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recorded in Brisbane, it was not readable in Darwin. Secondly, audio levels were less
than optimum in Darwin and had been for some time. These factors were enough to
degrade the transmission of the word ‘niner’.
Noise
Noise was a problem in the Brisbane Area Approach Control Centre. The room is
small considering the number of people working there and the Sector 5 console is in
close proximity to the flight data console. The controllers, however, reported that
there were no distractions to their duties.
Phraseologies and pronunciation
The number nine was correctly spoken as ‘niner’ by all parties except the Brisbane
trainee who often pronounced ‘nine’. The one notable exception was when reading
back the level of CZG after the Tindal co-ordination with the Darwin controller. On
this occasion he said ‘niner’—and it was not heard.
The Brisbane controllers misheard the flight level stated in two position reports (one
by the Darwin controller and one by the pilot of CZG at Ubdog). All communications
involving the number five were pronounced as ‘five’ by air crew and controllers alike.
The number is required to be pronounced ‘fife’. The word ‘five’ sounds like ‘nine’
whereas ‘niner’ has two syllables and is easy to distinguish from ‘five’ or ‘fife’. The
controllers were not in the habit of listening for a two-syllable word.
Readback error
The Darwin recording of the readback was monitored repeatedly during the
investigation but nobody was able to identify the word recorded. The controller,
however, was satisfied that she had received a valid response to her co-ordination.
This may be an example of expectation error. The system has no protection against
readback/hearback errors made by any one controller.
Sources: BASI, 1993; Byron, 1997; Airservices Australia, 1995.
50
9. Appendix 2 Case Study: Tenerife, 1977
Because a bomb had exploded at Las Palmas Airport in the Canary Islands, all flights
had been diverted to Los Rodeos on the island of Tenerife. This airport had only one
runway and inadequate parking areas to handle the sudden increase in traffic; the
runway was 150 feet wide and a Boeing 747 requires 142 feet to turn 180 degrees.
This meant that aircraft were parked on taxiways, obstructing others, and throwing
into confusion the normal ATC ground handling procedures for taxiing, departing and
arriving aircraft. Pan Am Flight PA1736 (‘Clipper 1736’—a Boeing 747) landed just
before Las Palmas reopened but, because it had to park behind KLM Flight KL4805
(‘KLM4805’, also a B747) which had off-loaded its passengers to refuel, it endured a
delay of several hours, unable to move while the taxiway was obstructed.
Eventually, KLM4805 was cleared to taxi down the active runway to the end and
make a 180 degree turn:
KLM: “We require backtrack on Runway 12 for takeoff on Runway 30.”
ATC: “Taxi to the holding position for Runway 30...taxi into the runway...leave the
runway third to your left.”
KLM: “Roger, Sir. Entering the runway at this time...and we go off the runway again
for the beginning of Runway 30.”
ATC: “Correction...taxi straight ahead...ah...for the runway...make...ah...backtrack.”
KLM: “Roger, make a backtrack...KLM4805 is now on the runway.”
ATC: “Roger.”
KLM (half a minute later): “You want us to turn left at Taxiway 1?”
ATC: “Negative, negative...taxi straight ahead...ah...up to the end of the
runway...make backtrack.”
KLM: “OK, Sir.”
Pan Am was cleared to follow by entering the runway, taxi part the way down, then to
vacate the runway onto a parallel taxiway; this would allow KLM4805 to take-off.
Tenerife is 2073 feet above sea level and near the coast, which means clouds rather
than fog float onto the airport. As KLM4805 backtracked, cloud moved in, obscuring
the following B747 and blocking the controller’s view of both aircraft. Pan Am was
taxiing inside this cloud.
Pan Am: “Ah...we were instructed to contact you and also to taxi down the
runway...is that correct?”
ATC: “Affirmative...taxi onto the runway third...third to your left.”
Pan Am: “Third to the left...OK.”
ATC: “Third one to the left.”
The Spanish controllers English pronunciation was evidently unclear because the
Captain remarked to the First Officer, “I think he said first”, and the FO replied, “I’ll
ask him again”. The controller, unused to handling B747’s, had issued a taxiway exit
　
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