13 PROBLEMS AND FEATURES OF INTERACTION BETWEEN CREW MEMBERS AND AIR TRAFFIC CONTROLLERS

Lecture

In this chapter we will attempt to describe the typical errors made in the process
of interaction between crew members and air traffic controllers. In the course of studying the errors arising in the interaction between air traffic controllers and pilots, A.I. Onufrash (1981, b) identified ten typical kinds of errors and determined the frequency of their occurrence. The most
frequent errors are violations of radio-communication procedures (26%) and contradictory flight information (22%). These are followed by: incorrect commands (10%); violations of
interaction between controllers of adjacent zones (8%); absence of radio communication (8%); absence of radar control over aircraft (6%); the crew's failure to make contact when
the radio equipment is serviceable (6%); failure to report an in-flight occurrence (6%); non-execution of controller commands (4%); unclear controller commands (4%).
The author (Onufrash A.I., 1981, b) also identified the main causes of violations of interaction between controllers and pilots.
1. Violations of the controller's technology for working with crews: lack of discipline, violation of instructions and manuals, transmission of contradictory flight information.
2. The controller's incomplete familiarity with the air situation (both in his own zone and in adjacent ones), which often leads to dangerous aircraft convergences.
3. Inattentiveness: reduced attention span, insufficient ability to distribute and concentrate attention.
4. Poor professional training.
5. Violations of the work-and-rest regime, resulting in fatigue and emotional strain.
Naturally, all the causes listed above will contribute to poor teamwork within a controller shift, and the causes of the latter are by no means limited to the list given. The causes of poor teamwork include the following.
1. Communication barriers in the form of excessive, non-standard information transmitted by air traffic controllers to pilots, or in the form of a double interpretation of phrases
by two air traffic controllers.
2. Contradiction between the information issued by the aircraft's onboard systems and the information coming from air traffic controllers.

3. Negative character traits of air traffic controllers or insufficiently developed
professionally important qualities.
4. The presence of conflicts within the air traffic control service.
5. Improper performance of duties by the management staff of the traffic
service (flight directors, deputy airport heads).
6. Incompatibility of members of a controller shift (most often due to rivalry that has developed between them).
Excessive, non-standard
information, which may originate from either the pilot or the air traffic controller, can act as a communication barrier. The aviation
occurrence at Berlin airport on 12 December 1986 involving a Tu-134 aircraft occurred precisely as a result of non-standard information transmitted over the air by the controller. The approach
to landing was being carried out via the ILS glide-path system in automatic mode onto runway
"25 Left" in difficult meteorological conditions. At a distance of 11 km from the runway the crew received non-standard information from air traffic controllers about the runway "25 Right" lights being switched on for a check. This information was
mistakenly perceived as requiring an approach to runway "25 Right". Being 500 m to the left
of the landing course of runway "25 Right", the crew switched to non-operating radio beacons, disengaged the autopilot, put the aircraft into a steep descent and made a turn onto runway "25 Right". At a distance of 6 km from the threshold of runway "25 Left" the crew received a command from the controller to turn left. Being 450
m to the right of the centerline of runway "25 Left" the crew again did not go around, reconfigured the ILS glide-path system to runway "25 Left" and
continued the descent with a left turn. At a height of 150-110 m, in violation of the flight operations manual, they reduced engine power to idle and engaged the autopilot. In
this situation the crew did not monitor altitude and did not react to the GPWS signals at
the decision height. The aircraft, at a speed of 263 km/h and with a vertical descent rate of 10 m/s, struck trees (at a distance of 3 km from the threshold of
runway "25 Left", 72 m from its centerline). This disaster clearly demonstrates that the requirement to confirm not only receipt of information but also how exactly
that information was understood is not without foundation.
A second example of the role of excessive information in interaction between an air traffic controller and a pilot is the incident that occurred on 11 January 2001 with a Boeing-737-
400 aircraft, whose crew made a double excursion off the runway. The crew of the airline "Aeroflot-RAL", on approach to Sheremetyevo airport, received the following weather report:
the runway was wet, with patches of wet snow, the taxiways were snow-covered,

slippery, the cloud base was 240 m, visibility 2,300 m, snow showers, the friction
coefficient equal to 0.37. The crew was prepared to land under Category III minima in autoland mode. As the aircraft approached the aerodrome zone, the controller passed the crew the following request: during the landing roll, to turn off not onto the second taxiway as prescribed, but onto the first, since a Tu-134 was following closely behind. For the pilot, this information meant
that during landing the spacing to the following aircraft might be reduced to
the minimum. As V.A. Ponomarenko (2001) points out, the captain perceived the message transmitted by the controller not as a request but as a signal requiring increased attention
to another aircraft (an additional characteristic - the other aircraft - was incorporated into
his own mental model of the flight).
After landing, the co-pilot engaged reverse thrust and automatic
braking activated. During the landing roll, at a speed of ~80 knots, the captain took over control
per the procedure specified in the crew operating technology, and thereafter carried out all
control inputs on the aircraft. At a speed of 32 knots the captain, contrary to the flight operations manual,
without reducing engine RPM to idle, disengaged reverse thrust and stopped braking (Information..., 2001). Two seconds later engine power was increased again to
"forward thrust," which led to a gradual increase in speed to 39 knots. These actions were taken in the area of the intersection with taxiway No. 3 and are explained by the captain's desire to reduce the aircraft's time on the runway, since it was followed by a Tu-134 (which at that moment was in the area of the outer marker). Having incorrectly assessed the distance required to shed the aircraft's actual speed on a runway with a low friction coefficient, the captain began re-braking late, and its intensity did not allow the speed to be reduced to a level acceptable for safely clearing the runway via taxiway No. 2. Passing abeam the second taxiway at a speed of ~20 knots with the brake pedals fully depressed, the captain, without coordinating with the start
controller, made a hasty decision to perform a 180° turn on the runway. To do this he turned right onto heading 260° and then initiated a left turn while advancing the right engine's power lever forward disproportionately and one-sidedly. Eight seconds later, on the then-current heading of 155°, the engine, which has the peculiarity of spooling up very slowly in the range from idle to N1 ~40%, reached 78%.
The aircraft's angular rate of left rotation increased on average to 30° per second,
and a rightward skid developed, increasing the turn radius. As the aircraft approached the heading opposite to the landing course, the captain, attempting to stop the aircraft's left rotation, fully depressed the right brake pedal and rapidly advanced the left engine's power lever (the right
engine at that time was operating at ~85%). Because the braking effect

