Tenerife airport disaster

Tenerife airport disaster
KLM Flight 4805 · Pan Am Flight 1736
Accident summary
Date March 27, 1977
Summary Pilot error, runway incursion, heavy fog, limitations and failures in communication
Site
Los Rodeos Airport
(now Tenerife-North Airport)

Tenerife, Canary Islands, Spain

Total fatalities 583
Total injuries (non-fatal) 61
Total survivors 61
First aircraft

PH-BUF, the KLM Boeing 747-206B
involved in the accident
Type Boeing 747-206B
Name Rijn ("Rhine")
Operator KLM Royal Dutch Airlines
Registration PH-BUF[1]
Flight origin Schiphol Airport
Amsterdam, Netherlands
Destination Gran Canaria Airport
Canary Islands, Spain
Passengers 234
Crew 14
Fatalities 248 (all)
Survivors 0
Second aircraft

A Pan Am Boeing 747-121
similar to the one involved
Type Boeing 747–121
Name Clipper Victor
Operator Pan American World Airways
Registration N736PA[2]
Flight origin Los Angeles Int'l Airport
Los Angeles, United States
Stopover John F. Kennedy Int'l Airport
New York City, United States
Destination Gran Canaria Airport
Canary Islands, Spain
Passengers 380
Crew 16
Fatalities 335 (326 passengers, 9 crew)
Injuries (non-fatal) 61
Survivors 61

On March 27, 1977, two Boeing 747 passenger jets collided on the runway at Los Rodeos Airport (now Tenerife North Airport), on the Spanish island of Tenerife, Canary Islands. The crash killed 583 people, making it the deadliest accident in aviation history. As a result of the complex interaction of organizational influences, environmental conditions, and unsafe acts leading up to this aircraft mishap, the disaster at Tenerife has served as a textbook example for reviewing the processes and frameworks used in aviation mishap investigations and accident prevention.[3]

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 be seen from the other, and the controller in the tower could not see the runway or the two 747s on it. As the airport did not have ground radar, the controller could find where each airplane was only by voice reports over the radio.

As the accident occurred in Spanish territory, Spain was responsible for investigating the accident. The crash involved aircraft from the United States and the Netherlands, which both conducted investigations as well. The investigations revealed that the primary cause of the accident was the captain of the KLM flight taking off without clearance from air traffic control (ATC).[4] 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.[4] Dutch investigators placed a greater emphasis on this than their American and Spanish counterparts,[5] but ultimately KLM admitted their crew was responsible for the accident, and the airline financially compensated the victims' relatives.[6]

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 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 clearing an aircraft to take off[7] or when cancelling that same clearance. 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), in which training is now mandatory for all airline pilots.[8]

Flight history

Photograph of Veldhuyzen van Zanten in a KLM magazine

For both planes, Tenerife was an unscheduled stop. Their destination was Gran Canaria International Airport (also known as Las Palmas Airport or Gando 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 southwest coast of Morocco.

Pan Am Flight 1736 had originated at Los Angeles International Airport, with an intermediate stop at New York's John F. Kennedy International Airport (JFK). The aircraft was a Boeing 747-121, registration N736PA, named Clipper Victor. Of the 380 passengers (mostly of retirement age, but including two children), 14 had boarded in New York, where the crew was also changed. The new crew consisted of Captain Victor Grubbs, first officer Robert Bragg, and flight engineer George Warns. There were 13 other crew members.

This aircraft had operated the inaugural 747 commercial flight on January 22, 1970.[9] In its first year of service, it also became the first 747 to be hijacked.[10] It left JFK for San Juan, Puerto Rico, at 1:07 am on August 2, 1970, with 359 or 360 passengers and 19 crew.[10] One hour and forty minutes later, a young man named R. Campos produced a gun and a bottle out of a bag that he claimed contained explosives, and hijacked the airplane to Havana, where it touched down at Jose Marti Airport at 5:31 am.[10] The first 747 to land in Cuba, it was met by Cuba's Premier Fidel Castro.[10]

KLM Flight 4805, a charter flight for Holland International Travel Group, had arrived from Amsterdam Airport Schiphol, the Netherlands.[9] Its captain was Jacob Veldhuyzen van Zanten, KLM's chief flying instructor.[11] The first officer was Klaas Meurs and the flight engineer was Willem Schreuder. The aircraft was a Boeing 747-206B, registration PH-BUF, named Rijn (Rhine). The KLM jet had 14 crew members and 235 passengers, including 52 children. 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, the passengers were transported to the airport terminal. One of the inbound passengers, who lived on the island, chose not to re-board the 747, leaving 234 passengers on board.[12][13]

