Flight Safety Foundation

Approach-and-landing Accident Reduction

Tool Kit
FSF ALAR Briefing Note
2.3 — Pilot-Controller Communication

Until data-link communication comes into widespread use,

air traffic control (ATC) will depend primarily upon voice Pilot-Controller Communication Loop:
communication that is affected by various factors. The Confirmation/Correction Process
ATC Clearance
Communication between pilot and controller can be improved
by the mutual understanding of each other’s operating Acknowledge Transmit
or Correct
environment.

Statistical Data
Listen
The Flight Safety Foundation Approach-and-landing Accident
Controller’s
Reduction (ALAR) Task Force found that incorrect or Hearback Pilot’s
inadequate ATC instruction/advice/service was a causal factor1 Readback
in 33 percent of 76 approach-and-landing accidents and serious Listen Transmit
incidents worldwide in 1984 through 1997.2

These accidents and incidents involved incorrect or inadequate:

• ATC instructions (e.g., radar vectors); ATC = Air traffic control
Source: Flight Safety Foundation Approach-and-landing Accident
• Weather or traffic information; and/or, Reduction (ALAR) Task Force

• Advice/service in an emergency.
Figure 1

Pilot-Controller Communication Loop Whenever adverse factors are likely to affect communication,
adherence to the confirmation/correction process is a line of
The responsibilities of the pilot and controller overlap in many defense against communication errors.
areas and provide backup.
Effective Communication
The pilot-controller confirmation/correction process is a “loop”
that ensures effective communication (Figure 1). Pilots and controllers are involved equally in the ATC system.

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 47

 Achieving effective radio communication involves many • Where — (at […] waypoint).
factors that should not be considered in isolation; more than
one factor usually is involved in a breakdown of the The construction of the initial message and subsequent
communication loop. message(s) should support this operational context by:
• Following the chronological order of the actions;
Human Factors
• Grouping instructions and numbers related to each
Effective communication is achieved when the intellectual action; and,
process for interpreting the information contained in a message
• Limiting the number of instructions in the transmission.
accommodates the message received.
The intonation, the speed of speaking and the placement and
This process can be summarized as follows:
duration of pauses may affect the understanding of a
• How do we perceive the message? communication.
• How do we reconstruct the information contained in the
message? Mastering the Language

• How do we link the information to an objective or to an CRM studies show that language differences on the flight deck
expectation (e.g., route, altitude or time)? are a greater obstacle to safety than cultural differences on the
• What bias or error is introduced in this process? flight deck.

Crew resource management (CRM) highlights the relevance Because English has become a shared language in aviation,
of the context and the expectation in communication. an effort has been initiated to improve the English-language
Nevertheless, expectation may introduce either a positive bias skills of pilots and controllers worldwide.
or a negative bias in the effectiveness of the communication.
Nevertheless, even pilots and controllers for whom English is
High workload, fatigue, noncompliance with the “sterile the native language may not understand all words spoken in
cockpit rule,”3 distractions, interruptions and conflicts are English because of regional accents or dialects.
among the factors that may affect pilot-controller
communication and result in: In many regions of the world, language differences generate
other communication difficulties.
• Incomplete communication;
• Omission of the aircraft call sign or use of an incorrect For example, controllers using both English (for
call sign; communication with international flights) and the country’s
official language (for communication with domestic flights)
• Use of nonstandard phraseology; hinder some flight crews from achieving the desired level of
• Failure to hear or to respond; and, situational awareness (loss of “party-line” communication).

• Failure to effectively implement a confirmation or

Nonstandard Phraseology
correction.
Nonstandard phraseology is a major obstacle to effective
Language and Communication
communication.
Native speakers may not speak their own language correctly
Standard phraseology in pilot-controller communication is
and consistently.
intended to be understood universally.
The language of pilot-controller communication is intended
Standard phraseology helps lessen the ambiguities of spoken
to overcome this basic shortcoming.
language and, thus, facilitates a common understanding among
speakers:
The first priority of any communication is to establish an
operational context that defines the following elements: • Of different native languages; or,
• Purpose — clearance, instruction, conditional statement • Of the same native language but who use, pronounce or
or proposal, question or request, confirmation; understand words differently.
• When — immediately, anticipate, expect;
Nonstandard phraseology or the omission of key words may
• What and how — altitude (climb, descend, maintain), change completely the meaning of the intended message,
heading (left, right), airspeed; and, resulting in potential traffic conflicts.

