Join us as we examine the 1977 crash at Los Rodeos Airport that killed 583 people and the shocking reasons behind it.
The Tenerife airport disaster occurred on 27 March 1977, when two Boeing 747 passenger jets collided on the runway at Los Rodeos Airport (now Tenerife North Airport) on the Spanish island of Tenerife. The collision occurred when KLM Flight 4805 initiated its takeoff run while Pan Am Flight 1736 was still on the runway. The impact and resulting fire killed everyone on board KLM 4805 and most of the occupants of Pan Am 1736, with only 61 survivors in the front section of the aircraft. Resulting in 583 fatalities, the disaster is the deadliest accident in aviation history.
A bomb set off by the Canary Islands Independence Movement at Gran Canaria Airport had caused many flights to be diverted to Los Rodeos, including the two aircraft involved in the accident. The airport quickly became congested with parked airplanes blocking the only taxiway and forcing departing aircraft to taxi on the runway instead. Patches of thick fog were drifting across the airfield, so visibility was greatly reduced for pilots and the control tower.
The subsequent investigation by Spanish authorities concluded that the primary cause of the accident was the KLM captain's decision to take off in the mistaken belief that a takeoff clearance from air traffic control (ATC) had been issued.[4] Dutch investigators placed a greater emphasis on a mutual misunderstanding in radio communications between the KLM crew and ATC,[5] but ultimately KLM admitted that their crew was responsible for the accident and the airline agreed to financially compensate the relatives of all of the victims.
The disaster had a lasting influence on the industry, highlighting in particular the vital importance of using standardized phraseology in radio communications. Cockpit procedures were also reviewed, contributing to the establishment of crew resource management as a fundamental part of airline pilots' training.
Flight history
Tenerife was an unscheduled stop for both flights. Their destination was Gran Canaria Airport (also known as Las Palmas Airport or Gando Airport), serving Las Palmas on the nearby island of Gran Canaria. Both islands are part of the Canary Islands, an autonomous community of Spain located in the Atlantic Ocean off the southwest coast of Morocco.
KLM Flight 4805
KLM Flight 4805 was a charter flight for Holland International Travel Group and had arrived from Amsterdam Airport Schiphol, Netherlands.[8] Its cockpit crew consisted of Captain Jacob Veldhuyzen van Zanten (age 50),[9] First Officer Klaas Meurs (42), and Flight Engineer Willem Schreuder (48). At the time of the accident, Veldhuyzen van Zanten was KLM's chief flight instructor, with 11,700 flight hours, of which 1,545 hours were on the 747. Meurs had 9,200 flight hours, of which 95 hours were on the 747. Schreuder had 17,031 flight hours, of which 543 hours were on the 747.
The aircraft was a Boeing 747-206B, registration PH-BUF, named Rijn (Rhine). The KLM jet was carrying 14 crew members and 235 passengers, including 52 children. Most of the KLM passengers were Dutch; also on board were four Germans, two Austrians and two Americans. After the aircraft landed at Tenerife, the passengers were transported to the airport terminal. One of the inbound passengers, Robina van Lanschot, who lived on the island with her boyfriend, chose not to re-board the 747, leaving 234 passengers on board.
Pan Am Flight 1736
Pan Am Flight 1736 had originated at Los Angeles International Airport, with an intermediate stop at New York's John F. Kennedy International Airport (JFK). The aircraft was a Boeing 747-121, registration N736PA, named Clipper Victor. It was the first 747 to be delivered to an airline. Of the 380 passengers (mostly of retirement age, but including two children), 14 had boarded in New York, where the crew was also changed. The new crew consisted of Captain Victor Grubbs (age 56), First Officer Robert Bragg (39), Flight Engineer George Warns (46) and 13 flight attendants. At the time of the accident, Grubbs had 21,043 hours of flight time, of which 564 hours were on the 747. Bragg had 10,800 flight hours, of which 2,796 hours were on the 747. Warns had 15,210 flight hours, of which 559 hours were on the 747.
This particular aircraft had operated the inaugural 747 commercial flight on 22 January 1970.On 2 August 1970, in its first year of service, it also became the first 747 to be hijacked: en route between JFK and Luis Muñoz MarÃn International Airport in San Juan, Puerto Rico, it was diverted to José Martà International Airport in Havana, Cuba.
Investigation
The accident was investigated by Spain's Comisión de Investigación de Accidentes e Incidentes de Aviación Civil (CIAIAC). About 70 personnel were involved in the investigation, including representatives from the United States, the Netherlandsand the two airline companies. Facts showed that there had been misinterpretations and false assumptions before the accident. Analysis of the CVR transcript showed that the KLM pilot thought that he had been cleared for takeoff, while the Tenerife control tower believed that the KLM 747 was stationary at the end of the runway, awaiting takeoff clearance. It appears that KLM's co-pilot was not as certain about take-off clearance as the captain.
