we were to fire everybody who makes a mistake and admonish them "come on, be a professional and don't make errors."

Sam Hoskins's picture

These discussions brings to light a problem I see too often in the workplace. A problem arises and we spend all sorts of time bitching about the system. This is a danger about going after the true "root cause", versus a source error. They are two different things and if the problem is systemic, you may not have the wherewithal to eliminate the root cause.

I am trying to get you folks to invent a DEVICE to keep the controller awake, even though all of these other root causes are present.

In a process at a former employer, they identified outside distractions as a root cause for some of the errors they were making. True enough, but you can't eliminate distractions. Instead, focus your efforts on inventing a Mistake-proofing DEVICE that will prevent the error from occurring even if distractions are present.

So - how are we going to keep the controllers awake? Come on guys, invent a device for me. What are your ideas that you could put in place tomorrow?

Mark Graban's picture

The blaming and vilification of ATCs kills me. Look how many are falling asleep - it's clearly a human factors and job design problem. The Secretary of Transportation REFUSES to accept planned controlled cat-napping since it would look bad, although evidence shows performance would improve. He's choosing politics and public perception over safety. Now, nodding off for a few minutes, that's understandable and a systemic problem. The one ATC who brought a BED into the control tower, he was planning on sleeping. He deserves to be fired. Dr. Deming never said 100% of the problem is the system.

Rather than a second controller, they need a minimum wage person reading a book to make sure the ATC stays awake. Having double ATCs seems like a waste of talent and a waste of expensive supposedly well trained resources.

Shashi's picture

Usually don't post here, but the topic is of interest to me so decided to jump in the fray. (I am an avid Pilot and fly regularly)

* First the news media has needlessly sensationalized the matter - as the article rightly pointed out - Pilots do the flying. There are several thousand airports across the US with no tower at all, and there are several thousand legal flights daily that are flown VFR (Visual Flight Rules) where no contact is made with any ATC or tower (it is optional and entirely legal). So the fact that a controller fell asleep is really not a newsworthy item. Fr those interested, please go and listen to and pick a busy airport like KJFK or KBOS and listen to what really goes on.

* I don't see a need to do any major rework or change the ATC procedures at all - if you look at how many hours a day these services are provided flawlessly - a couple incidents is well within the noise. The news made a huge issue of it. The incident with the first lady's plane is a very routine affair (go-around).

But if one has to look at a possible solution to this (non-issue), you can look to the fatigue monitoring systems used by large haul truck operators where a sensor picks up the blink-rate of the eyes and figures out the times of shut-eye vs normal blink rates and determines a sleepy condition and issues alerts.

Honestly, this is overkill, let's find a REAL issue to solve. How about an efficient cost-accounting system that can really make the airlines money and passengers low fares for example ? :)

Jim Haycock's picture

Just put in a motion sensor with REVERSE logic -- i.e. when there's no motion for x seconds a buzzer goes off (or you could send a small electric shock into the person's rump...)