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When communications between pilots and air traffic

control breaks down, the result can be fatal.

O

N 27 MARCH 1977, 583 PEOPLE
DIED when a KIM and a Pan Am

747 collided on a busy, foggy runway at Tenerife's Los Rodeos Airport in the Spanish Canary Islands.
A crucial factor contributing to the accident was poor communications between pilot
and controller.
The KLM pilot radioed, "We are now at
take-off," meaning the aircraft was taking-off,
but the tower controller misunderstood and
thought the plane was ready and waiting for
take-off.
English is the international language of aviation. But even when pilots and controllers
both speak English fluently, there are pitfalls
in the nature of language and the ways that it
is heard.
Even two people speaking face-to-face in
the same language frequently discover that
what was meant was not necessarily understood. In casual discussion or routine business situations, the results of such errors can
range from amusement to expensive mistakes.
In aviation, a simple misunderstanding can
lead to a major disaster.

Kinds of error
Researchers at the NASA-Ames Research Centre
in California have categorised the types of
errors in pilot-ATC misunderstandings. Some
errors were caused by technical problems such
as poor microphone techniques and frequency
congestion. Others resulted from neglecting
to provide necessary information or failure to
14 FLIGHT SAFETY AUSTRALIA AUTUMN 1997

monitor transmissions.
These errors can be prevented by improving conditions, training or discipline.
More serious are problems that arise from
characteristics of language itself and from the
way the mind processes what is heard.
Pilot-ATC communication problems can
be broken down into the following categories:
• Ambiguous phraseology.
• Unintelligible words.
• Mis-heard ATC clearance/instruction and
numerics.
• Cockpit mismanagement resulting in readback errors.
• Inadequate acknowledgment.
• Inattention to amendments to ATC instructions.
• Controller failure to hear error in pilot
read-back.
• Clearance amendment not acknowledged
by pilot and not challenged by the controller.

A major problem
Between January 1993 and October 1996
more than 650 communications-related aviation incidents, some of which could have
resulted in disastrous accidents, have been
reported to Australia's Bureau of Air Safety
Investigation (BASI).
Some of these incidents were exacerbated
by other factors such as distractions, fatigue,
impatience, obstinacy, laziness, frivolity or
conflict.
At least 10 per cent of incidents involve
communications errors, indicating that com-

munications pose a serious problem in Australian aviation.
The following incident, involving Melbourne approach and a Boeing 747 in April
1993, is a typical example of pilot/controller
miscommunication.
The aircraft was on radar vectors and the
previous heading was 105. Air traffic control
instructed the crew to turn on to 080. The
crew read back 010 and the controller did not
pick this up.
In this case, both the pilot and controller
were responsible for the communication
breakdown.

Tenerife "switch"
Overseas there have been a number of high
profile accidents attributed directly to communication errors. The best example of
ambiguous phraseology was highlighted in
the Tenerife accident.
The pilot of the KIM Boeing 747 radioed,
"We are now at take-off", as his aircraft began
rolling down the runway. The air traffic controller misunderstood this statement to mean
that the aircraft was at the holding point waiting for take-off clearance, and so did not warn
the pilot that another aircraft, a Pan American
B747 that was invisible in thick fog, was
already on the runway. The resulting crash
killed 583 people - the highest number of
fatalities in aviation history.
The KIM pilot's use of the non-standard
phrase "at take-off", rather than a clearer
phrase such as "taking-off" or "rolling for
take-off", can be explained as a subtle form of
what linguists refer to as "code switching'

