The Tenerife Air Disaster, Instructional Problems, and Possible Instructional Precautions - Case Study Example

The Tenerife Air Disaster, Instructional Problems, and Possible Instructional Precautions Introduction Instructional problems have been blamed for many air crashes, including some of the worst in flying history. It is with do doubt that instruction within the cockpit, between the cockpit and air traffic control (ATC), and among other agents related to flight is dependent highly on the reliability of the communication processes that take place (Flin, OConnor and Crichton 70). The Tenerife air disaster, which happened in 1977 in the Canary Islands, is the worst aviation catastrophe in history, which led to the loss of 583 lives (Weick 571). Different instructional and communication problems emerged at the time of the disaster, which involves a collision between two Boeing 747 airplanes, one from KLM Royal Dutch Airlines, and one from Pan American. Instructional and communication problems have been cited as the primary causes of the crash, ranging from ineffective group communication, ineffective instruction resulting from vertical command structures (McCreary, Pollard and Stevenson 28), and heavy accents as well as unsuitable flight terminology by the KLM crew members. This paper aims at discussing the instructional and communication problems as well as precautionary measures that could have been taken to avoid the fatal crash. Description of the Crash The accident took place on the 27th of March, 1977. KLM flight 4805 was inbound to the Canary Islands from Amsterdam, and so was Pan American flight 1736 from Los Angeles. The two flights were headed for the Las Palmas airport in the Canary Islands, but were diverted to Los Rodeos airport because the former airport, which was their destination, was facing a bomb threat. There was a seemingly minor problem with the latter, however, because its taxi space was smaller that could handle the number of passengers that were now inbound. Since KLM arrived first, Pan Am had no option but to back straight behind KLM and, as a result, Pan Am would only have to wait until KLM leaves so as to leave. Upon the airport reopening, KLM passengers had left the plane, which was refueling in an effort to minimize the turnaround at Las Palmas while Pan Am passengers, who never left the plane, were ready to leave (Weick 573). This caused a delay. KLM, as a result, started its taxiing more than two hours later when it was directed to follow a runway that was parallel to takeoff one. It was later redirected to take the takeoff runway, requiring it to make a 180-degree turn as it waited for further instructions. Pan Am was also directed to follow the takeoff runway but requested to hold the takeoff until KLM left, a request that was not accepted. Rather than hold takeoff until further instruction, KLM announced its takeoff, but crew members of both flights did not understand because the previous instructions were clear, so the announcement remained ambiguous. However, Pan Am crew announced to the controllers that it would announce when it would be clear out of the takeoff runway, which was reported to be clearly received in the KLM cockpit. When the engineer asked the KLM pilot if the Pan Am communique was clear, he said it was and no further conversation was heard. The collision occurred exactly 13 seconds later, which resulted in the loss of 583 passengers and crew members. Based on the report of Spanish Ministry of Transport and Communications, it emerged that there was miscommunication within the KLM cockpit and between KLM cockpit and ATC. ATC interpreted that the flight was “taking off position”, not actually taking off (Weick 574). The messages between ATC and the cockpit coincide on transmission and the clarity of the communication process was misinterpreted. None of the copilots, which would have made prior note of miscommunication, raised any alarm. Instructional and Communication Problems Causing the Crash The Tenerife Air Disaster case demonstrates the presence of several communication problems, which have been known to exist in different organizations. From the case, the presence of vertical communication is evident, implying that the possibility of subordinates questioning orders and directives was low. In addition, the cockpits command structure depicts lack of interactive communication, further pointing towards the likelihood of ineffective communication. This is because, at the organizational level, difficult situations necessitate a communication structure that enhances interactive relationships, as opposed to the traditional instructive approach. As Weick (1990) puts it, it is important to “speak up” when one realizes that there is a problem, which is a strong attribute of communication, something that the copilot was afraid to do. This comes out clear from the case as demonstrates a difficult situation that warranted quick and effective responses. However, the command structure within the cockpit and outside during communication with air traffic control was too rigid for such a situation. For instance, when the copilot received directions to adjust the frequencies, he wondered why they were being asked to vector towards Tenerife. Nonetheless, he did not ask the plane captain to reconsider the decision to adjust the frequencies, even though he saw a potential risk in it, and this obviously led to catastrophic repercussions. It is probable that the copilot could not object because he had to respect the authority of the captain, who was his immediate superior. Based on this fact, one would agree that there was a serious problem with