of the right main gear wheels at a friction coefficient of 0.37 was insufficient, and the left
engine, due to slow spool-up, only began to produce real thrust after 8-
10 s, these actions did not produce any noticeable slowing of the angular rotation.
During the rotation the aircraft's right landing gear bogie ran off onto the runway side
safety strip for about two seconds, on an intermediate heading of 200° and a speed of 7 knots.
The subsequent dynamics of the aircraft's movement on the runway were characterized by a gradual slowing of the angular rotation from 12 to 7 degrees per second, an intensive increase of forward speed to 17 knots due to both engines operating at high power, and its subsequent reduction after the captain sharply moved both power levers to idle and fully applied the left brake pedal. At heading 90° and a forward speed of about 10 knots
the aircraft again ran off the runway onto the opposite (left) side safety strip. At this moment the captain, not realizing that an excursion had occurred and
disregarding the co-pilot's warnings about the need to reduce engine power, attempted to continue moving the aircraft toward the runway centerline.
To do this, with the left brake pedal fully depressed, he again advanced both power levers.
As a result, the RPM of the left engine gradually rose to 101.9%, and of the right to
99.5%, significantly exceeding takeoff-power RPM. At heading 94° the aircraft stopped moving along the side safety strip, but by that time the engines' power had increased to almost
maximum, causing the aircraft to resume moving away from the runway, turning onto heading 117° and its landing gear subsequently sinking
into the ground, coming to a stop 23 meters from the side edge of the runway. As a result of the runway excursion the right engine was damaged. In the opinion of the investigation
commission, the most probable cause of the captain's actions was severe emotional strain provoked by the overriding goal of speeding up clearance of
the runway. Thus, the aircraft's double runway excursion resulted from the captain's ill-considered decision to clear the runway by performing a 180° turn using asymmetric engine power management (Information..., 2001).
A similar case to the one described above occurred on 29 June 2005 with the crew of Airbus-310 F-OHCZ of the airline "Sibir," whose captain (after taking over control from the co-pilot, guided by the air traffic situation and the recommendation of the "Domodedovo Tower" controller to clear the runway without delay), as in the previous
incident, hurrying to comply with the controller's request and slipping into a state of haste and emotional strain, was unable to cope with control, as a result of which the aircraft
ran off the edge of the runway. As established by the investigation commission, before control was transferred from the co-pilot to the captain the flight had proceeded without

remarks. The runway was to be vacated via taxiway No. 9,
located perpendicular to the runway centerline beyond its threshold. For the Airbus-310 the maximum
permissible taxi speed on straight sections of taxiways is 30 knots
(56 km/h), and for clearing the runway at a right angle - no more than 5 knots. Cancellation of
partial reverse and retraction of the spoilers were carried out practically simultaneously at a speed of 83 knots (153 km/h). At that point 1,644 m remained to the runway threshold, which did not comply with the requirements of the interaction and crew operating procedures, according to which spoiler retraction should be performed only after clearing the runway. Thereafter (over the course of 1 min 33 s) the landing roll proceeded with practically no speed reduction. In that time the speed was reduced by only 10 knots (18 km/h); the roll distance over that section was 1,064 m. The captain then resorted to more intensive braking, and over a section of 393 m the speed dropped from 73 to 40 knots (from 135 to 74 km/h). By this
time 187 m remained to the runway threshold. Realizing his actions were belated, the captain
used full engine reverse thrust for 11 s; the speed dropped to 5 knots
(9 km/h), and the distance to the runway threshold was reduced to 69 m. This speed was maintained
for another 5 s; the aircraft stopped and again began moving at a speed of 5 knots for 10 s. The aircraft ran off with its nose landing gear onto the end safety area.
Records of the cockpit voice recorder show that the captain's emotional strain
while controlling the aircraft during the final stage of the landing roll was extremely high: profanity,
disorganized and hasty actions, which manifested in increased engine power
and led to the aircraft resuming motion after having stopped.
The captain's phrases included: "...[Why] wasn't I braking." The friction coefficient
of the runway was 0.5.
A striking example of an aviation occurrence linked to a contradiction between information issued by the aircraft's onboard systems and information coming from air traffic controllers is the mid-air collision on 1 July 2002 between a Tu-154 and a Boeing-757.
According to the analysis of the disaster conducted by V.V. Kozlov (2004), the crew of the Tu-154 found itself hostage to a situation not described in flight documents, and acted strictly in accordance with the principle of priority of controller commands over TCAS instructions. The main cause of the disaster was deficiencies in the ATC system that resulted in the Tu-154 crew receiving controller commands inadequate to the developing situation: the controller was issuing descent commands, while TCAS was issuing climb commands.
An analysis of this same disaster was also the subject of a work by S.V. Zaiko and V.E. Ovcharova (2003).
The Tu-154 crew was operating a charter flight on the route "Moscow (Domodedovo) - Barcelona." At 21:30 (UTC, night-time) after entering Zurich air traffic

