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Clipper Victor
Tenerife, Spain
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Secretary of Aviation
Report On Tenerife Crash
KLM,
B-747, PH-BUF and Pan Am B-747 N736 collision at Tenerife Airport Spain on 27
March 1977
Report
dated October 1978 released by the Secretary
of Civil Aviation , Spain
Prepared
by Harro Ranter
Source:
Aircraft Accident Digest (ICAO Circular 153-AN/56) page 22-68.
2.-
ANALYSIS AND CONCLUSIONS
2.1
Analysis
On 27 March 1977, a bomb exploded in the terminal building of Las Palmas Airport
(Canary Islands) , and for this reason the passenger terminal was evacuated. As
there had been a threat of a second explosion, much of the traffic arriving at
Las Palmas Airport was diverted to that of Los Rodeos on Tenerife Island. For
this reason, the parking area at the latter airport was crowded with airplanes.
The
RLM Boeing 747, PH-BUF, arrived at Los Rodeos Airport at 1338 and was parked at
the end of the taxi runway next to a Braathens Boeing 737 (SAFE). Subsequently,
a Sterling Boeing 727, a SATA DC-8 and the Pan American 747, N736, were parked
in the same area.
The
Pan Am Boeing 747, which arrived at Los Rodeos Airport at approximately 1415,
was parked on the taxi runway next to the above-mentioned Braathens Boeing 737,
Sterling Boeing 727, SATA DC-8 and the KLM Boeing 747, PH-BUF, which had arrived
at Los Rodeos Airport at 1338.
Once
Las Palmas Airport had been reopened, the Pan Am N736 airplane called the tower
requesting permission to start up its engines; in reply, it was told that there
was no ATC delay, but that it could have problems taxiing on account of the KLM
airplane which was ahead of it, and that taxiing on the taxiway would not be
possible on account of the aircraft congestion on the main apron.
Indeed,
when the time came to taxi, the Pan Am airplane was forced, on account of the
position of the KLM airplane which was blocking its way, to wait for the
latter’s departure. The three other airplanes parked there had already departed.
Approximately
one hour later, KLM 4805 requested an estimated departure time. They said that
they needed to refuel and that this would take approximately 30 minutes. They
filled up with 55 500 L, while the passengers remained on board. Later the KLM
airplane requested permission to start up its engines, and then clearance to
taxi.
It
was cleared to taxi towards the holding position of runway 12 and to change its
surface frequency of 118.7 to the approach frequency of 119.7.
A
few minutes later, the Pan Am airplane called again in order to request
clearance to start up its engines, and was cleared to do so.
If
we keep in mind that the Tenerife-Las Palmas flight is one of about 25 minutes
duration, the taking on of 55 500 L of fuel leads us to suppose that the KLM
captain thereby wished to avoid the difficulties of refueling in Las Palmas,
with the resulting delay, because a great number of airplanes diverted from
Tenerife would be going there later. The aircraft could, in fact, have returned
to Amsterdam with the fuel it had without refueling in Las Palmas.
The
conversations-which took place between KLM 4805 and the control tower until the
airplane started to taxi on the main runway were as follows. The times are those
taken from the KLM CVR.
Time
Source Content1658:14.8 KLM 4805 Approach KLM four. eight zero five on the
ground in Tenerife.1658:21.5 APP KLM – ah- four eight zero five Roger.1658:25.7
KLM 4805 We require back track on one two for take-off runway three
zero.1658:30.4APPO.K. foureight.zero five… taxi… to the holding position
runway three zero taxi into the runway and – ah – leave runway (third) to your
left.1658:47.4KLM 4805Roger, sir, (entering) the runway at this time and the
first (taxiway) we, we go off the runway again for the beginning of runway three
zero.1658:55.3APP O.K. KLM eight zero – ah – correction four eight zero five
taxi straight ahead – ah – for the runway and – ah – make – ah – back
track.1659:04.5 KLM 4805 Roger, make a "back track"1659:10.0 KLM 4805
KLM four eight zero five is now on the runway.1659:15.9APP Four eight zero five
roger.1659:28.4KLM 4805 Approach, you want us to turn left at Charlie one,
taxiway charlie one?1659:32.28APP Negative, negative, taxi straight ahead – ah –
up to the end of the runway and make "back track".1659:39.9KLM 4805
O.K., sir.At 1703:14.4, KLM 4805 asked the tower controller if the runway centre
lights were in service because, as the weather conditions were becoming worse,
he wished to have this information in connection with the minimum required
take-off conditions.
