AASMAN

Mohsin Azhar Shah (GL)

Saqib Mehmood

BAM- 9205
BAM-9207

Saad Shoaib
Arslan Aslam

BAM-9210
BAM-9234

 General Overview of the Accident (How it

happened?)

Investigation
Findings Conclusion

Areas to be Covered

General
On March 27 1977, two Boeing 747 jumbo jets collided on a runway at Tenerife airport, Tenerife, in the Canary Islands, making this the world's worst civil aviation disaster.

Geographical Location
The Canary Islands are located in the Atlantic Ocean, off the Western coast of Africa, They are volcanic islands. Tenerife-North Los Rodeos Airport, in Tenerife, Canary Islands Spain is the airport where an accident was occurred.

Canary Islands

Tenerife North Los Rodeos Airport

This Tenerife North Los Rodeos Airport layout has one 12- 30 RWY and four exit taxi ways as shown above in the diagram. This is a small and busy airport.

 Unfortunately, On March 27 1977, A bomb had exploded at Las Palmas Airport so it was closed for repair and due to warning of second explosion. Many flights are diverted to Tenerife North Los Rodeos Airport and it was saturated with traffic.

Turning Point

Overview of the Accident

Due to diversion, Both 747 landed at Tenerife North Los Rodeos Airport.
First is KLM 747-206B (KLM 4805) with 248 people onboard, including 14 crew had landed before Pan Am Boeing 747-121 Second is Pan Am Boeing 747-121, (flight 1736) from Los Angeles and New York to Las Palmas having 396 people including 16 crew onboard that landed at Tenerife airport. .

 Taxiways were congested, So. KLM 747 was instructed to backtrack on runway 12 making 180 turn to line up for take-off on runway 30.

Overview of the Accident

Three minutes later at 17:02,The Pan Am flight 1736 was then cleared to backtrack runway 12 to follow the KLM aircraft
The Pan Am crew were told to leave the runway at the third taxiway and report when leaving.

What was actually happened?

 RWY was not visual to tower. The visibility was less than 200 meters. KLM lined up with RWY 30

Overview of the Accident

 After lining up on runway 30, KLM 747 started its take off role

When Pan Am was about to leave RWY Suddenly the Pan Am captain spotted the landing lights of the KLM Boeing 747 just 700 meters away in the fog. The Pan Am crew set full throttle to leave the runway as quickly as possible, but it was too late.

Overview of the Accident

 Dutch KLM 747 was about 170 knots. The captain applied full back stick pressure in order to take off and fly over the other 747. The nose climbed, the tail struck the runway, producing sparks. The aircraft climbed one meter above ground, but this wasn't enough.

 The KLM 747crashed. There were no survivors, all of the 248 people onboard expired. In the Pan Am 747, 64 people, including the First Officer survived, out of 396.

Consequences of Accident

 The heat produced by the fire on Pan Am aircraft cleared the fog 1 Km around the crash scene 583 Fatal injuries
64 people survived

Consequences of Accident

 About 70 crash investigators from Spain, the Netherlands, the United States, and the two airline companies were involved in the investigation.

KLM CVR
The KLM and Pan Am 747s are both in queue to taxi down the runway and turn around for takeoff. The KLM aircraft is ahead of the Pan Am aircraft.

Investigation

 CVR transcript showed that the KLM pilot was convinced that he had been cleared for takeoff, while the Tenerife control tower was certain that the KLM 747 was stationary at the end of the runway and awaiting takeoff clearance. It appears KLM's co-pilot was not as certain about take-off clearance as the captain

Investigation

 Evidences showed that there had been misinterpretations and false assumptions. Pan Am CVR The controller instructed Pan Am 747 to travel down the runway and then exit it via C3 taxiway.

Investigation

Pan Am CVR
F/O of Pan Am was convinced that the controller had intended that they take the fourth exit C4 because it was the most appropriate taxiway for Pan AM 1736. However, the controller delivered the message to take "the third one, sir; one, two, three; third, third one.

Investigation

Probable Causes
The fundamental cause of the accident was that Captain of KLM 747 took off without takeoff clearance. He had a desire to leave as soon as possible in order to comply with KLM's duty-time regulations, and before the weather deteriorated further. The Pan Am aircraft had not exited the runway at C-3. Misunderstanding or misinterpretation; Simultaneous radio transmissions, with the result that no message could be heard.

Findings

 1705:53.4 APP: KLM 8705 uh you are cleared to the Papa beacon. Climb to and maintain flight level 90 ... right turn after takeoff proceed with heading 040 until intercepting the 325 radial from Las Palmas VOR. 1706:09.6 KLM RT: Ah, roger, sir, we're cleared to the Papa beacon flight level 90, right turn out 040 until intercepting the 325, and we're now at takeoff. 1706:12.25 KLM 1: Let's go ... check thrust. 1706:18.19 APP: Okay. Use of ambiguous non-standard phrases by the KLM co-pilot ("We're at take off") and the Tenerife control tower ("OK").

Findings

 When both Air Traffic Control and Pan Am RT speak simultaneously. This causes a shrill noise in the KLM cockpit (Heterodyne) that lasts for almost four seconds. 1706:20.08 APP: Stand by for takeoff ... I will call you. PA1: No, uh. PA RT: And we are still taxiing down the runway, the Clipper 1736

Findings

 No CRM in KLM cockpit; Perhaps because of the KLM

pilot's very senior position, neither the copilot nor flight engineer questions the pilot again.

Human Factor Involved in the accident;

misunderstandings were common.

Findings

 Bomb Blasts at Las Palmas Airport Diversion to Tenerife Airport RWY centre line lighting out of service

Airport saturation
Football match on radio, at tower.

Some Latent Conditions

 Spanish report blaming the KLM captain for the accident Netherlands Department of Civil Aviation pointed out that crowded airport placed pressure on all, KLM, Pan Am, and the controller. CVR suggested that Spanish control tower crew listening to a football match on the radio. Transmission from the tower to KLM was ambiguous and Pan Am last call was not listened to both

Dutch Response

 The pilot should not take off until accepting clearance from tower. Pilots and traffic controllers should use standard phraseology. After the disaster at Tenerife, officials implemented standard aviation phrasing worldwide to avoid confusion in the future.

Recommendations

 The Dutch airline KLM ultimately accepted responsibility for the accident. KLM paid the victims or their families compensation of an average of $189,000 per victim.

Conclusion

Thank You