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40-Year Anniversary of the Tenerife Airport Disaster

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  • 40-Year Anniversary of the Tenerife Airport Disaster

    40 years today.

    Shall we talk about Capt Veldhuyzen van Zanten's 11,700 flight hours and exemplary airmanship? Or should we talk about non-standard procedure and confirmation bias?

  • #2
    How about Swiss Cheese and simultaneous radio broadcasts?

    ...and let's not forget the recent discussion of the definition of the word "clear" as a adjective vs. a verb and legal implications vs physical implications and context...

    ...seems to me that we need to come up with better wording.
    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

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    • #3
      Originally posted by Evan View Post
      40-Year Anniversary of the Tenerife Airport Disaster
      Deadly as none. Avoidable as any.

      --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
      --- Defend what you say with arguments, not by imposing your credentials ---

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      • #4
        Are you implying that if Capt. Iwannagethome had less experience, that the accident would not have happened?
        Be alert! America needs more lerts.

        Eric Law

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        • #5
          elaw, I think Evan is suggesting that thousands of hours can mean nothing at all, right Evan?

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          • #6
            Originally posted by elaw View Post
            Are you implying that if Capt. Iwannagethome had less experience, that the accident would not have happened?
            Not at all. I'm implying that massive hours do not a safe pilot make. Only caution and discipline can do that.

            Capt. Iwannagethome rolled without a CLEAR takeoff clearance. No pilot should ever do that.

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            • #7
              Originally posted by Evan View Post
              Not at all. I'm implying that massive hours do not a safe pilot make. Only caution and discipline can do that.

              Capt. Iwannagethome and his FO and his Engineer rolled without a CLEAR takeoff clearance. No three man crew should ever do that.
              Fixed.
              Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

              Comment


              • #8
                Originally posted by 3WE View Post
                Fixed.
                Broken.

                Both the F/O and the F/E expressed concern. When the Capt lined up and began rolling without ANY clearance, the F/O spoke up and asked to query the tower. The F/E questioned the Capt about the PamAm plane being on the runway just before the takeoff fatal roll. The Capt dismissed his concern. There was some serious confirmation bias going on here and some serious cockpit gradient getting in the way.

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                • #9
                  Originally posted by Evan View Post
                  ...the Capt lined up and began rolling without ANY clearance...
                  Disconcur.

                  They were cleared by the tower who was using incorrect phraseology.

                  Much like your use of the word "ANY"

                  Did the Frenchman's experience cause the tower to speak incorrectly?
                  Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                  Comment


                  • #10
                    Originally posted by 3WE View Post
                    Disconcur.

                    They were cleared by the tower who was using incorrect phraseology.

                    Much like your use of the word "ANY"

                    Did the Frenchman's experience cause the tower to speak incorrectly?
                    Confutate.

                    The KLM flight NEVER received take off clearance, neither in standard nor non-standard terms. The F/O reported that they were in take-off position and the tower replied "Okay", meaning "understood" but as a non-standard term may have been miscontrued as "okay for take off", however, this was immediately followed by "stand by for takeoff, I will call you". Unfortunatley this last part was stepped on by the heterodyne from the PamAm call to ATC. However, "okay" is certainly not "cleared for takeoff" and any cautious pilot would request clarification on that before rolling on an obscured runway that is being used for backtracking as well as takeoff. Furthermore, the Capt began the roll BEFORE any of this and stated "we're going" while the F/O was still requesting clearance. The evidence is pretty damning. Say all you want about the shitstorm of factors that came together here, it still doesn't excuse that abuse of procedure.

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                    • #11
                      Originally posted by Evan View Post
                      Confutate.

                      The KLM flight NEVER received take off clearance, neither in standard nor non-standard terms. The F/O reported that they were in take-off position and the tower replied "Okay", meaning "understood" but as a non-standard term may have been miscontrued as "okay for take off", however, this was immediately followed by "stand by for takeoff, I will call you". Unfortunatley this last part was stepped on by the heterodyne from the PamAm call to ATC. However, "okay" is certainly not "cleared for takeoff" and any cautious pilot would request clarification on that before rolling on an obscured runway that is being used for backtracking as well as takeoff. Furthermore, the Capt began the roll BEFORE any of this and stated "we're going" while the F/O was still requesting clearance. The evidence is pretty damning. Say all you want about the shitstorm of factors that came together here, it still doesn't excuse that abuse of procedure.
                      These things keep happening... Here the crew was instructed (and they acknowledged) to "line up and wait" but they took off anyway just when a plane was landing on an intersecting RWY.

                      An Air Dolomiti Embraer ERJ-195 on behalf of Lufthansa, registration I-ADJO performing flight LH-2293 from Brussels (Belgium) to Munich (Germany) with 62 passengers and 5 crew, was cleared to line up runway 07R and wait, however, commenced their takeoff roll.

                      An Aer Lingus Airbus A320-200, registration EI-EZW performing flight EI-638 from Dublin (Ireland) to Brussels (Belgium) with 156 passengers and 6 crew, was on very short final to Brussels' runway 01 below 250 feet AGL when tower - with raised voice - instructed the aircraft to go around as result of the unexpected takeoff by LH-2293. The aircraft positioned for another approach and landed safely about 11 minutes after the go-around.

