Monday, January 24, 2011

January 24th

Fresh Air Matters... with Capt. Yaw
How often do you hear what you thought you were going to hear?  Perhaps, more often, you have asked somebody to do something, and they have smilingly said ‘yes’, and then done something totally different!  When challenged, the person tells you proudly that they did what you asked them to do!  In fact, in such circumstances, they often get quite confused when you explain that they had not listened well. 

The reality is that we all hear a) what we want to hear and b) what we expected to hear, on a regular basis.  Newspapers love headlines that are ambiguous – so that you read what you want from that headline, so it really is a human trait.

In aviation we cannot afford to get these things wrong, and so we have a procedure called ‘read back’.  Read back means that you repeat back what you heard, which generally solves the problem… but not always.  A recent incident cost the American taxpayers a lot of money, and a great deal of inconvenience on New Year’s day…

As always in these matters, exact facts are still subject to investigations, but here is the general idea of what happened.

Piedmont Airlines Flight 4352 was flying from South Carolina to Ronald Reagan Washington National Airport, a regular route.  Along that route the pilot changes frequency on handing over from one Air Traffic Control unit to another, in the same way that it happens when you fly from Kotoka to Tamale, same procedure, same methods, throughout the world. 

At some point the tower would have stated which frequency to change to, for example ‘change frequency , one three zero decimal five’.  The pilot has to read back that frequency before changing to it, to make sure that they have heard correctly.  However, on Flight 4352 it appears that they not only mis-read-back the frequency, the ATC failed to pick up on it swiftly, in order to correct the crew, and then the pilot selected the mis-heard and mis-read-back frequency, resulting in loss of communications between air and ground, ground and air.

Imagine you tried to tune to an FM station and you tuned to the wrong station – you may not realise to start with, or you may simply get no contact, since the frequency may not be in use.

Well, that is what happened.  Unable to raise the airliner, and in accordance with the laid down procedures for that particular airspace, the authorities scrambled fighter jets from Andrews Air Force Base, worried that the aircraft may have been hijacked.  Furthermore the U.S. Capitol Police issued an order that US Capitol, Senate office and other buildings nearby were to be evacuated. 

About fifteen minutes later, communications were re-established – but not until after a lot of confusion, cost and inconvenience.  Fortunately, this was a national holiday, and the buildings were not too busy, but imagine on a busy day, with lots of people and traffic.  Accidents may have occurred, panic, fear and the disruption more costly – the knock on effects from well-trained individuals failing to hear clearly what each other said, and to failure to realise that they had it wrong after the ‘safety procedure’ of a read back!

How much more do we risk the challenge of mis-hearing and mis-understanding in our daily lives!

This was highlighted this week around the airfield and factory areas.  We have had a lot of bush fires nearby, and have taken precautions to prevent damage by burning breaks in key locations.  The tractor goes through the bush land, cuts a path and we burn an area under controlled conditions.  All well and good, if everybody listens – and understands, not only the words but also the meanings.

One thing that living and working in rural Africa has taught us, is that we should not assume, and that extra checks are necessary to ensure that safety is maintained.  In fact, maintaining safety in this part of the world is more costly and complicated than in many other parts of the world – due to the weather, infrastructure, language barriers and other factors.  So, when you set up your ‘burn team’ you have to cross check, ‘read back’, cross check again, and supervise.   People need to work in teams, language differences have to be addressed.  We have some team members who do not speak Twi, others who do not speak Ewe, some who speak neither, and many who work on the clearing and field work who’s English is not always as developed as we would like.  These are good workers, conscientious, devoted and reliable, but there are communication challenges.

So, when you ask somebody to start the back burning to the left of the hangar, and they repeat it ‘to the left of the hangar’ you know you are onto a good start.  But it is not the end of the matter.  In some cases ‘repeating the English’ is easy – but understanding it is more difficult.  In the particular case here, the member of staff, long serving, reliable and respected, got confused with their left and their right.  Had it not been for the procedure to check, cross-check and check again, the back burn would have become a major fire. 

I am certain that those with less experience of working in rural conditions with the diversity of personnel that we enjoy and benefit from here in Ghana, may not have watched to SEE if the words matched the actions.  There was no malice, no bad intentions here.  None at all, and when corrected, the individual was smiling and happy to be assisted - glad to have learned and more than glad to have been helped.

So many times what we learn and do in aviation has saved embarrassment, cost and inconvenience around our developments.  The constant motto of ‘Safety is NO Accident’ echoes and resounds around the place. 

How many times have I heard what I thought was said?  Too many! 
How many times have I assumed that others have understood what I have said?  Too many! 
How often should I check for understanding in others?  Always! 
How often should I check that I have understood?  Always!

If the Flight 4352 crew and associated ATC crew combination, with many millions of dollars of training, equipment and experience, following laid down procedures can get it wrong, how much more should we be conscious of the risks of misunderstanding in our day-to-day operations and mitigate against them!  You never know, it may make your operations not only safer, but more cost effective too!

Capt. Yaw is Chief Flying Instructor and Chief Engineer at WAASPS,  and lead Pilot with Medicine on the Move, Humanitarian Aviation Logistics ( e-mail

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