At
1704:58.7, the tower controller, after having checked, replied that the runway
centre lights were out of service, while he also passed on this information to
the PAA Clipper 1736.
At
1705:27.08, KLM 4805, which was already at the approach end of runway 30,
completed the turn in order to face in the direction for take-off.
From
this point on, see the diagram (Appendix 5) showing the time correlation between
the tower, the KLM 4805 and the Clipper 1736 CVR tapes, as well as the data
obtained from the KIM 4805 DPDR during the last 88 seconds.
At
1705:27.98, the engine braking begins and lasts for 2.54 seconds.
At
1705:36.7, the co-pilot finishes the take-off check-list and at 1705:41.22
(67.81 seconds before the impact), a slight forward movement due to opening of
the throttle is observed (increase of continued EPR in the four engines). At
1705:41.5, the co-pilot says: "Wait a minute, we don’t have an ATC
clearance." To which the captain replies, "No; I know that, go ahead,-
ask."
At
1705:44.6, KLM 4805 tells the control tower: "Ah – the KLM four eight zero
five is now ready for take-off, and we’re waiting for our ATC clearance."
This message ended at 1705:50.77. This communication was heard in the PAA 1736
cockpit.
At
1705:53.41, the controller gave KLM the following ATC instruction: KLM eight
seven zero five – uh – you are cleared to the Papa Beacon, climb to and maintain
flight level nine zero .. right turn after take-off proceed with heading zero
four zero until intercepting the three two five radial from Las Palmas VOR."
The message ended at 1706:08.9. At 1706:07.39, i.e.i 0.7 seconds before the
message ended, the aircraft captain said, "Yes", and.44.31 seconds
before the impact the nos. 3 and 4 engines Slightly increased their EPR.
At
1706:09.61, the co-pilot repeated the ATC instructions given by the tower
controller, at the following times and as follows:
Time
Source Content1706:09.61 KLM 4805 (RD
2)Ah- Roger, sir, we are cleared to the Papa Beacon flight level nine zero,
right turn out zero four zero until intercepting the three two five. We are now
at take-off. At 17:17.79, the co-pilot’s repetition of the ATC instructions
ended.
At
1706:11.08, the brakes of KLM 4805 were released. At 1706:12.25, the aircraft
captain said, "Let’s go … check thrust", ending this sentence at
1706:16.11.
The
following was ascertained from the DFDR data:
�
1706:11.70
(37.33 seconds before impact): it was deduced from the LONG that the airplane
began to move with longitudinal acceleration.
�
1706:13.99
(35.04 seconds before impact): the EPR have risen above the figures for idling
(1.12-1.12-1.14-1.14).
�
1706:14.94
(34.09 seconds before impact): the start of change of course was observed from
the HEAD.
�
1706:17.17
(31.86 seconds before impact): from the VANE it can be ascertained that lift had
begun. Value reached was 6.800. Air speed was increasing (46.41). Direction
straightened out.
From
everything that happened during this time, it is seen that while the first
officer was repeating the ATC instructions given by the controller, KLM 4805 had
already started its ground run, while at 1706:14.00, moreover, the sound of
engines starting to accelerate is observed.
At
1706:18.19, the controller replied to the read-back of his ATC clearance in the
following way: "O.K.", and at 1706:20.08, i.e. 1.89 seconds later,
added: "Stand by for take-off … I will call you," ending said
message at 1706:21.79.
During
this time, at 1706:19.35, the KLM 4805 take-off EPR had already been reached and
stabilized (1.39 to 1.42).
Simultaneously,
in the Pan Am cockpit, on hearing this conversation, the Pilot says "No
uh", and the co-pilot says, "and we are still taxiing down the runway,
tire Clipper one seven three six". This communication caused a shrill noise
in the KLM cockpit, which started at 1706:19.39 and ended af�1706:22.06.
At
1706:25.47, the tower controller confirmed reception of the Pan Am message in
the following way: "Papa Alpha one seven three six report runway clear.’.’
This was audible in the KLM cockpit. The message ended at 1706:28.89.
At
1706:29.59, the PAA replied: "O.K., will report when we’re clear."
This reply was audible in the KLM cockpit.
The
control tower replied, "Thank you", and then the following sentences
were spoken in the KLM cockpit:
Time
Source Content1706:32.43 C3 Is he not clear, then?1706:34.10C1What do you
say?1706:34.15PAYup1706:34.70C3Is he not clear that Pan American?1706:35.70C1Oh,
yes. (emphatic) At 1706:43.49, the co-pilot intoned the V1 and subsequently on
the DFDR PCC the following were observed: a pulling of the control column, with
the airplane nose pointing up, 16 per cent of the way back from a 44 per cent
forward position and from Pitch 2, airplane nose pointing up.
