1. Assignment #1: Dissuasion Facilitation Tianfei Jiang March 18, 2014
Cookson, S. (2009). Zagreb and Tenerife: Airline accidents involving linguistic factors.  Australian Review of Applied Linguistics, 32(3),
Assignment #1: Dissuasion Facilitation
Tianfei Jiang
March 18, 2014
Good afternoon everyone. Since March 8th, ongoing news are reporting the missing Malaysian airplane which carried 239 people bound for Beijing from Kuala Lumper. Until now, we still don’t know where the plane is and what happened. And there are still more questions than answers. We do crave explanations, especially for bad news. If you pick up an aviation magazine, you'll see that half the stories concern disasters, usually with the theme: Here is why bad things happened, and how to keep them from happening to you.. This article which I am going to present today is about aviation accidents, Zagreb accident in 1976 and Tenerife accident in 1977.

2. weather factors ( poor visibility caused by fog)
mechanical failure
weather factors ( poor visibility caused by fog)
FLIGHT ACCIDENTS
1) What causal factors do you think may cause a flight accident?
weather factors ( poor visibility caused by fog), mechanical failure (violations of instructions), and human error (mishearing or misinterpreting the message from the control tower).
I did not realize the importance of communication in a flight until I did some research, especially for international flight.
human error (violation of instructions, mishearing or misinterpreting the message from the control tower, ect)
Figure 1.

3. 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).
I did not realize the importance of communication in a flight until I did some research, especially for international flight. Based on this research, it is almost certain that communication has played a central role in a significant proportion of aviation accidents.
So today, I will present about miscommunication in two deadliest airline accidents in aviation history.

4. OUTLINE Article Summary Activity Discussions 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
At first, I will summarize this article, including its context, frameworks of the swiss chess model and the human factors analysis and classification system, the two accidents, and its conclusion. Then we will have activity discussions about pilot/air traffic controller communication.

5. Context
the International Civil Aviation Organization (ICAO) language proficiency program
language proficiency requirements (LPRs)
‘The Case for LPRs’, Language Proficiency Implementation Plan Workshop, 2008
English has been the language dominatedlly used in aviation. It was originally established as such by the ICAO IN Because the communication and its crucial role in aviation have been extensively studied, In order to improve the English language proficiency of pilots and controllers involved in international flights, ICAO has been implementing a language proficiency program. To justify the new language proficiency requirements, ICAO has cited a number of airline accidents that were at least partly caused by language factors at the Language Proficiency Implementation Plan Workshop in January The first two accidents cited by ICAO are examined in this paper, which are Zagreb and Tenerife.

6. “The Swiss cheese” model, developed by Reason (1990, pp. 199–212)
(the actions of pilots)
Airline accidents are not usually caused by a single factor, but rather by a combination of multiple factors. This accident causation model was developed by Reason in the factors are visualized as gaps, in the defensive layers of a system. One defensive layer represents the actions of pilots, then a gap in this layer represents an ‘unsafe act’. When gaps are continually changing position and size, and when all of them are aligned, as shown in this figure, it is possible for an accident trajectory to pass through all the defenses, like a skewer passing through the holes in slices of Swiss cheese. When this happens, an accident results.
(The causal factors, unsafe acts)
Figure 2.

7. the Human Factors Analysis and Classification System (HFACS), developed by Wiegmann & Shappell (2003, pp. 45–50)
organizational influences
unsafe supervision
preconditions for unsafe acts
Taking Reason’s model as a base, Wiegmann and Shappell in 2003 developed the Human Factors Analysis and Classification System (HFACS), a tool for analyzing and investigating accidents. HFACS focuses on defining the types of failure that may occur, and consists of the following four levels: unsafe acts, preconditions for unsafe acts, unsafe supervision, and organizational influences.
unsafe acts
Figure 3.

8. ACCIDENT 1: ZAGREB MIDAIR COLLISION 1976
On 10 September 1976 British Airways Flight 476 was flying from London Heathrow to Istanbul when it collided in mid-air with Inex-Adria Airways Flight 550, en route from Split to Cologne. The main cause is that air traffic controllers in the Zagreb Area Control Centre had not provided adequate separation between the aircraft, nor realized in time that a conflict was inevitable. Now let’s see what was happening before the fatal moment, a short exchange between the Zagreb upper sector controller and Flight 550 when the aircraft climbed towards its intended cruise altitude.
Figure 4.

9. 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
325 crossing Zagreb at One Four.
10:14:14
Zagreb Upp
What is your present level ?
10:14:17
JP550
327
10:14:22
Zagreb Upp
[ stammering ] .... e ... zadrizite se za na toj visini i javite prolazak Zagreba ( .... e ... hold yourself at this height and report passing Zagreb ).
10:14:27
JP550
Kojo visini ( What height ? )
10:14:29
Zagreb Upp
Na kojoj ste sada u penjanju jer ... e ... imate avion pred vama na sa leva na desno. ( The height you are climbing through because ... you have an aircraft in front of you at from left to right ).
10:14:38
JP550
OK, ostajemo tocno 330. ( OK, we'll remain precisely at )
With the exception of greetings, the dialogue between controller and flight crew had been entirely in English when – at 10:14:22 – the controller suddenly switched to Serbocroatian (a South Slavic language) and told Flight 550 to stop climbing, and instructed them to hold their current altitude because another aircraft was approaching at flight level 335 (= 33,500 feet). Here, the controller gave the incorrect flight level for the British Airways flight, because only ten minutes previously he had spoken with the British Airways crew and confirmed they were at flight level 330 actually. Moments later the two aircraft collided.