control's zone at flight level 11,000 m (FL 360) the crew reported this to the controller. At
the same time and at the same flight level a Boeing-757 was flying from south to north. The distance between the aircraft at that time was 116 km.
Both aircraft were equipped with Traffic Collision Avoidance Systems (TCAS), which were operating and issuing
the crews with appropriate advisories for resolving the conflict situation. The crew of the Tu-154 spotted the Boeing-757 at 21:34. As the aircraft converged the Tu-154 crew actively discussed
the information issued by the TCAS system. At 21:34:42 aboard both the Tu-154 and the Boeing-757
the TCAS systems issued the aural advisory "traffic, traffic." The distance between the aircraft was 19 km. Seven seconds after the TCAS visual and aural alert activated,
at 21:34:49 the Zurich controller transmitted the following information to the Tu-154 crew: "...descend to flight level 350, expedite your descent, I have crossing traffic."
The crew began to comply with this command. At the same time (21:34:56), aboard the Tu-154, while executing the descent per the controller's command, the TCAS system issued
the aural command "climb, climb." This meant that on the TCAS display the yellow
(amber) circle had turned into a red square, a red arc of prohibited vertical-speed values appeared on the digitized scale along with a green segment of recommended values. The TCAS system switched into RA (resolution advisory) mode. The distance between the aircraft
was 14 km; 35 seconds remained until the collision.
Thus, the Tu-154 crew found itself in a contradictory situation: the instrument information was completely opposite to the controller's information. At 21:34:56, aboard
the Boeing-757, the TCAS system issued a descend command - "descend, descend" - and the crew
began descending at a vertical speed of up to 10 m/s.
Six seconds after the TCAS alert activated, the Tu-154 crew received
a repeat command from the controller: "...descend to flight level 350, expedite your descent." As S.V. Zaiko and V.E. Ovcharova (2003) point out, the absence of additional information from the controller reinforced the imperative character of the command. At 21:35:09 the TCAS system on the
Boeing-757 issued the command "increase descent."
The Tu-154 crew confirmed receipt of the repeat information from the controller and
began the descent, but said nothing about the contradiction between the controller's instructions and the
TCAS system.
S.V. Zaiko and V.E. Ovcharova (2003) emphasize that the key moment
in the escalation of the special situation into a disaster was the controller's information in response
to the Tu-154 crew's confirmation of the descent: "Yes, we have traffic to you at 2 o'clock at flight level
360." The information was given without an addressee (without specifying the aircraft's call sign) and, in terms of perception, could

apply, as the authors point out, to either aircraft. The information was issued one second after the crew's report of the descent and was perceived by the Tu-154 crew as a continuation
of the dialogue with the controller. Moreover, the Tu-154 crew could not consider itself to be
at flight level FL 360, since it was descending at a vertical speed of about 10-13 m/s,
had left that level 16 seconds earlier and, consequently, was crossing an altitude 200 m (660 feet)
lower. Thus, the crew naturally understood the information to mean that it was precisely the conflicting aircraft that was at flight level FL 360, to the right at 2 o'clock. The crew's attention was shifted to the "right - forward" sector of view, which precluded visual detection of the Boeing-757. 10 seconds remained until the collision.
The controller's information was likewise not related to itself by the Boeing-757 crew. The Tu-154 crew's
reaction to the controller's warning was a visual search for the conflicting aircraft.
The second pilot, who was not at his station (his seat was occupied by a check pilot), immediately prompted: "It's on the left, on the left." Apparently the check pilot and the captain continued scanning the airspace to the right ("at 2 o'clock") and, being in a state of emotional strain that narrowed their attention span, ignored the information coming from the second pilot. At 21:35:24 the Tu-154's TCAS system issued the command "increase climb." Three to four seconds before the collision the crews spotted each other, but it was already impossible to avoid the collision. The uncertainty of the situation, caused by the controller's erroneous report, is confirmed by a phrase recorded on the Tu-154's cockpit voice recorder after the collision (21:35:33): "I told you it was on the left!", from which it follows that
the crew was searching for the conflicting aircraft to the right - contrary to the opinion of this crew member (Zaiko
S.V., Ovcharova V.E., 2003).
Let us turn to the next cause of poor teamwork - negative character
traits of air traffic controllers and insufficiently developed
professionally important qualities. One of the typical examples of improper performance of duties by air traffic controllers is the disaster that occurred on 11 October 1984 at Omsk
airport. The Tu-154 crew was operating the flight "Krasnodar - Omsk - Novosibirsk." Landing was carried out in difficult meteorological conditions (drizzle, visibility 3,000 m, a crosswind component close to the limit). The approach was carried out in automatic mode
with a heading of 66° with no deviations. On intercepting the glide slope on final approach the crew reported readiness to land to the controller but received no reply to the query and was cleared to land only after a repeat query. At a height of 100 m the aircraft emerged from the clouds and
the captain gave the command to switch on the landing lights, but because, in the drizzle conditions,
a light-screen effect had formed, the lights were switched off. After the navigator's report of visibility
of the approach lights and establishment of contact with ground references, the captain, at the

decision height, informed the crew: "We're landing." After passing the inner marker the lights were switched
back on and the captain addressed the crew: "What's on the runway?", to which he received a reply from
the navigator: "Something's reflecting light." At that time on the runway (2,500 m
long and 80 m wide) there were three items of special vehicle equipment (a KrAZ,
a URAL, and a UAZ truck), none of which had their signal lights switched on and none of which had radios for monitoring the frequency.
At a height of 30 m the autopilot was disengaged, the runway threshold was crossed at
a height of 10 m and a speed of 270 km/h. Touchdown occurred at a distance of 340 m at a speed of
265 km/h with a load factor of 1.2. In the light of the landing lights the crew saw one of the vehicles and made a turn
to the right. They then felt an impact on the left side, then a second one, after which the aircraft began
to spin. The collision was with two wind-measurement vehicles that were working
on the runway. Ahead of them was the work supervisor's UAZ vehicle, which upon collision
was thrown far forward. As a result of the aircraft's collision with the vehicles, which
had fuel tanks of 7.2 tonnes of kerosene each and whose engines were running, an
explosion occurred (Boltachyov V.Yu., Kharikov A.A., Shcherbakov L.K., 1995, b). The aircraft came to a stop
1,396 m from the runway threshold.
As a result of the collision and the fire, the aircraft and the three vehicles were completely destroyed. 169 of 170 passengers were killed, 5 of 9 crew members (the co-pilot sustained injuries, while the captain, navigator, and flight engineer were completely unharmed), and 4 people who were in
the vehicles on the runway (three drivers and one airfield-service foreman). Of the 16
survivors hospitalized, only one passenger survived.
The flight director was irresponsible in performing his official duties:
he neither organized nor supervised the work of the shift. The start controller grossly violated operating procedures: he allowed the airfield-service foreman to occupy the runway to
carry out work without switching on the "Runway Occupied" sign, exercised no control over the vehicles' work, and fell asleep at his post. The landing controller, having received, after
repeated queries, a report from the start controller on the runway's readiness in the form of an unintelligible phrase - "...eady" - unjustifiably cleared the aircraft to land.
According to the factual data, the largest number of air traffic controller errors (as
well as pilot errors) occurs in aviation occurrences related to controlled flight into
terrain or obstacles - CFIT (Controlled Flight Into Terrain).
A characteristic example of the crew's failure to make proper use of the navigation aids available to it, leading to a loss of spatial orientation en route and significant deviation from track, is the crash of a Yak-40 aircraft that occurred on 19 April 1983 in the vicinity of Leninakan. The aircraft took off from Nalchik

