Tenerife. March, 27th, 1977.
 

Just a sad note from today's internet London Times newspaper.....
Remembering the world’s worst aviation accidentPaul Simons: Weather Eye
The world’s worst aviation accident happened on this day 30 years ago. Two Boeing 747 jumbo jets collided on a runway shrouded in fog in Tenerife, Canary Islands, killing 583 people.
Flights had been diverted from Las Palmas international airport to the smaller regional Los Rodeos airport, Tenerife, which soon became congested with large aircraft it could not easily handle. KLM and Pan Am flights were parked on a long taxiway when news came through that Las Palmas airport had reopened.
Tenerife is often plagued by fogs as moisture-rich winds drift in from the Atlantic. On March 27, 1977, a thick fog suddenly rolled in over Los Rodeos. The KLM flight prepared for takeoff, unaware that the Pan Am aircraft was also on the same runway. The control tower could not see either aircraft in the fog, and there was no ground radar at the airport. As the KLM sped down the runway, the Pan Am crew only saw its landing lights at 700 metres on a head-on collision. The Pan Am captain spun his aircraft to get off the runway, and the KLM flight tried to climb over it but hit the Pan Am plane, ripping it apart. The KLM plane then plunged to the ground a short distance away and burst into flames, and was completely destroyed. Remarkably, 61 passengers and crew on board the Pan Am aircraft survived.
........

And one of the surviving cockpit crewmembers on the Pan Am 747, Robert Bragg, will be the lead speaker at today's one day incursion meeting at NTSB headquarters.
http://www.ntsb.gov/events/symp_ri/A...Panel_Bios.pdf
there is a webcast of this event:
http://www.ntsb.gov/events/webcasts.htm

And for us the big lesson is lies in the truth underlying the journalist's paraphrase that the KLM aircraft was..."unaware that the Pan Am aircraft was also on the same runway"....that is not quite true of course because the immortal (in aviation history) last words of KLM Flight Engineer Schreuder who said..."Is he not still on the runway, that Pan American?".

The KLM captain overrode his questioning Engineer, the First Officer remained silent, whatever his doubts might have been we'll never know.....and the captain, without a T/O clearance and the acquiescence of 2 crew members, commenced the take-off roll.

The Israeli Army ( i believe) used to take new officers up to the fortress of Massada to take an oath.."Never again". We as an aviation community could do worse than to take recruits to Tenerife for the same oath. Then tell them about the United DC-10 at Sioux city to show them what airmanship at the other end of the spectrum is all about.

Hear hear 019360!:ok:

27 Mar 1977 - The conception of modern CRM.
 

Current crews and passengers numbering in the hundreds of millions owe the survivors, those no longer with us and their families a great debt of gratitude.

Many, many accidents of all types have been successfully avoided thanks to the hard lessons learned that day. Tenerife is considered by most as a watershed moment in commercial aviation.

Perhaps lessons were thankfully learned in some parts of our world - but not all!

Still too many accidents in some parts of the world can be attributed to lack of CRM and the "saving face" culture. The latest could (I emphasize the word could) be the Adam Air overrun.

In the UK it think that the Midland Kegworth was one of those watershed moments. So much was learnt and is still tought today because of that accident.

Do you guys in the US study that one as well?

Landed at TFN a week after the accident. Apart from all the wreckage scattered about, there was a burned out Sabena 707 at the side of the runway. Never read anything about that. It certainly was a jinxed airport. As regards CRM, wasn't the KLM captain the chief pilot?:sad:

He was indeed the KLM CP. The whole thing came about as a result of a bomb scare at Las Palmas (?) which led to mass diversions into TFN, overcrowding the airfield - the Pan Am crew were obliged to send one of their number out to observe wing tip clearance on pushback due to the congestion.
The KLM CP put the 747 into its takeoff roll without clearance from ATC, unable to see down the runway due to fog & the young FO who realised the Pan Am hadn't cleared the runway but was also incredibly, given the circumstances, unwilling to contradict his Captain, radioed ATC with words to the effect of 'We're taking off' or 'we are at takeoff' in an effort to alert ATC to the imminent disaster. The rest is history.

I don't think he was the Chief Pilot as such but he was certainly a management pilot, and possibly the Chief Training Capt on the 74 fleet... He had also not long before been responsible for signing off the FO, something that was thought a factor in the FO not being more assertive in querying the captains actions... ( the full story has been recorded in so many books/articles that there's little to be gained going over it all on PPrune ).

One strange aspect of the accident was that the Capt apart from being one of KLM's most senior pilots had shortly before been selected to feature in a major KLM advertising campaign... partly because of what were considered to be his 'Hollywood' like good looks... his photograph was on bill-boards all over Holland... In addition, when the word of the accident reached HQ in Amsterdam a call went out to locate him as the senior 74 training Capt so that he could be involved in the investigation.

A quick Google suggests Jacob Van Zanten was KLM's Chief training captain for Boeing 747's at the time - I stand corrected.

Many factors involved in the accident at TFN but here we are 30 years later and hardly any aicraft are fitted with a simple device which prevents crossed transmissions when a/c transmit simultaneously. I believe this happened at TFN and was a potential source of confusion etc. One of the report findings was:-


The Captain on KLM had done a lot of simulator instruction where he had been in the habit of combining the ATC departure clearance with take off clearance. So on the day of the accident his mindset, having received the airways clearance, was that he was cleared for take off.
Perhaps we should also remember that this accident was an indirect result of terrorist action - that's why many a/c diverted to TFN.

