Aftermath. by Robert Firth

Transcription

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2 Aftermath by Robert Firth

3 Copyright 2012 Robert Firth, All rights reserved. Published in ebook format by ebookit.com ISBN-13: No part of this book may be reproduced in any form or by any electronic or mechanical means including information storage and retrieval systems, without permission in writing from the author. The only exception is by a reviewer, who may quote short excerpts in a review.

4 CONTENTS FOREWORD PREFACE CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 CHAPTER 7 CHAPTER 8 CHAPTER 9 CHAPTER 10 CHAPTER 11 CHAPTER 12 CHAPTER 13 EPILOGUE APPENDICES

5 FOREWORD by Captain Maynard P. Longworth, B Tenerife, the worst accident in aviation history; like all pilots, Captain Van Zanten s decision to go for the take-off was only one of the many thousands of decisions he had made in his career. Rain, snow or fog obscuring the view of the entire runway was not uncommon and something he had experienced many times. He was thinking about many things; the delays, his inconvenienced passengers, the schedule, and the flight legs facing him after dropping his passengers just 25 minutes away. Of course, he was 100% certain that the Pan Am aircraft was clear of the runway. As his aircraft was gaining speed, he was readying himself for the mental switch from visual to instruments as he would be climbing through the fog. The instant he saw the Pan Am aircraft looming into view directly ahead of him he knew, he knew right then and right there, he knew he was dead, he knew they were all dead everything flashed through his mind Instinctually, he pulled back on the yoke but he knew No pilot would ever consider, for a moment, initiating a take-off unless he was absolutely certain the runway was clear. Van Zanten s decision to shove those power levers forward began a terrible and inevitable chain of horrendous events sending a enormous shock wave of loss and sorrow down through the decades. His two children never saw their dad again. Consider the hundreds dead, each with many close friends, wives and children, relatives and associates, all suffering from this captain s fateful decision. As the wrecked, tortured and doomed fuselage hurled itself toward its fiery destruction, he, in those last seconds, understood everything. The survivors and relatives of the dead have to live for the rest of their lives with their losses and, every hour of every day, they remember and are, in this sense, forever damaged.. the changes are profound and permanent, deep scars in the psyche. AFTERMATH, speaks to these things In a way, the accumulated grief and loss of the aftermath eventually eclipses the enormity of the horrendous event itself

6 PREFACE I flew commercial airliners for 42 years, logging over 22,000 hours. During that time, I ve trained literally, hundreds of pilots, both in actual aircraft and simulators. I ve been an IP (Instructor Pilot) like Captain Van Zanten, for many of those years and have made it a point to study the mind-set of airline pilots. I have flown over a hundred different aircraft and I m rated and instructed in the following aircraft; DC-3 CV-440, Convair 240, 340, 440 DC-6, 7 Boeing 707 Boeing 727 L-188 Lockheed Electra Astra Jet In my view, almost all aviation accidents are caused by inadequate training, poor maintenance or mechanical failure. The majority however are caused by human error, by the pilot or by the controller. Of course, weather plays a role but that s what we train for- how to survive in bad weather and how to avoid it. Accidents in aircraft usually result in high loss of life. These aluminum tubes, moving at high rates of speed are relatively fragile compared to cumulo-granite (rocks in clouds) and good old terra firma. Most of us are familiar with the NTSB (National Transportation Safety Board). These are the guys that go to any accident site involving American aircraft immediately on notice. In Tenerife, on March 27, 1977, two 747 s collided on the runway. The NTSB team arrived the very next day. Their job is to study the evidence and determine the probable cause. Once their investigation is complete, they publish their findings in what they call a Blue Book. There s a string of coincidences involved in this tragedy that, one by one, lead the two aircraft, like lambs to slaughter into a no-win situation wherein death awaits them. Earnest Ghan, wrote a flying book called Fate Is The Hunter., in the case of Tenerife, it seems to me that death was indeed the hunter. We will discuss this disturbing occurrence and focus our attention on what happened after the accident- the Aftermath. Robert J. Firth