10. ACCIDENT 1: ZAGREB MIDAIR COLLISION 1976
No flight progress strip
organizational influences
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
Among the factors of preconditions for unsafe acts, the workload and stress are highlighted. High workload can cause recently acquired information to be forgotten or not remembered correctly. Consequently, incorrect information in warning was provided, which leads to the unsafe acts that the controller did not provide adequate separation between aircrafts.
Further the deadliest factor in this accident is the code switch to the controller’ L1. Under the workload pressure and time pressure, he may be incapable of accurately communicating in English, his L2. Meanwhile, the code switch prevented the pilots of British Airways Flight 476 from monitoring this critical part of the dialogue because they could not understand Serbocroatian.
The code switching
Figure 5.

11. ACCIDENT 2: TENERIFE RUNWAY COLLISION 1977
Let’s see the worst accident in aviation history. On 27 March 1977, KLM Flight 4805, flying from Amsterdam, and Pan Am Flight 1736, flying from Los Angeles. Due to a bomb attach in the airport on the Canary island, the aircraft were diverted to the airport on the island of Tenerife. After the airport on Canary island reopened, the Pan Am airline was following the KLM airline to depart.
Figure 6.

12. ACCIDENT 2: TENERIFE RUNWAY COLLISION 1977
We are now at take off.
Following the tower’s instruction, KLM taxied to the end of the main runway, turn around, and then began its takeoff. At the same time, the PanAm crew was instructed to taxi along the same main runway until they reached the exit 3 then to head further to the takeoff point. Because of the heavy fog that day, they missed the exist 3, so they decided to go on till exist 4.
When the ATC claimed clearance, the KLM first officer misunderstood it as a permission to takeoff, then he said, “we are now at takeoff”, which means ‘in the process of taking off” because of the linguistic interference from his L1 Dutch,’
On the controller’s side, the controller interpreted the first officer’s final sentence as meaning ‘We are now at take-off position’. So the controller said, “OK. Stand by for take off, I will call you.” However, unfortunately, the almost simultaneous radio transition from the controller and PanAm crew caused interference, so the KLM flight crew could not hear the messages clearly after OK.
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.

13. Organizational structure & hierarchy
organizational influences
Heavy fog & poor visibility
Pan Am failed to exist
unsafe supervision
Linguistic interference from L1 & Misinterpretation
Interfered radio massage
preconditions for unsafe acts
the effects of stress and fatigue
heavy Spanish accent of the controller
unsafe acts
Takeoff without permission
Multiple factors were combined to cause this accident. Regarding linguistic factors, interference from the first language and misinterpretation of phraseology are highlighted in preconditions for unsafe acts. Also, the organizational hierarchy is a factor here, since nobody dare to challenge the authority of the captain of KLM flight when he made the decision to take off.
Failed to follow instructions from ATC
Figure 8.

14. 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
1. airline accidents are often highly complex events involving multiple causal factors, not single causes.
2. both of the disasters involved significant linguistic factors – such as code switching, numerical slips, pronunciation problems and possible L1 interference – it should not be forgotten that they also involved many non-linguistic factors, technique issues, workload and stress, decision-making in the cockpit, ect.
3. workload pressure, stress and fatigue played crucial roles in both accidents. Therefore, pilots and controllers should be made aware of how these factors can hinder effective communication.
4. there would be value in language awareness training for native speakers that taught strategies for dealing with non-native speakers whose pronunciation is heavily influenced by their L1.

15. 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.
Questions:
Any comments on this video clip regarding miscommunication and its causal factors?
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?
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)

16. 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?

17. Implications
To establish a mistaken-free standard English and error-resistant 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
Good communication is as important as technical proficiency for the safety of flight. How to establish a mistaken-free standard English is always a crucial consideration. We should sincerely and rigorously strive to create an error-resistant and mistaken-free language environment. In this regard, linguistic and language educators can develop region-specific aviation ESL training programs. They can conduct research to analyze idiosyncratic usage and difficulties of local English in a given airspace, and these findings can be a great safety-enhancing resource for pilots and controllers. Researchers of cross-cultural communication may provide meaningful suggestions for the improvement of cross-cultural crew resource management in the cockpit. These research and efforts will greatly benefit the whole world by saving lives.

18. REFERENCES
Federal Aviation Administration (2004). Crew resource management. Advisory Circular120-51E. Washington, D.C.
Fowles, B. (2012, February 15). Debrief: Effective Pilot/Controller Communications. Retrieved from
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,
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 ). Hamburg, Germany. Helmut Buske Verlag. Electronic version retrieved 3/12/07 from
Tajima, A. (2004). Fatal communication: English in aviation safety. World Englishes. 23 (3),
I really wish that even if they cannot immediately figure out what went wrong at least they can find the plane so the families of those involved can start the healing process

19. Thank you!