Results 1 to 18 of 18

Thread: 40-Year Anniversary of the Tenerife Airport Disaster

  1. #1
    Senior Member Evan's Avatar
    Join Date
    Jan 2008
    Posts
    5,252

    Default 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. #2
    Senior Member 3WE's Avatar
    Join Date
    Jan 2008
    Posts
    3,823

    Default

    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.

  3. #3
    Senior Member Gabriel's Avatar
    Join Date
    Jan 2008
    Location
    Buenos Aires - Argentina
    Posts
    5,724

    Default

    Quote 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 ---

  4. #4
    Member
    Join Date
    Jan 2008
    Location
    MA, USA
    Posts
    656

    Default

    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

  5. #5
    Junior Member
    Join Date
    Jul 2013
    Posts
    59

    Default

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

  6. #6
    Senior Member Evan's Avatar
    Join Date
    Jan 2008
    Posts
    5,252

    Default

    Quote 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.

  7. #7
    Senior Member 3WE's Avatar
    Join Date
    Jan 2008
    Posts
    3,823

    Default

    Quote 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.

  8. #8
    Senior Member Evan's Avatar
    Join Date
    Jan 2008
    Posts
    5,252

    Default

    Quote 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.

  9. #9
    Senior Member 3WE's Avatar
    Join Date
    Jan 2008
    Posts
    3,823

    Default

    Quote 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.

  10. #10
    Senior Member Evan's Avatar
    Join Date
    Jan 2008
    Posts
    5,252

    Default

    Quote 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.

  11. #11
    Senior Member Gabriel's Avatar
    Join Date
    Jan 2008
    Location
    Buenos Aires - Argentina
    Posts
    5,724

    Default

    Quote 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.
    http://avherald.com/h?article=49f292af&opt=0

    --- 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 ---

  12. #12
    Senior Member Evan's Avatar
    Join Date
    Jan 2008
    Posts
    5,252

    Default

    Quote 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.

  13. #13
    Senior Member Gabriel's Avatar
    Join Date
    Jan 2008
    Location
    Buenos Aires - Argentina
    Posts
    5,724

    Default

    Quote 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 ---

  14. #14
    Senior Member 3WE's Avatar
    Join Date
    Jan 2008
    Posts
    3,823

    Default

    Quote 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.

  15. #15
    Member
    Join Date
    Jan 2008
    Location
    MA, USA
    Posts
    656

    Default

    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

  16. #16
    Senior Member 3WE's Avatar
    Join Date
    Jan 2008
    Posts
    3,823

    Default

    Quote Originally Posted by elaw View Post
    Yeah but you're describing two completely different scenarios!


    Gabriel told a story of a crew who was told "line up and wait" and apparently gave the official procedural read back to ATC...and yet they proceeded to take off, so that's where I see the similarity.

    ...and that it needs to be 'line up and wait because there's a plane crossing downfield' is my point (much like 'here's the runway that's rarely in use, and although it's kind of lame, I just looked and no one is on final approach either')...a little extra thought with regard to situational awareness.

    That contrasted with brief 'mindless' code words..."clear-clear"...."line up and wait-line up and wait"...

    ...and not saying we totally muck up the radio waves with Edith Bunker discussions, but maybe make the cockpit less sterile with some genuine discussion of the situation...

    ...AND (sorry)...

    Fully aware that 99.9999% of the time the crew may indeed say an extra word or two to be situationally aware.

    ...AND (hopefully the last AND, sorry a second time)...

    Fully aware that 0.000[who knows how many more zeros]1% of the time this may not fix a damn thing...

    ...JUST...

    Venting about mindless procedural operation vs. mindful procedural operation and wanting procedure to inspire mindfulness as opposed to being just something you utter...

    ...and they lived happily ever after.

    Thanks.
    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

  17. #17
    Senior Member Evan's Avatar
    Join Date
    Jan 2008
    Posts
    5,252

    Default

    Quote Originally Posted by Gabriel View Post
    Evan, honest mistakes do happen.
    Gabriel, I don't think you can simply call that an honest mistake. Unless the crew heard something they mistook for a takeoff clearance, this is negligence, not error. We've witnessed a lot of errors that can be made under pressure, fatigue and confusion but awaiting takeoff clearance before rolling is FUNDAMENTAL to being a pilot, and with two pilots monitoring ATC and thus aware of the instruction to wait and one of them reading back the instruction to wait, how could you proceed to mistakenly roll without clearance?

    I never suggested any more extreme defensive procedures or 'buttons' to prevent this. It should be: wait for clearance, readback clearance, announce takeoff and go. There are already two lines of defense there. That should cover it.

    This is just just negligence and lax discipline while commanding a dreadful responsibility. We can't let just anyone do this. A well-trained pilot rolling a airliner on a field with an active intersecting runway without clearance goes against the strongest of commercial pilot instincts. These guys shouldn't be flying at all. They're not pilot material.

    Unless there's more to the story...

  18. #18
    Senior Member Gabriel's Avatar
    Join Date
    Jan 2008
    Location
    Buenos Aires - Argentina
    Posts
    5,724

    Default

    Quote Originally Posted by Evan View Post
    Gabriel, I don't think you can simply call that an honest mistake. Unless the crew heard something they mistook for a takeoff clearance, this is negligence, not error. We've witnessed a lot of errors that can be made under pressure, fatigue and confusion but awaiting takeoff clearance before rolling is FUNDAMENTAL to being a pilot, and with two pilots monitoring ATC and thus aware of the instruction to wait and one of them reading back the instruction to wait, how could you proceed to mistakenly roll without clearance?
    In the same way that someone can tell you "turn left in the next corner", and you can reply "ok, next left", and right we go.
    Do the same thing one million times, and once or twice you can do it stupidly (but honestly) wrong.

    --- 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 ---

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •