Disasters due to ATC misunderstandings
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Disasters due to ATC misunderstandings
Hi folks,
since I've a lecture on communication in civil aviation I need a few examples of disasters due to ATC misunderstandings (or communication failures within the crew).
When was the accident with the 747s in Amsterdam? What went wrong? Do you have other misunderstanding/misleading examples?
I hope that you can help me out?!
Thx,
pilot007
P.S: This topic is also posted within the ATC section.
since I've a lecture on communication in civil aviation I need a few examples of disasters due to ATC misunderstandings (or communication failures within the crew).
When was the accident with the 747s in Amsterdam? What went wrong? Do you have other misunderstanding/misleading examples?
I hope that you can help me out?!
Thx,
pilot007
P.S: This topic is also posted within the ATC section.
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huh?
I presume you mean the ground collision between KLM and Pan Am in Tenerife, 1975? The only other 747 fatal in Amsterdam was an EL AL freighter in the late 90's.
Must be something in here using the search function....
I presume you mean the ground collision between KLM and Pan Am in Tenerife, 1975? The only other 747 fatal in Amsterdam was an EL AL freighter in the late 90's.
Must be something in here using the search function....
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This probably doesn't really belong in Rumours and News - but then I am not a moderator so I'll post a link to the Pan Am/ KLM CVR transcript which is Here
Plus - some information and analysis from the ICAO circular Here
Another disaster worthy of consideration is the collision of the Adria DC9 and British Airways Trident over Zagreb in 1976.
Plus - some information and analysis from the ICAO circular Here
Another disaster worthy of consideration is the collision of the Adria DC9 and British Airways Trident over Zagreb in 1976.
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The Zagreb was more systemic controller overload rather than a communications breakdown.
Try American 757 at Cali, crew misunderstood the controller then struggled to program the FMS.
Or the Dan Air 727 in the Canaries.
Try American 757 at Cali, crew misunderstood the controller then struggled to program the FMS.
Or the Dan Air 727 in the Canaries.
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DAN Air 727, Mount Tidy, Tenerife Canary Islands
Misunderstanding of ATC instructions and wrong actions by crew.
Recent 757/Tu154 over Switzerland and TCAS resolutions
This is a dynamic process, R/T phraseology with confusion between things like 'TO' and 'TWO' are being addressed all the time.
Flight Level 'Wun Zero Zero' being changed to Flight Level 'Wun Hundred' etc is proof that the system does 'care'.
Good on 'em, they've got my vote.
Good luck, the more we understand 'mis-understandings' the safer we'll all be.
Misunderstanding of ATC instructions and wrong actions by crew.
Recent 757/Tu154 over Switzerland and TCAS resolutions
This is a dynamic process, R/T phraseology with confusion between things like 'TO' and 'TWO' are being addressed all the time.
Flight Level 'Wun Zero Zero' being changed to Flight Level 'Wun Hundred' etc is proof that the system does 'care'.
Good on 'em, they've got my vote.
Good luck, the more we understand 'mis-understandings' the safer we'll all be.
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There are many examples in a book written by David Beatty, called "The Naked Pilot."
It is published by Airlife and the ISBN is 1-85310-482-5.
I lecture on project management and have applied the underpinning theory to show how we are all vulnerable to human factors.
It is published by Airlife and the ISBN is 1-85310-482-5.
I lecture on project management and have applied the underpinning theory to show how we are all vulnerable to human factors.
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A Flying Tigers B747 freighter got caught out by a communication misunderstanding, on approach to KUL, a number of years ago: "Descend 2400..." vs "descend to 400.." resulted in an impact well short of the Rwy 30 threshold.
Details hazy now but we used to use it as a communications case study.
Details hazy now but we used to use it as a communications case study.
Charles de Gaul a few years ago. A BritishShorts 330 crew were given a runway crossing clearance in English and acted on it. Meanwhile, a French airliner was given a take off clearance in French. The aircarft collided killing the British First Officer.
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I was given the clearance "descend now FL240" a couple of weeks ago and i read back "descend now 240", immediately and after thinking about it, quite rightly,i was asked to confirm flight Level 240,which at the time i was convinced i already had,but I could have read back "descend to 40",big difference.I used to fly with a guy (old school) who said that " The words TO and FOR should never be used on the RT,he has a point!
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Going back to cribble's post -
The controller's words "Descend Two Four Zero Zero" (correct in the phraseologies of the time) was the origin of the current use of "Thousand" in the altitude call. In today's words, it would have been "Descend to Two Thousand Four Hundred".
We live and we learn, it's surprising even today to hear many pilots, and some controllers, not using the "Hundreds" component of F/L 200,300 etc., but still using zeros.
Users of Australian airspace will note that there is no Runway 02 or 20 in the country, even if the runway direction indicates that it should be so. 01/19 or 03/21 is used instead, whichever is closer to the actual. This originated from an accident many decades ago when 02 was interpreted (fatally) as 20 by a pilot.
I'd be interested to know if the American practice of not using the preceding zero for runways such as 06, has lead to a significant incident or accident.
"Descend 2400..." vs "descend to 400.."
We live and we learn, it's surprising even today to hear many pilots, and some controllers, not using the "Hundreds" component of F/L 200,300 etc., but still using zeros.
Users of Australian airspace will note that there is no Runway 02 or 20 in the country, even if the runway direction indicates that it should be so. 01/19 or 03/21 is used instead, whichever is closer to the actual. This originated from an accident many decades ago when 02 was interpreted (fatally) as 20 by a pilot.
