Transcript Cookson, S. (2009). Zagreb and Tenerife: Airline accidents involving

Cookson, S. (2009). Zagreb and Tenerife: Airline accidents
involving linguistic factors. Australian Review of Applied
Linguistics, 32(3), 22.1-22.14.
Assignment #1: Dissuasion Facilitation
Tianfei Jiang
March 18, 2014
weather factors ( poor
visibility caused by fog)
mechanical failure
FLIGHT
ACCIDENTS
human error (violation of
instructions, mishearing or
misinterpreting the message from
the control tower, ect)
Figure 1.
A Central Role of Communication in Aviation Accidents
• Helmreich and Foushee (1993) note that 70% of aircraft
accidents involve human error.
• “Factors related to interpersonal communication have been
implicated in up to 80% of all aviation accidents in the past 20
years.” (Krifka, Martens, & Schwarz, 2003)
• Human error is a contributing factor in 60-80% of all air
carrier incidents and accidents, underlying causes of which are
ineffective communication and other communication-related
indicators (Federal Aviation Administration, 2004).
OUTLINE
• Article Summary
– Context
– the ‘Swiss cheese’ model & the Human Factors
Analysis and Classification System
– the mid-air collision above Zagreb in 1976
– the runway collision at Tenerife in 1977
– Conclusion
• Activity Discussions
Context
• the International Civil Aviation Organization
(ICAO) language proficiency program
• language proficiency requirements (LPRs)
• ‘The Case for LPRs’, Language Proficiency
Implementation Plan Workshop, 2008
“The Swiss cheese” model, developed by Reason (1990, pp. 199–212)
(the actions of pilots)
(The causal factors,
unsafe acts)
Figure 2.
the Human Factors Analysis and Classification System (HFACS),
developed by Wiegmann & Shappell (2003, pp. 45–50)
organizational
influences
unsafe supervision
preconditions for
unsafe acts
unsafe acts
Figure 3.
ACCIDENT 1: ZAGREB MIDAIR COLLISION 1976
Figure 4.
ACCIDENT 1: ZAGREB MIDAIR COLLISION 1976
10:14:04
JP550
Dobar dan ( Good-day ) Zagreb, Adria 550.
10:14:07
Zagreb Upp Adria 550, Zagreb dobar dan, go ahead.
10:14:10
JP550
325 crossing Zagreb at One Four.
10:14:14
Zagreb Upp
What is your present level ?
10:14:17
JP550
327
[ stammering ] .... e ... zadrizite se za na toj visini i javite prolazak
10:14:22 Zagreb Upp Zagreba ( .... e ... hold yourself at this height and report passing Zagreb
).
10:14:27 JP550
Kojo visini ( What height ? )
Na kojoj ste sada u penjanju jer ... e ... imate avion pred vama na ... 335
10:14:29 Zagreb Upp sa leva na desno. ( The height you are climbing through because ... you
have an aircraft in front of you at ... 335 from left to right ).
10:14:38 JP550
OK, ostajemo tocno 330. ( OK, we'll remain precisely at 330 - )
ACCIDENT 1: ZAGREB MIDAIR COLLISION 1976
organizational
influences
No flight progress strip
Upper sector controller assistant
was absent
unsafe supervision
Heavy workload & psychological stress
Delayed call by radio traffic
preconditions for
unsafe acts
Failed to follow vertical
movement of JP550
Inadequate separation between aircrafts
unsafe acts
Incorrect information provided in warning
The code switching
Figure 5.
ACCIDENT 2: TENERIFE RUNWAY COLLISION 1977
Figure 6.
ACCIDENT 2: TENERIFE RUNWAY COLLISION 1977
We are now at take
off.
17:05:41 ATC clearance had not received
17:05:53 The tower issued ATC clearance
KLM: “…We are now at take off.”
17:06:18 ATC: ‘O.K.’ (‘Stand by for take-off ... I will call you.’)
PAN AM: “we are still taxiing down the runway”
Figure 7.
Organizational structure & hierarchy
organizational
influences
Heavy fog & poor visibility
unsafe supervision
preconditions for
unsafe acts
Pan Am failed to exist
Linguistic interference from L1 &
Misinterpretation
Interfered radio massage
the effects of stress and fatigue
heavy Spanish accent of the controller
unsafe acts
Takeoff without permission
Failed to follow instructions from ATC
Figure 8.
Conclusion
• Highly complex events involving multiple
causal factors
• Linguistic factors & non-linguistic factors
• concerns of workload pressure, stress and
fatigue
• The interaction of native English speakers with
non-native speakers
Discussion Activity:
• This is an example of potential miscommunications which occur on
international flights. This is an Air China aircraft communicating with JFK
Ground. As you can tell, the potential for disaster is there.
http://www.youtube.com/watch?v=3AFv48IWhJw
 Questions:
1) Any comments on this video clip regarding miscommunication
and its causal factors?
2) What would you do when you feel hard to communicate with a
person who has awkward pronunciation? Do you have any
experience that you want to share with us?
3) The modern aviation system requires precision, accuracy,
efficacy, and predictability. (Howard, 2008)
If you were a language trainer , what would be your focus for
improving English language proficiency of pilots and air traffic
controllers? (for example, pronunciation, ect)
Discussion Activity:
Further Discussion Question:
Because of the significant differences in organizational
structure and culture, actor roles, task responsibilities and
personal expectations across pilot and air traffic controller
contexts, these socioenvironmental features challenge
communicative efficacy and system safety.
Considering the differences, what would you suggest to
facilitate effective communication in pilot–air traffic
controller interaction?
Implications
 To establish a mistaken-free standard English and errorresistant language environment (Tajima, 2004)
 To develop region-specific aviation ESL training
programs (Tajima, 2004)
 To conduct research to analyze idiosyncratic usage and
difficulties of local English in a given airspace
 To improve cross-cultural crew resource management
in the cockpit
REFERENCES
Federal Aviation Administration (2004). Crew resource management. Advisory Circular12051E. Washington, D.C.
Fowles, B. (2012, February 15). Debrief: Effective Pilot/Controller Communications. Retrieved
from https://www.tc.gc.ca/eng/civilaviation/publications/tp185-6207.htm
Helmreich, R.L., & Foushee, H.C. (1993). Why crew resource management? Empirical and
theoretical bases of human factors training in aviation. In E. Wiener, B. Kanki, & R.
Helmreich (Eds.), Cockpit resource management (pp. 3-45). San Diego, CA: Academic
Press.
Howard, J. W. (2008). ‘‘Tower, am I cleared to land?’’: Problematic communication in aviation
discourse. Human Communication Research. 34, 370-391.
Krifka, M., Martens, S., & Schwarz, F. (2003). Group interaction in the cockpit: some linguistic
factors. In R. Dietrich (Ed.), Communication in High Risk Environments, (pp.75-101).
Hamburg, Germany. Helmut Buske Verlag. Electronic version retrieved 3/12/07 from
http://amor.rz.hu-berlin.de/~h2816i3x/GihreLB-Krifka.pdf
Tajima, A. (2004). Fatal communication: English in aviation safety. World Englishes. 23 (3),
451-470.
Thank you!