48 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 For example, any message containing a number should indicate A deviation from an intended clearance may not be detected
what the number refers to (e.g., an altitude, a heading or an until the controller observes the deviation on his/her radar
airspeed). Including key words prevents erroneous display.
interpretation and allows an effective readback/hearback.
Less-than-required vertical separation or horizontal separation
Pilots and controllers might use nonstandard phraseology, with (and near midair collisions) and runway incursions usually
good intentions, for simplicity; however, standard phraseology are the result of hearback errors.
minimizes the potential for misunderstanding.
Expectations
Building Situational Awareness
Bias in understanding a communication can affect pilots and
Radio communication should contribute to the pilot’s and the controllers.
controller’s situational awareness, which may be enhanced if
they provide each other with advance information. The bias of expectation can lead to:
• Transposing the numbers contained in a clearance (e.g.,
Frequency Congestion
a flight level [FL]) to what was expected, based on
experience or routine; and,
Frequency congestion affects significantly the flow of
communication during approach-and-landing phases at high- • Shifting a clearance or instruction from one parameter
density airports, and demands enhanced vigilance by pilots to another (e.g., perceiving a clearance to maintain a
and by controllers. 280-degree heading as a clearance to climb/descend and
maintain FL 280).
Omission of Call Sign
Failure to Seek Confirmation
Omitting the call sign or using an incorrect call sign jeopardizes
an effective readback/hearback. Misunderstandings may involve half-heard words or guessed-
at numbers.
Omission of Readback or Inadequate Readback
The potential for misunderstanding numbers increases when
The term “roger” often is misused, as in the following an ATC clearance contains more than two instructions.
situations:
Failure to Request Clarification
• A pilot says “roger” (instead of providing a readback)
to acknowledge a message containing numbers, thus
Reluctance to seek confirmation may cause flight crews to
preventing any effective hearback and correction of
either:
errors by the controller; or,
• Accept an inadequate instruction (over-reliance on
• A controller says “roger” to acknowledge a message
ATC); or,
requiring a definite answer (e.g., a positive confirmation
or correction, such as acknowledging a pilot’s statement • Determine for themselves the most probable
that an altitude or airspeed restriction cannot be met), interpretation.
thus decreasing both the pilot’s and the controller’s
situational awareness. Failing to request clarification may cause a flight crew to
believe erroneously that they have received an expected
Failure to Correct Readback clearance (e.g., clearance to cross an active runway).

The absence of an acknowledgment or a correction following Failure to Question Instructions

a clearance readback is perceived by most flight crews as an
implicit confirmation of the readback. Failing to question an instruction can cause a crew to accept
an altitude clearance below the minimum safe altitude (MSA)
The absence of acknowledgment by the controller usually is the or a heading that places the aircraft near obstructions.
result of frequency congestion and the need for the controller to
issue clearances and instructions to several aircraft in succession. Taking Another Aircraft’s Clearance or Instruction

An uncorrected erroneous readback (known as a hearback This usually occurs when two aircraft with similar-sounding
error) may lead to a deviation from the assigned altitude or call signs are on the same frequency and are likely to receive
noncompliance with an altitude restriction or with a radar similar instructions, or when the call sign is blocked by another
vector. transmission.

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 49

 When pilots of different aircraft with similar-sounding call transmissions being blocked and unheard by the other stations
signs omit the call sign on readback, or when simultaneous (or being heard as a buzzing sound or as a squeal).
readbacks are made by both pilots, the error may go unnoticed
by the pilots and the controller. The absence of a readback (from the pilot) or a hearback
acknowledgment (from the controller) should be treated as a
Filtering Communications blocked transmission and prompt a request to repeat or confirm
the message.
Because of other flight deck duties, pilots tend to filter
communications, hearing primarily communications that begin Blocked transmissions can result in altitude deviations, missed
with their aircraft call sign and not hearing most other turnoffs and takeoffs, landings without clearances and other
communications. hazards.

For workload reasons, controllers also may filter

communications (e.g., not hearing and responding to a pilot Communicating Specific Events
readback while engaged in issuing clearances/instructions to
other aircraft or ensuring internal coordination). The following events should be reported as soon as practical
to ATC, stating the nature of the event, the action(s) taken and
To maintain situational awareness, this filtering process should the flight crew’s intention(s):
be adapted, according to the flight phase, for more effective • Traffic-alert and collision avoidance system (TCAS)
listening. resolution advisory (RA);

For example, when occupying an active runway (e.g., back- • Severe turbulence;
taxiing or holding in position) or when conducting a final • Volcanic ash;
approach to an assigned runway, the flight crew should listen
and give attention to communications related to the landing • Wind shear or microburst; and,
runway. • A terrain-avoidance maneuver prompted by a ground-
proximity warning system (GPWS) warning or terrain
Timeliness of Communication awareness and warning system (TAWS)4 warning.

