6 minute read
Airline Ops - Mike Gough
A few weeks ago, 27 March , marked the 44th anniversary of what is still the world’s worst aviation disaster – the collision of two Boeing 747s at Tenerife Airport, Spain.
Having Pilot Monitoring is invaluable for trapping mistakes.
WORST AS IN TWO ASPECTS: The highest single death toll for any aircraft accident, as well as the worst in human behaviour in the flight deck that resulted in this mega tragedy.
Thankfully, no one has yet beaten the total 583 fatalities in a single accident, and with the measures developed in terms of human factors as a direct result of this accident, we have been able to steadily and progressively train ourselves away from our occasional bizarre behaviour as humans.
As most of us are well familiar with the events that led up to this disaster, I’ll summarise just how many holes in multiple pieces of cheese had to line up for everything to go so perfectly wrong.
Starting at the end, the catastrophic decision of Captain Jacob Veldhuyzen van Zanten of the KLM Boeing 747 ‘Rijn’, to commence their takeoff without ATC clearance, had its own set of surrounding factors. This pilot was very much the ultimate company man, being head of training and ironically, head of the safety department. He was also under pressure to implement the then very new flight and duty plan, aimed at reducing fatigue in long-haul crew members, and by extension, reduce incidents and accidents.
The other aircraft, a Pan Am Boeing 747 ‘Clipper Victor’, happened to be the same aircraft that did the world’s first ever commercial 747 flight in January 1970. Eight months after this inaugural flight, it became the first (and only) B747 to be hijacked, and landed in Havana, Cuba.
Seven years after those events, it was inbound to the Grand Canaria Airport in the Canary Islands from New York, while the KLM machine was inbound from Amsterdam, on a holiday charter flight.
As both aircraft descended into Grand Canaria, a local terrorist group detonated a bomb in the terminal building, injuring eight people, but with a telephonic threat of another device having been planted. The airport was duly closed and flights diverted to Los Rodeos airport in Tenerife.
The Pan Am flight requested to hold until clearance could be obtained, as they had in excess of two hours additional fuel (those were the days, in terms of nonoptimised fuel planning), but ATC refused this request and sent them off to Tenerife.
The severely congested Los Rodeos airport had to contend with aircraft way bigger than they were used to, as well as drifting, heavy fog. Captain van Zanten, with the intention to complete the mission within the new Flight and Duty scheme, had been pushing for refuelling and clearance to depart, which, the moment Grand Canaria was declared safe, he obtained and was the first to taxi to the departure end of the single runway.
The Pan Am Clipper taxied behind them, at 3 knots (according to the surviving First Officer Bragg) due to the extremely dense fog. As the KLM Boeing completed their line up on the runway, the Pan Am aircraft was still painfully slowly backtracking. A triple radio transmission blocked the crucial call from ATC to KLM to hold their position, while Captain van Zanten advanced the thrust levers for takeoff. Both the First Officer and Flight Engineer’s concerned queries of the validity of the takeoff clearance was brushed off by the Captain with the words “Check Thrust”, an instruction to the engineer to set the correct takeoff thrust. The engineer realised that the Pan American was still on the runway and again asked the Captain if they were clear, to which he emphatically responded “Oh yes”.
All 249 souls on board the KLM aircraft perished (including 52 children), and only 61 of the 380 persons on board the Pan Am 747 survived, as the two aircraft collided.
This was mostly due to one man’s mission fixation, and the inadequate response of his crew, to challenge
the might of the uber Captain. However, the multitude of contributing factors demanded the attention of flight safety specialists around the world.
Two years later, in 1979, NASA held a workshop on a new-fangled concept that was referred to as Cockpit Resource Management, which focused on human factors in aviation accidents, and specifically the value of clear communications. This morphed into Crew Resource Management, as the variables in many instances extended beyond the cockpit.
In 1981, United Airlines in the US was the first airline in the world to introduce mandatory CRM training for their flight deck crews. It was only in 2006, through IATA initiatives, that CRM became mandatory training globally.
I did my first CRM course in early 1998, six months and several long range flights after joining what was once one of the world’s oldest legacy airlines (on similar B747 Classic aircraft that were involved), and immediately realised what an incredibly powerful safety tool this is – for those who choose to implement the lessons in the flight deck.
In 2010, I recall taxying out at night in Hong Kong for a flight to Johannesburg with one of our more ‘old school’ captains, who had recently returned from a contract with an Asian carrier. It was the Captain’s sector, and he was Pilot Flying. Taxi clearances at these large, busy airports can be complicated at the best of times and careful attention to clearances and read backs is essential.
Observing an imminent error in turning onto the wrong taxi way, I immediately pointed it out, and my concerns were dismissed with “I write things down you know”.
So do I, but maybe one of us wrote it down wrong…
A quick call from me to the ground controller to confirm the clearance showed the error of the Captain’s thinking, but accepting this was not to be, as he barked (on frequency!) for the controllers to stop changing their minds…to a brief moment of silence.
Despite not ‘loosing face’, the mood did soften on the flight deck, as the awareness of a near-significant error did sink into the left seat occupant, and a more ‘cooperative’ mood prevailed for the 13 hour flight back home.
The strides towards a less-steep cockpit gradient over the years has been significant, and now that we are on the 6th Generation of CRM training, we have accepted that even CRM in itself has issues.
It is interesting to note that it was only around six years ago that the concept of error management came to light. It’s taken us that long to realise that errors are inevitable, and as important as it is to avoid errors, we have to be able to trap and mitigate the consequences of this. We will continue to err as humans, so we need to learn to cope with that and recover the situation. This was the birth of Just Culture, which encouraged the reporting of errors and mistakes to add to our data base of knowledge.
Certain players in the industry (our CAA in South Africa, for example), feel it is appropriate to criminalise and penalise errors. How far in the Dark Ages are we with this approach to aviation safety? It is no wonder that this thinking may well be a contributory factor in the 28 aircraft accidents we have had this year so far in this country.
This brings me to the point of this article. For so many years, we have been developing methods to instil a practical practice of human factor mitigation in the professional cockpit. The lack of mandatory Single Crew CRM training in the General Aviation world is the seed that has been sown over time, with the grim harvest which we now reap.
As I find myself full time back in the GA environment, the gulf that exists between these two worlds is huge, and without astute and competent leadership, we will only watch that tally increase.
