ANALYSIS: The Boeing Battery Fires

“We do not expect to see fire
events onboard aircraft.
This is a very serious air-safety concern.”

-NTSB Chair Debra Hersman,
at a 1-24-13 press conference

The following analysis concerns the lithium ion battery fires that caused FAA to eventually declare an Emergency Airworthiness Directive (AD), grounding Boeing’s new Dreamliner.

There are four key players in this analysis:

Boeingis the largest commercial aircraft manufacturer in the world. Founded in 1916, they currently have roughly 174,000 employees worldwide. Revenues in 2011 were $69 Billion.
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Boeing’s 787
built mostly from composites, flew its maiden flight in late 2009 and began commercial service in late 2011. A total of 49 had been delivered by the end of 2012. Another 800+ of this $206 Million (+/-) jet are on order. In mid-January of 2013, there was a rapid series of problems: a windscreen crack, two battery fires (one with an emergency landing and evacuation), and a fourth incident (again related to batteries).
* *
FAAhas formally existed since 1958, and today has an annual budget of roughly $16 Billion. FAA has grown to 47,000+ permanent employees, but there are many thousands of other ‘contract’ employees; in fact, many of these are ‘double-dippers’, collecting their FAA retirement pension while also drawing FAA contractor wages. FAA has promoted the growth of the U.S. aviation industry, while also managing the safety of the U.S. aviation industry. Sometimes (actually, many times) these two functions have become confused. One of the most alarming examples in recent years was when the congressional hearings on 4/3/08 revealed that FAA managers were overriding the work of their inspectors and enabling airlines to fly aircraft years past due for required safety repairs. The hearings drew sharp criticism from members of Congress,link and pressure on FAA to abandon their Customer Service Initiative’.link That original ‘CSI’, begun in late 2003, had FAA trying to act like a business and help out their airline customers), and rename it as Consistency and Standards Initiative’. I kid you not…
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NTSB established in 1967, has roughly 400 employees responsible for investigating not just aviation but ALL transportation accidents: aviation, marine, highway, rail, and pipeline. With an annual budget of roughly $80 Million, NTSB is also charged with producing hundreds of safety recommendations. Nearly all accident investigations are related to aviation; roughly half of the safety recommendations are aviation-related (the others have to do with highway, rail, etc.). FAA routinely either ignores or fails to acceptably resolve a very large percentage of NTSB’s safety recommendations, which become closed by NTSB with a marking of ‘unacceptable status’.


Aviation has always been incredibly harsh and unforgiving

There are more than a few true professionals in aviation. For generations, a lot of careful effort has gone toward improving safety. Mechanical systems have become so reliable, we practically take them for granted. Overall, the present commercial aviation system tends to be reliable and racks up impressive safety statistics. But, on an individual flight, if anything starts to go wrong, there is always the potential that it can rapidly escalate into a full catastrophe. When you really get down to the details, today’s commercial aviation accidents appear to stem from two primary causes: complacency, or technical ignorance. We have modern technologies that layer so much automation into formerly manual processes, it becomes too easy for pilots and controllers to let down their guard. These are people, after all. Give them nothing to do for hours and they will sleep, check out the laptop (maybe watch a movie?), text or otherwise not pay attention. The problem, of course, is that these same systems are not foolproof, and if/when they do fail, the people sitting at the controls may not be able to figure out the problem, let alone recover. In aviation, there often is not enough time.

Here are three recent examples …

Air France, over the Atlantic, on 6/1/09. Nearly four hours after departing Rio for Paris, it’s the middle of the night and they are cruising at 38,000’, in  normal flight conditions. For reasons unknown, key portions of the autopilot disengage. Erroneous readings confuse the pilots who apply corrections which bring the aircraft into a stall. Eventually, they are nose up 35-degrees while descending toward the ocean at nearly 11,000 feet per minute. Four minutes after the disengage, the Airbus A330 impacts the ocean surface, killing 228
Colgan at Buffalo, on 2/12/09. Two fatigued commuter pilots, both with low experience, encountered icing on an otherwise routine flight from Newark to Buffalo. They commented to each other about the icing but failed to take corrective actions. At 10:17pm, while setting up for a final approach, they lost control and dove into a house. There were 50
Comair at Lexington, on 8/27/06. At 6:05am on a Sunday morning, a commuter jet was cleared to depart but took the wrong runway. Fifty seconds later, the takeoff roll commenced, at 6:06:05.0. The aircraft needed a speed of 138kts to rotate and safely takeoff. At 6:06:24.2, the captain called out “one hundred knots”, to alert the first officer he would soon call for rotation. Seven seconds later, at 6:06:31.2, the captain called out “Vee one rotate.” Flight data later showed this call was made early, at 131kts, as they ran out of runway. Both pilots pulled back on the controls to rotate, but tire marks show continued ground contact beyond the runway. A berm was impacted seconds later, and the aircraft went temporarily airborne, before eventually crashing into trees. The sound of the first impact was recorded at 6:06:33, and the recording ended at 6:06:36.2. Forty seconds later, the lone FAA controller in the tower (who was working no other aircraft at the time) observed the fire. He picked up the crash phone at 6:07:17, almost exactly two minutes after he had issued the takeoff clearance. While working in the tower, he had failed to notice that Comair was NOT at Runway 22 when ready to depart, and that Comair then took the wrong runway. He evidently did NOT look at Comair for the next minute, losing his opportunity to save the mistake. The controller also did NOT notice that he had failed to specify the runway number in the takeoff clearance. This oversight was critical due to confusion caused by both the runway/taxiway configuration and an ongoing construction project. There were 49 fatalities; the copilot was the sole


NTSB is the smaller/Better aviation safety advocate

So, the two key federal entities in U.S. aviation safety are FAA and NTSB. The larger of the two has 120-times as many permanent employees, and 200-times the annual budget ($16 Billion vs. $80 Million).

FAA has a proven track record: an ever-growing budget, hundreds of cases where managers and regulated airlines are NOT held accountable, a very high percentage of NTSB Safety Recommendations that are NOT complied with or are ‘closed, unacceptable’, and as compared to other federal agencies, an inordinately large number of damaged whistleblowers. FAA also has a huge amount of clout with members of Congress, by virtue of FAA money doled out each year to projects within all the congressional districts (the largest such fund, drawn primarily as a tax on airline passengers, is the Airport Improvement Fund that distributes nearly $4 Billion annually).

By contrast, NTSB carries a slingshot to FAA’s flamethrower. But, the more important contrast is that NTSB is fit and vigorous and appears to be ethical, while FAA is one donut short of a coronary occlusion. In recent years, NTSB has become increasingly impatient with – and is speaking up more about – FAA’s failures. Thus, when Comair happened at Lexington, Hersman was a new NTSB member and met hundreds of grieving crash victim relatives. She had to stomach the careful construction of a report that could-not/must-not allow the FAA air traffic controller to tell his whole story. The controller knows what happened, and one of the less considered tragedies of Comair is that he now has to carry that fact concealed for the rest of his life. He deferred to the controllers union, NATCA, which quickly jumped in and took charge, representing ATC and working hand-in-glove with FAA to make sure the blame was nebulously reassigned. The official NTSB record declared the controller was distracted doing administrative duties. In truth, the counting of fourteen paper strips at the end of an ATC shift takes ten seconds, max. To her great credit, Hersman (and one other Board member, Higgins) submitted a ‘concurring’ opinion that effectively laid out the need to start adding FAA to the list of those held accountable. When Colgan happened, NTSB hammered home the need for FAA to quit delaying on fatigue issues, as they had for decades. Then, in early 2011, when a supervisor at Reagan National airport fell asleep around midnight and two commercial flights had to land without landing clearances, NTSB jumped forward and did a thorough It seems highly likely, given the politics of Washington, that there were at least a few in FAA who cried ‘overreach’ at the time, and begged the White House or allies in Congress (yeah, the ones with ‘most-favored-grant-recipient status) to hold NTSB back. Why? Because NTSB was ‘doing well’ what FAA would have ‘well concealed’.

And what does FAA have to do with the burning batteries?

It comes down to a fear that FAA is not really performing its ‘certification’ duties. Patterns similar to the Dreamliner certification occurred a few years ago, with rushed certification of the Eclipse 500 VLJ (very light jet).link FAA Administrator Marion Blakey disregarded concerns raised by her certification employees, and helped accelerate the Eclipse into production, with a big certification media event at Oshkosh in 2006. Within two years, Eclipse was bankrupt, the limited fleet was experiencing dangerous incidents, and a 2008 Congressional hearing held by the House Aviation Subcommittee revealed just how far FAA had drifted from its core safety mission.

