Tenerife. March, 27th, 1977.
The One Your Mother Warned You About
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Sqwak 7700;
The last carrier I worked for had just such a programme, it just wasn't publicised. I worked in training, we would check out CRM both in the simulator and on line flights. If a pilot had CRM problems he was quietly re-assigned for a couple of weeks. He was told the reason for the re-assignment and given help both to overcome any flight deck problems and any personal problems he may have had from finding out his colleagues thought he was a t
. As far as I know it never failed, in one case it went too far when a captain who was an utter bully realised how hated he had been went round and apologised individually to all the co-pilots he had picked on. His methods before were to upbraid and discipline the unfortunate P2 in front of the cabin staff, afterwards he learned to criticize constructively, and listen to why the P2 had acted as he had. Often the P2 may have just completed a sim ride and learned something the captain wouldn't know about until his next six monthly check.
Nowadays I work in VIP charter. We pick our pilots either because we know them or they are recommended by someone we know. CRM problems seem a long time ago, we are away for weeks together as crews and as there are only a few of us knowledge, ideas, and lessons learned are very freely circulated.
FF
The last carrier I worked for had just such a programme, it just wasn't publicised. I worked in training, we would check out CRM both in the simulator and on line flights. If a pilot had CRM problems he was quietly re-assigned for a couple of weeks. He was told the reason for the re-assignment and given help both to overcome any flight deck problems and any personal problems he may have had from finding out his colleagues thought he was a t
. As far as I know it never failed, in one case it went too far when a captain who was an utter bully realised how hated he had been went round and apologised individually to all the co-pilots he had picked on. His methods before were to upbraid and discipline the unfortunate P2 in front of the cabin staff, afterwards he learned to criticize constructively, and listen to why the P2 had acted as he had. Often the P2 may have just completed a sim ride and learned something the captain wouldn't know about until his next six monthly check.Nowadays I work in VIP charter. We pick our pilots either because we know them or they are recommended by someone we know. CRM problems seem a long time ago, we are away for weeks together as crews and as there are only a few of us knowledge, ideas, and lessons learned are very freely circulated.
FF
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One of the investigators told me that the famous squeal obscuring the PanAm's transmission was in fact audible in the KLM cockpit. The Dutch would not accept this -- or a great many other things agreed on by the industry representatives, the Spanish and the Americans on the investigation -- and in fact they still do not. There was a TV documentary recently which reiterated all the Dutch justifications for what Van Zanten did, ending up with the pale excuse, "he thought he had TO clearance".
IN fact, when the Dutch first heard about the crash they said, "we'd better send for Van Zanten". The shock and disbelief at the scale of the casualties and who was involved was simply too great to take on board.
That TV doc brought up again another canard the Dutch have been belabouring ever since: the idea that the tower controllers were listening to a football match. This was based on some muted word similar to "football" (in Spanish) being heard on the tapes. No other investigators heard it but the Dutch fastened on it like a terrier and would not let it go. They filed a minority report which blames everyone but KLM. The web-site mentioned above holds to this view too, seeing it all as some vast conspiracy against the Dutch nation.
Proper appreciation of one's mistakes is required to learn from them. If you made no mistake....
IN fact, when the Dutch first heard about the crash they said, "we'd better send for Van Zanten". The shock and disbelief at the scale of the casualties and who was involved was simply too great to take on board.
That TV doc brought up again another canard the Dutch have been belabouring ever since: the idea that the tower controllers were listening to a football match. This was based on some muted word similar to "football" (in Spanish) being heard on the tapes. No other investigators heard it but the Dutch fastened on it like a terrier and would not let it go. They filed a minority report which blames everyone but KLM. The web-site mentioned above holds to this view too, seeing it all as some vast conspiracy against the Dutch nation.
Proper appreciation of one's mistakes is required to learn from them. If you made no mistake....
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One of the investigators told me that the famous squeal obscuring the PanAm's transmission was in fact audible in the KLM cockpit. The Dutch would not accept this
In any case it was well recorded. KLM CVR below, followed by PanAm CVR.
This accident follows the proverbial swiss cheese model with all the holes lining up etc. I dont think we should blame it all on the KLM Captain - he was let down by a dysfunctional system. Speech is a poor way of conveying safety critical communication. Should low vis ops be conducted when no ground movement radar is operational? (And yet Milan still happened years later).
Many lessons were learned from this accident but we still have quite a long way to go to prevent future incidents.
Many lessons were learned from this accident but we still have quite a long way to go to prevent future incidents.
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Fireflybob is dead on. Van Zanten and supposed lack of CRM should not shoulder all the blame for this accident, which happened because, tragically, [B]all[B] the holes in the Swiss cheese lined up. I'm sure Van Zanten was completely convinced he had received T/O clearance (after all, he had earlier acknowledged the FO's reminder that they hadn't). Maybe the FO realized, after they'd commenced their T/O roll, that they hadn't been cleared and/or that the Pan Am was still on the runway and was too intimidated to speak up but there is no substantive evidence for that. On the other hand, the F/E clearly had his doubts but was he merely unsure? Van Zanten, confident that he'd heard T/O clearance, emphatically confirmed to the F/E that the Pan Am had cleared the runway. Who knows, maybe he set the F/E's mind at rest. As long as human beings are at the controls (not just in aircraft but in the control tower and elsewhere), the potential for accidents remains.
Rockhound
Rockhound
Alba Gu Brath
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forget seems to be one of the few raising a major underplayed contributor to this accident. The crew were being pushed very close to the legal (literally in this case) limits of duty time. Disruption, confusion, max duty time. Sound familiar to anyone? Next time you are being 'encouraged' to use discretion to keep the program on track it may be worth taking a few extra minutes to consider your situation.
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I'm running a CRM course for cabin crew tomorrow and this awful accident will feature.....thanks to all who have contributed. I have used this case for the last 8 years but now have more information.
Thanks to all who have posted links...especially the Bob Bragg interview. Let us hope it never happens again.
aero
Thanks to all who have posted links...especially the Bob Bragg interview. Let us hope it never happens again.
aero
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A friend of mine who lived and flew in Holland for a long time told me that Dutch arrogance was to blame for it. Even the Dutch themselves admit to it.
Can anyone comment on this?
Mary
Can anyone comment on this?
Mary
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Mary, interesting you should say this. Having been in ATC a long time (38 years) including 5 years in Dubai and 12 years in Hong Kong, I would fully endorse your words regarding your friends observation. I have consistently found the World's oldest continually functioning airline to be the most arrogant when dealing with ATC. I remember one night in Dubai, when I was doing Approach at about 1am, only one radar controller (me), about 15 aircraft on frequency, and I had one of the above mentioned airlines aircraft inbound, and all he could do was bleat at me "what is the delay, what number are we?" Of course I had no time available other than to just ignore him. Funnily enough, I have found a consistency in this as my "international" ATC experience has gone by. A bit of a generalisation, but it sticks in my mind.
Further to the whole episode, as a controller, I can't imagine, given the circumstances, to allow an aircraft to backtrack down a runway, with vis probably about 500 metres, and not, and I repeat not, be doubly sure that any aircraft lining up/awaiting take off, would not be fully appraised of the runway occupancy situation. Still, languages and cultural differences leap out and bite you with this one.
Further to the whole episode, as a controller, I can't imagine, given the circumstances, to allow an aircraft to backtrack down a runway, with vis probably about 500 metres, and not, and I repeat not, be doubly sure that any aircraft lining up/awaiting take off, would not be fully appraised of the runway occupancy situation. Still, languages and cultural differences leap out and bite you with this one.
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Mary,
Notwithstanding Bedder B's comments, I cannot accept that "Dutch arrogance" had anything to do with the Tenerife catastrophe. This canard is doubtless an outcome of the belief entrenched in many people that van Zanten ruled his cockpit with an iron fist, browbeat his crew and brooked no backchat from any of them. I've even heard him called a murderer because he began his take-off roll knowing full well he did not have clearance. This accident could, I'm sure, have happened to anyone of any nationality.