At
1706:46.04, i.e., 2.99 seconds before impact, increased direction toward the
right is observed in the HEAD; 0.46 seconds later, a curving of the airplane to
the left is seen in the Roll parameter (ROLL) and, 1.54 seconds before impact, a
roll to the right is observed in the Roll Control Wheel Position parameter (RCW).
At
1706:47.44, the captain utters an exclamation, while the impact takes place
shortly afterwards.
On
listening to the PAA CFR, it may be deduced that its crew saw the KLM airplane
9.5 seconds before the impact.
From
the actions of the Tenerife Control Tower, it may be inferred that their
ordering the KLM airplane to leave the runway by the third taxiway was so that
they should leave the main runway as soon as possible and proceed along the
parallel taxiway. This third taxiway was the first by which it was possible to
take the airplane off the main runway because access to the parallel taxiway by
C-l and C-2 was not possible on account of the aircraft congestion on the
parking apron.
Later,
in order to make the maneuver easier, the controller chose to order this
airplane to continue down the right side of the main runway and at the end of
same make an 180 degree turn.
Likewise,
he indicated to the PAA crew that they should leave by the third taxiway. At
first there was some confusion regarding the words "first" and
"third". But this was finally dispelled because the controller made
the following clarification: "The third one, sir, one, two, three, third
one."
The
situation deteriorated further when low-lying clouds reduced visibility to the
point at which neither airplanes taxiing on the main runway, nor some of those
located in the parking area, were visible from the tower.
It
transpires from careful listening to the KLM CVR that although cockpit operation
was correct and the check-lists were adequately kept, there was some feeling of
anxiety regarding a series of factors, which were: the time margin remaining to
them, to the point of straining the allowable limit of their duty time; the poor
and changing visibility which, especially as the runway centre lights were not
operative, might prevent the possibility of take-off within the weather limits
required by the company; the inconvenience for the passengers, etc. It is also
observed that, as the time for take-off approached, the captain – perhaps on
account of all these worries – seemed a little absent from all that was heard in
the cockpit. He enquired several times, and after the co-pilot confirmed the
order to backtrack, he asked the tower if he should leave the runway by C-l, and
subsequently asked his co-pilot if he should do so by C-4. On arriving at the
end of the runway and making an 180 degree turn in order to place himself in
take-off position, he was advised by the co-pilot that he should wait as they
still did not have an ATC clearance. The captain asked him to request it, which
he did, but while the co-pilot was still repeating the clearance, the captain
opened the throttle and started to take off. Then the co-pilot, instead of
requesting take-off clearance or advising that they did not yet have it, added
to his read-back, ‘We are now at take-off." The tower, which was not
expecting the aircraft to take off as it had not given clearance, interpreted
the sentence as, "We are now at take-off position"1) and the
controller replied: "O.K., … stand by for take-off … I will call
you." Nor did the Pan Am crew, on hearing the "We are now at
take-off", interpret it as an unequivocal indication of take-off. However,
in order to make their own position clear, they said, "We are still taxiing
down the runway." This transmission coincided with the "Stand by for
take-off … I will call you", causing a whistling sound in the tower
transmission and making its reception in the KLM cockpit not as clear as it
should have been, even though it did not thereby become unintelligible.
The
communication from the tower to the PAA airplane requested the latter to report
when it left the runway clear. In the cockpit of the KLM airplane which was
taking off, nobody at first confirmed receiving these communications (Appendix
5) until the Pan Am airplane responded to the tower’s request that it should
report leaving the runway with an "O.K., we’ll report when we’re
clear." On hearing this, the KLM flight engineer asked: "Is he not
clear then?" The captain didn’t understand him and he repeated: "Is he
not clear that Pan American?" The captain replied with an emphatic
"Yes" and, perhaps influenced by his great prestige, making it
difficult to imagine an error of this magnitude on the part of such an expert
pilot, both the co-pilot and the flight engineer made no further objections. The
impact took place about thirteen seconds later.
1)
When the Spanish, American and Dutch
investigating teams heard the tower recording together for the first time, no
one, or hardly anyone, understood that this transmission meant that they were
taking off.
From
that moment until the next call to the airplanes, the tower took care of Flights
IB-185 and the BX-387 and awaited the communication from Pan Am Flight 1736
reporting the "runway clear". It also received information coming from
two airplanes located in the parking area that there was a fire in an
undetermined place on the field, sounded the alarm, informed the Fire Fighting
and Health Services, and broadcasted the news of the emergency situation; it
then called the two airplanes on the runway, without receiving any reply.
