The Federal Aviation Administration acknowledged yesterday that it violated its own rule by having only one air-traffic controller, rather than two, monitoring the Blue Grass Airport on Sunday.
And the lone controller who was there last saw Comair Flight 5191 before it taxied onto the wrong runway, according to investigators.
After clearing the plane for takeoff on Runway 22, the controller "turned his back to perform administrative duties," said Debbie Hersman, a member of the National Transportation Safety Board. "This controller did not have visual contact with the aircraft," she said.
Moments later, when he turned again, Flight 5191 had crashed, killing 49 of 50 people onboard.
Although his view of the runway was clear and unobstructed, the controller did not actually see which runway the plane lined up on, he told investigators yesterday.
Flight 5191 took off from Runway 26, which is much shorter than Runway 22, where it should have been.
Asked whether that was a mistake on the controller's part, Hersman said that any analysis will be a part of the NTSB's report and recommendations, which could be months or even a year away.
Some experts say that, if two controllers had been in the tower, the crash might have been averted.
The controller was performing at least two jobs, including radar and ground control. That's too much for one person, the flight controllers union said.
"That may be part of the problem there," said Ted Gaty, a retired businessman and private pilot from Lexington who has flown into Blue Grass. "Maybe it's because there was no ground control operator."
Scott Zoeckler, a retired Lexington air traffic controller, said the controller's main role is to direct air traffic to make sure planes aren't getting in each others' way Ð not to make sure the pilots are doing their jobs correctly.
Zoeckler said he has been in contact with the controller, who has 17 years experience, but would not offer his name.
"It's a hard time for him," Zoeckler said. "He did his job. He was doing everything he was supposed to do. And he turns around and sees this ball of fire."
'The pendulum swings'
The FAA requires that the airport be monitored by at least two controllers, but one of them did not have to be in Lexington, according to a memo sent to employees by Blue Grass Air Traffic Manager Duff Ortman in November.
The memo said, in part: "The Eastern Terminal Service Director is requiring that facilities separate the radar function from the tower function."
One of the jobs was to be done by a controller in Indianapolis, Ortman said. That never happened, according to the union.
From January to March, the Lexington tower did have two controllers, according to the National Air Traffic Controllers Association, an employee union.
However, since March, there has only been one controller on all overnight shifts at Blue Grass, said Andrew Cantwell, the union's regional vice president for the southern states.
Cantwell said he knew of instances at other airports where the lone controller had a heart attack or fell down stairs and the tower was unmanned until help arrived.
FAA spokeswoman Kathleen Bergen had previously said the overnight shift in Lexington was manned by one person only on the weekends. However, late yesterday, she said they have had -- even during the week only one controller overnight. She apologized for releasing incorrect information.
"Traffic at Lexington airport during overnight shifts is very low, with an average of fewer than eight aircraft between midnight and 6 a.m.," she said in a statement. "At this traffic level, only a single tower controller is needed to safely separate surface traffic."
Bergen said the two-controller mandate was still in place on Sunday, when the Bombardier CRJ-100 took off on the wrong runway, crashing into hilly, tree-filled terrain.
"Controllers not only have to do their jobs without making mistakes; they have to maintain vigilance and try (to) prevent other people's mistakes from becoming accidents," said Ruth Marlin, executive vice president of the union. "If there aren't enough controllers to do it, we can't maintain the safety margin."
Marlin, in a statement, said the FAA, which employs the controllers and manages the towers, has required two controllers during overnight shifts only after accidents or near misses.
After time passes without incident, "the pendulum swings back" and the FAA returns to allowing one controller during midnight-to-8 a.m. shifts, she said.
"Unfortunately for the people in Lexington, the pendulum swung against them," Marlin said.
Nineteen controllers are assigned by the FAA to the Lexington tower. It once had two controllers working midnight shifts, but staffing on that shift was cut back about five months ago, after air traffic slowed, Bergen said.
The union says the shift was cut because somebody retired. It says its contract with the FAA requires the facility to have at least 21 controllers.
The airport has returned to two-man crews for the midnight shift, Bergen said. The change was made after it was brought to the FAA's attention that there was only one controller on Sunday.
Cantwell said the same mandate was sent to Duluth, Minn., and Savannah, Ga., this week.
Lexington's staffing levels are close to those of similar-sized airports, she said. Chattanooga, for example, has the same number of controllers.
Marlin, the union official, said that whether Lexington's staffing is comparable to other airports is irrelevant. Having one person in the tower is never a good idea, she said.
The number of flights taking off in the morning in Lexington "is just too many for one person," Marlin said.
Two flights had departed before Flight 5191 on Sunday. Neither the FAA nor the NTSB has disclosed whether there were other planes in Lexington's air space, which controllers also must monitor, at the time of the crash.
Some experts disagree on whether an extra controller would have made a difference.
"We've always had one person at that time of day," said Zoeckler, the retired Lexington air traffic controller. "It's never been a problem."
Charlie Monette, president of Aero-Tech, a flight school at the airport, said the tower has a separate ground control person during busy times, but in slow times one person does both ground and air control.
The second person might have spotted Flight 5191's runway mistake, but by the time he or she did, "it would have been too late," Monette said.
'A matter of awareness'
Zoeckler, a 35-year veteran controller who retired two years ago after 27 years at Blue Grass Airport, said he knows of instances where pilots have lined up on the wrong runway at Blue Grass and have either caught themselves or been advised of the error by the tower.
"It's a matter of awareness of the runway. Before last week, it was just a pilot-awareness issue," he said. "The signage out there is perfectly fine."
Hersman said the NTSB is still working with the FAA to obtain "guidance, rules, requirements and what is appropriate for visual contact."
The controllers union has said for more than a decade that the United States needs to hire more controllers or it will face a major crisis.
In 2002, the FAA employed 15,606 controllers, according to Cantwell. It employed 14,305 this August.
During that time, air traffic in the U.S. has increased, the union notes.
The problem is compounded by tight federal budgets and the fact that controllers hired after the 1981 controller strike -- in which President Ronald Reagan fired 11,000 strikers -- are nearing retirement eligibility, the union has said.
In Lexington, seven controllers are expected to retire in the next four years, according to an FAA report.
The FAA says it is addressing the problem and has a plan to hire 11,800 new controllers over the next 10 years.