Intro were parked on the taxiway. The incident happened

Intro

The Tenerife disaster of 1977 is one of the most fatal
airline crashes to date which resulted in the death of 583 passengers and crew.
On the 27th of March 1977, KLM flight 4805 collided with Pan Am 1736
on the runway of Los Rodeos Airport, Tenerife. The air crash is thought to have
been a result of human error, miss communication and a lot of bad luck1.
KLM flight 4805 was supposed to fly from Amsterdam to Los Palmas airport and
Pan Am 1736 came from Los Angeles. However, both planes along with many others
bound for Los Palmas were diverted to Los Rodeos airport after a bomb was
detonated in the Los Palmas flower shop2. This meant that Los Rodeos
was full of diverted flights and due to a lack of space, other aircraft were
parked on the taxiway. The incident happened just after 4pm where flight 4805
started down the runway at takeoff speed while flight 1736 was still taxying
down the runway. Victor Grubbs was the captain of the Pan Am flight 1736 and
just before the collision he tried to maneuver out of the way by Turing out of
the path of the KLM flight but didn’t manage to get completely clear. The
captain of flight 4805 tried to raise the plane over the Pan AM flight and
almost made it, However the undercarriage caught the celling of flight 1736 and
ripped through the roof bringing KLM back down the ground where it started
skidding until it burst into flames before a single passenger or crew member could
escape leading to the death of all 248 on board. From the 369 people on flight
1736, 61 survived including the captain and his flight crew from the cockpit.   

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Analysis

KLM flight 4805 was the first to begin takeoff
procedures after Los Palmos opened again, quickly followed by Pan AM 1736 who
could not move until KLM did. Both planes began to taxi to runway 12 as runway
30 was blocked by the other parked aircraft. KLM flight 4805 was told by the
air traffic controller to reach the end of runway 12 then turn about and wait
for further instruction before taking off. Pan Am 1736 was ordered to taxi down
runway to the third exit where it was supposed to turn into and wait until
flight 4805 had taken off. As Pan Am 1736 is heading down the runway, the
pilots miss the correct exit and keep on going down the runway towards flight
4805. At this same point, flght 4805 is given clearance for the route which is
mistaken for clearance for takeoff. The pilot of 4805 relays over the radio that
they are taking off. At this point both the air traffic controller and flight
1736 send a radio message one from the Pan Am first officer saying, “And we’re
still taxiing down the runway” while the air traffic controller says “okay, stand
by for takeoff. I will call you”. As these messages are send at exactly the
same time they cancel each other and all that 4805 hears is “okay” which leads
them to believe it is fine to carry on with the takeoff procedure and the pilot
engages full throttle for takeoff. As 4805 is accelerating down the runway, the
air traffic controller tells flight 1736 to “Report when runway is clear” which
receives a reply of “we’ll report when we’re clear” from Pan Am 1736. This isn’t
acknowledged by the pilot, but it is by the second officer, who askes “is he
not clear?”, “That Pan American?” to which the pilot replies “oh, yes”. Seconds
later Flight 4805 emerges from the fog in front of Pan Am 1736 rapidly
increasing in speed and getting ever closer. Captain victor Grubbs immediately engages
full throttle trying to maneuver his plane out of the way of the oncoming Flight
4805, at the same time Flight 4805 tries to get over the top of Pan Am but
neither parties get fully clear as flight 4805 hits the top of Pan Am and rips
the roof off, destroying the mid-section in the process. The KLM lands back on
the ground ad skids a while before coming to stop and being completely engulfed
in flames. The only people to survive where the crew from the cockpit who had
just jump down but where mostly unharmed and also passengers who managed to get
onto the left wing and jump down. Up to and during take off, the pilot of KLM
is noted as being absent in thought as while KLM was taxing down the runway he
asked if he should leave the runway at the first exit then later at the fourth.
Once KLM made it to the end of the runway and had turned around, the pilot
asked the co-pilot to request clearance for takeoff, but while the co-pilot was
relaying this request to the air traffic controller, the pilot engaged full
throttle and started to take off. This isn’t questioned by the co-pilot and
instead he just adds “we are now at takeoff” to the end of his last message. Just
before both planes started taxing down the runway a thick blanket of fog covered
the airport which reduced visibility so that as Pan Am was only a short
distance behind KLM they still couldn’t see each other and it was only in the
last few seconds before the crash in which both planes had clear visibility of
each other. KLM had requested extra fuel at Los Rodeos as they didn’t want to
depart as quickly as they could at Los Palmas Airport, However this extra fuel
meant that KLM was a lot heavier than it should have been so when the pilot tried
to lift the plane over Pan Am, he couldn’t get it high enough. The extra fuel
was also one of the main reasons that KLM burst into flames as the fuel ignited
once KLM hit the ground. Los Rodeos was not build for handelling 747s as the
runway was only just big enough and the air traffic controllers were not used
to dealing with such big planes, this was made worse by the fact that there was
no ground radar so the air traffic controllers did not know where the two
planes were and could get a rough idea by asking them over the radio. This lead
to increased stress for the air traffic controllers along with the fact they
were used to speaking Spanish and had to give commands in a second language which
they were not as used to as their mother tongue. The centre lights were also
not operational down the run way which increased the stress for the pilots as
they did not have a clear route to follow in the fog. Finally the two 747s
should have been able to taxi down runway 30 but their route was blocked by
other parked aircraft as well as the first two exits to runway 12 so Pan Am had
to keep taxing to the third exit which they could not see due to the thick fog.
Pan Am had requested to wait just before the start of the runway until KLM had
taken off before taxing down and following suit, this request was denied by the
air traffic controller who told the pilot to taxi down to the third exit.

