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confirm that all was well.
The KLM pilot’s statement of “we are now at takeoff” is a case of code switching. In
Dutch, the verb ‘flying’ is expressed as ‘at fly’, so that “we are flying” translates as
“we are at fly”. The KLM pilot meant that he was taking off; the tower controller,
who had not issued a takeoff clearance, interpreted the sentence as, “we are now in
the takeoff position”. The controller also used Spanish language constructions in
some of his transmissions.
Expectation error
53
The KLM pilots were keen to depart. The pilots and the controllers ambiguously used
the words ‘takeoff’ and ‘clearance’ in the same sentences—the pilot for the clearance
request and the controller for the enroute clearance. The controller meant the
instruction to be the route clearance after a takeoff clearance which was yet to
come—this is standard procedure. The pilots, having completed their checks and lined
up ready to depart, had wanted both clearances and that is how the KLM captain
understood “you are cleared”. (It is unusual for the route clearance to be given when
the aircraft is lined up. The controller had offered it earlier but the crew were too
busy to accept it.)
The KLM captain had been a simulator instructor for more than ten years. In
simulation, in order to get a flight underway and not waste training time, takeoff and
route clearances are often issued together by the instructor; practice takeoffs often
occur without any clearance whatsoever. Under pressure, the captain appears to have
reverted to what he had done most often when sitting at the head of a runway.
Regression occurs when a person reverts to first learned responses.
Simultaneous transmission
Over-transmitting blocked important instructions. With none of the parties in visual
contact, the controller and the two aircraft were totally dependent upon radio
communications for their situational awareness.
Standard phraseology
Neither the controller nor pilots used standard phraseologies in their communications
and this contributed to misunderstandings. They were, however, those in normal
daily use in civil aviation at the time.
Sources: Cushing, 1994; Gero, 1996; Hawkins, 1993; Job, 1994; Stewart, 1986;
Weick, 1990.
54
10. References
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incident near Nairobi Airport, Kenya, on 3 September 1974. Aircraft
Accident Report 14/75. Department of Trade, HMSO, London.
Airservices Australia (1997a) Safety File: visual separation. The Airservices
Bulletin, Vol.1, No.3, pp 14-15
Airservices Australia (1997b) Australian academia needs to play a greater role in air
safety challenges: Lee. The Airservices Bulletin, Vol.1, No.3, pp 30-31.
.
Airservices Australia (1995) Manual of Air Traffic Services. Amendment List 22,
16 July 1998. Canberra.
Barrett, R. (1982) The Human Equation in Operating a Nuclear-Power Plant.
In Sills, D., Wolf, C. and Shelanski, V. (eds.) Accident at Three Mile Island:
The Human Dimension, pp 161-171. Westview Press, Boulder, Colorado.
Bartsch, R. (1996) Aviation Law in Australia. LBC Information Services, Sydney.
Besco, R. (1997) The awkward alliance: the controller/pilot team. The Journal of Air
Traffic Control. December, pp 24-31.
Billings, C. and Cheaney, E. (1981) The information transfer problem: summary and
comments. Information Transfer Problems in the Aviation System. NASA
Technical Paper 1875. NASA, California.
Borins, S. (1983) The Language of the Skies: The Bilingual Air Traffic Control
Conflict in Canada. McGill-Queen’s University Press, Montreal.
Boughen, D. (1994) Air traffic controller liability—the Australian perspective.
Aviation Law Association of Australia and New Zealand Annual Conference.
Bowers, C., Blickensderfer, E. and Morgan, Jr., B. (1998) ATC specialist team
co-ordination. In Smolensky, M. and Stein, E. (eds.) Human Factors in Air
Traffic Control, pp 215-236. Academic Press, San Diego.
Brauner, C. (1994) Communicating in Aviation. Swiss Reinsurance Company,
Zurich.
Brenlove, M. (1993) Vectors to Spare: The Life of an Air Traffic Controller. Iowa
State University, Ames.
Brookes, A. (1996) Flights to Disaster. Ian Alan Publishing, Surrey, England.
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Bureau of Air Safety Investigation (1998a) Bureau of Air Safety Investigation
Summary Report (Public) 1993-96. BASI, Canberra.
Bureau of Air Safety Investigation (1998b) ‘Eight’ in international callsigns. Asia-
Pacific Air Safety, June, Issue 18, p 28.
Bureau of Air Safety Investigation (1997a) An Analysis of Incidents Involving
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