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Judith Orasanu
NASA Ames Research Center
Ute Fischer
Georgia Institute of Technology
Jeannie Davison
San Jose State University
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routinized, especially among the flight crew and between the flight crew and air traffic
control (ATC). That is, much of the communication has been standardized: formulaic
utterances are part of check lists and standard operating procedures performed by
pilots (standardized call-outs during take-off, at certain altitudes, and during descent
and landings). Communication with air traffic control to request clearances or when
checking in at sector boundaries, and clearances given by controllers to flight crews, are
-- or should be -- grounded in rigorous, standardized, explicit language, with variation
coming primarily in the numbers (e.g., altitudes, speeds, headings, and runways). This
standardization of communication is intended to reduce communication errors. Why it
doesn't always work is the topic of this chapter.
In addition to discussing failures of communication in aviation, we will describe
features of effective communication and what can be done to enhance communication
success. These issues will be addressed from the perspective of what we have learned
about communication from flight crews talking within the flight deck and between
pilots and ground personnel (primarily air traffic controllers), both within the U.S. and
in other countries. The feasibility and appropriateness of "exporting" U.S.-developed
training approaches will also be discussed.
Successful flight operations require much more from air crews than the complex
skills necessary to fly the aircraft. Flight safety has repeatedly been jeopardized by poor
crew communication or poor communication between crews and ATC (for a review of
accident investigations and recommendations by the National Transportation Safety
Board (NTSB), see Kayten, 1993). To illustrate the importance of communication to
aviation, let us first consider two crashes in which language problems of some type
contributed to the crash.
The intended clearance was 2,400 ft., but what the pilots heard and read back was 400 ft.
The aircraft's altitude alert signaled at about 1,300 ft. (approximately 1,000 ft. above the
400 ft. set in the computerized landing system) and the ground proximity warning
sounded at about 500 ft. Sixteen seconds later the flight crashed into a mountain (NTSB,
1989).
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critical fuel state when they reached their destination. The first time the Avianca crew
mentioned their critical fuel situation to the controllers was when the first officer (F/O)
said: "I think we need priority..." There was some discussion about how long they could
hold and what their alternate was, but the crew never informed the controller that they
were declaring an emergency. A request for priority has no meaning in the ATC
vocabulary. The flight received normal handling for the next 39 minutes, and the crew
still did not inform the controllers that they were in trouble.
Due to wind shear in the JFK area, the crew was forced to do a missed-approach
on their first attempt, and the captain told the first officer, "Tell them we are in
emergency." While reading back the ATC instructions, the F/O added: "Ah we'll try
once again, we're running out of fuel." The captain again told the F/O to: "Advise
them we are in emergency," and the F/O replied "Yes, sir, I already advised him." The
captain told the F/O a third time to "... Advise him that we don't have fuel." Again the
F/O merely ended a routine read back with, "We're running out of fuel, sir." During
this time, the Avianca flight was handled by more than one controller, so the repeated
statements about their fuel were not all directed to a single controller.
After the missed approach, the controller informed the flight that he was going
to "...bring you about 15 miles northeast and then turn you back for the approach. Is
that fine for you and your fuel?" The F/O replied, "I guess so thank you very much."
When the captain asked what had been said, the F/O said, "The guy is angry." At 2132
Avianca 052's engines flamed-out and the aircraft crashed a minute later, approximately
15 miles from the airport. There were 73 fatalities as a result of the crash (NTSB, 1991).
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--------------------
Insert Table 1 about here
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6,000" referred to the traffic, but was interpreted as a directive and the pilot leveled off
at 6,000 feet.
From these examples, we can discern at least three different ways in which
communication can go wrong. First, a message may suffer in its transmission, resulting
in information not getting through to the addressee. From Table 1, Language/Accent
problems and Dual Language Switching would fall into this category. In these
instances, language itself is an impediment to transmission. Secondly, a message may
be transmitted accurately, but not be understood as intended. These cases of
misunderstanding may be grounded in various types of ambiguity or use of jargon.
Partial Readbacks, Unfamiliar Terminology, and Speech Act confusions of Table 1
would fall under this category. In the third type of communication failure, messages
are transmitted accurately and understood as intended, but there is a failure of
conversants to build a shared understanding of the situation.
