Tenerife. March, 27th, 1977.
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bomarc
I'll apologise in advance if you can prove it to be correct - but I don't believe that statement.
Please - a link to some official written document that says so.
In the US, "ready for takeoff" is the correct phrase.
Please - a link to some official written document that says so.
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Also the PANAM missed the exit he was to take due to the fog.
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KLM'S fault - certainly.
PAN AM'S contribution - Lack of discipline and complacency in the cockpit?The "good ol' boys", just working through it together? Typical poor US radio procedures as well?
I'm still waiting for a standard radio call from US pilots and controllers.
National carrier cover up - certainly.
Qantas also did it it Bangkok and still deny any fault. In fact, they blame the runway surface. Surely they could only partially blame the runway as they only ever saw the last half of it!
Have things changed?
PAN AM'S contribution - Lack of discipline and complacency in the cockpit?The "good ol' boys", just working through it together? Typical poor US radio procedures as well?
I'm still waiting for a standard radio call from US pilots and controllers.
National carrier cover up - certainly.
Qantas also did it it Bangkok and still deny any fault. In fact, they blame the runway surface. Surely they could only partially blame the runway as they only ever saw the last half of it!
Have things changed?
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Forget,
No, you didn't explicitly propose cultural superiority but that opinion was clearly implicit in your original post - some cultural differences are better than others.
Anyway, we've been down this road of cockpit cultures before on PPRune and it leads to a cul-de-sac (plus a lot of unnecessary name-calling).
Here's a question for you and your fellow-professionals:
Let's suppose F/E Schreuder had decided they were on a collision course and retarded the throttles but it transpired that the Pan Am had just managed to exit the runway and a routine takeoff could have been effected. What would have been the fallout from his action (a) in 1977 and (b) now (leaving aside, for the moment, the fact that T/O clearance had not been given)? In a present-day CRM environment, can a crewmember take drastic action, which turns out to have been unnecessary or in error, without fear of reprisal?
Rockhound
No, you didn't explicitly propose cultural superiority but that opinion was clearly implicit in your original post - some cultural differences are better than others.
Anyway, we've been down this road of cockpit cultures before on PPRune and it leads to a cul-de-sac (plus a lot of unnecessary name-calling).
Here's a question for you and your fellow-professionals:
Let's suppose F/E Schreuder had decided they were on a collision course and retarded the throttles but it transpired that the Pan Am had just managed to exit the runway and a routine takeoff could have been effected. What would have been the fallout from his action (a) in 1977 and (b) now (leaving aside, for the moment, the fact that T/O clearance had not been given)? In a present-day CRM environment, can a crewmember take drastic action, which turns out to have been unnecessary or in error, without fear of reprisal?
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Gentleman, I'm having serious difficulty with one part of this discussion. Do you really think that Van Zanten would have been overly concerned with duty hours on that day? I ask for the following reasons:
- They were diverted due to a bomb explosion in the terminal at Las Palmas.
- On 9/11, was any pilot anywhere too concerned about strict adherence to duty hours on that day, because of the surreal diversions?
- Would a diversion due to a bomb explosion at an airport on that day in 1977, have caused a similar one time change in attitude about duty hours, at least for the duration of that day?
- Even if violating duty hours was criminal to the Dutch in 1977, would exceeding duty hours by some amount on a day with exploding bombs in terminals, have caused great concern with the Dutch authorities?
- Would any aircrew have had thoughts along these lines in 1977, or today?
Last edited by Flight Safety; 31st Mar 2007 at 17:56.
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Flight Safety,
In 1977, exceeding duty time was a very serious matter for Dutch aircrew. In case of doubt, KLM crews were to contact Amsterdam and establish a limit to their duty day. Captains exceeding their limit were liable for prosecution under the law. Van Zanten had been told by KLM HQ that if they departed Las Palmas by 1900 hrs he would not exceed his duty time. The foregoing is from Stanley Stewart's book Air Disasters (1986).
