This air traffic control had trouble understanding English as

This report will be discussing the KLM-Panam Tenerife Disaster and
how crew resource management played a vital role in this tragedy. What is Crew
Resource Management? (CRM) is an arrangement of principles and systems for use
in planes where human mistake can have impacts. Used for enhancing air
security, CRM concentrates on communication, initiative, and basic leadership
in the cockpit of a carrier. Human error is the reason for around 80 percent of
aviation accidents, CRM has an essential influence and is there to reduce
chances of error and improve safety. One of the key components of CRM is
situational awareness, it is the comprehension of the conditions encompassing
your flight. Comprehending what will happen, and what has occurred before and
how that may influence you and your flight later. Situational awareness is most
likely best depicted as a prepared perspective while flying. It originates as a
matter of fact and learning and can be hindered by being unfit or having
fatigue for instance. Another key concept in CRM is communication.
This is an area best described in its own publication, as there are frequent
factors that contribute to successful or failed communication. There are many
factors to be considered when analysing communication, such as dialect. English
is the universal air traffic language however miscommunication played a huge
part in the Tenerife accident as the air traffic control had trouble
understanding English as it wasn’t there first language.


The Tenerife disaster was a runway crash between
two 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 hence
why human error occurred, and unsafe acts leading up to the accident, it has
become an event in the study of human factors in aviation safety. leading up to the crash, a bomb explosion at Gran Canaria Airport, and
the risk of a second bomb, caused many aircraft to be diverted to Los Rodeos
Airport. Among them were KLM Flight 4805 and Pan Am Flight 1736 – the two-aircraft
involved in the accident. At Los Rodeos Airport, air traffic controllers were told
to park many of the aircraft on the taxiway, thereby blocking it. Further
complicating the situation as the airport cannot handle lots of traffic at the
airport, while authorities waited to reopen Gran Canaria, a fog developed at
Tenerife, greatly reducing visibility. When Gran Canaria
reopened, the parked aircraft blocking the taxiway at Tenerife required both
747s to taxi on the only runway to get in position for take-off. The fog was so
thick to the point that neither one of the aircrafts could see the other, and
the controller in the tower couldn’t see the runway or the two 747s on it. As
the air terminal did not have ground radar, the controller knew about where
every plane was just by voice reports over the radio. Because of a few
misconceptions, the KLM flight attempted to take off while the Pan Am flight
was 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 board
the Pan Am flight. Sixty-one individuals on board the Pan Am flight, including
the pilots and flight design, survived the fiasco.

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The investigation revealed that the primary cause
of the accident was the captain of the KLM flight taking off without clearance
from Air Traffic Control (ATC). The investigation specified that the captain
did not intentionally take off without clearance; rather he believed he had
clearance to take off due to misunderstandings in radio communications with




The Investigation found that the reason
for this mishap was the way that the KLM Captain:


1.         Took
off without leeway.


2.         Did
not comply with the “remain by for take-off” from ATC


3.         Did
not interfere with take-off when Pan Am accounted for that they were still on
the runway.

. Contributory Factors were
additionally distinguished:


?          The
Poor 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 the
Tower, which led the “stand by for take-off” was likewise incorrect –
although unrelated in this case because the take-off had already started about
six and a half seconds before.  


Human Factors

 Stress is
a major factor in the Tenerife disaster. KLM crew were under stress because of
the terrorist attack attempt and were having to face uncertain weather
conditions with their flight duty time limits about to expire. Panam crew faced
the same conditions however were not near their limits of their duty time. The
air traffic control was dealing with much larger aircraft and more traffic in
the airport and having to speak in English a less familiar language. Demands
such as these disrupt cognitive processes, decrease alertness and diminish
judgement.  The KLM captain apparently
did 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 a
few more seconds against taking off quickly. Tenerife links to the principle of
stress causing regression this is when in stressful situations people regress
or behave differently or in ways that they learned first. KLM pilot was an
instructor for 10 years. He acted as a controller and issued take off
instruction. The KLM co-pilot and flight engineer might have gotten intimidated
by the captain and not raised the issue of the take-off clearance however Panam
crew chose to follow the controller’s instructions.


CRM LOFT is de?ned as training rather than formal
evaluation, with the goal of allowing crews to explore the impact of new
behaviours without exposing their certi?cation as crew members. LOFT should
influence behaviour most strongly when scenarios are crafted to require team
decision-making and coordinated actions to resolve in-flight situations