Disaster

Diversion of aircraft to Los Rodeos

Both flights had been routine until they approached the islands. At 1:15 p.m., a bomb (planted by the separatist Fuerzas Armadas Guanches) exploded in the terminal of Gran Canaria International Airport, injuring one person.[14] There had been a phone call warning of the bomb, and soon after another call claimed that a second bomb was at the airport. The civil aviation authorities had therefore closed the airport temporarily after the bomb detonated and diverted all of its incoming flights to Los Rodeos, including the two Boeing 747 aircraft involved in the disaster.[4] The Pan Am crew indicated that they would prefer to circle in a holding pattern until landing clearance was given, but were ordered to divert to Los Rodeos.[15]

In all, five large aircraft were diverted to Los Rodeos, a regional airport that could not easily accommodate them. The airport had only one runway and one major taxiway parallel to it, with four taxiways connecting the two. 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 had to taxi along the runway to position themselves for takeoff, a procedure known as a runway backtaxi or backtrack.[4]

After the threat at Gran Canaria had been contained, authorities reopened that airport. The Pan Am aircraft was ready to depart from Tenerife, but the KLM plane and a refueling vehicle obstructed its access to the runway. The Pan Am aircraft was unable to maneuver around the fueling KLM, reach the runway and depart due to a lack of safe clearance, which was a mere 12 ft (3.7 m).[12] Captain Veldhuyzen van Zanten had decided to fully refuel at Los Rodeos instead of Las Palmas, apparently to save time. The refueling took about 35 minutes. After that, the passengers were brought back to the plane. The search for a missing Dutch family of four delayed the flight even further. A tour guide chose not to reboard for Las Palmas, because she lived on Tenerife and did not think it practical to fly to Gran Canaria just to return to Tenerife the next day. She would be the only person who flew from Amsterdam to Tenerife on Flight 4805 to survive, as she was not on the plane at the time of the accident.

Taxiing and takeoff preparations

Following the tower's instructions, the KLM was cleared to taxi the full length of the runway and make a 180° turn to get into takeoff position.[16] While the KLM was backtaxiing on the runway, 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.[17]

Shortly afterward, the Pan Am was instructed to follow the KLM down the same runway, exit it by taking the third exit on their left and then use 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 reached them.[18]

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.[19] There were no markings or signs to identify the runway exits and they were in conditions of poor visibility. 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).[20]

The angle of the third taxiway would have required the plane to perform a turn of approximately 148°, which would lead back toward the still-crowded main apron. At the end of C-3, the Pan Am would have to make another 148° turn in order 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 (ALPA) after the accident concluded that making the second 148° turn at the end of taxiway C-3 would have been "a practical impossibility".[21] Subsequent performance calculations and taxi tests with a Boeing 747 turning off on an intersection comparable to the C-3 at Tenerife, as part of the Dutch investigation, indicate that in all probability the turns could have been made. The official report from the Spanish authorities explains that the controller instructed the Pan Am aircraft to use the third taxiway because this was the earliest exit that they could take to reach the unobstructed section of the parallel taxiway.[22]

Weather conditions at Los Rodeos

Los Rodeos airport is at 633 metres (2,077 feet) above sea level, which gives rise to cloud behavior that differs from that at many other airports. Clouds at 600 m (2,000 ft) above ground level at the nearby coast are at ground level at Los Rodeos. Drifting clouds of different densities cause wildly varying visibilities, from unhindered at one moment to below the minimums the next. The collision took place in a high-density cloud.[23]

The Pan Am crew found themselves in poor and rapidly deteriorating visibility almost as soon as they entered the runway. According to the ALPA report, as the Pan Am aircraft taxied to the runway, the visibility was about 500 m (1,600 ft). Shortly after they turned onto the runway it decreased to less than 100 m (330 ft).[24]

Meanwhile, the KLM plane was still in good visibility, but with clouds blowing down the runway towards them. The KLM aircraft completed its 180 degree turn in relatively clear weather and lined up on Runway 30. The next cloud was some 900 m (3,000 ft) down the runway and moving towards the aircraft at about 12 knots (6 meters per second).[25]