the command structure, which may have involved insubordination. For instance, when the pilot decided to thrust the levers, the copilot noted that they lacked ATC clearance (Weick 579), but the pilot ignored and the copilot made no further questioning, something he should have. Another element of inappropriate instructional communication comes up when the copilot sees an impending threat with the vector turn to Tenerife but does not raise any questions. Upon receiving an order to vector towards Tenerife, the captain, and the copilot found it inappropriate to make that move. They received directions in a communication process that demonstrates both miscommunication and impatience. It is not possible for the communication between the two sides to accomplish a common decision, which should be won over by both sides in an effort to take the right course of action (Allard-Poesi 169). On the other hand, there lacked proper communication between the pilots’ side and the KLM side. When the KLM pilot decided to make an unusual decision to take five minutes to refuel, a moment during which he did not leave enough space for the other plane, the other captain does not question the decision. The copilot who survived knew that the decision was inappropriate but he did not have enough communicative power to influence the captain towards reconsidering that decision, or leaving adequate space for the other plane. They are both impatient because of the two-hour delay they had already caused. Instructional communication within both KLM and Pan Am has also been associated with stress factors, especially for crew members and copilots. Even the captains of the places appeared to be overwhelmed by stress, which made it extremely difficult for them to digest the instructions. For instance, the Pan Am captain, having been overwhelmed by pressure and questions from passengers and the need to make tough decisions, he said that he was “ready for the sack”. This is a clear indication that he was making decisions under immense pressure, which would make it difficult for him to communicate or communicate to. Weick and Sutcliffe have also demonstrated the need to find ways of responding to uncertainty (Weick & Sutcliffe 101). It is evident that crew members are involved in high-risk jobs, which are surrounded by immense uncertainty. The extent of uncertainty should be understood and the risks are identified and addressed in time. Judging from the case of Tenerife, it is evident that the pilot of the KLM plane was notified of the risk of a terrorist attack when the flight had already taken off, putting him in a difficult situation. With that knowledge, he was directed to divert his flight towards Tenerife where he would have to wait for two hours before safety was confirmed. One would agree that there was the need for prior communication. It would have been important for traffic control workers to analyze the situation early enough in order to communicate the contingencies before the flight had taken off. This is poor management of uncertainty, which caused the deaths of people, the magnitude of the terror risk notwithstanding. In addition, communication was not effective because no one, not even the captain, had the knowledge of the imminent delay and how long it was going to take. The flights were just halted and no further communication followed until they were given the green light to move. It is understandable that the risk may have been realized too late. However, it would have been important to devise proper communication contingencies, including the use of external help (Helmreich, Merritt and Wilhelm 19). When communication was lost between the traffic control side and Tenerife, it was clear that there were technical problems, but these were not addressed. In responding to this uncertainty, air traffic control should have involved local authorities in and out of the airport to communicate to the pilots about the situation on the outside. Conclusion Being the most fatal ever, the Tenerife air disaster has received a lot of attention from flight analysts and different organizations, all of whom have come to similar conclusions, associating the cause of the problem with psychological problems and communication. In all the literature resources that have been studied in this analysis, communication, which is the primary source of instruction, has been found to have been intensely ineffective. Beginning with the delay and disorder at the airport and moving into the bomb threat scare, tensions were high and many parties involve in communication were making decisions under pressure. At the same time, command structures became a huge issue, such as the case of copilots being afraid of raising their concerns even though they sense the imminent danger. References Allard-Poesi, Florence. "The Paradox of Sensemaking in Organizational Analysis." Organization 12 (2) (2005): 169-196. Flin, Rhona, Paul OConnor and Margaret Crichton. Safety at the Sharp End: A Guide to Non-Technical Skills. New York: Ashgate Publishing, 2013. Helmreich, R. L., A. C. Merritt and J. Wilhelm. "The Evolution of Crew Resource Management Training in Commercial Aviation." International Journal of Aviation and Psychology 9 (1) (1999): 19–32. McCreary, John, et al. "Human Factors: Tenerife Revisited." Journal of Air Transportation World Wide Vol 3 No 1 (1998): 24-32. Weick, K. and K Sutcliffe. Managing the unexpected: Resilient performance in an age of uncertainty (2nd ed.). San Francisco, CA: Jossey-Boss, 2007. Weick, Karl. "The Vulnerable System: An Analysis of the Tenerife Air Disaster." Journal of Management 16 (3) (1990): 571-593. Read More