I think you will find that the KLM skipper at Tenerife that terrible day was , in fact , Safety Manager for KLM. Terrible irony , but proves that noone is exempt from SOPs and CRM ( which did not exist in 1977 ).
Another strange fact is that KLM and Danair who both suffered tragedy on Tenerife were the first airlines to establish CRM courses as compulsory . In Europe that is , believe United in the US may have been the first on the planet ? No matter , those 3 pioneered the concept . I was very lucky to have my initial CRM course ( about 87 ) conducted by the legendary Dr Roger Green , who was instrumental in its intrpduction and initial format.

I put this on Tech Log but it's worth repeating here -

-------------------------------

Extracts from Conclusions Presented to the Netherlands Board of Inquiry by the Director General of Civil Aviation.

Accident Inquiry Involving Boeing 747’s PH-BUF and N736A. Tenerife March 1977.

1. Before I commence my argument I want to commemorate the 583 crew members and passengers who have lost their lives so tragically in this accident and to express my sympathy to their next of kin.

2. The Pam Am crew was alarmed by the way in which the Air Traffic Clearance was issued. The captain has declared to have feared that, from this communication, the KLM could possibly take the ATC clearance as a take off clearance and, immediately after the tower controller had said ‘0kay’, and pauses for almost two seconds, he and his first officer jumped in to inform the KLM crew that they were still taxiing on the runway.

3. The message of the Pan Am crew coincided with the message of the tower controller who, at that moment, told the KLM aircraft to wait for take-off clearance.

4. The coinciding transmission on the same frequency resulted, in the KLM cockpit only, in a strong squeal.

5. Because of this, both vital messages were lost to the KLM crew.

6 The primary cause, therefore, must be sought in the fact that the safety of the system in which all concerned were operating was depending, and still is depending on, the weakest link - the radio communication.

7. This fatal accident has shown, once more, that the oral transmission of essential information via a single and vulnerable radio connection implies considerable dangers.

8. Facts and circumstances show that information transmitted by radio communication can be understood in a different way to that intended as a consequence of ambiguous terminology and the obliteration of essential parts.

9. As I have said in the beginning of my argument, the eminent lesson to be drawn from this accident is the urgent need for improvement of the communication between aircraft and control tower.

10. Compared with other developments in aviation radio communication has lagged far behind in that the fail safe principle, which has been generally applied in modem aviation in the field of construction, systems and procedures, and which has materially contributed to attain a higher level of safety, does not apply to radio communication. The latter is not fail safe.

11. It is known that at several airports all over the world, but also during flights, a number of incidents have occurred in the last few years which arose from radio communication.

12. Although these did not result in accidents some of them bore a great resemblance to the Tenerife accident. To my opinion the situation is more serious then is being presented.

13. Although from the statements of the experts these past days it may be derived that serious problems hardly exist I have the opinion that, considering the potential risks, urgent attention is needed for possibilities to improve the radio communication system. It is obvious that improvements in the field of communications can only be achieved at an international level and this will require research and time.

14. On an international level the existing interest within the International Civil Aviation Qrganisation, the International Air Transport Association and the International Federation of Air Line Pilots’ Associations should be fostered.

15. The problem of radio communication is recognised. IATA has established a working group to study the best approach to handle this problem. The Federal Aviation Administration requested a number of research institutes to make a fundamental study of the communications problems in which also NASA is involved.

16. It is essential that, on an international level, this matter receives the attention which it deserves so urgently. The problem needs our strongest efforts to obtain radical improvements soon. The public inquiry of your board and the world-wide publicity of your finding will, as I hope and expect, contribute considerably to this purpose.

I'd love to agree with the notion that this was a watershed moment - but I think that's excessively optimistic.

Of course it's influenced training and CRM, but just about every feature of this accident has subsequently occurred many times and is repeatable tomorrow.

John Cooper.
 

A note to remember John Cooper.

John was an A and P mechanic employed by Pan Am, on this occasion he was in Tenerife to fix an auto pilot snag, on completion he scrounged a lift home on the B747 on the jump seat.
He survived the impact, and managed to struggle clear of the aircraft before returning into the wreckage to help evacuate the passengers, a very brave act that saved lives.

John had a very adventurous life in aviation, from wartime RAF to a wide range of civil operations world wide, with many stories to tell, however the Tenerife incident was a very traumatic experience for him.

I had the privilege of working with this very quiet and unassuming gentleman later on, John was held in the highest regard by all that knew him, and sadly passed on in 1998.
RIP.

Best regards,
om15.

An ATC'er in the US just a week ago gave me a departure clearance on the runway, then bollocked me for not rolling immediately - with no takeoff clearance!

When I pointed out he hadn't actually cleared us for takeoff he sarcastically asked 'do you need one?'.

Yes this type of accident has indeed occurred many times since, and yes, it will continue happening - without eternal vigilance.

Incidentally - I once saw a photo on the cover of a news magazine, taken immediately after the Tenerife accident, it showed a pilot (I think the PanAm Captain) sitting on the ground amid the wreckage with his head in his hands. It was one of the most frightening and evocative images I've ever seen, and I've never been able to find it again.
Anyone know it?

According to another forum, van Zanten was featured in an ad that appeared in the KLM In-Flight magazine in print at the time of the accident - there were likely copies onboard the doomed aircraft.

http://img.photobucket.com/albums/v2...wind/KLMad.jpg

The headline seems rather chilling in retrospect. :sad: