SF 357 ERAU Daytona Beach Language Environments Analysis 1.Consider the list of language environments/situations in Appendix C (AI Handbook ). Consider the

SF 357 ERAU Daytona Beach Language Environments Analysis 1.Consider the list of language environments/situations in Appendix C (AI Handbook ). Consider the the LOT incident. What were the language environments that were relevant in one of these accidents /incidents? Be thorough. Identify the language environment(s) and tell why you think it is relevant. 2.Using the same accident/incident you used for the Accident Investigation Question part 1 analyze the accident using information from the accident that is in the ppts, or worksheets, using the Taxonomy. 1) Identify a language fact, or finding, or something that was presented in the Report (or articles we read, or ppts we used). 2) STATE it. 3) Tell what part of the Taxonomy is related to it. 4.) Tell why you think so, or why you think that was /is an important factor. Be thorough. Identify ALL the communication factors that we discussed, read, reviewed LOT. SAFETYREGULATION
I
n an incident described as typical of
the risks of not speaking the same
language, the crew of a Lot Polish
Airlines Boeing 737-500 struggled
to communicate with British air traffic
controllers after their electronic flight
displays went blank in instrument meteorological conditions (IMC) following departure from London Heathrow
Airport.
No one was injured and the airplane
was not damaged in the late morning
incident on June 4, 2007, which involved
a circuitous 27-minute return flight
to Heathrow, where the airplane was
landed safely, a report by the U.K. Air
Accidents Investigation Branch (AAIB)
said (Figure 1, p. 42). While the commander worked to resolve the problem,
the copilot flew the airplane by reference
to the standby instruments; the autopilots were not available, although the
autothrottle system was used.
At one point in the flight, as the
airplane was flown north instead of
north-northeast as directed, it came
into conflict with another aircraft,
whose crew was issued revised instructions to maintain separation, said the
report.
After a simple error wiped out much of their navigation
information, the Polish pilots of a 737 were unable to adequately
communicate their problem to British controllers.
Language
© Krzysztof Kaczala/Jetphotos.net
BY LINDA WERFELMAN
www.flightsafety.org | AeroSafetyWorld | August 2008
Barrier
| 41
SAFETYREGULATION
During the flight, there were “a
number of exchanges between [the pilots] and the controller in which it was
apparent that the commander, who was
making the radio calls, was not able to
understand some of the instructions,”
the report said.
At one point, the controller observed, “Lot 282 you appear to be
tracking to the west now,” and the commander responded, “Turning r-er right
on er west Lot er turning left on west.”
Later, after another controller issued
a clearance to land on Runway 09L,
the air traffic control (ATC) ground
supervisor became concerned that the
airplane’s flight path indicated that
the crew might be planning to land on
Runway 09R and asked that all traffic
be cleared from the runway; the airplane subsequently was landed on 09L
and taxied to a parking stand.
Handover from
London Control to
Heathrow Director
The commander’s workload was
heavy, and he was under stress in this
situation, contributing to his difficulties
understanding ATC; the crew was “not
able to communicate adequately the
nature and extent of their problem,” the
report said.
“Although much of the difficulty
in R/T [radiotelephony] communication may be explained by the added
workload and stress on the pilots,
this incident shows the problems
that can arise when there is a lack of
understanding between controllers
and flight crews. The introduction of
language proficiency standards should
ensure that all operational personnel
are qualified to a minimum and competent standard required for the task
being undertaken.”
Proficiency standards developed
by the International Civil Aviation
Organization (ICAO) call for pilots on
international routes, air traffic controllers and aeronautical station operators
to speak and understand English at an
“operational” level and give them until
March 2011 to achieve that goal (ASW,
11/07, p. 25). The initial deadline for
demonstrating operational proficiency
in English was March 2008, but, after
many ICAO member states had difficulty with that timetable, the ICAO
Assembly modified its requirements,
generally extending the deadline until
2011.
LOT282:
… we have a problem
with navigation …
‘Plain Language’ Proficiency
The report said that the commander, who had been flying the aircraft type
for Lot for 15 years, and the copilot,
who had been flying the type for six
years, “appeared confused by what had
occurred” with the airplane’s instruments. In events such as this one, “ATC
may not be able to rely upon pilots for
information about the aircraft’s status
and their ability to fly the aircraft accurately, with degraded instrumentation,”
the report said.
