Disasters due to ATC misunderstandings
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Quote:
"In Kuala-Lumpur, a final approach course CFIT.
747 is cleared to descent to 2400 feet as being transmitted "clear to descent TWO-four-hundred feet".
Acknowledeged as "descending TO four-hundred feet"
Why not "Descend "TIL" two tousand four hundred feet"? No ambiguity there!
"In Kuala-Lumpur, a final approach course CFIT.
747 is cleared to descent to 2400 feet as being transmitted "clear to descent TWO-four-hundred feet".
Acknowledeged as "descending TO four-hundred feet"
Why not "Descend "TIL" two tousand four hundred feet"? No ambiguity there!
Re the KUL CFIT - we used to use this incident as part of the CFIT training input. The video re-construction, which includes the actual CVR tape, is exceptionally powerful in getting the message across.
What is even more worrying than the misreading/mishearing is the fact that three experienced crew members accepted, without query, a descent clearance which they understood to be to a specified FOUR HUNDRED feet. Can anyone point me to ANYWHERE which would issue such a clearance to an aircraft operating IFR????
Additionally worrying was the TOTAL lack of any response to the repeated 'PULL UP' warnings.
This video ought to be an essential part of any initial and recurrent training - as, indeed we used to.
What is even more worrying than the misreading/mishearing is the fact that three experienced crew members accepted, without query, a descent clearance which they understood to be to a specified FOUR HUNDRED feet. Can anyone point me to ANYWHERE which would issue such a clearance to an aircraft operating IFR????
Additionally worrying was the TOTAL lack of any response to the repeated 'PULL UP' warnings.
This video ought to be an essential part of any initial and recurrent training - as, indeed we used to.
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EastCoaster,
ICAO Annex 10 and ICAO DOC 4444 prescribes how to speak altitude and flight level. That is exactly what you said, thousands and hundreds are spelled seperately:
2400 feet: "Two-thosand-four-hundred"
11500 feet: "one-one thousand -five hundred"
Cornish Jack,
Remember in this particular disaster "fatigue" is also a major contributing factor. But you know still we dont have SUBPART Q (FLIGHT AND DUTY TIME LIMITATIONS AND REST REQUIREMENTS)
in JAR OPS1
I do not know what they are waiting.
Why not "Descend "TIL" two tousand four hundred feet"? No ambiguity there!
2400 feet: "Two-thosand-four-hundred"
11500 feet: "one-one thousand -five hundred"
Cornish Jack,
Remember in this particular disaster "fatigue" is also a major contributing factor. But you know still we dont have SUBPART Q (FLIGHT AND DUTY TIME LIMITATIONS AND REST REQUIREMENTS)
in JAR OPS1
I do not know what they are waiting.
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Stanley Stewart book is called air disasters ( try amazon), it is I think number two next to Emergency- Crisis on the flight deck (only storys were crews saved the day...)and flying the big jets...
Regards
Micky
Regards
Micky
Although hardly examples of disasters, as a student pilot making my first (required) long distance solo flight, someone burst on the frequency for the uncontrolled (no tower) airport in a panicked voice IN FRENCH just as I was taking off.
I am not trying to make negative comments about the French, but whoever it was sounded like there was a major problem. I couldn't see any other plane, and still have no idea what it was about, but it got my attention as a student pilot.
Another non-event at an uncontrolled airport occurred when I was calling downwind for runway XX at airport xyz, when another aircraft announced that they too were landing at runway XX, but failed to mention the airport. Basically, whoever they were (they never identified their aircraft or the airport they were landing at) kept calling the same positions for a landing at a runway with the same heading as I was landing at, yet I never saw them, despite looking VERY carefully. (And, in fact, no other plane landed at that airport at the time.)
I don't know if it was someone landing at a different airport with the same runway heading (a possibilty), or if it was someone just having fun.
I am not trying to make negative comments about the French, but whoever it was sounded like there was a major problem. I couldn't see any other plane, and still have no idea what it was about, but it got my attention as a student pilot.
Another non-event at an uncontrolled airport occurred when I was calling downwind for runway XX at airport xyz, when another aircraft announced that they too were landing at runway XX, but failed to mention the airport. Basically, whoever they were (they never identified their aircraft or the airport they were landing at) kept calling the same positions for a landing at a runway with the same heading as I was landing at, yet I never saw them, despite looking VERY carefully. (And, in fact, no other plane landed at that airport at the time.)
