A letter to Tony Ferrante (AOV-1)

A PDF of the following letter was attached to a recent email, sent to Mr. Ferrante, who has been one of FAA’s top safety officials for well over a decade. The text here includes gold endnotes and green-box links to webpages…

January 21, 2013

Dear Mr. Ferrante:

I would appreciate your professional assistance to ensure appropriate FAA action to resolve a safety failure at the FAA tower in Camarillo, CA (KCMA).[1] This concerns a documented ATC operational error (OE) that occurred on 7/25/10.Œ This error had three ATC witnesses, including a supervisor (FLM) who failed to act with the required report. Perhaps the larger problem is that this safety failure has gone unresolved due to an ongoing series of deficient investigative activities by FAA management, at both the District and Service Area levels.[2] This matter was even shared with Mr. Foushee,Ž but I suspect he just reflexively passed it off (which clearly was not the best move, considering the purpose of Audit & Evaluation).

It is likely that you first became aware of this 7/25/10 KCMA OE via an 8/2/11 memo from Dianne Bebble, your subordinate at AOV-100. The subject of Ms. Bebble’s memo was ‘Report of Investigation: FAA Employee Complaint, Camarillo ATCT’. The memo’s five pages included a chronology of the OE and subsequent ‘investigations’; notes of the four interviews; a partial transcript from the ATC recordings;[3] and a list of facts gleaned from an ATC tape and interviews of the KCMA personnel. The production of this 5-page memo required a visit by ATSI Mark McClure, who flew down from AOV-210 in Renton, WA, to perform the investigation. Mr. McClure heard the tapes,[4] which were thoroughly consistent with the detailed account of a same-runway error, as provided by Ground Controller Mike Marcotte.[5] Oddly, the two other witnesses (both of whom had a vested interest to deny any safety incident) had no memory; i.e., both the Local Controller (Mr. One’ Nielsen, who has since been promoted to be a supervisor) and the FLM in the tower (Mr. Pruitt, who has since promoted to a busier tower) had no information to contribute to Mr. McClure’s investigation. Based on these interviews, Mr. McClure declared the investigation was ‘inconclusive’.

Please note, an ATSAP report WAS FILED by the Local Controller (Mr. Nielsen), but the facts within this critical record were not used (as they clearly should have been) to refresh the memories of Mr. Nielsen and Mr. Pruitt, and thus enable the conclusive analysis that ATSI McClure failed to produce (on his first try).

I trust that you agree, this is not acceptable performance by FAA. I also assume that you were not aware of many of these details when they were reported (or not?) to you in August 2011. Frankly, in an organization as large as FAA, it is quite conceivable that information often gets filtered and/or concealed and/or misdirected. Thankfully, consistent with our Safety Culture, we can easily and quickly remedy these failures.

Some online research shows that you are aware of the Peter Nesbitt whistleblower retaliation case. Mr. Nesbitt responsibly spoke up about serious safety failures at Memphis, TN (KMEM), including events where commercial pilots going around during intersecting runway operations had reported passing under other commercial flights with as little as 100’ vertical separation. You sent a 4/2/07 memo to Bruce Johnson‘ identifying this unsafe ATO noncompliance. Part of your memo stated: “…this ongoing lack of compliance with FAA regulations, despite the advice from ATO’s Safety Services, is unacceptable and requires your immediate attention to ensure compliance with the safety standards in FAA Order 7110.65.”

For the record, the issues at KMEM centered on unsafe operations’ on intersecting runways which management was failing to report, while the unreported 7/25/10 OE at KCMA centered on unsafe operations on the same runway. There is not a lot of difference between these two air traffic safety failures. Both represent clear noncompliances with safety standards. Both represent events that, had just one more link in the chain been broken, they would have produced real fatalities when FAA employees failed.

You are likely also aware that NTSB has included Improve General Aviation Safety“ on their top-ten most-wanted list. This is largely due to the much higher accident/fatality rate for GA vs. commercial aviation. Indeed, thus far in 2013, we have already seen fifteen fatal GA accidents” with at least 30 fatalities. At this rate, and consistent with past FAA safety oversight (which many believe is failing its potential to serve), we can expect roughly 500 aviation fatalities by the end of this calendar year. This is not acceptable.

When our organization fails to identify controller errors, and thus fails to adopt better and safer practices, we not only put pilots at risk; we also diminish public confidence AND we demoralize our best senior controllers, while destroying the potential of our new controllers.

Mr. Ferrante, I suggest our FAA needs to be more assertive in preventing GA accidents. A good place to start would be to ensure that all GA operational errors, such as the concealed KCMA OE of 7/25/10, are fully investigated. Give those two supervisors amnesty if you must, but get them to tell the whole truth. It seems reasonable to expect that, if we promptly conducted an assertive investigation and subsequent report of findings to hundreds of FAA and contract towers, it would reinforce the importance of maintaining same-runway separation. It would also reinforce the importance of timely and open communications related to systemic safety failures. And, it might just prevent a real accident.

So, would you please ensure this is done without any further delay? It would be so easy to resolve the ‘inconclusive’ status of the KCMA investigation by simply having one accountable official (such as you) actually read the ATSAP report and report its content.

Thank you for your service, and please let me know if there is anything I can do to assist.

Jeff Lewis
Former FAA ATCS/whistleblower


[1] It is my understanding that you are the Director of the Air Traffic Safety Oversight Service, AOV-1; further, that you report to Peggy Gilligan, who is the Associate Administrator for Aviation Safety (AVS). Please advise if any of this is incorrect and/or if there is another, more appropriate FAA official for this letter. I also understand you are a key FAA official behind the ATSAP MOU signed with NATCA.

[2] It is notable that there was no Local investigation. Two investigations were done belatedly at the District Level. First, in late September 2010, when Rolan Morel reviewed the tapes prior to their release under FOIA, and concluded there was no OE (though he never interviewed anyone, and his transcript erroneously added the word ‘turning’ to the taxiing arrival – you need to listen to the audio). And, second, in March 2011, when Jeff Cunnyngham did a phone interview of the Local Controller. A Western Service Area investigation was conducted in mid-June 2011; AOV-210’s Mark McClure flew down from Renton, WA, and conducted all three needed interviews for the ROI – a full eleven months after the safety failure had occurred.

[3] The key transmission was the ‘cancel takeoff clearance’‘ issued by Local Controller One’ Nielsen, when he recognized the arrival Cessna was still on the runway and being overtaken by the Cub departure on takeoff roll behind the Cessna. This clearly violates 7110.65 para. 3-9-6a and para. 3-9-6b.

[4] It is a measure of the lack of ATO cooperation that Mr. McClure had to obtain these tapes from the whistleblower, as they were not provided by local ATO management.

[5] Be sure to look at the details Mr. Marcotte provided at pgs.4-5. Thus far, the word of a credible and experienced controller has been completely ignored.