Situation awareness is also supported by what has been called "party line"
information. In addition to receiving clearances and other flight-relevant information
from ATC, pilots typically pick up communication between ATC and other pilots on
open radio channels. Midkiff (1992) found that U.S. pilots rely on party-line
information, particularly in terminal areas during departures and arrivals, for
information about wind shear, turbulence, weather and other traffic. If pilots cannot
understand these communications, a valuable source of information that enhances their
situation awareness is lost.
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one midair collision has resulted from such a loss of party-line information. A Mexico
City controller gave approach and landing clearances to the pilot of a small aircraft in
Spanish, which the pilots of a U.S. aircraft could not understand. The U.S. pilots were
unaware of the location of the small plane and collided with it in midair.
However, for resources on the ground to be helpful to crews in the air, the nature
of the problem and the crew's goals must be understood by all parties. This
understanding comes about through communication, which is especially critical
because the various participants are physically separated and do not share all the
relevant primary data about the problem. A shared understanding of the problem
enables all participants to contribute appropriately to its solution (Orasanu, 1994).
In the Avianca case described above, the flight crew and the several controllers
with whom they interacted during their approach to JFK never appeared to have
established a shared understanding of the Avianca fuel situation. Clearly, the captain
was fully aware of the critical fuel condition, and repeatedly instructed the first officer
to communicate this status to the controllers and to declare an emergency. The first
officer in turn told the controllers that they were running out of fuel, a true but
inadequate description of the situation. Most of the aircraft flying into New York that
day were also running low on fuel because of extensive holding due to bad weather on
the east coast. Without the magic word "emergency," no special handling was provided
to the Avianca flight and the first officer was unable to impress the various controllers
who handled their flight with the severity of their condition.
Similarly, in the Tenerife crash, the crews of the two jumbo jets and the air traffic
controllers did not have a shared understanding of the location of each aircraft and its
movements, which was essential for safe coordination on the busy runways. Just prior
to the crash there was low blowing fog. The controller could not see either aircraft nor
could they see each other, increasing the importance of clear communication to
establish a shared understanding of the situation. The ambiguous utterance, "We are at
take off," did not clearly tell the controller that the KLM flight was in the process of
taking off.
From both the accident examples and ASRS reports, we can see that
communication problems may occur in several different ways. In the next section of
this chapter we will discuss in more detail what causes crew communication to fail.
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Discourse on the flight deck and between flight crew and ground controllers
frequently co-occurs with other tasks and may thus be impeded by distractions. Pilots
may simply not hear what was said because something else demanded their attention.
Flight deck-ground communications are transmitted by radio and thus susceptible to
disruptions and distortions. For instance, in the KLM/PanAm accident described at the
beginning of this chapter, part of the miscommunication was due to inaudible and
noisy radio connections between pilots and controllers. In addition, unfamiliar accents
may lead to errors in transmission and requests for repetition, which may or may not
lead to successful transmission of the message.
Speakers normally take for granted that this background knowledge is shared by
their addressees (Clark & Marshall, 1981; Sperber & Wilson, 1986). For the aviation
environment the common ground presupposed by the participants has three parts:
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Sometimes speakers make wrong assumptions about the knowledge they have in
common with their addressees, and consequently do not provide sufficient information
to establish mutual understanding. From the point of view of the addressees,
understanding may be impaired because too little information or ambiguous
information was given, or because expected standards of talk were violated. For
example, in the following accident the controller and flight crew differed in their
problem understanding.
While the flight crew was focusing on its landing gear, the Miami controller was
focusing on the flight's decreasing altitude when he asked, "How are things comin'
along out there?" The word things was sufficiently ambiguous that a different message
was heard than was intended, with tragic results.
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Unfortunately there are situations like the Everglades crash in which problems
go by unnoticed and unrepaired, resulting in misunderstanding. We call this
"illusionary understanding." The speaker and addressee both believe they have
communicated successfully, but in fact the message received was not identical to the
message intended.
The illusion of understanding need not always be symmetrical across the speaker
and addressee, as in the above example. Instead, one participant may recognize that
ambiguous or incomplete information has been communicated and may attempt to
clarify it, but to no avail. The repair efforts may fail because the other party believes
that mutual understanding has been achieved and that there is no communication
problem. This situation is illustrated in communication between the captain and the
first officer in the Avianca accident. The captain had repeatedly asked the first officer
to advise ATC that they were low on fuel and that they were in an emergency. The first
officer assured the captain that he had done so and that ATC understood their problem.
The first officer, however, had never used the term "emergency" (NTSB, 1991).
Although the captain apparently suspected that the first officer did not communicate
appropriately with ATC, he failed to convey this to his first officer. The first officer, on
the other hand, presumably thought that he had understood what the captain wanted
him to do and had properly carried out his request.
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Ting-Toomey & Chua, 1988; Hall, 1976; Hofstede, 1980) and attitudes towards
leadership (Merritt & Helmreich, 1993; Redding & Ogilvie, 1984). Cultural
individualism, by stressing the self, personal choices and achievements, is believed to
promote a conversational style that is explicit, unambiguous, brief, goal-directed and
first-person oriented. In contrast, talk in collectivistic cultures has been characterized as
elaborate, often indirect, and role-centered in accordance with the cultural emphasis on
group harmony and group success.
Cultures also differ in the extent to which power distance between individuals is
accepted and expressed in their interactions (Hofstede, 1980). Using a questionnaire to
tap into attitudes toward preferred leadership and communication styles, Merritt and
Helmreich (1993) observed that pilots from Anglo cultures tend to prefer leaders who
are consultative rather than authoritarian. In emergencies, even junior crew members
expect to contribute to the decision making. Pilots from non-Anglo cultures tend to
prefer leaders who are authoritative, take command of the aircraft in emergencies and
tell other crew members exactly what to do.
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Shortly after being given clearance to take off, the first officer again expressed his
concern:
First Officer: Let's check those tops again since we been setting here
awhile.
Captain: I think we get to go here in a minute.
Finally, while they were on their takeoff roll, the first officer noticed that something was
wrong with the engine readings.
First Officer: That don't seem right, does it?
[three second pause] Ah, that's not right ....
Captain: Yes, it is, there's 80.
First Officer: Naw, I don't think that's right.
[seven-second pause] Ah, maybe it is.
Captain: Hundred and twenty.
First Officer: I don't know.
The takeoff proceeded, and 37 seconds later they crashed into the Potomac River due to
excessive snow and ice on the aircraft and a frozen indicator that gave them a false
engine power reading (NTSB, 1982).
In this unfortunate situation, the first officer made frequent references to the
dangerous conditions affecting both their own aircraft and others. He seemed to be
aware that the engine condition did not appear to be normal during the takeoff roll, but
did not succeed in getting the captain to take these concerns seriously or to act on them.
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A key difference between Linde's findings and Orasanu and Fischer's work is
that the latter analysis examined the functions and content of utterances, while the
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former addressed their form. As Watzlawick, Beavin and Jackson (1967) have pointed
out, every utterance has two components: the referential, which makes some direct
predication about the world, and the relational, by which we signal something about
our social relationship to the listener. Communication is not just a matter of what we
say; it is how we say it that determines the received message. The Air Florida example
(NTSB, 1982) highlights the tension between the safety requirement to communicate
essential information in a direct way (the referential component) versus the social
requirement of communicating with the appropriate level of politeness. Linde (1988)
noted:
It might at first appear desirable to train crew members to speak as
directly as possible.... However, in some situations, a subordinate's
speaking directly might be seen as challenging the hierarchical
relationship of crew members. If this is so, simple training in the direct
expression of matters of concern would not be sufficient. It would also be
necessary to train in forms of communication that can challenge a
superior's assessment of a situation, while indicating respect for the
superior's position. (p. 396)
At this point we can only suggest that the most effective U.S. crews are those that
address problem-relevant content (and build shared mental models for emergent
problems), but do it in an affiliative manner. This ideal poses a challenge for
cross-cultural communication within a flight deck, whether the personnel are culturally
homogenous or diverse, and between flight crews and air traffic command around the
world.
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Obviously, this procedure sometimes fails, as it did in the case of the Flying
Tigers crash in Kuala Lumpur. Communication failures are most likely when the
controller is busy and tries to pack many information components into one clearance,
thereby reducing his or her workload (i.e., only one radio transmission rather than two).
As Morrow and Rodvold (1993) have shown, more receptive errors on the part of the
pilots are likely when clearance messages include three or more elements of information
(heading, altitude, speed, climb rate, restrictions, traffic, etc.) than when they are
shorter. These errors are evident as readback errors by pilots. Thus, strategies that
reduce workload for controllers increase workload for pilots and vice versa. Moreover,
cross-language or culture-based misunderstandings are not necessarily eliminated by
this procedure.