I don't know if it was someone landing at a different airport with the same runway heading (a possibilty), or if it was someone just having fun.
Last edited by visibility3miles; 4th Nov 2004 at 14:38.
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Jabbara,
Think you might have missed my point. Wasn't the actual enunciation of the levels or the fact that the hundreds and thousands of feet are separated, it was the til in parentheses that I was trying to highlight.
Not much chance of getting that mixed up with an index in any clearance or instruction.
On the up-side though, nice to know that my knowledge of standard phraseology is still up to scratch!! Cheers Jab
Think you might have missed my point. Wasn't the actual enunciation of the levels or the fact that the hundreds and thousands of feet are separated, it was the til in parentheses that I was trying to highlight.
Not much chance of getting that mixed up with an index in any clearance or instruction.
On the up-side though, nice to know that my knowledge of standard phraseology is still up to scratch!! Cheers Jab
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RT phraseology
Think altimeter in a Piper, say. Think of two nationalities. Hear the words a) Set 29 92; b) Set to 992. Pilot a) sets 29.92" Hg direct; pilot b) looks at a card reads 992mb = 29.29" Hg. Roughly 600ft difference? Now that's one to avoid through explicit RT procedure.
Also wasn't there a case once where a ground vehicle asked permission to cross xxx but someone cut across the transmission? Next he heard was his callsign and the words "Go ahead.." Handbrake, clutch, bang!
Also wasn't there a case once where a ground vehicle asked permission to cross xxx but someone cut across the transmission? Next he heard was his callsign and the words "Go ahead.." Handbrake, clutch, bang!
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Tenerife (1977) was not down to controller misunderstanding. It was down to taking off without clearance. ATC was cleared in the Dan air too.
Uberlingen mid-air July 02 was a classic of ATC versus TCAS, as was Jan 31, 2001 JAL incident (DC10 and 744 with 677 total souls missed by 10 metres, and 100 injured in violent avoiding action) which was also ATC versus TCAS (and five other very close calls in Europe alone in 2000/1, according to a Eurocontrol survey).
The best example of true misunderstanding between cockpit and tower was Avianca 52 in January 1990 at JFK, where the co-pilot repeated he was running out of fuel and tower paid not attention because he did not hear the magic word "emergency". They flamed out and crashed on Long Island, killing about half on board.
Uberlingen mid-air July 02 was a classic of ATC versus TCAS, as was Jan 31, 2001 JAL incident (DC10 and 744 with 677 total souls missed by 10 metres, and 100 injured in violent avoiding action) which was also ATC versus TCAS (and five other very close calls in Europe alone in 2000/1, according to a Eurocontrol survey).
The best example of true misunderstanding between cockpit and tower was Avianca 52 in January 1990 at JFK, where the co-pilot repeated he was running out of fuel and tower paid not attention because he did not hear the magic word "emergency". They flamed out and crashed on Long Island, killing about half on board.
Tenerife (1977) was not down to controller misunderstanding. It was down to taking off without clearance. ATC was cleared in the Dan air too.
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It seems "Descend & Maintain 2 thousand 4 hundred" or "FL zero two four" does the deed sufficiently...no strange 'til's', no ambiguity.
As for altimeters, reporting an altimeter setting isn't an order to set it. "Altimeter two niner decimel five seven" , or "Altimeter two niner point five seven" would do; a controller should just report altimeters (and Transition Levels, when 'by ATC').
"Descend to" and "Set to" are inherently dangerous; other choices are available, AND non-ambiguous. Unfortunately, many don't use them (especially in F-Land, where they also hate to ID fixes/beacons phonetically, requiring 4 or 5 calls where 2 would do).
As for altimeters, reporting an altimeter setting isn't an order to set it. "Altimeter two niner decimel five seven" , or "Altimeter two niner point five seven" would do; a controller should just report altimeters (and Transition Levels, when 'by ATC').
"Descend to" and "Set to" are inherently dangerous; other choices are available, AND non-ambiguous. Unfortunately, many don't use them (especially in F-Land, where they also hate to ID fixes/beacons phonetically, requiring 4 or 5 calls where 2 would do).
