Analyzing the Tenerife Disaster

Analyzing the Tenerife Disaster

Analyzing the Tenerife Disaster

Introduction

 On the afternoon of Sunday, March 27, 1977, a horrific and unprecedented incident occurred at Los Rodeos Airport, currently known as Tenerife North Airport. Two Boeing 747 passenger jets collided head-on on the runaway causing numerous fatalities and leaving multiple casualties. The air disaster involving Pan Am Flight 1736 and KLM Flight 4805 jumbo jets claimed 583 lives and left 61 survivors, most of who were severely injured. The magnitude of the accident was so enormous that analysts pointed the cause to a chain of factors that preceded the crash including improbable errors and failures and strokes of jinx. Nearly 50 years later, the Tenerife disaster remains history’s biggest and deadliest air disaster.

The Event

Boeing 747-200 (PH-BUF) KLM 4805 flight was a passenger charter flight operating from Amsterdam en route Las Palmas while Boeing 747-100 (N73PA) was a Pan American Airways passenger flight operating between Los Angeles and Las Palmas. Both aircraft dispatched from their respective departure zones but diverted to Tenerife when Las Palmas was temporarily closed. They then taxied for their flights successively to Las Palmas when it reopened. KLM Boeing took off in low daylight visibility while Pan Am was backtracking the same runway. A collision accompanied by explosions and post-crash fire occurred, subsequently killing 335 of 396 occupants of Pan Am and all 248 occupants of KLM (Smith, 2017). Only 61 survivors escaped the crash, and significant damage occurred on the runway. The two aircraft were destroyed beyond repair by the collision and consequential inferno. The Tenerife catastrophe would have been avoided if the aircrafts landed in the usual Las Palmas Airport, which is equipped with all the necessary facilities for monitoring large passenger aircraft.

Contributing Psychology factors

Situational Awareness

            Situational awareness contributed to the mishap in three ways. Absence of surface movement radar that controls air traffic denied pilots a clear view of the airfield hence leading to the collision. In addition, the thick fog blocked ATC from directly visualizing the specific locations of any aircraft. The extra time used to refuel KLM provided more time for the fog to thicken after which visibility to deteriorate (Smith, 2017). The fuel increased the weight of the aircraft and decreased its takeoff speed. Furthermore, the additional petroleum fuelled the combustion thereby significantly decreasing survival chances. Lastly, the dense fog caused Pan Am to miss a turn due to the poor marking of the third intersection of the taxiway (Weick, 1990). Therefore, lack of radar, extra time taken to fuel KLM, and the extra fuel created chances for an inevitable collision.

Crew Resource Management

            The conversation retrieved from the cockpit voice recorder revealed that Captain Veldhuyzen van Zanten of KLM 4805 contributed to the crash. He blatantly ignored the requirement to obtain clearance from ATC before take-off. All aircraft crews are supposed to obtain mandatory clearance from the ATC before commencing takeoffs. However, Captain overruled the need for approval and commenced takeoff (Smith, 2017). Therefore, poor crew management worsened the austerity of the mishap.

Hazardous Attitudes

The key contributing factors to the Tenerife tragedy were stress and group dynamics. The superior attitude of KLM’s incumbent captain created an opportunity for the impending crash. The Captain’s senior position over the flight engineer and co-pilot contributed to his subordinates’ inability to convince him to delay the flight until they attained full clearance from ATC (Smith, 2017). Besides, the sudden closure of Las Palmas increased fatigue and stress for key personnel. Thus, the fundamental cause of the accident was KLM’s captain’s hazardous attitude.

Communication Problems

            Communication problems led to the catastrophe that would have been avoided if participants observed basic aviation rules. For instance, the air traffic controller sanctioned KLM’s take-off at a time when Pan Am was on the runway. Simultaneous conversation between KLM, Pan Am, and the controller resulted in a shrill noise that obstructed clear communication (Smith, 2017). Besides, the ATC vacillated between Spanish and English while KLM crew spoke Dutch and English. Therefore, the lack of understanding among the three parties created communication mishap.

Reason’s Model of Accident Causation

            James Reason‘s Swiss Cheese describes accident causation based on the underlying process of human error. It considers four levels of failure, including organizational influences, unsafe supervision, preconditions for unsafe acts, and unsafe acts. Reason’s model analyzes the latent conditions that facilitated active faults. The factors identified using Reason’s model resulted in a crush of the century.

Organizational Influences

            The Tenerife disaster is an example of the devastating consequences of ineffective organizational behavior during critical circumstances. Organizational practices that contributed to the accident include communication breakdown between ATC and KLM aircraft crew, failure of KLM crew to obtain departure clearance, and ignorance to basic take-off rules. Thus, organizational influences play a significant role in disaster dynamics.