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But how do such programs fare when injected into crew training in South
America, the Far East, or the Middle East? CRM programs have been accepted and
have succeeded in the U.S. because they are compatible with our cultural norms. The
U.S. is an egalitarian society that values individual effort. In Hofstede's (1980) terms,
the U.S. is a highly individualistic and moderately low power distance culture. This
means that all crew members are expected to participate in responding to problematic
situations and that junior crew members can volunteer information and suggestions.
In cultures that are high power distance, it would be unthinkable for a person of
lower status to challenge or question the judgment of a higher status person. Similarly,
collectivist cultures value group harmony over individual achievement. In highly
collectivist cultures, one's success or failure comes from the success or failure of the
group rather than one's own efforts. Challenges or pointing out mistakes made by the
captain would be seen as highly face-threatening, not just to the captain, but to the first
officer as well. Given the need to communicate critical information, a junior crew
member in such a culture experiences a conflict between safety and maintaining face
and harmony on the flight deck. No simple answer to this dilemma is readily available
(Johnston, 1993).
Merritt (1995) described some initial efforts to tailor training programs to the
social norms of various cultures by finding the appropriate "culture comfort zone."
Strong cultural models are adopted as the framework for crew training. For example, in
one high power distance/collectivist culture, the crew is represented as a family
business. While the captain is the head of the business, the first officer is the elder son
who has to learn the business so that he will be qualified eventually to take over. Thus,
it is important for the "son" to ask questions and to participate, while the "father" must
nurture him. First officers are asked to imagine that the other crew member (the
captain) is a brother or a friend in order to provide practice in assertiveness. In contrast,
to sensitize crew members from highly individualistic, low power distance cultures,
pilots are asked to imagine that the co-pilot is the company president.
Consider a further complication: What if one crew member is from a high power
distance/collectivist culture and the other is from a low power distance/individualistic
culture? If the captain is from the high power distance culture and the first officer is
from a low power distance culture, the captain may feel that the first officer is not
according him the respect he deserves because of his status. Conversely, if the captain
is from a low power distance culture and the first officer is from a high power distance
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culture, the captain may feel like the Lone Ranger, waiting for active input from the first
officer, who in turn is waiting for the captain to tell him or her what to do.
In this chapter we have reviewed several ways in which communication can fail
and how cultural factors can contribute to those failures. Three distinct problem areas
have emerged:
• Communication between pilots and air traffic controllers around the globe, in
which the official language is English but both pilots and controllers may speak
different native languages;
• The legitimacy of extending training practices and theories of effective
communication based on U.S. flight crews to cultures that differ from the U.S. in
terms of power distance and collectivism;
• How to train flight crews to operate in culturally diverse crew contexts.
Considerable progress has already been made by ICAO and other international
bodies to standardize the language of air traffic control, to create a "lingua franca" to
assure that all personnel can communicate effectively using formulaic agreed-upon
utterances. The advent of datalink will eliminate certain classes of errors. However, as
long as pilots and controllers interact using non-standardized language, the possibility
for miscommunication will exist. Sensitizing both controllers and crews to the
possibility of miscommunication and its various types may help.
With respect to exporting U.S. made CRM programs, theories that describe
culturally-bound forms of social interaction are bound to fail in some if not all ways
when transported beyond the boundaries of the culture in which they were developed.
However, some general principles may travel well, such as the need to assure that all
crew members understand the nature of a system malfunction or other emergency that
requires crew coordination and decision making. The challenge is to identify, for each
specific culture, appropriate ways of accomplishing certain crew tasks. How to
communicate "bad news" or to call attention to an error with safety consequences in a
manner that preserves "face" is a dilemma. Local rather than general solutions are
likely to emerge.
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to identify problems and to develop training programs that provide tools for interaction
are the only solutions that can be offered at this point.
In all of these situations it is critical that crew members work together and with
air traffic controllers to assure safety in flight. Learning how to foster effective
teamwork within a single culture has been the goal driving researchers for the past
decade. Now the challenge is to test the utility of their findings and theories in a
broader multicultural context. The safety of global aviation will depend on it.
Acknowledgments
We wish to acknowledge support for the research on which this paper was based from
NASA, Code UL, and the FAA, Office of the Chief Scientific and Technical Advisor for
Human Factors, AAR-100. In addition, we would like to thank Malcolm Brenner of the
National Transportation Safety Board and Robert Woodhouse of the International Air
Transport Association for their invaluable assistance in locating information used in this
chapter.
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Table 1
Frequency of Language-Based ASRS Reports
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