I'd be interested to know if the American practice of not using the preceding zero for runways such as 06, has lead to a significant incident or accident.
nitefiter:
the words "to" should only be used when descening/climbing to an Altitude. i.e. descend TO altitude XXXX. Omit the "TO" when climbing to a FL, i.e. Clmb FL 240. CAP 413 stuff for those interested.
the words "to" should only be used when descening/climbing to an Altitude. i.e. descend TO altitude XXXX. Omit the "TO" when climbing to a FL, i.e. Clmb FL 240. CAP 413 stuff for those interested.
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ALTITUDE vs HEADING
I once cleared an aircraft (using incomplete phraseology) "turn left three-one-zero"
vs the correct:
"turn left heading three-one-zero." Pilot read back: "Roger, three-one-zero" . . . and started a climb to FL310.
There's no substitute for proper phraseology. "Shortcuts" can be dangerous!
vs the correct:
"turn left heading three-one-zero." Pilot read back: "Roger, three-one-zero" . . . and started a climb to FL310.
There's no substitute for proper phraseology. "Shortcuts" can be dangerous!
Try Cushing's Fatal Words for a number of examples.
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>>Users of Australian airspace will note that there is no Runway 02 or 20 in the country, even if the runway direction indicates that it should be so. 01/19 or 03/21 is used instead, whichever is closer to the actual. This originated from an accident many decades ago when 02 was interpreted (fatally) as 20 by a pilot.<<
Sounds like a lysdexic urban legend <g>. Is this really true?
>>I'd be interested to know if the American practice of not using the preceding zero for runways such as 06, has lead to a significant incident or accident.<<
What would they confuse it with, runway 60? We try to keep things simple in America for safety's sake. Of course, we don't always succeed...
I'm always worried about those conditional clearances to taxi onto the runway that you get in many countries: "Behind landing traffic, line up and wait". I've seen this eagerly given as one aircraft is just touching down and another is on fairly short final. You could sure guess wrong in this case.
Perhaps just as bad is the U.S. practice of issuing multiple landing clearances on the expectation that the preceding aircraft will be clear of the runway in time.
One that gets some U.S. crews is "taxi to holding position runway 05". If you haven't flown overseas it sounds a lot like "taxi to hold in position runway 05".
Of course, my favorite taxi clearance is in SIN, "taxi on the greens..."
Sounds like a lysdexic urban legend <g>. Is this really true?
>>I'd be interested to know if the American practice of not using the preceding zero for runways such as 06, has lead to a significant incident or accident.<<
What would they confuse it with, runway 60? We try to keep things simple in America for safety's sake. Of course, we don't always succeed...
I'm always worried about those conditional clearances to taxi onto the runway that you get in many countries: "Behind landing traffic, line up and wait". I've seen this eagerly given as one aircraft is just touching down and another is on fairly short final. You could sure guess wrong in this case.
Perhaps just as bad is the U.S. practice of issuing multiple landing clearances on the expectation that the preceding aircraft will be clear of the runway in time.
One that gets some U.S. crews is "taxi to holding position runway 05". If you haven't flown overseas it sounds a lot like "taxi to hold in position runway 05".
Of course, my favorite taxi clearance is in SIN, "taxi on the greens..."
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Airbubba,
No, the Australian convention for 02/20 runways is not "lysdexic urban legend", it is policy. There's plenty of examples to prove the point, e.g. Townsville RWY 01 is actually 017 degrees. We don't seem to have the same problem in Singapore where there is an abundance of 02/20's.
My query regarding any history of incidents and/or accidents in the U.S. with common use of single digits for runways, was a query in reverse to what you may have thought it to be, if there's no problem then why doesn't the rest of the world use it as well, in the interests of simplicity. The only area that I could conceive of a problem would be at an airport with another runway ending in 6, e.g. Runway 26 at an airport also with a Runway 6.
And yes, "Taxi on the greens" in SIN does make life simpler, for pilots anyhow, it must be like working a train set up in the tower.
.
No, the Australian convention for 02/20 runways is not "lysdexic urban legend", it is policy. There's plenty of examples to prove the point, e.g. Townsville RWY 01 is actually 017 degrees. We don't seem to have the same problem in Singapore where there is an abundance of 02/20's.
My query regarding any history of incidents and/or accidents in the U.S. with common use of single digits for runways, was a query in reverse to what you may have thought it to be, if there's no problem then why doesn't the rest of the world use it as well, in the interests of simplicity. The only area that I could conceive of a problem would be at an airport with another runway ending in 6, e.g. Runway 26 at an airport also with a Runway 6.
And yes, "Taxi on the greens" in SIN does make life simpler, for pilots anyhow, it must be like working a train set up in the tower.
.
Brisbane and Townsville both seem to have 01/19s that would be more geometrically labelled as 02/20s. But Ayers Rock has a 13/31. Why avoid 02/20 but not 13/31?
(from Cambridge, UK, which used to have both 02/20 and 13/31
)
(from Cambridge, UK, which used to have both 02/20 and 13/31
)
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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"
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"
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A contributory factor to the Kegworth BMI 737 accident were the ATC requests made on the crew during a period of very high workload. Should be seen in context with the well-known inter-cockpit issues in that accident; prioritisation, clarity of decision making processes, use of SOP's and more.
Agree with the Naked Pilot recommendation above, also check out Stanley Stewart's book on accidents, the name of which escapes me right now.
Agree with the Naked Pilot recommendation above, also check out Stanley Stewart's book on accidents, the name of which escapes me right now.