7 CHAPTER 1 Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect. Captain A. G. Lamplugh, British Aviation Insurance Group, London. c. early 1930's The Tenerife airport disaster occurred on March 27, 1977 at 17:06:56 local time. Two 850,000 lb Boeing 747 passenger aircraft collided on the runway of Los Rodeos Airport (now known as Tenerife North Airport) on the Spanish island of Tenerife, one of the Canary Islands. On that fateful day, and at that moment in time, 583 human beings instantly ceased living. The carnage was spread over the tarmac in what was then and remains, the deadliest accident in aviation history. KLM Flight 4805 and Pan Am Flight 1736 were, along with other aircraft, diverted to Tenerife from Gran Canaria Airport after some whacked out terrorist detonated a bomb there. The sick bastards called in a threat of a second bomb forcing the authorities to close the airport while they searched for the remaining bomb- which, in the end, turned out to be a hoax. So many airplanes were diverted to the smaller Tenerife airport that the local controllers were forced to park many of them on the taxiways, thereby blocking them and further complicating the situation. While waiting for authorities to reopen Gran Canaria, a dense fog developed at Tenerife reducing visibility to a few hundred feet. When Gran Canaria reopened about 4:00 in the afternoon, the parked aircraft blocking the taxiways at Tenerife required both 747s to back- taxi on the only runway in order to get into position for takeoff. Due to the fog, neither aircraft could see the other, nor could the controller in the tower see the runway or the two 747s. As the airport didn t, at that time, have ground radar, the only means for the controller to identify the location of each airplane was via radio. As a result, several misunderstandings ensued, resulting in the KLM flight beginning its take off roll while Pan Am was still on the runway. The KLM 747, more than three quarters of a million pounds of aluminum, engines, fuel and passengers, was almost at take-off sped, kts, when the pilot finally saw the Pan Am jumbo through the fog 9 seconds away dead ahead - still on the runway- no room to stop- no room for anything

8 Van Zanten, the KLM Captain, hauled back on the yoke sending the giant aircraft skyward. He almost made it, another few seconds or less and he would have. The engines were at max power, pumping out almost 80,000 lbs of thrust or about 52,000 hp. The extreme deck angle drove the tail onto the runway, slowing the aircraft. KLM smashed into the Pan Am aircraft, ripping out KLM s right landing gear and spilling fuel everywhere. The resulting collision destroyed both aircraft, killing all 248 aboard the KLM flight and 335 out of 396 aboard the Pan Am aircraft. Sixty-one people aboard the Pan Am flight, including the pilots and flight engineer, miraculously survived the disaster. As the accident occurred in Spanish territory, that nation was responsible for investigating the accident. Investigators from the Netherlands and the United States also participated. The investigation would reveal the primary cause of the accident to be that the captain of the KLM aircraft attempted to take-off without clearance from Air Traffic Control. (human error) Throughout the writing of this book, I tried to place myself into the mind-set of Captain Van Zanten. I wanted to understand why did what he did and what I would do given the same situation. Do the same yourself. If you re a pilot or, even if you re not, consider carefully the circumstances and his actions; ask yourself- would you do the same? The investigation showed that the KLM captain certainly (positively) did not intentionally initiate a take-off without clearance. I m convinced, as were the investigators, that he fully believed he had clearance. Due to misunderstandings between his flight crew and ATC he believed the runway was clear- there can be absolutely no doubt about this! Dutch investigators naturally would place greater emphasis on this than their American and Spanish counterparts, but ultimately, KLM had to admit that their Captain was responsible for the accident. In the end, KLM, and their insurers, financially compensated the victims. Money however, is little comfort when a loved one is killed in a senseless tragedy. There is no compensation for such losses and the pain never really goes away. Money just seems the only thing we humans can think of to give- but it is so hopelessly inadequate. Time does not actually cure, it just dulls the ache. The accident had a huge influence on the industry, particularly in the area of communication. An increased emphasis was placed on using standardized

