Tenerife airport disaster

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Tenerife disaster
(KLM 4805 and Pan Am 1736)

CGI rendering of Pan Am 1736 about to be hit by KLM 4805. Some fog has been cleared to give a clearer perspective of the aircraft.
Accident summary
Date	March 27, 1977
Type	Ground collision involving weather conditions, pilot error, ATC error, technical limitations
Site	Los Rodeos Airport (now Tenerife North Airport) Tenerife, Canary Islands
Total fatalities	583
Total survivors	61
First aircraft
Type	Boeing 747-121
Name	Clipper Victor
Operator	Pan American World Airways
Tail number	N736PA
Flight origin	Los Angeles International Airport
Stopover	John F. Kennedy International Airport, New York City, USA
Destination	Gran Canaria Airport
Passengers	380
Crew	16
Fatalities	335 (326 passengers, 9 crew members)
Survivors	61
Second aircraft
Type	Boeing 747-206B
Name	Rijn ("Rhine")
Operator	KLM Royal Dutch Airlines
Tail number	PH-BUF
Flight origin	Schiphol Airport, Amsterdam, Netherlands
Destination	Gran Canaria Airport
Passengers	234
Crew	14
Fatalities	248 (all)
Survivors	0

The Tenerife airport disaster was the collision of two Boeing 747 airliners on the runway of Los Rodeos Airport (now known as Tenerife North Airport) on the Spanish island of Tenerife, one of the Canary Islands. With 583 fatalities, the crash remains the worst accident in aviation history.

The collision took place on March 27, 1977, at 17:06:56 local time. The planes were operating as Pan Am Flight 1736 (the Clipper Victor) under the command of Captain Victor Grubbs, and KLM Flight 4805 (the Rijn) under the command of Captain Jacob Veldhuyzen van Zanten. Taking off on the airport's only runway, the KLM flight crashed into the Pan Am aircraft backtaxiing on the runway in the opposite direction.

Contents 1 Flight details 2 Chain of events leading to disaster 2.1 Bombing at Las Palmas 2.2 Congestion at Los Rodeos 2.3 Refueling 2.4 Taxiing and weather conditions 2.5 Communication misunderstandings 2.6 Collision 3 Investigation 3.1 Probable cause 3.2 Speculations 3.3 Responsibility 4 Safety response 5 Memorials 6 Notable people killed in the disaster 7 The crash in popular culture 8 See also 9 References 10 External links

[edit] Flight details

For both planes, Tenerife was an unscheduled stop. Their destination was Gran Canaria International Airport (also known as Las Palmas airport), serving Las Palmas on the nearby island of Gran Canaria. Both are in the Canary Islands, an autonomous community of Spain located in the Atlantic Ocean off the west coast of Morocco.

Pan Am Flight 1736 had taken off from Los Angeles International Airport with an intermediate stop at New York's John F. Kennedy International Airport. The aircraft was a Boeing 747-121, registration N736PA. Of the 380 passengers, 14 had boarded in New York City. The crew was changed at New York. The new captain was Victor Grubbs, and the first officer ("co-pilot") was Robert Bragg. There were 14 other crew members. The airplane was Pan Am's first Boeing 747 (ex Clipper Young America).^[1]

KLM Flight 4805, a charter flight for Holland International Travel Group from the Netherlands,^[1] had taken off four hours before from Amsterdam Schiphol Airport. Its captain was Jacob Veldhuyzen van Zanten and the first officer was Klaas Meurs. The aircraft was a Boeing 747-206B, registration PH-BUF. The KLM had 235 passengers and 14 crew members. Among the passengers were 48 children and 3 infants. Most of the KLM passengers were Dutch; four Germans, two Austrians, and two Americans were also on the plane. After the aircraft landed at Tenerife, a tour guide named Robina van Lanschot, who lived on the island in Puerto de la Cruz and wanted to see her boyfriend that night, elected not to reboard the 747, leaving 234 passengers on board.^[2][3]

[edit] Chain of events leading to disaster

[edit] Bombing at Las Palmas

Events on both planes had been routine until they approached the islands. Then, at 1:15 pm, a terrorist bomb (planted by Fuerzas Armadas Guanches) exploded in the terminal of Gran Canaria International Airport. The civil aviation authorities closed that airport and diverted several of its incoming flights to Los Rodeos, including the two Boeing 747 aircraft involved in the disaster. Upon contacting Gran Canaria airport, the Pan Am flight was informed of the temporary closure. Although the Pan Am crew indicated that they would prefer to circle in a holding pattern until landing clearance was given, the plane was ordered to divert to Los Rodeos, along with the KLM flight.

