Of Hazardous Attitudes And Aligning The Swiss Cheese

We all want to sound cool on the radio, but shortcuts and word omissions can breed rampant confusion. 

Gemini Sparkle

Key Takeaways:

  • Casual and abbreviated radio communication in aviation is dangerous, increasing the risk of accidents by creating ambiguity and aligning "holes" in safety barriers, as illustrated by the Swiss cheese model.
  • Examples, including a near-collision at Washington National Airport (DCA), demonstrate how omitting critical words like "runway" or "taxiway," and failing to use proper phraseology, can lead to misinterpretations and hazardous situations.
  • To prevent errors, pilots must make clear, precise radio calls, use full and proper phraseology, meticulously read back clearances, explicitly confirm instructions (especially for runway crossings), and maintain strong situational awareness, recognizing that attention to detail is paramount.
See a mistake? Contact us.

A phrase I think I’ve heard all my life is, “Don’t sweat the small stuff.” I’ve heard it many times, but I have personally noticed how it doesn’t much apply to flying aeroplanes, or taxiing them on aerodromes. On the other hand, I heard “attention to detail” many times while in the U.S. Air Force, sometimes spoken quite loudly (“Forte” in musical terms).

Do you ever find yourself thinking, “All those details in radio calls—they couldn’t all matter, could they?” Maybe start throwing in a little slang or sometimes drop your call sign on a radio call, to “be quick”? I’ve thought it and done it, trying to be “cool.” Like the time I answered, to Sacramento Center’s query, “Roger that,” instead of “Affirmative.” They rightly and verbally spanked me like I was a red-headed stepchild, saying very clearly, very slowly, very sarcastically, “Roger. That.”

Hazardous Attitudes

Let’s see, which hazardous attitude was I exhibiting? Was it “Invulnerabilityism,” which I think is where a pilot believes “I can’t spell a word wrong, no way, no how!” Wait no, I think this is clearly a case of “Anti-Authority,” where a pilot thinks, “Don’t tell me how to spell, I mean, don’t tell me how to talk on the radio!” But let’s say, for purposes of the cockpit voice recorder, none of us good-natured pilot-folk reading this ever have the invulnerability or the anti-authority attitude. None of us ever get casual on the radio, and then dork things up and get into a goat-rope. We’re talking here about other pilots and controllers, of course, not me.

Let me repeat some radio calls I’ve heard recently.

Controller: “Skywest 9999, contact Minneapolis center, 120.25, good day.”

Skywest 9999: “Twenty and a quarter, 9999.” The thought flitted across my mind, “Whoa: cool-sounding, dude, I wish I could key the mic and talk like you.” Or:

Controller: “Cirrus 12345, contact departure, 125.0.”

Cirrus 12345: “Three four five, twenty-five nothing.”

Stunning. Of course not to any of us reading this, I’m just saying some people are enamored by radio calls like it.

We pilots have all heard a truckload of radio conversations where ATC starts by calling the pilot by their call sign, the pilot properly responds with their call sign—and then the conversation starts to sound like two guys trying to carry a couch up three flights of stairs in a house:

Controller: “Citation 987, can you shorten up your downwind to land ahead of a Southwest jet on six-mile final?

“Can do, Citation 987.”

“Thanks, 987.”

“You bet. We’re parking off Alpha by Jet Aviation, 987.”

“Okay, I’ll let you guys do a long landing rollout, save you some taxi time.”

“Thanks.”

“Turn your base now”

“Wilco. Oh, and tally on the Southwest guys.”

That’s ATC working with a Citation. It sounds eerily similar to the two guys with the couch:

“Wait, wait—stop, stop: lower your end—lower, lower! Now let’s both turn the couch to the left, and you lift. Up. Up!”

They’ve dispensed with the pesky call signs—it’s just two people talking here, right?  But sooner or later, someone, sometime, makes a mistake. They hear something incorrectly or repeat back something incorrectly, talking like this on the radio. It just doesn’t cause an accident or incident every single day.

But sometimes—oh my goodness sometimes—the slices of Swiss cheese shift, and the holes start to align. And an accident report is near.

When The Holes Align

Huh? Wait, what’s this Swiss cheese holes aligning stuff, over? James T. Reason, a former professor of psychology at the University of Manchester in the U.K., came up with the Swiss cheese theory. Basically, he said there are multiple “barriers” to accidents, and these barriers are represented by slices of Swiss cheese, which of course have “holes” in them. If the holes in all the barriers (slices of cheese) align, the hazard passes through the lined-up holes, and BAM! Accident. The patient in the hospital gets the wrong medicine or the doctor operates on the wrong patient, the pilot taxis or flies the aircraft somewhere dangerous or flat-out strange.

In the classic Swiss cheese model, the slices are arranged so most of the holes don’t align and are potential barriers to an accident. But eventually, the slices shift their alignment, permitting the accident.
Image: Ben Aveling/Wikimedia

It can quickly become very uncool to try to “sound cool” on the radio. Or if not sound cool, get a little too casual. Like the near-disaster on the ground at Washington’s National Airport (KDCA) the other day. See the diagram and narrative above.

The most important information in some of the these DCA calls is spoken over the radio very quickly and not-so-clearly enunciated, the words all tossed together into a nice word salad. The crucial word “runway” is not used in front of “four” or “one.” The word “taxiway” appears nowhere.