Rockhound
In 1977, exceeding duty time was a very serious matter for Dutch aircrew. In case of doubt, KLM crews were to contact Amsterdam and establish a limit to their duty day. Captains exceeding their limit were liable for prosecution under the law. Van Zanten had been told by KLM HQ that if they departed Las Palmas by 1900 hrs he would not exceed his duty time. The foregoing is from Stanley Stewart's book Air Disasters (1986).
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Rockhound, So cultural superiority was ‘clearly implicit’ in my original post.
My last word on the matter, and trust me on this one. I’m British but you’ll note I used Qantas as the Gold Standard and not an airline with a Union Flag on the side. Why? Because, in the 70’s, British airlines weren’t renowned for their safety record when it came to ‘crew communications and coordination’.
Take a look at a certain British European Airways Trident Papa India and you’ll see what I mean. What I was saying, and what many others believe to be true, is that Australian social attitudes, by some psychological quirk, played a large part in them operating aircraft in a safer manner than other nationalities. Can I be guilty of proposing cultural superiority of a culture other than my own.
Your queries on reprisal for pilots doing what they think is right, 70’s and now, will no doubt be answered by those better placed.
My last word on the matter, and trust me on this one. I’m British but you’ll note I used Qantas as the Gold Standard and not an airline with a Union Flag on the side. Why? Because, in the 70’s, British airlines weren’t renowned for their safety record when it came to ‘crew communications and coordination’.
Take a look at a certain British European Airways Trident Papa India and you’ll see what I mean. What I was saying, and what many others believe to be true, is that Australian social attitudes, by some psychological quirk, played a large part in them operating aircraft in a safer manner than other nationalities. Can I be guilty of proposing cultural superiority of a culture other than my own.
Your queries on reprisal for pilots doing what they think is right, 70’s and now, will no doubt be answered by those better placed.
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I don't have the transcript to hand, but I remember reading it and there was certainly talk on it about the consequences of exceeding duty hours - something along the lines of "they'll really hang you out to dry"*. So, whether the Dutch civil aviation authorities would have taken a lenient approach is open to question, but the crew certainly feared they would be in trouble.
Incidentally, there was a book written by a former IFALPA President, Jan Bartelski, himself a former DC10 captain with KLM, called "Disasters in the Air" (ISBN 1 8037 204 4), which gives an interesting perspective from the KLM angle. Among the assertions made are:
- Meurs had actually served as a temporary DC8 captain before converting to the 747, (he had been offered DC9 command) so suggestions that he was somehow intimidated by Van Zanten are inaccurate. (Indeed, one recent documentary on the crash showed the captain to be a right martinet). Although Bartlelski also acknowledges that he was a personal friend of Meurs, he says that his rating of him as an excellent pilot was shared by other captains.
- The match between Spain and Hungary was coming to a climax at the time the 747s were moving; Spain was down 1-0 and at 17.04, the ref had allowed a free kick close to the Spanish goal. The KLM plane entered the runway at 16.59 and the PAA at 17.02. Thus, it's claimed that the controllers were distracted.
- The KLM FO, Klaas Meurs, reported to ATC at 17.05 that the aircraft was awaiting ATC clearance and ATC came back with the communication. "KLM 8705 (sic), you are cleared to Papa Beacon, climb and maintain flight level niner zero ..." (This should have been preceded by "your ATC clearance is ...").
- Although Van Zanten has been described as the 747 fleet captain, Bartelski asserts that he was actually a reserve captain, although he was the chief of 747 training. His seniority was sufficient to be a DC9 captain, but he opted to be an FO on the 747 fleet. He qualified as an instructor and when the head of 747 training retired, Van Zanten was appointed and promoted to captain. Since his promotion was out of turn, he was only allowed to fly as a line captain when no other captains were available. (It's also suggested that the the reason he featured in the KLM ad (see a few pages back) was that he was the only captain available, being in the simulator section at the time.
