Tenerife. March, 27th, 1977.

[Rockhound]

In response to Badedas's post:
Here we go again! Van Zanten "ignored" his fellow crew members. Excuse me, he didn't ignore them. He responded with conviction to every one of their reminders and queries. Unfortunately and tragically his conviction was misplaced. Van Zanten, God rest his soul, cannot be defended. Ultimately, he was responsible for the disaster. All we can do is try and understand how and why his actions came about. Weather, superimposed radio transmissions, language, pressure to not exceed duty time, heavy traffic, human failings, etc., etc. - all the holes lined up, all of them.
Rockhound

[DozyWannabe]

Something that kept me awake at night when researching this subject was thinking about what might be on the last 10 seconds of the KLM CVR (which I haven't heard or read). Specifically, for all his conviction that he was in the right, what must have been going through Captain Van Zanten's head as it dawned on him just how wrong he'd gotten it - every pilot's worst nightmare.

The top-heavy cockpit management structure was as bad a tradition as the one that stated westbound mail boats should not slow down for ice. Both Captain Smith and Captain Van Zanten did everything my the mores of their times and were lauded by some as the best of their generation. That their names are now synonymous with tragedy should be ample warning for us all.

[Tarq57]

I've read the transcripts in the past, and a fair few others, with a view to try and have a notion about the various ways I might be misunderstood as a controller.
So I've been following this thread, and remembering the other horrid events, particularly those with an ATC content.
20/20 hindsight is a wonderful learning tool, albeit unacceptably expensive.

DozyWannabe, you got me thinking:
What are we doing right now, in the various professions that make up the aviation industry, that is by todays standards, agreed by most of the participants, acceptable, correct and safe,ie world's best practice, that might be frowned on in ten, twenty, thirty years?

[forget]

CRM is Crew Resource Management.... And one of the most valuable lessons learned from this accident was in fact that you have to think of the crew in a completely new way. The performance of the crew is not determined by the most skilled member, but it is determined by how well it functions as an entity.

Interesting point raised by bluefish. It's suggested that CRM was invented after Tenerife and other accidents. I believe it already existed in some airlines, but without a fancy name, and was discovered by the aviation world at large.

Mention cultural differences on Prune - and get ready for incoming - but I'll risk it, in as few words as possible.

Had the Tenerife 747 been JAL (just for example, but I can think of dozens of others), then it's likely the outcome would have been the same.

Had the Tenerife 747 been Qantas (and I can think of only one or two others) - then I do believe the query 'Is he not clear that PanAm' would have seen the throttles chopped - by all three on the flight deck.

[Dave Gittins]

One is inclined to think of a Korean 747 at Stansted

[ATC Watcher]

Bedder believeit, many thanks for your reply. I understand your point, mine was to say it was a very unusual situation and people had to improvise : the taxi routing as the taxi way was used to park a/c and low vis procedures as fog came very suddenly ( in about 4 minutes )

To make my point better, remember :
The PA missed the cleared exit ( C-3 also a 90deg turn, and took the next one.)
Controller understood KL was at take off position ( not taking off ) ,but he intervened to clarify he was not cleared to depart , the PA crew confirmed they were still on the runway at the same time and that resulted in a cross transmission, which everyone declared later they thought went out ( both the PA Capt , which survived, and the Controller declared so to the Spanish inquiry ) the " squeal" was only heard by others ( i.e also the KL) not by the controllers and the PA crew. .

The (Spanish ) inquiry decided that since the “OK… stand by for take off, I will call you “ was not a clearance , it did not need to be confirmed back by another transmission.
The Dutch argued that the pre-departure clearance received contained ,and was understood by the KL crew, as containing the take off clearance. ( This is still today the KLM position by the way ) .

Now should the controller , had called again to make sure : there you are , and this is your point I believe.
But for the controller the KL was lined up but not cleared, the PA still backtracking opposite, exiting at C-3 , well before the KL .That was his mental picture (as he declared it ). What would you have done more ? Remember the KL was backtracking the runway, not coming from a taxi way.

I have now found a brief description of the DC8/727 collision you were referring to. I did not know that case ,( it did not make our European database, possibly because there were no casualties ) but it is interesting. Thanks for this. I also found back part of the court case judgment, which refers to " failure of the controller to keep proper look out before issuing a take off clearance " and referring to the old famous " duty of care" that sent many of us in jail in the past.
This was not the case in TFN. The controller was unable to see anything, and issued a confirmation not to take off, but it never reached its intended recipient .

Should he had been more precise, or repeat his last instruction, with hindsight, of course.

If you want to understand better how the controller worked , the best details are in the 11 pages of the 1978 Dutch Comments annexed to the 2nd Spanish report .

Some 10 years ago I have heard the controller on duty that day talking about it. ( he was retired but still lived in Tenerife ) . Believe me, you do not want to be in his shoes, even 30 years later. The Dutch lawyer team seemed to have been particularly violent at the time , trying to prove he was responsible, not Van Zanten....This left some deep marks.