[edit] Congestion at Los Rodeos

In all, at least five large aircraft were diverted to Los Rodeos, a regional airport that could not easily accommodate them. The airport consisted of one runway and one major taxiway parallel to it, as well as several small taxiways connecting them. While waiting for Gran Canaria airport to reopen, the diverted aircraft took up so much space that they were parked on the long taxiway, meaning that it could not be used for taxiing. Instead, departing aircraft would have to taxi along the runway to position themselves for takeoff.

[edit] Refueling

After the threat at Gran Canaria International Airport had been contained, authorities reopened the airport. The Pan Am aircraft was ready to depart, but the KLM plane and a refueling vehicle obstructed the way to the active runway. Captain van Zanten had decided to refuel at Los Rodeos instead of Las Palmas, apparently to save time. The refueling took an estimated 35 minutes.^[2]

[edit] Taxiing and weather conditions

Following the tower's instructions, the KLM aircraft was cleared to backtaxi the full length of runway 30 and make a 180° turn to put the aircraft in takeoff position — a difficult maneuver to perform with a 747 on a runway only 45 m (150 ft) wide. While KLM 4805 was backtaxiing on runway 30, the controller asked the flight crew to report when it was ready to copy the ATC clearance. Because the flight crew was performing the checklist, copying this clearance was postponed until the aircraft was in takeoff position on Runway 30. During taxiing, the weather deteriorated and low-lying clouds now limited the visual range to about 300 m (1,000 ft).

Shortly afterwards Pan Am 1736 was instructed to also backtaxi the same runway, leaving it by taking the third exit on their left and then using the parallel taxiway. Initially the crew was unclear as to whether the controller had told them to take the first or third exit. The crew asked for clarification and the controller responded emphatically by replying: "The third one, sir; one, two, three; third, third one". The crew began the taxi and proceeded to identify the unmarked taxiways using an airport diagram as they slowly reached them. Based on the chronology of the cockpit voice recorder (CVR) and the distances between the taxiways (and the location of the aircraft at the time of the collision), the crew successfully identified the first two taxiways (C-1 and C-2), but their discussion in the cockpit never indicated that they had sighted the third taxiway (C-3), which they had been instructed to use. There were no markings or signs to identify the runway exits. The Pan Am crew appeared to remain unsure of their position on the runway until the collision, which occurred near the intersection with the fourth taxiway (C-4).

The angle of the third taxiway would have required the plane to perform a turn of approximately 145°, which would lead back toward the still-crowded main apron. At the end of C-3 another 145° turn would have to be made to continue taxiing towards the start of the runway. Taxiway C-4 would have required two 35° turns. A study carried out by the Air Line Pilots Association after the accident concluded that making the second 145° turn at the end of taxiway C-3 would have been "a practical impossibility", although the Dutch report stated that such a maneuver "could reasonably be performed". The official report from the Spanish authorities did not explain why the controller had instructed the Pan Am aircraft to use the third taxiway, rather than the easier fourth taxiway.^[4]

[edit] Communication misunderstandings

Immediately after lining up, the KLM captain advanced the throttles slightly (a standard procedure known as "spin-up", to verify that the engines are operating properly for takeoff) and the co-pilot advised the captain that ATC clearance had not yet been given. The captain responded, "I know that. Go ahead, ask." The co-pilot then radioed the tower that they were "ready for takeoff" and "waiting for our ATC clearance". The KLM crew then received a clearance which specified the route that the aircraft was to follow after takeoff. The instructions used the word "takeoff", but did not include an explicit statement of whether they were cleared for takeoff.

The KLM co-pilot read the clearance back to the controller, completing the readback with the statement "we're now at takeoff" or "we're now, uh, taking off" (the exact wording of his statement was not clear^{[citation needed]}), indicating to the controller that they were beginning their takeoff roll. The captain interrupted the tail end of the co-pilot's readback with the comment "We're going".

