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Final Report Of Tenerife Disaster

Prepared By AASMAAN GROUP


(Group # 10)
Mohsin Azhar Shah (Group Leader) Saqib Mehmood Saad Shoaib Arslan Aslam BAM-9205 BAM-9207 BAM-9210 BAM-9234

oday's flight and cabin crews are much different than they were during the early years of commercial aviation. The captain of the aircraft was once considered "God" and his decisions were always the "right" ones. There was little, if any, input from the other pilots because they assumed the captain knew what he was doing. It was also considered somewhat disrespectful to question the decisions of a superior. Part of this thinking had its genesis from the military. At one time the military was the biggest producer of pilots, and along with military training came a good dose of machismo, ego, and autocratic decisionmaking processes (many military fighters were single pilot aircraft and therefore lacked the redundancy of, and decision inputs from, another crewmember). This attitude did not transfer well into civilian cockpits. The problems began to manifest in pilot error related airline accidents that claimed hundreds of lives. Recent analyses of aviation incidents and accidents throughout the world have also increasingly drawn attention to the contributing role of imperfect pilot-controller communications. Within this overall category (which also includes defective microphone techniques, non-use of standard phraseology, etc) the inability of some controllers and pilots to communicate in English with clarity and ease in non-routine situations (i.e. beyond the limits of standard phraseology) has been widely noted. The obvious conclusion to be drawn from this observation is that deficiencies in common language skills need to be overcome in addition to any improvements in the design of phraseology and its

applications. To this end our Study Group will mention one of the worst disasters in aviation accidents history, the collision of two Boeing 747s on the runway of the Tenerife Airport, resulting in a loss of 583 precious lives that involved both communication incompetency as well as lack of CRM along with some other latent factors.

Introduction
It is a bleak and uncomfortable irony that history's worst 'air' disaster happened to two fully serviceable aircraft, one of them not even in the air. Both were 747's, PH-BUF operated by KLM, and N736PA by Pan American. Both were carrying sun-seekers to Las Palmas airport on Grand Canary Island on 27 March 1977. Spains Canary Islands are situated 250 nautical miles off the Moroccan coast of North Africa. They have, for many years, been a popular tourist attraction for people wanting the best of weather any time of the year. Ancient Greek and Roman seafarers knew them as Fortunate Isles. Tenerife these days is served mainly by the airport in the south of the island, known as Reina Sofia, but years ago the Island was served by the airport up in the north of the island, known as Los Rodeos. Los Rodeos is still used today, but mainly only for domestic flights around the islands, or for cargo flights. The events leading up to this accident started on the Island of Las Palmas, which is also part of the Canary Islands.

Sunday March 27, 1977 should have been no different than any other spring day at Las Palmas Airport, with usual flights operating from all over Europe and the Atlantic. But at 1:15 that afternoon, the passenger terminal was thrown in to chaos and panic after a small bomb planted by a terrorist exploded in a florists shop in the terminal concourse. The authorities were warned of these fifteen minutes prior, so although the bomb caused much damage to the building, no one was killed. Islands independence group, speaking from Algeria in north, claimed responsibility for the explosion and hinted that a second bomb was planted somewhere in the airport. On hearing this, the local police had no option but to close the airport and not to take any further chances, pend a thorough search for the second device. All international incoming flights were then diverted to Tenerifes Los Rodeos Airport, which was less than one hour of flying time away. Summary of the Accident; Tenerife Crash, 1977 Date March 27, 1977 Time: 17:06 Type Runway collision caused by pilot error, runway incursion Site Los Rodeos Airport (now Tenerife North Airport) Total fatalities 583 Total survivors 61

harsh cold winters of Northern Europe for the sunny climates of the Canary Islands. They include 3 babies and 48 children. Most were Dutch, but there were also two Australians, four Germans and two Americans on the flight. In command of 4805 was Captain Jacob Veldhuyzen van Zanten, KLMs chief training Captain for Boeing 747s. Van Zanten had been flying since 1947, and had been a pilot with KLM since 1951, when as a 24 year old; he commenced duty as a first officer on the company DC-3s. He now had nearly 12,000 hours experience, with more than 1500 hours on the Boeing 747. Most of his time, however, was spent in simulators training other pilots. After its four hour trip from Amsterdam, across Belgium, France and Spain, PH-BUF touched down at Los Rodeos Airport at 1340 hrs GMT (1:10 p.m. local time). The fabled Canary Islands for fine weather, failed to live up to its reputation as those on board the KLM 747 were greeted with the sight of low cloud sand light rain, and light fog coming over the airport in the distance. The apron area, together with a section of the taxiway, was already occupied by diverted aircraft, so on landing, the controller directed the 747 to vacate the runway via the last intersecting taxiway and to park their aircraft on the holding area next to a Norwegian Boeing 737. Shortly afterwards a Dan Air 727 and a Sata DC-8 landed and were both directed to park in the same area.

