The Tenerife Disaster - Research Paper Example

The Tenerife Disaster It was on a foggy afternoon of March 27, 1977 when two Boeing 747s collided on the runway of Tenerife’s Los Rodeos Airport, killing 583 people. A terrorist bombing, foggy runway, wrong assumptions, communication errors, and a top pilot’s strong value for punctuality proved to be a fatal combination of factors that ended with the world's worst aviation disaster in history. That fateful day, apart from the enormous fatality count, what is extraordinary concerning this misfortune is that the two planes neither had a scheduled landing at that airport (Mondout, 2010). Flight Details KLM Flight 4805: operated by the Royal Dutch Airlines; piloted by KLM chief 747 training captain / first class pilot Jacob Veldhuyzen van Zanten and first officer Klaas Meurs; carrying 235 passengers and 14 crew members. Pan Am Flight 1736: operated by Pan American World Airways; piloted by Captain Victor Grubbs (a 57-year-old with more than 21,000 hrs piloting experience) and first officer/co-pilot Robert Bragg; carrying 380 passengers and 16 crew members. The destination for both planes was Spain’s Gran Canaria International Airport (also known as Las Palmas Airport). KLM 4805 and Pan Am 1736 were not scheduled to land at Tenerife’s Los Rodeo’s Airport (Mondout, 2010). The Fatal Chain of Events Unscheduled Landing and Congestion at Los Rodeos Airport At the Gran Canaria International Airport, a terrorist's bomb exploded in the airport’s passenger terminal. The Spanish airport authorities received a call from an activist Canary Islands freedom group claiming accountability for the bombing and threatened to detonate another bomb in the airport. This caused the police authorities to close the airport and divert all international incoming flights, including Pan Am 1736 and KLM 4805, to Tenerife's Los Rodeos Airport. Because the airport at Tenerife was only a regional airport consisting of only of one runway and a major taxiway with small taxiways, the airport soon became congested with the diverted aircrafts, making large aircraft maneuver more difficult especially with the thickening fog limiting the visibility (Kilroy, 2008). KLM Refueling To save time, KLM Captain Van Zanten, chose to fully refuel at Los Rodeos Airport instead of Gran Canaria. The refuel added further weight to the aircraft which could significantly impede takeoff capacity. Finally, Gran Canaria Airport reopened after the authorities declared the airport safe. The Air Traffic Control (ATC) advised the Pan Am aircraft to line up for take off, however the KLM plane and its refueling tanker blocked the Pan Am access to the main runway. Pan Am first officer and flight engineer measured the clearance and discovered that it was impossible for them to maneuver around the KLM plane. This left Pan Am no choice but to wait until the KLM finished refueling and cleared the runway (Bruggink, 2000). Taxiing Through the Thick Fog By the time KLM was completely refueled, weather conditions at Los Rodeos Airport worsened with reduced surface visibility and light rain. Both planes asked for clearance. KLM must take off first before Pan Am. Upon orders from ATC, KLM taxied to the end of the main runway, maneuvered a difficult 180-degree turn and waited for takeoff clearance. Pan Am was then directed to taxi on the same runway and leave via the third exit. Because of poor visibility caused by the thick fog, Pan Am missed the third exit as there are no markings to identify the runway exits; then continued down the runway and headed to leave on the fourth exit (“Tenerife: Disaster,” 2010). Communication Misunderstandings KLM first officer informed the ATC, “KLM 4805 is now ready for takeoff…we’re waiting for our ATC clearance.” After that, KLM received a clearance, specifying the course it has to proceed after the takeoff. Seemingly, KLM Captain Van Zanten misunderstood the ATC instructions, thinking that they have been given permission to takeoff. ATC instructed KLM to standby for takeoff. On the other hand, simultaneous transmissions from Pan Am caused cross-interferences on ATC communications with both planes. Pan Am informed the ATC that they were still taxiing on the main runway. KLM heard an “Ok…” from the ATC and interpreted it as a go-signal for takeoff. Because of the thick fog, the two airplanes were not visible from the ATC tower. Moreover, KLM did not see Pan Am approaching on the runway towards their location (“Tenerife: Disaster,” 2010). Collision Believing that KLM was given permission to depart, Captain Van Zanten commenced takeoff, ignoring First Officer Klaas Meurs’ alarm that Pan Am was still taxiing on the runway. Just then, Pan Am Captain Victor Grubbs spotted the flashing lights of the oncoming KLM and attempted to get the plane out of the runway by taking a sharp left turn to the fourth exit. At last, KLM Captain Van Zanten saw the Pan Am and also tried to avoid the collision by pulling up; however there was not sufficient clearance. Its landing gear hit the upper right side of Pan Am 1736 and tore apart the upper fuselage of Pan Am. Upon collision, both planes caught fire. KLM hit the ground past the site of impact, slid a few hundred meters on the runway and exploded into a furious inferno (“Tenerife: Disaster,” 2010). Accident Survivability The Tenerife disaster killed 583 passengers and crew from both airplanes making it the worst aviation disaster of the twentieth century. All 234 passengers and 14 crew members aboard KLM Flight 4805 perished. Pan Am Flight 1736 carried 380 passengers and 16 crew members. 