Rockhound
Notwithstanding Bedder B's comments, I cannot accept that "Dutch arrogance" had anything to do with the Tenerife catastrophe. This canard is doubtless an outcome of the belief entrenched in many people that van Zanten ruled his cockpit with an iron fist, browbeat his crew and brooked no backchat from any of them. I've even heard him called a murderer because he began his take-off roll knowing full well he did not have clearance. This accident could, I'm sure, have happened to anyone of any nationality.
Rockhound
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Of course he didn't open the throttles knowing the RW was occupied. And therein lies the problem and challenge for us all. The KLM PIC was sure he was right. Until we get to a stage when our own certainties can be readily turned into a "check again"uncertainty as long as one crew member has any doubt, we'll get nowhere.
Its also true that any crew member (such as F/E Schreuder) who lets his own doubt be over-ruled by another crew member's certainty, has let the whole team down and ultimately the passengers.
Its also true that any crew member (such as F/E Schreuder) who lets his own doubt be over-ruled by another crew member's certainty, has let the whole team down and ultimately the passengers.
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Its also true that any crew member (such as F/E Schreuder) who lets his own doubt be over-ruled by another crew member's certainty, has let the whole team down and ultimately the passengers.
This leads to a question. How many of you would disagree firmly with your PIC, especially if he is your own CP. I know this all rhetorical but there’s always the possibility of having a ‘difficult’ PIC sharing the flight deck with a ‘weak’ FO…
Just a thought.
Fly safe
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If you try to pin the blame on any particular person in this event I think you are missing the point. 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.
Van Zanten may very well have been sure about what he assumed at the time. But the point here is that you shouldn't pinpoint his assumption as the reason for this accident. Today we may call it bad CRM that none of the other crew members intervened, but you also have to put the whole thing into its correct context, that is, into the 70s, when nobody talked about CRM. It wasn't a way of thinking back then. Thus you can't argue that the reason for the accident was bad CRM, since it was not something that had even been discussed as a subject back then.
What did come out of the accident, however, was a completely new way of thinking. And that way of thinking came to be known as CRM.
If something like that happened today we could very well point out disfunctional CRM as a reason for an accident, because we all know how it should work in theory. At the time of the accident however, Van Zanten and all the other crew members had a way of thinking which was in accordance with the culture of that time. They can't be blamed for that, they were just victims of it. I don't think anybody would really believe that Van Zanten ruled the cockpit with an iron fist. His way of doing things probably wasn't better or worse than the ways of anyone else at that time.
Van Zanten may very well have been sure about what he assumed at the time. But the point here is that you shouldn't pinpoint his assumption as the reason for this accident. Today we may call it bad CRM that none of the other crew members intervened, but you also have to put the whole thing into its correct context, that is, into the 70s, when nobody talked about CRM. It wasn't a way of thinking back then. Thus you can't argue that the reason for the accident was bad CRM, since it was not something that had even been discussed as a subject back then.
What did come out of the accident, however, was a completely new way of thinking. And that way of thinking came to be known as CRM.
If something like that happened today we could very well point out disfunctional CRM as a reason for an accident, because we all know how it should work in theory. At the time of the accident however, Van Zanten and all the other crew members had a way of thinking which was in accordance with the culture of that time. They can't be blamed for that, they were just victims of it. I don't think anybody would really believe that Van Zanten ruled the cockpit with an iron fist. His way of doing things probably wasn't better or worse than the ways of anyone else at that time.
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A bit of background of the ATC side :
Bedder believeit :
Remember this was 1977, not 2007 . Read one of the reports ( there are at least 4 , but the US APLA one is, and by far , the best one ) PM me if you want the link.