Communication misunderstandings

Immediately after lining up, the KLM pilot advanced the throttles and the aircraft started to move forward.[33] The co-pilot advised the captain that ATC clearance had not yet been given, and 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."[4] Captain Veldhuyzen van Zanten interrupted the co-pilot's read-back with the comment, "We're going."[4]

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. The controller then immediately added "stand by for takeoff, I will call you,"[4] indicating that he had not intended the clearance to be interpreted as a takeoff clearance.[34]

A simultaneous radio call from the Pan Am crew caused mutual interference on the radio frequency, which was audible in the KLM cockpit as a three-second-long whistling sound (or heterodyne). This caused the KLM crew to miss the crucial latter portion of the tower's response. The Pan Am crew's transmission was "We're still taxiing down the runway, the Clipper 1736!". This message was also blocked by the interference and inaudible to the KLM crew. Either message, if heard in the KLM cockpit, would have alerted the crew to the situation and given them time to abort the takeoff attempt.[35]

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.[4]

After the KLM plane had started its takeoff roll, the tower instructed the Pan Am crew to "report when runway clear." The Pan Am 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 in his own cockpit, "Is he not clear, that Pan American?" Veldhuyzen van Zanten emphatically replied "Oh, yes" and continued with the takeoff.[36]

Collision

Simplified map of runway, taxiways, and aircraft. The red star indicates the location of impact. Not to scale.

According to the cockpit voice recorder (CVR), the Pan Am pilot said, "There he is!" when he spotted the KLM's landing lights through the fog just as his plane approached exit C-4. When it became clear that the KLM was approaching at takeoff speed, Grubbs exclaimed, "Goddamn, that son-of-a-bitch is coming straight at us!" while the co-pilot Robert Bragg yelled, "Get off! Get off! Get off!". The Pan Am crew applied full power to the throttles and took a sharp left turn towards the grass in an attempt to avoid a collision.[4] By the time the KLM pilots saw the Pan Am, they were already traveling too fast to stop. In desperation the pilots prematurely rotated the aircraft and attempted to clear the Pan Am by climbing away, causing a severe tailstrike for 22 m (72 ft).

The KLM was within 100 m (330 ft) of the Pan Am when it left the ground. Its nose gear cleared the Pan Am, but the engines, lower fuselage and main landing gear struck the upper right side of the Pan Am's fuselage at approximately 140 knots (260 km/h; 160 mph),[12] ripping apart the center of the Pan Am jet almost directly above the wing. The right side engines crashed through the Pan Am's upper deck immediately behind the cockpit.

The KLM plane remained briefly airborne following the collision, but the impact with the Pan Am had sheared off the outer left engine, caused significant amounts of shredded materials to be ingested by the inner left engine, and damaged the wings. The KLM aircraft immediately went into a stall, rolled sharply, and hit the ground at a point approximately 150 m (500 ft) past the collision, sliding a further 300 m (1,000 ft) down the runway. The full load of fuel, which had caused the earlier delay, ignited immediately in a large fireball that could not be subdued for several hours.

One of the 61 survivors 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."[37]

Both airplanes were destroyed. All 234 passengers and 14 crew members in the KLM plane died, as did 326 passengers and nine crew members aboard the Pan Am,[38] primarily due to the fire and explosions resulting from the fuel spilled and ignited in the impact. The other 54 passengers and seven crew members aboard the Pan Am aircraft survived, including the captain, first officer and flight engineer. Most of the survivors on the Pan Am walked out onto the intact left wing, the side away from the collision, through holes in the fuselage structure. 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, and all control lines were severed, leaving no method for the flight crew to control the aircraft's systems. 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 and smoke. Eventually, most of the survivors on the wings dropped to the ground below.[12]

Captain Veldhuyzen van Zanten was KLM's chief of flight training and one of their most senior pilots. His photograph was used for publicity materials such as magazine advertisements, including the inflight magazine on board PH-BUF.[12][39] As such, KLM suggested that he should be part of the investigation team, before learning that he was the captain involved.[40] He had given the co-pilot on the flight his Boeing 747 qualification check about two months before the accident.[13]

