Brief Summary
Laura Savino discusses the Tenerife airport disaster of 1977, where two Boeing 747s collided on the runway, resulting in 583 fatalities. She shares insights gained from flying with Bob Bragg, the first officer on the Pan Am aircraft and a survivor of the crash. The presentation covers the events leading up to the disaster, the contributing factors, and the lessons learned that have shaped modern aviation safety practices, including the development of Crew Resource Management (CRM) and Advanced Qualification Programs (AQP).
- The disaster occurred due to a combination of factors, including a terrorist bomb at Gran Canaria Airport, poor weather conditions, communication errors, and human factors.
- The Tenerife disaster led to significant advancements in aviation safety, including the implementation of CRM and AQP.
- The media's portrayal of the KLM captain as solely responsible for the accident is inaccurate and based on a politically biased report.
Introduction
Laura Savino introduces the topic of the Tenerife airport disaster, which occurred in 1977 when two Boeing 747s collided on the runway, resulting in 583 fatalities. She mentions her unique experience of flying with Bob Bragg, the first officer on the Pan Am aircraft and the last surviving pilot from the accident. She aims to provide insights into the events and the pilots' perspectives, which differ from the media's portrayal over the years.
Laura's Path to Becoming a Pilot
Laura shares her unconventional journey to becoming an airline pilot. Unlike the typical story of aspiring pilots who dreamed of flying since childhood, Laura's early life did not involve airplanes or aviation. She discovered general aviation by chance, worked at a flight school in exchange for flying lessons, and eventually majored in aviation at Purdue. She built flight hours through various jobs, including freight cargo, sightseeing tours, and aircraft repossession, before landing her first airline job with Eastern Regional and later Pan Am, ultimately leading to her position at United Airlines.
Flying the 747 with Bob Bragg
Laura describes her experience flying the 747 at United Airlines, where she was assigned to Pan Am airplanes and routes due to United's acquisition of Pan Am's transpacific routes. She had the opportunity to fly with Bob Bragg, the first officer from the Pan Am aircraft involved in the Tenerife crash. Bob became a mentor to her, sharing valuable insights and details about the Tenerife accident. Laura notes that she was often the only woman in the flight crew, which consisted mostly of older, seasoned pilots.
The Tenerife Accident: Initial Diversion
Laura begins to explain the events of the Tenerife accident. On March 27, 1977, many planes were headed to Gran Canaria, a popular vacation destination in the Canary Islands. A terrorist bomb exploded at the airport's flower shop, leading to the diversion of all flights to Tenerife, a small island airport with a single runway and limited parking. The Pan Am crew initially requested to hold over Gran Canaria, as they had sufficient reserve fuel, but were denied and forced to land at Tenerife.
The Crews Involved
Laura details the experience levels of the crews of both planes. The Pan Am crew consisted of Captain Victor Grubbs with 21,000 hours, First Officer Bob Bragg with 10,000 hours, and Flight Engineer Greg Warren with 15,000 hours. The KLM crew included Captain Jacob van Zanten, a highly senior and respected figure at KLM with 11,700 hours, First Officer Claus Meurs, and Flight Engineer William Schreuder, who had over 17,000 hours and was a professional flight engineer and president of the European professional flight engineer organization.
Ground Delays and Refueling
Laura describes the situation after landing. After landing at Tenerife, the planes were stacked up due to the lack of parking space. KLM landed before Pan Am and was positioned in front. Passengers on the KLM aircraft were allowed to disembark, while Pan Am's request for air stairs was initially denied. The delay continued for three and a half hours, and Captain van Zanten of KLM decided to refuel the aircraft due to concerns about flight duty time.
Fog and Tension
Laura explains how the weather conditions worsened. While the planes were on the ground, a dense fog bank rolled in, reducing visibility significantly. The Pan Am pilots grew increasingly anxious and impatient, as KLM was blocking their departure. The Pan Am captain started to chide the KLM captain over the radio, adding to the tension. After refueling, KLM faced another delay when four passengers were missing.
Duty Time Concerns and Runway Setup
Laura goes into detail about the KLM crew's concerns about their flight duty time, which was a significant factor in their decision-making. New laws in the Netherlands made it a criminal act for pilots to exceed their duty time limits. The pilots were under stress to adhere to these limits, and the only way to determine their status was to constantly contact the HF radio company. Finally, after a long delay, KLM prepared to depart.
Communication Breakdown
Laura describes the events that led to the accident. KLM received clearance to enter the runway and back-taxi down Runway 30. The controllers at Tenerife had limited English proficiency and were using non-standard phraseology. The radio frequency was shared by all controllers, creating a chaotic environment. The KLM pilots were instructed to take their third left, but they proceeded to the end of the runway. Pan Am, following behind, received the same ambiguous clearance.