As I say, Bartelski is a former KLM pilot, but I thought it would be interesting to report a Dutch perspective ...
(*Just found an extract from the transcript: The FE asked "what are the repurcussions of exceeding the flight limits;another responded "You face the judge", to which Schreuder replied, "Then you are hanged from the highest tree".)
Incidentally, there was a book written by a former IFALPA President, Jan Bartelski, himself a former DC10 captain with KLM, called "Disasters in the Air" (ISBN 1 8037 204 4), which gives an interesting perspective from the KLM angle. Among the assertions made are:
- Meurs had actually served as a temporary DC8 captain before converting to the 747, (he had been offered DC9 command) so suggestions that he was somehow intimidated by Van Zanten are inaccurate. (Indeed, one recent documentary on the crash showed the captain to be a right martinet). Although Bartlelski also acknowledges that he was a personal friend of Meurs, he says that his rating of him as an excellent pilot was shared by other captains.
- The match between Spain and Hungary was coming to a climax at the time the 747s were moving; Spain was down 1-0 and at 17.04, the ref had allowed a free kick close to the Spanish goal. The KLM plane entered the runway at 16.59 and the PAA at 17.02. Thus, it's claimed that the controllers were distracted.
- The KLM FO, Klaas Meurs, reported to ATC at 17.05 that the aircraft was awaiting ATC clearance and ATC came back with the communication. "KLM 8705 (sic), you are cleared to Papa Beacon, climb and maintain flight level niner zero ..." (This should have been preceded by "your ATC clearance is ...").
- Although Van Zanten has been described as the 747 fleet captain, Bartelski asserts that he was actually a reserve captain, although he was the chief of 747 training. His seniority was sufficient to be a DC9 captain, but he opted to be an FO on the 747 fleet. He qualified as an instructor and when the head of 747 training retired, Van Zanten was appointed and promoted to captain. Since his promotion was out of turn, he was only allowed to fly as a line captain when no other captains were available. (It's also suggested that the the reason he featured in the KLM ad (see a few pages back) was that he was the only captain available, being in the simulator section at the time.
As I say, Bartelski is a former KLM pilot, but I thought it would be interesting to report a Dutch perspective ...
(*Just found an extract from the transcript: The FE asked "what are the repurcussions of exceeding the flight limits;another responded "You face the judge", to which Schreuder replied, "Then you are hanged from the highest tree".)
Last edited by akerosid; 31st Mar 2007 at 18:30. Reason: Clarification
In a present-day CRM environment, can a crewmember take drastic action, which turns out to have been unnecessary or in error, without fear of reprisal?
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Culture & CRM
Rockhound, forgetting "forget" for a moment let me say that there are huge differences in CRM depending on the culture one is operating within. I know from experience that some (I will not name them unless you insist) airlines in Asia think of CRM as a requirement to be endured and use it not at all when in an operating enviornment. These differences, actually resistance to use CRM in an operating enviornment, are in my mind a larger contributor to negative incidents, be they on the ground or in the air, than this thread, so far, seems to understand. As as example of what I am talking about there are pilots working for one of the world's major airlines than regularly appear for flight planning/in the cockpit with the smell of alcohol on their breath. The co-pilot, in this case, never says a word. When I was advised of this by him and his fellow co-pilots I was incredulous. They just accepted it as SOP, as to turn in a Captain in this culture is equivalent to requesting termination. Seems to me CRM could be useful in this type of situation.
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Akerosid, very interesting remarks .
However I doubt the F/O was a DC8 captain, never heard it before. he was only 42 and that would have be unusual in those days on the DC8 .
What I know is that he was very junior on the 747, and that Van Zanten himself gave him his 747 rating and did his line check few months before.
So he could have been intimidated by him. But pure speculation from my side ,I agree.
I was, and still am, very careful on the Dutch/ KLM version of facts :
The Dutch, from day 2 concentrated on disculping Van Zanten and concentrated on the errors made by others ( rush and exit miss by the Pan Am crew, ,imprecision of ATC R/T , and of course the famous football match that would have distracted the controller ).Their lawyers were particularly nasty.
