When communications between pilots and air traffic

control breaks down, the result can be fatal.

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'

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.
For whatever reason, perhaps because of
fatigue or the stress of having to work in conditions of low visibility, the normally Dutchspeaking pilot inadvertently switched into the
Dutch grammatical construction while keeping English words.
The Spanish-speaking controller, proficient
in English but not in Dutch, and unaware of
subtle language phenomena, had no clue that
this shift was going on. He interpreted that
"at" in a literal way, indicating a place the
take-off point.
The controller at Tenerife had, a few seconds earlier, inserted another kind of ambiguity into the controller/pilot exchange. The
controller had said, "KLM eight seven zero five
you are cleared to the Papa Beacon, climb to
and maintain flight level nine zero, right turn
after take-off".
The tower intended this departure instruction to mean that the aeroplane will track to
the Papa Beacon following take-off. But that
was not how the KLM pilot understood "you
are cleared". Take-off clearance was still to
come.

But when a speaker is distracted, stressed

or careless, these verbal keys can be omitted or
displaced, resulting in an important component of the communication being lost or distorted.
Words with uncertain reference, such as the
pronoun "him" or "it" or indefinite nouns
such as "things" can cause considerable confusion in aviation communications.
For example, 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. Problems can
also arise when different words sound almost
alike, such as left and west, or exactly alike,
such as 'to' and 'two
In one case, ATC cleared the aircraft to
descend "two four zero zero". The pilot read
back the clearance as "Four zero zero". The
aircraft then descended to 400 feet rather than
what the controller had meant, which was
2,400 feet.
In another case, the captain, who was the
pilot flying, heard his co-pilot say, "Cleared to
seven" He began to descend to 7,000 feet, but
at 9,500 feet the co-pilot advised the captain
that 10,000 feet was the correct altitude.
The co-pilot's communication, which the
captain had heard as "cleared to seven", was in
fact "cleared two seven" meaning, the
assigned runway for landing was 27.
In written language, tiny differences in
punctuation can drastically change the meaning of a sentence. Similarly, in spoken language, subtle differences in intonation and the
placement of pauses provide clues about how
the words are to be interpreted. A simple, oneword exclamation- "right!" can be understood as enthusiasm, resignation or sarcasm,
depending on the intonation.

Clarification
To clarify the time frame of an instruction,
and thus avoid the kind of confusion that
apparently occurred in the Tenerife accident,
controllers use the words "anticipate" or
"expect". Such modifiers are helpful, but they
are not without dangers of their own.
The expectation of an instruction can prime
a pilot to mistake a different communication
for the anticipated instruction. That is, the listener perceives that he or she heard what was
expected in the message transmitted. Pilots and
controllers alike tend to hear what they expect
to hear. Deviations from routine are not noted
and the read-back can be heard as being the
same as the transmitted message.

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. 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.
Failure to make a clear distinction between
a conditional statement and an instruction
can put one or more aircraft in peril.
During a cruise at FL 230 a co-pilot, who
was flying, asked ATC for permission to climb
to FL 310. The controller replied, "FL 310 is
the wrong altitude for your direction of flight;
I can give you FL 290......
The co-pilot replied, "Roger, cleared to 290,
leaving 230" The controller did not challenge
the read-back. When the aeroplane reached
24,000 feet, the controller queried the aeroplane's altitude and said, "I did not clear you
to climb, descend immediately to FL 230". The
pilot had understood "I can give you 290" to
mean you are cleared to climb to 290.

Number confusion
Misunderstanding can derive from the overlapping number ranges that are shared by
multiple aviation parameters.
For example, 240 can be a flight level, a
heading, an air speed or the flight number.
Aircraft call signs are particularly apt to be
confused with one another. Incidents in which

The controller at Tenerife

had, a few seconds earlier,
inserted another kind of
ambiguity into the
ntroller/pilot
exchange.
.

hh~

0
c-)

HISTORY'S WORST COMMERCIAL

AIR DISASTER
Date: 27 March 1977.
Location: Tenerife, (Spanish) Canary Islands.