It is this simple…

Good people like Debra Hersman do not want to have to face crowds of people who have lost a loved one, people who sense (or even know, with the angry clarity that often appears where grief collides with bureaucratic coverup) that an effective FAA would have prevented this disaster. NTSB has given cover to FAA in the past (two that come to mind are Piedmont 22 link in the early years, and Korean Air 801 link in the 1990’s), but those were different times, and NTSB was just a young waterboy. Changes at FAA in the last two decades are forcing a new reality: NTSB must come of age. Through their long pattern of dereliction, FAA has relinquished the safety authority they should no longer have. So, let’s assign it to NTSB. Give Hersman and her team as much authority as they can handle. Give NTSB the full resources they need to manage air safety.

What others are saying:

“…outsourcing of the certification processes to the actual beneficiaries of the process is incompatible with the purpose and intent of testing and certification…”

“…the weasel words you will find in the history of the Eclipse certification debacle came from the same FAA administrators that ‘facilitated’ rather than thoroughly and independently examined the early stages of the 787 project…”

Ben Sandilands’ ‘Plane Talking’ blog, on 1-19-13

“… Now watch out because she’s looking at the Dreamliner problem not just as something that needs to be found, fixed and flown, but maybe even illustrative of a bigger problem of FAA oversight of airplane certification. But here’s a safety professional willing to see a potential safety problem and acknowledge it for what it might be without mincing around. What does it take to have more like her? …”

Christine Negroni’s ‘Flying Lessons’ blog, on 1-24-13

“… In a detailed Bloomberg news account, the NTSB chair also said the plane’s design should have prevented the spate of recent lithium-ion battery meltdowns that have grounded the Dream. Are Hersman and the NTSB second-guessing the Federal Aviation Administration’s approval of Boeing’s plan? If so, it could spell trouble for the 787. Rule of thumb when the NTSB and FAA clash? The NTSB wins. …”

Joe Copeland’s‘TheDailyTroll’ blog, on 1-24-13

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.

How about a ‘Whistleblower-Amnesty Act’?

There is a major opportunity in the Lance Armstrong story, with ramifications for all Whistleblowers, past and future, including those in the FAA.

A current NYTimes news story says wealthy supporters of the Livestrong charity he started have been trying to persuade Lance to come clean: to clear his conscience.

Here’s the good and the bad on Lance Armstrong’s history:

The Good: he won seven Tour de France’s. He became an outstanding advocate for those impacted by cancer. He inspired; he was heroic.

The Bad: Lance Armstrong screwed up. He doped, and then he covered it up. His failure tarnished his image and diminished his cause.

This story would not even exist, if not for the few Whistleblowers who bravely spoke the truth. Now, others are encouraging Lance to become the final – and biggest – Whistleblower in his own case.

So, where is the opportunity?

Well, frankly, this guy should be a hero for what he did and does. After coming clean, he will forever be a tarnished hero, but an earnest confession might be as powerful as his past triumphs (and perhaps far more meaningful?), if it helps deter others from making the same mistakes. Plus, his confession would set an example; it would show true leadership toward cleaning up the performance-doping problem that afflicts all sports.

But that is only half of the opportunity. There is also a great opportunity here for political leaders – as in Congress – to help clean up the whistleblower messes that happen within many corrupted federal agencies, such as the FAA.

Imagine this:

What if Congress passed legislation that directed federal agencies to give full amnesty to those federal managers who were aware of (and even possibly aided) retaliation against a Whistleblower?

How might this improve the FAA?

If, under the terms of this new law, a single FAA manager came clean with the information they had felt compelled to conceal, he or she would receive nothing more than a ‘thank you’. Meanwhile, the information would enable FAA to ferret out the few FAA managers doing the real dirty business. Which, of course, would be the other half of the new law: FAA leaders would be directed to fully investigate and discipline the key agency wrongdoers.

Four examples…

(1) Let’s say a safety inspector in Texas acts to compel American or Southwest to comply with required repairs for a problem like cracked fuselages, but she finds an FAA manager is undermining her work while taking care of his ‘airline customers’. The safety problem was very serious, but due to the manager’s years of intervention, the repairs are still not done. In this case, no accidents have happened related to the failure. So, in the spirit of ‘No Harm, No Foul’, if that FAA manager (or any other employees with knowledge) came forward and admitted he felt pressured by perceived policies to aid the delay by his ‘customer’, why not grant him full amnesty?