326 passengers and 9 crew members died and 61 survived, including Pan Am Captain Grubbs. All passengers seated on the first-class lounge located on the upper deck of Pan Am Flight 1736 did not survive. Majority of passengers seated on the plane’s right side died immediately upon collision. Some were trapped and unable to flee the blaze (“’Subsecretaria de Aviacion Civil’ Accident Report,” 1978).  Investigations A team of 70 investigators from Spain, Netherlands, USA, Pan Am, and KLM were sent to investigate the Tenerife disaster. Analysis proved that communication errors, misinterpretations and wrong assumptions had caused the accident. The official transcript of the Cockpit Voice Recorder (CVR) showed that KLM Pilot Van Zanten mistakenly thought that he was given permission to takeoff and the Air Traffic Controller (ATC) of Tenerife was sure that KLM remained at position, waiting for takeoff clearance. Simultaneous communication transmissions among the three parties (Pan Am, KLM and ATC), particularly KLM’s "We're at take off"; the ATC’s “O.K.", and Pan Am’s “We are still taxiing down the runway” showed evidences of misunderstandings (Bruggink, 2000). Contributing Factors to the Accident A sequence of events that ended in the tragic accident started from a terrorist’s bombing of Gran Canaria International Airport (Pan Am and KLM’s destination airport) which prompted the diversion of all its incoming flights to Tenerife’s Los Rodeos Airport. Poor visibility conditions due to the thick fog; refueling of KLM that caused delay to both flights; the absence of ground radar at the airport; and Pan Am missing the third exit are some challenges that contributed to the disaster. Another factor was KLM Pilot Van Zanten’s strict adherence to company policies regarding “duty time limits” and delayed flights, and penalties such as imprisonment, fines, suspension or loss of license that await him when time limits were extended (Bruggink, 2000). It was also probable that KLM First Officer Klaas Meurs, being a new member of the flight crew may have felt too inferior to challenge or humiliate the most respectable and well-experienced Captain Van Zanten (“’Subsecretaria de Aviacion Civil’ Accident Report,” 1978).  Pilot Error The investigation concluded that KLM Captain Van Zanten was exclusively accountable for the accident. The pilot commenced takeoff without clearance, failed to follow ATC instruction to “standby for takeoff,” and did not abort takeoff when he saw the taxiing Pan Am on the runway ahead of his plane (Kilroy, 2008). KLM’s Responsibility for the Accident KLM Royal Dutch Airlines paid all attorneys’ fees. All families of every victim received the sum of $58,000. One family was paid $400,000 because the victim was the family supporter/wage earner. The airline awarded $600,000 to two children whose parents perished in crash (“How KLM accepted their responsibility for the accident,” n.d.). Lessons Learned Even in today’s modern aviation, no degree of scientific advancement can change the vital role of the “human factor.” Human instincts were explicitly portrayed by all three parties (KLM, Pan Am and ATC) in sequential events that led to the Tenerife disaster. Ex- deputy director of the Bureau of Accident Investigation at the National Transportation Safety Board, Gerard M. Bruggink, said that, “The role players in this accident failed, in varying degrees, to act in accordance with the most basic of human factors concepts: make it easier for yourself and others to stay out of harm's way. The several manifestations of this shortcoming had a common denominator: uncritical acceptance of easily verifiable assumptions” (Bruggink, 2000). Safety Response Extensive changes were implemented to airport and airline procedures as a consequence of the Tenerife Disaster. Los Rodeos Airport was installed with ground radar. Aviation authorities applied a universal rule to use standard English phrases. In radio communications, “OK” should never be used. “Departure” should be used instead of “takeoff.” However, “takeoff” could be used for the actual takeoff. Manufacturers of aircrafts installed every plane an apparatus that allowed visibility even in the worst weather conditions. Methods in the cockpit were modified for better functioning and communication. Management and staff in all airlines were trained to value shared conformity in making judgments especially in crucial situations. Because Los Rodeos Airport was situated in the North of Spain’s Canary Island and prone to patchy clouds and fogs, a bigger airport was built in the South: Reina Sofía Airport. All domestic and international flights used the new airport, and inter-island flights were transferred to Los Rodeos Airport (“Tenerife: Disaster,” 2010). References Bruggink, G. M. (2000). Remembering Tenerife. Retrieved 31 March 2010 from http://www.cf.alpa.org/internet/alp/2000/aug00p18.htm How KLM accepted their responsibility for the accident. (n.d.). Project – Tenerife. Retrieved 31 March 2010 from http://www.project-tenerife.com/engels/howklmaccept.htm Kilroy, C. (2008). Special Report: Tenerife. Air Disaster. Retrieved 31 March 2010 from http://www.airdisaster.com/special/special-pa1736.shtml - Mondout, P. (2010). Pair of 747s Collide in Worst Air Disaster of the Century. Super 70s. Retrieved 31 March 2010 from http://www.super70s.com/Super 70s/Tech/Aviation/Disasters/77-03-27(Tenerife).asp ‘Subsecretaria de Aviacion’ Civil Accident Report. (1978). ICAO Circular 153-AN/56. ICAO: Montreal Tenerife: Disaster. (2010). Economic Expert. Retrieved 31 March 2010 from http://www.economicexpert.com/a/Tenerife:disaster.htm Read More