Table 1: Summary of Tenerife Disaster

Aircraft Involved
Among the flights to be diverted was a charter trip flown by KLMs Boeing 747 -206B , with registration number PH-BUF and call sign of Rhine River. Operated by KLM as Flight KL4805 on behalf of the Holland International Travel Group, it had departed Amsterdams Schiphol Airport that morning at 9:31 a.m. local time, carrying 234 passengers escaping the

The wreckage of KLM Boeing 747 PH-BUF. (File Photo)

The other aircraft involved in the accident was of an air carrier from America, the Pan Am Boeing 747-121 with the registration number N736PA and a call sign of Clipper Victor. It was also diverted to the Los Rodeos Airport from Las Palmas. At 1:45 p.m. local time (a little more than a half hour after the arrival of KLM flight 4805) the Pan Am 747 landed and taxied to the same holding area, parking directly behind the KLM 747. N736PA, flight number 1736 had originated from Los Angeles, where 364 passengers , most of them of retirement age, had boarded Clipper Victor for the first stage of a charter flight to Gran Canaria.

Captain, Victor Grubbs, a 57 years old, 21,000 hour pilot sensed from the Spanish air traffic controllers instructions that Las Palmas was expecting to reopen before long and, knowing that his aircraft had more than adequate fuel reserves asked to possibly be put in a holding pattern until it did open. His requests were denied and therefore, N736PA had to land and join the rest of the waiting aircraft on the ground at Los Rodeos. By the time the two aircraft were ready to depart the weather had deteriorated somewhat to the fact that there was a good deal of thick fog descending on to the airport. At first the KLM passengers were not allowed to leave the aircraft, but after about twenty minutes they were all transported to the terminal building by bus. On alighting from the bus, they received cards identifying them as passengers in transit on Flight KL4805. Later, all passengers boarded KLM 4805 except the H.I.N.T. company guide, who remained in Tenerife. The Pan Am passengers stayed on their aircraft the whole time it was on the ground, only the doors being opened for them to get some fresh air and to take some photographs of what scenery they could see from the aircraft. When Las Palmas Airport was opened to traffic once more, the PA1736 crew prepared to proceed to Las Palmas, which was the flights planned destination. When they attempted to taxi on the taxiway leading to runway 12, where they had been parked with four other aircraft on account of the congestion caused by the number of flights diverted to Tenerife, they discovered that it was blocked by KLM Boeing 747, Flight 4805, which was located between PA1736 and the entrance to the active runway. The First Officer and the Flight Engineer left the aircraft and measured the clearance left by the KLM aircraft, reaching the conclusion that it was insufficient to allow PA1736 to pass by, obliging them to wait until the former had started to taxi.

The wreckage of Pan Am Boeing 747 N736PA.

Here they would join Royal Cruise Lines ship Golden Odyssey for a twelve day Mediterranean Highlights cruise. Departing LAX late the previous afternoon, they had flown directly to Kennedy Airport in New York. The aircraft was refueled, 14 additional passengers boarded, and there as a change of crew. After 90 minutes on the ground, the aircraft took off for Las Palmas. On approaching the Canaries six hours later the crew were informed of the temporary closure of the airport and diverted to Tenerifes Los Rodeos airport.

Chain of Incidents
This was unwelcome news to the crew, who had already been on duty for eight hours. The diversion would just add more hours to the trip, and there were also the passengers to consider most of them had already been on the aircraft for 13 hours as it was. Many were tired and majority of them were no longer young, so it was taking a greater toll on them. The Pan Am

First aircraft involved in accident Type: Boeing 747-121 Operator: Pan American World Airways Registration: N736PA Crew: Fatalities: 9 / Occupants: 16 Passengers: Fatalities: 326 / Occupants: 380 Total: Fatalities: 335 / Occupants: 396 Collision casualties: Fatalities: 248 Airplane damage: Destroyed Location: Tenerife-Norte Los Rodeos Airport (TFN) (Spain) Phase: Taxi (TXI) Tenerife-Norte Los Rodeos Airport (TFN) Departure airport: (TFN/GCXO), Spain Las Palmas-Airport de Gran Canaria (LPA) Destination airport: (LPA/GCLP), Spain Flight number: 1736 Second aircraft involved in accident Type Boeing 747-206B Operator KLM Tail number PH-BUF Crew 14 Passengers 234 Flight origin Schiphol Airport, Amsterdam, Netherlands Phase: Taking off (take off rolling) Location: Tenerife-Norte Los Rodeos Airport (TFN) (Spain) Tenerife-Norte Los Rodeos Airport (TFN) Departure airport: (TFN/GCXO), Spain Las Palmas-Airport de Gran Canaria (LPA) Destination airport: (LPA/GCLP), Spain Flight KL4805 Fatalities 248 (all) Survivors 0 (none)

Table 2: Aircraft Involved in Tenerife Disaster

Meteorological conditions
The weather deteriorated and low-lying clouds now limited the visual range to about 300 m. Legal or stipulated threshold for takeoff was 700 m visibility at the time of crash , as relayed by surviving Pan Am co-pilot Robert Bragg.

When both Pan Am 747 and KLM 747 started taxi on runway 12-30, the visibility was less than 200 m even runway was not visual to the tower but at time of crash visibility improves up to 700m.

The Disaster
KLM 4805 called the tower at 16:56 requesting permission to taxi. It was authorized to do so and at 16:58, was requested to backtrack on runway 12 for takeoff on runway 30. The tower controller first cleared the KLM flight to taxi to the holding point for runway 30 by taxiing down the main runway and leaving it by the (third) taxiway to its left. KLM 4805 acknowledged receipt of this message from the tower, stating that it was at the moment taxiing the runway, which it would leave by the first taxiway in order to proceed to the approach end of the runway 30. The tower controller immediately issued an amended clearance, instructing it to continue to taxi to the end of runway, where it should proceed to backtrack. The KLM flight confirmed that it had received the message, that it would backtrack, and that it was taxiing down the main runway. The tower signaled its approval, whereupon KLM 4805 immediately asked tower again if what they had asked it to do was to turn left on taxiway one. The tower replied in the negative and repeated that it should continue on to the end of the runway and then backtrack. Finally, at 16:59, KLM4805 replied, O.K. sir. At 17:02, the PA aircraft called the tower to request confirmation that it should taxi down the runway. The tower controller confirmed this, also adding that they should leave the runway by the third taxiway to their left. At 17:03:00, in reply to the tower controllers query to KLM 4805 as to how many runway exits they had passed, the latter confirmed that at that moment they were passing by taxiway C4. The tower controller told KLM 4805, O.K. at the end of runway make one eighty and report ready for ATC clearance. KLM 747 was instructed to backtrack on runway 12 making 180 turn to line up for take-off on runway 30. After lining up on runway 30, KLM 747 started its take off role.

Three minutes later at 17:02, The Pan Am flight 1736 was then cleared to back track runway 12 to follow the KLM aircraft. The Pan Am crews were told to leave the runway at the third taxiway; C-3 and report when leaving. The above diagram related to Tenerife Los Rodeos Airport is shown to display the tracks of both flights. In response to a query from KLM 4805, the tower controller advised both aircraft that the runway centerline lights were out of services. The controller also reiterated to PA1736 that they were to leave the main runway via the third taxiway to their left and that they should report leaving the runway. As the Pan American aircraft approached its turnoff in the thick fog, the First Officer noticed that the landing lights of the KLM aircraft looming through the fog. At first, they appeared stationary, but as several seconds passed, it became obvious that they were shaking. First Officer Bragg yelled to the Captain Get off, get off at which point full power was applied and the Captain turned the aircraft left towards the grass. They tried their level best to leave the runway as quickly as possible, but it was too late. Dutch Captain Van Zanten on the KLM aircraft desperately tried to rotate and climb out before the Pan Am aircraft, as was evidenced by a 3foot deep gash in the runway from the aircrafts tail. The KLM aircraft collided with the Pan Am airplane just after liftoff, and proceeded to climb to approximately 100 feet before losing control and crashing. The Pan Am aircraft immediately burst into flames and broke into

several pieces. The heat produced by the fire on Pan Am aircraft cleared the fog 1 Km around the crash scene. There were no eyewitnesses to the collision.