Discussion

The events leading up to the
crash left the pilots very stressed and irritated as they were diverted to Los Rodeos
where they weren’t exactly sure what was going on and after a long flight they
were ready to get back to Amsterdam. At the time the Dutch had imposed strict
flying times for flight crew in the “work and Rest Regulations for Flight Crews”
(Roitsch, Babcock, and Edmunds, 1979:14) and as it was near the end of march which
meant that the crew of KLM were close to the limits of flight time they were
allowed each month. If the crew went over these limits, they could be charged, arrested
or have their pilots license removed. The Crew of the KLM knew they were close
to these limits and so wanted to get back to Amsterdam before they went over
their limits, which they weren’t sure they were going to be able to do if there
were any more delays.           The pilot
also had to maneuver the KLM 747 180 degrees, so it was facing the opposite direction
which is hard enough on a full size runway but the runway in Tenerife was more
narrow than standard runways with a width of only 45.72 meters and a 747 needs
a minimum of 43.28 meters to perform a full turn. The fog that was on the
runway was a thick cloud as the runway in Tenerife is 633 meters above sea
level 1. KLM was out of the cloud as they were waiting to take off,
Pan Am was taxing inside the cloud so neither planes could see each other or
the Air traffic controller. The cloud was so thick that as the emergency services
got to KLM, they didn’t know that Pan Am was there and that it was on fire as
well as they couldn’t see it at all. Pan Am had requested to circle the airport
on a holding pattern as the had enough fuel and wanted to get away as soon as
possible but this request was denied and Pan Am was stuck behind KLM for over
two hours while KLM refueled which will have made the passengers more irritated
and the pilots will have been both irritated with the delays and stressed due
to annoyed passengers. The pilot of KLM was normally a training instructor and
so was not used to flying regular routes such as the route he was supposed to
take that day. It had been 12 weeks since he had last flown on a regular route
and as hew was normally a training pilot, he was used to clearing himself for
takeoff which is what normally happens on simulated flights and was what he was
used to. As the stress and pressure was so high at Tenerife on the day, it is
likely that the pilot just wanted to get out as quickly as he could and after
spending 10 years being a training pilot he did what he was most used to and
that was to clear his own takeoff instead of waiting for the air traffic
controller to give clearance. As the KLM pilot was so focused on the fact that
there were dangers at Los Palmas airport, his flight was delayed, the weather
was bad, the run way was slightly narrower than it should have been, and the air
traffic controller did not have the clearest accent. It is likely he could not
comprehend non-standard radio messages and so when the message came through “we’ll
report when we’re clear” it was not processed by his already stressed mind, so
he did not think much about it and chose to dismiss the second officer. The crew
of the KLM was made up of the captain who was head of the training flight team
but also very high up in management for KLM, the co-pilot had only just
qualified as a pilot for a 747 2 months before the incident. This meant he was
quite inexperienced in the 747 compared to the captain but he had also been
cleared by that captain, so he was less likely to question the pilot’s actions
and only commented on the choices that the pilot made before the crash twice.
When the pilot first engaged the thrust levers for take off, the co-pilot
questioned him asking “Wait a minute, we do not have ATC clearance”, the pilot pulled
back the thrust levers and responded “no, I know that, go ahead ask” as the
co-pilot was in the process of requesting clearance it was then that the pilot
engaged the thrust levers again for take off and stated in an unsteady and
unclear manor that KLM was taking off. It was because of the co-pilot being so
unsure in his message that both Pan Am and the air traffic controller were
unsure if the co-pilot meant they were in position for takeoff or if they had already
started to take off.  It is noted that
the crew in KLM acted nothing like a team at all and were acting alongside each
other in a line rather than as a team Hackman, 1987 which once again will
have increased the stress in the cockpit as the crew won’t have been working
together and listening to each other, instead they will have been against each
other almost in a competition of who could do the best. If they had been
talking together and working as a team, a lot of the pressure and stress would
have been taken of the pilot’s shoulders which is what is supposed to happen
and why there is a full team in a cockpit, not just one pilot working alone to
do everything. Team work could have lead to better communication between the
pilot and co-pilot and subsequently between the co-pilot and the air traffic
controller.