that he alone should not be blamed for the "mutual misunderstanding" that occurred between the controller and the KLM crew, and that limitations of using radio as a means of communication should have been given greater consideration. (See the KLM report in the appendices)
In particular, the Dutch response pointed out that the crowded airport had placed additional pressure on all parties, KLM, Pan Am, and the controller; sounds on the CVR suggested that during the incident the Spanish control tower crew had been listening to a football match on the radio and may have been distracted. The transmission from the tower in which the controller passed KLM their ATC clearance was ambiguous and could have been interpreted as also giving take-off clearance.
In support of this part of their response, the Dutch investigators pointed out that Pan Am's messages "No! Eh?" and "We are still taxiing down the runway, the Clipper 1736!" indicated that Captain Grubbs and First Officer Bragg had recognized the ambiguity; if the Pan Am aircraft had not taxied beyond the third exit, the collision would not have occurred. (Number five in our list of circumstances, which, all told, created a tangible and discernable path of happenings, inextricably leading to death on a massive scale.)
Speculation regarding other contributing factors includes: Captain Van Zanten's failure to confirm instructions from the tower. The flight was one of his first after spending six months training new pilots on a flight simulator, where he had been in charge of everything (including simulated ATC, which, by the way, is the norm, for any simulator instructor), and having been away from the real world of flying for extended periods. This, however, in itself, means little as there is almost no difference between the simulated experience and that of the real world. In fact, in the level C simulators a pilot can obtain his type rating so that his very first flight in the real aircraft will be with live passengers.
Another factor was the flight engineer's apparent hesitation to challenge Van Zanten further, possibly because Captain Van Zanten was not only senior in rank, but also one of the most able and experienced pilots working for the airline.
In point of fact, any rated airline captain with about ten thousand hours and 500 in type is just as good as any other…Anyone can have a bad day or make an error… as did Van Zanten…… On a foggy day, such as this was, caution is doubly important… Clearly, He shoved the power levers up prematurely but we can be certain that, at that moment, he absolutely believed he was cleared for take-off.
A study group put together by the Air Line Pilots Association found that not only the captain, but the first officer as well dismissed the flight engineer's question. In that case, the flight engineer might have been either reassured or even less inclined to press the question further. Again, we will never know…
The reason only the flight engineer reacted to the radio transmission "Alpha one seven three six report when runway clear" might lie in the fact that this was the first and only time Pan Am was referred to by that name. Before that, the plane was called "Clipper one seven three six".
The flight engineer, having completed his pre-flight checks, might have recognized the numbers but his colleagues, preparing themselves for take-off, might have subconsciously been tuned in to "Clipper."
The extra fuel the KLM plane took on added several factors: it delayed takeoff an extra 35 minutes, which gave time for the fog to settle in and it added over forty tons of weight to the plane which made it more difficult to clear the Pan Am when taking off. That fuel also increased the size of the fire from the crash that ultimately killed everyone on board. It took almost nine hours to extinguish the fires.
Captain Van Zanten's reaction, once he spotted the Pan Am plane, was to attempt to take off. There was nothing else he possibly could have done. Although the plane had exceeded its V1 speed, (in this case about 120 ks) it did not yet have adequate airspeed. The sharp lifting angle caused the KLM jet to drag its tail on the runway, thereby reducing its speed even further.
The collision was the inevitable result of physics. KLM, moving at about 120 ks, smashed into the side of the Pan Am aircraft exactly as the artist’s rendering above indicates. It’s a miracle that anyone survived.
CHAPTER 3
“In flying I have learned that carelessness and overconfidence are usually far more dangerous than deliberately accepted risks.” Wilbur Wright, in a letter to his father, September 1900
LIABILITY & CHANGE
Aftermath; The old bell rang on the ground floor of Lloyds on the morning hours of March 28th, 1977, the day following the worst air disaster in world history. The bell had been recovered from the first ship whose cargo was insured by Lloyds. In this case the ship was the Lustine and she carried a shipment of gold valued at $500,000.
The bell was traditionally struck when news of an overdue ship arrived - once for the loss of a ship (i.e. bad news), and twice for her return (i.e. good news). The bell was sounded to ensure that all brokers and underwriters were made aware of the news simultaneously.
The bell has since developed a crack and the traditional practice of ‘ringing the news’ has ended: the last time it was rung to tell of a lost ship was in 1979 and the last time it was rung to herald the return of an overdue ship was in 1989. Of course, the mournful tones from that long sunken wreck’s bell echoed throughout the Lloyds building on the afternoon of the Tenerife crash on March 27th, 1977.
The accessing of liability began on that morning and continued for two years. The issues were clear, the total destruction of two $25 million dollar aircraft and the death of 583 human beings. The aircraft could be replaced but the loss of life was irrevocable and final.
56 passengers and 5 crew members aboard the Pan Am aircraft survived, including the captain, first officer, and flight engineer. Most of the survivors on the Pan Am aircraft walked out onto the left wing, the side away from the collision, through holes in the fuselage structure.
The process of grieving for the families who had lost loved ones began on that day along with the search for answers as to why this senseless accident had happened. The various steps involved in understanding exactly what had happened were easily established. The voice and flight recorders were located and examined. The radio transmissions between the aircraft and the ground controller were crystal clear. Hundreds of investigators and lawyers heard them and they were carefully transcribed and studied. We include them here in Chapter 6.
Although the Dutch authorities were initially and naturally reluctant to blame Captain Van Zanten and his crew, the airline ultimately was compelled to accept responsibility for the accident. KLM’s insurer eventually paid the victims or their families on both aircraft compensation ranging between $58,000 and $600,000.
As reported in a March 25, 1980, Washington Post
