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Aviation History
1979
1979 - 0200.PDF
J- The greatest failure of the air-safety system occurred on March 27,1977, when a KLM 747 and a Pan American 747 collided on the runway with the loss of 583 lives. The Spanish accident report, summarised in our issue of December 23, page 2240, is here reviewed by J. M. RAMSDEN. WHO was responsible for the world's worst air disaster, the collision between two 747s on the Tenerife Los Rodeos runway at 1706.50 GMT on March 27, 1977? There werei 583 fatalities and 61 survivors, all from the Pan American 747, including the flight crew. The KLM captain is blamed by the Spanish accident report. On first hearing of the disaster we found it difficult to believe that a KLM captain, one of the most senior and experienced pilots of the world's safest airline, and his co-pilot could take off without clearance, knowing that the Pan American 747 was still on the runway. The Spanish report says that this is exactly what the KLM captain and his co-pilot did. We do not; believe it, nor do we think that the Spanish air-safety people believe it. The report's conclusion seeks to explain why Capt Veld- huyzen van Zanten, "whose state of mind during the stop over at Tenerife was perfectly normal and correct, was able, a few minutes later, to commit a basic: error in spite of all the warnings repeatedly addressed to him." The report speaks of the "growing feeling of tension as the problems for the captain continued to accumulate —"including flight-time limitations and worsening visi bility." But such problems are hardly likely to upset such a captain. Accidents are rarely caused by simple "pilot error," however easy such a finding may be, especially when the pilot is dead. Unless accident investigators look for coni- tributory causes, and are completely objective in their analysis, aviation learns nothing and merely deserves similar accidents in the future. The report is seriously deficient in omitting to include the evidence of the surviving crew. Indeed, we know that the Pan American captain and his colleagues were not interviewed by the Spanish investigators except for ques tioning within 48hr of the shocking event. Again, all three tapes—tower, PAA and KLM;—were recovered and correlated, yet they are not published in their totality in the report, not even in an appendix. We learn that the KLM tape contained "noises and echoes". We know that these were treated by Sundstrand to pro^ duce a proper playback. What was the source of these noises? Where were they on the tape? This is important, particularly because the tower's crucial transmission to KLM—"OK . . . Stand by for take-off ... I will call you"— coincided with Pan American's call "We are still taxiing down the runway". The coincidence of these transmissions caused a whistling sound lasting for three seconds on the KLM cockpit voice recorder (CVR). If the original tape is no longer available, complete with the "noises and echoes," then this is a serious shortcoming of the inquiry, even if the noises and echoes were merely a technical fault of the tape, If the tape is available, then it should have been analysed, including the noises and echoes, and included in the report. Why, we ask again, are the statements of the Pan American crew not part of the report? It is very clear that the Pan American captain was more alarmed by the fateful KLM "take-off" transmission than the tower was. Again, why does the report appear doubtful about the RLM "take-off" transmission, putting in brackets the words which come at the end of KLM's ATC clearance readback: "We are now (at take-off)'"! We know that some experts maintain that KLM said: "We are now, ah, taking off". A footnote on page 47 of the Spanish report says: "When the Spanish, American and Dutch investigating teams heard the tower recording together, and for the first time, no-one, or hardly anyone, understood that this transmission meant that they were taking off." What is the significance of the "hardly anyone"? We know that there have always been differences of opinion about precisely what the KLM, captain or his co-pilot said at 1705.10. Yet the debate and the possibilities are not discussed by the' Spanish report. The words at take-off are merely bracketed, presumably to indicate that the play back is not clear. Why was Pan American still on the runway at 1706: 19.39? There is absolutely no doubt that the tower told Pan American to take the third turn-off ("the third, sir, one-two-three, the third, third") and this was confirmed by the Pan American co-pilot. Yet, as we all know, Pan American went past the third turning, The report acknowledges that this was a contributory cause of the accident. We ask again: where is the evidence from the Pan American crew as to why they passed it?
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