The Spanish, on their side did everything to put all the blame on Van Zanten .
I would take both views with caution. The truth lies in the middle, as always and is burried into 10 or 15 factors, as always.
What I personally think, is that van Zanten truly believed he had a take off clearance. Why is THE question.
What I really find sad, after 30 years , is that this question is not yet ansewered, the report(s) looked into 4 or 5 factors, but let others untouched.
To be fair, Tenerife brough the " line up and wait " but many lessons from Tenerife are still out there, unlearned.
That is the sad part of this anniversary.
.
However I doubt the F/O was a DC8 captain, never heard it before. he was only 42 and that would have be unusual in those days on the DC8 .
What I know is that he was very junior on the 747, and that Van Zanten himself gave him his 747 rating and did his line check few months before.
So he could have been intimidated by him. But pure speculation from my side ,I agree.
I was, and still am, very careful on the Dutch/ KLM version of facts :
The Dutch, from day 2 concentrated on disculping Van Zanten and concentrated on the errors made by others ( rush and exit miss by the Pan Am crew, ,imprecision of ATC R/T , and of course the famous football match that would have distracted the controller ).Their lawyers were particularly nasty.
The Spanish, on their side did everything to put all the blame on Van Zanten .
I would take both views with caution. The truth lies in the middle, as always and is burried into 10 or 15 factors, as always.
What I personally think, is that van Zanten truly believed he had a take off clearance. Why is THE question.
What I really find sad, after 30 years , is that this question is not yet ansewered, the report(s) looked into 4 or 5 factors, but let others untouched.
To be fair, Tenerife brough the " line up and wait " but many lessons from Tenerife are still out there, unlearned.
That is the sad part of this anniversary.
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I will be accused of harping on, and I don't have an aerodrome map of Teneriffe in front of me, but I can't understand, given the circumstances, why the Tower controller, didn't back track KLM to the first high speed exit (45 degree turn), then off the runway, and then to the holding point via the parallel taxyway for the departure runway. This is just as expeditious, and causes far less wear and tear to both the runway surface and the landing gear of the 747. As a tower controller, I would only give a backtrack and line up to a large wide bodied pax aircraft if it was the very last resort. I would even think twice before giving it to any aircraft. Let's face it, if this was done, then we probably wouldn't be here discussing this. I will be accused again of being "hard", but it just doesn't make sense to me. Or am I wrong? Is that what happened in the 5 minutes before take-off roll commenced? We never seem to get the full picture of what went on well before the accident. If it was so, that the KLM taxyied via the parallel, well I then ask the question, what was he doing on the runway, without an airways clearance, and with another aircraft backtracking down the runway with vis less than 500 metres? Incomings???
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Perhaps
Bedder believeit, I love your handle.
Seems to me this thread has pretty much covered all the aspects known those who posted. There are many facts, derived from transcripts (complete?) and other sources. I remember the shock of that accident well. For me most of the ideas put forth here are intelligent and insightful. I have felt for many years that that complacency on the part of the Tenerife controllers played a large part. They just were not as involved, not as attentive, not as aware, did not use exact ICAO avaition phraseology in their communications. Yes, the Captain of the KLM flight could have been thinking any of the things mentioned here. It could have been from hurryupitis to downright egoism. What was in his mind is all speculation. Yes, the co-pilot could have taken over control of the aircraft, the F/E could have screamed ABORT. It is really all speculation on the motivation of the Captain. He is dead and even if alive no one can know what was in his mind during those moments when he obviously believed he was cleared for T/O and did just that...try to T/O. I have never seen any program, article, book or report by the Dutch (or anyone else) that really owned up to the critical part the KLM crew played in the accident. I've flown with many KLM jumpseat pilots and this topic has come up frequently. Never have I heard a Dutch KLM pilot agree that the KLM's crews actions were at the core of the accident. From my experience I have seen that when operating an aircraft, especially a high speed jet aircraft, if ones concentration is not totally on the job at hand (actively operating an aircraft)bad things can and do happen. It is very easy for one to have in their mind many things going on at once, and if they are distracting enough (divorce, death, disease, etc.) then it is easy for some to miss what would be obvious to anyone concentrating totally on the job. At his point it is a terrible tragedy in the past and a leanrning tool in the present. Is the lesson here for all involved keep your mind actively, totally focused on the job at hand, as attentive and aware as one can be and stopping all extraneous intermal mind/thought material until the brakes are set?