The
conversations which took place in the Pan Am cockpit and between the airplanes
and the control tower from 1701:57.0 were as follows. The times were taken from
the PAA CVR.
1701:57.0CL1736Tenerife
the Clipper one seven three six. (1702:00.2) 1702:01.8APPClipper one seven three
six Tenerife. 1702:03.6RDO-2Ah- We were instructed to contact you and also to
taxi down the runway, is that correct? (1702:07.4) 1702:08.4 APP Affirmative,
taxi into the runway and -ah leave the runway third, third to your left,
(background conversation in the tower). 1702:16.4RDO-2Third to the left, O.K.
(17:02.18.3) 1702:18.4CAM-3Third he said. CAM-?Three. 1702:20.6APP-ird one to
your left. 1702:21.9CAM-1I think he said first. 1702:26.4CAM-2I’ll ask him
again. CAM-?* * * 1702:32.2CAM-2Left turn. 1702:33.1CAM-1I don’t think they have
take-off minimums anywhere right now. 1702:39.2 CAM-1What really happened over
there today? 1702:41.6 CAM-4They put a bomb (in) the terminal, Sir, right where
the check-in counters are. 1702:46.6 CAM-1Well we asked them if we could hold
and -uh- I guess you got the word, we landed here ** CAM-?* * * 1702:49.8 APPKLM
four eight zero five how many taxiway -ah- did you pass? 1702:55.6 KLM I think
we just passed charlie four now. 1702:59.9 APPO.K. … at the end of the runway
make one eighty and report -ah- ready -ah- for ATC clearance (background
conversation in the tower). 1703:09.3 CAM-2The first one is a ninety degree
turn. 1703:11.0 CAM-1Yeah, O.K. 1703:12.1 CAM-2Must be the third … I’ll ask
him again. 1703:14.2 CAM-1O.K. 1703:16.6 CAM-1We could probably go in it’s ah
… 1703:19.1 CAM-1You gotta make a ninety degree turn. 1703:21.6 CAM-1Yeah, uh.
1703:21.6 CAM-2Ninety degree turn to get around this … this one down here it’s
a forty five. 1703:29.3 RDO-2Would you confirm that you want the clipper one
seven three six to turn left at the third intersection? (1703:35.4). 1703:35.1
CAM-1One, two. 1703:36.4 APP The third one, sir, one; two, three, third, third
one (1703:38.3).. 1703:38.3 CAM-?One two (four). 1703:39.0 CAM-1Good. 1703:40.1
CAM-1That’s what we need right, the third one. 1703:42.9CAM-3Uno, dos, tres.
1703:44.0CAM-1Uno, dos, tres. 1703:44.9CAM-3Tres – uh – si. 1703:46.5CAM-1Right.
1703:47.6CAM-3We’ll make it yet. 1703:47.6APP…er seven one three six report
leaving the runway. 1703:49.1CAM-2Wing flaps? 1703:50.2CAM-1Ten, indicate ten,
leading edge lights are green. 1703:54.1CAM-?Get that. 1703:55.0RDO-2Clipper one
seven three six (1703:56.4) 1703:56.5CAM-2Yaw damp and instrument?
1703:58.6CAM-1Ah- Bob we’ll get a left one * 1703:59.3CAM-2I got a left.
1704:00.6CAM-1Did you? 1704.00.9CAM-2And -ah- need a right. 1704:02.6CAM-1I’ll
give you a little * 1704:03.8CAM-2Put a little aileron in this thing.
1704:05.0CAM-1O.K., here’s a left and I’ll give you a right one right here.
1704:09.7CAM-1O.K. right turn right and left yaw. 1704:11.4CAM-2Left yaw checks.
1704:12.4CAM-1O.K., here’s the rudders. 1704:13.6CAM-1Here’s two left, centre,
two right centre. 1704:17.8CAM-2Checks. 1704:19.2CAM-2Controls.
1704:19.6CAM-1Haven’t seen any yet! 1704:20.3CAM-2I haven’t either. 1704:21. 7
CAM-1They’re free, the indicators are checked. 1704:24.6CAM-2There’s one.
1704:25.8CAM-1There’s one. 1704:26.4CAM-1That’s the ninety degree.
1704:28.5CAM-?O.K. 1704:34.5CAM-?*** CAM-2Weight and balance finals?
