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Confirm understanding: Crash of Tiger 66

On February 19, 1989 a 747-200 aircraft operating as Flying Tiger 66 crashed into the ground 12-miles short of the intended runway in Kuala Lumpur, Malaysia. This was a totally avoidable accident except for a lack of clarity and confirmation between the pilots and air traffic control. Due to the preoccupation of the pilots around the specific radio beacon they should be flying towards, they did not take the time to confirm a specific instruction given to them by air traffic control. At one point, late in the flight, the air traffic controller radioed up to Tiger 66 with the instruction to “descend two four zero zero” i.e. descend to 2400 feet above sea level. Possibly because the pilots’ attention was diverted towards choosing the correct beacon to fly towards, the captain simply replied, “OK, four zero zero” meaning he interpreted the controller’s words as “descend to four zero zero”. Unfortunately the aircraft impacted the ground at 437 feet above sea level. Leadership Lessons During times of stress at work, we often are so focussed that we either hear what we want to hear or don’t hear a message properly at all. It is all too easy to assume knowledge based on one’s own internal confirmation bias or experience. However, specifically when we are overworked, stressed and trying to juggle several balls in the air at the same time, this is the precise moment when we should always double-check our understanding of what other people are saying. In addition, if the consequences of misunderstanding the request, command or conversation could have dire results, then we need to force ourselves to be extra diligent and always confirm understanding before taking action. The phraseology of both the pilot and air traffic controller in the Tiger 66 incident was not standard and, therefore, added to the general level of misunderstanding, creating far from clear instructions. However, think back to a time when you were working in a high stress environment: were people (including yourself) always communicating is a clear, concise and unambiguous manner? The moral of the story is: always confirm understanding, especially when you are under stress and definitely if the consequences of getting it wrong is disastrous.


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