Aftermath. Robert J.D. Firth
that nation was responsible for investigating the accident. Investigators from the Netherlands and the United States also participated. The investigation would reveal the primary cause of the accident to be that the captain of the KLM aircraft attempted to take-off without clearance from Air Traffic Control. (human error)
Throughout the writing of this book, I tried to place myself into the mind-set of Captain Van Zanten. I wanted to understand why did what he did and what I would do given the same situation. Do the same yourself. If you’re a pilot or, even if you’re not, consider carefully the circumstances and his actions; ask yourself- would you do the same?
The investigation showed that the KLM captain certainly (positively) did not intentionally initiate a take-off without clearance. I’m convinced, as were the investigators, that he fully believed he had clearance. Due to misunderstandings between his flight crew and ATC he believed the runway was clear- there can be absolutely no doubt about this!
Dutch investigators naturally would place greater emphasis on this than their American and Spanish counterparts, but ultimately, KLM had to admit that their Captain was responsible for the accident. In the end, KLM, and their insurers, financially compensated the victims. Money however, is little comfort when a loved one is killed in a senseless tragedy. There is no compensation for such losses and the pain never really goes away. Money just seems the only thing we humans can think of to give- but it is so hopelessly inadequate. Time does not actually cure, it just dulls the ache.
The accident had a huge influence on the industry, particularly in the area of communication. An increased emphasis was placed on using standardized phraseology in ATC communication by both controllers and pilots alike, thereby reducing the chance for misunderstandings. The idea is to make some changes that hopefully, will help avoid similar accidents.
As one of these changes, the word "takeoff" was removed from general usage, and is now only spoken by ATC when actually clearing an aircraft to take-off. Crew members are encouraged to challenge their captains when they believe something may be not correct. Captains are instructed to listen to their crew and evaluate all decisions in light of crew concerns. This concept would later be expanded into what is known today as Crew Resource Management. CRM training is now mandatory for all airline and used today by corporate pilots.
For both planes, Tenerife was an unscheduled stop. Their destination was Gran Canaria International Airport (also known as Las Palmas 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 west coast of Morocco.
Pan Am Flight 1736 had taken off from Los Angeles International Airport with an intermediate stop at New York's John F. Kennedy International Airport. The aircraft was a Boeing 747–121, registration N736PA. Of the 380 passengers, 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. The same aircraft had operated the inaugural 747 commercial flight on January 22, 1970.
KLM Flight 4805, a charter flight for Holland International Travel Group from the Netherlands, had taken off four hours before from Amsterdam’s Schiphol airport. Its captain was Jacob Veldhuyzen van Zanten and the first officer was Klaas Meurs. The aircraft was a Boeing 747-206B, registration PH-BUF. The KLM jet had 14 crew members and 235 passengers, including 48 children and three infants. Most of the KLM passengers were Dutch; four Germans, two Austrians, and two Americans were also on the plane. Sadly, the 48 children never had a chance at life……they, as all the KLM passengers, were incinerated in their seats…
After the aircraft landed at Tenerife, a Dutch tour guide named Robina van Lanschot, who lived on the island in Puerto de la Cruz and wanted to see her boyfriend that night, chose not to re-board the 747, leaving 234 passengers on board. Fate, maybe!
Events on both planes had been routine until they approached the islands. Then, at 1:15 pm, a bomb (planted by the separatist Fuerzas Armadas Guanches), a pack of wild-eyed, scraggly-assed, miserable terrorists exploded in the terminal of Gran Canaria International Airport. (circumstance or coincidence one) It had been preceded by a phone call warning of the bomb, and soon after another call came in claiming a second bomb was at the airport. The civil aviation authorities closed that airport after the bomb detonated and diverted all of its incoming flights to Los Rodeos, including the two Boeing 747 aircraft involved in the disaster.
Upon contacting Gran Canaria airport, the Pan Am flight was informed of the temporary closure. Although the Pan Am crew indicated that they would prefer to circle in a holding pattern until landing clearance was given, the plane was diverted to Los Rodeos, along with the KLM flight. This led to the critical parking conditions at the smaller airport.
The Pan Am aircraft was ready to depart, but the KLM plane and a re-fuelling vehicle obstructed the taxiway to the active runway. The Pan Am aircraft was unable to maneuver around the fueling KLM to reach the runway and depart due to a lack of just 12 ft (3.7 m) of clearance.
Many coincidences in this terrible accident favored death such that, once events began to unfold, it seemed that the players were ensnared, as it were, in a macabre and inextricable dance of destruction………The reader can read “coincidence” like “fate.” In this case, perhaps they are interchangeable….?
Captain Van Zanten had decided to fully refuel at Los Rodeos instead of Las Palmas, apparently to save time. The re-fuelling took about 35 minutes. Another of the coincidences!
Following the tower's instructions, the KLM aircraft was cleared to back-taxi the full length of runway 30, make a 180° turn to takeoff position. This is a bit difficult maneuver to perform with a 747 on a 45 m (150 ft) wide runway. (coincidence two)
While KLM 4805 was back-taxiing on runway 30, 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- again, this is normal.
During taxiing, the weather deteriorated and low-lying clouds now limited the visual range to about 300 m (1,000 ft). Legal or stipulated threshold for takeoff was 700 m (2,300 ft) visibility, as noted in the NOVA documentary and relayed by surviving Pan Am co-pilot Robert Bragg. In actual fact, if there is a close-by take-off alternate, the minimum forward visibility can legally be just sufficient to maintain visual contact with the runway center line. Another coincidence, ( number three) perhaps the worst of them all….
Shortly afterward, Pan Am 1736 was instructed to also back-taxi, to follow the KLM aircraft down the same runway, to exit the runway by taking the "third exit" on their left and then down the parallel taxiway to the end. This would have had them in position behind KLM to take the duty runway after the Dutch aircraft had departed.
Initially the Pan Am 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. The instructions to Pan Am to follow KLM down the runway was another coincidence ( number four), and, along with the fog, the fatal one!
Based on the chronology of the cockpit voice recorder (CVR) and the distances between the taxiways (and the location of the aircraft at the time of the collision), 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