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Tenerife KLM/Pan Am The Worlds Worst Aviation Disaster Aircraft Involved History of the Flights The Turning Point The Diversion Personnel Information and Running the numbers The Disaster Analysis and Thoughts Objectives of Presentation

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tenerife klm pan am

Tenerife KLM/Pan Am

The Worlds Worst Aviation Disaster

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
Objectives of Presentation
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 5:06pm local time
Condensed Version
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
Aircraft Involved
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
History of the Flights
a turning point
At 1:15pm 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.
A Turning Point
diverting
Diversion of incoming flights were sent to Tenerief North Airport
  • Including a number of large aircraft on long international flights
  • Google Map
Diverting
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.
Personnel Information and running the numbers
personnel information and running the numbers9
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 KLM’s bill.
Personnel Information and running the numbers
the disaster

The Disaster

Tenerief North Airport

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 didn’t ATC tell the KLM to exit on a taxi way, instead of full a full back taxi?
“Take Taxi One, Two, Three..Three”
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”
Analysis
analysis13
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.
Analysis
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.
Thoughts onFacts
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.
Things the Crew could have done differently