Part One: The Announcement
The number one person in charge of air traffic control at FAA is the COO, Mr. David Grizzle. Within FAA he is also known as ATO-1.
On Tuesday, August 13th, it was announced that Mr. Grizzle will be retiring his position in December, and returning to work in the private sector. Here is the email announcement by his boss, FAA Administrator Michael Huerta: (highlights added)
…and here is a copy of the News Release by NATCA: (highlights added)
There is more to the story. Much more.
First, there is an interesting person at the heart of this story. And, second, this person has an opportunity to greatly serve aviation AND the larger Public, by responsibly acting with resolve and intention … during his final months as ATO-1.
…Part Two begins on the next page (click below)…
…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?
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 aiREFORM.com)…
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.
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 aiREFORM.com):
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:
- 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-AIDSdatabase. 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.
- 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-AIDSdatabase. 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.
- 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
- 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-AIDSdatabase. 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.