(2) Let’s say an air traffic controller was a witness to an error where two aircraft almost hit on the runway. As a true adherent to the principles of a Safety Culture, she promptly reports the facts to her management. She is shocked when they knowingly DO NOT investigate, and she watches them create no records. She recognizes the error could easily happen again, and with fatalities, so she shares her concern elsewhere. As in the previous example, given that they did not actually collide, let’s consider this another ‘No Harm, No Foul’ situation. There would be considerable value in cleaning this one up, as it would further confirm FAA’s commitment to safety (building the ‘Safety Culture), while also reducing the odds of a repeat with a more serious outcome. So, why not grant full amnesty to her supervisor and/or manager, when they come clean and confirm they failed under the pressure of perceived policies?

(3) Another air traffic controller knows that his brief failure while working alone at the end of his overnight shift contributed to a horrific accident with dozens of fatalities. He knows he was inattentive for just one minute – perhaps distracted by a movie on his laptop computer, or maybe a good book, or maybe he was just tired and shut his eyes – and thus failed to look out the tower window and make the one critically-timed transmission that would have averted this disaster. For that one minute, he failed to do his job. He feels horrible and scared, and is ready to openly share everything when the investigators arrive, but the union officials pressure him, so he speaks only through the union. Nobody is accountable while both the union and the agency do deep damage control, concealing all details so as to diminish liabilities. The result is a secondary tragedy: this controller now has to live with the sole awareness of his failure, which he knows has been improperly concealed. Much as Lance Armstrong is burdened with the extraordinary weight of his ‘secrets’, which have since been almost entirely revealed. So, if this controller could be granted full amnesty to come clean – to tell all that he knows, and reveal that which was creatively concealed during the major NTSB investigation – what good might come of it? Clearly, the controller would be healthier; the FAA would become less corrupt and more respectable (which would greatly improve employee morale); and, the FAA mission to protect safety would be furthered. FAA would be moving strongly toward a true Safety Culture.

Note that in most cases, FAA’s corruption is more in the overall culture than in the individual. So, even in a failure as serious as this, it would be hugely beneficial to safety if we took disciplinary action only against those individuals who clearly and knowingly operated in a manner solely accountable for the outcome.

(4) An FAA employee with a good record speaks up about a safety issue. She soon receives retaliation: loss of duties, demotion, suspension, maybe she is even fired. She tries to work with her supervisor, her manager, and dozens of other FAA officials, but everyone is afraid to work with her, so the improper retaliation persists. Her Due Process rights are virtually nonexistent. In this case, ‘No Harm, No Foul’ would not apply, as the Whistleblower was damaged. So, why not grant full amnesty to all FAA officials involved except the one manager who is accountable for initiating the retaliation? Then, conduct a full investigation and disciplinary action against that one accountable official. The outcome sets an example for other FAA officials, and will thus help clean up FAA’s deep-rooted corrupt practices.

So, what do you think? Should Congress pass REAL Whistleblower Protection by directing FAA and other federal agencies to grant some amnesties and follow through with the appropriate investigations and disciplinary actions?

I certainly think so. This is decades overdue.

Jeff Lewis
January 2013

Whistleblowers are often culled out of FAA via Disability Retirements

The NY Times published an interesting article about efforts to improve the practice of diagnosing Personality Disorders. At first glance, most would think this has NOTHING to do with the FAA and Whistleblowers. Or maybe it does… take a closer look.

[link to the NYTimes article]

Without dwelling on the technical details, we all intuitively understand what a Personality Disorder looks like. Most of us have experienced a family member or a classmate or coworker who is ‘out there’; famously narcissistic, astonishingly cruel and anti-social, prone to excessive drama, and so forth. At the extreme, these and other behavioral patterns can generate a lot of discomfort. So, it seems reasonable that in 1952 the American Psychiatric Association developed their Diagnostic and Statistical Manual of Mental Disorders, known as the ‘DSM’. The DSM is worth a lot of money, in that insurance payments tend to happen only when diagnoses are made. This alone creates a controversial incentive to produce diagnoses. But the tendency to diagnose can be increased by other pressures, such as from rogue managers within corrupted organizations. Furthermore, employees can become so beaten down within corrupted organizations that they may WANT a diagnosis, in order to leave a hostile workplace and collect a disability pension. More on that later…

Personality Disorders are diagnosed by mental health professionals. At the start, an evaluation needs to be justified; somebody (normally the individual, or an employer) needs to submit ‘presenting concerns’, which define the odd behaviors that are problematic to ‘normal’ people. The evaluator then uses standardized tests and methodologies and may ultimately diagnose a Personality Disorder. When the evaluator is unable to definitively assign a Personality Disorder, he/she has the discretion to use a catch-all “not otherwise specified (NOS)” diagnosis, called “301.9 – NOS”. Many concerns have been raised about the 301.9 – NOS being a garbage-can diagnosis, commonly misused by employers and other authorities.

