Incident Reports

On December 28, 2014, AirAsia Flight 8501, an Airbus A320, crashed into the Java Sea while en route from Surabaya, Indonesia, to Singapore. All 162 people on board perished. The accident was attributed to a combination of mechanical failure, miscommunication, and pilot error.

The flight encountered severe weather, with towering cumulonimbus clouds along the route. The crew requested a deviation to avoid the weather, but their request was delayed due to congestion in the ATC frequency. As a result, they entered turbulent air.

Compounding the situation was a malfunction in the aircraft’s rudder control system, which triggered repeated warning messages. The captain and first officer became overwhelmed, and their communication deteriorated. In their attempt to troubleshoot the issue, they inadvertently disengaged the autopilot, causing the aircraft to enter a steep climb and subsequent stall.

Investigators highlighted the crew’s lack of training in managing such emergencies and their failure to maintain situational awareness. The delayed response from ATC also contributed to the incident.

The crash prompted changes in ATC protocols, weather avoidance procedures, and pilot training programs to better prepare crews for handling similar situations.

AirAsia Flight 8501 (December 28, 2014)

AirAsia Flight 8501 crashed into the Java Sea after stalling during severe weather, killing all 162 people on board. Language barriers and communication lapses played a key role.

Language-Related Issues

1. Delayed ATC Response:
   The crew requested a deviation to avoid thunderstorms but faced delays due to congestion on the radio frequency. The communication went as follows:

   • First Officer: “Request deviation left, heading 340.”
   • ATC: (after a delay) “Standby.”

   The delayed clearance left the aircraft in turbulent air, increasing the crew’s stress.

2. Miscommunication About System Failure:
   When a rudder control warning appeared, the first officer attempted to explain the issue to the captain but used non-standard terminology:

   • First Officer: “Rudder fault, Captain. It’s stuck.”
   • Captain: “What stuck? Confirm.”

   The vague explanation led to confusion, causing the captain to disengage the autopilot inadvertently.

3. Language Under Stress:
   As the aircraft entered a stall, the crew’s communication became fragmented and less structured:

   • Captain: “Pull up, pull up!”
   • First Officer: “Up? Down? I don’t understand.”

   This lack of clarity worsened the loss of situational awareness.

On August 7, 2020, Air India Express Flight 1344, a Boeing 737-800, overran the runway at Kozhikode International Airport in India. The crash claimed the lives of 21 people, including both pilots, and injured many others. Poor weather conditions, combined with communication and decision-making challenges, were key factors in the accident.

The flight was repatriating Indian citizens stranded abroad during the COVID-19 pandemic and faced heavy rain upon arrival. The airport’s tabletop runway—situated on a plateau with steep drops on either side—posed additional challenges, especially in wet conditions.

During the approach, the pilots conducted two go-arounds after encountering unstable descent profiles. On the third attempt, the captain decided to land despite warnings about tailwind conditions exceeding safe limits. The aircraft touched down far beyond the normal touchdown zone, leaving insufficient runway length to stop.

The investigation revealed several communication issues. The crew did not fully discuss the risks of landing in tailwind conditions, and their coordination during the critical moments of the approach was lacking. Additionally, ATC did not provide timely updates on changing weather conditions, which could have influenced the decision to divert to another airport.

The crash highlighted the importance of adhering to standard operating procedures (SOPs), particularly in adverse weather conditions. It also underscored the need for clear and assertive communication within the cockpit.

Air India Express Flight 1344 (August 7, 2020)

Air India Express Flight 1344 overshot the runway while landing at Kozhikode International Airport in heavy rain. The accident killed 21 people, including both pilots, and highlighted multiple communication issues.

Language-Related Issues

1. Misinterpretation of Weather Reports:
   ATC provided weather updates in English, but the information was not fully discussed or analyzed by the cockpit crew. For example:

   • ATC: “Tailwind 15 knots, runway wet.”
   • Captain: “We can manage.”

   The captain’s response showed overconfidence, but the first officer did not strongly object or suggest a go-around, even though landing in such conditions exceeded safety thresholds.

