TITLE: Political conflict underlying the issue between Pan Am flight and KLM

flight crash.
TOPIC: Pan Am Flight 1736 and KLM Flight 4805
ABSTRACT
This unfortunate disaster occurred on the 27th of March 1979. Two Boeing
747s collided on the runway at Los Rodeos airport during taxi and take-off
procedures during low visibility conditions caused by fog.
HYPOTHESIS
To bring out the issues that caused the flights to crash?
Research questions
- what caused the KLM Pan am crash?
- Why was Pan Am Flight 1736 diverted to land in Los Rodeos, Tenerife, and
not in Las Palmas, Tenerife, as scheduled?
- Is the reason for “weather issues” enough to cover up the number of human
errors that took place which constituted the crash?
SCOPE OF STUDY
The study focuses specifically on the tragedy of Pan Am flight 1736 and KLM
flight 4805.
It would bring out the causes and reasons which lead to the accident.
It would also look at the measures taken by the government for compensation
for the lives that were lost. The study is limited to the tragedy of Pan Am flight
1736 and KLM flight 4805.

INTRODUCTION:
Tenerife airline disaster, the runway collision of two Boeing 747 passenger
aeroplanes in the Canary Islands on March 27, 1977, killed more than 580
people.
Both planes involved in the crash had been scheduled to depart from Las
Palmas on the island of Gran Canarias. However, a terrorist bombing there
earlier in the day caused the planes to be diverted to the small Los Rodeos
Airport on the island of Tenerife. Later, just as KLM flight 4805 prepared to
take off from the single airstrip at Los Rodeos, the plane barrelled into Pan
American World Airways (Pan Am) flight 1736, which had been taxiing toward
take-off at the same time. The force from the crash tore through the fuselage
of the Pan Am plane, and both aircraft exploded into flames. All passengers
and crew members aboard the KLM plane were killed. At least 330 people on
the Pan Am plane died, but more than 60, including the pilot, survived the
impact and fire. Many survivors escaped from a hole near the plane’s left wing.
Some experts speculated that the KLM plane had begun its take-off without
proper clearance, though a number of factors, including foggy weather and
unusual airport traffic conditions, likely played a role in the disaster.
FLIGHT HISTORY OF PAN AM AND KLM
Tenerife was an unscheduled stop for both flights. It was because a
bomb set off by the Canary Islands Independence Movement at Gran
Canaria Airport had caused many flights to be diverted to Los Rodeos.

 KLM Flight 4805 was a charter flight for Holland International Travel
Group and had arrived from Amsterdam Airport Schiphol, Netherlands.
Its cockpit crew consisted of Captain Jacob Veldhuyzen van Zanten (age
50), First Officer Klaas Meurs (42), and Flight Engineer Willem Schreuder
(48). The aircraft was a Boeing 747-206B, registration PH-BUF, named
Rijn (Rhine). The KLM jet was carrying 14 crew members and 235
passengers, including 52 children. Most of the passengers were Dutch,
but also included four Germans, two Austrians and two Americans. After
landing at Tenerife, one of the inbound passengers, Robina van
Lanschot, chose not to re-board the 747, leaving 234 passengers on
board.
 Pan Am Flight 1736 was a Boeing 747-121, registration N736PA, that was
the first 747 to be delivered to an airline. It was with 380 passengers,
mostly of retirement age and 14 of whom boarded in New York. All but
five passengers were Americans, and the non-American passengers were
Canadian nationals. The new crew consisted of Captain Victor Grubbs,
First Officer Robert Bragg, Flight Engineer George Warns, and 13 flight
attendants. The aircraft operated the inaugural 747 commercial flight on
January 22, 1970, and on 2 August 1970, it was diverted to José Martí
International Airport in Havana, Cuba.
DIVERSION OF AIRCRAFT TO LOS RODEOS
At 13:15, a bomb planted by the separatist Canary Islands Independence
Movement exploded in the terminal of Gran Canaria Airport, injuring eight
people. The civil aviation authorities had closed the airport temporarily after
the explosion, and all incoming flights bound for Gran Canaria had been
diverted to Los Rodeos, including the two aircraft involved in the disaster. The
Pan-Am crew indicated that they would prefer to circle in a holding pattern
until landing clearance was given, but they were ordered to divert to Tenerife.
The airport had only one runway and one major taxiway running parallel to it,
and the diverted aeroplanes took up so much space that they had to park on
the long taxiway, making it unavailable for the purpose of taxiing. Departing
aircraft needed to taxi along the runway to position themselves for take-off, a
procedure known as a back taxi or backtrack.
The Pan Am plane was ready to depart from Tenerife, but access to the runway
was obstructed by the KLM plane and a refuelling vehicle. The Pan Am aircraft
was unable to manoeuvre around the refuelling KLM in order to reach the
runway for take-off, due to a lack of safe clearance between the two planes.
The refuelling took about 35 minutes, after which the passengers were brought
back to the aircraft. The search for a missing Dutch family of four, who had not
returned to the waiting KLM plane, delayed the flight even further. Robina van
Lanschot, a tour guide, was the only survivor of those who flew from
Amsterdam to Tenerife on Flight 4805
There were a few factors which lead to the collision between the two flights
that are:
1. Taxiing and take-off preparations
2. Weather conditions at Los Rodeos
3. Communication misunderstandings

