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received and correctly interpreted—and be aware of, and avoid, common types of
linguistic misunderstandings. Use of deliberate miscommunications should form a
part of ATC training, and instructors and team leaders need to assiduously police
ATC/pilot communications.
There has been a tendency over the past few years to understate or forget the role of
verbal communications in the provision of air traffic services due, I believe, to the
rapid advances in communications technology. The energy of air traffic controllers
and Airservices Australia has been focused on implementing TAAATS, which brings
47
with it the ability to exchange digital data between pilots and controllers using the
global satellite system. This will be a major improvement for flights operating in
oceanic airspace and some parts of continental Australia which still rely on HF voice
communications. However, it will take many years for the world’s aircraft fleet to be
upgraded and many aircraft will never adopt the necessary technology. For the
majority of controllers, working in high-density traffic areas, the immediacy and
flexibility of VHF voice communications will ensure that it remains the primary
means of communications with pilots.
48
8. Appendix 1 Case Study: Mount Isa, 1991
On March 1 1991, two Boeing 737 aircraft were operating opposite direction services
between Darwin and Brisbane on a route which passes over Mt Isa, outside of radar
coverage. Ansett’s VH-CZG (‘Charlie Zulu Golf’) was operating from Darwin to
Brisbane and Australian Airlines’ VH-TJD (‘Tango Juliet Delta’) was operating
Brisbane to Darwin. Once beyond radar coverage, pilots are required to give position
reports and their cruising level at certain nominated points along the route. These
reports, entered on a flight strip, furnish the data with which air traffic controllers
establish aircraft separation based upon altitude, distance and time standards. The
controller will pass an aircraft’s position report to the next responsible sector prior to
the aircraft crossing the sector boundary; this allows the receiving controller time to
analyse the evolving traffic situation.
CZG departed Darwin and climbed to flight level (FL) 330. Prior to reaching Tindal
the pilot requested, and was issued with, a clearance to climb to FL350. The
subsequent position report at Tindal indicated that the aircraft was cruising at that
level. The Darwin controller passed the Tindal position report to the Brisbane
controller as “flight level three five zero”. Brisbane Sector 5 was being operated by a
trainee and training officer, and both heard the level as “three nine zero”. The trainee
read back “three niner zero”. When the word ‘niner’ was received in Darwin, a
temporary loss of clarity occurred. The Darwin controller heard ‘five’.
Meanwhile, TJD had departed Brisbane and climbed to FL350. Passing Swords
Range, the pilot reported maintaining FL350 and estimating Mt Isa at 0020 UTC
(universal time). At Ubdog, CZG contacted Brisbane Sector 5 with its position
report, maintaining “flight level three five zero” and estimating Mt Isa at 0024 UTC.
The trainee, now with another training officer, did not detect the level discrepancy
and left the flight strip endorsement as FL390.
With CZG’s call at Ubdog, both aircraft were now on the same frequency and within
radio range of each other. At 0020 UTC, TJD reported overhead Mt Isa, maintaining
FL350 and estimating Ubdog at 0040 UTC. Shortly after this report the pilot of CZG
asked for confirmation of the cruising level of TJD. The pilot of TJD confirmed that
he was maintaining FL350, whereupon the pilot of CZG advised that he also was at
that level and was turning left. The two aircraft were about 20 miles apart and would
have been closing at 14 to 16 miles per minute. The training officer established the
error with CZG’s level and cleared the aircraft to descend to FL330. Each crew saw
the other aircraft as they passed at 0021.
Miscommunication Issues
The BASI investigation found that all personnel involved were properly trained,
licenced and medically fit. The trainee controller, while only in his first week of
training, had eight years’ experience as a flight service officer. There were other
aspects to this incident which are not referred to here.
Equipment
49
The temporary loss of communications quality during co-ordination was determined
by engineers to stem from two factors. Firstly, the trainee controller’s microphone
technique was such that, while the word ‘niner’ was spoken clearly enough for it to be
 
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