Safety Failure: A Concealed Error at Camarillo Tower

Sometimes the cover-up is bigger than the lie. And so it is with this story…

The Initial Incident:

An Operational Error (OE) occurred at Camarillo, CA on July 25, 2010. It was one of the most common errors that typically occur at FAA’s smaller controlled airports. A simple error, the Local Controller cleared a departure for takeoff without recognizing that another aircraft who had just landed was still on the runway. It became an error at the moment the departure began to accelerate forward – with the arrival still rolling out ahead on the same runway.

So, what exactly happened? Check it out for yourself.Here are links to three records:

The OE Diagram explains the incident, and the ATC Tape is a true recording, obtained via FOIA. The AOV report is a memo from Dianne Bebble to Anthony Ferrante, two high-ranking officials at FAA’s Headquarters. Page four of the AOV report includes results of the three personnel interviews, although the three were not interviewed until eleven months after the incident. The Ground Controller presents a clear description of an OE, while the Local Controller and Supervisor both claim they have no memory. The Ground Controller’s interview is fully consistent with the actual ATC tape. On the other hand, both the Local Controller and the Supervisor had an incentive to forget an OE that they had failed to properly report.

The Cover-Up:

The incident should have been immediately documented by the Supervisor who was present and witnessed it. Nothing was done.

A few weeks later, a request was made under FOIA to obtain a copy of the ATC tapes. Rolan Morel, a support manager at LAX, reviewed the tapes before releasing them, and sent a 9/21/10 email to his boss, LAX District Manager Sherry Avery, declaring he found no evidence of an error.[1] Again, nobody was interviewed.

In November 2010, another FOIA request was submitted, seeking a wider collection of records, including documentation related to all Camarillo incidents for the year 2010. In December, a 224-page partially-redacted FOIA response was issued, signed by Michael O’Harra, the Acting Regional Administrator in Renton, WA .

In February 2011, some controllers at Camarillo remained especially concerned about the lack of interviews and overall failure to investigate. This concern was reported in a 2/10/11 email to Clay Foushee, the man in charge of FAA’s Office of Audit and Evaluation (AAE) at FAA Headquarters. Mr. Foushee forwarded the concern for processing by the FAA Administrator’s Hotline. They coordinated with the LAX District and yet another ‘investigation’ was conducted. This time, phone interviews were made by LAX support manager Jeff Cunnyngham, who proceeded to interview only two of the three FAA personnel. So it came as no surprise that the 3/18/11 short report again concluded that there had been no OE. Thus, as of late March 2011, eight months after the incident, three deficient investigations had been conducted; FAA had failed to interview all ATC personnel, and FAA had failed to produce any conclusive results.

In April 2011, an effort was made to obtain help from outside FAA. A FAX was sent to the local Congressman. This resulted in a flurry of papers that included a 5/24/11 letter to Congressman Gallegly, signed by Deputy Regional Administrator Lirio Liu. No further investigation was done; instead, FAA officials simply provided a copy of the March 2011 ‘finding’ (for which a key controller had NOT been interviewed).

There was still no meaningful investigation, so a renewed effort was made, this time trying engage a multitude of officials at the top of the FAA. A 6/6/11 email was sent to Clay Foushee,[2] Peggy Gilligan and David Grizzle.[3] The need to interview the Ground Controller was again expressed. One week later, investigator Mark McClure visited from the Seattle offices. Three interviews were conducted on 6/13/11, including the Ground Controller (finally!). He remembered all the details, while the other controller and supervisor continued to suffer total memory loss. So, these three interviews were weighed against the voice tapes and the ATSAP report, and an 8/2/11 Report of Investigation was produced by AOV-210.

The conclusion after finally interviewing the Ground Controller:

“…our investigation cannot conclusively state that an operational error did or did not occur….”


A Challenge: Who can come up with the best explanation that this is NOT an OE?

Here is a challenge to people who like to solve puzzles. Consider the facts presented in the tape and diagram and offer YOUR best explanation:

    • Is there a valid and reasonable scenario where this was NOT an Operational Error?
    • What are the details of that scenario? Please share it as a comment.

ATSAP: Another source of data to fully close this investigation

In recent years, FAA has been working with the controllers union, NATCA, to develop a voluntary reporting system for safety events. The Air Traffic Safety Action Program (ATSAP) encourages personnel to file reports, by providing immunity to most reporting employees. Item ‘d’ on the list at page two of the 8/2/11 AOV Report confirms that an ATSAP report was filed for the 7/25/10 Camarillo incident. ATSAP reports are not filed frivolously, nor are they filed without substantial details.[4] Therefore, this ATSAP report could be used to validate the sworn testimony of the Ground Controller, and would thus confirm the OE did occur and was knowingly concealed. A copy of the ATSAP report has been requested via FOIA, but FAA refuses to provide a copy. FAA officials offer the erroneous belief that, because a ‘contractor’ coordinates the ATSAP program, the reports are not subject to FOIA laws. is forwarding a link to this Post, as an attachment to a new FAA FOIA request seeking a copy of the Camarillo 7/25/10 ATSAP report. We hope to share results from this new FOIA request soon…


[1] The email included an erroneous transcript. Morel indicated the Cessna reported he was turning, but the tape includes no such statement.

[2] I supported the 6/6/11 request with a 6/14/11 letter sent to Mr. Foushee.

[3] Ms. Gilligan was the Deputy Associate Administrator for Aviation Safety – Administration. Mr. Grizzle had served as FAA’s Chief Counsel, and Chief Operating Officer for Air Traffic. Both continue in those same positions today.

[4] Per the ATSAP MOU, such reports would be rejected by the Event Review Committee (ERC), whose FAA and NATCA members would insist that there must be “…enough detail so that it can be evaluated by a third party….”

1 thought on “Safety Failure: A Concealed Error at Camarillo Tower

  1. Essentially the only important transmissions are “turn left at taxiway Bravo,” “cleared for take-off,” and “turn left at taxiway Charlie.” Any Air Traffic Controller who cares about his or her job or about aviation safety would immediately re-state “cancel take-off clearance” if the pilot didn’t understand the first cancellation and he or she knew the runway would not be available for another half a minute.

    I’m predicting you won’t get any reasonable scenarios that account for all of the transmissions. Any ATC type who listens to this recording is going to KNOW that there was an OE. Any ATC type who can’t figure this much out shouldn’t be an ATC type. (This is kind of a sad statement in that any AOV types investigating this have more than enough ATC knowledge to understand this stuff and yet they do nothing about it.) Sad. Any AOV person who reviewed and approved the AOV Report shouldn’t be working in aviation.

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