Deviating from an ATC clearance may be required for

Emergency Communication
operational reasons (e.g., a heading deviation or altitude
deviation for weather avoidance, or an inability to meet a
In an emergency, the pilot and the controller must communicate
restriction).
clearly and concisely, as suggested below.
Both the pilot and the controller need time to accommodate
Pilot
this deviation; therefore, ATC should be notified as early as
possible to obtain a timely acknowledgment.
The standard International Civil Aviation Organization (ICAO)
phraseology “Pan Pan”5 or “Mayday”6 must be used to alert a
Similarly, when about to enter a known non-radar-controlled
controller and trigger an appropriate response.
flight information region (FIR), the pilot should contact the
appropriate ATC facility approximately 10 minutes before
Controllers
reaching the FIR boundary to help prevent misunderstandings
or less-than-required separation.
Controllers should recognize that, when faced with an
emergency situation, the flight crew’s most important needs
Blocked Transmissions (Simultaneous
are:
Communication)
• Time;
Blocked transmissions often are the result of not immediately
• Airspace; and,
releasing the push-to-talk switch after a communication.
• Silence.
An excessive pause in a message (i.e., holding the push-to-
talk switch while considering the next item of the transmission) The controller’s response to the emergency situation could be
also may result in blocking part of the response or part of patterned after a memory aid such as ASSIST:
another message.
• Acknowledge:
Simultaneous transmission by two stations (two aircraft or one – Ensure that the reported emergency is understood and
aircraft and ATC) results in one of the two (or both) acknowledged;

50 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 • Separate: • Request clarification or confirmation when in doubt;
– Establish and maintain separation with other traffic • Question an incorrect clearance or inadequate
and/or terrain; instruction;
• Silence: • Prevent simultaneous transmissions;
– Impose silence on your control frequency, if • Listen to party-line communications as a function of the
necessary; and, flight phase; and,
– Do not delay or disturb urgent flight crew action by • Use clear and concise communication in an emergency.
unnecessary transmissions;
The following FSF ALAR Briefing Notes provide information
• Inform:
to supplement this discussion:
– Inform your supervisor and other sectors, units and
• 2.1 — Human Factors;
airports as appropriate;
• 2.2 — Crew Resource Management;
• Support:
• 2.4 — Interruptions/Distractions; and,
– Provide maximum support to the flight crew; and,
• 7.1 — Stabilized Approach.♦
• Time:
– Allow the flight crew sufficient time to handle the
emergency. References
1. The Flight Safety Foundation Approach-and-landing
Training Program Accident Reduction (ALAR) Task Force defines causal
factor as “an event or item judged to be directly
A company training program on pilot-controller instrumental in the causal chain of events leading to the
communication should involve flight crews and ATC accident [or incident].” Each accident and incident in the
personnel in joint meetings, to discuss operational issues and, study sample involved several causal factors.
in joint flight/ATC simulator sessions, to promote a mutual 2. Flight Safety Foundation. “Killers in Aviation: FSF Task
understanding of each other’s working environment, Force Presents Facts About Approach-and-landing and
including: Controlled-flight-into-terrain Accidents.” Flight Safety
• Modern flight decks (e.g., flight management system Digest Volume 17 (November–December 1998) and
reprogramming) and ATC equipment (e.g., absence of Volume 18 (January–February 1999): 1–121. The facts
primary returns, such as weather, on modern radar presented by the FSF ALAR Task Force were based on
displays); analyses of 287 fatal approach-and-landing accidents
(ALAs) that occurred in 1980 through 1996 involving
• Operational requirements (e.g., aircraft deceleration turbine aircraft weighing more than 12,500 pounds/5,700
characteristics, performance, limitations); and, kilograms, detailed studies of 76 ALAs and serious
• Procedures (e.g., standard operating procedures [SOPs]) incidents in 1984 through 1997 and audits of about 3,300
and instructions (e.g., CRM). flights.

