Tenerife Airport Disaster

Tenerife Airport Disaster

1. What happened?

   • Collision involving 2 Boeing 747 passenger aircraft
   • Runway of Los Rodeos Airport
   • 1977
   • 583 casualties
   • All 248 people aboard KLM flight died
   • 335 fatalities on Pan AM flight
   • ATC unaware PAN AM flight involved for 20 mins
   • Very heavy fog
   • Pan Am flight was backtracking KLM flight down only runway
   • Both large planes had to land here due to bomb threat
   • KLM thought PAN AM was off runway
   • KLM flight went to take off
   • Couldn't see PAN AM flight still on runway due to fog
   • Error in radio communication
   • ATC couldn't get through to warn them
   • KLM flight hits full speed to prepare for take off
   • KLM crashes over PAN AM

2. Why it happened?

   • Error in communication
     • Radio cut over when more than one person tried to talk
     • No back up communication
     • Only two people working ATC
     • KLM was never confirmed to take off
   • Understaffed
     • Only two people working ATC
       • More people would be more organised
       • Was a quiet day
         • Was a Sunday
           • Average number of people to work Sunday
   • Not use to having such large planes
     • 747 planes never landed there
       • Were only there because of chance of second bomb
         • Was recently a terrorist bomb set off
           • Planes possibly under threat
             • Landed closest airport

3. People

   • Team factors
     • ATC untrained for large aircrafts at their ariport
       • More training should have been conducted
     • Lack of staff
       • More staff should have been called in with the bomb threat
         • Help manage and organise planes
       • Unable to organise so many planes
   • Pilots
     • Both pilots had a lot of flying experience
       • Highly regarded pilots
     • Fluke error
   • Passengers
     • Passengers probably getting impatient
       • Waiting for so long
     • Scared and want to get going
       • Bomb threat
         • Pilot wanted to get them out of airport

4. Management

   • Organisational factors
     • Time pressures
       • Pressure to catch back up on time
       • Loss of money if they are late
       • Keep passengers happy
       • ATC trying to get them on their way to clear airport
   • Information Transfer
     • ATC failed to warn planes of fog
       • Prone to fog at airport
     • Not enough staff to communicate to all planes
     • Error in communication
       • Causing KLM flight to take off
         • Couldn't see PAN AM
           • Fog to thick
   • Job Design
     • Airport not designed to hold 747's
       • Only one runway
     • No system designed to work in situations like this
       • Perhaps more training?
         • Airport so small cant afford training?
     • Airport should have been designed bigger
       • Perfect for emergencies
         • No accidents

5. System Parts

   • Staff
     • Training
     • Roles
     • Responsibility
     • Experience
   • Passengers
     • Impatient
     • Scared
     • Tired
     • Angry
   • Aircraft
     • Large aircraft
     • Too big for airport
   • Management
     • Training
     • Emergency System
     • Organisational Systems
       • Training
       • Policies
       • Procedures
       • Costs
       • Accountability

6. Design Factors

   • Airport
     • Not busy
       • No real emergency systems
     • Small planes
     • Near vaolvano
       • Heavy fog from volcano
   • Aircraft
     • Too large for some airports
     • Bad turning circle
       • PAN AM unable to turn off runway
     • Very large
       • Need a lot of speed to take off