Wednesday, April 14, 2010

Disaster in Tenerife: The 1977 KLM/Pan Am Crash.

Date of accident: March 27, 1977, at 17:06:56 local time.

Place of accident: Los Rodeos Airport, Canary Islands.

Death Toll: 583.

Pan Am: 380 passengers and 16 crew.
Survivors: 61.

KLM: 234 passengers and 14 crew.
Survivors: None.

Cause of crash: Runway incursion, pilot error, ATC error and technical limitations.

To date the Tenerife crash is still the worst disaster in aviation history. "Crash of the Century":



Clearance for take-off was not given by ATC, but Captain Jacob Veldhuyzen van Zanten (KLM) thought the Pan Am had cleared the runway, and attempted to take-off. What this video doesn’t show is that co-pilot initially tried to stop the KLM captain from taking off, but on the second go he didn’t. When the captain proceeded to throttle the jumbo the first time, the co-pilot forcefully pulled the throttle-levers back and said they didn’t have permission to go. The captain replied, "I know that. Go ahead, ask." Moments later, as the co-pilot was repeating ATC instructions, the captain interrupted, “we’re going”. One might ask why the co-pilot and flight engineer didn’t try to stop him the second time. One of the speculations for this was:

The flight engineer's apparent hesitation to challenge Van Zanten further, 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….A study group put together by the Air Line Pilots Association found that not only the captain, but the first officer as well dismissed the flight engineer's question. In that case, the flight engineer might have been either reassured or even less inclined to press the question further.(1)

One of the changes made in the safety response to the accident was:

Cockpit procedures were also changed. Hierarchical relations among crew members were played down. More emphasis was placed on team decision-making by mutual agreement. This is known in the industry as Crew Resource Management.

Although there were a number of causes of the accident, the primary one is pilot error. Notwithstanding other errors and misunderstandings, 583 lives would not have been lost had the KLM captain not felt pressured to go before fog restrictions would delay the flight.

The investigation concluded that the fundamental cause of the accident was that the KLM captain took off without takeoff clearance. The investigators suggested the reason for his mistake might have been a desire to leave as soon as possible in order to comply with KLM's duty-time regulations, and before the weather deteriorated further.

Two things we can learn from this:

1) People’s lives should never be secondary to bureaucracy and business schedules.
2) Questioning, and even over-riding authority is sometimes necessary for the benefit of all.




Notes:

1) Wikipedia




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