Tenerife crash
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......and 25 years on - a revelation;
Dutch NLR Study Takes A Fresh Look At Common Causal Factors.
A study of runway incursion events carried out by the Netherlands National Aerospace Laboratory (NLR) has identified many causal factors. More detail on the report will be included in the next Runway Safety Letter, but here are the top 5 causal factors identified:
Incorrect use of conditional clearances.
Use of non-standard phraseology by controllers.
BLOCKED TRANSMISSIONS.
Multiple runway operations, especially closely spaced
parallel runways requiring many runway crossings.
Non-compliance with ICAO Annex 14 surface markings, signage and lighting.
Dutch NLR Study Takes A Fresh Look At Common Causal Factors.
A study of runway incursion events carried out by the Netherlands National Aerospace Laboratory (NLR) has identified many causal factors. More detail on the report will be included in the next Runway Safety Letter, but here are the top 5 causal factors identified:
Incorrect use of conditional clearances.
Use of non-standard phraseology by controllers.
BLOCKED TRANSMISSIONS.
Multiple runway operations, especially closely spaced
parallel runways requiring many runway crossings.
Non-compliance with ICAO Annex 14 surface markings, signage and lighting.
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Location: Horsham, England, UK. ---o--O--o---
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See Here:-
A comprehensive description of this accident and its causal factors is also available in McArthur Job's "Air Disaster Vol. 1" (ISBN 1875671110).
All four volumes in that series are valuable sources to help understand the history of aviation accidents and potential factors to watch out for.
All four volumes in that series are valuable sources to help understand the history of aviation accidents and potential factors to watch out for.
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It could still happen
Sad fact is that despite the terrible lessons learnt and the work done by the international aviation community, runway incursions are still occuring.
Witness the Eurocontrol campaign amongst others only last year highlighting the potential for a major catastrophe. Figures in Europe for gross errors are reducing, but what about the rest of the world?
Not everyone has, or can afford SMR, RIMCAS, lit stop bars or well developed lo-viz procs.
My wager is that if another collision between 2 large a/c happens on the ground it will be in the Far East. Not a brilliant deduction just that growth in air transport is outstripping safety management system maturity in some parts of the globe.
I sincerely hope that it doesn't happen.
Sir George Cayley
Witness the Eurocontrol campaign amongst others only last year highlighting the potential for a major catastrophe. Figures in Europe for gross errors are reducing, but what about the rest of the world?
Not everyone has, or can afford SMR, RIMCAS, lit stop bars or well developed lo-viz procs.
My wager is that if another collision between 2 large a/c happens on the ground it will be in the Far East. Not a brilliant deduction just that growth in air transport is outstripping safety management system maturity in some parts of the globe.
I sincerely hope that it doesn't happen.
Sir George Cayley
Coppula eam se non posit acceptera jocularum
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My wager is that if another collision between 2 large a/c happens on the ground it will be in the Far East.
And was language not a factor in Milano-Linate, 8 Ootober 2001?
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The report of this accident was re-printed by ICAO in their accident Digest No.23 p.22 onwards. There was also a Dutch Accident Inquiry Board report in English but I don't immediately have the number to hand (It's in our library somewhere!)
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Extracts from Conclusions Presented to the Netherlands Board of Inquiry by the Director General of Civil Aviation.
Accident Inquiry Involving Boeing 747’s PH-BUF and N736A. Tenerife March 1977.
1. Before I commence my argument I want to commemorate the 583 crew members and passengers who have lost their lives so tragically in this accident and to express my sympathy to their next of kin.
2. The Pam Am crew was alarmed by the way in which the Air Traffic Clearance was issued. The captain has declared to have feared that, from this communication, the KLM could possibly take the ATC clearance as a take off clearance and, immediately after the tower controller had said ‘0kay’, and pauses for almost two seconds, he and his first officer jumped in to inform the KLM crew that they were still taxiing on the runway.
3. The message of the Pan Am crew coincided with the message of the tower controller who, at that moment, told the KLM aircraft to wait for take-off clearance.
4. The coinciding transmission on the same frequency resulted, in the KLM cockpit only, in a strong squeal.
5. Because of this, both vital messages were lost to the KLM crew.
6. The primary cause, therefore, must be sought in the fact that the safety of the system in which all concerned were operating was depending, and still is depending on, the weakest link - the radio communication.
7. This fatal accident has shown, once more, that the oral transmission of essential information via a single and vulnerable radio connection implies considerable dangers.
8. Facts and circumstances show that information transmitted by radio communication can be understood in a different way to that intended as a consequence of ambiguous terminology and the obliteration of essential parts.
9. As I have said in the beginning of my argument, the eminent lesson to be drawn from this accident is the urgent need for improvement of the communication between aircraft and control tower.
10. Compared with other developments in aviation radio communication has lagged far behind in that the fail safe principle, which has been generally applied in modem aviation in the field of construction, systems and procedures, and which has materially contributed to attain a higher level of safety, does not apply to radio communication. The latter is not fail safe.
11. It is known that at several airports all over the world, but also during flights, a number of incidents have occurred in the last few years which arose from radio communication.
12. Although these did not result in accidents some of them bore a great resemblance to the Tenerife accident. To my opinion the situation is more serious then is being presented.