Best regards to you as well ( still with a headset on ? )

[PaperTiger]

Txiway C3 is more than a 90deg turn, more like 135 - it's a high speed in the opposite direction:
.
I don't think the "missing" CVR is particuarly sensitive:
17:06:32 - KLM (intra cockpit) - Is he not clear, then ? (Flt Eng, in Dutch)
17:06:34 - KLM (intra cockpit) - What yo you say ? (Capt, in Dutch)
17:06:34 - KLM (intra cockpit) - Yup ? (1st officer)
17:06:34 - KLM (intra cockpit) - Is he not clear, that Pan American ? (Flt Eng, in Dutch)
17:06:35 - KLM (intra cockpit) - Oh, yes (emphatic) ? (Capt, in Dutch)
17:06:XX - PAA (intra cockpit) - Let´s get the hell right here, get the hell out of here. (Capt)
17:06:XX - PAA (intra cockpit) - Yeah, he´s anxious, isn´t he ? (1st officer)
17:06:XX - PAA (intra cockpit) - Yeah, after he held us up for an hour and a half, that (expletive). (Flt Eng)
17:06:XX - PAA (intra cockpit) - Yeh, that (expletive). (1st officer)
17:06:XX - PAA (intra cockpit) - Now, he´s in a rush. (Flt Eng)
17:06:43 - KLM (intra cockpit) - Vee One (1st officer)
17:06:xx - PAA (intra cockpit) - There is...look at him (expletive) that... that son-of-a-bitch is coming. (Capt)
17:06:47 - KLM (intra cockpit) - exclamation (Capt)
17:06:XX - PAA (intra cockpit) - Get off, get off. (1st officer)
17:06:49 - COLLISION + End of Recordings

[Rockhound]

Forget,
Are you having us on? If you're serious, your post ranks as among the most inane it has ever been my misfortune to read on PPRune.
Rockhound

[747flyby]

Phraseology Changed

I remember that we were told in the ATPL long time ago by an Air Traffic Controller.

Before TFN accident they would say "¨Cleared for Takeoff Position"
After TFN accident it was changed to "Cleared for Runway Position"
then later "Cleared to Line Up"

There was a theory that KLM missed the position part and only heard the "Cleared for Takeoff part.

Also the PANAM missed the exit he was to take due to the fog.

This is a classic example of traps being laid for both the crews.

1. The Weather
2. Not clear English by the controllers
3. Hurry up syndrome because of legallity
4. Misunderstanding between controllers and both the crews.

At that time there were different rules and attitude in aviation.

Airlines were not very much CRM orientated at that time like we are now.
The KLM captain was the face of KLM in the media and was very much thought of as a hero in holland.

Some things we do not know and will never know, however the spanish and FAA blamed the accident completely on the KLM captain. The dutch would not accept it and came out with their own report.

I saw an interview on a documentary with the F/O of panam and he was standing on the spot of the accident and took up a handfull of debris 20 years after.

May they all RIP

[poorwanderingwun]

Rockhound

I think you're being a little hard on 'Forget'... It is true that certain cultures have varied approaches to authority.. The doctrine of the German / Japanese and some others to authority is markedly different to that of the Australians who have a healthy disrespect for it.. It has been recognised for many years ( I can remember reading a Psychological report on the Qantas flight crew working environment back in the '80s ) that the ready willingness to question an action by the skipper had more than once been effective in keeping an aircraft out of trouble.. seems obvious to everyone today but up until 20+ yrs ago the thought of question the skipper was almost sacrilage.

[019360]

Well we all need to focus on the key CRM point here, whatever culture we live in. "What is Right?" not "Who is Right?"
If we can embed that....and its a big "IF"....then we've nailed down things well. Any culture where we don't question things because of "WHO" said it.....is unsafe.And that can be any culture. It's just as bad to keep your mouth shut because someone like Chuck Yeager is in the LHS.
One of my very first instructors, way too long ago, said "Son, don't even trust your own mother if she says she checked the fuel. Check it yourself".
Schreuder was right of course, to question...his query was truly the very last line of defence, or hole in the cheese or whatever. But resolving queries by assertion or belief will kill you more quickly than almost anything else.

[Brian Abraham]

authority is markedly different to that of the Australians who have a healthy disrespect for it

Rockhound, I too have to defend Forget. poorwanderingwun's above quote comes directly from a "Flight International" article on world wide airline safety published so many years ago I forget. Is a national characteristic you will find was the cause of much consternation to the British officer class in World War One.