1704:37.7CAM (Sounds similar to stabilizer trim).(1704:44.8) 1704:37.2CAM-1We
were gonna put that on four and a half 1704:39.8CAM-3We got four and a half and
we weigh five thirty four (sound of stabilizer trim). 1704:44.6CAM-2Four and a
half on the right. 1704:46.8CAM-2Engineer’s taxi check. 1704:48.4CAM-3Taxi check
is complete. 1704:50.5CAM-2Take-off and departure briefing? 1704:52.1CAM-1O.K.,
it’ll be standard, we gonna go straight out there till we get thirty five
hundred feet then we’re gonna make that reversal and go back’ out to * fourteen.
1704:58.2APP-m eight seven zero five and clipper one seven … three six, for
your information, the centre line lighting is out of service. (APP transmission
is readable but slightly broken.) 1705:05.8KLMI copied that.
1705:07.7RDO-2Clipper one seven three six. 1705:09.6CAM-1We got centre line
markings (* only) (could be "don’t we) they count the same thing as … we
need eight hundred meters if you don’t have that centre line… I read that on
the back (of this) just a while ago. 1705:22.0CAM-1That’s two. 1705:23.5
CAM-3Yeh, that’s forty-five there. 1705:25.7CAM-1Yeh. 1705:26.5 CAM-2That’s this
one right here. 1705:27.2 CAM-1(Yeh)I know. 1705:28.1 CAM-3O.K.
1705:28.5CAM-3Next one is almost a forty-five, huh yeh. 1705:30.6CAM-1But it
goes… 1705:32.4CAM-1Yeh, but it goes … ahead, I think (it’s) gonna put us on
(the) taxiway. 1705:35.9CAM-3Yeah, just a little bit yeh. 1705:39.8CAM-?O.K.,
for sure. 1705:40.0CAM-2Maybe he, maybe he counts these (are) three. CAM-?Huh.
1705:44.8 CAM-?I like this. 1705:44.8KLMUh, the KLM … four eight zero five is
now ready for take-off … uh and we’re waiting for our ATC clearance.
1705:53.4APPKLM eight seven * zero five uh you are cleared to the Papa Beacon
climb to and maintain flight level nine zero right turn after take-off proceed
with heading zero four zero until intercepting the three two five radial from
Las Palmas VOR. (1706:08.2) 1706:09.6 KLM Ah roger, sir, we’re cleared to the
Papa Beacon flight level nine zero, right turn out zero four zero until
intercepting the three two five and we’re now (at take-off). (1706:17.9) From
the foregoing it may be inferred that the Pan Am crew at first had difficulty in
understanding "third", thinking that it was "first". In any
case, the co-pilot asked again and this doubt was dispelled at 1703:36.4 as the
tower controller told him: "The third, sir, one, two, three, the third,
third", and the co-pilot confirmed this at 1703:39.2.
As
a result of the poor visibility, the crew had difficulty in localizing the exits
from the runway whose position they were following on the little map that they
had with them. Nevertheless, at 1704:26.4 the captain identified C-l (which is
the 90 degree exit). At 1705:22.0, they also identified C-2. Then, perhaps
through error, or thinking that C-4 was an easier exit than C-3, they overshot
the exit ordered by the Tower.
From
Appendix 5, which gives the time correlation between the conversations taking
place with the tower and inside the KLM 4805 and Clipper 1736 cockpits, as well
as the data obtained from the KLM 4805 DFDR during the last 88 seconds before
impact, the following may be ascertained.
When,
at 1706:17.9, RLM 4805 finished reading back the ATC clearance given by the
control tower and added, "We are now (at take-off)" and before the
controller finished the sentence "O.K…. stand by for take-off, I will
call you.", only "…k" is heard in the Pan Am cockpit. The pilot
says: "No uh …" and the co-pilot says "And we’re still taxiing
down the runway, the Clipper one seven three six…" (1706:23.6). These
communications caused a shrill noise in the KLM cockpit, which lasted
approximately 3.74 seconds.
During
this time the KLM take-off EPR was reached and stabilized (1.39 to 1.42).
At
1706:25.6, the tower controller gave the Pan Am crew confirmation in the
following manner: "Roger alpha one seven three six report the runway
clear" – to which the Pan Am crew replied at 1706:29.6, "O.K., we’ll
report when we’re clear." The tower replied, "Thank you", but the
KLM aircraft had already started its take-off run. The PanAm crew saw the KLM
airplane approximately 8.50 seconds before the impact. Amidst logical
exclamations of alarm they accelerated in order to try to get off the runway,
but the collision was already inevitable.
2.2
Conclusions
From all of this it may be ascertained that the KLM 4805 captain, as soon as he
heard the ATC clearance, decided to takeoff.