Probable cause
The investigation concluded that the fundamental cause of the accident was that Captain Veldhuyzen van Zanten attempted to take off without clearance. The investigators suggested the reason for this was a desire to leave as soon as possible in order to comply with KLM's duty-time regulations (which went in place earlier that year) and before the weather deteriorated further.
Other major factors contributing to the accident were:
The sudden fog greatly limited visibility and the control tower and the crews of both planes were unable to see one another.
Interference from simultaneous radio transmissions with the result that it was difficult to hear messages.
The following factors were considered contributing but not critical:
The use of ambiguous non-standard phrases by the KLM co-pilot ("We're at take off") and the Tenerife control tower ("OK").
The Pan Am aircraft did not leave the runway at the third intersection as instructed.
The airport was forced to accommodate a great number of large aircraft due to rerouting from the terrorist incident resulting in disruption of the normal use of taxiways.
Dutch response
The Dutch authorities were reluctant to accept the Spanish report blaming the KLM captain for the accident. The Netherlands Department of Civil Aviation published a response that, while accepting that the KLM captain had taken off "prematurely", argued that he alone should not be blamed for the "mutual misunderstanding" that occurred between the controller and the KLM crew, and that limitations of using radio as a means of communication should have been given greater consideration.
In particular, the Dutch response pointed out that:
The crowded airport had placed additional pressure on all parties, including the KLM cockpit crew, the Pan Am cockpit crew, and the controller;Sounds on the CVR suggested that during the accident the Spanish control tower crew had been listening to a football match on the radio and may have been distracted;
The transmission from the tower in which the controller passed KLM their ATC clearance was ambiguous and could have been interpreted as also giving take-off clearance. In support of this part of their response, the Dutch investigators pointed out that Pan Am's messages "No! Eh?" and "We are still taxiing down the runway, the Clipper 1736!" indicated that captain Grubbs and first officer Bragg had recognized the ambiguity (this message was not audible to the control tower or KLM crew due to simultaneous cross-communication);
The Pan Am had taxied beyond the third exit. Had the plane turned at the third exit as instructed, the collision would not have occurred.
Although the Dutch authorities were initially reluctant to blame captain Veldhuyzen van Zanten and his crew,the airline ultimately accepted responsibility for the accident. KLM paid the victims' families compensation ranging between $58,000 and $600,000 (or $259,000 to $2.7 million today, adjusted for inflation).The sum of settlements for property and damages was $110 million (or $492 million today),an average of $189,000 (or $845,000 today) per victim, due to limitations imposed by European Compensation Conventions in effect at the time.
Speculations
This was one of the first accident investigations to include a study into the contribution of "human factors". These included:
Captain Veldhuyzen van Zanten, a KLM training captain and instructor for over ten years working on simulators regularly, had not flown on regular routes during the twelve weeks prior to the accident.
The apparent hesitation of the flight engineer and the first officer to challenge Veldhuyzen van Zanten further. The official investigation suggested that this might have been due not only to the captain's seniority in rank, but also to his being one of the most respected pilots working for the airline.This view is questioned by Jan Bartelski, a former KLM captain and the president of the International Federation of Air Line Pilots' Associations (IFALPA), who knew both officers and believes this explanation to be inconsistent with his knowledge of their personalities. The first officer had intervened when Veldhuyzen van Zanten first opened the throttles, but had then failed to do so on the second occasion. Although the flight engineer had indeed asked the captain whether or not the Pan Am was clear of the runway, he seemed reassured by the captain's answer. The co-pilots had clearly challenged the captain's decisions, but were not insistent enough to convince him to abort the attempted takeoff.
The flight engineer was the only member of the KLM's flight crew to react to the control tower's instruction to "report when runway clear"; this might have been due to him having completed his pre-flight checks, whereas his colleagues were experiencing an increased workload, just as the visibility worsened.
The ALPA study group concluded that the KLM crew did not realize that the transmission "Papa Alpha one seven three six, report when runway clear" was directed at the Pan Am, because this was the first and only time the Pan Am was referred to by that name. Previously, the Pan Am had been called "Clipper one seven three six", using its proper callsign.
The extra fuel taken on by the KLM added several factors:
Takeoff was delayed by an extra 35 minutes, allowing time for the fog to settle in;
More than 45 tonnes of additional weight was added to the aircraft,[63] increasing the takeoff distance and making it more difficult to clear the Pan Am when taking off;
The increased severity of the fire caused by the additional fuel led ultimately to the deaths of all those on board.
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