Tenerife. March, 27th, 1977.
Off the record:
The Dutch aviation authorities were doing their very best to put the blame of the accident on Los Rodeos ATC and/or PamAm. They tried very hard to clear KLM. Despite the fact that KLM itself realised pretty quickly that their pilots were ultimately to blame.
The reason for the behaviour of the Dutch Aviation Authorities was that they were responsible for the work/rest regulations as they were in 1977, and also because they were the ones overseeing KLM and their procedures.
So by trying to clear KLM, they were actually trying to cover their own asses.
This all became clear in a documentary on TV in the Netherlands (in Dutch) which aired on the 25th anniversary of this accident. (5 years ago)
The Dutch aviation authorities were doing their very best to put the blame of the accident on Los Rodeos ATC and/or PamAm. They tried very hard to clear KLM. Despite the fact that KLM itself realised pretty quickly that their pilots were ultimately to blame.
The reason for the behaviour of the Dutch Aviation Authorities was that they were responsible for the work/rest regulations as they were in 1977, and also because they were the ones overseeing KLM and their procedures.
So by trying to clear KLM, they were actually trying to cover their own asses.
This all became clear in a documentary on TV in the Netherlands (in Dutch) which aired on the 25th anniversary of this accident. (5 years ago)
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Good Idea
Roy Hudd, I cound not agree with you more and your idea is a good one. When I proposed going to the television, radio or media of anykind with this information my brother (who flys with these people) was horrified because there, the nail that sticks up gets hammered down and out. And that is just one aspect of the culture of this airline. When a large group of pilots got together to discuss forming an union management thugs came in and beat the heck out of many there. People hid in churchs to avoid being arrested and jailed.
If you know of such a site, their address I would definately drop them a line. I'll look about too.
Michael
If you know of such a site, their address I would definately drop them a line. I'll look about too.
Michael
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I believe that the time pressure perceived by Van Zanten was increased because of the quickly deteriorating visibility. While he may have had sufficient time to get to Las Palmas, the fog was quickly becoming too thick to take off. The conditions were marginal and getting worse. Wait any longer and he might have missed his opportunity to not infringe his duty hours.
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Looking at the time pressure from another perspective, suppose Van Zanten and crew were not able to leave Las Palmas in time (for whatever reason) to get back to Amsterdam before exceeding their duty time. After a day like that one (bomb explosion in a terminal, airport shutdown, diversion, possible weather delay from fog, etc), do you think KLM would have been upset with the crew if they had to stay the night in Las Palmas? If the duty time for that day included a trip back to Amsterdam, then it’s a given they would have made Las Palmas that day, with no need to accommodate the passengers overnight, just the crew.
Depending on the reaction of KLM to these possible circumstances, how then does the time pressure look if the crew couldn’t make Amsterdam that day?
Depending on the reaction of KLM to these possible circumstances, how then does the time pressure look if the crew couldn’t make Amsterdam that day?
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ATC Watcher writes:
What I personally think, is that van Zanten truly believed he had a take off clearance. Why is THE question.
I agree with ATC W. As to his question, it seems to me that when van Zanten, not long after his FO had requested both ATC and TO clearances, heard the tower advise "KLM 4805, you are cleared to the papa beacon...", he accepted it as clearance to take off. He was in a frame of mind to expect and to accept TO clearance, he was in a hurry, and so on and so forth. Stanley Stewart in Air Disasters points out that van Zanten was a senior training captain and lacked recent line flying practise. He was more used to simulator operations, where formalities such as acknowledging a specific clearance are often dispensed with in favour of drills and procedures.
It appears to me as nothing more than an eminently human error, an error that could be made by anyone of any nationality, but this particular error could not have been made at a worse time.
Flight Safety asks why van Zanten was so sure Pan Am had vacated the runway. Obviously (to me, at least) because van Zanten was convinced he had been given TO clearance, he was sure the runway was clear. Again, a very natural thought process (it seems to me). Incidentally, Stewart states that when van Zanten answered F/E Schreuder's query with an emphatic "Yes", the F/O also answered simultaneously in the affirmative. I can't verify this because I don't have the accident reports and transcripts in front of me but I'll check them.
I'm still unconvinced that better CRM would have prevented this accident. However, Forget, I'll check out those threads on cultural differences!
Rockhound
What I personally think, is that van Zanten truly believed he had a take off clearance. Why is THE question.
I agree with ATC W. As to his question, it seems to me that when van Zanten, not long after his FO had requested both ATC and TO clearances, heard the tower advise "KLM 4805, you are cleared to the papa beacon...", he accepted it as clearance to take off. He was in a frame of mind to expect and to accept TO clearance, he was in a hurry, and so on and so forth. Stanley Stewart in Air Disasters points out that van Zanten was a senior training captain and lacked recent line flying practise. He was more used to simulator operations, where formalities such as acknowledging a specific clearance are often dispensed with in favour of drills and procedures.
It appears to me as nothing more than an eminently human error, an error that could be made by anyone of any nationality, but this particular error could not have been made at a worse time.
Flight Safety asks why van Zanten was so sure Pan Am had vacated the runway. Obviously (to me, at least) because van Zanten was convinced he had been given TO clearance, he was sure the runway was clear. Again, a very natural thought process (it seems to me). Incidentally, Stewart states that when van Zanten answered F/E Schreuder's query with an emphatic "Yes", the F/O also answered simultaneously in the affirmative. I can't verify this because I don't have the accident reports and transcripts in front of me but I'll check them.
I'm still unconvinced that better CRM would have prevented this accident. However, Forget, I'll check out those threads on cultural differences!
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One of the main reasons I read these threads is because they are about exceptions to the logical rule. Being human, my admission fee is exacted in the coin of agony, as it is for many of you.
I see that sometimes the threads become almost weary in their well-intentioned pursuit of reason and probability. This thread tries SO hard to make sense of a disaster.
But a disaster is by definition a problem which has no solution. You shall never solve the mystery of Tenerife, my friends. You shall never know why the KLM pilot did what he did.
There is real value in your discussion, of course. The discussion is excellent. But rest your weary minds from time to time. You are not going to be able to determine totally satisfactory reasons why these accidents happened, because they were accidents. A crude comparison would be in your attempting to analyze why someone won the lottery. How is okay; why is just not gonna happen. In discussing accidents, the reason why is edging on oxymoronic.
If what I say makes no sense, distance yourself a bit and reconsider. These accidents are mistakes—the KLM pilot quite likely did not intend to kill himself that day. If he were reading this thread—I wonder if he is—he would be caught up in the very same riddle.
Personally, at the time, I was as much horrified by KLM's stance, which came through loud and clear, as I understood such an attitude would clear the runway for the potential for another such disaster. Even when we are sure we are dead right, we must always allow that we may in fact be dead wrong—and which is a mute point when we are dead either way.
— A brief aside to Rockhound, who lives in my country, albeit thousands of miles away from Vancouver: If you are quite young, I might forgive your wishful thinking that cultural differences are not terribly much part of the real universe, but I'm afraid you have been terribly misled by a tribe who seems fearful of any racial distinctions. Discrimination is not an inherently evil act—bird-watchers use it all the time, as do buyers of sports cars, as will your pilot next time he attempts to bring you safely back to Canada.
Any series of entities must have a fastest, a slowest, a brightest, a dullest, and so on. Politics is related to poles, and forums have traditionally been discussions amongst those with opposing perspectives.
"Political correctness" must be a contradiction in terms, because it demands these opposing perspectives all be correct. It is a ridiculous notion, so you are best to ridicule it. Cultures will always be extremely different in the way they do things, and any difference at all must surely make you a winner this time and a loser next time. Heads or tails on that?
To consider cultural differences as causes is just as important as considering whether the engine that failed was on the right or left wing of the plane. It does not mean that we are sinistraphobic, say. (Brand new word. Yours if you want it.)
To be wise and just, we must recognize cultural propensities; not attempt to blur them out. If we Canadians don't accept cultural differences—which are in truth many and varied—then we may well be quite easily influenced to spend our tax money doing something terrible: oh, I don't know—such as killing a distant culture we don't understand,
for its differences.