The
fundamental cause of this accident was the fact that the KLM captain: 1. Took
off without clearance. 2. Did not obey the "stand by for take-off"
from the tower.
3.
Did not interrupt take-off when Pan Am reported that they were still on the
runway.
4.
In reply to the flight engineer’s query as to whether the Pan Am airplane had
already left the runway, replied emphatically in the affirmative.
Now,
how is it possible that a pilot with the technical capacity and experience of
the captain, whose state of mind during the stopover at Tenerife seemed
perfectly normal and correct, was able, a few minutes later, to commit a basic
error in spite of all the warnings repeatedly addressed to him?
An
explanation may be found in a series of factors which possibly contributed to
the occurrence of the accident.
1.
A growing feeling of tension as the problems for the captain continued to
accumulate. He knew that, on account of the strictness in the Netherlands
regarding the application of rules on the limitation of duty time, if he did not
take off within a relatively short space of time he might have to interrupt the
flight – with the consequent upset for his company and inconvenience for the
passengers. Moreover, the weather conditions in the airport were getting rapidly
worse, which meant that he would either have to take off under his minima or
else wait for better conditions and run the risk of exceeding the aforementioned
duty-time limit.
2.
The special weather conditions in Tenerife must also be considered a factor in
themselves. What frequently makes visibility difficult is not actually fog,
whose density and therefore the visibility which it allows can be fairly
accurately measured, but rather layers of low-lying clouds which are blown by
the wind and therefore cause sudden and radical changes in visibility. The
latter can be O m at certain moments and change to 500 m or 1 km in a short
space of time, only to revert to practically zero a few moments later. These
conditions undoubtedly make a pilot’s decisions regarding take-off and landing
operations much more difficult;
3.
The fact that two transmissions took place at the same time. The "stand by
for take-off … I will call you" from the tower coincided with Pan Am’s
"we are still taxiing down the runway", which meant that the
transmission was not received with all the clarity that might have been desired.
The whistling sound which interfered with the communication lasted for about
three seconds.
The
following must also be considered factors which contributed to the accident:
Inadequate
language. When the KLM co-pilot repeated the ATC clearance, he ended with the
words, "we are now at take-off". The controller, who had not been
asked for take-off clearance, and who consequently had not granted it, did not
understand that they were taking off. The "O.K." from the tower, which
preceded the "stand by for take-off" was likewise incorrect – although
irrelevant in this case because take-off had already started about six and a
half seconds before.
The
fact that the Pan Am airplane had not left the runway at the third intersection.
This airplane should, in fact, have consulted with the tower to find out whether
the third intersection referred to was C-3 or C-4, if it had any doubts, and
this it did not do. However, this was not very relevant either since the Pan Am
airplane never reported the runway clear but, on the contrary, twice advised
that it was taxiing on it.
Unusual
traffic congestion which obliged the tower to carry out taxiing maneuvers which,
although statutory, as in the case of having airplanes taxi on an active runway,
are not standard and can be potentially dangerous.
Although
contributing to the accident, the following occurrences must not he considered
direct factors in it: the bomb incident in Las Palmas; the KLM refueling; the
latter’s take-off at reduced power; etc.
3.-
RECOMMENDATIONS
3.1
Placing of great emphasis on the importance of exact compliance with
instructions and clearances.
3.2
Use of standard, concise and unequivocal aeronautical language.
3.3
Avoidance of the word "TAKE-OFF" in the ATC clearance and adequate
time separation between the ATC clearance and the TAKE-OFF clearance.
ICAO
Note: Only Appendix 5 to the report is reproduced. ICAO Ref.: AIG/056/77.
Copyright
� 1996-98 Harro Ranter/Aviation Safety Web Pages
Tenerife Cockpit
Voice Recorder
1701:57.0
PanAm
Radio(c/p)Tenerife
the Clipper one seven three six.
(1702:00.2)1702:01.8
TENERIFE
TOWERClipper
one seven three six Tenerife.
1702:03.6
PanAm
Radio(c/p)Ah-
We were instructed to contact you and also to taxi down the runway, is that
correct?
(1702:07.4)1702:08.4
TENERIFE
TOWERAffirmative,
taxi into the runway and -ah leave the runway third, third to your left,
(background conversation in the tower).
1702:16.4
PanAm
Radio(c/p)Third
to the left, O.K.
(17:02.18.3)1702:18.4
PanAm
FLT ENGRThird
he said.CAM-?Three.
1702:20.6
TENERIFE
TOWER-ird
one to your left.
1702:21.9
PanAm
CAPTAINI
think he said first.