Unsafe Supervision

            The dynamics of authority created circumstances that favored the collision. KLM’s chief flying instructor determined the authority gradient during the flight. His capacity as a senior staff induced the engineer and co-pilot not to question his decisions because they assumed that he was always right (Littman-Ovadia & Raas-Rothschild, 2018). In addition, poor supervision of flights at the control center made the collision inevitable (Rudolph & Repenning, 2002). They could not find a clear view of aircraft on the runway to inform the pilots unambiguously about an impending danger following unsafe takeoff. Lack of ground radar to aid safe supervision of takeoffs by the ATC set stage for the occurrence of the crush.

Preconditions for Unsafe Acts

            The context for the flight set stage for the accident. First, the usual Las Palmas hub was unexpectedly closed forcing the two jumbo jets to divert to a much smaller airport. Second, weather conditions at the airport characterized by dense fog and low clouds interfered with visibility. In addition, communication error about backtracking of Pan Am flight created confusion. Thirdly, unusual traffic congestion forced the tower to conduct taxiing maneuvers, which are potentially dangerous. Fourth, the act by Pan Am to leave the runway at the fourth rather than the third intersection facilitated the collision with KLM, which sat motionless at the opposite end (Smith, 2017). Lastly, the additional fuel refilled in KLM ignited the fire after the collision. Thus, the preconditions miscommunication, dense fog, and mismarking of the runway intersection led to the mishap. 

The Unsafe Acts

            The fundamental cause of the accident was the unsafe acts of KLM Captain. Foremost, he took off without full clearance from the ATC. As a result, he was not privy of Pan Am aircraft’s simultaneous takeoff. Second, he disobeyed the ‘stand-by for take-off’ command from the control tower. Thirdly, the captain failed to interrupt take-off when he was informed that Pan Am 1736 reported that it was still on the runway (Smith, 2017). Fourth, he was unable to heed to the engineer’s appeal to confirm the runway status of Pan Am but instead replied affirmatively that it had already left. The collision is emphatically blamed on the actions and inactions of KLM chief flying instructor, Captain Veldhuyzen van Zanten.

Implications of the tragedy

Several aviation psychology principles aid in averting aviation tragedies. NTSB recommends the development of an operations bulletin that will ensure that pilots understand good operating procedures before receiving certification (NTSBa, 2019). In addition, communication should be standardized to avoid confusion, which increases the likelihood of critical misunderstanding (NTSBb, 2019). Crew resource management should also be implemented to offer specific training to aircraft crew (McChesney, 2017). Additionally, English should be reiterated as the standard aviation language to promote understanding (Anderson, 2011). Lastly, all airports should procure Ground Radar installation to detect potential runway intrusion. Adherence to the new aviation standards will avert the reoccurrence of catastrophes of this magnitude in the future.

Conclusion

            Dubbed as the crush of the century, the Tenerife tragedy of 1977 in Canary Islands, Spain, remains history’s deadliest air accident to date. The catastrophe involved two Boeing 737 jumbo jets and claimed 583 lives and left 61 casualties. The accident was caused by a set of unsafe acts including poor decisions made by the KLM captain, bad weather, mismarking the interception, poor communication, and human errors.  To avert future tragedies, NTSB recommends the development of an operations bulletin to ensure that pilots understand proper operating procedures before receiving certification. The Tenerife accident remains the history’s deadliest air accident whose occurrence informed the recommendation of a set of aviation policies by NTSB to avert future tragedies.

References

Anderson, B. L. (2011). The Psychology of Safety. Retrieved from

https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20110015735.pdf

Littman-Ovadia, H., & Raas-Rothschild, E. (2018). Character Strengths of Airline Pilots:

Explaining Life and Job Satisfaction and Predicting CRM Performance. Psychology, 9(08), 2083.

McChesney, J. (2017). The Hogan Development Survey: Personality in Selecting and Training

Aviation Pilots. Retrieved from https://cornerstone.lib.mnsu.edu/cgi/viewcontent.cgi?article=1681&context=etd

NTSBa. (2019). Safety Recommendation A-86-034. Retrieved from

NTSBb. (2019). Aviation Accident Report AAR-72-17. Retrieved from

Rudolph, J. W., & Repenning, N. P. (2002). Disaster dynamics: Understanding the role of

quantity in organizational collapse. Administrative Science Quarterly, 47(1), 1-30.

Smith, P. (2017). The true story behind the deadliest air disaster of all time. Retrieved from

https://www.telegraph.co.uk/travel/comment/tenerife-airport-disaster/

Weick, K. E. (1990). The vulnerable system: An analysis of the Tenerife air disaster. Journal of

management, 16(3), 571-593.

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