Tenerife KLMPan Am

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Tenerife KLM/Pan Am

• The Worlds Worst Aviation Disaster

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Objectives of Presentation

• Aircraft Involved
• History of the Flights
• The Turning Point
• The Diversion
• Personnel Information and Running the numbers
• The Disaster
• Analysis and Thoughts

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Condensed Version

• In 1977 two Boeing 747s collided on the runway of
  Tenerife North Airport, resulting in the death of
  583 people, making it the worst accident in
  aviation history
• Taking off on the only runway of the airport, the
  KLM flight crashed into the Pan Am aircraft
  taxiing in the opposite direction of the same
  runway
• The disaster took place on March 27th, 1977 at
  506pm local time

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Aircraft Involved

• Pan Am flight 1736 Boeing 747-121 (the clipper
  victor, first 747 for Pan Am)
• Was under the command of Captain Victor Grubbs
  and FO Robert Bragg
• KLM Royal Dutch Airlines Flight 4805 Boeing
  747-206
• Captain Jacob Veldhuyzen van Zanten

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History of the Flights

• Pan Am flight 1736
• Had taken off from Los Angeles International
  Airport, with a stop at JFK International
• Crews were changed at the New York stop. The new
  captain was Victro Grubbs, and FO Robert Bragg
• 380 passengers were aboard flight 1736 when
  leaving JKF
• KLM flight 4805
• Had taken off four hours before from Amsterdam
  Airport on a charter flight for Holland
  International Travel Group.
• The KLM had 235 passengers and 14 crew members.
  48 children and three infants were among the
  passengers

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A Turning Point

• At 115pm on the same day of the disaster a Bomb
  had been planted at the Las Palmas airport and
  was detonated in the terminal seriously injuring
  8 people
• Later, a telephone call was received claiming
  responsibility for the explosion and hinting that
  a second bomb was somewhere in the terminal
• This is the moment that the civil aviation
  authorities over Las Palmas closed the airport.

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Diverting

• Diversion of incoming flights were sent to
  Tenerief North Airport
• Including a number of large aircraft on long
  international flights
• Google Map

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Personnel Information and running the numbers

• The combined flying experience of the three Pan
  Am flight crew members was 47,053 hours of which
  3,919 were on the B-747. For the three KLM flight
  crew members, these figures were 36,110 and 2,170
  hours.
• The KLM captain was a training captain and the
  head of the company's Flight Training Department.
  Over the previous 6 years, he had spent most of
  his time conducting training on the B-747. He had
  given the first officer on the accident flight
  his B-747 qualification check about 2 months
  before the accident at Tenerife.

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Personnel Information and running the numbers

• At the time of the accident, the Pan Am crew had
  11 hours 20 minutes of duty time. The KLM crew
  had been on duty about 9 hours 20 minutes.
• KLM corporate had newly strict issued duty day
  procedures. Giving the crew only 20min before
  take off before the flight and all 235 passengers
  would have to stay the night all on KLMs bill.

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The Disaster

• Tenerief North Airport

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Take Taxi One, Two, Three..Three

• Confusion between the third taxi exit and current
  position on runway
• Why would the controller tell a 747 to turn onto
  taxi way 3 instead of 4?
• Why didnt ATC tell the KLM to exit on a taxi
  way, instead of full a full back taxi?

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Analysis

• KLM mistakenly took off without a take-off
  clearance.
• The sudden fog limited visibility greatly. The
  control tower and the crews of both planes were
  unable to see each other.
• Pan Am mistakenly continued to exit 4 instead of
  exiting at number 3 as directed by ATC.
• Squelched Radio messages (two calls between the
  planes and the control tower interfered with each
  other because they happened at precisely the same
  instant). Or being Walked On

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Analysis

• Use of ambiguous non-standard phrases by the KLM
  co-pilot ("We're at take off") and the Tenerife
  control tower ("O.K.").
• The airport was (due to rerouting from the bomb
  threat) forced to accommodate a large number of
  large aircraft, resulting in disruption of the
  normal use of taxiways.

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Thoughts on Facts

• Captain Veldhuyzen van Zanten's failure to
  confirm instructions from the tower. The flight
  was one of his first after spending six months
  training new pilots on a flight simulator. He may
  have suffered from 'training syndrome', having
  been in charge of everything at the simulator
  (including simulated ATC), and having been away
  from the real world of flying for extended
  periods.
• The flight engineer's apparent hesitation to
  further challenge Veldhuyzen van Zanten, possibly
  because Captain van Zanten was not only senior in
  rank, but also one of the most able and
  experienced pilots working for the airline.
• The possibility that van Zanten was in a hurry to
  commence the delayed flight due to Dutch
  regulations on exceeding crew duty hours.

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Things the Crew could have done differently

• Or simply put.. The possibility that captain Van
  Zanten was just an asshole like most captains in
  those days. Retired 747/777 Captain Robert
  Becker of United Airlines
• Was the main cause of such the accident
• Question more of ATCs instructions
• KLMs need to listen more closely to position
  reports of the Pan AM flight along runway
• Challenge the Captain once again
• More emphasis placed on decision-making by mutual
  agreement. Also known as Crew Resource
  Management.