Airport closure

Los Rodeos airport, the only operating airport on Tenerife in 1977, was closed to all fixed wing traffic for two days. The first crash investigators to arrive at Tenerife the day after the crash travelled there by way of a three hour boat ride from Las Palmas.[41] The first aircraft that was able to land was a United States Air Force C130 transport, which landed on the airport's main taxiway at 12:50 p.m. on March 29. It transported all surviving and injured passengers from Tenerife to Las Palmas; many of the injured would be taken from there to Air Force bases in the United States for further treatment.[42]

Spanish army troops were tasked with clearing crash wreckage from the runways and taxiways.[43] By March 30, a small plane shuttle service was approved, but large jets still could not land.[43] Los Rodeos was fully reopened on April 3, after wreckage had been fully removed and engineers had repaired the airport's runway.[44]

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. It appears KLM's co-pilot was not as certain about take-off clearance as the captain.

Probable cause

The investigation concluded that the fundamental cause of the accident was that Captain Veldhuyzen van Zanten took off without clearance. The investigators suggested the reason for this was 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 following factors were considered contributing but not critical:

Dutch response

The Dutch authorities were reluctant to accept the Spanish report blaming the KLM captain for the accident. The Netherlands Department of Civil Aviation published a response that, while accepting that the KLM aircraft had taken off "prematurely", argued that he alone should not be blamed for the "mutual misunderstanding" that occurred between the controller and the KLM crew, and that limitations of using radio as a means of communication should have been given greater consideration.

In particular, the Dutch response pointed out that

Although the Dutch authorities were initially reluctant to blame Captain Veldhuyzen van Zanten and his crew,[5][46] the airline ultimately accepted responsibility for the accident. KLM paid the victims or their families compensation ranging between $58,000 and $600,000.[6] The sum of settlements for property and damages was $110 million[47] (an average of $189,000 per victim, due to limitations imposed by European Compensation Conventions in effect at the time).

Speculations

This was one of the first accident investigations during which the contribution of "human factors" was studied.[48] The human factors included:

The extra fuel the KLM plane took on added several factors:

Safety response

As a consequence of the accident, sweeping changes were 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.

Several national air safety boards began penalizing pilots for disobeying air traffic controllers' orders. Air traffic instruction should not be acknowledged solely with a colloquial phrase such as "OK" or even "Roger" (which simply means the last transmission was received[56]), but with a readback of the key parts of the instruction, to show mutual understanding. The phrase "take off" is now spoken only when the actual takeoff clearance is given or when cancelling that same clearance (i.e. "cleared for take-off" or "cancel take-off clearance"). Up until that point, aircrew and controllers should use the phrase "departure" in its place, e.g. "ready for departure". Additionally, an ATC clearance given to an aircraft already lined-up on the runway must be prefixed with the instruction "hold position".[57] Cockpit procedures were also changed. Hierarchical relations among crew members were played down. More emphasis was placed on team decision-making by mutual agreement, part of what has become known in the industry as Crew Resource Management.[58]

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. In 2002 a new terminal was opened and it carries international traffic once again, including budget airlines.

The Spanish government installed a ground radar at Tenerife North following the accident.

Memorials

Tenerife Memorial
Monument in Westgaarde Cemetery, Amsterdam

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 an international commemoration service held at the Auditorio de Tenerife in Santa Cruz; the International Tenerife Memorial March 27, 1977, was inaugurated at the Mesa Mota on March 27, 2007. The monument was designed by Dutch sculptor Rudi van de Wint.

Notable victims

Documentaries

The disaster has been featured in many TV shows and documentaries. These include the Mayday special episode "Crash of the Century" and the Season 16 episode "Disaster at Tenerife", the Survival in the Sky episode "Blaming the Pilot", the Seconds From Disaster episode "Collision on the Runway", PBS's NOVA episode "The Deadliest Plane Crash" in 2006, the PBS special Surviving Disaster: How the Brain Works Under Extreme Duress (based on Amanda Ripley's book The Unthinkable) in 2011, and the Discovery Channel TV series Most Deadly and Destroyed in Seconds.

Similar incidents

Similar incidents involving two large airliners in collision or near misses when one aircraft was taking off whilst another was occupying the runway include...

