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-Collected and Contributed by
A.Sanyal, DGM (ATC), Ahmedabad
Safety is no
Accident or Incident. Air Traffic Control with adherence to proper RT
discipline and proper procedures must be used to increase safety in the
skies. Use of standard phraseology prevents misunderstanding and
language difficulties particularly where English is not the pilot’s
mother tongue. To underline the need of proper RT discipline a few case
studies are elaborated for the benefit of working controllers. 
Incident -1
An ATC error
placed two aircraft in confliction with each other and the controller
was late in recognizing the developing situation. When the controller
became aware of the confliction he gave prompt heading and level
instructions to resolve it but in a manner of delivery which would be
used for routine communications. This resulted in the aircraft’s
manoeuvre rate being insufficient to provide adequate separation and an
AIRPROX occurred. Use of the phrase ‘Avoiding Action’ plus the provision
of ‘Traffic Information’ would have allowed the pilots to react
expeditiously and may have assisted in early visual contact being
established. Visual acquisition can help provide the crew with the means
to ensure that separation is sufficient to prevent a mid-air collision.
RT Causal Factors
When taking
action to resolve the situation, ATC did not use standard phraseology
that would immediately alert pilots to take immediate avoiding action.
Incident-2
A foreign ATC
unit cleared an aircraft for descent and a procedural approach using the
phrase ‘Descend two four zero zero, cleared for NDB approach’. It was
night, there was no radar available, and the flight was following a
procedural approach which commenced at the NDB at 2400 feet AMSL. The
pilot read back ‘OK, four zero zero’. Playback of the cockpit voice
recorder indicated that the pilots received a momentary GPWS warning and
the aircraft was destroyed, killing all on board. The impact points was
1 NM before the NDB and 8 NM from touchdown.
RT Causal Factors
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The pilot
misheard this as a clearance to descend ‘to’ 400 feet AMSL.
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The pilot’s
readback was non-standard.
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ATC did not
hear the incorrect readback and so failed to correct the error.
Incident-3
A foreign ATC
unit cleared an aircraft for descent using the phrase ‘Re-clear to three
thousand feet …. (pause)…. Expect an ILS approach report level at three
thousand feet’. There was no radar available and the pilot was flying in
intermittent IMC. The pilot read back ‘re-cleared to two thousand feet’
however this transmission commenced during the pause in the ATC
transmission and was missed by the controller. ATC did not query the
lack of a readback from the pilot. In addition, although not a RT
factor, ATC had also passed an incorrect QNH value, which placed the
aircraft 240 feet lower than was indicated on the aircraft altimeter.
The playback of the cockpit voice recorder indicated that the crew took
action to level at an indicated 2000 feet AMSL and almost
instantaneously the aircraft received a GPWS warning. This was 7 seconds
before impact as the aircraft passed through an actual altitude of 1800
feet AMSL. No action was taken on the GPWS warning and the aircraft
crashed into a mountainside at 1795 feet AMSL, only 100 feet below the
summit. All 144 persons on board were killed.
RT Causal Factors
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The pilot
misheard this as a clearance to descend to 2000 feet AMSL.
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A pause
during a continuous ATC transmission meant that the pilot’s incorrect
readback, which took place simultaneously, was not heard by ATC.
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ATC did not
query the lack of a readback from the pilot.
Incident-4
Aircraft ‘A’
was climbing on a Standard Instrument Departure (SID) within busy TMA
airspace, initially to 6000 feet AMSL. Aircraft ‘B’ was descending to
FL90 inbound to a TMA airfield and conflicted in plan with the departing
aircraft. To establish separation which would allow continuous climb and
descent for the subject aircraft, ATC cleared aircraft ‘A’ to ‘Head one
hundred degrees and climb Flight Level eight zero’. The pilot read back
‘One zero zero and Flight Level eight zero’. Subsequently aircraft ‘A’
was noted on radar by ATC climbing through FL80 and confirmation of his
level was sought by the controller. The pilot reported ‘We were cleared
climb one zero zero’. Aircraft ‘A’ was instructed to stop its climb
immediately at FL90 and aircraft ‘B’ was instructed to stop descent at
FL100. However due to the late call and the fact that radar updates lag
behind an aircraft’s true vertical position, aircraft ‘B’ was unable to
arrest its descent until FL93. Specific avoiding action was then given
and the aircraft passed with less than 1 NM horizontal and only 300 feet
vertical separation. The subsequent AIRPROX investigation also revealed
that the ATC controller’s RT discipline leading up to the incident was
generally poor with regular omissions of key phrases such as ‘to
Altitude xxxx’ when passing level instructions, e.g. he said ‘Descend
one thousand feet’ and ‘Climb six thousand feet’. Phrases such as these
could be open to misinterpretation, particularly where English may not
be the pilot’s first language. The pilot could interpret that ATC
require him to change his height or altitude by an amount rather than
fly to a cleared height or altitude.
RT Causal
Factors
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ATC used the
phrase ‘One hundred’ when passing a heading instruction. (‘One
hundred’ must only be used for Flight Level instructions.)
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Although the
pilot of aircraft ‘A’ read back the clearance in the correct format,
the second pilot on board erroneously set the autopilot’s Flight Level
/ Altitude selector to FL100, probably due to association of Flight
Level one hundred with the incorrect phraseology used by ATC to give
vectoring instructions.
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When taking
action to resolve the situation, ATC did not use standard phraseology
that would immediately alert pilots to a deteriorating situations.

Ways to improve
RT discipline
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Let us aim
for accurate, brief and clear transmissions.
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Let us LISTEN
carefully and just not HEAR what we expect to HEAR.
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Before
transmitting anything, let us learn to listen out first. Let us not
interrupt a dialogue or block another transmission.
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On first
contact with an ATC center, pilots must report their actual flight
level / altitude and cleared flight level / altitude if different.
Such a report provide ATC with a safety check, a level verification
and allow other airspace users to build up situational awareness.
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Let us pass
all instructions and clearances in clear and unambiguous manner using
standard phraseology.
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Let us try to
limit the number of instructions passed in any one transmission to a
maximum of three-ideally only two if practicable. Where there are
large amount of numbers to be passed let us speak clearly and slowly.
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The mandatory
items that pilots need to always read back are –
QTaxi
instructions
QLevel
instructions
QHeading
instructions
QSpeed
instructions
QAirways
or route clearances
QRunway-in-use
QClearances
to enter, land on, take-off on, backtrack, cross, or hold short of
an active runway.
QSSR
operating instructions
QAltimeter
settings
QVDF
information
QFrequency
changes
QTypes
of radar service
If we are in
doubt about any transmission receive, or do not receive an expected read
back, then we should immediately demand a read back from pilot for
checking.
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