top of page
Writer's pictureStrategic Results

Test Saturated

In this mishap accident that Jeff describes, what may seem like clear communication can actually be catastrophic due to a subtle language error.


“There was a fatal misunderstanding that brought down a Flying Tigers 747 back in 1989 and it involved the word ‘to.’ On this night the 747 is approaching Kuala Lumpur, after a short flight from Singapore. The crew were clear direct to the KL Beacon for runway three three approach. The controller said ‘Descend two four zero zero,’ which the crew interpreted as ‘to 400.’ The aircraft basically descended below the minimum altitude and crashed into a hillside at 600 feet before reaching the NDB (non-directional beacon) The minimum descent height over the NDB was 2400 feet. ‘Descend and maintain 2400 feet’ was the phraseology that probably would have saved that Flying Tigers crew.


“Controllers have a part to play in listening to feedback as a captain replied, ‘Okay 400,’ which went unchallenged by the controller. I don't want to oversimplify this mishap, as there were other circumstances involved, such as poor cockpit resource management and poor situational awareness. The first officer had earlier complained in the flight that he did not have the use of an approach play. The crew ignored the ground proximity warning system and there was weather at the time. But one of the key links in the accident chain was the miscommunication that occurred.


“There's a lesson in that, and this is something I used to do. When a controller talks and you're processing the information, does what the controller saying match the expectation of what you think you should be hearing? If it doesn't, never guess what the controller meant and have them repeat the transmission.


“Interestingly, studies have shown there's a multitude of possible problems in communications in flight. One of the phenomena that I've experienced is when a pilot becomes test saturated, their mental capacity is tapped out. This may help explain why test saturated pilots tune out, or sometimes fail to understand radio communications from air traffic control. As a survival mechanism, the pilots brain will filter all other stimuli not directly related to aircraft control.


For more information, check out the Flight Talk episode "Communicate or Crash" on our front page or your favorite podcast platform.



2 views0 comments

Comments


bottom of page