Seems to me this thread has pretty much covered all the aspects known those who posted. There are many facts, derived from transcripts (complete?) and other sources. I remember the shock of that accident well. For me most of the ideas put forth here are intelligent and insightful. I have felt for many years that that complacency on the part of the Tenerife controllers played a large part. They just were not as involved, not as attentive, not as aware, did not use exact ICAO avaition phraseology in their communications. Yes, the Captain of the KLM flight could have been thinking any of the things mentioned here. It could have been from hurryupitis to downright egoism. What was in his mind is all speculation. Yes, the co-pilot could have taken over control of the aircraft, the F/E could have screamed ABORT. It is really all speculation on the motivation of the Captain. He is dead and even if alive no one can know what was in his mind during those moments when he obviously believed he was cleared for T/O and did just that...try to T/O. I have never seen any program, article, book or report by the Dutch (or anyone else) that really owned up to the critical part the KLM crew played in the accident. I've flown with many KLM jumpseat pilots and this topic has come up frequently. Never have I heard a Dutch KLM pilot agree that the KLM's crews actions were at the core of the accident. From my experience I have seen that when operating an aircraft, especially a high speed jet aircraft, if ones concentration is not totally on the job at hand (actively operating an aircraft)bad things can and do happen. It is very easy for one to have in their mind many things going on at once, and if they are distracting enough (divorce, death, disease, etc.) then it is easy for some to miss what would be obvious to anyone concentrating totally on the job. At his point it is a terrible tragedy in the past and a leanrning tool in the present. Is the lesson here for all involved keep your mind actively, totally focused on the job at hand, as attentive and aware as one can be and stopping all extraneous intermal mind/thought material until the brakes are set?
Originally Posted by forget
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.
Originally Posted by poorwanderingwun
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.
Authority was still respected in The Netherlands in the 1950's, but since the 1960's having a healty mistrust of authority has been the norm. Even today, a German doctor in science would still be adressed as "Herr Doctor"; a Dutch doctor in science is simply called by his first name and people would frown upon him using his scientific title "inappropriately" (or simply ridiculise the guy).
Not national culture, but company culture directed this disaster. That company culture still stemmed from the colonial pre- and post-war era; KLM today has little resemblence to the company from 1977. Many lessons have been learned from this tragedy, in particular by KLM. But some lessons still ought to be learned, and the price for these lessons has been awfully high.
Last edited by xetroV; 1st Apr 2007 at 11:32.
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Boozy captains
Michael 744,
Is there not an anonymous reporting system through IATA, ICAO, or IFALPA that allows you to describe the event/s and name the airline? This is an important issue.
My bet is on ...e..
Is there not an anonymous reporting system through IATA, ICAO, or IFALPA that allows you to describe the event/s and name the airline? This is an important issue.
My bet is on ...e..
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On 'cultural differences' there's a very interesting thread, started today at, oddly enough, Dunnunda and Godzone.
( Get in there Rockhound - tell 'em what you think.
http://www.pprune.org/forums/showthread.php?t=270331
( Get in there Rockhound - tell 'em what you think.
http://www.pprune.org/forums/showthread.php?t=270331
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Since my last post, I’ve been researching this accident further.
