TENERIFE AIRPORT DISASTER

REPORT
1 AFIQ AIMAN B SALIME 53235211072
2 AHMAD KHAEZURAN B EZANI 53235211192
3 WAN ROHAZAMLY B WAN HASSAN 53235211315
4 AHMAD SALMAN B HARIS

By

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ACCIDENT SUMMARY
Date : March 27, 1977
Summary : Pilot error, runway incursion, heavy fog, limitations and failures in
communication
Site : Los Rodeos Airport (Tenerife North Airport)
Total injuries (non-fatal) : 61
Total fatalities : 583
Total survivors : 61






Aircraft

Type Boeing 747-121 Boeing 747-206B
Name Clipper Victor Rijn
Operator Pan American World Airways KLM Royal Dutch Airlines
Registration N736PA PH-BUF
Flight Origin Los Angeles International
Airport,
Los Angeles, United States
Schiphol Airport
Amsterdam, Netherlands
Stopover John F. Kennedy International
Airport, New York City, United
States
-
Destination Gran Canaria Airport
Canary Island, Spain
Gran Canaria Airport
Canary Island, Spain
Passengers 380 234
Crew 16 14
Injuries (non-fatal) 61 0
Fatalities 335 (326 Passengers, 9 crew) 248 (all)
Survivors 61 0



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1 HOW THE ACCIDENT HAPPEN

The Tenerife airport disaster was a fatal runway collision between two Boeing 747s on March 27,
1977 at Los Rodeos Airport (now called Tenerife North Airport) on the Spanish island of Tenerife, one of
the Canary Islands. The crash killed 583 people, making it the deadliest accident in aviation history.
A bomb explosion at Gran Canaria Airport, and the threat of a second bomb, caused many aircraft
to be diverted to Los Rodeos Airport. Among them were KLM Flight 4805 and Pan Am Flight 1736 the
two aircraft involved in the accident. At Los Rodeos Airport, air traffic controllers were forced to park
many of the airplanes on the taxiway, thereby blocking it. Further complicating the situation, while
authorities waited to reopen Gran Canaria, a dense fog developed at Tenerife, greatly reducing visibility.
When Gran Canaria reopened, the parked aircraft blocking the taxiway at Tenerife required both
of the 747s to taxi on the only runway in order to get in position for takeoff. The fog was so thick that
neither aircraft could see the other, nor could the controller in the tower see the runway or the two 747s
on it. As the airport did not have ground radar, the only means for the controller to identify the location of
each airplane was via voice reports over the radio. As a result of several misunderstandings, the KLM
flight attempted to take off while the Pan Am flight was still on the runway. The resulting collision
destroyed both aircraft, killing all 248 aboard the KLM flight and 335 of 396 aboard the Pan Am flight.
Sixty-one people aboard the Pan Am flight, including the pilots and flight engineer, survived the disaster.
As the accident occurred in Spanish territory, that nation was responsible for investigating the
accident. Investigators from the Netherlands and the United States also participated. The investigation
revealed that the primary cause of the accident was the captain of the KLM flight taking off without
clearance from Air Traffic Control (ATC). The investigation specified that the captain did not
intentionally take off without clearance; rather he fully believed he had clearance to take off due to
misunderstandings between his flight crew and ATC. Dutch investigators placed a greater emphasis on
this than their American and Spanish counterparts, but ultimately KLM admitted their crew was
responsible for the accident, and the airline financially compensated the victims' relatives.
The accident had a lasting influence on the industry, particularly in the area of communication.
An increased emphasis was placed on using standardized phraseology in ATC communication by both
controllers and pilots alike, thereby reducing the chance for misunderstandings. As part of these changes,
the word "takeoff" was removed from general usage, and is only spoken by ATC when actually clearing
an aircraft to take off. Less experienced flight crew members were encouraged to challenge their captains
when they believed something was not correct, and captains were instructed to listen to their crew and
evaluate all decisions in light of crew concerns. This concept was later expanded into what is known
today as Crew Resource Management. CRM training is now mandatory for all airline pilots.


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2 INJURIES TO PERSONS

2.1 KLM FLIGHT 4805

Injuries Crew Passengers Others
Fatal 14 234 -
Non-fatal - - -
None - - -

2.2 PAN AM FLIGHT 1736

Injuries Crew Passengers Others
Fatal 9 317 -
Non-fatal 7 61* 2**
None - - -

* 9 of these passengers subsequently died as a result of injuries received
** Company employees, sitting on the cockpit jumpseats, who had boarded the
aeroplane in Tenerife

3 PHASE OF FLIGHT OF THE ACCIDENT
At take off stage. At 12:30 a bomb explodes in the Las Palmas passenger terminal.
Because of Warnings of a possible second bomb, the airport was closed. A large number of
flights were diverted to Tenerife, KLM Flight 4805 from Amsterdam and Pan Am Flight 1736
(coming from Los Angeles and New York). Las Palmas Airport opened to traffic again at 15:00.
Because the Pan Am passengers remained on aboard it was possible to leave Tenerife at
once. The taxiways were congested by other aircraft however. This meant the Pan Am crew had
to backtrack on runway 12 for take-off on runway 30. The entrance to runway 12 however, was
blocked by the KLM Boeing. The Pan Am flight had to wait for almost 2 hours before all KLM
passengers had reboarded and refueling had taken place.
The KLM flight was then cleared to backtrack runway 12 and make a 180deg. turn at the
end. Three minutes later (at 17:02) Pan Am 1736 was cleared to follow the KLM aircraft and

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backtrack runway 12. The Pan Am crew were told to leave the runway at the third taxiway and
report leaving the runway. At 17:05:44.
KLM 4805 reported ready for take-off and was given instructions for a Papa beacon
departure. The KLM crew repeated the instructions and added "We are now at take-off". The
brakes were released and KLM 4805 started the take-off roll.
A number of second before impact the KLM crew saw the PanAm Boeing still taxiing
down the runway. The crew tried to climb away and became airborne after a 65 feet tail drag in
an excessive rotation.
The Pan Am crew immediately turned the aircraft to the left and applied full power. The
KLM aircraft was airborne, but the fuselage skidded over the Pan Am's aft fuselage, destroying it
and shearing off the tail. The KLM aircraft flew on and crashed out of control 150m further on,
sliding another 300m bursting into flames.
4 CAUSE OF ACCIDENT

4.1 Human Factors

It is also observed that, as the time for take-off approached, the captain of KLM - perhaps
on account of all these worries - seemed a little absent from all that was heard in the cockpit.
He enquired several times, and after the co-pilot confirmed the order to backtrack, he asked
the tower if he should leave the runway by C-l, and subsequently asked his co-pilot if he
should do so by C-4. On arriving at the end of the runway, and making a 180-degree turn in
order to place himself in take-off position, he was advised by the co-pilot that he should wait
as they still did not have an ATC clearance. The captain asked him to request it, which he did,
but while the co-pilot was still repeating the clearance, the captain opened the throttle and
started to take off.

The co-pilot of KLM, instead of requesting take-off clearance or advising that they did
not yet have it, added to his read-back, "We are now at take-off." The tower, which was not
expecting the aircraft to take off as it had not given clearance, interpreted the sentence as,
"We are now at take-off position" and the controller replied: "Okay, ... stand by for take-off ...
I will call you." Nor did the Pan Am on hearing the "We are now at take-off", interpret it as
an unequivocal indication of take-off. However, in order to make their own position clear,
they said, "We are still taxiing down the runway." This transmission coincided with the
"Stand by for take-off ... I will call you", causing a whistling sound in the tower transmission
and making its reception in the KLM cockpit not as clear as it should have been, even though
it did not thereby become unintelligible.'
The communication from the tower to the PAA requested the latter to report when it left
the runway clear. In the cockpit of the KLM airplane which was taking off, nobody at first
confirmed receiving these communications (Appendix 5) until the Pan Am airplane
responded to the tower's request that it should report leaving the runway with an "Okay, we'll
report when we're clear."

5
On hearing this, the KLM flight engineer asked: "Is he not clear then?" The captain didn't
understand him and he repeated: "Is he not clear that Pan American?" The captain replied
with an emphatic "Yes" and, perhaps influenced by his great prestige, making it difficult to
imagine an error of this magnitude on the part of such an expert pilot, both the co-pilot and
the flight engineer made no further objections. The impact took place about thirteen seconds
later.
When the Spanish, American and Dutch investigating teams heard the tower recording
together and for the first time, no-one, or hardly anyone, understood that this transmission
meant that they were taking off.

4.2 Time Factors
At the time of the accident, investigators learned that the Dutch rules regarding duty time
limits had recently been changed. Prior to this, the captain had a great deal of discretion in
extending his crew's duty time in order to complete the scheduled service. However, new
rules imposed absolute rigidity with regard to duty time limits. The captain was forbidden to
exceed these limits and, in the event that duty times were exceeded, could be prosecuted
under the law.
Moreover, until December 1976, it was relatively easy to adjust the duty time by taking
only a few factors into account. The investigation concluded that the new calculation methods
were so complicated that, in practice, it was impossible for a flight crew to calculate
adjustments in the cockpit. For this reason, KLM management strongly recommended that
they be contacted in order to determine the adjusted duty time.
This was the situation on the day of the accident. The investigators noted that during the
delay at Tenerife, the KLM captain, using HF radio, contacted the company's operations
office in Amsterdam. He was told that if he was able to takeoff before a certain time it
seemed that there would be no problems with duty time. However, if there was any risk of
exceeding the limit, the company would send a telex to Las Palmas. This uncertainty of the
crew as to their duty time limit was found by the accident investigation to be an important
psychological factor.