2. Why had Captain Grubbs been instructed to vacate the runway at taxiway C3, which would have taken him back towards the main apron, and not C4 which would have put him on the holding point for runway 30? 3. Why did the KLM crew not grasp the significance of the Pan Am aircrafts report that it had not yet cleared the runway, and would report again to the tower when it did?

A diagram showing the orientation of runways and taxiways at Los Rodeos Airport, Tenerife, as well as the location of the debris field following the accident.

Investigation
About 70 crash investigators from Spain, the Netherlands, the United States, and the two airline companies (Pan Am and KLM) were involved in the investigation. KLM CVR Evidences showed that there had been misinterpretations and false assumptions. At 4:58 p.m. on March 27, 1977, when transcript begins, the KLM and Pan Am 747s are both in queue to taxi down the runway and turn around for takeoff. The KLM aircraft is ahead of the Pan Am aircraft (see Figure below). Some back-andforth occurs initially about what Air Traffic Control considers the best way to get the KLM plane into position for takeoff, but ultimately the controllers decide to send it taxiing straight down the runway. This portion of the transcript comes from the KLM cockpit voice recorder.

Injuries and Fatalities to persons abroad KLM 4805 None of the 234 passengers and 14 crew members survived the accident. Damage to KLM Boeing 747 PH-BUF The aircraft lifted off briefly before the collision with the Pan Am aircraft, but due to severe damage caused on impact, fell back to the runway 250 yards after impact. The aircraft was totally destroyed by fire. Injuries and Fatalities to persons aboard PA1736 Of the 16 crew on board, there were 9 fatalities, 7 survivors +2 company employees who were sitting in the cockpit jump seats. Of the 317 passengers on board, 61 survived the accident, but 9 died of their injuries at a later date. Damage to Pan Am Boeing 747, N736PA The aircraft was written off in the accident due to the severe impact caused by the KLM aircraft, and the resulting fire. Between 15 and 20 tons of kerosene was later recovered from the one remaining wing that survived the fire. There were many questions regarding the cause of this accident; 1. Why had Dutch Captain Van Zanten commenced takeoff without the ATC clearance?

Analysis of the CVR transcript showed that the KLM pilot was convinced that he had been cleared for takeoff, while the Tenerife control tower was certain that the KLM 747 was stationary at the end of the runway and awaiting takeoff clearance. It appears KLM's co-

pilot was not as certain about take-off clearance as the captain. In the final minute before the collision, key misunderstandings occur among all the parties involved. And in the end, the KLM pilot initiates takeoff, even though Air Traffic Control has not issued the proper take off clearance, he only issued the route clearance or SID (Standard Instrument Departure) clearance to the aircraft, as shown from the recording written below; 1705:41.5 KLM 2: Wait a minute; we don't have an ATC clearance. KLM 1: No, I know that. Go ahead, ask. 1705:44.6 KLM RT: Uh, the KLM 4805 is now ready for takeoff and we're waiting for our ATC clearance. 1705:53.4 APP: KLM 8705, uh you are cleared to the Papa beacon. Climb to and maintain flight level 90 ... right turn after takeoff proceed with heading 040 until intercepting the 325 radial from Las Palmas VOR. 1706:09.6 KLM RT: Ah, roger, sir, we're cleared to the Papa beacon flight level 90, right turn out 040 until intercepting the 325, and we're now (at takeoff) . 1706:11.08: [Brakes of KLM 4805 are released.] 1706:12.25 KLM 1: Let's go ... check thrust. 1706:14.00: [Sound of engines starting to accelerate.] 1706:18.19 APP: Okay . Why Air Traffic Control would say "okay" after KLM has said it is taking off is unknown. Perhaps, the official investigation noted, the controller thought that KLM meant "we're now at takeoff position." But the problem is compounded in the moments immediately following, when both Air Traffic Control and Pan Am RT speak simultaneously. This causes a shrill noise in the KLM cockpit that lasts for almost