See also

References

  1. ↑ "Civil aircraft register". Inspectie Leefomgeving en Transport.
  2. ↑ "FAA Registry". Federal Aviation Administration.
  3. ↑ "TENERIFE DISASTER - 27 MARCH 1977: The Utility of the Swiss Cheese Model & other Accident Causation Frameworks". Go Flight Medicine. Retrieved 13 October 2014.
  4. 1 2 3 4 5 6 7 8 9 "ASN Accident Description". Aviation Safety Network. Retrieved 11 May 2011.
  5. 1 2 3 "Dutch comments on the Spanish report" (PDF). Project-Tenerife.
  6. 1 2 "How KLM accepted their responsibility for the accident". Project-Tenerife.
  7. ↑ "The Tenerife Airport Disaster - the worst in aviation history". Tenerife Information Centre. Retrieved 11 May 2011.
  8. ↑ Baron, Robert. "The Cockpit, the Cabin, and Social Psychology". Global Operators Flight Information Resource. Retrieved 11 May 2011.
  9. 1 2 Kilroy, Chris Special Report: Tenerife AirDisaster.com.
  10. 1 2 3 4 "A Day of "Firsts"". Pan Am Historical Foundation.
  11. ↑ "Official report" (PDF). (5.98 MB), section 5.2, p. 38 (PDF page 41 of 63)"
  12. 1 2 3 4 5 6 7 Macarthur Job (1995). Air Disaster Volume 1, ISBN 1-875671-11-0, pp.164–180
  13. 1 2 "The Deadliest Plane Crash". PBS. October 17, 2006. Retrieved 2014-09-23.
  14. ↑ The Tenerife disaster. 1001 Crash (1977-03-27). Retrieved on 2011-01-14.
  15. ↑ The Tenerife Airport Disaster – the worst in aviation history. Tenerife-information-centre.com (1977-03-27). Retrieved on 2011-01-14.
  16. ↑ "Official report" (PDF). (5.98 MB), p. 2 (PDF page 5 of 63)
  17. ↑ "Official report" (PDF). (5.98 MB), p. 3-4 (PDF pages 6-7 of 63)
  18. ↑ "Official report" (PDF). (5.98 MB), p. 3 (PDF page 6 of 63)
  19. ↑ "Official report" (PDF). (5.98 MB), pp. 56-57 (PDF pages 59-60 of 63)
  20. ↑ "Official report, annex 6" (PDF).
  21. ↑ "ALPA report on the crash" (PDF). (2.70 MB), p. 19 (PDF page 23 of 97)
  22. ↑ "Official report" (PDF). (5.98 MB), pp. 46 (PDF page 49 of 63)
  23. ↑ "ALPA report on the crash" (PDF). (2.70 MB), p. 8 (PDF page 12 of 97)
  24. ↑ "ALPA report on the crash" (PDF). (2.70 MB), p. 11 (PDF page 15 of 97)
  25. ↑ "ALPA report on the crash" (PDF). (2.70 MB), p. 12 (PDF page 16 of 97)
  26. ↑ "Project-Tenerife.com" (PDF). Retrieved 2012-05-05.
  27. ↑ "Airdisaster.com". Airdisaster.com. Archived from the original on April 20, 2012. Retrieved 2012-05-05.
  28. ↑ Aircraft safety: accident investigations, analyses, and applications By Shari Stamford Krause. Books.google.com. 2003-07-23. Retrieved 2012-05-05.
  29. ↑ "NOVA/PBS.org: The final eight minutes". Pbs.org. 1977-03-27. Retrieved 2012-05-05.
  30. ↑ JAR Professional Pilot Studies by Phil Croucher. books.google.com. Retrieved 2013-05-03.
  31. ↑ "1001 Crash - The Tenerife disaster". www.1001crash.com. Retrieved 2016-06-28.
  32. ↑ "KLM-PANAM CRASH". www.travelok.net. Retrieved 2016-06-28.
  33. ↑ Official report, p.48
  34. ↑ Bruggink, Gerard M. "Remembering Tenerife". Retrieved 24 February 2014.
  35. ↑ "Air travel's communications killer". Salon.com. 2002-03-28.
  36. ↑ "Plane Crash Info, March 1977, page 18". Planecrashinfo.com. 1977-03-27. Retrieved 2012-05-05.
  37. ↑ "Tenerife Disaster, 1977 Year in Review.". Upi.com. 2012-04-30. Archived from the original on April 20, 2012. Retrieved 2012-05-05.
  38. ↑ Fatal Events Since 1970 for KLM AirSafe.com.
  39. ↑ Advertisement showing Veldhuyzen van Zanten, Project-Tenerife.
  40. ↑ Jan Reijnoudt en Niek Sterk: Tragedie op Tenerife: de grootste luchtramp, optelsom van kleine missers, 2002. ISBN 9043505633
  41. ↑ "Experts converge on Canaries to probe plane crash (March 29, 1977)". Retrieved 2016-06-28.
