Written by Jochen Di Vincenzo
On 27th March 1977, two Boeing 747 passenger jets — a Dutch aircraft from KLM and an American Pan Am — began their preparations for departure at Los Rodeos Airport on the Spanish island of Tenerife, Canary Islands. Due to a terrorist attack at the neighbouring Gran Canaria Airport, many flights had been diverted to Tenerife causing in the airport becoming quite crowded. Parked aircrafts occupying the taxiway forced departing aircrafts to taxi on the runway.
The fatal collision occurred when the KLM 4805 started its take-off run while Pan Am 1736, shrouded in mist, was still on the runway and about to turn off onto the taxiway. The massive impact and resulting fire killed all 248 people on the KLM plane and most of the 396 passengers of the Pan Am plane, with only 61 survivors in the front section of the aircraft.
As one of many reasons leading to the catastrophe, personality traits of the KLM crew have been pointed out as a key factor. Captain Veldhuyzen van Zanten’s haste to depart early led him to increase thrust twice with take-off- intention prior to Air Traffic Control (ATC) clearance. Even though the other two pilots in the KLM cockpit, first officer and flight engineer, expressed doubts about whether the Pan Am aircraft had left the runway, van Zanten ignored their concerns and decided to continue take-off. Investigators stated afterwards that captain van Zanten’s senior position — as KLM’s chief of flight training — over his first officer and flight engineer contributed to their inability to effectively delay van Zanten’s decision to start take-off until full clarification from ATC.
Unfortunately, this vast disaster is not the only one where poor crew communication played a crucial role. Only one year later, United Airlines Flight 173 ran out of fuel and crashed in a suburban Portland neighbourhood. When UA 173 approached Portland, the crew noticed a problem with the landing gear and started preparing an emergency landing while the plane flew circles in a holding pattern. The captain focused on the landing gear problem for an hour, ignoring repeated warnings from the first officer and the flight engineer about their dwindling fuel supply.
As a reaction to these accidents, the American Space Agency NASA and the aviation industry organized a conference to discuss and introduce “Crew Resource Management” (CRM). Beginning in the 1980s, CRM has been implemented in the cockpits of many airlines around the world. Primary goals of CRM are to foster situational awareness, self-awareness, leadership, decision making, flexibility and communication among flight personnel. Besides this, CRM aims to support a climate and culture where authority may be respectfully questioned. In the beginning of the program, this happened to be a quite delicate subject especially for the strongly hierarchy-based cockpit crews.
However, over the years, people’s mindset changed and CRM became a key factor in every pilot’s training. Nowadays, it seems obvious for us that people collaborating in such safety-critical environments need to be skillful in communication and leadership. But it took a long time and many incidents until CRM finally had been implemented in all civil and military procedures. Recent successful emergency landings like the Hudson River incident 2009 where CRM played an important role keep testifying to the enormous importance of these communication standards.
Today, these break-through developments in CRM allow us ESTIEMers, our friends and families to get on a plane with a calm feeling, trusting the crew and their leadership and communication skills.
Originally published at http://estiemblog.azurewebsites.net.