3. The sterile cockpit rule refers to U.S. Federal Aviation

Special emphasis should be placed on pilot-controller
Regulations Part 121.542, which states: “No flight
communication and task management during emergency
crewmember may engage in, nor may any pilot-in-
situations.
command permit, any activity during a critical phase of
flight which could distract any flight crewmember from
the performance of his or her duties or which could interfere
Summary
in any way with the proper conduct of those duties.
Activities such as eating meals, engaging in nonessential
The following should be emphasized in pilot-controller
conversations within the cockpit and nonessential
communication:
communications between the cabin and cockpit crews, and
• Recognize and understand respective pilot and controller reading publications not related to the proper conduct of
working environments and constraints; the flight are not required for the safe operation of the
aircraft. For the purposes of this section, critical phases of
• Use standard phraseology;
flight include all ground operations involving taxi, takeoff
• Adhere to the pilot-controller confirmation/correction and landing, and all other flight operations below 10,000
process in the communication loop; feet, except cruise flight.” [The FSF ALAR Task Force says

FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 51

 that “10,000 feet” should be height above ground level Koenig, Robert L. “Excess Words, Partial Readbacks Score
during flight operations over high terrain.] High in Analysis of Pilot-ATC Communication Errors.” Airport
Operations Volume 23 (January–February 1997).
4. Terrain awareness and warning system (TAWS) is the term
used by the European Joint Aviation Authorities and the
FSF Editorial Staff. “Flight Crew of DC-10 Encounters
U.S. Federal Aviation Administration to describe equipment
Microburst During Unstabilized Approach, Ending in Runway
meeting International Civil Aviation Organization (ICAO)
Accident.” Accident Prevention Volume 53 (August 1996).
standards and recommendations for ground-proximity
warning system (GPWS) equipment that provides predictive
FSF Editorial Staff. “Pilot of Cessna 441 Incorrectly Taxis
terrain-hazard warnings. “Enhanced GPWS” and “ground
onto Active Runway and Aircraft Is Struck by McDonnell
collision avoidance system” are other terms used to describe
Douglas MD-82 on Takeoff Roll.” Accident Prevention Volume
TAWS equipment.
53 (March 1996).
5. ICAO says that the words “Pan Pan” at the beginning of a
communication identifies urgency — i.e., “a condition FSF Editorial Staff. “Unaware That They Have Encountered a
concerning the safety of an aircraft … or of some person Microburst, DC-9 Flight Crew Executes Standard Go-around;
on board or within sight, but which does not require Aircraft Flies Into Terrain.” Accident Prevention Volume 53
immediate assistance.” ICAO says that “Pan Pan” (February 1996).
(pronounced “Pahn, Pahn”) should be spoken three times
at the beginning of an urgency call. Cushing, Steven. “Pilot–Air Traffic Control Communications:
It’s Not (Only) What You Say, It’s How You Say It.” Flight
6. ICAO says that the word “Mayday” at the beginning of a
Safety Digest Volume 14 (July 1995).
communication identifies distress — i.e., “a condition of
being threatened by serious and/or imminent danger and
Duke, Thomas A.; FSF Editorial Staff. “Aircraft Descended
of requiring immediate assistance.” ICAO says that
Below Minimum Sector Altitude and Crew Failed to Respond
“Mayday” should be spoken three times at the beginning
to GPWS as Chartered Boeing 707 Flew into Mountain in
of a distress call.
Azores.” Accident Prevention Volume 52 (February 1995).

FSF Editorial Staff. “Cockpit Coordination, Training Issues

Related Reading from FSF Publications Pivotal in Fatal Approach-to-Landing Accident.” Accident
Prevention Volume 51 (January 1994).
Flight Safety Foundation (FSF) Editorial Staff. “ATR 42 Strikes
Mountain on Approach in Poor Visibility to Pristina, Kosovo.” Gless, Richard D. “Communication Creates Essential Bond
Accident Prevention Volume 57 (October 2000). to Allow Air Traffic Control System to Function Safely.”
Accident Prevention Volume 49 (May 1992).
FSF Editorial Staff. “Use of Standard Phraseology by Flight
Crews and Air Traffic Controllers Clarifies Aircraft Wilson, Donald R. “My Own Mouth Shall Condemn Me.”
Emergencies.” Airport Operations Volume 26 (March–April Accident Prevention Volume 47 (June 1990).
2000).