000 feet. I can give you FL 290. and thus avoid the kind of confusion that apparently occurred in the Tenerife accident. resignation or sarcasm. Problems can also arise when different words sound almost alike. During a cruise at FL 230 a co-pilot. inserted another kind of ambiguity into the ntroller/pilot exchange. An example: an aircraft cruising at flight level 310 asked for a descent clearance to FL 240 and was told to expect the clearance in 20 miles. "Roger. The expectation of an instruction can prime a pilot to mistake a different communication for the anticipated instruction. proficient in English but not in Dutch. right turn after take-off". stressed or careless. Aircraft call signs are particularly apt to be confused with one another. hh~ - - 0 c-) HISTORY'S WORST COMMERCIAL AIR DISASTER Date: 27 March 1977. Boeing 747-121. Location: Tenerife.. depending on the intonation. oneword exclamation. which was 2. who was the pilot flying. the assigned runway for landing was 27. Boeing 747-206B. (Spanish) Canary Islands. an air speed or the flight number.000 feet. The tower intended this departure instruction to mean that the aeroplane will track to the Papa Beacon following take-off. such as the pronoun "him" or "it" or indefinite nouns such as "things" can cause considerable confusion in aviation communications.. inserted another kind of ambiguity into the controller/pilot exchange. When the aeroplane reached 24. tiny differences in punctuation can drastically change the meaning of a sentence. who was flying. asked ATC for permission to climb to FL 310. "FL 310 is the wrong altitude for your direction of flight. Failure to make a clear distinction between a conditional statement and an instruction can put one or more aircraft in peril."right!" can be understood as enthusiasm. In written language. but they are not without dangers of their own. Deviations from routine are not noted and the read-back can be heard as being the same as the transmitted message. had no clue that this shift was going on. The controller at Tenerife had.. "I did not clear you to climb. heard his co-pilot say. Pilots and controllers alike tend to hear what they expect to hear. leaving 230" The controller did not challenge the read-back. or exactly alike. But when a speaker is distracted. Similarly.400 feet. He interpreted that "at" in a literal way. but at 9. "Cleared to seven" He began to descend to 7. Words with uncertain reference. First aircraft: KLM Royal Dutch Airlines. a controller asking "how are things going up there?" could be understood by the crew to mean "how is the turbulence?" or "are you visual yet?" when in fact what the controller means is "why are you heading towards the side of the mountain?" - Like words Communications problems are not confined to situations where difficulties with the English language are concerned. cleared to 290.. For whatever reason. such as left and west. the normally Dutchspeaking pilot inadvertently switched into the Dutch grammatical construction while keeping English words. .Careful studies of bilingual and multilingual speakers have shown that they habitually switch back and forth from one of their languages to another in the course of a conversation. The controller had said. Take-off clearance was still to come. Number confusion Misunderstanding can derive from the overlapping number ranges that are shared by multiple aviation parameters. The co-pilot's communication. controllers use the words "anticipate" or "expect". But that was not how the KLM pilot understood "you are cleared". A simple. descend immediately to FL 230". and unaware of subtle language phenomena. The aircraft then descended to 400 feet rather than what the controller had meant. a few seconds earlier. For example.. Such modifiers are helpful. a heading. these verbal keys can be omitted or displaced. In another case. such as 'to' and 'two In one case. The controller replied. the captain. The Spanish-speaking controller. The pilot read back the clearance as "Four zero zero". perhaps because of fatigue or the stress of having to work in conditions of low visibility. the controller queried the aeroplane's altitude and said. the listener perceives that he or she heard what was expected in the message transmitted. The co-pilot replied. indicating a place the take-off point. For example. The captain subsequently mistook the first officer's read-back of a 280 degree heading change as a clearance to FL 280 and began a premature descent. climb to and maintain flight level nine zero. a few seconds earlier. resulting in an important component of the communication being lost or distorted. Clarification To clarify the time frame of an instruction. Incidents in which The controller at Tenerife had. in spoken language. 240 can be a flight level. FLIGHT SAFETY AUSTRALIA AUTUMN 1997 15 .000 feet was the correct altitude. was in fact "cleared two seven" meaning. The pilot had understood "I can give you 290" to mean you are cleared to climb to 290. That is. "KLM eight seven zero five you are cleared to the Papa Beacon. ATC cleared the aircraft to descend "two four zero zero". subtle differences in intonation and the placement of pauses provide clues about how the words are to be interpreted.500 feet the co-pilot advised the captain that 10. Second aircraft: Pan American World Airways (US). which the captain had heard as "cleared to seven".

