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Incorrect Altitude Readback Leads To Near CFIT Incident

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Have you ever misunderstood or misread a clearance? Here's how one mistake nearly lead to a deadly CFIT accident...

Boldmethod

Report: ATC Misses Incorrect Altitude Readback

Even the smallest of mistakes can lead to disastrous consequences as a pilot or air traffic controller. We found the following NASA ASRS report published last year about a near CFIT (controlled flight into terrain) accident with a jet flying under IFR. Here's what happened...

I was piloting a Cessna Citation in the south part of ZZZ1 Class B airspace. I was on an IFR flight plan and was in communication with Approach Control. From somewhere a few miles west of ZZZ2, I was told to turn to a heading of north and descend to 2,500'. After a short amount of time, I started to look at my charts thinking that was too low for my position.

I recall the controller being busy, trying to reach an aircraft that did not respond, and was awaiting an opportunity to confirm my altitude, when the controller called my tail number and told me to immediately climb to 3500' as I was in the middle of antennas. I later listened to the tape, and ATC assigned us to 3,500', but I understood 2,500', and repeated back 2,500' twice. Despite saying 2,500' twice, the controller did not catch it.


beltz6

Trust, But Verify

ATC does a great job of keeping you clear of terrain and obstacles, especially under IFR. But controllers are human too and can make mistakes. In this case, both the pilot and ATC made a mistake. The pilot misheard and ATC didn't catch the mistake. In a busy radio environment, thoughts and calls can get jumbled.

As the PIC, this means you need to "trust but verify." If you're close to the ground, cross-check the ATC instruction with navigation charts to see your altitude above the terrain. It sounds like in this case the pilot only realized how low he/she was flying once already well below the assigned 3,500 feet.

Boldmethod

If The Radios Are Busy, Wait

Unless quantified by an "immediately" or "expedite," you don't need to rush your climb or descent. If the radios are busy and you can't get a word in to verify the instructions, stay at your current altitude. It's better to stay where you are, then assume you've heard correctly and try to get clarification after a major mistake has been made.

Contributing Factor: Expectation Bias

Most of the time, pilots read back clearances correctly. And if either party doesn't hear the readback clearly, they ask for it to be repeated. Since ATC was accustomed to aircraft following instructions as-stated, there likely wasn't a pressure to double-check that the pilots were following the proper clearance. Controllers are far more familiar with the minimum IFR altitudes around their particular airports than the pilots flying in and out.

Expectation bias is a real threat to all of us in aviation, whether we're pilots or air traffic controllers. When we expect to hear or see something, our minds have a tendency to convince us that we've accomplished the stated goal.

NATCA

Have you ever been confused by an ATC clearance? Tell us in the comments below.


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Swayne Martin

Swayne is an editor at Boldmethod, certified flight instructor, and an Embraer 145 First Officer for a regional airline. He graduated as an aviation major from the University of North Dakota in 2018, holds a PIC Type Rating for Cessna Citation Jets (CE-525), and is a former pilot for Mokulele Airlines. He's the author of articles, quizzes and lists on Boldmethod every week. You can reach Swayne at swayne@boldmethod.com, and follow his flying adventures on his YouTube Channel.

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