What does this have to do with Whistleblowers? At the heart of it, a Personality Disorder diagnosis means that an evaluator has concluded that a person is substantially ‘different’ from the normal population. Whistleblowers exhibit behavioral patterns centered on transparency, openness, speaking the truth. Place an observant Whistleblower into a safety-related workplace such as aviation safety inspection or air traffic control, and they should thrive while optimizing system performance. But, what if that safety-related workplace is corrupted, with a prevailing culture wherein errors and accidents are concealed? Well, in that case, the Whistleblower is non-normative; he or she stands out like a used disposable diaper left on the floor of an elevator, and tends to be treated accordingly.

When a Whistleblower speaks up, he or she becomes a threat to the status quo. There are many others at the Whistleblower’s worksite who perceive benefits from sustaining the program: less effort, more pay, less oversight, a sense of security, etc. They likely also fear severe consequences if the program is revealed, even more so if the corruption has been going on for years. So, one of the best methods for those in the prevailing culture to protect and sustain their corrupt program is to simply destroy the credibility of the Whistleblower. A bunch of tactics, relevant to DSM Personality Disorders, includes:

  • Ostracize. A rogue manager will cultivate a hostile work environment in which those participating in the corrupt practices will treat the Whistleblower like he/she is just a social misfit. Because in truth, at that workplace, THEY ARE A MISFIT.
  • Build a disciplinary history. A rogue manager will ‘ride the Whistleblower’ with a program of disparate treatment. Ideally, his/her efforts will show a progression of worsening behavior and increasing disciplinary action. Via this tactic, so long as the Union does not defend the employee, most federal employees can be driven to leave, or can be fired for their alleged disciplinary history, after just a year or two of pressure from a rogue manager.
  • If needed, go for the mental health disability retirement. What are the odds that Congress would ever ask a retired aviation safety inspector to testify after a horrific fatal air crash, if that retiree had left FAA on a mental health disability? Not likely. So, a rogue manager serves the program well if he/she creates a paper trail that supports a later diagnosis. There is no need for truth, just documentation, so that the problem is removed, and will not return later to haunt.
  • Make life so miserable that the employee WANTS to retire on disability. No doubt some people REALLY are driven crazy when subjected to a relentless hostile work environment. Many others may just say ‘to hell with it’ and take the best they can get as they leave. Sadly, even the most ethical person can eventually be reduced to joining a disability fraud, once they have endured enough abuse.


The NYTimes’ article, Clearing the Fog Around Personality Disorders” by Benedict Carey, has generated a hearty discussion, with more than 300 comments
(selected comments viewable via this link).


I added the following comment to the NYTimes comments (w/added links here)
– Jeff Lewis

Thanks for a valuable article, and many excellent and thoughtful comments. I would like to note the prevalent abuse of DSM-IV diagnoses to medically resolve ‘problems’ such as whistleblowers. Simple fact is, an ethical person is ‘disordered’ when they are employed within a corrupt work culture.

I spent 22-years as an FAA air traffic controller, and spoke up about a near-midair caused when a coworker watched a TV wired into our tower cab in Oregon, and later a concealed midair between a helicopter and a Cessna in the pattern at San Jose. I had the personality trait of speaking up truthfully about safety/waste issues. FAA managers retaliated in 1991 by liberally abusing their authority to compel me to be evaluated under DSM-III.

In 2007, I was inexplicably locked out from work and FAA officials threatened discipline if I did not spend $2,000 and get an evaluation. I set up a DSM-IV with the same PhD psychologist who evaluated in 1991. Those same FAA officials refused to talk with the PhD psychologist . He was baffled, and seeking to help, issued a 301.9 NOS diagnosis. FAA used this to attempt to retire me on disability. I challenged and won; FAA’s own doctor fully restored my ATC medical clearance on 1/10/08.

They then proceeded to fire me in November 2008, six months prior to retirement eligibility. I had to go to MSPB, where FAA offered to ‘settle’, by offering me a disability retirement. I declined.