at 17:07. On the "Kislovodsk - Gori" leg of the route the aircraft deviated to the right, and in response to commands from the Mineralnye Vody area control center to return to the
planned track, the crew reacted reluctantly and in fact never returned to the track, instead flying parallel to it at a distance of 10 km. After entering the Tbilisi area control center's zone the aircraft was 8 km west of track. As a result of measures taken by the controller and the crew, by the
time it passed the Gori turning point the aircraft had been brought back onto the planned track. At
17:53 the crew reported to the Tbilisi area control center passing Gori at an altitude
of 6,600 m, and the controller confirmed the pass and instructed it to descend to and maintain 5,700 m
(Boltachyov V.Yu., Kharikov A.A., Shcherbakov L.K., 1995, a).
On the flight from Gori to the boundary for transfer of air traffic control to the Leninakan approach zone, the crew repeatedly altered its heading, reducing it from the
planned value (from 185° to 130°), and did not actively navigate the aircraft, as a result of which it
deviated 28 km to the left of track. At 18:02 the crew reported to the Tbilisi area control
center that it was leaving the zone as planned at an altitude of 5,700 m. At that time the aircraft was
57 km from Tbilisi (the planned exit distance being 100 km) and 28 km to the left
of track (with 39 km still remaining to the transfer boundary). The Tbilisi area control center controller
managed air traffic on the "Gori - transfer boundary" section of the route
unsatisfactorily: he did not monitor the flight by radar, did not prevent the aircraft's deviation from
the route, took no measures to bring the aircraft back onto track, and handed the aircraft over to
the Leninakan approach zone without informing the crew of its position. At 18:03 the crew
established contact with the Leninakan approach controller, reporting entry into the zone. In
fact the aircraft was 87 km from Leninakan and 29 km to the left of track.
1.5 minutes after establishing contact the crew requested the aircraft's position. The controller stated that the aircraft was not observed on radar and gave an azimuth value of 30°. This
meant that the aircraft had deviated to the left of the planned track, but the crew took no measures to return to track. Subsequently, not knowing its actual position, the crew, having reported passing the
control point "21 km" and the presence of conditions for visual flight, was cleared to descend to an altitude of 3,300 m. During the descent to 3,300 m the crew failed to bring the aircraft onto the radio-navigation fix of the aerodrome using onboard and ground-based radio navigation aids and, having reported to the approach controller crossing 3,600 m,
was transferred to the circuit controller (Boltachyov V.Yu., Kharikov A.A., Shcherbakov L.K.,
1995, a).

The circuit controller (who was also the approach controller), lacking continuous radar
surveillance of the aircraft either in the approach zone or in the circuit zone, did not bring the aircraft onto the aerodrome's radio-navigation fix, did not require it to perform a safe-altitude
identification circuit, and cleared it to descend to 900 m for the third turn.
The aircraft was in fact about 40 km from the aerodrome. At 18:09, while in cloud, the aircraft struck the slope of Mount Shishtepe at an altitude above sea level of
2,523 m (41 km from the aerodrome).
The investigation into the circumstances preceding the crash established the following. The controller at the Tbilisi area control center had been observing the aircraft's flight using data from the "Mech" surveillance radar
from the boundary of the Mineralnye Vody ATC district to an azimuth of 260° after
passing the Gori NDB. Thereafter he monitored the flight by radio direction-finder, giving the crew azimuths. After the captain's report of approaching the planned boundary for leaving
the Tbilisi area control center's zone, the controller gave the crew an azimuth of 238° and transferred the
aircraft to the control of the Leninakan approach controller. The approach controller, using the DRL-7S approach radar from the moment the aircraft was accepted for control until
the crash, did not observe the aircraft on radar, which he reported to the crew. During the 6 minutes
the aircraft was under his control, the controller gave an azimuth of 30° once and twice requested a "keying" transmission, but did not obtain a bearing on the aircraft. The Leninakan approach and circuit controller could not see the aircraft on the display of the approach radar because it was outside its coverage. He used the radio direction-finder to monitor the flight belatedly,
only in the final stage of the flight, when the low altitude no longer allowed the aircraft to be bearing-fixed, although the crew twice transmitted "keying" signals. The senior controller was standing near
the circuit and approach controller and did not help him properly organize the air traffic. At the
last moment he went outside to try to determine, by sound, the aircraft's passage of the outer
marker (Boltachyov V.Yu., Kharikov A.A., Shcherbakov L.K., 1995, a).
Thus, the area control center controller was directing the flight relying only on data
from the radio direction-finder and information coming from the crew. The approach and circuit controller had
no way of determining the aircraft's position by radar, but could have determined the direction of flight using the radio direction-finder, which he used insufficiently actively, and subsequently cleared the aircraft to descend per the aerodrome approach scheme without having identified it. The Tbilisi area control center controller showed no personal initiative in coordinating with air defense units, with which there was a direct communication link and which had observed the aircraft's deviation from track.
Many aviation accidents, in particular collisions of aircraft with high ground, occurred because a crew recklessly followed a controller's instruction without
first verifying the aircraft's position with the controller. In some cases the crew requested a landing approach that deviated from the established scheme - a "straight-in" landing, bypassing the required reporting points - and the controller granted permission for this without