A pilot or controller might say, “Dude!—you’re being pretty picky here. You’re armchair quarterbacking this. Anyone listening to the radio calls could tell what everyone meant. The meaning of the calls is very clear.” Decoding it and using the recommended phraseology, the call meant: “Cross Runway Four at Taxiway Charlie, pull over to the right side of Taxiway Charlie, contact Washington Tower on the other side of Runway Four.” But it became one long string of syllables: “crossfouratcharliepullovertotherighttowerontheotherside.”

Why? To save time? Okay, but, “cross four” is a pretty important piece of information. How about at least saying, clearly, “Cross runway four?” Maybe that’s why the other controller, the tower guy, couldn’t catch the meaning of that quick “crossfouratCharlie” call. He didn’t catch that an aircraft was cleared to cross Runway 04. Surely the other controller, the tower controller, heard the call? He “heard without listening,” maybe, like when I “look but don’t see” sometimes, when clearing. The object is there but it doesn’t somehow “register” and I don’t “see” it.

Or maybe the Southwest jet wasn’t monitoring the tower frequency, didn’t hear the other aircraft cleared for takeoff on the runway they were cleared to cross? Or maybe they were monitoring, and “heard without listening” also?

Maybe if the ground controller slowed the rate of speech down ever so slightly, and used the words “cross runway four,” it would have prevented the radio call, a scream, really: “SOUTHWEST STOP!!! SOUTHWEST 2937 STOP!!!”

[su_box title=”What Happened At DCA?” box_color=”#e5eaef” title_color=”#273957″ radius=”6″]

On April 18, 2024, two airliners almost collided on Runway 01 at Washington National Airport (DCA). Before the near-collision, Southwest Airlines Flight 2937, a Boeing 737, was cleared to taxi to Runway 01 for takeoff. The taxi clearance used taxiway Charlie and included the phrase “cross four.” Shortly thereafter, JetBlue Flight 1554, an Embraer E190, was cleared for takeoff from Runway 04. Both aircraft crews were complying with their clearances.

Alert controllers in the DCA tower realized the developing situation and called for both aircraft to “STOP, STOP, STOP.” According to online sister publication AVweb, they did stop—about 300 feet apart.

It was the latest in a series of close calls at various airports around the country, all of which invariably involve air traffic control but not all of which are/were ATC’s fault. — J.B.

[/su_box]

Close To Home

So, I went flying the other day at my home ‘drome, Fargo, KFAR, a couple days after reading about the DCA runway incursion. I land, intending to full-stop and taxi back to parking in what are called the “north T-hangars.” Fargo tower asks me on my landing rollout where I’m parking, and I tell them.  Fargo Tower responded, as fast as a human can speak, “TurnrightonEchotaxiBravoCharlietoJetCenterremainthisfrequency.”

Of course, I could say, “Stand by,” but I know Fargo’s airport layout, anticipated his radio blast and knew what he meant. There was no one else on the frequency, the airport abandoned.

I repeated back, “Lancair 12345, right on Echo, left on Bravo, taxi Bravo, Charlie to the north T-hangars, remain this frequency.” Mentally patting myself on the back for my dazzling readback, I turned onto Taxiway Echo. Whoa—I suddenly realized—it is this easy to make a mistake that could lead to an accident.

See, the tower didn’t clear me to cross Runway 27, but I’d have to cross it to get to Taxiway Charlie. So I queried them: “Fargo Tower, Lancair 12345, understand cleared to cross Runway 27?” Tower came back and cleared me to cross Runway 27, which I read back. I suspect that since no one was on final or taking off from Runway 27, and the airport had no traffic, period, it became “easy” to kinda forget that I had to be cleared to cross Runway 27. And it sure was “easy” for me to read back a clearance that didn’t include crossing Runway 27.

Blocking The Holes

The solution, if there is one for me, is to make clear, precise radio calls, and not get lazy. I should read back any calls I’m not sure of, not guess (of course) and not assume. I use the words “taxiway” and, especially, “runway,” if I can fit them in. I don’t want to have engraved on my tombstone, sculpted to look like a slice of Swiss cheese, “I was right. It wasn’t my fault.”

[su_box title=”Defensive Flying 101: Ground Control Edition” box_color=”#e5eaef” title_color=”#273957″ radius=”6″]

Even at the sleepiest towered airport, getting from parking to the runway, and back, can require a handful of radio calls. They all are important and, at busier fields, they take on much greater significance. How can you be sure you didn’t miss anything, or that your heard the clearance correctly? Some tips:

Follow The Taxi Chart

Any electronic charting device in your cockpit should be GPS-aware and plot your position on the published airport diagram in real-time. You can annotate the chart for the clearance, you can pinch and zoom and you can declare you’re unfamiliar and request progressive taxi instructions. You can also ask for clarifications.

Don’t Cross a Runway Without a Clearance

During a lengthy taxi operation, it’s easy to forget whether you’ve been cleared to cross intervening runways. If you heard the phrase “hold short” in your clearance, you may not be. Before crossing the hold-short line, ask Ground Control if you’re cleared to cross. Trust, but verify.

Keep your Head On a swivel

Controllers make mistakes. They’re all human, like us. Just because you’re cleared to cross a runway doesn’t mean that someone else might not be using it.

[/su_box]

Ready to Sell Your Aircraft?

List your airplane on AircraftForSale.com and reach qualified buyers.

List Your Aircraft
AircraftForSale Logo | FLYING Logo
Pilot in aircraft
Sign-up for newsletters & special offers!

Get the latest stories & special offers delivered directly to your inbox.

SUBSCRIBE