[Bedder believeit]

ATC watcher, further to this topic, unfortunately we read the so called transcripts, but they only tell half the story. Also the written word often loses it's meaning compared to the spoken. It would be interesting to hear the full tower tapes, not just truncated ones that relate to the accident. I am sure that there would have been a number of other aircraft on the frequency clamouring to get their bit in given that things had been, and were developing into a pretty chaotic situation. People calling for various clearances etc, changing and (critical) weather situations evolving rapidly, taxyways not available, runway lighting issues. It doesn't take long for the realisation to dawn that when the crocodiles start biting your arse, the original intention was to drain the swamp. Cheers watcher.

747flyby: The controller you quote wasn't at Kittyhawk was he? Since I started in ATC in 1968 (well before this accident), the "non American" way of doing things has always been either:
"Line up"
"Behind the departing .....line up (and wait)"
or
"Line up and wait"
I know the Americans have their:
"Enter position and hold"

I have always been of the understanding that the prefix "Cleared" is only used when an executive instruction is being given as in "Cleared to land" or "Cleared for take off". It also is used when issuing an airways clearance. Unfortunately I have always found it a bit difficult to come to terms with the fact that part of the airways clearance given to KLM by the tower included the phrase "....after Take off....". BB

[4Greens]

Excellent discussion on culture, amongst other matters, in 'Attitude or Latitude' by Dr Graham Braithwaite. Ashgate the publishers and Graham currently runs accident investigation courses at Cranfield University in the UK.

[forget]

forget, Are you having us on? If you're serious, your post ranks as among the most inane it has ever been my misfortune to read on PPRune. Rockhound

Thank you Rockhound, but flattery will get you nowhere. Now sit back sonny, read, learn, then get back to your rocks.

In the 70’s the Orient Airlines Association commissioned the University of Hong Kong to investigate why some member airlines were way above the regional accident average, and some were way below. There didn’t seem to be an in-between.

The conclusions were published on the three pages of A4. The reasons had nothing do with ‘flying’ ability, or a deep understanding of how aviation ‘worked’. It was simply national Culture.

Qantas, as an OAA member, was used as the Gold Standard, as you’d sort of expect. The university concluded that there is hardly any social class structure within Australia and Trevor, in the right seat, knows he’s equal to Bruce, in the left seat. If Bruce ever looked to be heading for a screw-up then Trevor wouldn’t think twice about a verbal clip around the ear.

Now, replace Bruce and Trevor with Bokusui and Tadahiko ……………

The chances of Tadahiko criticising the actions of ‘my captain’ is nil, zero.

( You may be too young to recall a DC-8 in Tokyo harbour.)

This is natural CRM, or lack of, by cultural default.

Years ago I had a friend who was doing in-flight 747 Nav trials with Tadahiko’s outfit. He laid his pencil on the FE’s table - and the FE took on a look of shock and horror. Turns out that that my friend had just shown enormous disrespect to the captain by leaving the pencil pointing at him. Difficult to operate an aircraft with that sort of bullsh*t.

Rockhound, A private word if I may. By all means continue to use Prune to ask your many questions on aviation basics, but do try to limit your sneering assaults on the supported opinions of others. This particular ‘other’ has spent better than forty five years living in hangars and on airfields in a dozen different countries. My experience of the business isn’t limited to air-band radios and decoding ACARS messages. Have a think about it – there’s a good chap.

[ATCO1962]

forget,

Are we thinking about the same DC-8 incident? If it was JAL into the harbour near Haneda, it was a suicidal captain who pushed the nose down to end his life but not before the crew tried to restrain him. That was most definitely not a cultural problem. Having lived in Japan for over 10 years and having kept some ties with the country, it is changing. While there may have been a strong "captain rules" mentality in the past, I believe it is not so evident now.

[Rockhound]

Forget,
You read an awful lot of significance into a single query from a crewmember, uttered during a TO roll, that was answered emphatically by the PIC. And you think if the crew had been Aussies, they'd all have reached for the throttles but not if they'd been Asian? Sorry, your childlike faith in cultural superiority is touching but I still think your ideas don't hold water in this particular case.
Rockhound

[ATCO1962]

Oh, and Qantas were just a tad lucky in Bangkok. Accidents are often caused by humans and they come in all shapes, sizes, cultures, etc,etc.

[forget]

Sorry, your childlike faith in cultural superiority is touching but I still think your ideas don't hold water in this particular case.

Rockhound, You are coming across as a prize prat. Where have I mentioned cultural superiority - we're talking cultural differences.

Do yourself a favour and take my previous advice.

ATCO 1962.

Are we thinking about the same DC-8 incident?

I believe we are. The captain in question didn't 'push the nose' down, he pulled 2 and 3 into reverse. However, as I recall, the last 30 minutes of CVR recorded serious unrest from the FO and FE due to the captain's behaviour. Enough time to have got him off the flight deck with a bit of altitude to play with. Seems they didn't even consider it.

[Graybeard]

I'm sure this isn't new to many here, but the order of command in many countries is:

1. the Captain
2. God
3. Everybody else