9 phraseology in ATC communication by both controllers and pilots alike, thereby reducing the chance for misunderstandings. The idea is to make some changes that hopefully, will help avoid similar accidents. As one of these changes, the word "takeoff" was removed from general usage, and is now only spoken by ATC when actually clearing an aircraft to take-off. Crew members are encouraged to challenge their captains when they believe something may be not correct. Captains are instructed to listen to their crew and evaluate all decisions in light of crew concerns. This concept would later be expanded into what is known today as Crew Resource Management. CRM training is now mandatory for all airline and used today by corporate pilots. For both planes, Tenerife was an unscheduled stop. Their destination was Gran Canaria International Airport (also known as Las Palmas Airport), serving Las Palmas on the nearby island of Gran Canaria. Both are in the Canary Islands, an autonomous community of Spain located in the Atlantic Ocean off the west coast of Morocco. Pan Am Flight 1736 had taken off from Los Angeles International Airport with an intermediate stop at New York's John F. Kennedy International Airport. The aircraft was a Boeing , registration N736PA. Of the 380 passengers, 14 had boarded in New York, where the crew was also changed. The new crew consisted of captain Victor Grubbs, First Officer Robert Bragg, and Flight Engineer George Warns; there were 13 other crew members. The same aircraft had operated the inaugural 747 commercial flight on January 22, KLM Flight 4805, a charter flight for Holland International Travel Group from the Netherlands, had taken off four hours before from Amsterdam s Schiphol airport. Its captain was Jacob Veldhuyzen van Zanten and the first officer was Klaas Meurs. The aircraft was a Boeing B, registration PH-BUF. The KLM jet had 14 crew members and 235 passengers, including 48 children and three infants. Most of the KLM passengers were Dutch; four Germans, two Austrians, and two Americans were also on the plane. Sadly, the 48 children never had a chance at life they, as all the KLM passengers, were incinerated in their seats After the aircraft landed at Tenerife, a Dutch tour guide named Robina van Lanschot, who lived on the island in Puerto de la Cruz and wanted to see her boyfriend that night, chose not to re-board the 747, leaving 234 passengers on board. Fate, maybe!

10 Events on both planes had been routine until they approached the islands. Then, at 1:15 pm, a bomb (planted by the separatist Fuerzas Armadas Guanches), a pack of wild-eyed, scraggly-assed, miserable terrorists exploded in the terminal of Gran Canaria International Airport. (circumstance or coincidence one) It had been preceded by a phone call warning of the bomb, and soon after another call came in claiming a second bomb was at the airport. The civil aviation authorities closed that airport after the bomb detonated and diverted all of its incoming flights to Los Rodeos, including the two Boeing 747 aircraft involved in the disaster. Upon contacting Gran Canaria airport, the Pan Am flight was informed of the temporary closure. Although the Pan Am crew indicated that they would prefer to circle in a holding pattern until landing clearance was given, the plane was diverted to Los Rodeos, along with the KLM flight. This led to the critical parking conditions at the smaller airport. In all, at least five large aircraft were diverted to Los Rodeos, a regional airport that could not easily accommodate them. The airport had only one runway and one major taxiway parallel to it, as well as several small taxiways connecting the main taxiway and the runway. While waiting for Gran Canaria airport to reopen, the diverted aircraft took up so much space that they were parked on the long taxiway, meaning that it could not be used for taxiing. Instead, departing aircraft would have to taxi along the runway to position themselves for takeoff, a common procedure known as a runway back-taxi. The Pan Am aircraft was ready to depart, but the KLM plane and a re-fuelling vehicle obstructed the taxiway to the active runway. The Pan Am aircraft was unable to maneuver around the fueling KLM to reach the runway and depart due to a lack of just 12 ft (3.7 m) of clearance. Many coincidences in this terrible accident favored death such that, once events began to unfold, it seemed that the players were ensnared, as it were, in a macabre and inextricable dance of destruction The reader can read coincidence like fate. In this case, perhaps they are interchangeable.?

11 Captain Van Zanten had decided to fully refuel at Los Rodeos instead of Las Palmas, apparently to save time. The re-fuelling took about 35 minutes. Another of the coincidences! Following the tower's instructions, the KLM aircraft was cleared to back-taxi the full length of runway 30, make a 180 turn to takeoff position. This is a bit difficult maneuver to perform with a 747 on a 45 m (150 ft) wide runway. (coincidence two) While KLM 4805 was back-taxiing on runway 30, the controller asked the flight crew to report when it was ready to copy the ATC clearance. Because the flight crew was performing the checklist, copying this clearance was postponed until the aircraft was in takeoff position on Runway 30- again, this is normal. During taxiing, the weather deteriorated and low-lying clouds now limited the visual range to about 300 m (1,000 ft). Legal or stipulated threshold for takeoff was 700 m (2,300 ft) visibility, as noted in the NOVA documentary and relayed by surviving Pan Am co-pilot Robert Bragg. In actual fact, if there is a close-by take-off alternate, the minimum forward visibility can legally be just sufficient to maintain visual contact with the runway center line. Another coincidence, ( number three) perhaps the worst of them all. Shortly afterward, Pan Am 1736 was instructed to also back-taxi, to follow the KLM aircraft down the same runway, to exit the runway by taking the "third exit" on their left and then down the parallel taxiway to the end. This would have had them in position behind KLM to take the duty runway after the Dutch aircraft had departed. Initially the Pan Am crew was unclear as to whether the controller had told them to take the first or third exit. The crew asked for clarification and the controller responded emphatically by replying: "The third one, sir; one, two, three; third, third one". The crew began the taxi and proceeded to identify the unmarked taxiways using an airport diagram as they reached them. The instructions to Pan Am to follow KLM down the runway was another coincidence ( number four), and, along with the fog, the fatal one! Based on the chronology of the cockpit voice recorder (CVR) and the distances between the taxiways (and the location of the aircraft at the time of the collision), the crew successfully identified the first two taxiways (C-1 and C-2), but their discussion in the cockpit never indicated that they had sighted the third taxiway (C-3), which they had been instructed to use. Mistake or coincidence number five?