_________
[@Fair Reader: Yes, the sic pun back there was intended.
]
I see that sometimes the threads become almost weary in their well-intentioned pursuit of reason and probability. This thread tries SO hard to make sense of a disaster.
But a disaster is by definition a problem which has no solution. You shall never solve the mystery of Tenerife, my friends. You shall never know why the KLM pilot did what he did.
There is real value in your discussion, of course. The discussion is excellent. But rest your weary minds from time to time. You are not going to be able to determine totally satisfactory reasons why these accidents happened, because they were accidents. A crude comparison would be in your attempting to analyze why someone won the lottery. How is okay; why is just not gonna happen. In discussing accidents, the reason why is edging on oxymoronic.
If what I say makes no sense, distance yourself a bit and reconsider. These accidents are mistakes—the KLM pilot quite likely did not intend to kill himself that day. If he were reading this thread—I wonder if he is—he would be caught up in the very same riddle.
Personally, at the time, I was as much horrified by KLM's stance, which came through loud and clear, as I understood such an attitude would clear the runway for the potential for another such disaster. Even when we are sure we are dead right, we must always allow that we may in fact be dead wrong—and which is a mute point when we are dead either way.
— A brief aside to Rockhound, who lives in my country, albeit thousands of miles away from Vancouver: If you are quite young, I might forgive your wishful thinking that cultural differences are not terribly much part of the real universe, but I'm afraid you have been terribly misled by a tribe who seems fearful of any racial distinctions. Discrimination is not an inherently evil act—bird-watchers use it all the time, as do buyers of sports cars, as will your pilot next time he attempts to bring you safely back to Canada.
Any series of entities must have a fastest, a slowest, a brightest, a dullest, and so on. Politics is related to poles, and forums have traditionally been discussions amongst those with opposing perspectives.
"Political correctness" must be a contradiction in terms, because it demands these opposing perspectives all be correct. It is a ridiculous notion, so you are best to ridicule it. Cultures will always be extremely different in the way they do things, and any difference at all must surely make you a winner this time and a loser next time. Heads or tails on that?
To consider cultural differences as causes is just as important as considering whether the engine that failed was on the right or left wing of the plane. It does not mean that we are sinistraphobic, say. (Brand new word. Yours if you want it.)
To be wise and just, we must recognize cultural propensities; not attempt to blur them out. If we Canadians don't accept cultural differences—which are in truth many and varied—then we may well be quite easily influenced to spend our tax money doing something terrible: oh, I don't know—such as killing a distant culture we don't understand,
for its differences._________
[@Fair Reader: Yes, the sic pun back there was intended.
]
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MGifos :
Wrong assumption, anybody who has been in TFN ( and van Zanten had been there before) knows that the " fog" is in fact a Cu or St passing "on" the runway ( Normal TFN ATIS in that case are something like cloud 7/8 at zero meter, 1/8 at 30 m ) .
When they started to taxi the RVR was 2-3 Km.(at 16:50 ) The local wx reports gave close to the time of collision (17:02 ): RVR 300m In fact 4 minutes after the collision the RVR was more than 5 Km. ( 17:10 RVR : 4-5 Km intermittent 7 Km )
Rockhound :
I cannot find a record to this . In the official Spanish CVR/FDR transcript ( a rare roneocopy of the original from 1978 which I have in front of me ) the "Ja well " only comes from C1 . the quieries about Pan Am all comes from C3 ( F/E), the only thing that ever comes from C2 is "V1"
I believe that the time pressure perceived by Van Zanten was increased because of the quickly deteriorating visibility. While he may have had sufficient time to get to Las Palmas, the fog was quickly becoming too thick to take off. The conditions were marginal and getting worse
When they started to taxi the RVR was 2-3 Km.(at 16:50 ) The local wx reports gave close to the time of collision (17:02 ): RVR 300m In fact 4 minutes after the collision the RVR was more than 5 Km. ( 17:10 RVR : 4-5 Km intermittent 7 Km )
Rockhound :
Stewart states that when van Zanten answered F/E Schreuder's query with an emphatic "Yes", the F/O also answered simultaneously in the affirmative. I can't verify this because I don't have the accident reports and transcripts in front of me but I'll check them.