FSF Editorial Staff. “Studies Investigate the Role of Regulatory Resources

Memory in the Interaction Between Pilots and Air Traffic
Controllers.” Airport Operations Volume 24 (January– International Civil Aviation Organization (ICAO).
February 1998). International Standards and Recommended Practices, Annex
6 to the Convention of International Civil Aviation, Operation
Uplinger, Shannon. “English-language Training for Air Traffic of Aircraft. Part I, International Commercial Air Transport –
Controllers Must Go Beyond Basic ATC Vocabulary.” Airport Aeroplanes. Appendix 2, “Contents of an Operations Manual,”
Operations Volume 23 (September–October 1997). 5.15. Seventh edition – July 1998, incorporating Amendments
1–25.
FSF Editorial Staff. “Preparing for Last-minute Runway
Change, Boeing 757 Flight Crew Loses Situational Awareness, ICAO. Procedures for Air Navigation Services. Rules of the
Resulting in Collision with Terrain.” Accident Prevention Air and Air Traffic Services. Thirteenth edition – 1996,
Volume 54 (July–August 1997). incorporating Amendments 1–3.

FSF Editorial Staff. “During Nonprecision Approach at Night, ICAO. Procedures for Air Navigation Services. Aircraft
MD-83 Descends Below Minimum Descent Altitude and Operations. Volume I, Flight Procedures. Fourth edition –
Contacts Trees, Resulting in Engine Flame-out and Touchdown 1993. Reprinted May 2000, incorporating Amendments
Short of Runway.” Accident Prevention Volume 54 (April 1997). 1–10.

52 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000

 ICAO. International Standards, Recommended Practices and 121.419 “Pilots and flight engineers: Initial, transition, and
Procedures for Air Navigation Services, Annex 10 to the upgrade ground training,” 121.421 “Flight attendants: Initial
Convention of International Civil Aviation, Aeronautical and transition ground training,” 121.422 “Aircraft dispatchers:
Telecommunications. Volume II, Communication Procedures Initial and transition ground training.” January 1, 2000.
Including Those With PANS Status. Chapter 5, “Aeronautical
Mobile Service.” Fifth edition – July 1995, incorporating FAA. Advisory Circular 60-22, Aeronautical Decision Making.
Amendments 1–74. December 13, 1991.

ICAO. Manual of Radiotelephony. Second edition – 1990. FAA. Aeronautical Information Manual: Official Guide to
Basic Flight Information and ATC Procedures.
ICAO. Human Factors Training Manual. First edition – 1998,
incorporating Circular 216. Joint Aviation Authorities. Joint Aviation Requirements –
Operations 1. Commercial Air Transportation (Aeroplanes).
ICAO. Circular 241, Human Factors Digest No. 8, “Human 1.945 “Conversion training and checking,” 1.955 “Nomination
Factors in Air Traffic Control.” 1993. as commander,” 1.965 “Recurrent training and checking.”
March 1, 1998.
U.S. Federal Aviation Administration (FAA). Federal Aviation
Regulations. 121.406 “Reduction of CRM/DRM programmed U.K. Civil Aviation Authority. Radiotelephony Manual.
hours based on credit for previous CRM/DRM training,” January 2000.

Notice
The Flight Safety Foundation (FSF) Approach-and-landing Accident • Flight management system;
Reduction (ALAR) Task Force has produced this briefing note to • Automatic ground spoilers;
help prevent ALAs, including those involving controlled flight into
terrain. The briefing note is based on the task force’s data-driven • Autobrakes;
conclusions and recommendations, as well as data from the U.S. • Thrust reversers;
Commercial Aviation Safety Team (CAST) Joint Safety Analysis • Manufacturers’/operators’ standard operating procedures; and,
Team (JSAT) and the European Joint Aviation Authorities Safety
Strategy Initiative (JSSI). • Two-person flight crew.

The briefing note has been prepared primarily for operators and pilots This briefing note is one of 34 briefing notes that comprise a
of turbine-powered airplanes with underwing-mounted engines (but fundamental part of the FSF ALAR Tool Kit, which includes a variety
can be adapted for fuselage-mounted turbine engines, turboprop- of other safety products that have been developed to help prevent
powered aircraft and piston-powered aircraft) and with the following: ALAs.
• Glass flight deck (i.e., an electronic flight instrument system This information is not intended to supersede operators’ or
with a primary flight display and a navigation display); manufacturers’ policies, practices or requirements, and is not
• Integrated autopilot, flight director and autothrottle systems; intended to supersede government regulations.

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FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 53