I have to say that several years ago and earlier in my studies of Flight Safety issues I was more “systemic failure” oriented in my analysis and responses to accidents. By this I mean “the certification standards aren’t right, “the FAA change in this regulation was detrimental”, “the design was flawed and how did they certify that”, “why weren’t there enough systemic checks outside of the flight crew to trap the human error”, etc. Some of my earlier posts on Pprune reflect this orientation. I still believe these issues are important, but as the years have gone by, I’ve shifted to a more pilot responsibility focus, which is how I view this accident.
Regarding time pressure for Van Zanten, other contributors to this thread are correct in that the Dutch authorities at that time had enacted strict rules regarding duty time, and flight crews were subject to prosecution for violating them. Also the criteria and methods of calculating duty time under the regs were complex, so Van Zanten checked with KLM operations and found he had until 18:00 GMT to reach Las Palmas, his charter’s final destination. Shortly after this duty time check, at 14:30GMT, he and all the other flight crews at Los Rodeos (on Tenerife) were notified that Las Palmas had been reopened, after failure to find a second bomb. Las Palmas was only about 60 nautical miles away from Los Rodeos. If I have the details correct, he them gathered his passengers together and got them back on the aircraft, and decided he had enough time to request refueling the aircraft, so he wouldn’t have to get fuel at Las Palmas for a return flight to Amsterdam (the following day I assume?). It took some time to get refueled. He then got engines started at 16:56 GMT (I’ve read slightly different numbers on this). The accident occurred at 17:06 GMT during takeoff.
My question regarding time pressure is this, to those that have flown these routes, would 54 minutes be enough time for Van Zanten to reach Las Palmas 60 nautical miles away (a very short flight) and still finish his flight duties by 18:00 GMT? I personally think he had enough time, but this directly addresses the time pressure problem and its influence on his thinking. He already tried to advance the throttles once before, and his co-pilot checked him this first time, but not the second time. To me he was clearly in a hurry, but was the time pressure the exact reason?
Regarding the personal responsibility focus I mentioned earlier, I have to tell you I find it very hard to understand the decision that Van Zanten (and his co-pilot) made regarding when to start the takeoff roll. We know the flight engineer questioned whether the Pan Am aircraft had cleared the runway. Van Zanten emphatically stated that it had (which silenced the flight engineer), but what facts did he have in hand to reach that conclusion?
To me this whole accident boils down to one question (from a pilot responsibility perspective), “has the Pan Am jet cleared the runway yet?” Since the KLM crew knew a Pam Am jet was taxing behind them on the runway in the fog, and the Pan Am crew knew a KLM jet was taxing ahead of them on the runway in the fog (and they also knew the KLM would perform a 180 turn to reach takeoff position), there was really only one thing that could go wrong with this scenario. In reading the transcripts, the Pam Am crew seemed to be keenly aware of what could go wrong, as they were discussing the very possibility of the KLM pilots being in a hurry to takeoff.
To me, the KLM crew had to ask only one question, “has the Pan Am jet cleared the runway yet’? That’s all they had to ask. If it were me, I would want confirmation that the Pan Am jet had cleared the runway before advancing the throttles, and I would have asked for it on the radio. If I can't see them in the fog and I know they're out there, you can be certain I would ask.
To me this is a lot like the Comair Lexington Kentucky takeoff accident. All the pilots had to do in that situation was ask one question “are we where we’re supposed to be?” That’s all they had to ask.
I’m a common sense kind of guy. To me anytime a situation becomes unusual (or out of the ordinary) when flying, it can become more dangerous. All you have to do is pay attention to what can go wrong when the unusual (or the out of the ordinary) is happening, and you’ll be just fine. When taxing down a runway in the fog with another aircraft behind you, make sure the other aircraft is clear of the runway before starting a takeoff roll. To me this is common sense. When an airport is under construction and its dark and raining, make sure you’re where you’re supposed to be before you start a takeoff roll. To me this is also common sense. The whole point of FAR 121.542 (the sterile cockpit rule) is to make sure you’re undistracted during these times, so you can focus on both the routine and the unusual.
I’ve read that CRM is now in its 5th generation of priorities and subject focus. The 5th generation has moved back to the primary focus when CRM was new (not long after this accident) to flight safety and the trapping of human errors before they become serious mistakes. CRM is still trying to overcome the cultural problems with cockpit authority. Every pilot’s duty must be to flight safety first. To heck with losing face, etc, this is about not dying. Every culture understands duty and responsibility and if safety is duty number one, that should overcome ANY cultural problems with cockpit authority and losing face, etc. At least I think it should.
I have to say that several years ago and earlier in my studies of Flight Safety issues I was more “systemic failure” oriented in my analysis and responses to accidents. By this I mean “the certification standards aren’t right, “the FAA change in this regulation was detrimental”, “the design was flawed and how did they certify that”, “why weren’t there enough systemic checks outside of the flight crew to trap the human error”, etc. Some of my earlier posts on Pprune reflect this orientation. I still believe these issues are important, but as the years have gone by, I’ve shifted to a more pilot responsibility focus, which is how I view this accident.
Regarding time pressure for Van Zanten, other contributors to this thread are correct in that the Dutch authorities at that time had enacted strict rules regarding duty time, and flight crews were subject to prosecution for violating them. Also the criteria and methods of calculating duty time under the regs were complex, so Van Zanten checked with KLM operations and found he had until 18:00 GMT to reach Las Palmas, his charter’s final destination. Shortly after this duty time check, at 14:30GMT, he and all the other flight crews at Los Rodeos (on Tenerife) were notified that Las Palmas had been reopened, after failure to find a second bomb. Las Palmas was only about 60 nautical miles away from Los Rodeos. If I have the details correct, he them gathered his passengers together and got them back on the aircraft, and decided he had enough time to request refueling the aircraft, so he wouldn’t have to get fuel at Las Palmas for a return flight to Amsterdam (the following day I assume?). It took some time to get refueled. He then got engines started at 16:56 GMT (I’ve read slightly different numbers on this). The accident occurred at 17:06 GMT during takeoff.
My question regarding time pressure is this, to those that have flown these routes, would 54 minutes be enough time for Van Zanten to reach Las Palmas 60 nautical miles away (a very short flight) and still finish his flight duties by 18:00 GMT? I personally think he had enough time, but this directly addresses the time pressure problem and its influence on his thinking. He already tried to advance the throttles once before, and his co-pilot checked him this first time, but not the second time. To me he was clearly in a hurry, but was the time pressure the exact reason?
Regarding the personal responsibility focus I mentioned earlier, I have to tell you I find it very hard to understand the decision that Van Zanten (and his co-pilot) made regarding when to start the takeoff roll. We know the flight engineer questioned whether the Pan Am aircraft had cleared the runway. Van Zanten emphatically stated that it had (which silenced the flight engineer), but what facts did he have in hand to reach that conclusion?
To me this whole accident boils down to one question (from a pilot responsibility perspective), “has the Pan Am jet cleared the runway yet?” Since the KLM crew knew a Pam Am jet was taxing behind them on the runway in the fog, and the Pan Am crew knew a KLM jet was taxing ahead of them on the runway in the fog (and they also knew the KLM would perform a 180 turn to reach takeoff position), there was really only one thing that could go wrong with this scenario. In reading the transcripts, the Pam Am crew seemed to be keenly aware of what could go wrong, as they were discussing the very possibility of the KLM pilots being in a hurry to takeoff.
To me, the KLM crew had to ask only one question, “has the Pan Am jet cleared the runway yet’? That’s all they had to ask. If it were me, I would want confirmation that the Pan Am jet had cleared the runway before advancing the throttles, and I would have asked for it on the radio. If I can't see them in the fog and I know they're out there, you can be certain I would ask.
To me this is a lot like the Comair Lexington Kentucky takeoff accident. All the pilots had to do in that situation was ask one question “are we where we’re supposed to be?” That’s all they had to ask.
