Tenerife Air Accident at Canary Islands; one of the deadliest air accident in aviation history

7/31/2019 Tenerife Air Accident at Canary Islands; one of the deadliest air accident in aviation history

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AASMAN

Mohsin Azhar Shah (GL) BAM- 9205

Saqib Mehmood BAM-9207Saad Shoaib BAM-9210

Arslan Aslam BAM-9234


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Areas to be Covered

General Overview of the Accident (How it

happened?)

Investigation

Findings

Conclusion


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GeneralOn March 27 1977, two Boeing 747 jumbo jets collided on a

runway at Tenerife airport, Tenerife, in the Canary Islands,

making this the world's worst civil aviation disaster.

Geographical Location

The Canary Islands are located in the

Atlantic Ocean, off the Western coast of Africa,

They are volcanic islands.

Tenerife-North Los Rodeos Airport, in Tenerife,

Canary Islands Spain is the airport where an

accident was occurred.Canary Islands


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Tenerife North Los Rodeos Airport

This Tenerife North Los Rodeos Airport layout has one 12- 30 RWY and fourexit taxi ways as shown above in the diagram. This is a small and busy airport.


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Unfortunately, On March 27 1977, A bomb had

exploded at Las Palmas Airport so it was closed forrepair and due to warning of second explosion.

Many flights are diverted to Tenerife North Los Rodeos

Airport and it was saturated with traffic.

Turning Point


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Overview of the Accident Due to diversion, Both 747 landed at Tenerife North

Los Rodeos Airport. First is KLM 747-206B (KLM 4805) with 248 people onboard,

including 14 crew had landed before Pan Am Boeing 747-121

Second is Pan Am Boeing 747-121, (flight1736) from LosAngeles and New York to Las Palmas having 396 people

including 16 crew onboard that landed at Tenerife airport.

.


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Taxiways were congested, So.

KLM 747 was instructed to backtrack on runway12 making 180 turn to line up for take-off onrunway 30.

Overview of the Accident


10/29What was actually happened?

Three minutes later at 17:02,The Pan Am flight 1736 was then

cleared to backtrack runway 12 to follow the KLM aircraft

The Pan Am crew were told to leave the runway at the third

taxiway and report when leaving.


11/29Overview of the Accident

RWY was not visual to tower.

The visibility was less than 200 meters.

KLM lined up with RWY 30


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13/29Overview of the Accident

After lining up on runway 30, KLM 747 started its take off role

When Pan Am was about to leave RWY Suddenly the Pan Am

captain spotted the landing lights of the KLM Boeing 747 just

700 meters away in the fog.

The Pan Am crew set full throttle

to leave the runway as quickly as

possible, but it was too late.


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Dutch KLM 747 was about 170 knots. The captain

applied full back stick pressure in order to take off and

fly over the other 747. The nose climbed, the tail struckthe runway, producing sparks. The aircraft climbed one

meter above ground, but this wasn't enough.


15/29Consequences of Accident

The KLM 747crashed. There were

no survivors, all of the

248 people onboard

expired.

In the Pan Am 747,64 people, including the

First Officer survived, out

of 396.


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The heat produced by the fire on Pan Am

aircraft cleared the fog 1 Km around the crash

scene

583 Fatal injuries

64 people survived

Consequences of Accident


17/29Investigation

About 70 crash investigators from Spain, the

Netherlands, the United States, and the twoairline companies were involved in theinvestigation.

KLM CVR The KLM and Pan Am 747s are both in queue

to taxi down the runway and turn around fortakeoff. The KLM aircraft is ahead of the Pan

Am aircraft.


18/29Investigation

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


19/29Investigation

Evidences showed that there had beenmisinterpretations and false assumptions.

Pan Am CVR

The controller instructed Pan Am 747 to traveldown the runway and then exit it via C3

taxiway.


20/29Investigation

Pan Am CVR

F/O of Pan Am was convinced that the controller had intended

that they take the fourth exit C4 because it was the most

appropriate taxiway for Pan AM 1736. However, the controller

delivered the message to take "the third one, sir; one, two,

three; third, third one.


21/29Findings

Probable Causes

The fundamental cause of the accident was that Captain ofKLM 747 took off without takeoff clearance.

He had a desire to leave as soon as possible in order to

comply with KLM's duty-time regulations, and before the

weather deteriorated further.

The Pan Am aircraft had not exited the runway at C-3.

Misunderstanding or misinterpretation; Simultaneous radio

transmissions, with the result that no message could be

heard.


22/29Findings

1705:53.4 APP: KLM 8705 uh you are cleared to thePapa beacon. Climb to and maintain flight level 90 ...right turn after takeoff proceed with heading 040 untilintercepting the 325 radial from Las Palmas VOR.

1706:09.6 KLM RT: Ah, roger, sir, we're cleared to thePapa beacon flight level 90, right turn out 040 untilintercepting the 325, and we're now at takeoff.

1706:12.25 KLM 1: Let's go ... check thrust.1706:18.19 APP:Okay.

Use of ambiguous non-standard phrases by the KLMco-pilot ("We're at take off") and the Tenerife control

tower ("OK").


23/29Findings

When both Air Traffic Control and Pan Am RT speak

simultaneously. This causes a shrill noise in the KLMcockpit (Heterodyne) that lasts for almost fourseconds.

1706:20.08 APP: Stand by for takeoff ... I will call you.PA1: No, uh.

PA RT: And we are still taxiing down the runway, theClipper 1736


24/29Findings

No CRM in KLM cockpit; Perhaps because of the KLMpilot's very senior position, neither the copilot nor flightengineer questions the pilot again.

Human Factor Involved in the accident;misunderstandings were common.


25/29Some Latent Conditions

Bomb Blasts at Las Palmas Airport

Diversion to Tenerife Airport

RWY centre line lighting out of service

Airport saturation

Football match on radio, at tower.


26/29Dutch Response

Spanish report blaming the KLM captain for the

accident

Netherlands Department of Civil Aviation pointed out

that crowded airport placed pressure on all, KLM, Pan

Am, and the controller.

CVR suggested that Spanish control tower crewlistening to a football match on the radio.

Transmission from the tower to KLM was ambiguous

and Pan Am last call was not listened to both


27/29Recommendations

The pilot should not take off until accepting clearance

from tower. Pilots and traffic controllers should use standard

phraseology.

After the disaster at Tenerife, officials implemented

standard aviation phrasing worldwide to avoid

confusion in the future.


28/29Conclusion

The Dutch airline KLM ultimately accepted

responsibility for the accident.

KLM paid the victims or their families compensation of

an average of $189,000 per victim.


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Thank You

Documents

Tenerife Air Accident at Canary Islands; one of the deadliest air accident in aviation history