Because pilots of aircraft with
electronic flight instrument systems
do not usually fly their aircraft using
only basic instruments, when they are
suddenly faced with such a situation,
“pilots will need time to adapt their
instrument scan and a higher level of
crew coordination to enable them to
conduct a safe instrument approach,”
the report said.
Radar Track of Lot 737
London Control:
… do you wish to
return to Heathrow …
London Control:
… what heading do
you think you are
flying at the moment …
London Control:
… you seem to be
tracking to the west …
London Control:
… can you fly
a heading of
050 degrees …
Reading
London
Heathrow
Airport
Heathrow Director:
… start your turn now …
Source: U.K. Air Accidents Investigation Branch
Figure 1
42 |
London Control:
… turn right heading 265 …
London
Elizabeth Mathews, a specialist in applied linguistics and the leader of the
international group that developed
the ICAO requirements, said that the
Heathrow incident “highlights a number of important aspects of the ICAO
language proficiency requirements,”
including the need for aviation personnel to be fluent in not only “aviation
flight safety foundation | AeroSafetyWorld | August 2008
SAFETYREGULATION
operational–related” English but also
“plain language.”
“The need for plain language proficiency can arise quickly,” whenever an
unusual situation develops, she said.
This incident also is a prime example of why ICAO decided to develop
language proficiency requirements,
said Rick Valdes, a captain for United
Airlines who represented the International Federation of Air Line Pilots’
Associations on the ICAO group that
developed the requirements.
The pilots of the incident airplane
“had their hands full” flying the airplane in IMC with only standby instruments; communicating in English with
ATC was an added burden, Valdes said.
“All the holes in the Swiss cheese
were beginning to line up,” he said,
referring to psychologist James Reason’s
“unsafe acts model,” in which Reason
likens the accumulation of difficulties
preceding an incident or accident to
the line-up of holes in several slices of
Swiss cheese.
Valdes said that similar incidents,
in which pilots and controllers struggle
to communicate in non-routine situations, probably are occurring every day
somewhere in the world. This incident
drew more attention than most because
it occurred at Heathrow, with its heavy
volume of traffic, he said.
Mathews agreed that incidents like
this one — in which language is not
a cause of the incident but a factor in
its safe resolution — are likely to draw
more attention in the future, as the
public and the news media become
more aware of ICAO’s language proficiency standards.
She said that the incident also reinforces her belief that “you can’t hide inadequate English language proficiency.
“It doesn’t matter what test is used,
or how easy or how difficult it seems to
www.flightsafety.org | AeroSafetyWorld | August 2008
be to pass. At the end of the day, pilots
have to communicate in international
settings with controllers. Perhaps a
good command of phraseology will
suffice most of the time. But when
phraseology isn’t adequate to manage
the communicative needs of a given
situation, inadequate plain language
proficiency shouldn’t prevent otherwise
competent and professional pilots and
controllers from resolving the issue
safely.”
As a result of its internal investigation of the incident, the air traffic
service provider incorporated the
circumstances of the incident into its
training programs. The operator was
considering two actions: issuing a
reminder to its pilots to exercise extra
caution when manually entering into
the flight management system (FMS)
the longitude coordinates for locations
near the prime meridian, and revising
its pilot training with an emphasis on
the benefits of declaring an emergency
in situations like this one.
‘Simple Error’
The investigation relied primarily on
recorded data and reports from the two
pilots, and the report said that, in some
respects, information from the two
sources was inconsistent. The investigation found “no technical cause for the
loss of the navigational data,” the report
said.
Nevertheless, the report added, the
Heathrow incident occurred because
of a “fairly simple error” during
preflight preparations, as the pilots
performed a “fast realignment” of their
two inertial reference systems (IRSs);
the procedure required the entry of
their ground location. Using the FMS,
the copilot entered the wrong longitudinal coordinates for the airplane’s
ground location. The mistake involved
“the use of ‘E’ instead of ‘W,’” the
report said.
“The airports around London,
because of their proximity to the prime
meridian, can lead flight crews to make
… coordinate-entry errors of this
nature. … The operator’s route network
is such that there are few destinations
to the west of the prime meridian and
hence the majority of longitude coordinates that need to be entered would be
‘eastings.’ Because the geographic error
was less than 1 degree, the only alert
apparent to the crew would have been
a ‘VERIFY POSITION’ scratchpad
message.”
The copilot did not recall seeing
such a message, and the report said
that, if the message appeared, it might
have been “dismissed as an automated
response, without consideration of the
reason for the message.”
