This report will be discussing the KLM-Panam Tenerife Disaster andhow crew resource management played a vital role in this tragedy.
What is CrewResource Management? (CRM) is an arrangement of principles and systems for usein planes where human mistake can have impacts. Used for enhancing airsecurity, CRM concentrates on communication, initiative, and basic leadershipin the cockpit of a carrier. Human error is the reason for around 80 percent ofaviation accidents, CRM has an essential influence and is there to reducechances of error and improve safety. One of the key components of CRM issituational awareness, it is the comprehension of the conditions encompassingyour flight.
Comprehending what will happen, and what has occurred before andhow that may influence you and your flight later. Situational awareness is mostlikely best depicted as a prepared perspective while flying. It originates as amatter of fact and learning and can be hindered by being unfit or havingfatigue for instance. Another key concept in CRM is communication.This is an area best described in its own publication, as there are frequentfactors that contribute to successful or failed communication. There are manyfactors to be considered when analysing communication, such as dialect. Englishis the universal air traffic language however miscommunication played a hugepart in the Tenerife accident as the air traffic control had troubleunderstanding English as it wasn’t there first language.
The Tenerife disaster was a runway crash betweentwo Boeing 747s, in 1977, at Los Rodeos Airport on the Spanish island of Tenerife,the crash killed 583 people making it a fatal crash. CRM was not followed hencewhy human error occurred, and unsafe acts leading up to the accident, it hasbecome an event in the study of human factors in aviation safety. leading up to the crash, a bomb explosion at Gran Canaria Airport, andthe risk of a second bomb, caused many aircraft to be diverted to Los RodeosAirport. Among them were KLM Flight 4805 and Pan Am Flight 1736 – the two-aircraftinvolved in the accident. At Los Rodeos Airport, air traffic controllers were toldto park many of the aircraft on the taxiway, thereby blocking it. Furthercomplicating the situation as the airport cannot handle lots of traffic at theairport, while authorities waited to reopen Gran Canaria, a fog developed atTenerife, greatly reducing visibility. When Gran Canariareopened, the parked aircraft blocking the taxiway at Tenerife required both747s to taxi on the only runway to get in position for take-off.
The fog was sothick to the point that neither one of the aircrafts could see the other, andthe controller in the tower couldn’t see the runway or the two 747s on it. Asthe air terminal did not have ground radar, the controller knew about whereevery plane was just by voice reports over the radio. Because of a fewmisconceptions, the KLM flight attempted to take off while the Pan Am flightwas still on the runway. The subsequent crash demolished both airplane,murdering every one of the 248 on board the KLM flight and 335 of 396 on boardthe Pan Am flight. Sixty-one individuals on board the Pan Am flight, includingthe pilots and flight design, survived the fiasco.
The investigation revealed that the primary causeof the accident was the captain of the KLM flight taking off without clearancefrom Air Traffic Control (ATC). The investigation specified that the captaindid not intentionally take off without clearance; rather he believed he hadclearance to take off due to misunderstandings in radio communications withATC. The Investigation found that the reasonfor this mishap was the way that the KLM Captain: 1. Tookoff without leeway. 2. Didnot comply with the “remain by for take-off” from ATC 3. Didnot interfere with take-off when Pan Am accounted for that they were still onthe runway. .
Contributory Factors wereadditionally distinguished: ? ThePoor use of language. The KLM co-pilot repeated the air traffic control clearance,he was told with the words, “We are now at take-off.” However the controller,who had not been asked for take-off clearance. The “OK” from theTower, which led the “stand by for take-off” was likewise incorrect -although unrelated in this case because the take-off had already started aboutsix and a half seconds before. Human Factors Stress isa major factor in the Tenerife disaster. KLM crew were under stress because ofthe terrorist attack attempt and were having to face uncertain weatherconditions with their flight duty time limits about to expire. Panam crew facedthe same conditions however were not near their limits of their duty time.
Theair traffic control was dealing with much larger aircraft and more traffic inthe airport and having to speak in English a less familiar language. Demandssuch as these disrupt cognitive processes, decrease alertness and diminishjudgement. The KLM captain apparentlydid not even consider the possibility that the Pan Am was still on the runway.He made a premature decision. He did not choose the better option of waiting afew more seconds against taking off quickly. Tenerife links to the principle ofstress causing regression this is when in stressful situations people regressor behave differently or in ways that they learned first.
KLM pilot was aninstructor for 10 years. He acted as a controller and issued take offinstruction. The KLM co-pilot and flight engineer might have gotten intimidatedby the captain and not raised the issue of the take-off clearance however Panamcrew chose to follow the controller’s instructions. CRM LOFT is de?ned as training rather than formalevaluation, with the goal of allowing crews to explore the impact of newbehaviours without exposing their certi?cation as crew members.
LOFT shouldinfluence behaviour most strongly when scenarios are crafted to require teamdecision-making and coordinated actions to resolve in-flight situations