Taxiway Confusion and Worsening Visibility
Laura explains the confusion regarding taxiway instructions. Pan Am was given the same clearance as KLM, but the pilots were unsure if they were told to take the first or third left. The taxiways lacked proper signage, and the controllers did not use standard terminology. The available taxiways were unsuitable for a 747 to make a reverse high-speed turn. As Pan Am taxied down the runway, the fog rolled in, reducing visibility to near zero.
KLM's Takeoff Attempt
Laura describes the final moments before the collision. KLM reached the end of the runway and performed a 180-degree turn. The first officer called for takeoff clearance, and the tower responded with their en route clearance. The KLM pilots interpreted this as a takeoff clearance and began their takeoff roll. The controller said "okay" after KLM announced they were taking off, which the KLM crew interpreted as confirmation.
Pan Am's Warning and the Blocked Transmissions
Laura explains how the Pan Am crew tried to warn the tower. As KLM began its takeoff roll, the Pan Am pilots heard the transmissions and realized the potential danger. Bob Bragg transmitted that they were still taxiing down the runway. Simultaneously, the tower controller attempted to say "stand by for takeoff," but the two transmissions were blocked, and neither crew heard the other. The tower then instructed "pop Alpha 1736 report when Runway clear" which didn't register to the KLM crew.
The Collision
Laura recounts the collision from Bob Bragg's perspective. Sitting in the same 747, she imagined what Bob was thinking as he saw KLM's lights approaching. Realizing KLM was rolling, Bob screamed, "Get off, get off!" The Pan Am captain firewalled the engines and attempted to pivot the aircraft, but it was too late. KLM, attempting to get airborne, struck the Pan Am aircraft. The last sound on the Pan Am cockpit voice recorder was the takeoff warning horn and the sound of the KLM engine passing over the cockpit. On the KLM recorder, the last sound was the captain's scream.
Aftermath and Survival
Laura describes the immediate aftermath of the collision. Bob Bragg survived the impact and found himself alone in the cockpit. He saw the upper deck was gone and passengers in their seats. He pulled the fire handles, but there was nothing there. He doesn't know if he fell out or jumped from the plane. He ran from the wreckage and then returned to pull people from the fire. The passengers on the Pan Am plane were mostly alive but trapped by debris. The KLM aircraft crashed further down the runway, and all occupants were killed.
Emergency Response Failure
Laura explains the failure of the emergency response. Bob Bragg waited for fire trucks and ambulances, but none arrived. The controllers were unaware of the crash and did not call for help. Another pilot reported the fire, but the controllers believed it was a terrorist bomb and considered evacuating the tower. When the fire trucks arrived, they stopped at the KLM wreckage and were unaware of the second aircraft until the fog lifted. Bob Bragg eventually went to the hospital in a taxi.
Links in the Chain of Disaster
Laura summarizes the chain of events that led to the disaster. The terrorist bomb, KLM's parking position, the decision to refuel, the fog, lack of taxiway signage, inoperative runway centerline lights, blocked transmissions, and the controller's use of "pop Alpha" all contributed to the accident. It was a communication disaster involving good airplanes and good pilots.
KLM Cockpit Voice Recorder Analysis
Laura analyzes the KLM cockpit voice recorder. The KLM captain, after completing the 180-degree turn, was eager to depart. He called the tower for clearance, and Bob Bragg believed they had received a takeoff clearance. However, during the investigation, listening to the cockpit voice recorder revealed that the flight engineer questioned whether they were clear, asking, "Is he not clear, that Pan American?" Both the captain and first officer responded affirmatively, but the captain's response blocked the first officer's. The flight engineer's question was not emphasized, and the captain proceeded with the takeoff.
Human Factors and Lessons Learned
Laura discusses the human factors study conducted by NASA to understand why the experienced KLM pilots made such critical errors. The study identified factors such as pressure, criminalization of duty time violations, training syndrome, and expectation bias. The captain expected that calling for takeoff clearance meant he was given one and that the runway was clear. The language barrier also contributed to the confusion.
CRM and AQP Development
Laura explains how the Tenerife disaster led to the development of Crew Resource Management (CRM) and Advanced Qualification Programs (AQP). Following a United Airlines crash in Portland, Oregon, caused by a communication breakdown in the cockpit, United Airlines initiated CRM training to improve communication and teamwork among crew members. CRM evolved into AQP, which involves practicing scenarios that have caused accidents in the past. These programs have significantly improved aviation safety.
Conclusion and Additional Resources
Laura concludes her presentation by promoting her book, "Jet Boss," which explores the human aspect of being a pilot. She also mentions her YouTube channel, where she analyzes aviation incidents and accidents. Additionally, she provides links to aviation scholarships on her website. She addresses a question about the negative portrayal of the KLM captain in documentaries, attributing it to a politically biased report and the media's sensationalized narrative.