ensuring proper monitoring of the aircraft's flight. The crew, having lost track of its position and failing to report passing the boundaries (reporting points), descended prematurely below a safe altitude, and the controller, not monitoring the aircraft's flight using the serviceable radar and radio equipment available, issued the command for such a descent.
A characteristic example of a crew's deliberate track-shortcutting and controllers' failure to prevent a gross violation of regulatory documents are the circumstances
preceding the crash of a Yak-40 aircraft on 7 November 1991 in the vicinity of Makhachkala.
The flight on the route "Elista - Makhachkala" was to be flown along route segments through the turning points Aktur, Almar, Ronka, Kizlyar and then via corridor No. 3
of the aerodrome area, descending via a separate outer marker beacon (OPRM) for landing. At 12:58 the controller of sector V1 of the SKTs ASUVD "Strela" DPK, at the established boundary (at flight level 5,100 m), accepted the aircraft for control from the Elista
United Air Detachment's traffic service and instructed it to proceed along the established route abeam Grozny. At 13:02
the crew requested the controller's permission to fly off-track, bypassing the Ronka turning point, direct to the separate radio beacon (OPRS) at Kizlyar. The controller refused to allow it to proceed to Kizlyar but did grant permission to proceed off-track abeam Grozny. This decision to shortcut the route was, in all likelihood, taken by the controller out of reluctance to move the aircraft out of his zone of responsibility and hand it over to
the adjacent controller of sector M1 at the established boundary. Furthermore, shortcutting the route from Almar to Kizlyar, bypassing abeam Grozny, would have required coordination with the Astrakhan Zonal Center of the Unified ATC System, through whose airspace the aircraft's flight would have passed
(Boltachyov V.Yu., Kharikov A.A., Shcherbakov L.K., 1995, a).
As the aircraft approached abeam Grozny, the controller informed the crew of its position and instructed it to proceed to the Kizlyar radio beacon, which the crew did. At 13:
23 the aircraft, at the established boundary, was handed over to the control of the DPK controller
of the adjacent sector M1. These violations, on the part of both the crew and the air traffic controllers, did not affect the outcome of the flight. At 13:23 the crew, proceeding to Kizlyar,
established contact with the sector M1 DPK controller and reported to him that it was flying at flight level 5,700 m and
its estimated time for passing the Kizlyar radio beacon. Ten seconds after accepting the aircraft for control and establishing contact with the crew, the controller instructed the crew to proceed on a heading toward
the Makhachkala beacon, thereby directing the aircraft off-track along a route not established by the Makhachkala Aerodrome Flight Operations Instructions (IPP), toward the mountain
range of the Kanabur ridge. The crew of the aircraft changed heading from Kizlyar toward the Makhachkala beacon,
knowing that it was flying toward a mountain range, and nevertheless recklessly complied with
the controller's command. At 13:34, having descended the aircraft to flight level 5,100 m, at a distance of about

100 km from Makhachkala aerodrome and 35 km to the right of the airway (corridor No. 3) axis, at an
unestablished boundary in terms of direction, the SKTs ASUVD DPK controller transferred the aircraft to
the control of the Makhachkala aerodrome DPP controller. Despite the fact that the aircraft was flying off-track, the DPK controller passed information to the DPP controller stating that the aircraft was proceeding
and entering the Makhachkala ATC zone via the established third corridor. On the flight segment from abeam
Grozny to the boundary for transferring the aircraft to ATC by the Makhachkala approach control unit, the DPK SKTs ASUVD controller directed the aircraft off the established route and handed it over for air traffic control to the adjacent unit at an unestablished boundary, and
also misinformed the Makhachkala DPP controller that the aircraft was proceeding along
the third corridor (Boltachyov V.Yu., Kharikov A.A., Shcherbakov L.K., 1995, a).
At 13:34 the Makhachkala district approach controller accepted the aircraft for control at flight level 5,100 m at an unestablished boundary. Observing on the approach radar (DRL) display the Yak-40's deviation from the established route and
descent scheme, the controller made no attempt to bring the aircraft onto the established route and descent scheme and did not inform the crew of its position.
Instead he instructed the crew to descend to flight level 1,800 m toward the aerodrome beacon
along an unestablished descent path. The aircraft's descent was carried out toward
a mountain ridge with elevations of 890 and 720 m, which lie within a sector hazardous for IFR flights and bounded by bearing, distance and altitude (315°, 1,800
m and 30 km respectively).
At 13:39, at flight level 1,800 m, 45 km from the aerodrome and 23 km to the right of track,
the DPP controller transferred control of the aircraft to the controller of the adjacent
landing-system control point (DPSP). The handover was made at an unestablished boundary without coordinating the transfer conditions. For its part, the crew took no measures to clarify its position and bring the aircraft onto the established route. At 13:39 the
DPSP controller accepted the aircraft for control at an unestablished boundary (the aircraft was 41
km from the aerodrome and at an altitude of 1,800 m). Based on the flight strip and the aircraft's blip on the approach-radar display, the controller passed the crew position data (reciprocal bearing 122°, distance 36 km) and instructed it to descend, on the aerodrome QFE, to 1,050 m and proceed to the separate beacon. The crew acknowledged the instruction to descend to 1,050 m and proceed to the separate beacon. In fact the reciprocal bearing was 118°, and
the distance from the aerodrome was 41 km. At 13:40 the crew received new position data: "distance 2..., 308." In fact the bearing was 296°, and the distance was 35 km. It is most likely that the DPSP controller, in passing the crew position data, was not observing the aircraft's blip on the radar display but was passing