Taxi :
TFN was receiving without warning diversion of far more aircraft than it could park, that the main taxi way was used for parking, that taxi situation was not designed for 747s ( relatively new a few in 77 in the canaries ). Controllers had to devise their own ad-hoc procedures to taxi aircraft.
The reason was all that was a terrorist bomb on LPA and the situation in TFN was exceptional . ( probably a bit like Halifax on 9/11 If I may use this comparison )
Visibility : TFN, for those who know it, has this particularity to have Cu or St clouds “ sitting” on it with no warning.
15 minutes before the collision, Vis was 10Km with 1/8 clouds. At time collision it was 300m vis in light rain and fog, and 10 min after the collision you had 7km vis.
Visibility can change between the time you issue a clearance and the time it is executed.
Technical : runway center line lights were US ( Notam’ed) only 2 serviceable VHF frequencies and only a ground and APP controller ( due staff shortages no TWR controller was available ) No radar, no ground movement radar ( not a usual thing in 1977, especially not in a relatively small regional airport that TFN was )
The 2 controllers tried to do their best regarding the circumstances. Misunderstanding occurred ( not only on the KL side, remember the C3-C4 runway exit discussion on the PA CVR) and a lot has been learned and changed as a consequence .
Don’t be too harsh on to controllers, who knows what you would have done then under the same circumstances.
Bedder believeit :
as a controller, I can't imagine, given the circumstances, to allow an aircraft to backtrack down a runway, with vis probably about 500 metres, and not, and I repeat not, be doubly sure that any aircraft lining up/awaiting take off, would not be fully appraised of the runway occupancy situation.
Taxi :
TFN was receiving without warning diversion of far more aircraft than it could park, that the main taxi way was used for parking, that taxi situation was not designed for 747s ( relatively new a few in 77 in the canaries ). Controllers had to devise their own ad-hoc procedures to taxi aircraft.
The reason was all that was a terrorist bomb on LPA and the situation in TFN was exceptional . ( probably a bit like Halifax on 9/11 If I may use this comparison )
Visibility : TFN, for those who know it, has this particularity to have Cu or St clouds “ sitting” on it with no warning.
15 minutes before the collision, Vis was 10Km with 1/8 clouds. At time collision it was 300m vis in light rain and fog, and 10 min after the collision you had 7km vis.
Visibility can change between the time you issue a clearance and the time it is executed.
Technical : runway center line lights were US ( Notam’ed) only 2 serviceable VHF frequencies and only a ground and APP controller ( due staff shortages no TWR controller was available ) No radar, no ground movement radar ( not a usual thing in 1977, especially not in a relatively small regional airport that TFN was )
The 2 controllers tried to do their best regarding the circumstances. Misunderstanding occurred ( not only on the KL side, remember the C3-C4 runway exit discussion on the PA CVR) and a lot has been learned and changed as a consequence .
Don’t be too harsh on to controllers, who knows what you would have done then under the same circumstances.
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For gods sake. I can't believe there are people here defending van Zanten.....
Even if it was a criminal offence to work too long, would that justify ignoring your fellow crew members and putting the lives of hundreds of innocent people at stake as he did? It's a well known syndrom in CRM; getting home despite... People ended up in all sorts of misery because of that.
And with respect to RT, I was learned to ask twice when either a fellow crewmember or me is in doubt... Especially in those conditions. This was a one man show, and Braggs says that himself.
Mary P, your friend is right. That man was known as Mr KLM at the time and the airline looked for certain characteristics in pilots which can be translated into a higher than average level of arrogance and being self-absorbed. Looks and attitude mattered. Certainly at that time KLM pilots were seen as the gift of god to Dutch aviation.
Even if it was a criminal offence to work too long, would that justify ignoring your fellow crew members and putting the lives of hundreds of innocent people at stake as he did? It's a well known syndrom in CRM; getting home despite... People ended up in all sorts of misery because of that.
And with respect to RT, I was learned to ask twice when either a fellow crewmember or me is in doubt... Especially in those conditions. This was a one man show, and Braggs says that himself.