I’m a common sense kind of guy. To me anytime a situation becomes unusual (or out of the ordinary) when flying, it can become more dangerous. All you have to do is pay attention to what can go wrong when the unusual (or the out of the ordinary) is happening, and you’ll be just fine. When taxing down a runway in the fog with another aircraft behind you, make sure the other aircraft is clear of the runway before starting a takeoff roll. To me this is common sense. When an airport is under construction and its dark and raining, make sure you’re where you’re supposed to be before you start a takeoff roll. To me this is also common sense. The whole point of FAR 121.542 (the sterile cockpit rule) is to make sure you’re undistracted during these times, so you can focus on both the routine and the unusual.
I’ve read that CRM is now in its 5th generation of priorities and subject focus. The 5th generation has moved back to the primary focus when CRM was new (not long after this accident) to flight safety and the trapping of human errors before they become serious mistakes. CRM is still trying to overcome the cultural problems with cockpit authority. Every pilot’s duty must be to flight safety first. To heck with losing face, etc, this is about not dying. Every culture understands duty and responsibility and if safety is duty number one, that should overcome ANY cultural problems with cockpit authority and losing face, etc. At least I think it should.
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Xetro
I wasn't making any reference to KLM work practises in particular and did not mention KLM... My comment was addressed at ROCKHOUND who I thought was being unduly harsh regarding a post by FORGET...
FS
It's been several years since I last read anything relating to this accident so I'm probably wrong but I was under the impression that KLM was due to return to Amsterdam that evening after trading the pax at Las Palmas and that the reason for fueling at Los Rodeos was to save time on the turn around... at las Palmas... the thought of having all this ahead of him would put considerable pressue on Capt V Z to get airborne... still with a considerable task to accomplish. Somehow I doubt that a simple two leg operation to Las Palmas and return could not be accomplished in one FDP... the unusual events however involving a diversion to a rarely visited and problematical airport such as Los Rodeos would add considerably to the stress levels and the onset of fatigue cannot also be discounted when consedering the prospect of the long flight back to Amsterdam after the turnaround at LPA.
I wasn't making any reference to KLM work practises in particular and did not mention KLM... My comment was addressed at ROCKHOUND who I thought was being unduly harsh regarding a post by FORGET...
FS
It's been several years since I last read anything relating to this accident so I'm probably wrong but I was under the impression that KLM was due to return to Amsterdam that evening after trading the pax at Las Palmas and that the reason for fueling at Los Rodeos was to save time on the turn around... at las Palmas... the thought of having all this ahead of him would put considerable pressue on Capt V Z to get airborne... still with a considerable task to accomplish. Somehow I doubt that a simple two leg operation to Las Palmas and return could not be accomplished in one FDP... the unusual events however involving a diversion to a rarely visited and problematical airport such as Los Rodeos would add considerably to the stress levels and the onset of fatigue cannot also be discounted when consedering the prospect of the long flight back to Amsterdam after the turnaround at LPA.
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Flight Safety,
In response to your query, that route TFN-LPA could be then (and today) be flown in about 20 min flight time or 30 min block time, so they (KLM) could be setting the brakes at LPA by approx 1735z.
However, unless I am mistaken this crew was scheduled to return to Amsterdam that day after the turnaround in Las Palmas.
In response to your query, that route TFN-LPA could be then (and today) be flown in about 20 min flight time or 30 min block time, so they (KLM) could be setting the brakes at LPA by approx 1735z.
However, unless I am mistaken this crew was scheduled to return to Amsterdam that day after the turnaround in Las Palmas.
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PW and TR, thanks. I wonder if the time of 18:00 GMT given to Van Zanten by KLM was arrival time at LPA or departure time from LPA. If is was departure time, it would certainly explain the time pressure, if they were going on to Amsterdam. Even so, would the Dutch authorities have really made an issue on a day like that one, if they arrived in Amsterdam say 20 minutes past their duty limit?