Communications problems at uncontrolled aerodromes B ETWEEN JANUARY 1993 AND OCTOBER 1996. it would require just a momentary slip of attention to transpose a three-digit flight level and a three-digit heading. over 150 incidents relating to poor use of radio by pilots were recorded in Australia. Remember. The pilot answered. but there was no reply. the controller asked about the aircraft's airspeed. outside controlled airspace you are responsible for your own separation. "295" The controller said that the aircraft was cleared only to FL 280." • "While work was in progress on runway 11/29 an aircraft was noticed to enter the circuit area. regardless of the requirements of the regulations. have one selected on the frequency relevant to your area and the other on the next frequency to be used so you can develop a picture of what is happening in the airspace adjacent to you. comprehensible radio communications is on pilots . look out and listen for other aircraft which might not have heaulyour initial transmission Remember that other aircraft may be using a different runway to you. reduce speed to 250 knots. Aircraft departing an uncontrolled aerodrome should report when taxiing with an all stations broadcast detailing: the location. At about FL 260. Data collected by the US Federal Aviation Administration's (FAA) Office of Safety Information and Promotion show that communication problems were cited as contributing factors in around 27 per cent of confirmed operational errors. "315 knots". Timely and accurate radio reports are essential for safe operations in all phases of flight." The communications problems associated with these pilot to pilot situations can be categorised as follows: Radio not switched on. descend to nine thousand. leaving a string line across the runway which the aircraft ran over. For example. ATC vectored the aircraft to "three one zero' The aeroplane's first officer acknowledged "three one zero" and then climbed to FL 310 instead of turning to a course of 310 degrees. Not checking NOTAM5 for frequency changes. When these pilots were asked why they hadn't made any calls. slowed to 280 knots. • Carrying incorrect documentation that is. QNH 1011. The primary responsibility for clear. most said they didn't think there was any other traffic around or they weren't sure of radio procedures in MTAF5. Common sense must be exercised . Most of the reports were made by air transport category pilots operating at Mandatory Broadcasting Zones (MBZ5) and Common Traffic Advisory Frequencies (CTAF5). If you are in doubt about the traffic situation around you. and the controller had not taken notice of the extra word. • Not bothering to make any calls for whatever reason. At about FL 295 the controller asked for the aeroplane's altitude and the pilot replied. 16 FLIGHT SAFETY AUSTRALIA AUTUMN 1997 one aircraft accepted an instruction meant for another have included pairs with only mild similarities. Broadcasting position reports. Attempts to contact the aircraft were unsuccessful and the pilot also failed to respond to broadcasts. out-of-date charts or enroute supplements. Before entering the runway for departure. The FAA report goes on to say that faulty communications has been implicated in 36 per cent of all airspace incidents reported in Aviation Safety Reporting System (ASRS) reports. heading and speed in the same instruction. Some were worried about embarrassing themselves in front of other pilots because they believed they had a poor radio technique. which is itself a number. The pilot had then given a read-back that combined what the controller actually said "280" with the presumed context "knots". turn left heading 280. 40 per cent of pilot deviations from instructions and 15 per cent of the near misses reported in 1993 and 1994. The majority of the incidents involved non-commercial category aircraft using incorrect procedures at or near airports. not working or used incorrectly. high-workload cockpit or control centre. The highest proportion of radio problems at uncontrolled airports is not making any calls. the controller had established a context of airspeed through his first question and failed to indicate that the subject had changed for his next question. even when there appears to be no other traffic. Consider this incident." • "The pilot did not make any calls despite the fact he said his radio was working. can only help in avoiding an incident or accident. call approach on 118 decimal 7' Saying a number after another number that is supposed to be remembered creates a classic condition for confusion. • Poor use and understanding of English. Confusion about the sequence or meaning of numbers is worse when two or more sets of numbers are given in the same transmission. Yet this is what happens when the pilot states an understood numeric command (such as an assigned altitude) and then states his or her flight identification. The workmen were monitoring the MTAF frequency and heard no calls from the aircraft. Several calls were made to the aircraft to ascertain the pilot's intentions. aircraft type." • "The pilot had difficulty understanding the transmissions due to the slipstream noise. In a high-pressure. Others said they had difficulty interpreting traffic information given by other aircraft. In this case. call sign. Number sequence errors can occur most often when ATC gives changes in assigned altitude. These extracts from Bureau of Air Safety Investigation reports speak for themselves: • "No communications could be established with the aircraft departing the MTAF. there is nothing wrong with calling "all stations" with your position." • "RPT F27 at holding point observed an aircraft turning on to final for runway 06. If you have two VHF radios. An aircraft was flying on a heading of 300 degrees at FL 270. "Kiwi 135. altitude and intentions at any time. The Aeronautical Information Publication sets out the broadcast requirements for radio broadcast procedures at airspace boundaries and associated airports. departure runway and intentions after take-off. and continued to climb to FL 310.radios should be switched on and used. Some also believed that their operation would not conflict with other traffic. The pilot answered "280 knots". The controller said "Maintain 280". The aircraft then lined up for a landing on runway 29 causing the workmen to hurriedly remove their vehicles.