I have since learned of many others who have been similarly damaged.

“…the FAA will not tolerate any degradation in safety…

…and we recognize that Congress and the traveling public share that view.”

This statement was made by David Grizzle, testifying last July before a House subcommittee. The purpose of his testimony was to reassure Congress (and the Public) about FAA’s performance, and to garner support for further funding of FAA, including the contract tower program.

Mr. Grizzle is the Chief Operating Officer (COO) at FAA’s Air Traffic Organization (ATO). He is thus the top person in charge of air traffic control in the United States, and reports directly to the FAA Administrator. When something bad happens at an FAA tower, Mr. Grizzle should know about it, so he can ensure the problem is fixed, not repeated. But, in fact, Mr. Grizzle very likely does not actually know about the errors and accidents that are routinely concealed. Why? Because the chain  from controller to COO is long. Quite long.

Suppose an error happens. The controller who erred or witnessed the incident typically reports to a supervisor (aka Front Line Manager, FLM)…

…who reports to the facility manager (Air Traffic Manager, ATM),

…who reports to a District Manager,

…who reports to the Director of Terminal Operations at the Service Area (there are three service areas: Eastern, Central and Western),

…who reports to the Vice President of Terminal Services, at FAA HQ,

…who reports to COO David Grizzle (or perhaps to his deputy, Teri Bristol).

The critical information has to pass through five intermediate officials to get to the ATO COO. Furthermore, each of those intermediate officials typically has oversight responsibilities for ten or more comparable sub-units; so, for example, the LAX District Manager oversees nine facilities, while the Seattle District Manager oversees fifteen facilities.

Here it is graphically, on one page: a diagram showing the FAA ATO chain-of-command from the ATO COO down to the District Manager level. In this example, the yellow boxes reflect the chain-of-command from Mr. Grizzle to the Los Angeles District (which happens to be responsible for errors at an FAA tower at the beautiful coastal town of Camarillo).

Now, couple the huge organizational structure of FAA’s ATO with one simple and universal fact: that people do not like to reveal their failures, so they are inclined to withhold information for as long as possible, even forever. This problem is intensified by two other factors: first, a prevailing culture of mistrust, wherein FAA employees know that speaking up about problems (aka whistleblowing) often precipitates an attack on YOUR career, so they are inclined to stay quiet. And, second, a long FAA tradition (perhaps rooted in the predominant military culture?) wherein those who ignore rigid ‘chain-of-command’ and attempt to communicate beyond their immediate supervisor, …well, they quickly get into trouble.

Which brings us to the concealed Operational Error at Camarillo. A highly credible employee, working at the Ground Control position, was not interviewed on the day of the incident or in numerous followup efforts at Camarillo, at the Los Angeles District, or at the Western Service Area. It was eleven months later that he was finally interviewed, for an investigation conducted by the Air Traffic Safety Oversight Service (AOV), out of FAA Headquarters. The investigator heard exactly what happened from this one brave person, but was told by the errant Local Controller and the witness FLM that they have no memory. So, what came of it? Despite the presence of clear confirming evidence on an ATC audio tape (as saved by another whistleblower), and despite the existence of an ATSAP report, AOV concluded the investigation was ‘inconclusive’.

Absolutely amazing. And scary, too.

Mr. Grizzle, you seem like a nice guy, a good person, and you project what we citizens need to hear, that our FAA is safe and efficient and filled with hard-working, respectable professionals. But, this citizen speaks for a larger Public and respectfully asks:

…do you really find no degradation of aviation safety, when you read about the concealment of the 7/25/10 Operational Error at Camarillo?

[link to CMA-OE diagram]

[link to the AOV report]

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….”

‘Failures’ not mentioned during Babbitt’s ‘Communicating for Safety’ speech

At around midnight, very early on March 23rd 2011, a serious FAA failure occurred. A supervisor fell asleep for about a half hour, while working alone in the tower cab at Reagan National Airport, in the heart of Washington, DC. Two arrivals, AAL1012 and UAL628T,[1] radioed the Tower and got no answer. They then radioed the TRACON controller, asking what to do. The TRACON controller tried to contact the Tower on the shoutline,[2] but there was no answer. For all they knew, the one FAA Tower just a couple miles from both the Pentagon and the White House, had been overtaken by terrorists. The TRACON controller notified his supervisor. After some delay, and still not knowing what was really happening at the Tower, the pilots were allowed to land without a clearance. Fortunately, the Tower supervisor had only dozed off.