information about where, in his estimation, the aircraft should be (the flight strip and
blip for the aircraft may have been lost in a "shadow" zone) (Boltachyov V.Yu., Kharikov A.A.,
Shcherbakov L.K., 1995, a).
The crew continued flying on the same heading, which would not bring it to
the OPRM, and entered the mountainous area beyond the boundary bearing of 315° at an altitude below the safe altitude
for that area. At 13:41:41 the crew reported reaching flight level 1,050 m. Flying
off the landing course, without an aural or visual signal indicating passage of the
marker, the crew reported to the controller at 13:42:16: "Passed the beacon." The controller accepted
the crew's inaccurate report of passing the OPRM and at 13:42:24 instructed it to descend to an altitude of 400 m for the fourth turn. The crew began descending to an altitude of 400 m.
Five seconds before impact with a spur of Mount Kukurtbash, the crew, without reducing its vertical
rate of descent, began a left turn to intercept the landing course. The impact occurred at a speed of 366 km/h, on a heading of 127° and with a 20° left bank, at an altitude of 550 m.
All those on board the aircraft (47 passengers and 4 crew members) were killed.
Thus, the emergency situation began developing already at the moment of the crew's request to shortcut
the route, which was granted without any hesitation whatsoever. Here we are dealing with overconfidence and ambition on the part of both the aircraft crew and the air traffic controllers,
who, having worked for many years in aviation, came to believe that they themselves could already establish
the rules for conducting flights, ignoring the approved operating procedures: "Who if not
us, with our great experience, should know the tenets of the 'true' way of doing things." Further on, we
were able to observe that the transfer of control of an aircraft from one controller to another was accompanied by them holding two different plans of action: specifically, on one hand
it was transmitted over the air that the aircraft was within the corridor, while the controller himself had already directed it off
track. In other words, the controller was simultaneously thinking about how to "lead" the aircraft in accordance with the route shortcut he had "approved," as well as about how to conceal this information, presenting it over the air in an acceptable form. It is quite understandable that this leads to increased errors and confusion. Moreover, in granting permission to shortcut the route, the controllers evidently did not realize that managing the aircraft under such conditions
was beyond their capability, beyond the limits of their abilities (in transferring control of the
aircraft at an unestablished boundary, they did not discuss the conditions of transfer - they acted spontaneously and inconsistently - and all because the algorithm of action for such conditions had not
been formed). As is well known, an air traffic controller's algorithm of action is determined by his formed spatial model of the air situation. But the existing spatial model is built on the basis of the approved operating procedure, and any deviation from it requires a different model, which, for understandable reasons, is absent: no one has ever been taught, either in a simulator

or in on-the-job training under real ATC conditions, how one is supposed to violate the established rules, the air traffic controller's operating procedure (Evstigneev
D.A., Karnaukhov V.A., 2005).
Let us consider an incident in which a favorable outcome to a special situation caused by a separation violation was ensured by the competent and timely actions of the crew members. The incident took place on 2 February 2006 and consisted of a dangerous convergence of two aircraft (a Boeing 747-400 and an Airbus A340-300). Air traffic control was being provided by the radar control controller (DRU), the senior controller of the Mineralnye Vody-Makhachkala direction of the RDTs, and the procedural control controller (DPK).
The senior direction controller was checking the practical skills of the procedural control controller returning from leave. At the time of the dangerous convergence 7 aircraft were under control.
Before the Boeing 747-400 entered the zone, the DPK received information from the Astrakhan area control center controller that the crew wished to change flight level, but did not use it
to analyze the air situation and did not report it to the DRU. At 01:03:49 the crew of the Boeing 747-
400 reported entering the sector at flight level 10,600 m, passing the KAMIS reporting point, and proceeding
to the LISMU reporting point. The Airbus A340-300, after entering the zone at flight level 11,100 m, was proceeding
to LISMU. 11 seconds after entering the sector (01:04) the crew of the Boeing 747-400 requested a climb to flight level 11,600 m, and 11 seconds later was
cleared without a specified vertical climb rate. The longitudinal spacing between the aircraft at that time was about 84
km. Calculations showed that, given the aircraft's closing speed, this distance was sufficient for crossing the opposing occupied flight level only if the Boeing 747-400 crew maintained a vertical rate of 10 m/s or more, and provided there was a lateral spacing of 10 km. For nearly a minute, having received no information from the DRU or DPK about
the climb, the Boeing 747-400 continued in level flight, after which (at 01:05:09
) it began climbing at an average vertical rate of 3 m/s. As a result, vertical and longitudinal separation was reduced, resulting in a dangerous convergence and activation of the TCAS system on both aircraft. The minimum altitude difference at a longitudinal
spacing of about 12 km was 60 m. The aircraft separated per TCAS advisories with a lateral spacing of about 1 km and an altitude difference of about 270 m.
The investigation commission established that, in clearing the crew of the Boeing 747-400 to
climb to flight level 11,600 m, the DRU and DPK failed to carry out a number of established procedural operations:
- they did not conduct the necessary analysis of the air situation before deciding to change the flight level of the Boeing 747-400;
- in response to the DRU's query about the possibility of climbing to flight level 11,600 m, the DPK did not give a recommendation, but instead suggested acting at his own discretion, citing his own workload;
- the DPK did not calculate the minimum distance required between the aircraft or the vertical climb rate needed to maintain safe intervals;
- the DRU did not analyze the air situation, did not specify a vertical
climb rate, and did not give the Boeing 747-400 crew information about the existing air situation.
At 01:05:46, warning symbols for a conflict situation appeared on the flight-progress strips:
the DRU became flustered and did not instruct the aircraft, which were flying on converging headings with no lateral spacing, to turn away. The DRU then transmitted an unintelligible instruction over the air: "Malaysian 16, uh...clm...rate of descent 8 m/s." The DPK provided no assistance in this situation. It is worth noting the competent actions of the Airbus A340-300 crew: upon
receiving TCAS instructions, the crew began climbing.
As the analysis of the video recording from the control room showed, during the shift the DRU and DPK repeatedly left their workstations without relief, the DPK handled air traffic control
duties in place of the DRU, and at the moment of directly controlling air traffic the DRU was reading a newspaper.
For an even fuller understanding of all the complications that can arise in the process
of interaction between pilots and air traffic controllers, let us analyze an incident that occurred on 14 February 2007 with a Boeing-737 aircraft, whose crew began the takeoff
without the corresponding clearance from the controller. The aircraft's crew consisted of the captain,
a co-pilot, and a co-pilot under training. The flight was operated on the route
"Vnukovo - Rostov-on-Don." After starting the engines the crew was cleared to taxi to the holding point (taxiway No. 2 - RD-2). While on the second taxiway
the crew reported being at the holding point, and received instructions to
hold. At 20:47:54 the start controller addressed the crew with the question: "Sky
Express, are you ready for an immediate takeoff without delay?" The crew confirmed readiness for an immediate
takeoff without delay. At 20:48:04 the crew received clearance from the start controller:
"Sky Express-203, line up runway 24 and wait." To this
information the crew replied: "Lining up and waiting, 203." The controller's instruction to wait was prompted by the fact that a Learjet-60 had just landed
and would not have time to clear the runway promptly.
At 20:48:47 the start controller transmitted the following information to the Boeing-737 crew: "Sky Express, cloud base 120 m." At that moment the crew of the aircraft began