1. The tower instructed the KLM plane to taxi down the runway and make
a 180° turn to get into the take-off position. While the KLM was taxiing,
the controller asked the flight crew to report when it was ready to copy
the ATC clearance. The Pan Am plane 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
Pan Am crew successfully identified the first two taxiways (C-1 and C-2),
but they had not sighted the third taxiway (C-3). 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. The third taxiway would have required the
plane to perform a 148° turn, which would lead back toward the still-
crowded main apron. Taxiway C-4 would have required two 35° turns.
The official report from the Spanish authorities explained that the
controller instructed the Pan Am aircraft to use C-3 because it was the
earliest exit that they could take to reach the unobstructed section of
the parallel taxiway.
2. Los Rodeos airport is 633 meters (2,077 ft) above sea level, creating
weather conditions that differ from those at other airports. Drifting
clouds of different densities cause wildly varying visibilities, from
unhindered at one moment to below the legal minimum the next. The
Pan Am crew found themselves in poor and rapidly deteriorating
visibility almost as soon as they entered the runway. The KLM plane was
still in good visibility, but with clouds blowing down the runway towards
them.
3. The lack of communication and the high authority gradient, which
prohibited other team members from questioning the aircraft captain's
judgement, are more particular external variables. The engineer and
officer heard Pan Am tell the controller that they will let them know
when they clear the runway, according to internal communications
between the KLM team. Nonetheless, they remained mute out of stress
or apprehension about casting doubt on a senior officer's judgement.
The upper portion of the Boeing Pan Am was cut off by a KLM plane as a
result, causing a collision that resulted in both aircraft exploding but only
with a brief delay for Pan Am. As a result, the interaction between poor
visibility and the human factor led to tragic consequences.
The investigation involved three countries:
In the months after the crash, before the official report was released, the three
different nations [Spain, the Netherlands, and the United States] tended to
shift blame away from themselves. The Dutch government originally noted
that the Pan Am airliner had missed its assigned turnoff from the runway,
which was true. It was also true that the Spanish air traffic controllers had been
less than clear in their instructions to both flight crews. But the KLM crew did
get much of the bad publicity because of the captain’s unilateral action, and
when the final report was released, the KLM crew received the largest portion
of the blame.
The Spanish investigators placed most of the blame on Captain van Zanten for
taking off without clearance, while the Dutch reply to the report took an
equally dubious stance. The Dutch comments on the report included several
questionable takes, including that there was no evidence of stress, nothing
wrong with the authority gradient, and no errors by the KLM crew. Their report
also suggested that the controllers had been listening to a football match and
that this fact had been covered up by Spain. The Dutch investigators concluded
that this likely had no effect on the sequence of events and chose not to place
any blame on the controller or the Pan Am crew. The system itself, they said,
was at fault in the crash. Despite the fact that poor infrastructure made the
accident possible, Spain was blamed for the poor infrastructure.
The investigation concluded that Captain Veldhuyzen van Zanten attempted to
take off without clearance due to a desire to comply with KLM's duty-time
regulations. Other factors contributing to the accident included fog,
interference from simultaneous radio transmissions, and the use of ambiguous
non-standard phrases by the KLM co-pilot and Tenerife control tower.
COMPENSATION: Although the Dutch authorities were initially reluctant to
blame captain Veldhuyzen van Zanten and his crew. KLM accepted
responsibility for the accident and paid the victims' families compensation
ranging from $58,000 to $600,000. The sum of settlements for property and
damages was $110 million, with an average of $189,000 per victim due to
limitations imposed by European Compensation Conventions.
CONCLUSION
The subsequent investigation by Spanish authorities concluded that the
primary cause of the accident was the KLM captain's decision to take off in the
mistaken belief that a take-off clearance from air traffic control (ATC) had been
issued.
Safety measures which are taken to avoid such disasters in the future- Aviation
authorities around the world introduced requirements for standard phrases
and a greater emphasis on English as a common working language. The phrase
"take off" is now spoken only when the actual take-off clearance is given or
when cancelling that same clearance. Aircrew and controllers should use the
phrase "departure" in its place, and an ATC clearance given to an aircraft
already lined up on the runway must be prefixed with the instruction "hold
position". Cockpit procedures were also changed, with less experienced flight
crew members encouraged to challenge their captains when they believed
something was not correct. CRM training was mandatory for all airline pilots,
and the Spanish government installed a ground radar at Tenerife North
following the accident.

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