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Aviation Crash Case Study

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Module 4.3 Case Study of accident at Tenerife
Warren Applegate
ASC 634 Aviation Psychology
Submitted on April 20, 2013
Embry-Riddle Aeronautical University

Abstract
On March 27, 1977 two Boeing 747’s collided on the runway with each on the Spanish island of Tenerife, killing 583 people. This has been documented as the deadliest disaster in aviation history. The carriers involved were KLM flight 4805 and Pan Am flight 1736 (McNerney, 2011). The following case study will unfold the sequence of events and the attributes that lead to this avoidable catastrophe. Highlighted areas will include situational awareness, CRM, attitudes, and communication problems. This will be reinforced using Reason’s model to illustrate how breakdown in an organization can lead to chaos.

Case Study of the accident at Tenerife
The pilot in command of KLM 4805 was Captain Jacob Veldhuyzen van Zanten. He was Boeing’s chief training Captain for Boeing 747’s. He had accumulated almost 12,000 hours of experience and had been a pilot with KLM for 26 years. The pilot commanding Pan Am 1736 was Captain Victor Grubbs had 21,000 hours and was 57 years old. There was a lot of experience between the two Captains. But on March 27, 1977 there experience would be tested.
The KLM flight originated from Schiphol airport in Amsterdam, Netherlands and was destined for Gran Canaria airport (Las Palmas) in the Canary Islands, Spain. It was carrying 234 passengers and 14 crew. The Pan Am flight originated from Los Angeles airport in Los Angeles, California and was also destine for Gran Canaria airport (Las Palmas) in the Canary Islands, Spain. It was carrying 380 passengers and 16 crew. Due to a bomb threat at Gran Canaria, both aircraft were diverted to Los Rodeos airport at Tenerife, a neighboring island (Kilroy, n.d.).
The diversion was the genesis to that fatal day in 1977. The KLM flight landed first and then about 45 minutes later the Pan Am flight landed. Both aircraft were parked at the end of the runway as the normal parking ramp was full of other diverted aircraft. About 15 minutes later the Las Palmas airport had been reopened from the bomb threat. Figure 1 shows the layout of the airport and sequence of event as they happened. KLM 4805 was lined up in front of Pan Am 1736. In the interim KLM 4805 requested to be refueled. The passengers had to deplane during this evolution. Two hours had transpired before KLM was ready for takeoff.
In the meantime a bad weather pattern entered the airfield bringing visibility down to as low as 300 meters. This impeded both ATC and the pilot’s view of the airfield making them reliant on radio communication only. The original instruction by ATC to KLM was to taxi down the takeoff runway, turn around, and wait for further instruction. Pan Am was to follow behind KLM on the takeoff runway, turn off at taxiway C3, and use a parallel runway for the rest of its taxi. (McCreary, 1998). Unable to differentiate the taxiways in the low visibility, the Pan Am pilots miss their assigned turnoff. By this time KLM has turned around and in position for takeoff. The first officer, Klass Meurs receives route clearance from ATC but not takeoff clearance. Aggravation has set in amongst the pilot, crew, and passengers. They are tired and anxious to get underway to their final destination. In the midst of the chaos Pan Am is still taxiing down the runway toward KLM. The communication between ATC and KLM is misunderstood for flight clearance as KLM begins take off down the same runway Pan Am is taxiing on. KLM uses non-standard language “We are now, uh, at takeoff”. At the same time Pan Am is telling ATC they are still taxiing. There is massive radio confusion going on at this point. KLM, Pan Am, and ATC are all trying to transmit on their radios at the same time, effectively cancelling each other out.
The first officer recognizes that Pan Am has not cleared the runway. The Pan Am CVR recognized they are about to be hit head on. The Pan Am pilot attempts to steer left off the runway, but this action is too late. KLM attempted to pull full up and go over Pan Am, but the landing gear and bottom of the aircraft slices right through Pan Am. KLM bolts back to the ground in a massive fire ball. All 248 passengers and crew died in the fire. Of the 396 passengers and crew on Pan Am, 61 survived (Smith, 2014).

Figure 1. Los Rodeos accident layout Situational Awareness
The weather conditions were worsening during the time parked on the taxiway. This added visual disability and reduces awareness. During both aircraft taxing down the runway, situational awareness was lost. Especially once KLM was turn around and in position for takeoff.
Crew Resource Management
Flight and duty time limits were nearing expiration due to being diverted and additional ground wait times. Secondly, checklist were not followed properly. The flight clearance read back should have been accomplished prior KLM attempting to take off. The pilot had lost command of the aircraft and let his frustration get the best of him.
Attitudes
In this case the normal behavior of the pilot, crew, and passengers was being coerced by the delay. Frustration and stress was mounting as time passed on with further delay. Additional pressure was imposed because the original destination was closed for a bomb threat.
Communication Problems
The ATC were dealing with much heavier loads than normal at Los Rodeos. The controllers were speaking in English, which was less familiar to the native Spanish speakers.
There was a communication breakdown from the original instruction. KLM should have never released the brakes and started rolling until the read back to ATC was complete.

Four Levels of Failure
Organizational Influence
The KLM pilot exercised his authority as being Boeing’s chief training Captain. Being so senior with 12,000 hours of experience his first officer was not resilient enough to stop the premature takeoff.
Unsafe Supervision
I believe ATC at Los Rodeos became overwhelmed since they were not used to handling this type of load. They could have requested additional supervision to clear the field. As for the pilots, Pan Am was following instructions, but due to missing their taxiway kept them on the runway too long. The KLM pilot created an unsafe condition as he was the supervising pilot in command.

Preconditions for Unsafe acts
This is clearly where the holes in the swiss cheese start lining up. Too many of the variables have created the perfect storm. Bomb threat, diversion, long crew duty day, bad weather, refuel, stress, organizational breakdown, and communication breakdown. All of these were preconditions which made this nightmare of an accident occur.
Unsafe Acts Themselves
With heavy fog and low visibility ATC could have suspended the takeoff. There should have been better communication of field location back to ATC once visibility was lost. ATC not KLM knew exactly where Pan Am was on the runway. Pan Am missed their directed taxiway. The most obvious unsafe act was KLM proceeding with takeoff without proper clearance from ATC.

References
Los Rodeos Airport image. Retrieved from http://www.disastersinflight.com/wp-content/plugins/RSSPoster_PRO/cache/b8efd_teneife%2520disaster%2520diagram.jpg
Kilroy, C. (n.d.) Special Report: Tenerife. Retrieved from http://www.airdisaster.com/special/special-pa1736.shtml
McCreary, J., Pollard, M., Stevenson, K., & Wilson, M.B. (1998). Human Factors: Tenerife Revisited. Journal of Air Transportation World Wide Vol. 3, No. 1. Retrieved from http://ntl.bts.gov/lib/7000/7500/7585/jatww3-1wilson.pdf
Smith, P. (March 27, 2014). How A Tiny Island Runway Became The Site Of The Deadliest Plane Crash Ever. Retrieved from http://www.businessinsider.com/deadliest-plane-crash-in-history-2014-3

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