increasing engine power and starting the takeoff roll. According to the flight-data-recorder readout,
the Boeing-737 crew, on heading 237°, at a speed of
18.6 km/h, 90 m from the start of the turn, increased engine power to 46.8-48
% and began the takeoff without clearance from the start controller. During the attempted takeoff the start controller twice warned: "Sky Express-203, hold position (Sky
Express-203, hold position)." The crew ignored these warnings. At a speed of 81
km/h, at a distance of 240 m from the start of the turn (150 m from the start of the takeoff roll), with the engines
at 87.3 and 83.8% power (corresponding to takeoff power), the crew aborted the takeoff.
The violations did not end there. At 20:49:21 the auxiliary starting point controller (VSDP-060) transmitted
the information: "60, runway clear." Upon receiving this information the start controller cleared the Boeing-737 crew to take off
from runway 24. This was in violation of the "Instructions for Conducting Flights in the Vnukovo
Aerodrome Area": clearance was given without knowing the Boeing-737's takeoff roll distance, the takeoff distance available, or the accelerate-stop distance available under the given meteorological conditions and friction coefficient. Clearance was given while the Boeing-737
was 750 m from the start of the runway. No acknowledgment of this takeoff command
was received from the crew: despite repeated calls from the start controller the crew stubbornly failed to establish contact and did not report what was happening on board.
At the same time the landing controller transmitted over the loudspeaker: "Is he
taking off? Abort the takeoff!" The start controller, in violation of several governing
documents, without having received a report from the Learjet-60 crew that the runway was clear, cleared
the Boeing-737 to take off. In the event of a rejected takeoff, the start controller should have instructed the crew of the Boeing-737 to clear the runway and taxi to the parking stand.
A subsequent departure of the aircraft after a rejected takeoff could only be authorized on the instruction of the flight director.
But the breakdowns in the work of the flight and ATC personnel did not end there either. At 20:49:
29 the crew of a Tu-134 aircraft reported: "Radar 9638, established on the glide slope, gear down,
ready to land." Because the artificial runway was occupied, the crew was informed: "9638, landing delayed." It is worth quoting a fragment of the loudspeaker communication between the SDP-24 start controller and the landing
controller PDP:
20:49:47 (SDP-24 controller): "Uncle Zhenya, send him around."
20:49:48 (PDP controller): "Did he start his roll without clearance? Yes?"
20:49:56 (PDP controller): "Sending him around, yes?"
20:49:57 (SDP-24 controller): "Yes."

At 20:50:02 the landing controller instructs the crew of the Tu-134 aircraft: "9638, the runway is occupied, discontinue the descent, go around." Thus, from the start of the exchange between the controllers until the go-around instruction
15 seconds elapsed (during which time the aircraft covered 1,150 m). At 20:50:06 the Tu-134 crew reports: "9638, going around." According to the flight-data-recorder readout,
the crew began the go-around at an altitude of 175 m, at a speed of 276 km/h, 2,350 m from the runway threshold.
The situation described demonstrates both that any single violation
(whether on the part of the crew or the controllers) entails a chain of subsequent violations, and that there is an elementary lack of knowledge of operating procedures, as well as an inability, in a tense situation, to apply existing knowledge of procedures in practice. All
this, as we have already noted, points to a mismatch between the spatial model formed in the psyche
and real situations. Understandably, after such incidents the conceptual model is corrected, the gaps that existed in it are eliminated, and the model becomes more complete.
In many aviation accidents and disasters, a contributing cause is the flight director's
inability to properly organize the work of the controller shift. And this is no accident: the character of an individual controller's work
depends not only on his relevant professional and personal characteristics, but also on how
strictly compliance with operating procedures is monitored. There are cases in which the flight director was the sole party responsible for
particular incidents and accidents. As an example let us consider a precursor to an aviation accident that took place at one of Russia's airports.
At night, in simple meteorological conditions, the flight director drove out to inspect the runway. He first inspects the condition of the main taxiway, then
moves to the southern end of the runway and gradually proceeds
along it by car in a northerly direction. During this the flight director maintained no radio contact with the ATC service, and in particular with the start controller. He did not notify
the ATC service that he was on the runway. At the moment when
the flight director was proceeding along the runway in a northerly direction,
the start controller cleared a Tu-134 for takeoff. Because the runway was 3,850 m
long and had a rise in its central section, there was no view of
the entire runway. As the Tu-134 and the flight director's car converged, they

