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Determination, Communication, and the Worst Disaster in Aviation History

by Scott Gardiner
Reprinted with permission from FAA Aviation News

The following article highlights the thoughts and opinions of the Seattle FSDO's Safety Program Manager Scott Gardiner and is based on his 30 plus years of aviation experience.

I was a full-time flight instructor for seven years before I joined the FAA in 1977. In those days most of my studies concentrated on the federal aviation regulations, the Aeronautical Information Manual, and the Practical Test Standards (Airman's Information Manual and Flight Test Guides in those days). The first time I ever studied national aircraft accidents on an ongoing basis was after I joined the FAA. In my accident studies, several consistencies jumped right out at me. For example, pick a year. Pick any year. Landing accidents, many caused because pilots refuse to go around no matter how badly the approach is going, is always the number one cause of general aviation airplane accidents. The number one cause of fatal general aviation airplane accidents nation wide is always 'continued VFR into deteriorating weather.' (Density altitude is the number one cause of fatal airplane accidents in the seven northwestern states, not including Alaska). Running out of fuel always ranks in the top ten.

One question kept running through my head. 'Why?' Why do we keep making the same dumb mistakes over and over again? The NTSB makes the accident statistics available on line. The FAA does seminars all over the nation. Flying magazine does, 'I learned about flying from that.' The AOPA Air Safety Foundation does its seminars all across the nation. And yet, year after year, the probable causes really never seem to change. About 81 per cent of general aviation airplane accidents are caused by pilot error. About one-half of those are caused by skill errors (loss of competency, lack of currency, etc.). But the other half of the pilot error accidents is caused simply by bad mental mistakes. Why? Most of these accidents are easily avoidable. Why aren't we learning from the mistakes of others? Why don't we change the way we fly and avoid the well-known pit falls?

Searching for the answer to 'why' has taken me on a 15-year search for knowledge (a long trip for me), but now I honestly think I know the answer. I don't claim to be smart, and I don't claim to understand all I know about the subject. I assure you, I am NOT a trained psychologist. But I have spent my entire adult life involved in the flight training of adults, and I must admit I do find human behavior fascinating. Recently, several things presented by a number of different people clicked in my head, came together, and suddenly it all made perfect sense. It is an insight that I truly believe can reduce aircraft accidents. We are talking human behavior here, so nothing is guaranteed. Of course, there are exceptions. But as I go through life observing people, I gotta tell you, I see it a lot.

Here's one that really has nothing to do with the subject at hand, but I find it fascinating in that it shows just how similar we pilots are. Have you ever had a dream where you were flying an airplane very low (maybe 15 or 20 feet) over a busy city street? What appears to be hundreds of power lines cross the street above your airplane. You fly along looking for a space between the lines with enough room that you can zoom your airplane up to freedom? But there's never enough room. Have you ever had that dream? I'll bet you thought you were the only one who ever had that dream. But ask your pilot friends. I'm not sure what the significance of the dream is. And I don't understand the meaning of the dream. But I find it fascinating how similar we all are.

Although I am writing this in the first person, these are not original thoughts. They come from a variety of sources; I am simply the one combining them into this article. One of the most significant of the sources is a videotape of a two and a half hour lecture delivered in 1981 by a gentleman named Morris Massey. During the sixties, seventies, and eighties, Mr. Massey traveled the nation delivering his message to corporations on the subject of internal company communication. The title of his lecture is, 'What you are is where you were when'when your personality matured.'

It seems that in the 1960s, '70s, and '80s, a lot of managers who were in the 50 to 65 year old age group were having trouble motivating 20-year-old new hires. There was a huge generation gap. The old timers just didn't understand how to motivate the younger new hires. Mr. Massey's message explains why.

It seems our basic, gut level, core value systems get sealed into our personalities when our personalities mature, which happens somewhere between age 10 and age 15. Located within your core value system are things like what you consider to be right or wrong. And what you consider to be good or bad. Also, what you consider to be normal or not normal. How you look at and deal with the world. How you deal with people. Whether you are basically an optimist or basically a pessimist. What battles you are willing to fight, and which are not even worth worrying about. These basic, gut level, core values are sealed in our personalities when our personalities mature. Whatever was important in your family, and whatever was important in the world when you were between the ages of 10 and 15 has a huge influence on your basic personality makeup. Hence the title of Mr. Massey's lecture. 'What you are is where you were when'when your personality matured.'