2. Failure to Communicate Risks:
   The captain’s decision to proceed with the landing was not adequately questioned by the first officer. CRM training emphasizes assertiveness in questioning decisions, yet:

   • First Officer: “Should we go around, Captain?”
   • Captain: “It’s under control.”

   The vague language and lack of further discussion about the risk of tailwind conditions contributed to the accident.

3. Inconsistent Phraseology During Descent:
   The crew did not use standard callouts for altitude and speed checks, which could have helped identify the unstable approach. For example, instead of saying, “Stabilized, gear down,” the captain casually remarked, “We’re good to land.”

On October 31, 2000, Singapore Airlines Flight 006, a Boeing 747-400, crashed while attempting to take off from Taiwan’s Taoyuan International Airport. The crash resulted in 83 fatalities and 71 injuries among the 179 passengers and crew. The accident occurred during adverse weather caused by a typhoon, and miscommunication between the crew and ground control played a significant role.

The flight was scheduled to depart for Los Angeles but encountered visibility issues due to heavy rain and strong winds. As the crew prepared for takeoff, they mistakenly aligned the aircraft with a closed runway (Runway 05R) instead of the designated active runway (05L). The closed runway was under construction and littered with heavy equipment.

The confusion arose partly from poor signage and lighting at the airport. However, a critical factor was the breakdown in communication between the cockpit and ATC. The tower had cleared the flight for takeoff on 05L, but the crew misinterpreted the instructions, and their deviation went unnoticed by ATC.

As the aircraft accelerated, it collided with construction equipment on the closed runway, resulting in a catastrophic fire and structural damage. Many passengers were trapped in the fuselage, and the chaotic evacuation was hindered by the severity of the fire and the destruction of exit routes.

Investigators found that the captain’s overconfidence and the lack of cross-checking by the first officer and flight engineer contributed to the error. Additionally, ATC did not monitor the aircraft’s movements closely after issuing the takeoff clearance, missing an opportunity to intervene.

The accident led to significant changes in airport safety protocols, including improved signage, lighting, and procedures for managing runway closures. Singapore Airlines also enhanced its training programs to address situational awareness and CRM.

Singapore Airlines Flight 006 (October 31, 2000)

Singapore Airlines Flight 006 mistakenly attempted to take off from a closed runway at Taiwan’s Taoyuan International Airport during typhoon conditions. The collision with construction equipment resulted in 83 fatalities.

Language-Related Issues

1. Misinterpretation of ATC Clearance:
   ATC had cleared the aircraft for takeoff on Runway 05L, but the crew mistakenly aligned the aircraft with 05R, which was closed. The clearance phraseology from ATC, although technically correct, was not reinforced with explicit warnings about the closure of 05R:

   • ATC: “Cleared for takeoff, Runway 05L.”
   • Captain: (to the first officer) “Takeoff on 05R?”

   The question was not addressed explicitly by the crew, and they proceeded with their incorrect assumption.

2. Lack of Challenge by Crew Members:
   The hierarchical nature of cockpit communication led to a lack of assertiveness by the first officer and flight engineer, who failed to correct the captain’s mistaken alignment with the wrong runway. For example:

   • First Officer: “Captain, is it not 05L?”
   • Captain: “It’s fine; we’re good.”

   The ambiguity in the first officer’s challenge and the captain’s dismissive response reflected poor cockpit resource management (CRM).

3. ATC Monitoring Deficiency:
   ATC did not verify the aircraft’s position visually or electronically after issuing takeoff clearance. A phrase such as, “Confirm Runway 05L position,” might have prompted the crew to recheck their alignment.

4. Non-Standard Cockpit Communications:
   The cockpit crew used informal and vague language among themselves. Clear callouts like “Runway alignment checked” were absent, which could have caught the error before acceleration began.

Korean Air Flight 801, a Boeing 747-300, was en route from Seoul, South Korea, to Guam on August 6, 1997. Tragically, the aircraft crashed while on its approach to Guam International Airport, killing 228 of the 254 people on board. The accident became a pivotal case study in aviation, emphasizing the critical role of clear communication, cultural dynamics, and adherence to procedural protocols.