noticed each other quite unexpectedly, whereupon the Tu-134 crew
rejected the takeoff and the car's driver sharply veered off the runway
and cleared it. After this a very heated argument and confrontation developed between the members of the Tu-134 crew and the
flight director. In the room designated for reviewing the tape recordings, the flight director insisted that
he had queried the start controller (to his great surprise) and had received clearance to drive onto the runway. Listening to the tape recordings did not confirm
this claim. The flight director was removed from his post (Evstigneev D.A.,
Karnaukhov V.A., 2005).
Speaking of the personality of the flight director, a great deal depends on him. In
particular, as V.L. Marishchuk, K.K. Platonov, and E.A. Pletnitsky (1969) report, flight directors play an important role in overcoming emotional strain among crew
members. The authors emphasize that not only the clarity of the flight director's instructions and commands, but even the tone of those commands, is of great importance. A calm flight director instills confidence, whereas nervousness is quickly transmitted to the pilot
carrying out his commands. In particular, a command given loudly and unintelligibly by a flight director
led to an unwarranted ejection.
The flight director's qualities become especially valuable in unforeseen situations. For instance, at one aerodrome the weather unexpectedly deteriorated, and in the situation that developed
a very fast decision had to be made regarding crews airborne at the time, who had differing levels of training. The flight director decided to send the young pilots to an alternate aerodrome where weather conditions were better, while allowing the most experienced ones to land at his own aerodrome. All crews landed
safely (Silyonok D., 1970). Another example of competent action by a flight director is also known. During a training interception flight at night a young pilot made
an error and flew into the wake of the target aircraft. The aircraft, with a large right bank, began
to descend; the pilot shifted his gaze to the artificial horizon and vertical-speed indicator. The instruments indicated a rapid descent, and the pilot had a fleeting thought - "the aircraft is falling." The pilot then made another
error: instead of immediately rolling the aircraft out of the bank, he energetically pulled back on
the stick in an effort to stop the descent. Making sense of the situation from the instruments was difficult; the vertical rate of descent kept increasing (averaging around 60 m/s).
The artificial-horizon indications became impossible to interpret. Help came from the flight director:
on his instruction the pilot engaged the bank stabilization system and, with difficulty, recovered from the situation that had developed (Pikovsky A., 1972).
Another illustration of a flight director's competent actions in a difficult situation
is the following episode. During training flights over the aerodrome, being flown solo for the first time by cadets, a storm wind arose,

threatening the safety of landings by the light, poorly stable Po-2 training aircraft. There was as yet no radio communication on the training aircraft, so a signal panel was
laid out on the landing strip reading: "Land immediately - storm wind." Seeing this sign, the cadets
hurried to land. In doing so they began to make gross piloting errors. Not
one of them could make a normal approach to the runway. From the nature of the cadets'
errors it was clear that they had been overcome by fear. The flight director then ordered the
sign warning of the storm wind to be removed. The cadets, who were airborne, began to fly calmly again as before and landed safely, even though the wind had not died down (Golubev G.G., 1958).
The flight director's work is complicated by the fact that his practice often presents situations requiring the simultaneous exercise of opposing qualities (Chernaenko T.K., 1986). The psychological fitness of a flight director depends on how well he manages to combine diligence with initiative in his work, and to use a creative approach alongside standard, regulatory procedures. Sometimes
the flight director's subordinate position relative to higher-level managers leads to a situation in which, acting under contradictory instructions (as a result of pressure
from above), he is unable to ensure flight safety. As T.K. Chernaenko (1986) points out,
successful management presupposes a high level of reflection as an ability
to adequately reflect reality. This is important because the flight director, in the course of his work, is compelled to reason on behalf of others, to put himself in their place, to reproduce their
intentions, and to foresee their actions.
A.N. Orekhov (1989) notes that it is not only flight directors who can provoke
aviation occurrences. The author examined an incident whose participants included not only
air traffic controllers but also a deputy airport chief. The graphic-plotting controller
S.A.N. failed to ensure safe spacing between two Tu-154 aircraft flying
on crossing headings at flight level 10,600 m. The controller in question was inexperienced (cleared for independent work a month before the incident), and he was the only one
managing air traffic at that moment. The radar-monitoring controller was not present at his
workstation - he had "stepped out for 10-15 minutes." Regarding his having left his
workstation, the radar-monitoring controller stated that "that's always how it's done."
The flight director was in an adjoining room, preparing to hand over and debrief the shift. The senior shift controller was engaged in so-called maintenance work -
along with two shift controllers, installing a cabinet in the deputy airport chief's office at the latter's

request. The deputy airport chief was perfectly well aware that involving controllers in work unrelated to air
traffic control was strictly prohibited. As the investigation revealed, involving controllers in all manner of "maintenance work" was standard practice at this facility, and repeated protests about it from the flight director had had no effect - the higher-level management had proven the stronger force.
This situation vividly illustrates the force known as "administrative leverage."
This phenomenon is so widespread and so difficult to resist that every year we lose highly qualified specialists - it is precisely they who bear the brunt
of this force. As unfortunate as it is, the higher the position, the less professionalism there tends to be.
It is worth recalling in this connection a category of managers known as the neurotic boss, brilliantly described and analyzed by the classic psychoanalyst K. Horney. Bosses of this type arise from their own inadequacy - the neurotic needs power and money, since without them he cannot build even the most ordinary relationships with people. Power and money are, for
such people, the only means of extinguishing the appalling anxiety generated by their character neurosis, the only way to feel any degree of comfort at all. Such a manager is usually characterized by the fact that he can only manage those whom he places in a position of dependence.
Let us return to the situation under consideration. It is quite obvious that the atmosphere within
the shift itself had already provided fertile ground for trouble to arise. A.N. Orekhov (1989)
notes that the deputy airport chief saw no connection between the controllers' errors
and his own actions: "Well, who else is going to do this piddling maintenance work?"
The next aviation occurrence we will examine is the crash of a Yak-40 aircraft in Vologda on 16 November 1979. This disaster became possible owing to a criminal collusion between the flight director and the weather observers at the outer marker and at the main observation point. The flight was operated on the route "Veliky Ustyug - Vologda." The