                      The Embraer crew got to hear that they had no takeoff clearance, but were now permitted to continue takeoff. The crew apologized after the aircraft had become airborne. The aircraft continued to destination for a safe landing.
                      Aviation Herald - News, Incidents and Accidents in Aviation

                      --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                      --- Defend what you say with arguments, not by imposing your credentials ---

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                      • #12
                        Originally posted by Gabriel View Post
                        These things keep happening... Here the crew was instructed (and they acknowledged) to "line up and wait" but they took off anyway just when a plane was landing on an intersecting RWY.

                        Comment


                        • #13
                          Originally posted by Evan View Post
                          Evan, honest mistakes do happen. In this case there were 2 additional layers that worked ok. The tower and the pilots of the landing plane (who had already spotted the conflict when the tower yelled to go around).

                          Yes, additional layers of safety can be put in place. Every time that the crew receives a taxi clearance that involves getting in the runway but not take off they can be required (by the SOPs) to warn each other "we are not cleared to take off". When they receive a clearance that is undoubtedly a take off clearance they can be required (both of them) to call "that was a take-off clearance" and push (each of them) a "cleared for take-off" button, when both buttons are pushed the warning light "No Take-off clearance" would extinguish. A last vital "memory item" checklist, just before commencing the take-off roll can include "we are cleared to take off and the warning light is out", and the thrust would not go above taxi settings anyway unless the light is off.

                          Now, this is for ONE mistake that can be made. There are HUNDREDS of those. Could you imagine the workload and workflow in the cockpit if such measures where implemented for all them? What additional risks would this raise? Would the pilots be bothered so much for all that bureaucracy that they will stop paying attention to it and just do it (for example push the buttons) as part of the instinctive motions? (as it seems was the case here anyway).

                          We need to find practical and user-friendly ways to avoid and timely detect and correct mistakes, but mistakes like this have always been and will always be made.
                          Did you ever passed a red light without noticing?
                          Did you ever turned left when told to turn right?
                          Did you ever made a grammar mistake that you perfectly knew was not correct, but just didn't notice it? (your for you're, effect for affect, wrong tense...)

                          Yes, some of these errors may be not so critical, but the mechaincs of the rror is the same: Humans do err, even if they responsibly try not to.
                          And if you make one of these errors every 1 million flights (that's 1 PPM and better than six-sigma), you will still have 40 of those per year.
                          Eventually, one of those will lead to an accident. There is a point where we need to live with it.

                          The Los Rodeos one was worse for me, because the FO and engineer tried to warn the captain, they knew there was something fishy there, they were feeling uncomfortable with the situation, so the collective mistake was not so "honest" (plus the reasons that you mentioned... dense fog, they knew that airplanes were taxiing on the same runway, they knew that a Pan Am plane was out there somewhere...)

                          --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                          --- Defend what you say with arguments, not by imposing your credentials ---

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                          • #14
                            Originally posted by Gabriel View Post
                            These things keep happening... Here the crew was instructed (and they acknowledged) to "line up and wait" but they took off anyway just when a plane was landing on an intersecting RWY.
                            I've told this story before...Once I got to wear a headset on a J-31 flight.

                            On taxi, we approached an intersecting runway that is used 5% of the time in unusual weather.

                            The captain dutifully uttered his memory procedure "clear"...the FO dutifully replied "clear".

                            This still bothers me because it is too easy for the human mind to dutifully utter one word than it is to truly analyze the situation.

                            Would it not have been better for the Captain to say- Ok, we are approaching runway 6-24 and I haven't seen it in use today, nor are the winds favorable, AND I do not see any aircraft on approach...

                            ...and the FO might have said. Concur on the right.

                            Of course, what I have just described is improvisational cowboy airmanship as opposed to following the proper procedure...right?







                            Footnote: I also worry that the official utterances "line up and wait" and the official read back don't become stale...Again, more Cowboy improvisation from the tower AND the aircraft are needed..."Line up and wait, traffic landing on intersecting runway"....Inside the cockpit...Ok, line up and we do (do not?) have the traffic in sight and will wait for them to cross and for clearance.
                            Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                            Comment


                            • #15
                              Yeah but you're describing two completely different scenarios!

                              In your runway-crossing case, approaching the intersection one pilot says "clear", the other says "clear", just like they've done 100 times before, when the crossing runway was in fact clear. The danger there is that they both say "clear" out of habit because it's okay to cross 99.9% of the time, and they may not be paying attention that one time where there's another aircraft they could collide with. In other words, repetition can result in inattention, which can result in an anomalous condition not being detected.

                              In the case of a pilot being told to wait, repetition is a *beneficial* thing. Every single time the pilot is instructed to wait and follows the instruction, the more ingrained the proper behavior becomes. The only way there would be an anomaly is if the pilot did not properly respond to the instruction.
                              Be alert! America needs more lerts.

                              Eric Law

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