12 There were no markings or signs to identify the runway exits. (Coincidence number six) This was a crucial omission on the part of the airport authorities as these exist are marked clearly all over the world and certainly were at that time. The Pan Am crew appeared to remain unsure of their position on the runway until the collision, which occurred near the intersection of the fourth taxiway (C-4). Pan Am's lack of visibility and runway exiting confusion contributed to a slow taxi speed, thereby causing the aircraft to remain on the runway longer than anticipated. (coincidence number seven) The angle of the third taxiway would have required the plane to perform a turn of approximately 145, which would lead counter-productively back toward the stillcrowded main apron. At the end of C-3 another 145 turn would have to be made to continue taxiing towards the start of the active runway. (see diagram above) Taxiway C-4 would have required two turns of just 35. A study carried out by the Air Line Pilots Association after the accident concluded that making the second 145 turn at the end of taxiway C-3 would have been "a practical impossibility", although the Dutch report stated that such a maneuver "could reasonably be performed". The official report from the Spanish authorities did not explain why the controller had instructed the Pan Am aircraft to use the third taxiway, rather than the sensible and easier fourth taxiway. Immediately after lining up, the KLM captain advanced the throttles (a standard procedure known as "spool-up", to verify that the engines are operating properly for takeoff) and the co-pilot, surprised by the maneuver, quickly advised the captain that ATC clearance had not yet been given. Captain Van Zanten responded, "I know that. Go ahead, ask." Meurs, the FO, then radioed the tower that they were "ready for takeoff" and "waiting for clearance". The KLM crew then received instructions which specified the route that the aircraft was to follow after takeoff. (the departure clearance) The instructions from the controller used the word "takeoff," but did not include an explicit statement that they were cleared for takeoff. Meurs read the flight clearance back to the controller, completing the read-back with the statement: "We are now at takeoff." Captain Van Zanten interrupted the co-pilot's read-back with the comment, "We're going." As noted in the NOVA documentary of the incident, the co-pilot sadly chose not to contradict or embarrass his superior a second time by stating that they still did not have the proper clearance to take off. Tragic error (coincidence eight and the close to the final one of the series) When in doubt

13 speak the hell up! In a cockpit environment, too often the FO (co-pilot) is too damm timid. The old-time captains often contributed to this by acting like pompous idiots, further intimating the co-pilot. The controller, who could not see the runway due to the fog, initially responded with "OK" (terminology which is nonstandard), which reinforced the KLM captain's misinterpretation that they had takeoff clearance. The controller's response of "OK" to the co-pilot's nonstandard statement that they were "now at takeoff" was likely due to his misinterpretation that they were in takeoff position and ready to begin the roll when takeoff clearance was received, but not actually in the process of taking off. The controller then immediately added "stand by for takeoff, I will call you," indicating that he had not intended the clearance to be interpreted as a takeoff clearance. He probably had not heard the captain's announcement that they were "going," since Van Zanten had said this to his fellow crew members and not transmitted it on the radio himself. A simultaneous radio call from the Pan Am crew caused mutual interference on the radio frequency, which was audible in the KLM cockpit as a three second long whistling sound (or heterodyne). This made the crucial latter portion of the tower's response audible only with difficulty by the KLM crew. The Pan Am crew's transmission, which was also critical, was reporting, "We're still taxiing down the runway, the Clipper 1736!" This message was also blocked by the heterodyne and inaudible to the KLM crew. Either message, if heard in the KLM cockpit, would have given the KLM crew time to abort its second takeoff attempt. What blocked these crucial transmissions? Whatever it was it was in this, the final coincidence, number nine! Due to the fog, neither crew was able to see the other plane on the runway ahead of them. In addition, neither of the aircraft could be seen from the control tower, and the airport was not equipped with ground radar. After the KLM plane had started its takeoff roll, the tower instructed the Pan Am crew to "report when runway clear." The Pan Am crew replied: "OK, we'll report when we're clear." On hearing this, the KLM flight engineer expressed his concern about the Pan Am not being clear of the runway by asking the pilots in his own cockpit, "Is he not clear, that Pan American?" Van Zanten emphatically replied "Oh, yes" and continued

