The Tenerife airport disaster occurred on Sunday, March 27, 1977, when two Boeing 747 passenger aircraft collided 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 a total of 583 fatalities, the crash is the deadliest accident in aviation history.
After a bomb exploded at Gran Canaria Airport, many aircraft were diverted to Tenerife. Among them were KLM Flight 4805 and Pan Am Flight 1736 – the aircraft involved in the accident. Many airplanes had been diverted to the smaller Tenerife airport where air traffic controllers were forced to park many of the airplanes on the taxiway, thereby blocking it.
Watch this video to see an explanation of what happened next…
583 innocent people lost their lives on March 27, 1977 due to 4 reasons:
- Pilot error
- Poor weather conditions
- Failures in communication
PILOT ERROR: When the Gran Canaria International Airport had been reopened the Pan Am aircraft was
ready to depart, but the KLM pilot, in order to save time back at Gran Canaria, decided to refuel at Tenerife. This delayed their departure by 35 minutes and kept the Pan AM aircraft from leaving as well.
COLLISION: The decision to refuel in Tenerife changed the outcome in two possible ways
- The Pan Am plane could have left earlier if it had not had to wait for the KLM plane to refuel
- If the KLM plane had not been full of fuel, they may have been able to clear the Pan Am plane instead of colliding with it at take off.
POOR 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.
During taxiing, the weather deteriorated and low-lying clouds now
limited the visual range to about 300 m (1,000 ft).
FAILURES IN COMMUNICATION: Immediately after lining up, the KLM captain advanced the throttles and the co-pilot advised the captain that ATC clearance had not
yet been given. Captain Veldhuyzen van Zanten responded, “I know that.
Go ahead, ask.” Meurs then radioed the tower that they were “ready for
takeoff” and “waiting for our ATC clearance”. The KLM crew then received
instructions 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 that they were cleared for takeoff.
Meurs read the flight clearance back to the controller, completing the readback with the statement: “We are now at takeoff.” Captain Veldhuyzen van Zanten interrupted the co-pilot’s read-back with the comment, “We’re going.”
The controller, who could not see the runway due to the fog,
initially responded with “OK” (terminology which is nonstandard), which
reinforced the KLM captain’s misinterpretation that they 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 in the
process of taking off.
I imagine that in your business or healthcare practice that you’re not normally concerned about the death of 500+ people; however examining the cause of this accident is something we should all consider. How do your decisions effect the lives of your patients or team members?
Failure in communication was the final piece of this disastrous puzzle. Even with the other elements going wrong, the accident would not have been so horrific if communication had been more clear. Communication is VITAL is EVERY aspect of your business.
So, how is your communication? Is there clarity in your team? Or is it possible that misunderstandings are the norm?
I can help you with clarity of your communication. I can help you divert certain disaster in your business. I’m in the tower waiting for your call.