  42. ↑ "Desert Sun 29 March 1977 — California Digital Newspaper Collection". cdnc.ucr.edu. Retrieved 2016-06-28.
  43. 1 2 "30 Mar 1977, Page 4 - The Naples Daily News". Newspapers.com. Retrieved 2016-06-19.
  44. ↑ "Newspaper Full Page - New Nation, 4 April 1977, Page 5". eresources.nlb.gov.sg. Retrieved 2016-06-28.
  45. ↑ "Official report" (PDF). (5.98 MB), pp. 61–62
  46. 1 2 Nicholas Faith (1996, 1998). Black Box: pp.176–178
  47. ↑ The Washington Post, March 25, 1980
  48. ↑ "ALPA report on the crash" (PDF). (2.70 MB), p. 2 (PDF page 6 of 97). "The study group notes with approval that the official report of the spanish government has, itself, included a section on human factors involved in this accident. We feel that this is an excellent beginning toward a better understanding of the causal factors of aviation accidents, an idea whose time has finally come."
  49. ↑ "Official report" (PDF). (5.98 MB), section 5.2, p. 38 (PDF page 41 of 63): "... these circumstances could have induced the co-pilot not to ask any questions, assuming that his captain was always right"
  50. ↑ Bartelski, Jan (2001). Disasters in the air: mysterious air disasters explained. Airlife. ISBN 978-1-84037-204-5.
  51. ↑ "ALPA report on the crash" (PDF). (2.70 MB), p. 22 (PDF page 26 of 97). "Both pilots were contending with heavy demands on their attention as the visibility rapidly worsened. The flight engineer, to the contrary, had completed the heaviest part of his workload and was now reverting to an instrument monitoring mode."
  52. ↑ "ALPA report on the crash" (pdf). project-Tenerife.com. (2.70 MB), p. 22 (PDF page 26 of 97). "It is our opinion that the flight engineer, like the pilots, did not perceive the message from the controller to the Pan Am asking them to report when runway clear. (Because of the use of the address "Papa Alpha)."
  53. ↑ This Spanish report says 55,500 liters of jet fuel. Based on a density of 0.8705 kg/l that weighs some 45 metric tons, or 49 US tons Archived April 12, 2009, at the Wayback Machine.
  54. ↑ The Deadliest Plane Crash - transcript, NOVA, The 55 tons of fuel the Dutch plane had taken on creates a massive fireball that seals the fate of everyone onboard
  55. ↑ The full load of new fuel ignited immediately, Crossroads Today
  56. ↑ CAP 413 Radio Telephony Manual (Edition 15), chapter 2 page 6
  57. ↑ CAP 413 Radio Telephony Manual (Edition 15), chapter 4, page 6, paragraph 1.7.10
  58. ↑ Helmreich, R. L.; Merritt, A. C.; Wilhelm, J. A. (1999). "The Evolution of Crew Resource Management Training in Commercial Aviation" (PDF). Int. J. Aviat. Psychol. 9 (1): 19–32. doi:10.1207/s15327108ijap0901_2. PMID 11541445. Archived from the original (pdf) on March 6, 2013.
  59. ↑ "Passenger list of the PanAm". ProjectTenerife.com. Retrieved 2016-02-10.
  60. ↑ "San Jose Inside – Dutch Hamann – Part 2". Sanjoseinside.com. 2006-01-23. Retrieved 2012-05-05.
  61. ↑ "Special Investigation Report 71-1" (PDF). Air Saftety Investigation Branch. August 1971. Retrieved 30 October 2016.
  62. ↑ Hradecky, Simon (11 October 2016). "Incident: China Eastern A333 at Shanghai on Oct 11th 2016, runway incursion forces departure to rotate early and climb over A333". Aviation Herald. Retrieved 30 October 2016.

External links

Wikimedia Commons has media related to Tenerife airport disaster.
External images
PH-BUF (KLM 4805) - Airliners.net
N736PA (Pan Am 1736) - Airliners.net

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

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