The controller initially responded with "OK" (terminology which, although commonly used,^{[citation needed]} is nonstandard), which reinforced the KLM crew's misinterpretation that they indeed had takeoff clearance. The controller's response of "OK" to the co-pilot's nonstandard statement that they were "now at takeoff" was likely due to his misinterpretation that they were in takeoff position and ready to begin the roll when takeoff clearance was received, but not actually in the process of taking off. He also most likely hadn't heard the captain's announcement that they were "going", since van Zanten had said it so soon after the co-pilot's readback. Aware of the possible misinterpretation, the controller then immediately added "Stand by for takeoff, I will call you", indicating that he had never intended the clearance to be interpreted as a takeoff clearance.

However, a simultaneous radio call from the Pan Am crew at that precise moment caused mutual interference on the radio frequency and all that was audible in the KLM cockpit was a heterodyne beat tone, making the crucial latter portion of the tower's response inaudible to the KLM pilots. The Pan Am crew's transmission, which was also critical, was reporting that "We're still taxiing down the runway, the Clipper 1736." This message was also blocked by the heterodyne and inaudible to the KLM crew. Either message, if broadcast separately, would have been audible in the KLM cockpit and given the KLM crew time to abort its takeoff.

Due to the fog, neither crew was able to see the other plane on the runway ahead of them. In addition, neither of the aircraft could be seen from the control tower, and the airport was not equipped with ground radar.

After the KLM plane had started its takeoff roll, the tower instructed the Pan Am crew to "report when runway clear". The crew replied: "OK, we'll report when we're clear". On hearing this, the KLM flight engineer expressed his concern about the Pan Am not being clear of the runway by asking the pilots, "Is he not clear, that Pan American?". However, the captain emphatically replied "Oh, yes" and continued with the takeoff.^[5]

[edit] Collision

According to the CVR, Captain Grubbs, captain of the Pan Am plane, spotted the KLM's landing lights just as the plane approached exit C-4, exclaiming, "Goddamn, that son-of-a-bitch is coming!" with the co-pilot Robert Bragg yelling, "Get off! Get off! Get off!". The Pan Am crew applied full power and took a sharp left turn towards the exit to avoid a collision. KLM Captain van Zanten attempted to avoid a collision by climbing away, scraping the tail of the plane along the runway for 20 m (70 ft). The lower fuselage of the KLM plane hit the upper right side of the Pan Am's fuselage at approximately 190 MPH,^{[citation needed]} ripping apart the center of the Pan Am jet nearly directly above the wing.

The KLM plane was briefly airborne, but the impact with the Pan Am had sheared off the #1 (outer left) engine, and the #2 (inner left) engine had ingested significant amounts of shredded materials from the Pan Am. The KLM pilot quickly lost control, went into a stall, rolled sharply, slammed into the ground at a point 150 m (500 ft) past the point of collision and slid a further 300 m down the runway.

A survivor of the Pan Am flight, John Coombs of Haleiwa, Hawaii, said that sitting in the nose of the plane probably saved his life: "We all settled back, and the next thing an explosion took place and the whole port side, left side of the plane, was just torn wide open."^[6]

Both airplanes were destroyed. All 234 passengers and 14 crew members in the KLM plane died, while 326 passengers and 9 crew members aboard the Pan Am flight were also killed,^[7] primarily due to the fire and explosions resulting from the fuel spilled in the impact. The other 56 passengers and 5 crew members aboard the Pan Am aircraft survived, including the captain, first officer, and flight engineer. Most of the survivors on the Pan Am aircraft walked out onto the left wing, the side away from the collision, through holes in the fuselage structure. Also, the Pan Am's engines were still running for a few minutes after the accident despite First Officer Bragg's intention to turn them off. The top part of the cockpit, where the engine switches were located, had been destroyed in the collision. Survivors waited for rescue, but it did not come promptly as the firefighters were initially unaware that there were two aircraft involved and were concentrating on the KLM wreck some distance away in the thick fog. Eventually, most of the survivors on the wings dropped to the ground below.^[2]

Captain Jacob van Zanten was KLM's chief of flight training and the airline's preferred pilot for publicity such as magazine advertisements. As such, KLM attempted to contact him to give public statements regarding the disaster, before learning that he was the captain involved.^[8] Van Zanten had given Klaas Meurs, the first officer on the ill-fated flight, his Boeing 747 qualification check about two months before the accident.^[3]

[edit] Investigation

About 70 crash investigators from Spain, the Netherlands, the United States, and the two airline companies were involved in the investigation. Facts showed that there had been misinterpretations and false assumptions. Analysis of the CVR transcript showed that the KLM pilot was convinced that he had been cleared for takeoff, while the Tenerife control tower was certain that the KLM 747 was stationary at the end of the runway and awaiting takeoff clearance.