First aircraft: KLM Royal Dutch Airlines,

Boeing 747-206B.
Second aircraft: Pan American World Airways (US), Boeing 747-121.

FLIGHT SAFETY AUSTRALIA AUTUMN 1997 15

Communications problems
at uncontrolled aerodromes

ETWEEN JANUARY 1993 AND OCTOBER

1996, over 150 incidents relating to poor
use of radio by pilots were recorded in Australia.
Most of the reports were made by air transport category pilots operating at Mandatory
Broadcasting Zones (MBZ5) and Common
Traffic Advisory Frequencies (CTAF5).
The majority of the incidents involved
non-commercial category aircraft using

incorrect procedures at or near airports.

These extracts from Bureau of Air Safety
Investigation reports speak for themselves:
"No communications could be established with the aircraft departing the MTAF."
"RPT F27 at holding point observed an
aircraft turning on to final for runway 06.
Attempts to contact the aircraft were unsuccessful and the pilot also failed to respond
to broadcasts."
"The pilot had difficulty understanding
the transmissions due to the slipstream
noise."
"The pilot did not make any calls despite
the fact he said his radio was working."
"While work was in progress on runway
11/29 an aircraft was noticed to enter the circuit area. 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, but
there was no reply. The aircraft then lined
up for a landing on runway 29 causing the
workmen to hurriedly remove their vehicles,
leaving a string line across the runway which
the aircraft ran over."
The communications problems associated with these pilot to pilot situations can be
categorised as follows:
Radio not switched on, not working or

used incorrectly.
Carrying incorrect documentation that is,
out-of-date charts or enroute supplements.
Not checking NOTAM5 for frequency
changes.
Poor use and understanding of English.
Not bothering to make any calls for whatever reason.
The highest proportion of radio problems at
uncontrolled airports is not making any calls.
When these pilots were asked why they hadn't
made any calls, most said they didn't think
there was any other traffic around or they
weren't sure of radio procedures in MTAF5.
Some were worried about embarrassing
themselves in front of other pilots because
they believed they had a poor radio technique.
Others said they had difficulty interpreting
traffic information given by other aircraft.
Some also believed that their operation would
not conflict with other traffic.
Timely and accurate radio reports are
essential for safe operations in all phases of
flight.
Common sense must be exercised - radios
should be switched on and used, regardless of
the requirements of the regulations. Broadcasting position reports, even when there
appears to be no other traffic, can only help
in avoiding an incident or accident.
The Aeronautical Information Publication sets out the broadcast requirements for
radio broadcast procedures at airspace
boundaries and associated airports.
Aircraft departing an uncontrolled aerodrome should report when taxiing with an
all stations broadcast detailing: the location,
call sign, aircraft type, departure runway and
intentions after take-off.
Before entering the runway for departure, 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.
If you have two VHF radios, 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.
If you are in doubt about the traffic situation around you, there is nothing wrong
with calling "all stations" with your position,
altitude and intentions at any time. Remember, outside controlled airspace you are
responsible for your own separation.