four seconds and makes the following three communications hard to hear in the KLM cockpit: 1706:20.08 APP: Stand by for takeoff ... I will call you. PA1: No, uh. PA RT: And we are still taxiing down the runway, the Clipper 1736. From the voice recorder of KLM, it is evident that the captain was aware that the ATC clearance was not received yet and he allowed himself normal time for it but he was in hurry, he want to leave the airport as soon as possible. He started take off role, while co pilot was reading back the clearance. Already supplied information was asked by the captain from copilot. It indicates some form of absent mindedness. Perhaps because of the KLM pilot's very senior position, neither the copilot nor flight engineer questioned the pilot again, and the impact occurs about 13 seconds later. Pan Am CVR With the KLM aircraft now taxiing down Runway 12, Air Traffic Control turns its attention to Pan Am 1736. The controllers instruct the plane to travel down the runway and then exit it using one of the transverse taxiways. This would clear the way for the KLM plane to take off. This portion of the transcript comes from the Pan Am cockpit voice recorder. From the voice recorder of Pan Am aircraft, it shows that during the taxi, the Pan Am crew was highly irritated caused by refueling of KLM aircraft. Subsequent to the crash, first officer Robert Bragg, who was responsible for handling the Pan Am's radio communications made public statements which conflict with statements made by the Pan Am crew in the official transcript of the CVR. In the documentary Crash of the Century (produced by the makers of Mayday), he stated he was

convinced the tower controller had intended they take the fourth exit C-4 because the controller delivered the message to take "the third one, sir; one, two, three; third, third one" after the Pan Am had already passed C-1 (making C-4 the third exit counting from there). The CVR shows unequivocally that they received this message before they identified C1, with the position of the aircraft somewhere between the entrance and C-1. Also, in a Time article, Bragg stated that he made the statement "What's he doing? He'll kill us all!" which does not appear in the CVR transcript.

1702:33.1 PA 1: I don't think they have takeoff minimums anywhere right now. 1702:39.2 PA 1: What really happened over there today? 1702:41.6 PA 4: They put a bomb (in) the terminal , sir, right where the check-in counters are. 1702:46.6 PA 1: Well, we asked them if we could hold anduhI guess you got the word, we landed here... 1702:49.8 APP: KLM 4805 taxiwaysahdid you pass? how many

F/O of Pan Am was convinced that the controller had intended that they take the fourth exit C4 because it was the most appropriate taxiway for Pan AM 1736. However, the controller delivered the message to take "the third one, sir; one, two, three; third, third one. 1701:57.0 PA RT: Tenerife, the Clipper 1736. 1702:01.8 APP: Clipper 1736, Tenerife. 1702:03.6 PA RT: Ahwe were instructed to contact you and also to taxi down the runway, is that correct? 1702:08.4 APP: Affirmative, taxi into the runway andahleave the runway third, third to your left, [background conversation in the tower]. 1702:16.4 PA RT: Third to the left, okay. 1702:18.4 PA 3: Third, he said. PA?: Three. 1702:20.6 APP: Third one to your left. 1702:21.9 PA 1: I think he said first. 1702:26.4 PA 2: I'll ask him again. 1702:32.2 PA 2: Left turn.

1702:55.6 KLM RT: I think we just passed Charlie 4 now. 1702:59.9 APP: Okay ... at the end of the runway make 180 [degree turn] and report ahreadyahfor ATC clearance. [Background conversation in tower] 1703:09.3 PA 2: The first one is a 90-degree turn . 1703:11.0 PA 1: Yeah, okay. 1703:12.1 PA 2: Must be the third ... I'll ask him again. 1703:14.2 PA 1: Okay. 1703:16.6 PA 1: We could probably go in, it's ah... 1703:19.1 PA 2: You gotta make a 90-degree turn. 1703:21.6 PA 1: Yeah, uh. 1703:21.6 PA 2: Ninety-degree turn to get around this ... this one down here, it's a 45 . 1703:29.3 PA RT: Would you confirm that you want the Clipper 1736 to turn left at the third intersection? ["Third" drawn out and emphasized] 1703:35.1 PA 1: One, two.

1703:36.4 APP: The third one, sir, one, two, three, third, third one. 1703:38.3 PA: One two (four). 1703:39.0 PA 1: Good. 1703:39.2 PA RT: Very good, thank you. 1703:40.1 PA 1: That's what we need right, the third one. Based on the Pan Am cockpit voice recording, investigators determined that the Pan Am flight crew saw the KLM coming at them out of the fog about nine seconds before impact. The Pan Am captain says "There he is ... look at him! Goddamn, that [son of bitch] is coming!" and his copilot yells "Get off! Get off! Get off!" The Pan Am pilot guns the engines but it's too late. At 1706:47.44, the KLM pilot screams, and the collision occurs.