Because the IRSs — which provide
attitude, heading, acceleration, vertical
speed, groundspeed, track, present
position and wind data to the aircraft
systems and were the sole source of
attitude and heading information
on the incident airplane, except for
the standby instruments — were not
initialized with the correct ground
location information, they could not
function in the navigation mode, the
report said.
“Better cross-checking procedures,
either when initially entering data or
by conducting a check of the entered
route against that displayed on the map,
would have prevented the situation
from developing,” the report said. “This
incident demonstrates how reliant
pilots may become upon the FMS and
how essential it is to ensure that the system is provided with accurate data.” 
This article is based on U.K. AAIB incident
report EW/C2007/0602, published in the AAIB
Bulletin: 6/2008.
| 43
LANGUAGE AS A FACTOR IN AVIATION ACCIDENTS AND SERIOUS INCIDENTS
A HANDBOOK FOR ACCIDENT INVESTIGATORS
A Publication from
LANGUAGE AS A HUMAN FACTOR IN AVIATION RESOURCE CENTER
EMBRY-RIDDLE AERONAUTICAL UNIVERSITY
September 2019
LANGUAGE AS A FACTOR IN AVIATION ACCIDENTS AND SERIOUS INCIDENTS:
A HANDBOOK FOR ACCIDENT INVESTIGATORS
Date
2019
Authors
Pages
Appendices
27
A-E
Elizabeth Mathews, Embry-Riddle Aeronautical University
Anthony Brickhouse, Embry-Riddle Aeronautical University
Joan Carson, Ph.D. Applied Linguistics (Retired, Georgia State
University)
Captain Enrique “Rick” Valdes (retired United Airlines)
Descriptors (keywords): Language; Human Factors; ICAO Language Proficiency Requirements
Synopsis
In an increasingly multicultural and multilingual aviation industry, it is important that
accident investigators understand the complex role of language in maintaining safe
operations. This Handbook supports investigators to systematically identify and consider
possible language factors in aviation accidents and serious incidents.
References
ICAO Annexes 1, 6, 10, 11
ICAO Doc. 4444: PANS-ATM
ICAO Doc. 9835: Manual for the Implementation of ICAO Language Proficiency Requirements
Taxonomy
The Taxonomy of Communication Factors in Aviation is based on research by E. Mathews in
2012, revised collectively (2013 – 2018) by Angela Albritton, Michael Kay, and Elizabeth
Mathews. The final version, included in this Handbook, was based on a linguistic review of
the Aviation Safety Network Database conducted in 2018 by Joan Carson, E. Mathews, Steven
Singleton, Enrique “Rick” Valdes, and Dave Williams.
Usage Note
All accident information contained in this Handbook is based on official accident
investigation reports, published on the Flight Safety Foundation’s Aviation Safety Network
Database, unless otherwise noted. https://aviation-safety.net
Reviewers
See Appendix E—End Notes for complete list of reviewers
Contact
Elizabeth Mathews
elizabeth.mathews@erau.edu
Page 2
TABLE OF CONTENTS
Part One: Purpose of Handbook ………………………………………………………………………………………4
Part Two: The Role of Language in Maintaining Safe Operations ………………………………………….5
Part Three: ICAO Language Proficiency Requirements ……………………………………………………….6
ICAO LPRs synopsis
7
Part Four: How to Use This Manual ……………………………………………………………………………….. 10
A. Be Aware of possible language environments and situations
10
B. Employ Initial “Language Environment” Checklist
12
C. Use Communication Taxonomy
13
D. Use Linguistic Expertise When Necessary
15
APPENDIX A—Examples of How Language Impacts Flight Safety ……………………………………..16
APPENDIX B—ICAO Language Proficiency Rating Scale …………………………………………………. 18
APPENDIX C—Checklist of Language Environment Factors ………………………………………………20
APPENDIX D—Taxonomy of Communication Factors ……………………………………………………….22
APPENDIX E—List of Reviewers …………………………………………………………………………………….27
Page 3
PART ONE: PURPOSE OF HANDBOOK
The purpose of this handbook is to support accident investigators in the identification
and consideration of possible language factors in aviation accidents and serious incidents. This
handbook provides guidance, background information, and tools that will assist accident
investigators in conducting a systematic review of possible language factors.
Page 4
PART TWO: THE ROLE OF LANGUAGE IN MAINTAINING SAFE OPERATIONS
The International Society of Air Safety Investigators (ISASI) suggests that accident
investigation “findings” be defined as “all significant conditions and events, causal and noncausal, found in the investigation.” Relatedly, “Cause” has been defined as a “deficiency [that]
the correction, elimination, or avoidance of which would likely have prevented or mitigated the
mishap, damage, or significant injuries. A cause is an act, an omission, a condition or a
circumstance [that] either starts or sustains the mishap sequence1.”
Operational and safety experts universally acknowledge that communication plays a role
in maintaining safe operations. Yet, investigating and analyzing communications is problematic
in accident investigations because of the complexity of its various components which, in addition
to language, include cultural, technical, and procedural elements.
A communication failure can be the result of technical issues, such as static noise on the
radio, or an equipment failure. Communication problems can include procedural issues such as
readback / hearback errors or a failure to share information. Communications can be hindered by
cultural factors such as group versus individual orientation, issues of power distance, principles
of Crew Resource Management, or issues within an organization’s culture. There is generally
broad industry awareness and understanding of these categories of communication factors.
Accident investigators bring technical, operational, and human factors expertise to the analysis of
technical, procedural, and cultural factors in aviation accidents and serious incidents.
The most important component of communication, however, is language. The effect of
language on aviation safety includes not only issues addressed by the Language Proficiency
Requirements, adopted by the International Civil Aviation Organization (ICAO) in 2008,
including the use of standard ICAO phraseology and plain language proficiency for radio
communications, but also the role of language in other aspects of aviation safety 2.
Without adequate awareness and understanding of language as a human factor, accident
investigators and the industry in general can miss language factors as a “significant condition”
upon which other errors may have been allowed to develop. For example, in many anonymous
reporting systems, and in taxonomies of human factors, language factors are simply included
under “communication” or “language barrier.” Without a clear description of what these factors
are, it is simply not possible to provide the industry with recommendations/actionable items to
improve aviation safety.
Wood, Richard H., and Sweginnis, Robert W. Aircraft Accident Investigation, ed. 2. Endeavor Books. p.
8.
1
2 Appendix A—Examples
of Language as a Human Factor in Accidents.
Page 5
PART THREE: ICAO LANGUAGE PROFICIENCY REQUIREMENTS
In an initial effort to address language safety concerns, ICAO has defined oral language
proficiency requirements for pilots and air traffic controller radiotelephony communications3.
The ICAO language Standards and Recommended Practices are generally referred to as the
ICAO Language Proficiency Requirements (ILPRs) and are intended to ensure that pilots and
ATCs have minimum adequate levels of language proficiency. The LPRs require that pilots and
air traffic controllers demonstrate proficiency in English in order to operate along international
routes. In cases where these requirements are not met, safety may be compromised.
The ICAO LPRS are intended to apply to Pilot and ATC radiotelephony—i.e., spoken
language. They do not specify the language proficiency required for safe and effective flight
crew communications, for threat and error management communications, or crew resource
management. The ICAO LPRS do not address the language proficiency needed in ground school,
simulator or flight training instruction conducted in an English as a foreign or second language
environment. There are no ICAO language requirements that address the demands of written
language in aviation; there are no reading proficiency requirements, even though globally most
operational and safety manuals are published in English and used by operational personnel who
use English as a foreign language. Neither are there ICAO language requirements that address
the range of communication environments and situations faced by other key aviation personnel
(maintenance technicians, cabin crew, etc.), all of which may be implicated in accidents or
incidents.
Because language is a key factor in every phase of aviation, accident investigators need
to be aware of what ICAO has specified as the minimum adequate language proficiency so that
they can identify situations in which a lack of language proficiency—for whatever reason and to
whatever extent—may have played a role in the accident/incident.
ICAO LPRS are contained in the following ICAO Documents, (and are excerpted in
ICAO Document 9835—Manual on the Implementation of the ICAO Language Proficiency
Requirements, Appendix A):
Annex 1—Personnel Licensing (Chapter 1.2.9 and Appendix 1)
Annex 6—Operation of Aircraft (Part 1, chapter 3.1.8)
Annex 10—Aeronautical Telecommunications, Volume II (Chapter 5.1 and 5.2)
Annex 11—Air Traffic Services (Chapter 2.29)
Doc 4444—PANS-ATM (Chapter 12.2.1)
3 Appendix
B—The ICAO Rating Scale
Page 6
ICAO LPRS SYNOPSIS
From the point of view of the accident investigator, the more salient aspects of the ICAO
LPRs are as follows:
1. It is the responsibility of the Civil Aviation Authorities (CAAs) to provide oversight
of national English language testing.
•
CAAs may provide national testing, eithe…
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