According to the NTSB investigative report, this incident was reported to the Regional Operations Center at 2:30AM. Nine hours after that, NATCA President Paul Rinaldi was introducing FAA Administrator Randy Babbitt, who was the featured speaker in Las Vegas, at a gathering of NATCA air traffic controllers. This was the final day of a three-day annual convention called Communicating for Safety 2011. [see NATCA media release]

Administrator Babbitt spoke for quite a while [video]. A transcript (it is lengthy, so I put it into a separate link – but it is well worth reading) shows 44 occurrences of the keywords ‘safety’, ‘culture’ and ‘collaborate’. Babbitt spoke of FAA’s ‘incredibly safe system’, safety teams, safety culture, safety partnership, safety systems, and the importance of collaboration for safety. At one point he said:

“You know, I think if you follow a lot of the remarks I make, I talk about fundamentally two things in the system: professionalism, and safety. And if you stop and think about it, you really can’t have just one of those. You really can’t. It’s impossible to have an unprofessional system that’s safe. And, I think it is impossible to have a safe system where you have people being unprofessional. And so this is something that together we are working on and I think we are making huge progress.”

Now, when the Reagan National supervisor was waking up from his nap, it was 9:30PM in Las Vegas. Administrator Babbitt was still at, or had just departed from, a social mixer with the many NATCA members attending Communicating for Safety 2011 (he talks about this in his speech). It seems inconceivable that, eleven hours later, while being introduced for his morning speech, Administrator Babbitt had not yet been briefed about the Reagan doze-off incident. But suppose he knew nothing; what does that say about the quality of communications within FAA?

Two weeks later the world learned of yet another sleeping incident. In this case, Administrator Babbitt answered a question from a congressman by revealing the first details of the Knoxville sleeping controller incident. FOIA records show that the lone controller working in the Knoxville TRACON on February 19, 2011 made a bed on the floor using couch cushions, then slept from 12:24AM until 4:55AM.[3] Worse, the controller alone in the Knoxville Tower cab had to ‘wing it’ to provide radar services to the flights that early morning; he was not certified to work radar.

Back to Communicating for Safety 2011. It is 8:30AM in a large convention hall with controllers from all over the U.S., and the heads of both the FAA and NATCA. Mr. Rinaldi and Administrator Babbitt are gushing about professionalism and safety, as if they know nothing about the failures at Knoxville and at Reagan National. Not a word was shared about the incredible safety and security breach that had happened eleven hours earlier. Not a word, while Communicating for Safety. Go figure.

*     ***     *****     ***     *

Related Records:

3/23/11 press release by DoT Secretary Ray LaHood 

[1] AAL is American, UAL is United
[2] when a controller pushes a shoutline button, she can speak directly into the ear of another controller, at a distant facility or even at the adjacent sector. It gets their attention.
[3] A related article will be posted soon on the fascinating content in this FOIA response. There is much more to the Knoxville story than made the mainstream press.

Protected: Will FAA Whistleblowers Soon Start to Get the Respect they Deserve?

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An Actual Midair Between a Helicopter and a Cessna at San Jose’s Reid-Hillview Airport, on May 9, 1999

Below is a copy of a news article about a San Jose midair collision on a Sunday morning in May 1999. This collision was literally inches short of a midair fireball, with debris raining down onto houses and a park, where hundreds were gathered for Sunday soccer matches.

There were three critical FAA failures in this incident:

  • First, the supervisor working the aircraft failed to issue necessary traffic to ensure the pilots would see and avoid each other.
  • Second, the FAA management failed to develop de-conflicted traffic patterns, and knowingly allowed excessively busy flight operations where helicopters and fixed-wing flights would be unavoidably in dangerously close proximity.
  • And third, once the May 9, 1999 midair collision happened, FAA management (Supervisor Roberto Aranda, Tower Manager Paul Pagel, and likely un-named higher officials in the Hub and Regional offices) knowingly concealed facts and failed to notify NTSB. FAA management had a requirement to notify NTSB, so that an investigation could be conducted, to help improve aviation system safety.