1702:26.4
PanAm
CO-PILOTI’ll
ask him again.CAM-?* * *
1702:32.2
PanAm
CO-PILOTLeft
turn.
1702:33.1
PanAm
CAPTAINI
don’t think they have take-off minimums anywhere right now.
1702:39.2
PanAm
CAPTAINWhat
really happened over there today?
1702:41.6
CAM-4They
put a bomb (in) the terminal, Sir, right where the check-in counters are.
1702:46.6
PanAm
CAPTAINWell
we asked them if we could hold and -uh- I guess you got the word, we landed here
**CAM-?* * *
1702:49.8
TENERIFE
TOWERKLM
four eight zero five how many taxiway -ah- did you pass?
1702:55.6
KLM
(Radio)I
think we just passed charlie four now.
1702:59.9
TENERIFE
TOWERO.K.
… at the end of the runway make one eighty and report -ah- ready -ah- for ATC
clearance (background conversation in the tower).
1703:09.3
PanAm
CO-PILOTThe
first one is a ninety degree turn.
1703:11.0
PanAm
CAPTAINYeah,
O.K.
1703:12.1
PanAm
CO-PILOTMust
be the third … I’ll ask him again.
1703:14.2
PanAm
CAPTAINO.K.
1703:16.6
PanAm
CAPTAINWe
could probably go in it’s ah …
1703:19.1
PanAm
CAPTAINYou
gotta make a ninety degree turn.
1703:21.6
PanAm
CAPTAINYeah,
uh.
1703:21.6
PanAm
CO-PILOT
Ninety
degree turn to get around this … this one down here it’s a forty five.
1703:29.3
PanAm
Radio(c/p)Would
you confirm that you want the clipper one seven three six to turn left at the
third intersection?
(1703:35.4).1703:35.1
PanAm
CAPTAINOne,
two.
1703:36.4
TENERIFE
TOWERThe
third one, sir, one; two, three, third, third one
(1703:38.3)..1703:38.3
CAM-?One
two (four).
1703:39.0
PanAm
CAPTAINGood.
1703:40.1
PanAm
CAPTAINThat’s
what we need right, the third one.
1703:42.9
PanAm
FLT ENGRUno,
dos, tres.
1703:44.0
PanAm
CAPTAINUno,
dos, tres.
1703:44.9
PanAm
FLT ENGRTres
– uh – si.
1703:46.5
PanAm
CAPTAINRight.
1703:47.6
PanAm
FLT ENGRWe’ll
make it yet.
1703:47.6
TENERIFE
TOWER…er
seven one three six report leaving the runway.
1703:49.1
PanAm
CO-PILOTWing
flaps?
1703:50.2
PanAm
CAPTAINTen,
indicate ten, leading edge lights are green.
1703:54.1
CAM-?Get
that.
1703:55.0
PanAm
Radio(c/p)Clipper
one seven three six
(1703:56.4)1703:56.5
PanAm
CO-PILOTYaw
damp and instrument?
1703:58.6
PanAm
CAPTAINAh-
Bob we’ll get a left one
*1703:59.3
PanAm
CO-PILOTI
got a left.
1704:00.6
PanAm
CAPTAINDid
you?
1704.00.9
PanAm
CO-PILOTAnd
-ah- need a right.
1704:02.6
PanAm
CAPTAINI’ll
give you a little
*1704:03.8
PanAm
CO-PILOTPut
a little aileron in this thing.
1704:05.0
PanAm
CAPTAINO.K.,
here’s a left and I’ll give you a right one right here.
1704:09.7
PanAm
CAPTAINO.K.
right turn right and left yaw.
1704:11.4
PanAm
CO-PILOTLeft
yaw checks.
1704:12.4
PanAm
CAPTAINO.K.,
here’s the rudders.
1704:13.6
PanAm
CAPTAINHere’s
two left, centre, two right centre.
1704:17.8
PanAm
CO-PILOTChecks.
1704:19.2
PanAm
CO-PILOTControls.
1704:19.6
PanAm
CAPTAINHaven’t
seen any yet!
1704:20.3
PanAm
CO-PILOTI
haven’t either.
1704:21.7
PanAm
CAPTAINThey’re
free, the indicators are checked.
1704:24.6
PanAm
CO-PILOTThere’s
one.
1704:25.8
PanAm
CAPTAINThere’s
one.
1704:26.4
PanAm
CAPTAINThat’s
the ninety degree.
1704:28.5
CAM-?O.K.
1704:34.5
CAM-?***PanAm
CO-PILOTWeight and balance finals?
