Accident Analysis

6 June 2016

In March 27, 1977, one of the World’s worst civil aviation disaster happened in the Los Rodeos Airport, Tenerife (in the Canary Islands). Earlier that day a bomb explosion in the terminal building of Las Palmas airport took place which required aircrafts to divert in Tenerife airport. A runway collision took place between the two Boeing 747 airplanes (KLM and Pan American). In this crash, a total of 583 people were killed while 64 people from Pan Am aircraft survived the disaster. In the overview of the accident, human error and the CRM elements involve in the mishap were analyzed to identify the weakness or the factors that contributed to the catastrophic event.

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The KLM aircraft, a charter flight has landed 45 minutes ago. It has 248 people on-board including the 14 crew members. The Dutch captain of the KLM aircraft had ignored the concerns of his crewmembers. The feeling of tension or pressure for the captain increased considering that the Dutch regulation on time is very strict.

As a result of these the KLM captain was took off prematurely without clearance. The KLM captain was in a haste to avoid the risk of further interruptions and delay. The captain became complacent and relaxed that he believed taking off immediately was the best decision to do. Due to relatively high stress level the Dutch captain became imprudent and disregarding of the concern of his crewmembers.

The assertiveness of the first officer was also a factor on why the captain had not been stop to take off without complete ATC clearance. The fact that the captain has more authority than the first officer gave him the choice to make final decisions. The first officer told the captain to wait as they still not have an ATC clearance. The captain then asked him to request again but while the first officer was still repeating the clearance the captain opened the throttle and started to take off. The co-pilot didn’t become assertive enough to remind the captain that they still have to wait for further instruction before taking off. Instead, the co-pilot accepted the condition that they were already taking off and followed the captain.

The ATC communication system and blocked transmission affected and contributed in the process or the turn of the events. There were certainly some inadequacies in the ATC equipment of Tenerife airport. Added to that the airport was crowded and had unusual workload that day.

The absence of ground radar together with the problem in visibility in the airport due to heavy fog made the situation even worst. The runway center lights were out of service also during that time. The runway at Tenerife airport has been used as a taxiing lane for these large aircrafts giving them higher risk for accidents. The ATC has poor situation awareness and also poor communication with aircrafts that aggravated the situation.

Certainly there are many factors that lead to this accident in Tenerife. The accident could not be blame for just one cause only but due to a string of related events and deficiency. There were human factors in all the systems involve. The KLM was the primary cause of the accident since the aircraft has taken off without take-off clearance. The Pan Am aircraft had also made a mistake by missing the taxiway. The ATC also have problems in their communication system as there are some transmission interruptions or background noises that contribute to their poor performance.

 Another human factor in the incident to be considered is the fatigue brought by the situation. Much earlier the captain was angry and the passengers of Pan Am were already unhappy of the situation which required them to transfer to Tenerife airport. The KLM captain on the other hand was reported nervous and uneasy of the situation since he knew that it was forbidden for them to exceed their hour quotas. The fatigue that started from the bomb explosion and the inconvenience to land in Las Palmas airport had affected everyone.

The accident could have a greater chance to be prevented if the two aircrafts have made the right decisions and have double check everything. If the Tenerife airport could have been well equip and prepared for that situation it would not have happened. This event has opened the minds of aviation system to improve intensively the CRM and airport facility.


“Tenerife Crash March 27th, 1977” (2008) I001 . . Retrieved September 20, 2008, from

“Human Factors Still The Current Challenge Of The Aviation Industry” (2008) CulturAiles: Human Factors In Air Safety. Retrieved September 20, 2008 from


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