The problem in the '60s, '70s, and '80s was that the basic, core values of the 50 to 65 year old managers where formed during the Great Depression. During those years, those who had jobs considered themselves very fortunate indeed, and they would do absolutely anything to impress the boss, to keep the business profitable, and to keep their jobs. Employees were as dedicated to the future of the company as were the owners. They knew there were 50 people on the street waiting for any job opening, and they did not want to be out there with the unemployed. If a piece of equipment broke towards the end of the shift, workers would gladly stay around after hours and get it fixed before the next shift arrived in the morning. If it kept the company profitable, it had to be done. And they would stick around as long as it took to get it fixed, even if they were not paid to do so!

Fast forward to the new hires that were 10 to 15 during the sixties and seventies. Jobs were plentiful. The economy was good. If the 60-something manager approached a 20- something employee and asked them to stick around after hours to fix equipment, the new hire would laugh and say, 'When my shift is over, I'm on my own time, and I certainly am not going to waste my time here.' The manager would counter with, 'I'll give you time and a half.' To which the new hire would answer with a laugh and, 'I wouldn't hang around here after hours for triple time! I gotta go out and have some fun.' The manager fires back, 'If you don't stay and fix it, I'll fire you!!!' To which the new hire responds, 'If you are going to fire me, you better do it quick, I'm about to quit. There's another job waiting for me around the corner and I certainly don't need to hang around here and be hassled by you!'

Our core values are sealed into our personalities when we are 10 to 15 years old and influence our thinking forever. We cannot change it. OK, OK, OK. The experts say that if you really, really, really want to change, and are willing to undergo several years of psychological testing and therapy, for every 100 people who really, really, really want to change there will be one or two who actually can change. But the rest of us will take our basic, core, gut level values with us to our graves. You want proof? Go visit your parents' or your grandparents' garage or basement. There you will find old rusty junk and parts to things that don't even exist anymore. Things like badly scratched 45-RPM records. Things like rusty blades for a rotary, push, lawnmower. Things like shovels with the handles broken off. Why do they keep this stuff? Because they were 10 to 15 years old during the Great Depression or they were raised by parents who were 10 to 15 during the Great Depression. And they can't throw that stuff away. They can't throw anything away. Their basic, core, gut level values won't let them throw anything away. Fifty years later, they are still keeping that stuff because keeping stuff is burned into their personalities. Besides, 'You never know when you might need it.'

In the spring of 2003, I was fortunate enough to sit through a class taught by Mr. Mike Alverado. He presented some fascinating things about the makeup of pilots. It seems we are rather a unique group of people. For example, compared to the general population of the United States, an unusually large percentage of pilots are the first child born in the family. Ask your pilot friends. Mr. Alverado theorizes that parents who have no experience raising kids raise first-born children, but they are sure of one thing - they are dedicated to raising a perfect human being. As a result, parents have higher expectations of the first-born child. First-born children are encouraged more than their siblings. And first-born children are given more responsibility than their siblings. As a result, first-born children come through that 10 to 15 year age range being very focused, very goal oriented people. And they are accustomed to achieving those goals. Whether or not you are a first-born child, you as a pilot are a focused, goal-oriented person, confident that you can be successful in achieving your goals.

This can be a wonderful personality trait. It helps us get things done. For example, saving up money to buy flying lessons. If we couldn't set that goal, focus on it, and work until it was successfully accomplished, we would never have accumulated the money to complete pilot training. If we couldn't set a goal, focus on it, and work until it was successfully accomplished we never would have passed the knowledge test. It's a multiple-choice test, but you've got to admit it is the toughest multiple-choice test you ever took. If we didn't have the basic core values we do, we never would have passed that test, and we never would have become pilots. Our basic core values of dedication, determination, and focus, help us achieve goals.

And they can kill us! Imagine you are flying home to Boeing Field VFR from (it really doesn't matter where) say somewhere in Montana. You are over eastern Washington, flying in severe clear VFR weather. But heading west you notice that clouds are obscuring the tops of the Cascade Mountain range. You have decided that you will be home before sunset. So, even though the weather ahead looks daunting, do you land somewhere in eastern Washington and wait out the weather? No. There is some little voice inside encouraging you to get this flight done. Something is pushing you to find a way to get the airplane through. It's that focused, goal-oriented, success, part of our personality that says, 'It might be risky, but I can do it.' So, you go down low and try to sneak through the pass. Another needless 'continued VFR into deteriorating weather' accident. The problem is our goal-oriented, success-oriented personalities can drive us to take unreasonable risks. The result is a kind of a 'tunnel vision' focus in which we don't realize or even care that we are taking an unreasonable risk.

On another day, another cross-country, you are about an hour from destination and low on fuel. You consider landing short of your original destination to refuel. But then you think, 'It could take 45 minutes to descend, fly the pattern, taxi to the pumps, find someone to refuel the plane, taxi back out, takeoff, and climb back up to altitude.' So, rather than descend and refuel, you focus on getting the airplane through to the original destination. That's why running out of fuel accidents occur over and over again. It's in our personalities. It's not like us to fail to meet our intended goals. Something inside is pushing us to take the unreasonable risks.

Yet another flight, and on short final, you are lower than you would like, the airspeed is slower than you would like, and the crosswind is really blowing from the right. You look out the window and think, 'Boy, I'm really not even close to being on target here.' Do you think to yourself, 'Well, it's fourth down and forty eight yards to go. In situations like this, we punt. I better go around?' No!!! We focus on the problem and try to find some extreme way to make it work. Another needless, crosswind landing accident.

Are these accidents happening because we cannot read the METAR and TAF reports? No! Do they happen because we do not know how many gallons of usable fuel the airplane carries? No!! Is it because we do not know the maximum demonstrated crosswind component of the airplane? No!!! They happen because buried way down deep in our personalities we are accustomed to setting goals for ourselves and finding ways to successfully accomplish them. It is a personality trait that helps us get stuff done. It's a personality trait that we cannot change. And left unchecked, it can convince us to take unreasonable risks, even the ones that end in accidents.

In fact, the worst accident in aviation history is primarily attributed to just such a personality trait in the captain of a 747. On Sunday, March 27, 1977, two 747's collided on the runway at Los Rodeos Airport on the Island of Tenerife, one of Spain's Canary Islands. 583 people were killed. To this day, it is still the record. I use this accident as an example because it is well documented and it shows how pilot's personalities, when focused on a goal, can persuade them to take unreasonable risks. Although the airplanes involved where 747's, it could easily have happened to pilots of light airplanes too.

One of the many strange things about that day was that neither plane set out to land on Tenerife. The airplanes, one a Dutch KLM 747 and the other a Pan American 747 were chartered flights taking vacationers to the Canaries, the European equivalent of our Hawaii. The original destination of both planes was the Las Palmas airport, 50 nautical miles from Tenerife. However, as the airplanes were starting their descents, a bomb exploded in the flower shop in the Las Palmas terminal building. Shortly after the explosion, someone called the airport manager, took credit for the bomb, and threatened that there would soon be another one. The airport manager closed the airport for a bomb search. ATC diverted many inbound planes, including both 747s, to Tenerife.

The Los Rodeos airport, not accustomed to so many airliners landing, soon became saturated with parked airplanes. Although the runway was clear, airplanes were parked all over the parking areas and adjacent taxiways. After a two-hour bomb-sniffing search found no evidence of a second bomb at Las Palmas, the airport opened back up for normal operations, and the airplanes planned for departure from Tenerife.

But the two-hour delay left the crew of the KLM 747 short on duty time, and the Dutch had just recently increased the penalties for exceeding duty time. If the KLM captain could get his 747 off the ground soon, he could get to Las Palmas within his allotted duty time. If he could not take off soon, he would be forced to spend the night on Tenerife, with his airline responsible for finding hotels for all the passengers, and for paying all their overnight and meal expenses. Also, they would have to deal with angry passengers who would miss their cruise ship connections. The captain was in a rush.

Both 747s were parked at the west-northwest end of the airport, and the winds favored runway 30. Since the taxiways were clogged with parked airliners, the plan was for the KLM to back taxi on the runway, with the Pan Am following about a mile (half the runway length) behind. The KLM would taxi to the departure end of 30, turn around and wait. Meanwhile the Pan Am would taxi about three quarters of the length of the runway and pull off onto the taxiway. Then the KLM would takeoff, and only then would the Pan Am 747 taxi to the end of runway 30.

It was a good plan. Both airplanes were using the same tower frequency. But, as the airplanes were back taxiing on the runway, the fog blew in and dropped the visibility nearly to zero. It was so dense that neither crew could see the other 747, nor the tower operator could see neither the airplanes nor the runway. The situation required some good, coordinated communication using words and phrases, which go well beyond those defined in the aviation English pilot/controller dictionary. Keep in mind too, that the situation involved a U.S. crew, a Dutch crew, and a Spanish tower controller, all trying to communicate in English.