13. Although from the statements of the experts these past days it may be derived that serious problems hardly exist I have the opinion that, considering the potential risks, urgent attention is needed for possibilities to improve the radio communication system. It is obvious that improvements in the field of communications can only be achieved at an international level and this will require research and time.
14. On an international level the existing interest within the International Civil Aviation Qrganisation, the International Air Transport Association and the International Federation of Air Line Pilots’ Associations should be fostered.
15. The problem of radio communication is recognised. IATA has established a working group to study the best approach to handle this problem. The Federal Aviation Administration requested a number of research institutes to make a fundamental study of the communications problems in which also NASA is involved.
16. It is essential that, on an international level, this matter receives the attention which it deserves so urgently. The problem needs our strongest efforts to obtain radical improvements soon. The public inquiry of your board and the world-wide publicity of your finding will, as I hope and expect, contribute considerably to this purpose.
Accident Inquiry Involving Boeing 747’s PH-BUF and N736A. Tenerife March 1977.
1. Before I commence my argument I want to commemorate the 583 crew members and passengers who have lost their lives so tragically in this accident and to express my sympathy to their next of kin.
2. The Pam Am crew was alarmed by the way in which the Air Traffic Clearance was issued. The captain has declared to have feared that, from this communication, the KLM could possibly take the ATC clearance as a take off clearance and, immediately after the tower controller had said ‘0kay’, and pauses for almost two seconds, he and his first officer jumped in to inform the KLM crew that they were still taxiing on the runway.
3. The message of the Pan Am crew coincided with the message of the tower controller who, at that moment, told the KLM aircraft to wait for take-off clearance.
4. The coinciding transmission on the same frequency resulted, in the KLM cockpit only, in a strong squeal.
5. Because of this, both vital messages were lost to the KLM crew.
6. The primary cause, therefore, must be sought in the fact that the safety of the system in which all concerned were operating was depending, and still is depending on, the weakest link - the radio communication.
7. This fatal accident has shown, once more, that the oral transmission of essential information via a single and vulnerable radio connection implies considerable dangers.
8. Facts and circumstances show that information transmitted by radio communication can be understood in a different way to that intended as a consequence of ambiguous terminology and the obliteration of essential parts.
9. As I have said in the beginning of my argument, the eminent lesson to be drawn from this accident is the urgent need for improvement of the communication between aircraft and control tower.
10. Compared with other developments in aviation radio communication has lagged far behind in that the fail safe principle, which has been generally applied in modem aviation in the field of construction, systems and procedures, and which has materially contributed to attain a higher level of safety, does not apply to radio communication. The latter is not fail safe.
11. It is known that at several airports all over the world, but also during flights, a number of incidents have occurred in the last few years which arose from radio communication.
12. Although these did not result in accidents some of them bore a great resemblance to the Tenerife accident. To my opinion the situation is more serious then is being presented.
13. Although from the statements of the experts these past days it may be derived that serious problems hardly exist I have the opinion that, considering the potential risks, urgent attention is needed for possibilities to improve the radio communication system. It is obvious that improvements in the field of communications can only be achieved at an international level and this will require research and time.
14. On an international level the existing interest within the International Civil Aviation Qrganisation, the International Air Transport Association and the International Federation of Air Line Pilots’ Associations should be fostered.
15. The problem of radio communication is recognised. IATA has established a working group to study the best approach to handle this problem. The Federal Aviation Administration requested a number of research institutes to make a fundamental study of the communications problems in which also NASA is involved.
16. It is essential that, on an international level, this matter receives the attention which it deserves so urgently. The problem needs our strongest efforts to obtain radical improvements soon. The public inquiry of your board and the world-wide publicity of your finding will, as I hope and expect, contribute considerably to this purpose.
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While the Spanish report dated October 1978 does acknowledge the contributary factors mentioned above, the conclusions ascertained remain the same:
a) The KLM Captain decided to commence take-off on hearing the ATC clearance
b) Ignored the ATC's instructions to 'Standby for take-off'
c) Did not interrupt take-off when Pan-Am aircraft reported they were not clear of the active runway
d) Emphatically replied in the affirmative the F/E's query as to whether the Pan-Am aircraft had vacated the active runway.
a) The KLM Captain decided to commence take-off on hearing the ATC clearance
b) Ignored the ATC's instructions to 'Standby for take-off'
c) Did not interrupt take-off when Pan-Am aircraft reported they were not clear of the active runway
d) Emphatically replied in the affirmative the F/E's query as to whether the Pan-Am aircraft had vacated the active runway.
Re: Tenerife crash
As in most disasters of course one link in a long chain....
I can't help thinking of the Pivotal role the F/E played in this. He had the ability to stop everything even when he queried the other crew as to the Pan Am (and it has been demonstrated even at that late stage disaster would have been averted). He definitely had the correct mental model in place as regards to situational awareness.
He clearly was unhappy with the decision to continue.
A tragedy that is a textbook CRM case.
I can't help thinking of the Pivotal role the F/E played in this. He had the ability to stop everything even when he queried the other crew as to the Pan Am (and it has been demonstrated even at that late stage disaster would have been averted). He definitely had the correct mental model in place as regards to situational awareness.
He clearly was unhappy with the decision to continue.
A tragedy that is a textbook CRM case.