Subsequent to the crash, first officer Robert Bragg, who was responsible for handling the Pan Am's radio communications, made public statements which conflict with statements made by the Pan Am crew in the official transcript of the CVR. In the documentary Crash of the Century (produced by the makers of Mayday), he stated he was convinced the tower controller had intended they take the fourth exit C-4 because the controller delivered the message to take "the third one, sir, one; two, three; third, third one" after the Pan Am's had already passed C-1 (making C-4 the third exit counting from there).^[9] The CVR shows that they received this message before they unequivocally identified C-1, with the position of the aircraft somewhere between the entrance and C-1. Also, in a Time article, Bragg stated that he made the statement "What's he doing? He'll kill us all[!]" which does not appear in the CVR transcript.^[10]

[edit] Probable cause

The investigation concluded that the fundamental cause of the accident was that the KLM captain took off without a takeoff clearance. The investigators suggested the reason for his mistake might have been a desire to leave as soon as possible in order to comply with KLM's duty-time regulations, and before the weather deteriorated further.

Other major factors contributing to the accident were:

• The sudden fog greatly limited visibility. The control tower and the crews of both planes were unable to see each other.
• Simultaneous radio transmissions, with the result that neither message could be heard.

The following factors were considered contributing but not critical:

• Use of ambiguous non-standard phrases by the KLM co-pilot ("We're at take off") and the Tenerife control tower ("OK").
• Pan Am mistakenly continued to exit C-4 instead of exiting at C-3 as directed.
• The airport was (due to rerouting from the bomb threat) forced to accommodate a large number of large aircraft, resulting in disruption of the normal use of taxiways.^[11]

[edit] Speculations

Speculation regarding other contributing factors includes:

• Captain van Zanten's failure to confirm instructions from the tower. The flight was one of his first after spending six months training new pilots on a flight simulator. He may have suffered from "training syndrome", having been in charge of everything at the simulator (including simulated ATC), and having been away from the real world of flying for extended periods.^[2]
• The flight engineer's apparent hesitation to further challenge van Zanten, possibly because Captain van Zanten was not only senior in rank, but also one of the most able and experienced pilots working for the airline.^[2]
• The extra fuel that the KLM plane took on added several factors:
  • it delayed takeoff an extra 35 minutes, which gave time for the fog to settle in;
  • it added over forty tons of weight to the plane, which made it more difficult to clear the Pan Am when taking off;
  • it increased the size of the explosion from the crash that ultimately killed everyone on board.
• Captain van Zanten's reaction, once he spotted the Pan Am plane, was to attempt to take off before he had adequate airspeed. The sharp lifting angle caused the KLM jet to drag its tail on the runway, thereby reducing its speed even further. The plane had, however, exceeded its V1 speed^[12].
• There was disagreement between the various investigative bodies, with the Dutch investigators suggesting that during the incident the Spanish control tower crew had been listening to a football game on the radio and that the American crew was at fault for staying on the runway. Both the Spanish and Pan American investigations pointed the finger primarily at the KLM crew.^[13]

[edit] Responsibility

Although the Dutch authorities were initially reluctant to blame Captain van Zanten and his crew ^[13][14], the airline ultimately accepted responsibility for the accident. KLM paid the victims or their families compensation ranging between $58,000 and $600,000.^[15]

[edit] Safety response

As a consequence of the accident, there were sweeping changes made to international airline regulations and to aircraft. Aviation authorities around the world introduced requirements for standard phrases and a greater emphasis on English as a common working language. For example, ICAO calls for the phrase "line up and wait" as an instruction to an aircraft moving into position but not cleared for takeoff. The FAA equivalent is "position and hold"^[16]. Air traffic instruction should not be acknowledged solely with a colloquial phrase such as "OK" or even "Roger", but with a readback of the key parts of the instruction, to show mutual understanding. Additionally, the phrase "takeoff" is only spoken when the actual takeoff clearance is given. Up until that point both aircrew and controllers should use the phrase "departure" in its place (e.g. "ready for departure"). Cockpit procedures were also changed. Hierarchical relations among crew members were played down. More emphasis was placed on decision-making by mutual agreement. This is known in the industry as Crew Resource Management, and is now standard training in all major airlines.^{[citation needed]}