The crash occurred as the aircraft attempted to land in poor weather conditions, compounded by a lack of visibility due to heavy rain. The flight crew relied heavily on the airport’s Instrument Landing System (ILS), but they were unaware that the glideslope—a key component of the system used for guiding planes during landing—was out of service for maintenance. Notices about the outage were issued via NOTAMs (Notices to Airmen), but they were not effectively communicated to or acknowledged by the crew.

The cockpit voice recorder revealed significant communication breakdowns. A key contributing factor was the hierarchical structure within the cockpit, influenced by cultural norms. The captain, who held a higher rank, made decisions without adequately considering input from the first officer and flight engineer. This dynamic created an environment where junior crew members were reluctant to challenge the captain’s decisions, even when they had doubts about the approach.

As the aircraft descended, the captain believed he was correctly following the ILS. However, due to the inactive glideslope, the crew misjudged their altitude and failed to cross-check their position using alternative navigation aids, such as the Distance Measuring Equipment (DME). Communication between the flight crew and air traffic control (ATC) was also insufficient. The crew did not confirm the unavailability of the glideslope with ATC and proceeded with the assumption that it was functional.

The final minutes of the flight were marked by confusion and disorientation. The crew's situational awareness deteriorated as they descended below the minimum safe altitude. Despite audible terrain warnings from the aircraft’s Ground Proximity Warning System (GPWS), the captain continued the descent, believing the runway was in sight. Ultimately, the plane struck a hill approximately three miles short of the runway, leading to the catastrophic crash.

Investigators highlighted several contributing factors, including inadequate crew training on alternative approaches, poor cockpit resource management (CRM), and ineffective communication between ATC and the flight crew. The crash underscored the importance of addressing cultural influences on cockpit dynamics, ensuring redundancy in navigation systems, and improving the clarity and dissemination of NOTAMs.

In the aftermath, Korean Air revamped its training programs, emphasizing CRM and promoting open communication among crew members. The accident also led to global improvements in NOTAM systems and reinforced the need for pilots to confirm critical information with ATC.

Korean Air Flight 801 (August 6, 1997)

Korean Air Flight 801 crashed while attempting to land at Guam International Airport in poor weather, killing 228 of the 254 people on board. Language issues, combined with cultural dynamics and procedural breakdowns, were significant contributors to this tragedy.

Language-Related Issues

1. Confusion Over Instrument Status:
   The glideslope, a component of the Instrument Landing System (ILS), was out of service for maintenance. Although this information was available through a NOTAM (Notice to Airmen), it was either overlooked or misunderstood by the flight crew. Miscommunication between air traffic control (ATC) and the crew exacerbated the issue:

   • ATC had not explicitly informed the crew about the inoperative glideslope during their approach briefing.
   • When the captain asked, “Glideslope, OK?” the flight engineer responded vaguely with, “Yes, sir,” even though the glideslope was unavailable. This indicated a lack of clear understanding or willingness to challenge authority.

2. Cultural and Hierarchical Communication Barriers:
   Korean Air’s cockpit culture at the time was influenced by strict hierarchical dynamics, where junior crew members hesitated to challenge the captain. This was evident in exchanges like:

   • First Officer: “Captain, the glideslope seems unreliable.”
   • Captain: “Let me handle this.”

   Despite apparent doubts about the glideslope, the first officer did not insist on further cross-checking the navigation aids. This deference to authority hindered effective decision-making.

3. Ambiguity in ATC Communication:
   The language used by Guam ATC lacked the specificity required in critical situations. For instance:

   • ATC instructed the crew to “descend to 2,600 feet,” but did not emphasize that the Minimum Descent Altitude (MDA) was higher due to terrain. The lack of precise phraseology in standard English left room for misinterpretation.

4. Failure to Use Readback for Verification:
   The flight crew’s readback of ATC instructions was incomplete or absent in key moments. Proper readback and confirmation could have clarified discrepancies in altitude or approach instructions.