14 with the takeoff, accelerating into eternity and into the hands of death, the hunter. The red star in the above diagram indicates the location of impact. According to the CVR, Captain Grubbs, captain of the Pan Am plane, spotted the KLM's landing lights just as the plane approached exit C-4, exclaiming, "Goddamn, that son-of-a-bitch is coming straight at us!" while the co-pilot Robert Bragg yelled, "Get off! Get off! Get off!". The Pan Am crew applied full power and took a sharp left turn towards the grass to avoid the impending collision. KLM Captain Van Zanten, already traveling too fast to stop, also attempted to avoid a collision by prematurely rotating his aircraft and attempting to climb, scraping the tail of the plane along the runway for 20 m (66 ft). As the KLM left the ground, its steep angle of attack allowed the nose gear to clear the Pan Am but the engines, lower fuselage and aft landing gear struck the upper right side of Pan Am's cabin at approximately 140 knots (260 km/h; 160 mph), ripping apart the center of the Pan Am jet almost directly above the wing. The right side engines crashed through the Pan Am's upper deck immediately behind the cockpit. The KLM plane was briefly airborne, but the impact with Pan Am sheared off the #1 (outer left) engine, and the #2 (inner left) engine had ingested significant amounts of shredded materials from Pan Am s aircraft. Van Zanten lost control, and his 747 went into a stall, rolling sharply, impacting the ground 150 m (500 ft) past the collision, sliding a further 300 m down the runway. The full load of fuel which had caused the earlier delay ignited immediately. The KLM crew saw what happened, they were alive and conscious as their tortured and disintegrating aircraft hurled toward their doom. A survivor of the Pan Am flight, John Coombs of Hawaii, said that sitting in the nose of the plane probably saved his life: "We all settled back, and the next thing an explosion took place and the whole side of the plane, was just torn wide open."

15 Both airplanes were destroyed. All 234 passengers and 14 crew members in the KLM plane died, incinerated in their seats. 326 passengers and 9 crew members aboard the Pan Am flight were killed, primarily due to the fire and explosions resulting from the fuel spilled and ignited in the impact. The other 56 passengers and 5 crew members aboard the Pan Am aircraft survived, including the pilots 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. Pan Am s engines were still running at takeoff power for a few minutes after the accident despite First Officer Bragg's attempt to shut them down.. The cockpit overhead, where the engine emergency shut down switches were located, had been destroyed in the collision- all control lines were severed, leaving no way for the flight crew to control them. After a short time running at full power the engines began to disintegrate, throwing engine parts at high speed, killing one of the flight attendants who had escaped the burning plane. Survivors waited for rescue but it did not come promptly as the firefighters were initially unaware that there were two aircraft involved and were concentrating on the KLM wreck some distance away in the thick fog. Eventually, most of the survivors on the Pan Am aircraft wings jumped to the ground some 10 below. ( photo above) Captain Veldhuyzen van Zanten was KLM's chief of flight training and the airline's preferred pilot for publicity such as magazine advertisements. As such, KLM management attempted to contact him to give public statements regarding the disaster before learning that he was the captain involved. Veldhuyzen van Zanten had, in fact, given the co-pilot on this ill-fated flight his 747 qualification check about two months before the accident.

16 Robert J. Firth The Author flew for 42 years for various airlines. He now lives in South Florida with his wife, two dogs and a cat. He spends his time sailing, flying traveling and writing. OTHER BOOKS BY THE AUTHOR FLYING THROUGH LIFE VANISHMENT THE BATTLE OF TOURS THE ENEMY WITHIN SCOUNDRELS