1704:37.7
CAM(Sounds
similar to stabilizer trim).
(1704:44.8)1704:37.2
PanAm
CAPTAINWe
were gonna put that on four and a half
1704:39.8
PanAm
FLT ENGRWe
got four and a half and we weigh five thirty four (sound of stabilizer trim).
1704:44.6
PanAm
CO-PILOTFour
and a half on the right.
1704:46.8
PanAm
CO-PILOTEngineer’s
taxi check.
1704:48.4
PanAm
FLT ENGRTaxi
check is complete.
1704:50.5
PanAm
CO-PILOTTake-off
and departure briefing?
1704:52.1
PanAm
CAPTAINO.K.,
it’ll be standard, we gonna go straight out there till we get thirty five
hundred feet then we’re gonna make that reversal and go back’ out to * fourteen.
1704:58.2
TENERIFE
TOWER-m
eight seven zero five and clipper one seven … three six, for your information,
the centre line lighting is out of service. (TENERIFE TOWER transmission is
readable but slightly broken.)
1705:05.8
KLM
(Radio)I
copied that.
1705:07.7
PanAm
Radio(c/p)Clipper
one seven three six.
1705:09.6
PanAm
CAPTAINWe
got centre line markings (* only) (could be "don’t we) they count the same
thing as … we need eight hundred metres if you don’t have that centre line…
I read that on the back (of this) just a while ago.
1705:22.0
PanAm
CAPTAINThat’s
two.
1705:23.5
PanAm
FLT ENGRYeh,
that’s forty-five there.
1705:25.7
PanAm
CAPTAINYeh.
1705:26.5
PanAm
CO-PILOTThat’s
this one right here.
1705:27.2
PanAm
CAPTAIN(Yeh)
I know.
1705:28.1
PanAm
FLT ENGRO.K.
1705:28.5
PanAm
FLT ENGRNext
one is almost a forty-five, huh yeh.
1705:30.6
PanAm
CAPTAINBut
it goes…
1705:32.4
PanAm
CAPTAINYeh,
but it goes … ahead, I think (it’s) gonna put us on (the) taxiway.
1705:35.9
PanAm
FLT ENGRYeah,
just a little bit yeh.
1705:39.8
CAM-?O.K.,
for sure.
1705:40.0
PanAm
CO-PILOTMaybe
he, maybe he counts these (are) three.CAM-?Huh.
1705:44.8
CAM-?I
like this.
1705:44.8
KLM
(Radio)Uh,
the KLM … four eight zero five is now ready for take-off … uh and we’re
waiting for our ATC clearance.
1705:53.4
TENERIFE
TOWERKLM
eight seven * zero five uh you are cleared to the Papa Beacon climb to and
maintain flight level nine zero right turn after take-off proceed with heading
zero four zero until intercepting the three two five radial from Las Palmas VOR.
(1706:08.2)1706:09.6KLM
(Radio)
Ah
roger, sir, we’re cleared to the Papa Beacon flight level nine zero, right turn
out zero four zero until intercepting the three two five and we’re now (at
take-off).
(1706:17.9)1706:13.0
KLM
CAPTAINWe
gaan. (We’re going)
1706:18.19
TENERIFE
TOWEROK.
1706:19.3
PanAm
Radio(c/p)No
.. eh.
1706:20.08
TENERIFE
TOWERStand
by for take-off, I will call you.
1706:20.3
PanAm
Radio(c/p)And
we’re still taxiing down the runway, the clipper one seven three six.
1706:19.39-
1706:23.19
RDO
and TENERIFE TOWER communications caused a shrill noise in KLM cockpit –
messages not heard by KLM crew.
1706:25.6
TENERIFE
TOWERRoger
alpha one seven three six report when runway clear
1706:29.6
PanAm
Radio(c/p)OK,
we’ll report when we’re clear.
TENERIFE
TOWERThank
you
1706:32.43
KLM
FLT ENGRIs
hij er niet af dan? {Is he not clear then?}
1706:34.1
KLM
CAPTAINWat
zeg je? {What do you say?}
1706:34.15
KLM-?Yup.
1706:34.7
KLM
FLT ENGRIs
hij er niet af, die Pan American? {Is he not clear that Pan American?}
1706:35.7
KLM
CAPTAINJawel.
{Oh yes. – emphatic}
1706:40.0
PanAm
captain sees landing lights of KLM Boeing at approx. 700m
1706:44.0
PH-BUF
started rotation
1706:47.44
KLM
CAPTAIN[Scream]1706:50.0collision
Source:
ICAO Circular 153-AN/56 (p.22-68)
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