Findings
Probable causes The investigation concluded that the fundamental cause of the accident was that Captain Van Zanten took off without takeoff clearance. The investigators suggested the reason for his mistake might have been a desire to leave as soon as possible in order to comply with KLM's duty-time regulations, and before the weather deteriorated further. Other major factors contributing to the accident were: The sudden fog greatly limited visibility. The control tower and the crews of both planes were unable to see one another. Another finding was the simultaneous radio transmissions, with the result that neither message could be heard. The following factors were contributing but not critical: considered

Use of ambiguous non-standard phrases by the KLM co-pilot ("We're at take off") and the Tenerife control tower ("OK"). The Pan Am aircraft had not exited the runway at C-3. The Tower Controller The investigation shows that the controller was on duty for the whole day and had to unusually handle the traffic load. The controller has less experience about the maneuverability of the Boeing 747 regarding its limited turn to assigned taxiwayC-3. There was transmission of football match at tower on the radio. This match transmission is heard from the voice recorder of the KLM and there was a shrill noise when tower controller and Pan Am or KLM flights communicate simultaneously. The airport was (due to rerouting from the bomb threat) forced to accommodate a great number of large aircraft, resulting in disruption of the normal use of taxiways. No CRM in KLM cockpit Perhaps because of the KLM pilot's very senior position, neither the copilot nor flight engineer questioned the pilot again, and the impact occurs about 13 seconds later. Human Factor Involved in the accident In this accident human factor is very much involved like; The KLM captain was in hurry and in absent mindedness condition. He initiates takeoff role without ATC clearance.

The Pan Am crew was highly irritated due to extra delay, they were about to leave the runway by C-4 but it was told the crew to leave the runway via C-3. The controller had work load and was on duty the whole day. A football match was listened on radio at tower. There was shrill noise in communication between both aircraft and control tower. Some Latent (Hidden) Conditions Here were some latent conditions available that led to the accident: Bomb Blasts at Las Palmas Airport There was a bomb blast at Las Palmas Gran Canaria Airport so due to the warning of second bomb, airport was closed and all traffic was diverted to Tenerife North Los Rodeos International Airport. Diversion to Tenerife Airport Diversion of a number of flights to the Tenerife North Los Rodeos International Airport was a contributing factor in the development of a distressful environment. RWY centre line lighting out of service Crew of both KLM and Pan Am was informed about unserviceable of runway centerline lights. Airport saturation It was small airport and it was saturated with too many flights even the aircraft are parked on taxiways. Transmission of Football match on radio, at tower Radio transmission of foot ball was at tower and when controller communicated, a shrill noise was listened in the cock pit of both Flights

Dutch response
The Dutch authorities were reluctant to accept the Spanish report blaming the KLM captain for the accident. The Netherlands Department of Civil Aviation published a response that, whilst accepting that the KLM aircraft had taken off "prematurely", argued 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. 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.( this was not mentioned in the Spanish report) 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 (this message was not audible to the control tower or KLM crew due to simultaneous cross-communication); If the Pan Am aircraft had not taxied beyond the third exit, the collision would not have occurred.

Recommendations
The KLM pilot should not have commenced take off until accepting proper clearance from tower. Pan Am crew should have followed the ATC instructions properly and should have vacated the runway via C-3.

Pilots and traffic controllers should use standard phraseology. There should be proper CRM (Cockpit Resource Management) in the cockpit of every flight. After the disaster at Tenerife, officials implemented standard aviation phrasing worldwide to avoid confusion in the future.

Tenerife Memorial March 27, 1977 was inaugurated at the Mesa Mota March 27, 2007. The monument was designed by Dutch sculptor Rudi van de Wint.

Conclusion
Although the Dutch authorities were initially reluctant to blame Captain Van Zanten and his crew. The airline ultimately accepted responsibility for the accident. KLM paid the victims or their families, compensation ranging from $58,000 to $600,000. As reported in a March 25, 1980, Washington Post article, the sum of settlements for property and damages was $110 million (an average of $189,000 per victim, due to limitations imposed by European Compensation Conventions in effect at the time).

International Tenerife Memorial March 27, 1977, Mount Mesa Mota, Tenerife, Canary Islands

Memorials
A Dutch national memorial and final resting place for the victims of the KLM plane is located in Amsterdam, at Westgaarde cemetery. There is also a memorial at the Westminster Memorial Park and Mortuary in Westminster, California.

Monument in Amsterdam

Westgaarde

Cemetery,

The 30th anniversary marked the first time that Dutch and American next of kin, and aid helpers from Tenerife, joined in international commemoration service held at the Auditorio de Tenerife in Santa Cruz; the International