In 1978 a second airport was inaugurated on the island: the new Tenerife South Airport (TFS). This airport now serves the majority of international tourist flights. Los Rodeos, renamed to Tenerife North Airport (TFN), was then used only for domestic and inter-island flights, but in 2002 a new terminal was opened and it carries international traffic once again, including budget airlines. The Spanish authorities installed a ground radar at Tenerife North following the accident.

[edit] Memorials

Monument in Westgaarde Cemetery, Amsterdam

International Tenerife Memorial, Mount Mesa Mota, Tenerife, Canary Islands

A Dutch national memorial and final resting place for the victims of the KLM plane is located in Amsterdam, at Westgaarde cemetery. There is also a memorial at the Westminster Memorial Park and Mortuary in Westminster, California.

The 30th anniversary marked the first time that Dutch and American next of kin, and aid helpers from Tenerife, joined in international commemoration service held at the Auditorio de Tenerife in Santa Cruz; the International Tenerife Memorial was inaugurated at the Mesa Mota March 27, 2007. The monument was designed by Dutch sculptor Rudi van de Wint. A special 50-page commemorative booklet including a DVD in English, Dutch, and Spanish was published a year later, on March 27, 2008.

[edit] Notable people killed in the disaster

• Eve Meyer, a pin-up model, film actress and producer and former wife of Russ Meyer.^[8]
• A. P. Hamann, the former city manager of San Jose, California, and his wife Frances Hamann.^[17]

[edit] The crash in popular culture

The disaster has featured in many TV shows and documentaries. These include Survival in the Sky, Black Box, Seconds From Disaster: Season 1: Collision on the Runway, Cineflix's Crash of the Century and the Discovery Channel TV series Most Deadly and Destroyed In Seconds. It featured in PBS's NOVA episode "The Deadliest Plane Crash" in 2006.

[edit] See also

• Linate Airport disaster (October 2001)
• List of accidents and incidents on commercial airliners grouped by year
• National Geographic Seconds From Disaster episodes

[edit] References

[edit] External links

Wikimedia Commons has media related to: Tenerife airport disaster

• Accident description for Pan Am Flight 1736 at the Aviation Safety Network
• Accident description for KLM Flight 4805 at the Aviation Safety Network
• AirDisaster.com Accident Database (Pan Am 1736)
• AirDisaster.com Accident Database (KLM 4805)
• ICAO document mentioning phrasing used in the accident
• Tenerife – a survivor’s tale, by Robert L. Bragg (Capt., Pan Am and United, Ret.)
• Historic BBC news report
• NOVA "The Deadliest Plane Crash" - Homepage to the NOVA TV episode
• International Tenerife Memorial
• Project Tenerife
• List of passengers on the Pan Am
• List of passengers on the KLM
• PlaneCrashInfo.Com - Tenerife Disaster
• Ask the Pilot on the Tenerife disaster Patrick Smith, Salon.com
• Airliners.net photos:
  • PH-BUF (KLM 4805)
  • N736PA (Pan Am 1736)

Coordinates: 28°28′54″N 16°20′18″W / 28.48165°N 16.3384°W / 28.48165; -16.3384

v • d • e ← 1976 Aviation accidents and incidents in 1977 1978→ Linjeflyg Flight 618 (January 15) — Tenerife airport disaster (KLM 4805 and Pan Am 1736) (March 27) — Southern Airways Flight 242 (April 4) — Philippine Airlines Flight 421 (April 18) — Aviateca Convair 240 crash (April 27) — Israeli CH-53 crash (May 10) — Dan-Air Boeing 707 crash (May 14) — Aeroflot Ilyushin 62 crash (May 27) — Japan Airlines Flight 472 (September 28) — Convair 240 crash (October 20) — TAP Portugal Flight 425 (November 19) — Malaysia Airlines Flight 653 (December 4) — SA de Transport Aérien Flight 730 (December 18) Bold indicates accidents resulting at least 50 deaths Orange color indicates the deadliest accident in 1977