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Flight Safety:
The thing is, terrorism in the '70s wasn't the massively over-hyped problem it is today. We're not talking the same level as masterminds like Ramsi Yousef, and we're not talking about the kind of act that the WTC attacks were, where the likelihood was that both crew and passengers were in mortal danger... not even close.
These were Canary Island separatists detonating a small, home-made device in a terminal to create disruption and panic, many hours before the two 747s arrived in Spanish airspace. There was no threat to the aircraft themselves and the pilots didn't concern themselves with the act itself. By all accounts they saw it as an annoyance rather than a threat and the only thing in danger was their ability to keep to schedule.
Aside from the threat of criminal prosecution, Van Zanten was a senior enough pilot to know and care that there was likely to be a significant financial penalty to KLM if they didn't make it on time. It would appear that when the ATC clearance was given he heard what he wanted to hear and it was a momentary lapse of judgement that he paid for with his life.
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?
* 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?
These were Canary Island separatists detonating a small, home-made device in a terminal to create disruption and panic, many hours before the two 747s arrived in Spanish airspace. There was no threat to the aircraft themselves and the pilots didn't concern themselves with the act itself. By all accounts they saw it as an annoyance rather than a threat and the only thing in danger was their ability to keep to schedule.
Aside from the threat of criminal prosecution, Van Zanten was a senior enough pilot to know and care that there was likely to be a significant financial penalty to KLM if they didn't make it on time. It would appear that when the ATC clearance was given he heard what he wanted to hear and it was a momentary lapse of judgement that he paid for with his life.
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Flight Safety wrote:
The trip AMS-LPA would not require a scheduled layover (2x4hrs), so there was obviously no relief crew in Las Palmas. He had to continue home or face the cost of accomodation for a 747-load of pax at Gran Canaria.
Recall this being explained as another reason for his haste, in the paper media just after the accident. (I was in the airline business at that time.)
Someone got a copy of Flight International spring -77?
If the duty time for that day included a trip back to Amsterdam, then it’s a given they would have made Las Palmas that day, with no need to accommodate the passengers overnight, just the crew.
Recall this being explained as another reason for his haste, in the paper media just after the accident. (I was in the airline business at that time.)
Someone got a copy of Flight International spring -77?
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NR, I understand, however the charter's destination was Las Palmas (as this is what I've read). Once he made that airport, there would be no need to accommodate the passengers, only the crew, if they had to overnight in Las Palmas.
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Finally found it! 
http://www.airmanshiponline.com/marz...20Bruggink.pdf (page 2, line 3-5)
So, the cost of several hundred hotel rooms were also on the captain's mind...
http://www.airmanshiponline.com/marz...20Bruggink.pdf (page 2, line 3-5)
So, the cost of several hundred hotel rooms were also on the captain's mind...
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So there were passengers waiting to go to Amsterdam from Las Palmas. What a time squeeze Van Zanten was in. The cost of all those hotel rooms if he couldn't get out on time, or face possible prosecution if he tried to make it out, but failed to get back to AMS before his duty time expired. Now I think I understand his decision making process, which is what I wanted to know.
In the end, you can only control the things you CAN control, and not the things you can't control. Trying to control what you can't control, can result in a decision like this one.
If he set brakes at 17:35 GMT as Las Palmas, he was never going to get the aircraft unloaded and loaded again, and back into the air by 18:00 GMT anyway. Maybe the request for fuel at Las Rodeos was a mistake and created the time pressure that led him to the rushed decision. Maybe he could have arrived at Las Palmas earlier, and he could have unloaded and loaded passengers again while getting fuel at the same time, overlaping the time requirements for both tasks. Maybe this would have given him more time and reduced the time pressure. Time management is such an important thing, by at least trying to keep yourself out of such time squeezes.
In the end, you can only control the things you CAN control, and not the things you can't control. Trying to control what you can't control, can result in a decision like this one.