Mary P, your friend is right. That man was known as Mr KLM at the time and the airline looked for certain characteristics in pilots which can be translated into a higher than average level of arrogance and being self-absorbed. Looks and attitude mattered. Certainly at that time KLM pilots were seen as the gift of god to Dutch aviation.
Last edited by badedas; 29th Mar 2007 at 15:19.
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Tenerife & Fatigue
Interested to know if fatigue was a significant factor in this collision ... very timely given what a large number of you have been telling me in recent days...
Thks
Ian Shoesmith
BBC News
Thks
Ian Shoesmith
BBC News
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My own humble opinion would be that it almost certainly played a part... fatigue is not falling asleep at the wheel... although that can certainly be one of the effects. We can't know what was going on in the mind of the Capt of KLM but I think we can safely surmise that he was anxious to get back into the air as quickly as possible, he'd been on duty for a considerable time... flown to an alternate, he'd been under considerable pressure to second guess correctly a chain of circumstances he had no control over... made a decision to fuel while held on the taxi-way in order to save time at LPA if and when he arrived there... and following all this he still had no clear idea when he would be allowed to depart... all the time knowing that his 747 crammed with passengers would have major problems finding accomodation if he failed to get airborne by a certain time that was now very close indeed. Fatigue inducing circumstances ? Absolutely... and having suffered it on too many occasions I'm well aware that the brain will try to dump inconvenient data that suggests an alternative to what appears the easy, attractive and readily available option... This was a highly motivated, extremely capable professional at the top of his profession.. Fatigue can, does and will go on muddling even the best brains.... Like almost all aviation accidents, this is not the whole cause but if asked "Did it play a part ?".. my own feeling is yes, most certainly.
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ATC watcher, over the years I have read as much as I can on the whole event. Somewhere in my junk I have the official ICAO report. When I have new trainee controllers under my belt, I look up on the internet and print the whole sorry saga out and run through it with them. My last paragraph was one all inclusive sentence, and the stress of it is in the last few words about "runway occupancy", and I stick to my thoughts that the info given/not given was all part of the chain of events. I get involved (as do you if you are an active controller) in events all the time where through misunderstandings, a little extra care/advice/instruction can confirm/clear up/clarify confusing/different situations. I might be a bit hard, it may well have been 1997, but I was a tower check controller in Sydney in that year, and I would hope that things haven't changed too much for me. This may sound high and mighty, but I just believe that just a few more words from the tower controller may well have gone a long way to avoiding the whole catastrophe.
PS, Though at the time I was not occupying a control position (making tea for the boys), I was training in Sydney tower on the night of the collision between the Canadian Pacific DC 8 and the TAA B727 in 1971, and having been dragged through the court case on that one I am acutely sensetive to runway occupancy issues and the words that relate to this. If you are not aware of that accident, well look it up on the internet and if ever there was a look into the window of Tennerife, this was one very lucky escape!
All the best to you "Watcher".
PS, Though at the time I was not occupying a control position (making tea for the boys), I was training in Sydney tower on the night of the collision between the Canadian Pacific DC 8 and the TAA B727 in 1971, and having been dragged through the court case on that one I am acutely sensetive to runway occupancy issues and the words that relate to this. If you are not aware of that accident, well look it up on the internet and if ever there was a look into the window of Tennerife, this was one very lucky escape!
All the best to you "Watcher".
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"get-home-itis" i hear it's often called? particularly in relation to flying "just one more sector" to get back to base for the night rather then report fatigue?
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Kegworth
Kegworth was mentioned at the beginning of this thread.
Held up as an example ? - within bmi it is almost positively not ever talked about, whereas you'd think the multitude of lessons from this major company event would be mentioned frequently during training sessions....
probably says a lot about something of the management culture there....
Held up as an example ? - within bmi it is almost positively not ever talked about, whereas you'd think the multitude of lessons from this major company event would be mentioned frequently during training sessions....
probably says a lot about something of the management culture there....