As the KLM 747 reached the departure end of runway 30 and turned around, the Pan Am 747 was approximately at the mid field position, taxiing very slowly in the dense fog. The KLM lined up on the centerline and the captain, in his rush to get going, started to advance the throttles. The KLM copilot stopped him, explaining that they had not yet received their IFR clearance. The captain relented, closed the throttles, and told the co-pilot to get the clearance.

The tower delivered the IFR route clearance to the KLM, but offered no takeoff clearance. The tower would not have issued the takeoff clearance because the Pan Am 747 was still on the runway. As the co-pilot was reading back the clearance, the captain again ran the power up, stated, 'Let's go,' and called to the flight engineer to, 'Check thrust.' This accident was in the days before Crew Resource Management, when co-pilots were considered quite inferior to captains. The KLM co-pilot knew they had not yet received their takeoff clearance. He had stopped the captain from taking off once, but probably thought he could not get away with it again. So, rather than insisting the captain stop the takeoff roll again, the co-pilot blurted into the mic, 'We are at takeoff.'

It is my understanding that the Dutch speak pretty good English, but that they never use 'ing' at the end of any word. If you ask someone where his or her spouse is, the answer would not be 'working.' It would be 'at work.' The tower, interpreting the KLM transmission to mean they were ready for takeoff, replied, 'Okay'standby for takeoff'I will call you.'

The Pan Am crew, hearing the 'Okay' part of the tower's transmission, were understandably alarmed. In a rather excited voice the Pan Am co-pilot transmitted, 'We are still taxiing down the runway!' Unfortunately, the Pan Am transmission 'stepped on' the last of the tower's transmission and all the KLM heard the tower say was, 'Okay,' followed by the all too familiar radio squeal.

The tower operator had NOT issued a takeoff clearance to the KLM and would not have until he was certain the Pan Am was off the runway. The tower called the Pan Am, 'Pan Am 1736, are you clear of the runway?' The Pan Am answered, 'Negative. But we will report when we are clear.'

This transmission was clearly audible to the KLM pilots. However, by this time they were 20 seconds into their takeoff run and intensely concentrating on takeoff duties. Only the KLM flight engineer took in the possible significance of the two transmissions. He asked his pilots, 'Did he not clear the runway, the Pan American?' Both pilots emphatically answered, 'Yes, he did!'

A few seconds later, the Pan Am caught sight of the KLM lights piercing the fog. The Pan Am captain desperately pushed all four throttles to max power and turned left to exit the runway. When the KLM saw the Pan Am on the runway, they tried to lift their 747 over the Pan Am. But it was too late; there was not enough room. The KLM 747 ripped the entire upper third of the Pan Am fuselage off, igniting fires throughout the Pan Am. The KLM fell to the runway and the entire airplane burned up. No one aboard the KLM airplane survived. Only 61 from the Pan Am survived.

The Spanish were the official investigators in this accident. Although U.S. and Dutch investigators were allowed to participate, they did not determine probable cause. The Spanish concluded that the accident was caused by the KLM commencing its takeoff roll without a takeoff clearance. The Dutch concluded that it was a simple misunderstanding between the KLM crew and the tower. They said their captain 'thought' he had a takeoff clearance. Communication clearly played a role in this disaster. But I believe it was the mistake of the KLM captain, focused on departing in a hurry, even though he did not have a proper takeoff clearance, that lead to the disaster. A mistake made because of his 'tunnel vision' determination to get off the ground in time to arrive at Las Palmas before running out of duty time. I believe it was the 'can do' part of his personality. It was his 'get it done at all cost' mentality that created the opportunity for disaster.

The scary part is, we've all got it in us. If we didn't, we never could have become pilots. I now believe it is the root cause of most of our avoidable 'pilot error' accidents. I believe it is the reason we press on into deteriorating weather. I believe it is the reason we continue toward destination even though we are low on fuel. And I believe it is the reason we refuse to go around when common sense says going around is the only reasonable thing to do. My hope is that if we can understand that part of our personality, maybe we can recognize when it starts to sneak up on us. And if we can recognize it, perhaps, when we really need to, we can do something to control it.

May you always find VFR and tailwinds.

FAA Safety Hotline

Scott Gardiner is the Safety Program Manager at the FAA's Seattle Flight Standards District Office.

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