If he set brakes at 17:35 GMT as Las Palmas, he was never going to get the aircraft unloaded and loaded again, and back into the air by 18:00 GMT anyway. Maybe the request for fuel at Las Rodeos was a mistake and created the time pressure that led him to the rushed decision. Maybe he could have arrived at Las Palmas earlier, and he could have unloaded and loaded passengers again while getting fuel at the same time, overlaping the time requirements for both tasks. Maybe this would have given him more time and reduced the time pressure. Time management is such an important thing, by at least trying to keep yourself out of such time squeezes.
Last edited by Flight Safety; 2nd Apr 2007 at 17:38.
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FL
The points you're making are the ones I referred to in my post of the 29th.. my conclusion goes beyond simple pressure or a case of get home Itis ...it also involves fatigue... the decision to fuel at Los Rodeos may well have delayed departure ...it was a good decision based on bad information... Las Palmas opened for traffic a lot sooner than Capt V Z had been led to believe. These decisions, frustratiion, pressure, uncertainty, the diversion and the impending two legs yet to fly against the clock must have had his brain pretty stressed for a considerable period... and that will lead to fatigue.
When all the factors are considered it does look more like human frailty than blind incompetance... all of the factors could come together again in a similar set of circumstances and there will still be a human being in the chain who might fail... maybe we should concentrate a bit less on second guessing what Capt VZ was thinking and try accept that when frail man embarks on a task such as manipulating hundreds of tons of sophisticated and potentially deadly machinery around in zero visibility the ingrediants of catastrophy or very close to hand.
The points you're making are the ones I referred to in my post of the 29th.. my conclusion goes beyond simple pressure or a case of get home Itis ...it also involves fatigue... the decision to fuel at Los Rodeos may well have delayed departure ...it was a good decision based on bad information... Las Palmas opened for traffic a lot sooner than Capt V Z had been led to believe. These decisions, frustratiion, pressure, uncertainty, the diversion and the impending two legs yet to fly against the clock must have had his brain pretty stressed for a considerable period... and that will lead to fatigue.
When all the factors are considered it does look more like human frailty than blind incompetance... all of the factors could come together again in a similar set of circumstances and there will still be a human being in the chain who might fail... maybe we should concentrate a bit less on second guessing what Capt VZ was thinking and try accept that when frail man embarks on a task such as manipulating hundreds of tons of sophisticated and potentially deadly machinery around in zero visibility the ingrediants of catastrophy or very close to hand.
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PW, you wrote;
If my understanding is correct, the KLM crew were informed at 14:30 GMT of Las Palmas being open, as were all of the other flight crew at Los Rodeos. The information came over the radios as Las Palmas was 60 nautical miles away. I would imagine that the Los Rodeos tower would have also informed all flight crew as well.
Your second paragraph is puzzling in its content. I want to learn how to avoid making this mistake. In order to do that, I need to understand as best as possible, how it was made. Systemic issues are important, but apply to changes that can be made in the future. When you're in the cockpit and passengers are boarding your aircraft, I want to know what I can do now (all that's possible for me to know) about the circumstances at hand. I won't resign myself to fate. If I learn where I might get into a decision trap in the midst of unusual circumstances, I can learn how to avoid those traps.
Las Palmas opened for traffic a lot sooner than Capt V Z had been led to believe.
Your second paragraph is puzzling in its content. I want to learn how to avoid making this mistake. In order to do that, I need to understand as best as possible, how it was made. Systemic issues are important, but apply to changes that can be made in the future. When you're in the cockpit and passengers are boarding your aircraft, I want to know what I can do now (all that's possible for me to know) about the circumstances at hand. I won't resign myself to fate. If I learn where I might get into a decision trap in the midst of unusual circumstances, I can learn how to avoid those traps.
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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: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)
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SaturnV, yes he is. The KLM aircraft had the Pan Am jet blocked in the holding area, and they could not move until the KLM jet moved first. This didn't happen until the KLM aircraft was refueled, then afterwards they moved out and the Pan Am jet could finally move.