Read-back or "hearback" errors still occur. even with highly experienced controllers and pilots. Some researchers suggest ways that pilotATC linguistic problems can be minimised.a pilot's incorrect read-back. which precludes any controller double-check of the exchange. Flight crews tend to rely too much on controllers' active listening. Although recognising the realities of congested traffic conditions approaching major terminals during peak periods.Sender transmits message. or seek assistance. Linguistic errors generally represent an aberration in step 1: the transmission falls victim to one of the kinds of anomalies discussed earlier. a four-digit transponder code "two seven seven two" may be easier to understand and retain if presented as two two digit numbers "twenty-seven seventy two". The standard RTF requirements can be found in the OPS section of the Aeronautical Information Publication. • After receiving an instruction. there is no opportunity for read-back acknowledgement and the controller will not know of any missed instructions.or does not listen to . Don't believe that your short-term memory powers are special. 4. As the Tenerife incident showed. For example. The system's built-in safety margin depends on all four elements of a communication being performed correctly. 40 per cent of pilot deviations from instructions and 15 per cent of the near misses reported. Recipient repeats the message back to sender. They should call attention to their uncertainty by prefacing their read-back with the word "verify" or "confirm". Pilot-ATC communications problems will not be easy to eliminate. second. now an aviation writer and consultant. They recommend that: • Pauses between messages should be long enough for the message to be completely understood before more information is transmitted.Sender actively listens for a correct readback.resolve it. The pilot interprets the lack of response as silent confirmation that the read-back was correct. Do not assume that it will all work itself out or that the controller will sort it out. Explicit instructions by controllers. it makes it easier to miss one's own call sign in the jumbled messages and. communications breakdown can involve various aircrew members and ATC. If there is any ambiguity . Two common examples are: • A controller does not hear . Run-on ATC messages or instructions to one aircraft which continue without a break in transmission into multiple instructions to numerous other aircraft evoked some pilot protest. Rod Pascoe is a former Air Traffic Controller. First. Correct pilot-ATC communications techniques involve a confirmation/correction loop. Therefore. FLIGHT SAFETY AUSTRALIA AUTUMN 1997 17 ." pressures it will be the rare person who can completely avoid them. In a complex traffic environment. 2.Recipient actively listens to message. • Flight crews shouldn't assume that a routine read-back of a questionable clearance or instruction is adequate. strict adherence to steps 2 through 4 becomes the next line of defence against errors. Some pilots complain about controllers not picking up their incorrect read-backs. The steps are: 1. the pilot signs off with an inadequate "Roger" or "Okay". • Some research in the US suggests that the technique of "chunking" orally transmitted information into smaller units makes information easier to understand. Using proper radio phraseology is critical.COVER STORY and controllers. make notes if necessary. complete read-backs by pilots and active listening by controllers to pilots' read-backs are the best defence against errors in communication. Awareness of linguistic traps may help to avoid introducing them into the communication in the first place. Delivery technique Issuing instructions too quickly and non-stop ATC transmissions are the most common delivery technique problems. and often complimenting controllers for doing a good job under difficult circumstances. 3. No pilot or controller will think any less of you if you transmit "say again" or "stand by". but under workload "Communications problems [are] cited as contributing factors in around 27 per cent of confirmed operational errors. Some pilots tend to downgrade the significance of their own listening errors. pilots nevertheless pointed out a double danger from "non-stop transmissions".