16 FLIGHT SAFETY AUSTRALIA AUTUMN 1997

one aircraft accepted an instruction meant for

another have included pairs with only mild
similarities.
Consider this incident. An aircraft was flying on a heading of 300 degrees at FL 270. 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.
At about FL 260, the controller asked about
the aircraft's airspeed. The pilot answered,
"315 knots". The controller said "Maintain
280". The pilot answered "280 knots", slowed
to 280 knots, and continued to climb to FL
310. At about FL 295 the controller asked for
the aeroplane's altitude and the pilot replied,
"295" The controller said that the aircraft was
cleared only to FL 280.
In this case, 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. The pilot had
then given a read-back that combined what
the controller actually said "280" with the presumed context "knots", and the controller had
not taken notice of the extra word.
Confusion about the sequence or meaning
of numbers is worse when two or more sets of
numbers are given in the same transmission.
In a high-pressure, high-workload cockpit or
control centre, it would require just a momentary slip of attention to transpose a three-digit
flight level and a three-digit heading.
Number sequence errors can occur most
often when ATC gives changes in assigned altitude, heading and speed in the same instruction. For example, "Kiwi 135, turn left heading 280, descend to nine thousand, QNH 1011,
reduce speed to 250 knots, call approach on
118 decimal 7'
Saying a number after another number that
is supposed to be remembered creates a classic
condition for confusion. 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, which is itself a number.
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, 40 per cent of pilot deviations from instructions and 15 per cent of the
near misses reported in 1993 and 1994.
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.
The primary responsibility for clear, comprehensible radio communications is on pilots

COVER STORY

and controllers. Correct pilot-ATC communications techniques involve a confirmation/correction loop. The steps are:
1.Sender transmits message.
2.Recipient actively listens to message.
3. Recipient repeats the message back to sender.
4.Sender actively listens for a correct readback.
The system's built-in safety margin depends
on all four elements of a communication
being performed correctly. Linguistic errors
generally represent an aberration in step 1:
the transmission falls victim to one of the
kinds of anomalies discussed earlier.
Awareness of linguistic traps may help to
avoid introducing them into the communication in the first place, but under workload

"Communications
problems [are] cited
as contributing
factors in around 27
per cent of confirmed
operational errors, 40
per cent of pilot
deviations from
instructions and 15
per cent of the near
misses reported."
pressures it will be the rare person who can
completely avoid them. Therefore, strict
adherence to steps 2 through 4 becomes the
next line of defence against errors.
Two common examples are:
A controller does not hear - or does not listen to - a pilot's incorrect read-back. The pilot
interprets the lack of response as silent confirmation that the read-back was correct.
After receiving an instruction, the pilot signs
off with an inadequate "Roger" or "Okay",
which precludes any controller double-check
of the exchange.
Some pilots tend to downgrade the significance of their own listening errors. Flight
crews tend to rely too much on controllers'
active listening. Some pilots complain about
controllers not picking up their incorrect
read-backs.

Delivery technique
Issuing instructions too quickly and non-stop
ATC transmissions are the most common
delivery technique problems. 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.
Although recognising the realities of congested traffic conditions approaching major
terminals during peak periods, and often
complimenting controllers for doing a good
job under difficult circumstances, pilots nevertheless pointed out a double danger from
"non-stop transmissions".
First, it makes it easier to miss one's own
call sign in the jumbled messages and, second,
there is no opportunity for read-back
acknowledgement and the controller will not
know of any missed instructions.
Pilot-ATC communications problems will
not be easy to eliminate. 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.
They recommend that:
Pauses between messages should be long
enough for the message to be completely
understood before more information is transmitted.
Some research in the US suggests that the
technique of "chunking" orally transmitted
information into smaller units makes information easier to understand. For example, 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".
Flight crews shouldn't assume that a routine read-back of a questionable clearance or
instruction is adequate. They should call attention to their uncertainty by prefacing their
read-back with the word "verify" or "confirm".
Explicit instructions by controllers, complete read-backs by pilots and active listening
by controllers to pilots' read-backs are the best
defence against errors in communication.
If there is any ambiguity - resolve it. Do not
assume that it will all work itself out or that
the controller will sort it out.
No pilot or controller will think any less of
you if you transmit "say again" or "stand by",
or seek assistance.
Using proper radio phraseology is critical. As
the Tenerife incident showed, communications
breakdown can involve various aircrew members and ATC.
Don't believe that your short-term memory
powers are special. In a complex traffic environment, make notes if necessary.
The standard RTF requirements can be
found in the OPS section of the Aeronautical
Information Publication.
Rod Pascoe is a former Air Traffic Controller; now an
aviation writer and consultant.
FLIGHT SAFETY AUSTRALIA AUTUMN 1997 17