4.3 Weather Conditions
Another factor identified in the investigation was the low-lying clouds that descended
upon the airport just prior to the accident. Visibility both before and during the accident was
variable. While runway visibility was reported to be 2 to 3 kilometers 17 minutes prior to the
accident, visibility reduced to just 300 meters 12 minutes later. Just after the accident,
visibility had improved to one kilometer. The investigators concluded that the changing
visibility caused "...an increase in subconscious care to the detriment of conscious care, part
of which was already focused on takeoff preparation (completing of checklists, taxiing with
reduced visibility, etc.)."
The investigation also concluded that the KLM crew also had a "...fixation on what was
being seen (increasing fog) with a consequent diminished capacity to assimilate what was
heard." The crew was also fixated "...on trying to overcome the threat posed by a further

6
reduction of the already precarious visibility. Faced with this threat, the way to meet it was
either by taking off as soon as possible, or by testing the visibility once again and possibly
refraining from taking off (a possibility which certainly must have been considered by the
KLM captain)."
The investigation also concluded that the KLM crew probably felt a certain level of
relaxation following the execution of a "...difficult 180 degree turn, which must have
coincided with a momentary improvement in the visibility (as proved by the CVR, because
which shortly before arriving at the approach end of the runway they turned off the
windshield wipers), the crew must have felt a sudden feeling of relief which increased their
desire to finally overcome all of the ground problems: the desire to be airborne."

4.4 Airport Facilities

The Tenerife airport was never designed to accommodate the large number of aircraft
that were diverted there the day of the accident. As a result of parking congestion on the ramp,
it was necessary for the controllers to devise an ad-hoc taxi routing for the two jumbos which
involved both being on the active runway at the same time.

The controllers were required to provide aircraft separation under very poor visibility
conditions without the aid of ground radar. The tower building was being refurbished and
reequipped. Since Runway Visual Range (RVR) measurement equipment was not available,
the controllers were not able to provide accurate visibility information to the KLM or Pan Am
pilots. In addition, the runway centreline lights were out of service.

4.5 Language on the Radio

The controllers normal language was Spanish, the KLM crews was Dutch, and the Pan
American crews was English. Although ATC instructions were given over the radio in
English, information transfer may have been adversely affected due to accent and
terminology used by each party transmitting on the approach control frequency.








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5 MODEL OF ACCIDENT CAUSATION
5.1 Reasons Model
Organizational influences:
Regulations on limitation of duty time put pressure on KLM captain to take off
quickly.
Precondition for unsafe acts:
1. Bomb incident in Las Palmas caused diversions
2. Low-lying cloud blown by wind cause rapid changes in visibility at
Tenerife
3. KLM aircraft refueled at Tenerife causing a delay and making
aircraft heavier and more combustible
4. Unusual traffic congestion meant non-standard and potentially
dangerous taxiing maneuvers had to be used
5. Pan Am crew had difficulty finding correct intersection to exit
runway
6. KLM first officer said we are now at take-off after KLM aircraft
had started moving but controller did not understand the aircraft was
taking off
7. Radio transmission from control tower took place at same time as
Pan Am transmission causing interference so KLM crew could not
clearly hear either message
Unsafe Acts
1. KLM captain took off without clearance from control tower
2. KLM captain did not follow order stand by for take-off instruction
from control tower
3. KLM captain did not interrupt take-off when Pan Am crew reported they
were still on the runway
4. When KLM flight engineer asked if Pan Am aircraft had left the runway,
KLM captain replied affirmative
Factors:
1. The communication issues between the pilots and control towers.
2. Pan Am crew did not see the correct exit as they taxied down the runway,
there were no signs marking taxiway exits.
3. Visibility was poor.
4. Crew were not familiar with the airport.


