30th Anniversary of Tenerife.
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30th Anniversary of Tenerife.
Tuesday, 27th, is the 30th Anniversary of the Tenerife Accident.
Has anything really changed - apart from a handful of suspect 'phraseologies'.
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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.
Has anything really changed - apart from a handful of suspect 'phraseologies'.
-------------------------------
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.
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Good grief, is it really 30 years? Seems like only yesterday (or maybe the day before...)
Has anything really changed - apart from a handful of suspect 'phraseologies'.
Yes. The quality and procedures in radio communications has been absolutely transformed, at least in the UK.
I well recall an interim sheet of changes in phraseologies coming out soon after the disaster. We all studied the list and understood the implications behind the changes. Sadly, some folk (who I suppose are too young or inexperienced to remember the reasoning behind the changes) are backsliding. I'm starting to hear people reporting 'runway clear' instead of 'runway vacated' and 'go ahead' instead of 'pass your message' and 'takeoff' instead of 'departure'. When I teach my trainees RTF I not only tell them about the appropriate phraseology, but also the circumstances that led up to the changes being made. This reinforces the lesson.
We have also developed the principle of readback into a sophisticated error trapping and correction procedure. This goes a long way to mitigate the admitted limitations of our old-fashioned VHF system. So no, we don't have just a 'handful of suspect phraseologies', we have a vast improvement in communication safety as a result of this tragedy.
Cheers,
TheOddOne
Has anything really changed - apart from a handful of suspect 'phraseologies'.
Yes. The quality and procedures in radio communications has been absolutely transformed, at least in the UK.
I well recall an interim sheet of changes in phraseologies coming out soon after the disaster. We all studied the list and understood the implications behind the changes. Sadly, some folk (who I suppose are too young or inexperienced to remember the reasoning behind the changes) are backsliding. I'm starting to hear people reporting 'runway clear' instead of 'runway vacated' and 'go ahead' instead of 'pass your message' and 'takeoff' instead of 'departure'. When I teach my trainees RTF I not only tell them about the appropriate phraseology, but also the circumstances that led up to the changes being made. This reinforces the lesson.
We have also developed the principle of readback into a sophisticated error trapping and correction procedure. This goes a long way to mitigate the admitted limitations of our old-fashioned VHF system. So no, we don't have just a 'handful of suspect phraseologies', we have a vast improvement in communication safety as a result of this tragedy.
Cheers,
TheOddOne
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The extreme irony is that little has changed since then….the most dangerous place to be in a transport aircraft is on the ground.
Ground based radar/multilat/software is woefully inadequate for the task. Among other limitations, any warning is issued to the controller only…..he/she must react and transmit the alert to appropriate aircraft on appropriate frequency. This in an environment where seconds, even fractions of seconds, count.
As for the aircraft itself, we are flying in aircraft that are capable of worldwide lateral navigation measured in meters, autoland capability in near zero visibility, but once the aircraft is on the ground, it is a piece of paper
(10-9 chart) and a compass to navigate the increasingly hazardous taxiway mazes at international airports.
Unfortunately, I think it will take another severe accident to mandate an appropriate technical response and mandate (yes, in this day and age, few airlines will voluntarily buy non mandated equipment).
The NTSB will, this week, hold a one day meeting on this issue. Let’s all hope there is much more light than heat generated from this get together.
http://www.ntsb.gov/Pressrel/2007/070322.htm
Ground based radar/multilat/software is woefully inadequate for the task. Among other limitations, any warning is issued to the controller only…..he/she must react and transmit the alert to appropriate aircraft on appropriate frequency. This in an environment where seconds, even fractions of seconds, count.
As for the aircraft itself, we are flying in aircraft that are capable of worldwide lateral navigation measured in meters, autoland capability in near zero visibility, but once the aircraft is on the ground, it is a piece of paper
(10-9 chart) and a compass to navigate the increasingly hazardous taxiway mazes at international airports.
Unfortunately, I think it will take another severe accident to mandate an appropriate technical response and mandate (yes, in this day and age, few airlines will voluntarily buy non mandated equipment).
The NTSB will, this week, hold a one day meeting on this issue. Let’s all hope there is much more light than heat generated from this get together.
http://www.ntsb.gov/Pressrel/2007/070322.htm
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30 years indeed! What a striking coincidence that I'm rostered to fly on the date of the anniversary into the same airport that saw the worst disaster in aviation history.
Has anything really changed? Well, yes, a lot has changed in those thirty years. But there is still far more to do. While the equipment is more reliable, there are more and better facilities everywhere and ATC has generally improved, it is no less true than some places are far more dangerous than others. And while improvements in SOPs, CRM and ATC procedures have been implemented, the dramatic increase in traffic at some airports may well offset whatever benefits those bring, and some airports/areas are no less prone to incidents than they were 30 years ago.
Food for thought. Could the same accident be repeated now somewhere? Yes, it could. Perhaps it will. Maybe we pilots, through our associations should take a more aggresive stand about this.
Has anything really changed? Well, yes, a lot has changed in those thirty years. But there is still far more to do. While the equipment is more reliable, there are more and better facilities everywhere and ATC has generally improved, it is no less true than some places are far more dangerous than others. And while improvements in SOPs, CRM and ATC procedures have been implemented, the dramatic increase in traffic at some airports may well offset whatever benefits those bring, and some airports/areas are no less prone to incidents than they were 30 years ago.
Food for thought. Could the same accident be repeated now somewhere? Yes, it could. Perhaps it will. Maybe we pilots, through our associations should take a more aggresive stand about this.
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You know what they say...
Seasoned aircraft accident investigators all seem to say that there are very few "new" reasons for accidents.
Mostly it's just "new" pilots making the same "old" mistakes.
That said, the victims of Tenerife are in my thoughts.
Mostly it's just "new" pilots making the same "old" mistakes.
That said, the victims of Tenerife are in my thoughts.
