On March 27, 1977, two Boeing 747 airliners dropped on Los Rodeos Airport (now Tenerife North Airport) on the Spanish island of Tenerife, Canary Islands. Crash killed 583 people, making it an accident in the history of aviation. The complex interplay of organizational effects, environmental conditions and safe practices, leading to the disaster in Tenerife as an example of textbooks for reviewing aviation disaster and accident prevention processes and frameworks.
The bomb explosion at Gran Canaria airport and the threat of another bomb caused many aircraft to fly to Los Rodeos Airport. Among them were KLM Flight 4805 and Pan Am Flight 1736 – two accidents. At Los Rodeos airport, air traffic controllers were forced to park many airplanes by taxi, blocking it. Making the situation even more difficult, while the authorities expected the opening of the dense fog in Gran Canaria, developed in Tenerife, significantly reducing visibility.
When Gran Canaria was reopened, a parking airplane that blocked the Tenerife Road, both required 747 taxi on the only track to get started. The fog was so thick that neither aircraft could be seen from the other, and the tower controller could not see it on the track or on the two 747s. As there were no terrestrial radars at the airport, the controller found each airplane on the radio only with voice reports.
As the accident occurred on Spanish territory, Spain was responsible for investigating the accident. The crash involved aircraft from the United States and the Netherlands, both of which also conducted investigations. The studies showed that the main cause of the accident was the pilot of the KLM flight, which flew without ATC (ATC). The investigation showed that the captain did not intentionally take off without clearance; rather, he fully believed that he could take off due to misunderstandings between the flight crew and the ATC. Dutch researchers put more emphasis on this than their American and Spanish counterparts but finally, KLM acknowledged that their team was responsible for the accident and the airline compensated the victims' relatives financially.
The accident had a lasting impact on industry, especially in the communications sector. Greater emphasis was put on the use of standardized phraseology by air traffic controllers and pilots in both ATC communications, thereby reducing the possibility of misunderstandings. As part of these changes, the word "start" was removed from the general use, and this is only stated by the ATC to remove the aircraft or cancel the same emptying. Less experienced flight crew members were encouraged to challenge their captain when they believed that something was wrong, and the captains were asked to listen to their team and evaluate all decisions in the light of the crew's concerns. Later, this concept, now known as CRM, is now extended to all airlines.
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