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6 ANALYSIS AND RECOMMENDATION
6.1 Analysis factor which contributed in the accident:

1. Inadequate language. When the KLM co-pilot repeated the ATC clearance, he ended with
words "we are now at take off". The controller who had not been asked for take-off
clearance, and who consequently had not granted it, did not understand that they we
taking off. The "O.K." from the tower, which preceded the "stand by for take-off" was
likewise incorrect - although irrelevant in this case because take-off had already started
about six and half second before.
2. The fact that the Pan Am aeroplane had not left the runway at the third intersection.
3. Unusual traffic congestion which obliged the tower to carry out taxiing maneuvers which
it is dangerous to the aeroplanes taxi on the active runway.
6.2 Recommendations from the investigator

1. Placing of great emphasis on the importance of exact compliance with instructions and
clearances.
2. Use of standard, concise and unequivocal language.
3. Avoidance of word "TAKE-OFF" in the ATC clearance and adequate time separation
between the ATC clearance and the take-off clearance.
7 CAUSED OF ACCIDENT FOUND FROM CVR AND FDR
From the conversation (see Appendix 1) we found out that the fact that the K.L.M. Captain are:

1. Took off without clearance.
2. Did not obey the "stand by for take-off" from tower.
3. Did not interrupt take-off on learning that the PAN AM was still on the runway.
4. In reply to the Flight Engineer's query as to whether the PAN AM had already left the
runway, replied emphatically in the affirmative.
So the responsible and the cause of the accident are the act of Captain Veldhuyzen Van Zautan
which decided to take off faster and neglecting the ATC.





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APPENDIXES
Appendix 1: Cockpit and Tower Communications
CVR and FDR from the KLM and Pan Am found out the conversation between
pilot and co-pilot also radio communication with the ATC tower.
The communication are:
1705:36.7
[KLM first officer completes pre-flight checklist. KLM 4805 is now at the end of
the runway, in position for departure.]
1705:41.5
KLM FIRST OFFICER Wait a minute, we don't have an ATC clearance. [This
statement is apparently a response to an advancing of the throttles in the KLM.]
KLM CAPTAIN No, I know that, go ahead, ask.
1705:44.6 - 1705:50.8
KLM (RADIO) The KLM four eight zero five is now ready for take-off and we
are waiting for our ATC clearance.
1705:53.4 - 1706:08.1
TENERIFE TOWER KLM eight seven zero five [sic] you are cleared to the
Papa Beacon, climb to and maintain flight level nine zero, right turn after take-
off, proceed with heading four zero until intercepting the three two five radial
from Las Palmas VOR.
1706:07.4
KLM CAPTAIN Yes.
1706:09.6 - 1706:17.8
KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level
nine zero until intercepting the three two five. We are now at take-off [or
"uh..taking off"].
1706:11.1
[KLM brakes released.]


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1706:12.3
KLM CAPTAIN We gaan ... check thrust. [We're going ... check thrust].
1706:14.0
[Engine acceleration audible in KLM cockpit]
1706:18.2 - 1706:21.2
TENERIFE TOWER OK.... Stand by for take-off, I will call you. [Only the
start of this message was heard by the KLM crew due to a radio heterodyne.]
1706:19.3
PAN AM (RADIO) No... uh. [This message was not heard by the KLM crew
due to a radio heterodyne.]
1706:20.3
PAN AM (RADIO) And we're still taxiing down the runway, the clipper one
seven three six. [This message was not heard completely by the KLM crew due
to a radio heterodyne.]
1706:25.5
TENERIFE TOWER Ah, papa alpha one seven three six report the runway
clear.
1706:29.6
PAN AM (RADIO) OK, will report when we're clear.
1706:31.7
TENERIFE TOWER Thank you
1706:xx.x
PAN AM CAPTAIN Let's get the hell right out of here.
1706:xx.x
PAN AM FIRST OFFICER Yeah, he's anxious, isn't he?
1706:xx.x
PAN AM FLT ENGR Yeah, after he held us up for all this time. Now he's in a
rush.

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1706:32.4
KLM FLT ENGR Is hij er niet af dan? [Is he not clear then?]
1706:34.1
KLM CAPTAIN Wat zeg je? [What do you say?]
1706:34.2
KLM UNKNOWN Yup.
1706:34.7
KLM FLT ENGR Is hij er niet af, die Pan American? [Is he not clear, that Pan
American?]
1706:35.7
KLM CAPTAIN Jawel. [Oh yes. - emphatic]
1706:40.5
[Pan Am captain sees landing lights of KLM Boeing at approx. 700 m]
PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is
coming!
PAN AM FIRST OFFICER Get off! Get off! Get off!
1706:43.5
KLM FIRST OFFICER V-1.
1706:44.0
[PH-BUF (KLM 4805) started rotation.]
1706:47.4
KLM CAPTAIN [Exclamation/expletive]
1706:50
N736PA (Pan Am 1736) records sound of collision.




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Appendix 2: Map of Tenerife Disaster


























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Appendix 3: Reasons Model