Here is the article (highlights added by…20000124.. SJMercury article on 5-9-99 RHV midair_120000124.. SJMercury article on 5-9-99 RHV midair_220000124.. SJMercury article on 5-9-99 RHV midair_3

Two of the controllers at the FAA tower at Reid-Hillview Airport spoke up, when they saw that the tower management was sweeping the accident (and controller error) under the rug. We (Jeff Lewis and Don Hiebert) both repeatedly questioned the supervisor, Roberto Aranda, who repeatedly blew off our concerns and claimed that management was still waiting for ‘metallurgical tests’.

Here is a portion of a draft memo I had compiled, to issue to Mr. Aranda. I never gave him a copy; I was fearful of the repercussions if I were to be that aggressive in speaking up for aviation safety. So, eight months after the midair, it was a surprise to me when the news story appeared in the San Jose Mercury News.
19990512.. clip re NTSB reporting, from DRAFT memo to KRHV Sup.Aranda, re 5-9-1999 midair

So, Did NTSB Ever Do an Investigation?

No. FAA did not notify NTSB, and instead investigated this incident internally.

Instead, the limited data collected by an FAA investigator was compiled into the FAA’s in-house Aviation Safety Information Analysis and Sharing (ASIAS). Here is the event description from the Cessna N9568G ASIAS report (underlines added by

19990509.. N9568G ASIAS report, screencap of narrative


I wanted to determine which online databases included reports related to the May 9, 1999 Reid Hillview midair collision. I soon established that there are three major databases, all accessible using these links:


While researching the three major accident/incident databases, I came across numerous collisions, but three others seemed to best illustrate the failure by FAA to act on the Reid Hillview midair. Below, I have compiled details of each of the four total incidents. Three are midair collisions (including the 5/9/1999 KRHV midair), and one is a ground collision. For all of these incidents (except the KRHV midair collision) the incident was promptly reported to NTSB, and then investigated by a non-FAA agency. Here are short summaries:

  1. On 5/16/1998, two flight instruction aircraft based at the same KRHV FBO collided midair near the uncontrolled airport in Hollister, CA [KCVH]. A departing light twin and an arriving single-prop were both able to safely land at the airport after their left wingtips had collided .
    FAA employees created no record within the ASIAS-AIDS database. None of the four pilots filed a report with the ASRS. But, at least one pilot must have complied with AIM Para. 7-6-2, as NTSB did investigate. They created  a detailed Full Narrative Report for Incident LAX98LA164A.
  2. On 5/26/1998, a ground collision happened at the controlled airport in Lincoln, NE [KLNK]. ATC cleared both single-engine aircraft to land: a Christian Eagle (taildragger) was cleared for Runway 14, while a Mooney was cleared for Runway 17L. ATC issued taxi instructions and a hold-short of Runway 17L to the Eagle, then instructed the landed Mooney to turn left at the same location. The Mooney turned and stopped, then ATC told the Eagle to move ahead. This caused a collision because the taildragger pilot had to taxi with S-turns and could not see the position of the Mooney. The Eagle’s propeller sliced the elevator of the Mooney, but there were no injuries.
    FAA employees created no record within the ASIAS-AIDS database. None of the four pilots filed a report with the ASRS. But, either ATC or at least one of the two pilots must have complied with AIM Para. 7-6-2, as NTSB did investigate. They created  a detailed Full Narrative Report for Incident CHI98LA177A.
  3. On 5/9/1999, the concealed midair at KRHV:
    FAA employees created a record within the in-house ASIAS-AIDS, and (1) ASRS was filed by the Cessna pilot (no filings by helo or ATC). Nobody submitted the mandatory notification to NTSB.
  4. On 5/30/1999, a Cessna Skyhawk and a motorglider collided in midair while in the pattern for the controlled airport in Mesa, AZ [KFFZ]. The Cessna was flying left closed traffic to Runway 04L. The motorglider called ATC and got a takeoff clearance off Runway 04R and advised he wanted to stay in the pattern. ATC told the motorglider to extend upwind, and also told him to follow the Cessna ahead and to his left. In hindsight, it appears the pilot looked over and saw another Cessna entering the downwind and turned to follow him. Thus, the motorglider ended up slightly in front of the Cessna, then was run over by the Cessna in the downwind. Both aircraft were damaged but able to make runway landings.
    FAA employees created no record within the ASIAS-AIDS database. None of the three pilots filed a report with the ASRS. But, either ATC or at least one of the three pilots must have complied with AIM Para. 7-6-2, as NTSB did investigate. They created  a detailed Full Narrative Report for Incident LAX99LA204A.