The Aircraft Collision Issues

On March 27, 1977 at 1706:52 G. M. T. A KLM 747 collided with a Pan Am 747 in dense fog on runway 30 at Los Rodeos Airport in the Spanish Canary Islands. KLM flight 4805 was a 747-206B with serial number PH-BUF. Pan Am flight 1736 was a 747-121 with serial number N736PA. Both aircraft were properly maintained and airworthy according to the regulations of the country of registration. All crew members of both aircraft were properly certified and current for their particular crew member positions on the Boeing 747. The KLM captain had 11,700 hrs. With 1,545 of those hours on the 747. The First officer had a total of 9,200 hours at the time of the accident with only 95 hours on the 747. The flight engineer had 17,031 hours with 543 hours on the 747. The Pan Am captain had 21,043 total with 584 hours on the 747. His co-pilot had 10,800 hours with 2,796 hours on the 747. The flight engineer had 15,210 hours total flight time with 559 hours on the 747. KLM 4805 was a charter flight from Amsterdam, Netherlands to Las Palmas, Canary Islands on behalf of Holland international Travel Group. Pan Am 1736 was also a charter flight to Las Palmas originating in Los Angeles, California the previous afternoon with a stop over and crew change at New York (JFK). The two aircraft involved in the accident were diverted to Los Rodeos because of a terrorist bomb explosion at Las Palmas Airport. There was a threat of another bomb so for security reasons no one could land there. Upon arrival at Los Rodeos several other diverted airliners were already on the ground waiting to go to Las Palmas. The Pan Am parked next to the KLM. The captain of the KLM was constantly on the radio trying to find out when the airport would reopen. He was concerned that he and his flight crew were going to run out of duty time. He decided to get fuel while he was waiting in order to avoid the servicing delay that would be awaiting them at Las Palmas. Las Palmas was reopened while the KLM was in the middle of refueling. The Pan Am was ready to depart but had to wait for the KLM to finish refueling because they couldn't taxi around them. Both aircraft were given instruction to use the active runway 30 as a taxiway because aircraft were parked on the paralleling taxiway. The KLM taxied to the end of the runway and made a 180 degree turn to align itself for takeoff. The Pan Am lagged behind because a blanket of fog surrounded them making it difficult to find their turn off. The Pan Am crew was unsure which taxiway they were to get on. The controller told the Pan Am to exit at the 3rd taxiway. This didn't make sense to them because they would have needed to make a 135 degree turn. The fourth taxiway was only 45 degrees. As the KLM 747 completed its turn and the pre-takeoff checklists were complete the captain started adding power for take off. The first officer noticed this and said, â€Å"Wait a minute, we don't have an ATC clearance. The captain held the brakes and said, â€Å"No†¦ I know that. Go ahead ask. † The KLM requested ATC clearance. The tower read them their departure clearance but did not clear them for takeoff. The KLM captain advanced the throttles again as the first officer read back the clearance. The KLM first officer told ATC they were, â€Å"at takeoff. † The Pan Am heard this and said that they will report when clear the runway. They understood â€Å"at takeoff† to mean at takeoff position. The KLM second officer questioned the captain, â€Å"Did he not clear the runway – that Pan American? The captain said, â€Å"Yes, he did. † Moments later the Pan Am first officer noticed the takeoff lights of the KLM approaching fast. He shouted, â€Å"Get off, Get off! † The captain put in full power and tried to drive the airplane into the grass. The pilots on the KLM noticed the Pan Am slewing across the runway after V1 was called. The captain knew that there wasn't enough room to stop so he over-rotated causing the tail of his aircraft to strike the runway in a shower of sparks. But lift the KLM did – just before reaching the Pan AM. The KLM smashed (with a nose up attitude) into the port side of the Pan Am 747. The KLM continued airborne down the runway another 450 meters past the point of collision where it crashed with full fuel and burned killing all 248 souls on board. The Pan Am was soon engulfed in flames. The impact tore off the top of the Pan Am 747 fuselage from the tail to the back of the cockpit. The Pan Am with its entire top fuselage having been carried away by the KLM, caught fire killing 326 of the 396 souls on board. No one in the tower saw the accident because of the fog. Other aircraft waiting on the taxiway saw a series of explosions and reported them to the tower. Emergency crews were immediately notified. The dense fog delayed the effort of the emergency crews to find the planes. The firemen didn't realize that there were two aircraft involved until they were at the wreckage of the KLM and the fog cleared a little bit to see the Pan AM on fire further down the runway. The main cause of this accident was that the KLM captain took off without clearance. The captain also failed to heed the towers instruction to â€Å"standby for takeoff. Finally, the captain did not abandon the takeoff when it became apparent that the Pan Am was still on the runway. He was obviously in a hurry due to the fact that he and his crew might run out of flight time. They had been flying for a long time and probably had get-homeitis. KLM 4805 was nearing the takeoff minimums perscribed for KLM because of the thick fog which put more pressure on the Captain to takeoff. He didn't want to have to leave the aircraft over night and wait for a change of crew because that would inconvienience everyone and cost money. It is also interesting to note that a procedure error took place. This experienced captain should know the difference between being given takeoff clearance and being given a route of flight clearance. The fact of the matter is that the captain had been spending most of his time for the past ten years as a training captain at Schiphol Airport. â€Å"This tended to reduce his day to day familiarity with route flying and its procedures†(Job 177). This idea then leads to the probability that there was a miscommunication between the tower and the KLM. The tower controller and the Pan Am transmitted over each other information that would have prevented the accident. The tower said, â€Å"OK†¦ standby for takeoff†¦ I will call you. † The Pan Am said, â€Å"We are still taxiing down the runway! † The KLM only heard the controller say, â€Å"OK. † The first officer on the KLM declined to take their clearance while they were taxiing because they were too busy doing their pre-takeoff checklists. They instead received their clearance as they lined up for takeoff. This led the captain to believe that the airway clearance they were given also counted as their clearance to takeoff. The first officer already told him once that they didn't have their clearance. He wasn't about to do it again out of fear because the first officer felt resignation. He thought that this captain gave him his 747 rating only 95 flight hours ago and he was in no place to second guess him. The crew of the KLM had poor situational awareness because they turned a deaf ear to the conversations between ATC and the Pan Am crew. They never heard the tower tell Pan Am to report when they were clear. This is proven by the emphatic response to the flight engineers query as to whether or not the Pan Am was cleared of the runway. The captain and first officer said, â€Å"Yes, he's cleared! † The Pan Am crew contributed to the accident by missing their assigned taxiway. If they had turned at the assigned taxiway they would have been off the runway in time. There are several contributing factors to the Tenerife disaster that could have been avoided. If any one of these mistakes didn't happen, the accident would have never happened. If the Pan Am crew had better charts and diagrams of the Los Rodeos Airport, they would have never missed their turn off. The Pan Am would have been off the runway in plenty of time. If the KLM crew was not in such a hurry, the captain would not have commenced takeoff roll before distinct clearance to takeoff. If KLM had Cockpit Resource Management training, the first officer would not have felt intimidated by the captain. He would have corrected the captain again for trying to takeoff without adequate clearance. The captain would have been trained to accept the input of his fellow crew members. If the Pan Am first officer and the tower had not stepped on eachother over the radio, the KLM would have heard both warnings that would have prevented the accident.