Austin Smith 1

Austin Smith

Dr. Peters

EAM 4013-001

November 9, 2016

Case Study 3

As an emergency manager, you have no idea when an accident or a disaster is going to

happen. They can come at any given time. You can prepare for them, but in reality you cant

always fully prepare for them. In this case, on March 27, 1977, Two flights were taking flight

like a normal day, but with inconsistencies within the flight, they both collided head on with each

other midflight to their destinations. One flight was KLM flight 4805, a 747 that left Amsterdam

and was headed to the Canary Islands. The other flight was Pan Am flight 1736, a 747 that left

Los Angeles and New York that was also headed to the Canary Islands. This crash is considered

the deadliest airplane accident in history. The event killed 583 passengers (Weick, 1990).

Now researchers were trying to figure out what possibly went wrong in this scenario

when the two planes collided. Knowing how advanced our technology is in this modern day,

how could two huge planes end up colliding together. They determined that miscommunication

played a huge part in this accident. Both planes were headed to the Canary Islands, but both

flights were changed to go to Los Rodeos airport because the original destination was closed due

to a bomb threat. This is when the miscommunication happened. As both airplanes were sitting

at the airport and it the bomb threat was lifted at the original destination, air traffic control gave

the okay to KLM that it could taxi the runway in order to prepare for takeoff. KLM was taxying
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to the other side of the runway to take off towards the direction it came. As KLM was making its

way down the runway. Air traffic control instructed Pan am flight to follow KLM, but turn down

another channel in order to clear the runway so KLM could take off. First off, looking at the

recordings of the instructions, Pan Am flight was getting confused on which channel they needed

to take to clear the runway which probably made air traffic control a little confused. In the

meantime, air traffic control was instructing Pan am down the runway, they were also instructing

flight KLM in giving the go ahead to take off. The weather became an obstacle at this point. A

heavy fog set in over the runway so the length of visibility was definitely hindered. KLM was

given the go ahead to take off even though Pan Am was still in the runway and the two planes

ended up colliding (Krock, 2006).

Researchers have concluded that Tenerife was at a stressful state when the two planes had

to suddenly land there in order to wait till the bomb threat was lifted. It isnt a big airport and it

wasnt used to getting much traffic. They are also not used to dealing with two Boeing 747s

trying to take off in a short notice. Researchers concluded that there are several events that put

the workers of the Los Rodeos airport in stress. One of the events was the stress of doing a good

job at the stressful time. The researchers knew that the workers of the airport were under stress

from their higher authorities in order to do a good job in instructing these planes to get where

they need to go. They felt like this could have been a reason why the miscommunication was not

that great out of nervousness of getting in trouble with what they were saying.

Conducting more research, researchers found out that KLM flight 4805 was under a lot of

stress. The flight had stress coming from Dutch Law in Amsterdam, difficult maneuvers in the

flight and the airport, and the unpredictable weather at the time. The researchers also realized

that the flight happened at the end of March which coincides that the flight crew of the KLM was
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under stress because they were near the limits of time that they were allowed to fly in one month.

The reason why there is so much stress on that is because the Dutch Law demands work and rest

regulations for flight crews and puts strict limits on flight and duty time. The stress came from

the crew thinking of the possibility of fines, imprisonment, and losing their pilot licenses. They

were informed that if left Las Palmas airport by a certain time, then they could make it back to

Amsterdam legally. So thats probably the reason why they were in a rush to leave when they

didnt know for sure the runway was for sure clear. The stress of maneuver difficulty came from

trying to turn around the plane on a narrow runway without getting stuck or wasting time that

they could be flying to their destination. According to the geography of the area that the Los

Rodeos airport is at, they are 2073 feet above sea level meaning that clouds become a big

problem that this airport. The cloud became a problem in the accident because flight KLM could

see it coming down the runway not knowing that flight Pan am was on the other side coming in

their direction. The airport was under stress too. They had Pan Am flight wanting to leave the

airport immediately, but the flight had to wait for KLM to take off first. Pan Am was blocked for

two and a half hours. This left the crew of Pan Am mad and didnt help the situation at all.

I think the most important stress factor came from the air traffic control at the airport.

The air traffic control tower was in the most stress. They werent just trying to deal with two

planes that needed to leave in order to get to their destination in a decent amount of time, but

they were also short staffed that day. Back to my original point, the airport is not used to dealing

with Boeing 747s because its a small airport. So this was something new to the airport and

really didnt know how to deal with it efficiently. The air traffic control center at an airport is a

crucial element to these flights that come in and out. The air traffic didnt have the technology

that it needed in order to provide better services to these planes or any plane in general. The air
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traffic control center didnt have a ground radar to determine where the planes were at. If they

had this, then maybe they would have seen the accident coming a long time before it actually

happened. That day, the centerline lights of the runway were not operating so the runway was not

clearly visible especially with the unpredictable weather of the area. With the cloud coming in

that hindered everyones vision at the time, the air traffic control could have probably had a

better visual on the runway from their point of view and if the lights were on, then maybe they

could have potentially seen Pan Am coming down the runway. The air traffic control was also

talking to these flights in English when English is a second language to them. Their

communication skills could have been better if they had somebody working in the control center

that could speak better English to conduct instructions more efficiently. Another problem that the

air traffic control had was that their normal routine for routing planes on the runway was

disrupted because they had planes parked in areas that they would normally use (Weick, 1990).

Especially for a small airport, the extra routes that they had were probably too small for these

747s to use.

How can we mitigate this accident? The first action that can be taken is to give the airport

more technology that can recognize airplanes in the area. For instance, since they didnt have any

ground radar. If you give the air traffic control a ground radar in the control room, then maybe it

will be easier for them to watch airplanes and to instruct them more efficiently. Knowing, that

the airport isnt that big at all and that they dont have much big traffic come in, they can

mitigate the runway to make it wider so there is more room to work with. During the incident,

the air traffic control center couldnt use the normal routes that they make planes take because

there were already planes parked in the areas where they needed to go. They can mitigate this

problem by building hangers and parking the planes that arent being used there in the meantime
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to prevent an accident occurring. Another thing they can mitigate is the air traffic control

workers and what languages they can speak. The airport could do research on what main

languages come into the airport and hire linguist or operators that can easily communicate in

these languages because during this accident, the workers werent fluent in English and it created

problems. One last thing that can be mitigated is the workplace. The workplace can be mitigated

to be more of stress-free environment so they can perform their duties in a more efficient

manner. They can do this by making a more positive environment by building trust in the

workplace and developing relationships among people. Even the boss can be included in these

mitigation strategies.

Once these things become mitigated, the airport could see an increase in work

productivity and safety in maneuvering the planes around the runway. They can also see a

decrease of stress in the workplace. Once these things become mitigated, they can guarantee that

an accident on that degree between the two flights will not happen again. Little accidents will

happen. No one can be fully prepared for an accident to happen. But by mitigating these things,

the airport can see a decline in accidents and an increase in workplace productivity and

efficiency.
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References

Krock, L. (2006, October 17). The Final Eight Minutes. Retrieved from NOVA:

http://www.pbs.org/wgbh/nova/space/final-eight-minutes.html

Weick, K. E. (1990). The Vulnerable System: An Analysis of the Tenerife Air Disaster. Journal

of Management, 571-593.